Changes In Serum Sodium Levels Research Articles

Association of initial serum sodium change and clinical outcome in patients with diabetes receiving sodium-glucose cotransporter-2 inhibitor therapy: A multicentre database analysis in Taiwan.

The study aimed to assess the impact of varying degrees of initial serum sodium change among patients with type 2 diabetes (T2D) starting sodium-glucose cotransporter-2 inhibitor (SGLT2i) therapy and their subsequent clinical outcome. We used medical data from a multicentre health care provider in Taiwan and recruited 4400 patients with T2D with baseline normal serum sodium (135-145 mmol/L) and follow-up serum sodium measures available after 3 months of SGLT2i treatment from 1 June 2016 to 31 December 2021. After a median of 2.9 (2.4, 3.4) months of SGLT2i treatment, overall, there was a minimal change in serum sodium levels (from 139.6 ± 2.4 to 139.5 ± 3.7 mmol/L). Most patients (87.8%) maintained normal sodium levels, while 8.6% (n = 378) experienced hyponatraemia (<135 mmol/L) and 3.6% (n = 158) hypernatraemia (>145 mmol/L). Factors independently associated with hyponatraemia included cancer history, chronic lung disease, insulin use, higher glycated haemoglobin, impaired liver function, lower baseline sodium and greater initial decline in kidney function. Conversely, factors linked to hypernatraemia included older age, absence of cancer history, loop diuretic and non-steroidal anti-inflammatory drug use, higher baseline sodium and a lesser initial decline in kidney function. Over a median of 26.0 months of follow-up, hyponatraemia shortly after starting SGLT2i therapy was associated with significantly increased risks of major adverse cardiovascular events [hazard ratio (HR): 2.52; 95% confidence interval (CI): 1.83-3.48], heart failure for hospitalization (HR: 1.66; 95% CI: 1.16-2.37), major adverse renal events (HR: 2.27; 95% CI: 1.73-2.96) and all-cause death (HR: 2.98; 95% CI: 2.17-4.11) after adjusting for clinically relevant factors. Non-linear analysis indicated that a more pronounced initial decline in serum sodium levels correlated steeply with higher risks of these adverse events. While most patients with T2D maintain stable serum sodium homeostasis on SGLT2i therapy, a subset may experience dysnatraemic events with potential worse clinical consequences. Physicians should be vigilant about monitoring sodium levels and considering the associated risks when initiating SGLT2i therapy in patients with risk.

COMPARISON OF THE OUTCOME OF MONOPOLAR VERSUS BIPOLAR DIATHERMY USE DURING TRANSURETHRAL RESECTION OF PROSTATE

Monopolar transurethral resection of the prostate (M-TURP) remains a widely used surgical modality for treating benign prostatic hyperplasia (BPH). However, bipolar TURP (B-TURP), which uses isotonic saline as an irrigant, may reduce the risk of dilutional hyponatremia and transurethral resection (TUR) syndrome associated with M-TURP. Objective: To compare the outcomes of bipolar versus monopolar diathermy during transurethral resection of the prostate. Methods: This randomized controlled trial was conducted at the Department of Urology &amp; Renal Transplantation, Bahawal Victoria Hospital, Bahawalpur, from March 1, 2022, to May 31, 2023. The study included 100 patients, aged 55 to 85 years, scheduled for transurethral resection of the prostate due to BPH. Exclusion criteria were prostatic carcinoma, previous prostate surgery, cirrhosis, chronic renal failure, and bleeding disorders. Patients were randomized into Group A (M-TURP with 5% dextrose water as irrigant) and Group B (B-TURP with normal saline as irrigant). Outcomes, including changes in serum sodium levels, hemoglobin levels, and incidence of TUR syndrome, were assessed 12 hours postoperatively. Statistical analysis was performed using appropriate methods to compare the two groups. Results: The mean drop in hemoglobin (g/dL) was significantly more significant in the bipolar group (51.71 ± 7.28) compared to the monopolar group (47.86 ± 8.26) (p = 0.0001). The mean decrease in serum sodium levels (mEq/L) was significantly less in the monopolar group (143.57 ± 13.85) compared to the bipolar group (75.51 ± 7.98) (p = 0.0001). TUR syndrome occurred in 2 (4.0%) patients in the M-TURP group, whereas no cases were reported in the B-TURP group (p = 0.153). Conclusion: Bipolar transurethral resection of the prostate is associated with a smaller drop in hemoglobin, a lesser decrease in serum sodium levels, and a lower incidence of TUR syndrome than monopolar transurethral resection.

Tolvaptan therapy for edema in patients with chronic kidney disease.

Tolvaptan is a vasopressin V2 receptor antagonist that is commonly prescribed to alleviate edema associated with renal diseases. However, the clinical benefits of tolvaptan in chronic kidney disease (CKD) remain unclear. This study aimed to evaluate the effectiveness of tolvaptan in managing edema caused by CKD. The efficacy and treatment regimen of tolvaptan were assessed in a cohort of 96 patients with renal edema and CKD. During the treatment, the patients' creatinine (CR), uric acid (UA), and estimated glomerular filtration rate (eGFR) were monitored as important indicators of kidney function. Coagulation-associated molecules including fibrinogen, D-dimer, and fibrin degradation products (FDPs) were measured. Electrolyte disorders and acute kidney injury were closely monitored. Tolvaptan was administered at a daily dose of 7.5 mg, and 30 mg of edoxaban was administered to manage deep vein thrombosis. During the course of tolvaptan therapy, the eGFR of the patients was not declined. Edema was eliminated in 82.18% of patients. Proteinuria was reduced in the patients (p<0.05). There were no significant changes in serum sodium levels throughout treatment, and no significant difference was observed in blood volume between the end of treatment and baseline levels. Importantly, acute kidney injury did not occur, and renal edema and deep vein thrombosis were successfully treated. As long as a rational treatment regimen is followed, tolvaptan is a safe and effective diuretic for treating edema in CKD, even in the late stages of CKD without reducing residual renal function in the patients.

Safety and efficacy of proactive versus reactive administration of desmopressin in severe symptomatic hyponatremia: a randomized controlled trial

This randomized controlled trial aimed to evaluate the safety and efficacy of proactive versus reactive desmopressin (DDAVP) strategies in treating severe symptomatic hyponatremia. Conducted from June 20, 2022, to February 20, 2023, it involved 49 patients with serum sodium levels below 125 mmol/L. Patients were assigned to either the proactive group, receiving DDAVP immediately upon diagnosis, or the reactive group, receiving DDAVP only if the serum sodium level tended to be overcorrected. The primary outcome was the incidence of overcorrection. The study revealed no significant difference in the overcorrection incidence between the proactive (16.7%) and reactive (28%) groups (p = 0.54). The change in serum sodium levels at 1, 6, 12, and 24 h were not different, however, at 48 h, the proactive group exhibited a higher but still safe change in serum sodium levels compared to the reactive group (10.3 ± 3.6 mmol/L vs. 7.7 ± 3.6 mmol/L, p = 0.013). Other parameters including time to symptom improvement, total intravenous fluid administered, DDAVP dose, urine volume, hospital stay duration, osmotic demyelination syndrome incidence, and 28-day mortality did not significantly differ between the groups. In conclusion, our findings suggest that there was no significant disparity in overcorrection rates between proactive and reactive DDAVP strategies for treating severe symptomatic hyponatremia. However, further large-scale studies are warranted to validate these results.

Serum sodium level fluctuations following the resection of childhood-onset craniopharyngioma.

Craniopharyngiomas are low-grade malignancies (WHO I) in the sellar region. Most cases of childhood-onset craniopharyngioma are adamantinomatous craniopharyngioma, and neurosurgery is the treatment of choice. Affected patients have postoperative complications, including water and electrolyte disturbances, because these malignancies develop near the hypothalamus and pituitary gland. Determining postoperative serum sodium fluctuation patterns in these patients can reduce postoperative mortality and improve prognosis. To measure changes in serum sodium levels in pediatric patients who underwent craniopharyngioma surgery and identify influencing factors. This retrospective study measured the serum sodium levels of 202 patients aged 0-18 years who underwent craniopharyngioma resection in Beijing Tiantan Hospital and Beijing Children's Hospital and identified predictors of severe hyponatremia and hypernatremia. The mean age of the cohort was 8.35±4.35 years. The prevalence of hypernatremia, hyponatremia, and their severe forms (serum Na+ >150mmol/L and serum Na+ <130mmol/L) within 14 days after surgery was 66.3%, 72.8%, 37.1%, and 40.6%, respectively. The mean postoperative serum sodium level showed a triphasic pattern, characterized by two peaks separated by a nadir. Sodium levels peaked on days 2 (143.6±7.6mmol/L) and 14 (143.2±6.7mmol/L) and reached their lowest on day 6 (135.5±7.5mmol/L). A total of 31 (15.3%) patients met the diagnostic threshold for hyponatremia and hypernatremia of the triphase response, whereas 116 (57.4%) patients presented this pattern, regardless of met the diagnostic criteria or not. The prevalence of severe hyponatremia varied depending on preoperative endocrine hormone deficiency, tumor status (primary or recurrent), and surgical approach. Serum sodium levels after craniopharyngioma resection in children showed a triphasic pattern in most cases. The risk of postoperative hyponatremia varied depending on preoperative endocrine hormone deficiency, tumor status (primary or recurrent), and surgical approach.

Oral Sodium to Preserve Renal Efficiency in Acute Heart Failure: A Randomized, Placebo-Controlled, Double-Blind Study

Evidence for modulating the sodium chloride (NaCl) intake of patients hospitalized with acute heart failure (AHF) is inconclusive. Salt restriction may not benefit; hypertonic saline may aid diuresis. To compare the safety and efficacy of oral NaCl during intravenous (IV) diuretic therapy in renal function and weight. Seventy hospitalized patients with AHF who were being treated with IV furosemide infusion consented to receive, randomly, 2 grams of oral NaCl or placebo 3 times a day in a double-blind manner during diuresis. Treatment efficacy (bivariate primary endpoints of change in serum creatinine levels and change in weight) was measured at 96 hours, and adverse safety events were tracked for 90 days. Sixty-five patients (34 NaCl, 31 placebo) were included for analysis after 5 withdrew. A median of 13 grams of NaCl was given compared to placebo. At 96 hours, there was no significant difference between treatment groups with respect to the primary endpoint (P = 0.33); however, the trial was underpowered, and there was greater than expected standard deviation in weight change. The mean change in creatinine levels and weight was 0.15 ± 0.44 mg/dL and 4.6 ± 4.2 kg in the placebo group compared with 0.04 ± 0.40 mg/dL and 4.0 ± 4.3 kg in the NaCl group (P = 0.30 and 0.57, respectively). Across efficacy and safety endpoints, we observed no significant difference between the 2 groups other than changes in serum sodium levels (-2.6 ± 2.7 in the placebo group and -0.3 ± 3.3 mEq/L in the NaCl group; P < 0.001) and in serum blood urea nitrogen levels (11 ± 15 in the placebo group; 3.1 ± 13 mEq/L in the NaCl group; P = 0.025). In this single-center study, liberal vs restrictive oral sodium chloride intake strategies did not impact the safety and efficacy of intravenous diuretic therapy in patients with AHF. (ClinicalTrials.gov registration NCT04334668.).

Association between serum sodium level trajectories and survival in patients with heart failure.

The effect of changes in serum sodium levels on the survival of patients with heart failure (HF) is unclear. We aimed to analyse the impact of serum sodium level trajectories on survival in intensive care unit (ICU) patients with HF. A total of 4760 patients diagnosed with HF between 2001 and 2012 from the Medical Information Mart for Intensive Care III (MIMIC-III) database were extracted. Of these patients, 1132 patients who died within 48h of ICU admission were excluded, and 3628 patients were included in this retrospective cohort study. Sodium levels were measured at baseline, 6, 12, 18, 24, 30, 36, 42, and 48h. Patients were divided into hyponatremia, normal, and hypernatremia groups based on baseline sodium levels, and trajectory modelling was performed for each group separately. Group-based trajectory model (GBTM) method was utilized to identify serum sodium levels trajectories. The number of patients with hyponatremia (<135mmol/L), normal sodium levels (135-145mmol/L), and hypernatremia (>145mmol/L) at baseline were 594 (16.37%), 2,738 (75.47%), and 296 (8.16%), respectively. A total of seven trajectory groups were identified, including hyponatremia-slow rise group [initial levels (IL), 128.48±5.42mmol/L; end levels (EL), 131.23±3.83mmol/L], hyponatremia-rapid rise to normal group (IL, 132.13±2.18mmol/L; EL, 137.46±3.68mmol/L), normal-slow decline group (IL, 137.65±2.15mmol/L; EL, 134.50±2.54mmol/L), normal-steady-state group (IL, 139.20±2.26mmol/L; EL, 139.04±2.58mmol/L), normal-slow rise group (IL, 140.94±2.37mmol/L; EL, 143.43±2.89mmol/L), hypernatremia-rapid decline to normal group (IL, 146.31±1.98mmol/L; EL, 140.71±3.61mmol/L), and hypernatremia-slow decline group (IL, 148.89±5.54mmol/L; EL, 146.28±3.90mmol/L). The results showed that hyponatremia-slow rise group [hazard ratio (HR)=1.35; 95% confidence interval (CI), 1.01-1.80, P=0.040], hyponatremia-rapid rise to normal group (HR=1.37; 95% CI, 1.11-1.71, P=0.004), hypernatremia-rapid decline to normal group (HR=1.46; 95% CI, 1.08-1.97, P=0.014), and hypernatremia-slow decline group (HR=1.49; 95% CI, 1.07-2.07, P=0.018) trajectories were associated with an increased risk of 1-year mortality in HF patients compared with normal-steady-state group. After adjustment for all confounders, hyponatremia-rapid rise to normal group (HR=1.26, 95% CI; 1.01-1.57, P=0.038) and hypernatremia-rapid decline to normal group (HR=1.36; 95% CI, 1.01-1.84, P=0.047) trajectories were still related to an increased risk of 1-year mortality in patients with HF. Serum sodium level trajectories were associated with mortality in patients with HF. Association between serum sodium level trajectories and prognosis in patients with HF deserve further study.

Hepatik Ensefalopati Tip C Hastalarında Tetikleyici Faktörler ve Kliniko-Endoskopik Çalışma

Introduction: Hepatic encephalopathy (HE) is a decline in brain function as a result of severe liver disease and its inadequacy to remove toxins from the body. It is characterized by personality changes, intellectual impairment, and loss of consciousness. This study was conducted to determine the precipitating factors and endoscopic features of hepatic encephalopathy in patients with liver cirrhosis and evaluate the associated clinical features admitted in a tertiary hospital in Central India. Materials and Methods: This hospital-based descriptive cross-sectional study was conducted from November 2016 to October 2018 on 102 patients with hepatic encephalopathy type C, aged above 18. All patients were carefully examined, relevant investigations performed, and data collected through pre-designed proforma. They were sent for statistical analysis where categorical outcomes were compared between study groups using the Chi-square test /Fisher's Exact test. Results: The prevalence of HE was 19.6% in our study. In this study, we observed that constipation (26.5%), electrolyte imbalance (21.6%), renal failure (18.6%), and upper GI bleeding (18.6%) be among the leading precipitants for HE. Besides liver failure, the associated abnormalities in various factors like coagulation abnormalities, renal derangement, and changes in serum sodium levels can lead to the progression of HE to higher grades. Conclusion: It is essential to identify the different factors like constipation, electrolyte imbalance, renal failure, and upper GI bleeding early in the course of cirrhosis to help prevent the development of HE.

0.45% Versus 0.9% Saline in 5% Dextrose as Maintenance Fluids in Children Admitted With Acute Illness: A Randomized Control Trial.

The safety of giving intravenous (IV) maintenance fluids according to Holliday and Segar's recommendations of 1957 has recently been questioned after reports of complications caused by iatrogenic hyponatremia in children receiving hypotonic fluids. However, the current practice of choice of maintenance IV fluids for hospitalized children varies worldwide. This study was planned to compare 0.45% and 0.9% saline in 5% dextrose at standard maintenance rates in hospitalized children aged 3 months to 12 years. Primary objective was to study change in serum sodium level at 24 hours in children receiving total IV fluid maintenance therapy as 0.45% or 0.9% normal saline in 5% dextrose. Secondary objectives of this study were to estimate change in serum sodium levels from the baseline to 48 or 72 hours, if IV fluids were continued, and to find incidence of hyponatremia and hypernatremia after administering these 2 types of maintenance fluids. This study was an open-label, randomized control trial conducted at the Department of Pediatrics of a tertiary care hospital from July 22, 2019, to October 28, 2019. Two hundred children aged 3 months to 12 years admitted in pediatric emergency and requiring IV maintenance fluid were randomized into 2 groups (group A received 0.45% saline in 5% dextrose, group B received 0.9% normal saline in 5% dextrose) with 100 in each group. Both groups were comparable for baseline characteristics. Fall in mean serum sodium from baseline was more with increasing duration of IV fluids until 24 hours in 0.45% saline group as compared with 0.9% saline group, which was statistically significant (P < 0.001). The incidence of mild and moderate hyponatremia was significantly more in hypotonic group at 12 hours (P < 0.001) and 24 hours (P < 0.001). However, there was no significant difference at 48 hours. The fall in serum sodium values was significant, and there was significant risk of hyponatremia with the use of hypotonic fluids at 12 and 24 hours. Hence, the use of isotonic fluids seems to be more appropriate among the hospitalized children.Trial Registration: CTRI/2019/10/021791.

Comparative Study Between Serum Level of Total L-carnitine in Neonatal Hypoxic Ischemic Encephalopathy (HIE) and Transient Tachypnea of the Newborn (TTN)

Background: Neonatal hypoxic-ischemic encephalopathy (HIE) is one of the most common causes of cerebral palsy. Objectives: We aimed to compare the serum levels of total L-carnitine in newborns with HIE and Transient tachypnea of the newborn and to determine the correlation between associated demographic data, associated changes in laboratory findings, and outcome in cases with HIE. Methods: This comparative, prospective, and observational study was conducted at the Neonatal Intensive Care Unit (NICU) of Assiut University Children Hospital. All the cases of perinatal asphyxia and TTN admitted to the NICU during 2016 - 2018 were included. Results: It was found that the serum level of total L-carnitine decreased in both HIE (I) and TTN (II) cases, but the difference was not significant (5.51 ± 1.30 µmol/L in group I vs. 6.22 ± 2.56 µmol/l in group II). Male factor with changes in the serum sodium level (132.63 ± 9.30) and abnormal serum creatinine level (1.4 [0.7 - 15.0]) were significantly related to the outcome of HIE cases. Conclusions: The serum level of total L-carnitine declined in both HIE and TTN cases. Male factor with changes in serum sodium level and abnormal serum creatinine level were significantly related to the mortality of cases with HIE.

Comparison of equiosmolar doses of 10% hypertonic saline and 20% mannitol for controlling intracranial hypertention in patients with large hemispheric infarction

ObjectiveWe conducted this prospective self-crossover controlled trial to compare the efficacy and safety of 10 % hypertonic saline (HS) and 20 % mannitol in doses of similar osmotic burden for the treatment of increased intracranial pressure (ICP) in patients with large hemispheric infarction (LHI). Patients and MethodsPatients with LHI were enrolled from January 2017 to January 2018. We used an alternating treatment protocol to compare the effects of HS with mannitol given for episodes of increased ICP in patients with LHI. Indicators such as ICP, mean arterial pressure (MAP) and cerebral perfusion pressure (CPP) were continuously monitored at regular intervals for 240 min after initiation of infusion. Electrolytes, plasma osmolality and renal functions were measured before and 240 min after initiation of infusion to compare the efficacy and safety of the two drugs. ResultsA total of 49 episodes of increased ICP occurred in 14 patients with LHI, of which 24 were infused with 10 % HS and 25 with 20 % mannitol. Both the treatments were equally effective in reducing ICP (P < 0.01). The differences in the duration and degree of reduction were not significant between the groups (P > 0.05). Although both the osmolar agents decreased MAP, the degree was greater in the mannitol group (P < 0.05) at T120. The increase in CPP was greater in the HS group compared with the mannitol group (P < 0.05) at T120. However, HS was associated with faster heart rate (HR) and higher serum chloride levels (P < 0.05). Changes in serum sodium levels and osmolality were not significant between the groups in spite of being higher in the HS group. ConclusionsBoth the drugs can serve as first-line agents for treating intracranial hypertension caused by LHI and should be selected rationally according to the differences in efficacy and adverse effects.

Salt and water balance after sweat loss: A study of Bikram yoga.

Bikram yoga is practiced in a room heated to 105°F with 40% humidity for 90 min. During the class a large volume of water and electrolytes are lost in the sweat, specifically, sodium is lost, the main cation of the extracellular fluid. There is little known about the volume of sweat and the amount of sodium lost in sweat during Bikram yoga or the optimum quantity of fluid required to replace these losses. The participants who took part in this small feasibility study were five females with a mean age of 47.4 ± 4.7 years and 2.6 ± 1.6 years of experience at Bikram yoga. The total body weight, water consumed, serum sodium concentration, serum osmolality, and serum aldosterone levels were all measured before and after a Bikram yoga practice. Sweat sodium chloride concentration and osmolality were measured at the end of the practice. The mean estimated sweat loss was 1.54 ± 0.65 L, while the amount of water consumed during Bikram yoga was 0.38 ± 0.22 L. Even though only 25% of the sweat loss was replenished with water intake during the Bikram yoga class, we did not observe a change in serum sodium levels or serum osmolality. The sweat contained 82 ± 16 mmol/L of sodium chloride for an estimated total of 6.8 ± 2.1 g of sodium chloride lost in the sweat. The serum aldosterone increased 3.5‐fold from before to after Bikram yoga. There was a decrease in the extracellular body fluid compartment of 9.7%. Sweat loss in Bikram yoga predominately produced a volume depletion rather than the dehydration of body fluids. The sweating‐stimulated rise in serum aldosterone levels will lead to increased sodium reabsorption from the kidney tubules and restore the extracellular fluid volume over the next 24 hr.

Effect of Rehydration With Normal Saline Versus Ringer Lactate on Serum Sodium Level of Children With Acute Diarrhea and Severe Dehydration: A Randomized Controlled Trial

To demonstrate the equivalence of Normal Saline (NS) and Ringer Lactate (RL) for change in serum sodium levels during correction of severe dehydration in children with acute diarrhea based on World Health Organization (WHO) plan C. Equivalence randomized control trial. Pediatric diarrhea unit of a tertiary care hospital from May, 2016 to April, 2017. 72 children of 1-12 years with acute diarrhea and severe dehydration were enrolled. Children with dysentery, severe acute malnutrition, severe anemia, meningitis, and known surgical and systemic diseases were excluded. RL (n=36) or NS (n=36) were used as per WHO plan C. Blood samples were drawn before intravenous fluid correction and 3 h post-intervention. Mean change in serum sodium level from the baseline between the RL and NS groups. 70 children (35 in each group) completed the study. The difference in mean serum sodium levels from baseline in RL and NS groups were 1.4 (4.5) mEq/L and 2.1(4.9) mEq/L, respectively (P=0.58). Both RL and NS are equivalent in terms of change in serum sodium from baseline for intravenous rehydration in children with acute diarrhea and severe dehydration.

Anesthetic Fluid Management of Patients With Hyponatremia Undergoing Living Donor Liver Transplantation

ObjectiveThe objective of this study is to evaluate the changes in serum sodium levels in adult recipients with and without hyponatremia undergoing living donor liver transplantation (LDLT) without using hypertonic solution. MethodsPatients were divided into 2 groups according to serum sodium level higher (GI) or lower (GII) than 130 mEq/L. The changes of serum sodium levels during an LDLT procedure and total sodium loads were compared between groups by using the Mann-Whitney U test, while the changes in the same group were paired by using the Student t test. A P value <.005 was considered significant. ResultsThe total sodium load for GI (n = 438) and GII (n = 28) were 2737 ± 2159 mEq and 4017 ± 2830 mEq, respectively. Although GI received a significantly lower sodium load than GII, the serum sodium levels during the procedure were always within a normal range and higher than GII at all the measured time points; however, the changes of serum sodium level in GI from one point to the next measured point in the same group were unremarkable, while that of GII increased significantly between the 2 measured time points during the procedure. The mean total increase of serum sodium in GII was 5.57 ± 4.9 mEq/L in 14 hours of the LDLT procedure. None of the patients developed central pontine myelinosis (CPM) postoperatively. ConclusionPatients with hyponatremia can be managed safely without using a hypertonic solution during liver transplantation. The mean increase of serum sodium of GII was of 5.57 ± 4.9 mEq/L, which was still within the acceptable and safe level. No postoperative CPM was observed in our GII patients.

Changes in selected electrolytes in adult intensive care patients at the University Teaching Hospital, Lusaka, Zambia

Background: The importance of regulating electrolyte levels is well recognized in most Intensive Care Units (ICU). Various institutions across the globe have found varying figures on the extent and causes of electrolytes derangements in ICUs. The extent of electrolyte and fluid imbalance in patients being admitted and already admitted to the Main ICU (MICU) at the University Teaching Hospital (UTH) Lusaka Zambia is unknown. This study aimed to explore the 24hour changes in sodium and potassium in adult MICU patients at the UTH, Lusaka, Zambia. Methods: This was a prospective cohort study of the patients admitted to the MICU at UTH, Lusaka, Zambia. Data was collected over a four-month period (August to November) in 2017. Only consenting patients 18 years and above admitted for at least 24 hours in the unit were enrolled. On admission, routine baseline investigations were obtained from every patient which included a full blood count and renal function tests. The second set of investigations was collected 24 hours post MICU admission. The blood samples were obtained from a peripheral vein in heparinized bottles for renal function tests. Serum electrolyte analysis was done was at UTH. Normal serum concentrations of sodium and potassium were considered as 135-145mmol/l and 3.5 - 4.5mmol/L, respectively. Comparisons between means were done with the Wilcoxon signed-rank test. Logistic regression analysis was used to investigate the relationship between dependent and independent variables. A p-value &lt; 0.05 was considered statistically significant. Statistical analysis was performed with STATA 13 SE. Results: A total number of 100 patients were included in this study with a mean age of 36.8 years (SD = 12.1). The mean value of sodium level was 136.7 (SD = 8.9) mmol/L and 139.0 (SD = 11.6) mmol/L, on admission and 24 hours post-admission respectively. This difference in serum sodium level was shown to be statistically significant with a P-value = 0.0051. Hypernatremia was shown to be associated with an increased risk of death (p = 0.021) in the Unit with an odds ratio of 4.0 at 95% confidence interval of 1.3 to 13.8. Hyponatremia was the most prevalent electrolyte imbalance but was neither shown to be associated with mortality (P-value = 0.18) nor prolonged ICU stay (0.56) at 24 hours post-admission. The mean value of potassium level was 4.2 (SD = 1.1) mmol/L and 4.3 (SD = 1.1), on admission and 24 hours post-admission respectively. This difference was not statistically significant (P-value = 0.57). Conclusion: There was a statistically significant change in serum sodium levels after 24 hours post-admission but there was no statistically significant change in potassium. Hyponatremia was the most prevalent abnormality whilst hypernatremia had a statistically significant association with mortality. Therefore, electrolyte imbalances can occur as early as the first day of admission in ICU with fatal complications. Correcting electrolyte imbalances in MICU patients is an urgent necessity and should not be delayed.

Tolvaptan in reversing worsening acute heart failure: A systematic review and meta-analysis.

ObjectiveIn this meta-analysis, we aimed to compare efficacy and clinical outcomes of tolvaptan in treating acute heart failure (AHF).MethodsUsing MEDLINE, we searched relevant clinical studies using tolvaptan that investigated clinical effects in treating AHF. We performed meta-analysis for potentially extractable clinical outcomes such as body weight reduction, change in serum sodium levels, and clinical or safety events including worsening heart failure, worsening renal function (WRF), all-cause mortality, rehospitalization, and dyspnea improvement.ResultsThe results showed that tolvaptan significantly reduced body weight (mean change: −1.28 kg, 95% credible interval (CI): −1.58–0.98), increased serum sodium levels (mean change: 3.48 mmol/L; 95% Cl: 3.22–3.74), and improved dyspnea function (odds ratio (OR): 1.43; 95% CI: 1.26–1.62) versus conventional therapy. The event risk of WRF was also significantly reduced (OR: 0.35; 95% CI: 0.15–0.80). Low, intermediate, and high tolvaptan doses did not reduce mortality and rehospitalization risks. No significant publication bias was observed regarding effects on mortality and rehospitalization.ConclusionCurrent evidence indicates that using tolvaptan as add-on therapy can decrease body weight, increase sodium levels, improve dyspnea function, and reverse WRF, which may circumvent loop diuretics overdose and improve outcomes in patients with AHF.

Isotonic versus hypotonic saline as maintenance intravenous fluid therapy in children under 5 years of age admitted to general paediatric wards: a randomised controlled trial

ABSTRACTBackground: To prevent the risk of iatrogenic hyponatraemia in hospitalised children, isotonic fluid has been recommended as maintenance intravenous fluid (IVF). There are few studies which compare half normal saline with normal saline as maintenance IVF in general paediatric wards.Aim: To compare the safety and efficacy of half normal saline with normal saline as maintenance IVF in general paediatric wards.Methods: Children aged between 3 months and 5 years with an anticipated requirement for IVF for 24 h were randomised to receive either half normal saline (0.45% saline in 5% dextrose) or normal saline (0.9% saline in 5% dextrose). The primary objective was to compare the incidence of hyponatraemia (serum sodium <135 mmol/L with a decrease from baseline of at least 4 mmol/L) at 24 h in children receiving half normal saline with those receiving normal saline. Secondary objectives were to compare the incidence of moderate (sodium <130 mmol/L), severe (sodium <125 mmol/L) and symptomatic hyponatraemia, change in serum sodium level from baseline and the incidence of hypernatraemia.Results: A total of 168 children were randomised to receive either normal saline (n = 84) or half normal saline (n = 84). More than two-thirds of the children were suffering from respiratory diseases (pneumonia and bronchiolitis) and diseases of the nervous system (meningoencephalitis, febrile seizures and epilepsy). The incidence of hyponatraemia at 12 h in children receiving half normal saline was similar to that in those receiving normal saline (6 vs 4.8%; Relative risk (RR) 1.2; 95% CI 0.3.0–4.8; p = 0.73). Although the incidence of hyponatraemia at 24 h in children receiving half normal saline was higher than in those receiving normal saline, the difference was not statistically significant (14.3 vs 6%; RR 2.6; 95% CI 0.9–7.8; p = 0.07). One child in the isotonic group and one in the hypotonic group developed moderate and severe hyponatraemia, respectively. There was no significant difference in the incidence of hypernatraemia between two groups (RR 0.7; 95% CI 0.16–3.3).Conclusion: Half-normal saline as maintenance IVF does not result in a significantly increased risk of hyponatraemia in general paediatric ward patients under 5 years of age.

Abstract TP532: Decreased Serum Sodium Levels Predict Symptomatic Vasospasm in Patients With Subarachnoid Hemorrhage

Background: Symptomatic vasospasm (SVS) is one of the major causes of morbidity and mortality in patients with subarachnoid hemorrhage (SAH). Hyponatremia and dehydration due to natriuresis after SAH is related to SVS and predicts it. Therefore, nowadays most institutions target to euvolemia and eunatremia in SAH patients to avoid complications. In this study, we retrospectively investigated the predictors of SVS in terms of water and sodium homeostasisunder maintaining euvolemia and eunatremia after SAH. We also analyzed the relationship between hyponatremia and the effect of treatment modality (clipping and endovascular coiling). Methods: We monitored changes in serum sodium levels, serum osmolarity, daily sodium intake, daily urine volume, and daily water balance during 14 days after SAH. Outcome was assessed using the modified Rankin scale one month after subarachnoid hemorrhage. Results: Among 105 patients, 29 (27.6%) had SVS. Patients with SVS were older than those without SVS and SVS affected outcome. Serum sodium levels were sequentially significantly decreased within normal range from one day before occurrence of SVS.Among the patients, 67 (63.8%) were treated with surgical clipping and 38 (36.2%) were treated with endovascular coiling. The group with coiling suffered significantly more severe hyponatremia and had less urine volume compared with the clipping group. Conclusions: SVS occurs more often in older patients and affects outcome. Serum sodium level decrease occurs one day before SVS. This observation may help predict SVS. A further large prospective study is necessary to resolve the detailed relationships among hyponatremia, urine volume, treatment modality and SVS in patients with SAH.

Serum sodium level variability as a prognosticator in older adults

Our aim was to explore biological variation of serum sodium levels as a method of quantifying health risk in older adults. We investigated whether dynamic changes in serum sodium levels could provide additional prognostic information to standard predictors of mortality in older people. Analysis of routinely collected clinical datasets containing information on demographics, hospitalisation, biochemistry, haematology and physical function for Dundee in-patient rehabilitation services, between 1999 and 2011. Older people admitted to inpatient rehabilitation following an acute medical or surgical hospitalisation. Five dynamic measures of sodium levels homeostasis – minimum, maximum, standard deviation, and minimum and maximum deviation from mean – were derived for each individual, using biochemistry data from the year preceding their rehabilitation discharge. Cox regression models tested for associations with time to death. Covariates included age, sex, discharge Barthel score, co-morbid diagnoses, haemoglobin, albumin and eGFR. 3021 patients were included (mean age 84 years, 1776 (58.8%) females). 1651 (54.7%) patients experienced hyponatraemia and 446 (14.8%) became hypernatraemic. Mean sodium was correlated with all mean, minimum and SD of sodium. Kaplan–Meier survival curves showed that those without sodium perturbations had the best mortality outcomes, whilst those with both hyponatremia and hypernatremia had the worst. Multivariate Cox regression showed that standard deviation and hypernatraemia were significant predictors of death in non-adjusted models, but not fully adjusted models. All dynamic measures of dysnatraemia were associated with increased mortality risk, but failed to add predictive value to established static measures after adjusting for covariates.

Prognostic factors for long-term outcomes in acute decompensated heart failure patients under tolvaptan treatment.

Inconsistent results have been reported concerning the effect of tolvaptan treatment on long-term prognostic outcomes in patients with acute decompensated heart failure (ADHF) and data are limited on prognostic factors affecting this patient population. We investigated prognostic factors influencing long-term clinical outcomes in patients with ADHF treated with tolvaptan in a real-world setting. A total of 263 consecutive patients hospitalized for ADHF and treated with tolvaptan were retrospectively enrolled. The patients were stratified into those who developed the combined event of cardiac death or rehospitalization for worsening heart failure within 1year (n = 108) and those who were free of this combined event within 1year (n = 155). Adjusted multivariate Cox proportional hazards model revealed that change in serum sodium level between pre-treatment and 24h after tolvaptan administration [hazard ratio (HR) 0.913, 95% confidence interval (CI) 0.841-0.989, p = 0.025] and the time taken for tolvaptan initiation from admission (HR 1.043, 95% CI 1.009-1.074, p = 0.015) were independent predictors of combined event occurrence within 1year. Moreover, change in serum sodium level >1mEq/L between pre-treatment and 24h after administration and initiation of tolvaptan <5days after admission correlated significantly with the incidence of the combined event (log-rank test p = 0.003 and p = 0.002, respectively). In conclusion, increased serum sodium level early after administration and early initiation of tolvaptan are possibly useful for assessing the long-term prognosis after tolvaptan treatment in patients with ADHF.