ICU-Acquired Hypernatremia Is Associated with Persistent Inflammation, Immunosuppression and Catabolism Syndrome.

Christopher Rugg,Stefan Schmid,Benedikt Treml,Janett Kreutziger,Mirjam Bachler,Mathias Ströhle

doi:10.3390/jcm9093017

Abstract

Developing hypernatremia while on intensive care unit (ICU) is a common problem with various undesirable effects. A link to persistent inflammation, immunosuppression and catabolism syndrome (PICS) can be established in two ways. On the one hand, hypernatremia can lead to inflammation and catabolism via hyperosmolar cell stress, and on the other, profound catabolism can lead to hypernatremia via urea-induced osmotic diuresis. In this retrospective single-center study, we examined 115 patients with prolonged ICU stays (≥14 days) and sufficient renal function. Depending on their serum sodium concentrations between ICU day 7 and 21, allocation to a hypernatremic (high) and a nonhypernatremic group (low) took place. Distinct signs of PICS were detectable within the complete cohort. Thirty-three of them (28.7%) suffered from ICU-acquired hypernatremia, which was associated with explicitly higher signs of inflammation and ongoing catabolism as well as a prolonged ICU length of stay. Catabolism was discriminated better by the urea generation rate and the urea-to-creatinine ratio than by serum albumin concentration. An assignable cause for hypernatremia was the urea-induced osmotic diuresis. When dealing with ICU patients requiring prolonged treatment, hypernatremia should at least trigger thoughts on PICS as a contributing factor. In this regard, the urea-to-creatinine ratio is an easily accessible biomarker for catabolism.

Highlights

Hypernatremia is a common problem in critically ill patients [1]
Another intensive care unit (ICU)-acquired disorder associated with an undesirable outcome is the persistent inflammation, immunosuppression and catabolism syndrome (PICS)—not to be mistaken for the so-called postintensive care syndrome, which is abbreviated likewise
Speaking, these patients present with a prolonged ICU stay under the coexistence of ongoing inflammation and immunosuppression, resulting in persistent catabolism and organ dysfunction [18,19,20]

Summary

Introduction

Hypernatremia is a common problem in critically ill patients [1]. While general causes are broken down to a net gain in total sodium or a net loss of free water, clinical discrimination of the main underlying pathology is not always done. Regardless of whether it was present at admission or acquired during intensive care, hypernatremia has been shown to be a predictor and independent risk factor for mortality by numerous studies in various situations [9,12,13,15,16] Another ICU-acquired disorder associated with an undesirable outcome is the persistent inflammation, immunosuppression and catabolism syndrome (PICS)—not to be mistaken for the so-called postintensive care syndrome, which is abbreviated likewise. The paradigm implies that, following the simultaneously triggered pro- and anti-inflammatory responses to a major inflammatory insult (e.g., trauma, burns, sepsis, acute pancreatitis, etc.), the increasing number of acute survivors either proceed to a fairly rapid recovery or a prolonged trajectory partially ending in CCI [18,19] Speaking, these patients present with a prolonged ICU stay (typically >14 days) under the coexistence of ongoing inflammation and immunosuppression, resulting in persistent catabolism and organ dysfunction [18,19,20]. This was associated with older age, an increased rate of hospital-acquired infections and a six-month survival of merely 63% [25]

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