Frequent Electrolyte Disorder Research Articles

#1925 A rare cause of hyponatremia due to adrenal insufficiency in a patient with small cell lung cancer

Abstract Background and Aims Hyponatremia is the most frequent electrolyte disorder. Small Cell Lung Cancer (SCLC) release often antidiuretic hormone paraneoplastically. But Adrenal insufficiency is a rare cause of hyponatremia in SCLC. Prior one can cause euvolemic hyponatremia, latter one can cause hypovolemic hyponatremia. Opposite treatments should be applied for each one. So They should be investigated carefully before starting the treatment. Method A male patient who had metastatic SCLC was admitted to the emergency. After physical examination blood and urine tests were provided. Results A 52-year-old male patient who had metastatic SCLC was admitted to the emergency unit because of fatigue, weakness and confusion. On physical examination the patient's face was darkened but his conjunctiva was pale, his tongue and mucous membranes were dry. The blood pressure was 90/60 mm Hg. The test results provided were as follows: Glucose 106 mg/dL, creatinine 0.42 mg/dL, urea 38.1 mg/dL, sodium 109 mmol/L, potassium 3.3 mmol/L, white blood cells 9760 /mm3, hemoglobin: 9 g/dL, platelets: 176000/mm3. The patient had no chemotherapy during the last three months. He also did not have a history of antihypertensive treatment. The echocardiographic examination revealed that the ejection fraction was 60%. The abdominal computerized tomography scan showed multiple metastasis of the tumor, but adrenal glands were free of metastasis. The sodium deficit was calculated targeting to 120 mmol/L and therapy was started. The patient's weight was 70 kg. The calculated sodium deficit was 420 mmol. Since the hyponatremia was chronic, the deficit was planned to be given in 24 hours. Potassium was also given. During hospitalization, on day 2nd the patient's blood and urine tests were as follows: Creatinine 0.58 mg/dL, urine creatinine 22.8 mg/dL, 24-hour urine volume 2200 mL, 24-hour creatinine clearance 60 ml/min. Urine sodium concentration 105.6 mmol/L, serum sodium 114 mmol/L, sodium clearance: 1.41 ml/min. Fractional sodium excretion was 2.3%. Although the treatment was continued for 6 days, with the same dose of 420 mEq sodium given for each day, the serum sodium concentration reached to 115 mmol/L on day 6. (Totally, 2520 mEq of sodium was given for 6 days). Therefore, hyponatremia was thought to be due to urinary loss of sodium. The fractional sodium excretion of 2.3% supported this. All these findings suggested the diagnosis of renal salt wasting in this patient. We decided to give the patient fludrocortisone (Astonin H 0.1 mg) twice a day orally in addition to sodium chloride tablets (approximately 1.5 gram = 25-30 mmol). During the follow-up of the patient, the both fludrocortisone pills and salt tablets increased to 2 × 2, finally, when reached the level of sodium is above 130 mmol/L, salt tablets were stopped. One thing need to be noted here; hyponatremia did not improve unless giving fludrocortisone. But after this, although more sodium was given during sodium replacement, there was no increase in fractionated sodium excretion, on the contrary, it decreased. On day 14th, Fractional sodium elimination was 1.7%. Serum Na: 133 mmol/L. The patient was advised to take fludrocortisone tablets twice a day orally and was discharged from hospital on day 15th when serum sodium concentration was 138 mmol/L. If a patient with serum cortisol level below 4 mcg/dl have been evaluated as adrenal insufficiency regardless of ACTH level in sera.; additionally, hyperpigmentation and hyponatremia due to salt wasting through the kidneys led us to diagnose. The hyponatremia resolved only after added fludrocortisone. Conclusion However SCLC can give rise euvolemic hyponatremia producing ADH generally, besides, SCLC can cause adrenal insufficiency leading to serious hypovolemic hyponatremia. Diagnose is of crucial importance for correct treatment which can be only achieved by replacing the both sodium and fludrocortisone.

Descriptive Analysis Of Electrolyte Imbalance In Relation To Severity Of Illness In Covid-19 Pediatric Patients Admitted In A Tertiary Care Hospital In Rawalpindi Pakistan

Objective To determine the frequency of electrolyte imbalance in pediatric COVID-19 patients and their impact on the severity of disease and outcome. Methods: A retrospective observational study was done from January 2021 to July 2021 on 61 children admitted in Benazir Bhutto Hospital Rawalpindi, a tertiary care teaching hospital affiliated with Rawalpindi Medical University (RMU) Pakistan. The age of the patients ranged from infants to 12 years. All the children who were PCR positive or those whose HRCT was suggestive of COVID-19 were included in the study. Results: During the study period of 7 months, 61 confirmed COVID-19 patients were admitted. 37(60.7%) were males and 24 (39.3%) were females. The age of the patients ranged from infants to 12 years with a mean age of 27.25 months. Out of 61 admitted cases, 28 children (45.9%) had moderate & 33(54.1%) patients had severe disease. 46(75%) patients were discharged while 15(25%) patients expired. A number of electrolyte abnormalities were observed. A total of 30 patients (49.2%) were hyponatremic &13 patients (21.3%) were hypernatremic. Hypokalemia was observed in 34(55.7%) & hyperkalemia was found in 2 patients (3.3%), hypochloremia was observed in 13(21.3%) while hyperchloremia was present in 3(4.9%) patients. Hypocalcemia was found in 9(14.7%) patients. 11(18%) patients with Hyponatremia and 6(9.8%) patients with hypernatremia expired. The potassium abnormalities were also associated with significant mortality.14(22.9%) patients with hypokalemia and 2(3.2%) with hyperkalemia expired. Hypocalcemia was found in 9(4.9%) patients who expired. Conclusion: Hypokalemia and hyponatremia were frequent electrolyte disorders in children with COVID-19. These electrolyte abnormalities were associated significantly with severity of disease and a higher risk of death in children with COVID-19 Keywords: COVID-19, Electrolytes, Hypokalemia, Hyperkalemia, Hyponatremia, Hypernatremia, Hypocalcemia

Association of hypertension in pregnancy with serum electrolyte disorders in late pregnancy among Cameroonian women

Multiple electrolyte disorders, including sodium, potassium and calcium disorders, have been associated with hypertension in pregnancy. Most of these studies failed to evaluate the combined effect of low and high sodium, potassium, calcium and chloride ion concentrations on hypertension in pregnancy. This study evaluates the combined effect of these ion categories (low, normal, high) on hypertension in pregnancy. Biochemical ion assays and blood pressure measurements were carried out on 1074 apparently healthy pregnant women in late third trimester. Serum potassium, sodium, chloride, and ionised calcium were measured by ion-selective electrode potentiometry, while total plasma calcium was measured by absorption spectrophotometry. Hypertension in pregnancy was defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. The prevalence of hyponatraemia, hypokalaemia, hypochloraemia, ionised hypocalcaemia and total hypocalcaemia in late pregnancy was 1.30 [0.78–2.18]%, 3.55 [2.60–4.84]%, 1.96 [1.28–2.97]%, 1.49 [0.92–2.21]% and 43.58 [40.64–46.56]%, respectively. Hypernatraemia, hyperkalaemia, hyperchloraemia, ionised hypercalcaemia and total hypercalcaemia were found in 1.49 [0.92–2.41]%, 2.34 [1.59–3.43]%, 4.38 [3.31–5.77]%, 39.94 [37.06–42.90]%, 2.79 [1.96–3.96]% of the participants, respectively. The prevalence of hypertension in pregnancy was 7.17 [5.77–8.87]%. When ion categories were considered in multiple logistic regression, only ionised and total calcium had significant associations with hypertension in pregnancy. Women with ionised hypercalcaemia had lower odds of hypertension in pregnancy (AOR = 0.50 [0.29–0.87], p-value = 0.015), and women with total hypocalcaemia had higher odds of hypertension in pregnancy (AOR = 1.99 [1.21–3.29], p-value = 0.007), compared to women with ionised and total normocalcaemia, respectively. Increasing kalaemia was associated significantly with higher odds of hypertension in pregnancy; however, kalaemia below and above the normal concentrations had no significant association with hypertension. Nonetheless, participants with kalaemia ≤ 3.98 mmol/L, had lower odds of hypertension in pregnancy compared with those with higher kalaemia (OR = 0.40 [0.24–0.66], p-value = 0.0003). Calcium disorders remain the most frequent electrolyte disorders in pregnancy. When normal cut-offs are considered for calcium and other ions, only ionised and total calcium influence the occurrence of hypertension in pregnancy. Kalaemia seems to affect hypertension in pregnancy but primarily within its normal concentrations. Serum electrolyte follow-up is indispensable for a proper pregnancy follow-up.

Hypernatremia: Epidemiology and Predictive Role in Emerging and Established Acute Kidney Injury.

Hypernatremia (plasma sodium > 145 mmol/L) reflects impaired water balance, and affected patients can suffer from severe neurologic symptoms. Hyponatremia, on the other hand, is the most frequent electrolyte disorder in hospitals. It may be diagnosed in acute kidney injury (AKI), but hyponatremia prior to the diagnosis of AKI has also predictive or prognostic value in the short term. Aim of the article was to summarize data on both, epidemiology and outcomes of in-hospital acquired hypernatremia ("In-hospital acquired" refers to the diagnosis of either hypo- or hypernatremia in patients, who did not exhibit any of these electrolyte imbalances upon admission to the hospital). It also aimed to discuss its predictive role in patients with emerging or established AKI. Five databases were searched for references: PubMed, Medline, Google Scholar, Scopus, and Cochrane Library. Studies published between 2000 and 2023 were screened. The following keywords were used: "hypernatremia", "mortality", "pathophysiology", "acute kidney injury", "AKI", "risk prediction", "kidney replacement therapy", "KRT", "renal replacement therapy", "RRT", "hyponatremia", and "heart failure". A total of 16 studies were deemed eligible for inclusion. Among these, 13 studies had a retrospective design, two investigations were published as secondary analyses from prospective trial cohorts, and one study was prospective in nature. Out of the 16 studies, 11 focused on the epidemiology and outcomes of hypernatremia, while five investigations were related to AKI and/or AKI-associated endpoints. The prevalence of hypernatremia diagnosed during hospitalization varied from 1.9% to 6.8%, with one exception where it was 30.8%. All studies demonstrated associations between hypernatremia and mortality, even over extended periods after discharge. In AKI patients, hypernatremia shows potential for predicting in-hospital death. In conclusion, hypernatremic individuals are at higher risk of death during in-hospital therapy. Also, the electrolyte disorder potentially qualifies as a future biomarker for AKI onset and AKI-associated mortality.

#3235 ELECTROLYTE DISORDERS IN COMMUNITY-ACQUIRED ACUTE KIDNEY INJURY

Abstract Background and Aims The kidney plays a decisive role in regulating the homeostasis of the internal environment. Acute kidney injury (AKI) compromises the kidney's ability to maintain this regulation intact, and the appearance of various electrolyte disorders is to be expected in this situation. There are few data in the literature that describe these alterations in patients with community-acquired AKI (CA-AKI). The purpose of this study is to analyze the incidence of electrolyte disorders in a cohort of patients with CA-AKI admitted to the nephrology service of a tertiary level hospital. Method This is a single-center, observational, longitudinal, and retrospective study based on a cohort of patients with CA-AKI admitted to the Nephology Service of a third level hospital from January 2010 to December 2018. We analyzed the incidence of changes in sodium, potassium, chloride, bicarbonate, calcium, and phosphorus in these patients and their clinical consequences during admission and follow-up after hospital discharge. Results A total of 639 patients were included in the final analyses. The mean age was 72,93±13,38 years. 61,7% were men. Charlson comorbidity index was 5,87 ±2,4 points. The length of stay was 11,63±10,14 days. In view of the Etiology of AKI, 72,1% had prerenal AKI and 27,9% non-prerenal. 436 patients had a history of previous chronic kidney disease (CKD) (68.23%). AKI KDIGO stages were: stage I, 105 cases (16.4%); stage II, 67 cases (10.5%); stage III 467 cases (63.1%). Hemodialysis (HD) was required in 114 patients (17.8 %). 62 patients (9.7 %) died during hospital stay. The percentage of patients with alterations in the different ions was: chlorine 54%, potassium 60.1%, sodium 45.23%, bicarbonate 85.67%, calcium 52.68%, phosphorus 54.49%. The most frequent ionic alterations at a global level were low bicarbonate (78.3%), hyperkalemia (53.05%), hypocalcemia (49.6%) and hyponatremia (41.5%). No significant differences were observed in these percentages when comparing patients with previous CKD with respect to carriers of normal baseline renal function (glomerular filtration rate > 60 ml/min). When analyzing whether electrolyte alterations occurred simultaneously: 2.2% of cases did not present any, 6.3% only one, 18.2% two, 26.4% three, 26.1% four, 14.9% five and 5.9% six simultaneous alterations. In the univariate analysis, patients with hypernatremia (Chi square 22.7; p < 0.001), hyperkalemia (Chi square 9.7; p = 0.008) and hyperphosphatemia (Chi square 18.5; p < 0.001) had higher mortality during admission. In the multivariate analysis using logistic regression, the variables that were independently associated with mortality during hospitalization were phosphorus (OR 1.425; 95% CI 1.212 - 1.676) and chlorine (OR 1.045; 95% CI 1.002 - 1.089). In the follow-up after hospital discharge, the Kaplan-Meier curves in the univariate analysis showed higher mortality in patients who presented hyperkalemia (log rank test: Chi square 15.5; p < 0.0001), hypernatremia (log rank test: Chi square 47.7; p < 0.0001), hypocalcemia (log rank test: Chi square 6.73; p < 0.034) and hyperphosphatemia (log rank test: Chi square 10.24; p < 0.006). In the multivariate analysis using Cox regression, the variables that were independently associated with mortality after hospital discharge were sodium (Exp(B) 1.001; 95% CI 1.002 - 1.048; p = 0.048), potassium (Exp(B) 1.140; 95% CI 1.055 - 1.233; p = 0.001) and phosphorus (Exp(B) 1.087; 95% CI 1.023 - 1.048; p = 0.154). Conclusion In our series of patients with CA-AKI, we detected a high prevalence of electrolyte disorders, without a history of previous CKD having any influence on it. The most frequent was the finding of three or four simultaneous alterations. Phosphorus and chlorine independently influenced mortality during admission. In the follow-up after hospital discharge, sodium, potassium, and phosphorus were independent predictors of mortality. The clinician who treats cases of CA-AKI must expect the appearance of frequent electrolyte disorders and must be prepared for their correct management.

Challenge in hyponatremic patients- the potential of a laboratory-based decision support system for hyponatremia to improve patient's safety.

Hyponatremia is the most frequent electrolyte disorder in hospitalized patients with increased mortality and morbidity. In this study, we evaluated the follow-up diagnostic, the risk of inadequate fast correction and the outcome of patients with profound hyponatremia (pHN), defined as a blood sodium concentration below 120mmol/L. The aim was to identify a promising approach for a laboratory-based clinical decision support system (CDSS). This retrospective study included 378,980 blood sodium measurements of 83,315 cases at a German tertiary care hospital. Hospitalized cases with pHN (n=211) were categorized into two groups by the time needed for a follow-up measurement to be performed (time to control, TTC) as either <12h (group 1: "TTC≤12h", n=118 cases) or >12h (group 2: "TTC>12h", n=93 cases). Length of hospital stay, sodium level at discharge, ward transfers, correction of hyponatremia, and risk of osmotic demyelination syndrome (ODS) due to inadequate fast correction were evaluated with regard to the TTC of sodium blood concentration. pHN was detected in 1,050 measurements (0.3%) in 211 cases. Cases, in which follow-up diagnostics took longer (TTC>12h), achieved a significantly lower sodium correction during their hospitalization (11.2 vs. 16.7mmol/L, p<0.001), were discharged more frequently in hyponatremic states (<135mmol/L; 58 (62.4%) vs. 43 (36.4%), p<0.001) and at lower sodium blood levels (131.2 vs. 135.0mmol/L, p<0.001). Furthermore, for these patients there was a trend toward an increased length of hospital stay (13.1 vs. 8.5days, p=0.089), as well as an increased risk of inadequate fast correction (p<0.001). Our study shows that less frequent follow-up sodium measurements in pHN are associated with worse outcomes. Patients with a prolonged TTC are at risk of insufficient correction of hyponatremia, reduced sodium values at discharge, and possible overcorrection. Our results suggest that a CDSS that alerts treating physicians when a control time of >12h is exceeded could improve patient care in the long term. We are initiating a prospective study to investigate thebenefits of our self-invented CDSS (www.ampel.care) for patients with pHN.

Paralysis Due to Hypokalemia and Hypocalcemia: A Case Report

Background&#x0D; Hypokalemia is the most frequent electrolyte disorder encountered in clinical practice. It caused by inadequate potassium intake or excessive renal or gastrointestinal potassium loss. Hypokalemia may associate with muscle weakness. Hypocalcemia can result from disorders of vitamin D metabolism and action, hypoparathyroidism, resistance to parathyroid hormone (PTH), or other conditions such as nutritional deficiency. Numbness and tingling sensation may occur on hypocalcemia.&#x0D; Case presentation &#x0D; A 36-year-old woman came with complaints of weakness of upper and lower limbs three days before admission. At first, the weakness felt suddenly on the left arm and left foot after waking up in the morning, making her not being able to walk. Patient felt tingling sensation on her face, upper limbs, and lower limbs. Her hands felt stiff as well as her mouth. Patient had a decreasing serum level (3 mEq/l) and decreasing total calcium level (4,8 mg/dL).&#x0D; Conclusion&#x0D; In young adult patients with limbs weakness, it is necessary to consider electrolyte imbalance, such as hypokalemia and hypocalcemia. Hypokalemia can be caused by decreased potassium intake, excessive vomiting, drug consumption, kidney disease, and endocrine disease. To diagnose hypokalemia, it is necessary to carry out further examinations such as basic biochemical laboratories (magnesium, calcium, phosphorus), blood gas analysis, TSHs, urine analysis (urine calcium, potassium excretion in 24-hour urine collection), drug screening.&#x0D;

Incidence of Refeeding Syndrome in Critically Ill Children With Nutritional Support

IntroductionEarly enteral nutrition is recommended for critically ill children, potentially exposing those who are undernourished to the risk of refeeding syndrome. However, data on its incidence is lacking, and the heterogeneity of diagnostic criteria and frequent electrolyte disorders in this population make its diagnosis complex. In 2020, the American Society for Parenteral and Enteral Nutrition (ASPEN) developed consensus recommendations for identifying patients at risk and with refeeding syndrome. These state that undernourished children are considered at risk of refeeding syndrome; those who develop one significant electrolyte disorder (decrease ≥ 10% in phosphorus, potassium, and/or magnesium) within the first five days of nutritional support, combined with a significant increase in energy intake, are considered to have refeeding syndrome. The aim of this study was to determine the incidence of refeeding syndrome according to the ASPEN definition in critically ill children on nutritional support.Materials and MethodsA secondary analysis of two prospective cohorts conducted in a tertiary pediatric intensive care unit in France was undertaken, and additional data were retrospectively collected. Children included were those (0–18 years) admitted to the pediatric intensive care unit with a minimum of one phosphorus, potassium, and/or magnesium assay and who received exclusive or supplemental nutritional support. Undernourished children (body mass index z-score < –2 standard deviations) were considered at risk of refeeding syndrome. The ASPEN critiera were used to identify those with probable refeeding syndrome.ResultsA total of 1,261 children were included in the study, with 199 children (15.8%) classified as undernourished, who were at risk of refeeding syndrome. Of these, 93 children were identified as having probable refeeding syndrome, giving an overall incidence of 7.4%. The incidence rate among at-risk children was 46.7%. Most patients (58.1%) were classified as having severe refeeding syndrome.ConclusionRefeeding syndrome remains difficult to diagnose in critically ill children, due to frequent confounding factors impacting electrolyte plasma levels. These findings suggest that refeeding syndrome incidence may be high in undernourished children, and that refeeding syndromes can be severe. Further prospective studies using the ASPEN definition and risk criteria are required.

Prevalence, risk factors and impact of proteinuria-associated hypomagnesemia in chronic kidney disease patients: cross-sectional study

BackgroundHypomagnesemia is a predictor of progression and mortality of chronic kidney disease (CKD) patients. However, limited data is available about the prevalence and kidney-related risk factors of hypomagnesemia in the CKD patients. We aimed to investigate the prevalence and risk factors of low serum magnesium level associated with proteinuria and its impact on CKD patients. This cross-sectional study enrolled 100 CKD patients with different stages according to estimated glomerular filtration rate (eGFR), divided into 2 groups (proteinuric and non-proteinuric) in the period from February 2020 to August 2020.ResultsThe number of participants in this study was 100 subjects, 50 patients were proteinuric and 50 patients had no proteinuria. The study participants’ serum magnesium levels ranged from 1.2 to 2.7 mg/dL. Fourteen (28%) of proteinuric individuals had a serum magnesium level of less than 1.8 mg/dL. Hypomagnesemic patients had significantly higher urine albumin creatinine ratio (UACR) (2071 mg/g vs. 812 mg/g, P<0.001), significantly higher CRP (48 mg/L vs. 12 mg/L, P<0.001), and lower mean hemoglobin levels as well (10.4 g/dL vs. 10.91 g/dL, P= 0.044). Serum magnesium level showed negative correlation with UACR (r=−0.504, P<0.001), parathyroid hormone (r=−0.276, P=0.005), and CRP (r=−0.505, P<0.001).ConclusionsHypomagnesemia is a frequent electrolyte disorder in patients with CKD. Hypomagnesemia is independently associated with proteinuria. Hypomagnesemia is a risk factor of inflammation, anemia and hyperparathyroidism in pre-dialysis CKD population.

Hypernatremia in the intensive care unit.

Hypernatremia is a relatively frequent electrolyte disorder seen in critically ill patients. As many as 27% of patients in intensive care units (ICUs) develop hypernatremia of variable severity during an ICU stay. Debate among specialists often ensues as to whether to correct hypernatremia or not. Some practitioners, particularly intensivists, believe that correction of hypernatremia with fluids may cause expansion of the extracellular fluid volume (ECFV) thereby worsening ventilation and impeding extubation. Other practitioners, including many nephrologists, do not expect correction of hypernatremia to lead to clinically apparent ECFV expansion, and fear other deleterious effects of hypernatremia. In this review we address the controversy regarding appropriate practice. There are no randomized, clinical trials (RCTs) to guide the administration of electrolyte-free fluid administration in hypernatremic patients. However, there are associations, demonstrated in the literature, suggesting that hypernatremia of any severity will increase the mortality and length of stay in these patients. These associations generally support the practice of correction of hypernatremia. In addition, our knowledge of the distribution of total body water influences us towards correcting hypernatremia as an appropriate therapy. We do not expect that adequate RCTs addressing this question will be performed. Allowing persistence of any degree of hypernatremia is associated with increased mortality, length of stay (LOS) and postdischarge mortality. We expect that proper use of electrolyte-free water intake will avoid adverse outcomes.

Скрытые опасности периоперационного периода: фокус на гипофосфатемии

Гипофосфатемия (ГФЕ) — одно из частых электролитных расстройств, для развития которого в периоперационном периоде существует много причин. Мы проанализировали базу данных Medline за последние 20 лет с целью идентификации статей, которые содержали бы в качестве одного из ключевых слово «гипофосфатемия». В поиск включили клинические и экспериментальные исследования, обзоры и сообщения о клинических случаях при наличии англоязычного резюме. Этот поиск дал 1754 публикации. На основе изученных статей нами были суммированы сведения о метаболизме фосфатов, основных клинических проявлениях ГФЕ, влиянии ГФЕ на течение периоперационного периода. Авторами представлен собственный опыт выявления и лечения ГФЕ. Определение уровней фосфатов проведено у 328 больных, перенесших хирургические вмешательства в операционных различного хирургического профиля. Наиболее высокая частота ГФЕ наблюдалась у ожоговых больных (23,08 %), после нейрохирургических (17,94 %) и абдоминальных (17,64 %) оперативных вмешательств. Установлено, что коррекцию ГФЕ тяжелой степени целесообразно проводить введением препарата D-фруктозо-1,6-дифосфата натрия — Эзафосфины. После проведенной коррекции препаратом уровень фосфатемии стабилизировался до референтных значений, что совпало с клиническим улучшением состояния пациентов. Больные в целом хорошо перенесли терапию Эзафосфиной, ни у одного из них не было зарегистрировано побочных эффектов.

An Evidence-Based Narrative Review of the Emergency Department Management of Acute Hyperkalemia

The normal range for potassium is within narrow limits. Hyperkalemia is an electrolyte disorder that frequently affects patients in the emergency department (ED), and can result in significant morbidity and mortality if not identified and treated rapidly. This article provides an evidence-based narrative review of the management of hyperkalemia, with focused updates for the emergency clinician. We searched in MEDLINE, EMBASE, Web of Science, and Scopus databases for articles in English published in peer-reviewed journals and indexed up until May 2020. We used multiple search terms, including hyperkalemia, potassium, acute hyperkalemia, emergency department, dyskalemia, potassium disorders, kidney disease, epidemiology, electrolyte disturbance, severe hyperkalemia, and emergency management. In the ED, interventions aimed to protect patients from the immediate dangers of elevated serum potassium are divided into the following: stabilizing cardiac membrane potentials, reducing serum potassium levels through shift from the extracellular fluid to intracellular fluid, and elimination of potassium through excretion via urinary or fecal excretion. Calcium is widely recommended to stabilize the myocardial cell membrane, but additional research is necessary to establish criteria for use, dosages, and preferred solutions. Redistribution of potassium ions from the bloodstream into the cells is based on intravenous insulin or nebulized β2-agonists. Hyperkalemia is a frequent electrolyte disorder in the ED. Because of the risk of fatal dysrhythmia due to cardiac membrane instability, hyperkalemia is a medical emergency. There is a lack of scientific evidence on the optimal management of hyperkalemia and more research is needed to establish optimal strategies to manage acute hyperkalemia in the emergency department.

Prevalence of Hyponatremia in an Elderly Population: A Case Study

Hyponatremia is the most frequent electrolyte disorder both in hospitalized and outdoor patients. Elderly patients represent a high-risk group for the occurrence of hyponatremia because age is a strong independent risk factor for hyponatremia. Decreased serum sodium concentration is a rather frequent electrolyte disorder in the elderly population because of the presence of factors contributing to increased antidiuretic hormone, the frequent prescription of drugs associated with hyponatremia and also because of other mechanisms such as the “tea and toast” syndrome[1]. Hyponatremia in elderly subjects is mainly caused by drugs (more frequently thiazides and antidepressants), the syndrome of inappropriate antidiuretic hormone secretion (SIAD) or endocrinopathies; however, hyponatremia is multi-factorial in a significant proportion of patients. Special attention is needed in the elderly population to exclude endocrinopathies as a cause of hyponatremia before establishing the diagnosis of SIAD, which then requires a stepped diagnostic approach to reveal its underlying cause. Hyponatremia is an important and common electrolyte abnormality that can be seen in isolation or, as most often is the case, as a complication of other medical illnesses (eg, heart failure, liver failure, renal failure, pneumonia). The normal serum sodium level in the body is 135-145 mEq/L. Therefore, hyponatremia is defined as a serum sodium level of less than 135 mEq/L. This research is based on the prevalence of hyponatremia in an elderly population. This study indicates an increase in patients of hyponatremia above 60 years of age. This study also tells the increase in number of patients having hyponatremia as well as abnormal creatinine levels.

Electrolytes Profile of Critically Ill Patients Admitted To Pediatric Intensive Care Unit (PICU) Dr. Soetomo General Hospital

Introduction: Fluid and electrolyte disorders can be affected by various conditions or diseases. Electrolyte disorders are often found in pediatric patients with critically ill conditions and are associated with increased morbidity also mortality that requires extra care in the Pediatric Intensive Care Unit (PICU). Objective: To describe the electrolyte profile of critically ill patients with electrolyte disorders admitted to the Pediatric Intensive Care Unit (PICU) Dr. Soetomo General Hospital. Materials and Methods: The study was conducted prospectively with a descriptive method in patients with electrolyte disorders aged 1 month – 18 years old admitted to PICU Dr. Soetomo General Hospital, Surabaya in a period from August to November 2018. Data on patient age, gender, electrolyte profile (sodium, potassium, calcium, chloride), and origin before PICU admission were recorded. Results and Discussion: From 37 patients with electrolyte disorders showed that patients were dominated by the male in 56.8% (n=21), in the age group of infants or 1-12 months old in 45.9% (n=17). Common main diagnosis in most patients were digestive system disorders in 27% (n=10), followed by central nervous system, respiratory system, kidney and cardiovascular disorders, and the origin before PICU admission were from Emergency Room (ER) in 62.2% (n=23). There were found 97 incidences of electrolyte disorders. Most frequent electrolyte disorders were hypocalcemia in 59.5% (n=22), hypokalemia in 54.1% (n=20), hyponatremia in 40.5% (n=15) and the least was hypochloremia in 35.1% (n=13). Mean serum sodium level was 138.18 ± 12.071, serum potassium level was 3.608 ± 1.2247, serum calcium level was 8.057 ± 1.9473 and serum chloride level was 101.45 ± 13.266. Conclusions: Critically ill patients admitted in PICU tend to experience low electrolyte levels.

Hyponatremia in children under 100days old: incidence and etiologies.

Hyponatremia is one of the most common electrolyte disorders in hospitalized children. The underlying mechanisms are poorly understood and potentially multifactorial, making management difficult, particularly in neonates. This retrospective study aimed to determine the incidence and etiologies of hyponatremia in hospitalized children under the age of 100days, in our pediatric tertiary care hospital over a 1-year period. The etiology of hyponatremia was determined by reviewing the data noted in each patient's medical reports. Neonatal hyponatremia had a prevalence of 4.3% (86/2012 patients) and was mostly hospital-acquired (74/86 patients). Fifty-nine patients (68.9%) were preterm neonates. The etiology was iatrogenic in 26 cases (30.2%). In other cases, hyponatremia was due to transient (23 patients, 26.7%) or genetic abnormalities of the renal mineralocorticoid pathway (3 patients, 3.4%), SIADH (12 patients, 14%), digestive disease (3 patients, 3.5%), acute renal failure (3 patients, 3.5%), or heart failure (1 patient, 1.2%).Conclusion: Our findings confirm that hyponatremia is a frequent electrolyte disorder in neonates. Various mechanisms underlie this condition, most of which could be prevented by optimized management. The prevalence of genetic hypoaldosteronism and pseudohypoaldosteronism was higher than expected. We provide a simple diagram to help physicians identify the mechanisms underlying neonatal hyponatremia. What is Known: • In neonates, hyponatremia may be multifactorial, making it difficult to treat. • Newborns display partial resistance to aldosterone, and preterms have a defect in aldosterone secretion. What is New: • Four percent of hospitalized neonates had hyponatremia, 86% hospital-acquired. Hyponatremia was due to a transient or constitutional defect of the mineralocorticoid pathway in 26/86 patients (30%) which is higher than expected. • We propose a tree diagram for improving the management of hyponatremia in neonates.

Sarcopenia as a potential cause of chronic hyponatremia in the elderly

Hyponatremia is the most frequent electrolyte disorder found in clinical practice, particularly in hospitalized elderly patients, where it is associated with fractures, falls, hospital readmission, prolonged hospital stay and increased mortality. Pathophysiologically, hyponatremia can be induced by the reduction in sodium or potassium body content, and/or the increase in water body content. Sarcopenia is an ageing-associated progressive and generalized loss of musculoskeletal mass and strength which leads to low physical performance, particularly in the frail elderly. Since muscle mass is the main potassium body store, this condition usually represents a reduced body potassium content.In the present article it is hypothesized that sarcopenia, as a cause of low potassium body content, could induce or co-induce hyponatremia, particularly in elderly individuals suffering from frailty phenotype.

Hyponatremia in the elderly: challenges and solutions.

Decreased serum sodium concentration is a rather frequent electrolyte disorder in the elderly population because of the presence of factors contributing to increased antidiuretic hormone, the frequent prescription of drugs associated with hyponatremia and also because of other mechanisms such as the “tea and toast” syndrome. The aim of this review is to present certain challenges in the evaluation and treatment of hyponatremia in the elderly population and provide practical solutions. Hyponatremia in elderly subjects is mainly caused by drugs (more frequently thiazides and antidepressants), the syndrome of inappropriate antidiuretic hormone secretion (SIAD) or endocrinopathies; however, hyponatremia is multifactorial in a significant proportion of patients. Special attention is needed in the elderly population to exclude endocrinopathies as a cause of hyponatremia before establishing the diagnosis of SIAD, which then requires a stepped diagnostic approach to reveal its underlying cause. The treatment of hyponatremia depends on the type of hyponatremia. Special attention is also needed to correct serum sodium levels at the appropriate rate, especially in chronic hyponatremia, in order to avoid the osmotic demyelination syndrome. In conclusion, both the evaluation and the treatment of hyponatremia pose many challenges in the elderly population.

Artificial Syndrome of Inappropriate Antidiuresis Model as Potential Use for Diagnostic and Therapeutic Strategies.

Hyponatremia is the most frequent electrolyte disorder with the syndrome of inappropriate antidiuresis (SIADH) being its predominant cause. Physiological studies in patients with SIADH are difficult to interpret due to usually several comorbidities and polymedication. Therefore, a SIADH model in healthy volunteers would be very helpful to allow insight in this complex disease and to test new therapeutic approaches. The aim of the study was to create a SIADH model with evaluation of subsequent physiological changes.The prospective interventional study on 14 healthy volunteers was carried out at the University Hospital Basel. The intervention was done by induction of hypotonic hyponatremia through hydration and administration of desmopressin. Clinical and laboratory parameters in a SIADH model were the main outcome of the measure.14 participants (64% males), BMI 23.1 kg/m2 (±2.4), aged 28.6 years (±9), completed the study. Through the intervention, serum sodium level decreased from 140 mmol/l (±1.3) to 132 mmol/l (±2.0) and serum osmolality from 286 mmol/kg (±4.7) to 267 mmol/kg (±3.5). Simultaneously urine osmolality increased to 879 mmol/kg (±97.7) and urine sodium to 213 mmol/l (±51.5) verifying the artificial SIADH model. A significant decrease of copeptin (5 pmol/l (±1.9) to 2.6 pmol/l (±0.5), p 0.002), aldosterone (314.7 pmol/l (±154.1) to 86.7 pmol/l (±23.6), p 0.019), and renin (21.2 ng/l (±26.7) to 3.6 ng/l (3.2), p 0.035) were noted, while NT-proBNP and MR-proANP significantly increased (31.7 ng/l (±18.6) to 50.5 ng/l (±33.0), p 0.001; 48.4 pmol/l (±16.8) to 56.8 pmol/l (±9.0), p 0.003).In conclusion, we were able to induce an artificial SIADH in healthy volunteers and study the changes of various hormonal biomarkers involved. This SIADH model could be helpful in evaluating diagnostic and therapeutic approaches.

Hyponatremia is a marker of disease severity in HIV-infected patients: a retrospective cohort study

BackgroundHyponatremia is a frequent electrolyte disorder in HIV-infected patients with a prevalence of up to 56% in the pre-cART era. Several studies have demonstrated that patients with hyponatremia are at an increased risk of death. We aimed to investigate the prevalence of hyponatremia in the recent cART-era and evaluate its association with mortality.MethodsSingle-center retrospective cohort study. A total of 1196 newly diagnosed and cART-naïve HIV patients followed at the AIDS Reference Center, St Pierre University Hospital in Brussels, Belgium, between 1 January 1998 and 31 December 2013 were included. Hyponatremia was defined as a baseline natremia lower than 135 mmol/l. The outcome of interest was the occurrence of death.ResultsIn this study 177 (14.8%) patients had hyponatremia at baseline with a median natremia of 132.0 mmol/l [interquartile range (IQR) 130.0-134.0 mmol/l]. Hyponatremic patients had a lower CD4 cell count (207.5 ± 197.7/μl vs 400.4 ± 277.0/μl; P < 0.0001) and a higher prevalence of AIDS (50.3% vs 12.4%; P < 0.0001) compared to normonatremic patients. A significantly higher proportion of patients with hyponatremia were hospitalized at first contact (72.3% vs 20.0%; P < 0.0001). During the follow-up hyponatremic patients had a shorter median time to a first hospitalization (2.0 IQR [0.0-12.0] months vs 13.0 IQR [2.0-29.0] months; P = 0.001) and an increased incident hospitalization rate (785/1000 patient-years, 95% CI 725–845 vs 370/1000 patient-years, 95% CI 352–388; P < 0.0001]. The incident mortality rate was 28.3/1000 patient-years (95% CI 18.15-42.16) in patients with hyponatremia compared to 9.33/1000 patient-years (95% CI 6.63-12.75) in normonatremic patients (P < 0.0001). Three-year cumulative survival rates were 85.8% ± 3.0% in hyponatremic patients and 96.3% ± 0.7% in normonatremic patients (log-rank P < 0.0001). However, in a multivariate Cox model adjusting for other risk factors such as AIDS, CD4 count < 350/μl and hepatitis C, hyponatremia was no longer a predictor for patient death (hazard ratio: 1.03, 95% CI 0.54-1.97; P = 0.935).ConclusionsHyponatremia is a marker of severity of HIV-disease but not an independent risk factor for mortality. HIV-patients with a low serum sodium at baseline might benefit from a close follow-up to improve outcomes.

Hyponatraemia alters the biophysical properties of neuronal cells independently of osmolarity: a study on Ni(2+) -sensitive current involvement.

What is the central question of this study? Hyponatraemia, an electrolyte disorder encountered in hospitalized patients, can cause neurological symptoms usually attributed to a reduction in plasma osmolarity. Here, we investigated whether low [Na(+) ] per se can cause neuronal changes independent of osmolarity, focusing on involvement of the Na(+) -Ca(2+) exchanger. What is the main finding and its importance? We show that hyponatraemia per se causes alterations of neuronal properties. The novel finding of Na(+) -Ca(2+) exchanger involvement helps us to elucidate the volume regulation following hyponatraemia. This might have relevance in a translational perspective because Na(+) -Ca(2+) exchanger could be a target for novel therapies. Hyponatraemia is the most frequent electrolyte disorder encountered in hospitalized patients, and it can cause a wide variety of neurological symptoms. Most of the negative effects of this condition on neuronal cells are attributed to cell swelling because of the reduction of plasma osmolarity, although in hyponatraemia different membrane proteins are supposed to be involved in the conservation of neuronal volume. We have recently reported detrimental effects of hyponatraemia on two different neuronal cell lines, SK-N-AS and SH-SY5Y, independent of osmotic alterations. In this study we investigated, in the same cell lines, whether hyponatraemic conditions per se can cause electrophysiological alterations and whether these effects vary over time. Accordingly, we carried out experiments in low-sodium medium in either hyposmotic [Osm(-)] or isosmotic [Osm(+)] conditions, for a short (24h) or long time (7days). Using a patch pipette in voltage-clamp conditions, we recorded possible modifications of cell capacitance (Cm ) and membrane conductance (Gm ). Our results indicate that in both Osm(-) and Osm(+) medium, Cm and Gm show a similar increase, but such effects are dependent on the time in culture in different ways. Notably, regarding the possible mechanisms involved in the maintenance of Cm , Gm and Gm /Cm in Osm(+) conditions, we observed a greater contribution of the Na(+) -Ca(2+) exchanger compared with Osm(-) and control conditions. Overall, these novel electrophysiological results help us to understand the mechanisms of volume regulation after ionic perturbation. Our results might also have relevance in a translational perspective because the Na(+) -Ca(2+) exchanger can be considered a target for planning novel therapies.