Consensus document on the management of hyponatraemia of the Acqua Group of the Spanish Society of Endocrinology and Nutrition

INTRODUCTION

Hyponatremia is the most prevalent electrolyte disorder in the outpatient and inpatient settings. Despite this frequency, hyponatremia, including severe hyponatremia, is frequently underestimated and inadequately treated, thus highlighting the need to produce consensus documents and clinical practice guidelines geared towards improving the diagnostic and therapeutic approach to it in a structured fashion.

MATERIAL AND METHODS

Members of the Acqua Group of the Spanish Society of Endocrinology and Nutrition (SEEN) met using a networking methodology over a period of 20 months (between October 2019 and August 2021) with the aim of discussing and developing an updated guideline for the management of hyponatraemia. A literature search of the available scientific evidence for each section presented in this document was performed.

RESULTS

A document with 8 sections was produced, which sets out to provide updated guidance on the most clinically relevant questions in the management of hyponatraemia. The management of severe hyponatraemia is based on the i.v. administration of a 3% hypertonic solution. For the management of chronic euvolemic hyponatraemia, algorithms for the initiation of treatment with the two pharmacological therapeutic options currently available in Spain are presented: urea and tolvaptan.

CONCLUSIONS

This document sets out to simplify the approach to and the treatment of hyponatraemia, making it easier to learn and thus improve the clinical approach to hyponatremia.

Metabolic control and satisfaction in a diabetes education programme in flash glucose monitoring through telemedicine in type 1 diabetes

OBJECTIVE

To evaluate metabolic control and satisfaction with a telemedicine diabetes education programme for the initiation of flash glucose monitoring (FGM) in type 1 diabetes.

MATERIAL AND METHODS

Prospective study in 48 patients (52.1% women, 22.9% on insulin pump) who started FGM. They were analysed at baseline and 3 months after the beginning of the FGM. The results were compared with an on-site learning cohort matched by age, sex and HbA1c.

RESULTS

At the beginning and 3 months after the MFG, HbA1c improvement was observed (7.9±1.4 vs 7.3±1.1%), p<0.01; with a decrease in time below range - TBR - (4.7±4.9 vs 3.5±3.5%), p<0.05 and number of hypoglycaemic events (9.4±8.7 vs 6.9±5.7/15 days), p<0.05, associated with a worsening in time above range - TAR - (33.5±19.9 vs 37.0±20.9%), p<0.05. No significant differences were observed in the TIR 70-180mg/dl (61.7±18.6 vs 59.4±20.0%), glycemic variability or the use of FGM. Patient satisfaction with telemedicine training was 4.8±0.3 out of 5. No significant differences were observed in the follow-up, either in HbA1c or other glucometer parameters between on-site and online training. In a multivariate analysis adopting the HbA1c at follow-up as the dependent variable, only the TIR (β=-0.034; p<0.001) and the initial HbA1c (β=0.303; p<0.001) maintained statistical significance, unrelated to the on-site or online training (β=0.136; p=ns).

CONCLUSIONS

A telemedicine programme is an adequate tool for training in FGM, with results similar to on-site training, and it was associated with a high degree of satisfaction.

Impact of flash glucose monitoring on quality of life and glycaemic control parameters in adults with type 1 diabetes mellitus⋆

INTRODUCTION

Flash glucose monitoring (FGM) improves some glycaemic control variables and quality of life parameters.

OBJECTIVE

Our aim was to evaluate the quality of life and glycaemic control parameters after initiating FGM in patients with type 1 diabetes (DM1) in clinical practice.

MATERIAL AND METHODS

A prospective observational study in DM1 patients that started using FGM between June 2019 and April 2020. We analysed their scores on the Diabetes Quality of Life (DQOL) questionnaire, Diabetes Distress Scale (DDS), Diabetes Treatment Satisfaction Questionnaire (DTSQ) and glycaemic control parameters at baseline and 3 months after the FGM onset.

RESULTS

We recruited 114 patients, 56% male, mean age 37.2 (standard deviation, SD 12.4), with 18.7 (SD 11.5) years of DM1, 24.6% of which used continuous subcutaneous insulin infusion. Differences were observed (baseline vs. 3 months) in the DTSQ score (22 [15.5-27] vs. 25 [22-28], P < 0.001) and in the DQOL score (88 [74-104] vs. 84 [70-101], P = 0.017) but not in the DDS score. HbA1c was 7.8% (SD 1.3) vs. 7.4% (SD 1.1) (P < 0.001), without improvement in other glycaemic control variables, except for the mean number of hypoglycaemic events/14 days: 14 (SD 9) at baseline vs. 11.5 (SD 7) at 3 months (P < 0.001).

CONCLUSIONS

The initiation of FGM, combined with a structured educational programme, was associated with improvement in quality of life and patient satisfaction in DM1 patients. An improvement in HbA1c and a reduction in the number of hypoglycaemia events was observed, but not in the rest of glycaemic control parameters.

Aetiological diagnosis of hyponatraemia in non-critical patients on total parenteral nutrition: A prospective multicentre study

BACKGROUND

In patients receiving total parenteral nutrition (TPN), the frequency of hyponatraemia is high. However, the causes of hyponatraemia in TPN have not been elucidated, although diagnosis is required for appropriate therapy. The aim of this study is to describe the aetiology of hyponatraemia in non-critical hospitalised patients receiving TPN.

METHODS

Prospective multicentre study in 19 Spanish hospitals. Non-critically hyponatraemic patients receiving TPN and presenting hyponatraemia over a 9-month period were studied. Data collected included sex, age, previous comorbidities, and serum sodium levels (SNa) before and following TPN initiation. Parameters for study of hyponatraemia were also included: clinical volaemia, the presence of pain, nausea, gastrointestinal losses, diuretic use, oedema, renal function, plasma and urine osmolality, urinary electrolytes, cortisolaemia, and thyroid stimulating hormone.

RESULTS

162 patients were included, 53.7% males, age 66.4 (SD13.8) years. Volume status was evaluated in 142 (88%): 21 (14.8%) were hypovolaemic, 96 (67.6%) euvolaemic and 25 (17.6%) hypervolaemic. In 111/142 patients the analytical assessment of hyponatraemia was completed. Hypovolaemic hyponatraemia was secondary to GI losses in 10/111 (9%), and to diuretics in 3/111 (2.7%). Euvolaemic hyponatraemia was due to Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) in 47/111 (42.4%), and to physiological stimuli of Arginine Vasopressin (AVP) secretion in 28/111 (25.2%). Hypervolaemic hyponatraemia was induced by heart failure in 19/111 (17.1%), cirrhosis of the liver in 4/111 (3.6%).

CONCLUSIONS

SIADH was the most frequent cause of hyponatraemia in patients receiving TPN. The second most frequent cause was physiological stimuli of AVP secretion induced by pain/nausea.

Aetiological diagnosis of hyponatraemia in non-critical patients on total parenteral nutrition: A prospective multicentre study

BACKGROUND

In patients receiving total parenteral nutrition (TPN), the frequency of hyponatraemia is high. However, the causes of hyponatraemia in TPN have not been elucidated, although diagnosis is required for appropriate therapy. The aim of this study is to describe the aetiology of hyponatraemia in non-critical hospitalised patients receiving TPN.

METHODS

Prospective multicentre study in 19 Spanish hospitals. Non-critically hyponatraemic patients receiving TPN and presenting hyponatraemia over a 9-month period were studied. Data collected included sex, age, previous comorbidities, and serum sodium levels (SNa) before and following TPN initiation. Parameters for study of hyponatraemia were also included: clinical volaemia, the presence of pain, nausea, gastrointestinal losses, diuretic use, oedema, renal function, plasma and urine osmolality, urinary electrolytes, cortisolaemia, and thyroid stimulating hormone.

RESULTS

162 patients were included, 53.7% males, age 66.4 (SD13.8) years. Volume status was evaluated in 142 (88%): 21 (14.8%) were hypovolaemic, 96 (67.6%) euvolaemic and 25 (17.6%) hypervolaemic. In 111/142 patients the analytical assessment of hyponatraemia was completed. Hypovolaemic hyponatraemia was secondary to GI losses in 10/111 (9%), and to diuretics in 3/111 (2.7%). Euvolaemic hyponatraemia was due to Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) in 47/111 (42.4%), and to physiological stimuli of Arginine Vasopressin (AVP) secretion in 28/111 (25.2%). Hypervolaemic hyponatraemia was induced by heart failure in 19/111 (17.1%), cirrhosis of the liver in 4/111 (3.6%).

CONCLUSIONS

SIADH was the most frequent cause of hyponatraemia in patients receiving TPN. The second most frequent cause was physiological stimuli of AVP secretion induced by pain/nausea.

Influence of nutritional status on hospital length of stay in patients with type 2 diabetes

INTRODUCTION

In the hospitalized patient, Diabetes mellitus type 2 (DM2) may result in a worse nutritional status due to its pathophysiology and dietary treatment.

OBJECTIVES

The aim of this study was to know if a hospitalized diabetic patient has a worse nutritional status, and to establish the influence of DM2 on the hospital length of stay in patients with malnutrition.

MATERIAL AND METHODS

This was a transveral study from January 2014 to October 2016; 1017 patients were included who were assessed by the Endocrinology and Nutrition Department. The data collected included anthropometry, plasma albumin, delay in performing the nutrition interconsultation and hospital length of stay. Nutritional status was evaluated using the Mini Nutritional Assesment (MNA) questionnaire and the nutritional risk score (NRS).

RESULTS

24.4% of the patients were diabetic and 75.6% were not. Diabetic patients had a higher body mass index (BMI) [23.18 (20.78-25.99) kg/m² vs. 22.31 (19.79-25.30) kg/m2, P˂.01], a lower total score in the MNA questionnaire [16.5(13.12-19) points vs. 17(14-20) points, P˂.01], and a lower NRS score [83.09(77.72-91.12) points vs. 85.78(79.27-92.83) points, p=0.03]. According to the MNA and the NRS, diabetic patients had an increased risk of malnutrition (<17.5 points) [OR=1.39, IC95%(1.04-1.86), p=0.02]; and NRS (<85 points) [OR=1.65, IC 95% (1.07-2.54) p=0.02], respectively. When adjusted for age these significant results disappeared. Diabetes combined with malnutrition showed that diabetic patients with malnutrition (MNA˂17.5) spent longer in hospital [21(12-36) days vs. 17(9-30) days, P=.01].

CONCLUSIONS

Diabetic patients have a worse nutritional status than non-diabetic patients. Diabetic patients with a poor nutritional status spend a longer period in hospital.

Development of hyponatremia in non-critical patients receiving total parenteral nutrition: A prospective, multicenter study

BACKGROUND & AIMS

Hyponatremia is frequent in hospitalized patients, especially in those receiving total parenteral nutrition (TPN). Furthermore, the presence of hyponatremia is associated with increased morbimortality in both groups. The goal of this study is to describe the prevalence of hyponatremia developing during TPN in non-critical patients, and identify risk factors for its appearance.

METHODS

This prospective multicenter study involved 19 Spanish hospitals. Noncritically-ill patients prescribed TPN over a 9-month period were studied. Variables analyzed demographic characteristics, prior comorbidities, drug therapy, PN composition, additional iv fluids, and serum sodium levels.

RESULTS

A total of 543 patients were recruited, 60.2% males. Age: 67 (IR 57-76). Of 466/543 who were eunatremic when starting TPN, 18% developed hyponatremia (serum sodium < 135 mmol/L) during TPN. Independent risk factors identified by logistic regression analysis: female (OR 1.74 [95% CI = 1.04-2.92], p = 0.036); severe malnutrition (OR 2.15 [95% CI = 1.16-4.35], p = 0.033); opiates (OR 1.97 [95% CI = 1.10-3.73], p = 0.036); and nausea/vomiting (OR 1.75 [95% CI = 1.04-2.94], p = 0.036).

CONCLUSIONS

Previously eunatremic patients frequently develop hyponatremia while receiving TPN. In this group, severe malnutrition is an independent risk factor for hyponatremia, as well as previously described risk factors: opiates, nausea/vomiting, and female gender.

Unresectable Recurrent Multiple Meningioma: A Case Report with Radiological Response to Somatostatin Analogues

Medical treatment of meningiomas is reserved for cases in which surgery and radiotherapy have failed. Given that a high percentage of meningiomas express somatostatin receptors, treatment with somatostatin analogues has been proposed. In addition, these medications have been shown to have an antiproliferative and antiangiogenic effect in vitro. To date, very few cases with clinical response and none with radiological response have been described. The case described here is the first to report a radiological response. A 76-year-old Caucasian male was first diagnosed with unresectable meningioma at age 47. The patient experienced multiple recurrences and underwent three surgeries and radiotherapy over the years from the initial diagnosis. Despite treatment, the disease continued its progression. Based on an Octreoscan positive for tumour uptake, therapy with extended-release somatostatin analogues was started. Although no clinical neurological improvement was observed, magnetic resonance imaging scans revealed a discreet but continuous radiological response over time. After >2 years of continuous administration of lanreotide, the patient remains progression free. In highly selected cases, somatostatin analogue treatment for meningioma may be beneficial. Based on our findings, treatment with somatostatin analogues should be maintained longer than previously described before evaluating treatment response.