Normonatremic Patients Research Articles

Effect of Change in Sodium after Slow Low-Efficiency Dialysis in Critically Ill Patients with Acute Kidney Injury

Introduction: The effect of sodium (Na) correction by slow low-efficiency dialysis (SLED) in dysnatremic (135 mEq/L <Na >145 mEq/L) critically ill patients is unclear. Methods: Prospective observational study enrolled dysnatremic critically ill adult patients with acute kidney injury undergoing the first SLED as cases and normonatremic patients as controls. Baseline and SLED-related parameters and 30-day mortality were noted. Results: 100 dysnatremic and 51 normonatremic patients were included, with a median age of 31 (25–52) years and median admission SOFA scores of 10 (9–12). Patients with dysnatremia at study inclusion had a mortality of 53%, with the highest mortality in severe hypernatremia (Na >160 mEq/L) (75%), followed by those with severe hyponatremia (Na <120 mEq/L) (68.6%). SLED-associated natremia change >10 mEq/L was significantly associated with mortality, in patients with mild dysnatremia and normonatremia (Na: 130–150) (p < 0.001), and not in those with moderate to severe dysnatremia (Na <130 and Na >150) (p = 0.72). Upon multivariate logistic regression analysis, a model with pre-SLED pH, dialyzate-pre-SLED Na difference, and duration of SLED significantly predicted SLED-associated natremia change (R2 0.18, p = 0.001). Conclusions: SLED can be safely and effectively performed in critically ill adults with dysnatremia requiring renal replacement therapy with mortality comparable to normonatremic controls.

Relationship of severity of hyponatremia and adverse outcomes in children visiting the emergency department.

Mild hyponatremia is often found in patients visiting pediatric emergency departments (PEDs), but there are few large-scale studies on its association with adverse outcomes, including mortality. We conducted this study to identify the association of mild hyponatremia with adverse outcome. This retrospective observational study included children under 18 years of age visiting the PED at a tertiary hospital. We used electronic medical record data from January 1, 2009 to December 31, 2020. Clinical outcomes, including ward admission, vasopressor administration, pediatric intensive care unit (PICU) admission, and mortality, were assessed for the total of 44,147 patients. Among these, 1,639 (3.7%) were in the hyponatremia group, with 1,521 (3.4%) exhibiting mild hyponatremia. Mild hyponatremia was more prevalent in younger patients, particularly in the 1-3 years age group, and less common in females. Patients with mild hyponatremia had a significantly prolonged median length of stay in the PED compared to normonatremic patients (5.8 h vs. 4.4 h, p < 0.001). Moreover, they showed significantly higher rates of ward admission (51.1% vs. 35.6%, p < 0.001), vasopressor administration (1.1% vs. 0.6%, p = 0.014), PICU admission (2.4% vs. 1.0%, p < 0.001), and mortality (1.5% vs. 0.3%, p < 0.001). Compared with the normonatremia group, the odds ratios (95% CI) for ward admission, vasopressor administration, PICU admission, and mortality in the mild hyponatremia group were 1.90 (1.71-2.10), 1.91 (1.17-3.13), 2.62 (1.86-3.68), and 5.56 (3.51-8.80), respectively. Furthermore, our findings demonstrate a notable upward trend in adverse outcomes, including vasopressor administration, PICU admission, and mortality, from mild hyponatremia to severe hyponatremia. In conclusion, we found that adverse outcomes increase with the severity of hyponatremia in children presenting to the PED, highlighting the importance of immediate intervention alongside the identification of the underlying cause.

Hyponatremia causing factors and its association with disease severity and length of stay in COVID-19 patients: A retrospective study from tertiary care hospital.

The coronavirus disease-2019 (COVID-19) infection has taken the world by storm within a few months. Evidence has suggested that patients with electrolyte imbalances at baseline may have a longer duration of hospital stay. We aimed to determine the factors associated with hyponatremia on admission in COVID-19 patients and its impact on the length of stay. We conducted a retrospective study including 521 patients who tested positive for COVID-19 and had their electrolytes checked on admission from June 2020 to October 2020. Patients with sodium <135 mmol/l were included in the hyponatremic group and were compared against normonatremic patients. The severity of COVID-19 was found to be more prevalent in the case group as compared to control (38.3% vs 29.2%; 21.1% vs 17.7%). Hyponatremic patients stayed more than 5 days in hospital (56.3% vs 46.5%), and stayed longer in special care (23.4% vs 20.0%) as compared to controls. Hyponatremic patients as compared to control were more likely to have diabetes (47.9% vs 30.0%), hypertension (49.0% vs 38.5%), ischemic heart disease (20.7% vs 15.4%), chronic liver disease (2.7% vs 1.2%), and chronic kidney disease (9.6% vs 3.8%). Upon matching on the age, the adjusted odds of hyponatremia in COVID-19-positive patients were 1.9 times among diabetic patients. Moreover, COVID-19-positive patients suffering from CKD had a higher risk of developing hyponatremia (OR = 2.3, 95% CI: 1.1-5.6). The risk of hyponatremia among COVID-19-positive patients is statistically higher in patients with 1 comorbidity (OR = 1.9, 95%CI: 1.3-3.4). Hyponatremia on admission can be used to forecast the length of hospital stay and the severity of illness in COVID-19 patients.

Outcomes of Hospital-Acquired Hypernatremia.

Hospital-acquired hypernatremia is highly prevalent, overlooked, and associated with unfavorable consequences. There are limited studies examining the outcomes and discharge dispositions of various levels of hospital-acquired hypernatremia in patients with or without CKD. We conducted an observational retrospective cohort study, and we analyzed the data of 1,728,141 patients extracted from the Cerner Health Facts database (January 1, 2000, to June 30, 2018). In this report, we investigated the association between hospital-acquired hypernatremia (serum sodium [Na] levels >145 mEq/L) and in-hospital mortality or discharge dispositions with kidney function status at admission using adjusted multinomial regression models. Of all hospitalized patients, 6% developed hypernatremia after hospital admission. The incidence of in-hospital mortality was 12% and 1% in patients with hypernatremia and normonatremia, respectively. The risk of all outcomes was significantly greater for serum Na >145 mEq/L compared with the reference interval (serum Na, 135-145 mEq/L). In patients with hypernatremia, odds ratios (95% confidence interval) for in-hospital mortality, discharge to hospice, and discharge to nursing facilities were 14.04 (13.71 to 14.38), 4.35 (4.14 to 4.57), and 3.88 (3.82 to 3.94), respectively ( P < 0.001, for all). Patients with eGFR (Chronic Kidney Disease Epidemiology Collaboration) 60-89 ml/min per 1.73 m 2 and normonatremia had the lowest odds ratio for in-hospital mortality (1.60 [1.52 to 1.70]). Hospital-acquired hypernatremia is associated with in-hospital mortality and discharge to hospice or to nursing facilities in all stages of CKD.

Occurrence and clinical relevance of postoperative hypernatremia in dogs undergoing cholecystectomy.

Patients undergoing cholecystectomy have not been reported previously to develop clinically relevant postoperative hypernatremia. Describe the frequency of postoperative hypernatremia in dogs undergoing cholecystectomy and its clinical relevance (duration of hospitalization and survival). Thirty-seven dogs undergoing cholecystectomy at 2 private referral hospitals. Retrospective study of dogs undergoing cholecystectomy with available preoperative and postoperative serum sodium concentrations. Postoperative hypernatremia (>150 mEq/L) was common (56%; 95% confidence interval [CI], 40%-70%) and was associated with significantly higher mortality compared to nonhypernatremic patients (52%; 95% CI, 30%-70% vs 12.5%; 95% CI, 2%-40%; P = .02). Nonsurvivors had higher mean postoperative peak serum sodium concentrations (155 mEq/L; range, 146-172) than survivors (150 mEq/L; range, 142-156; P = .01). Dogs developing hypernatremia within 6 hours after surgery had 7.7 higher odds of nonsurvival (odds ratio [OR], 7.7; 95% CI, 5.9-9.4). A delta value (serum sodium concentration on admission [T0] - serum sodium concentration 6 hours postoperatively [T2]) of ≥10 mEq/L carried 3.3 higher odds of mortality (OR, 3.3; 95% CI, 1.6-5.1). All dogs with a postoperative peak sodium concentration >160 mEq/L did not survive. Admission acute patient physiologic laboratory evaluation fast (APPLEfast ) scores were not different between survivors and nonsurvivors or between postoperative hypernatremic and normonatremic patients. Hospitalization time was no different between hypernatremic and normonatremic patients (6 days vs 4.5 days; P = .15). Dogs with gallbladder mucocele were more likely to develop postoperative hypernatremia and have poorer outcomes. Hypernatremia was a common and clinically relevant postoperative complication in dogs after cholecystectomy. Detection of hypernatremia within 6 hours after surgery may be associated with poorer outcomes.

The incidence of hyponatremia in hospitalized patients due to hip fracture and its effect on mortality

Purpose: Hyponatremia is associated with high morbidity and mortality in elderly patients. This study aimed to investigate the incidence of hyponatremia and its effects on the duration of hospitalization, in-hospital and 1-year mortality in elderly patients admitted to the hospital due to hip fracture.&#x0D; Materials and Methods: After the approval of the ethics committee, patients over the age 65 and had hip surgery between January-December 2020 were retrospectively analyzed. The age, gender, fracture type, current comorbidities, and American Society of Anesthesiology physical status scores of the patients were recorded. Plasma Na, K, and Ca values in admission to hospital were recorded. Patients with hyponatremia and normonatremia were compared in terms of demographic data, comorbidities, duration of hospitalization, in-hospital, and 1-year mortality rates.&#x0D; Results: Of the total 253 patients, 52(%20.5) had hyponatremia at hospital admission. Demographic data were similar in hyponatremic and normonatremic patients. In hyponatremia group mean Na values were 131.13±3.96 mmol/L and significantly lower than normonatremia group (138.73±2.27). In the hyponatremic group, diabetes mellitus was observed in 23 (44%) patients, and congestive heart failure was observed in 9 (17%) patients, which was higher than the normonatremic group. The preoperative and total duration of hospitalization was 5.21±2.68 and 9.92±4.49 days respectively and higher in patients with hyponatremia. In-hospital and 1-year mortality rates were similar between the groups.&#x0D; Conclusion: The incidence of hyponatremia was found to be 20.5% in patients with hip fractures, and both the preoperative and total hospital stays were prolonged in these patients. Although mortality rates were similar in this study, hyponatremia requires careful follow-up and early treatment in these patients, since it is known that the length of hospital stay increases mortality.

EVALUATION OF IMPACT OF HYPERGLYCEMIA AND HYPONATREMIA ON CLINICAL OUT-COME OF ACUTE STROKE

Hyponatremia and hyperglycemia are common metabolic disorders which could worsen the outcome after a cerebrovascular accident (stroke). This study aimed to evaluate the impact of hyponatremia and hyperglycemia on stroke and its clinical outcome, including morbidity and mortality. This prospective cohort study included 50 stroke patients admitted in tertiary care hospitals. Stroke severity, Glasgow coma scale (GCS), conscious level, gag reflex, clinical presentations, and outcomes were recorded. Following a stroke, patients were monitored for a period of six months, during which the patient's death was recorded on the event form. Linear logistic regression model was used to determine the stroke mortality. Hyponatremia and hyperglycaemia were associated with higher odds ratio of deaths, poor functional recovery, severe disability, low mean GCS score as compared to normonatremic and normoglycemic patients (odds ratio [OR] = 4.7; 95% CI= 0.929-43.782) and hyperglycaemia (OR= 2.74; 95% CI=0.577-13.03). Stroke patients admitted with hyperglycemia or hyponatremia were associated with greater morbidity and mortality and poor functional recovery.

Haptoglobin-Related Protein without Signal Peptide as Biomarker of Renal Salt Wasting in Hyponatremia, Hyponatremia-Related Diseases and as New Syndrome in Alzheimer’s Disease

The application of pathophysiologic tenets has created significant changes in our approach to hyponatremia and hyponatremia-related conditions. This new approach incorporated the determination of fractional excretion (FE) of urate before and after the correction of hyponatremia and the response to isotonic saline infusion to differentiate the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) from renal salt wasting (RSW). FEurate simplified the identification of the different causes of hyponatremia, especially the diagnosis of a reset osmostat and Addison's disease. Differentiating SIADH from RSW has been extremely difficult because both syndromes present with identical clinical parameters, which could be overcome by successfully carrying out the difficult protocol of this new approach. A study of 62 hyponatremic patients from the general medical wards of the hospital identified 17 (27%) to have SIADH, 19 (31%) with reset osmostat, and 24 (38%) with RSW with 21 of these RSW patients presenting without clinical evidence of cerebral disease to warrant changing the nomenclature from cerebral to renal salt wasting. The natriuretic activity found in the plasma of 21 and 18 patients with neurosurgical and Alzheimer's disease, respectively, was later identified as haptoglobin-related protein without signal peptide (HPRWSP). The high prevalence of RSW creates a therapeutic dilemma of deciding whether to water-restrict water-logged patients with SIADH as compared to administering saline to volume-depleted patients with RSW. Future studies will hopefully achieve the following: 1. Abandon the ineffective volume approach; 2. Develop HPRWSP as a biomarker to identify hyponatremic and a projected large number of normonatremic patients at risk of developing RSW, including Alzheimer's disease; 3. Facilitate differentiating SIADH from RSW on the first encounter and improve clinical outcomes.

Normonatremic Transient Renal Salt Wasting (TRSW) Is Not Rare in a Department of Internal Medicine.

We previously reported that for around 5% of patients hospitalized with hyponatremia, it was related to what is called "transient renal salt wasting" (TRSW). In the present study we ask whether TRSW can also be observed in patients without hyponatremia. In this observational retrospective study we analyze the urine solute excretion of 200 consecutive normonatremic patients with normal kidney function and admitted in our department over one year. Patients were selected for analyses of FE.K, UCa/UCr and FE.PO4 if FE.Na was higher than 2% (N &lt; 1.6%) before any treatment, and only if they were not taking diuretics. Eleven normonatremic patients presented with transient high FE.Na &gt; 2% on admission (2.9 ± 0.6% with a high FE.K of 28 ± 6.4%; a high UCa/UCr of 0.37 ± 0.13 and a high FE.PO4 of 23.2 ± 9.6%). All of these patients were elderly. Seven were female and four were male. Neurological disorders were observed in six patients (three strokes, one transient ischemic attack, one syncope and one epileptic attack). Heart problems were observed in three patients (all angina pectoris, two of which also had HBP). One patient presented with rectal bleeding with HBP, and another presented COPD with a pneumothorax. One patient with angina pectoris showed a transient relapse after four days of hospitalization (FE.Na 3.6%). The urine electrolyte excretion in these patients are similar to those observed after furosemide intake. Normonatremic TRSW is not a rare observation, particularly in patients with neurological or cardiac problems.

The prevalence and prognostic effect of hyponatremia in children with COVID-19 pneumonia: a retrospective study.

The aim of the study was to examine the effect of hyponatremia at admission as a negative prognostic factor in children hospitalized with COVID-19 pneumonia. The data of patients aged 1 month-18 years, who were followed with the diagnosis of pneumonia at Çanakkale Onsekiz Mart University Hospital, Department of Pediatrics, between January 2018 and May 2021 were examined, retrospectively. Patients (n=661) were divided into two main groups; COVID-19 pneumonia (n=158) and the other pneumonias [other viral pneumonia (n=161) and pneumonia of unknown etiology (n=342)]. Six hundred and twenty-three patients with a median (Q1-Q3) age of 4 (1.5-8) years, 59.4% of whom were male were included in the study. The overall prevalence of hyponatremia at admission was 11.2% and was lower in those with COVID-19 pneumonia than in those with other viral pneumonia (6.4% vs. 15.2%, p=0.013). When evaluated irrespective of their COVID-19 status, hyponatremic patients had a higher supplemental oxygen requirement (OR 2.5 [1.4-4.3], p < 0.001), higher need for intensive care unit (ICU) admission (OR 3.7 [1.3-10.2], p=0.009) and longer duration of hospitalization (p=0.016) than the normonatremic patients. In patients with COVID-19 pneumonia, being hyponatremic had no effect on supplemental oxygen requirements or the duration of hospitalization. When hyponatremic patients were evaluated, the supplemental oxygen requirements and duration of hospitalization of those with COVID-19 pneumonia were similar to the other pneumonias (p > 0.05 for all comparisons). However, normonatremic COVID-19 pneumonias had higher supplemental oxygen requirements than other viral pneumonias and pneumonia of unknown etiology (OR 4.7 [2.2-10.3], p < 0.001; OR 1.6 [1 -2.7], p=0.043, respectively). This study found that hyponatremia at admission is rarer in children with COVID-19 pneumonia than other viral pneumonias and has no effect on supplemental oxygen requirements or the duration of hospitalization.

New Approach to Hyponatremia: High Prevalence of Cerebral/Renal Salt Wasting, Identification of Natriuretic Protein That Causes Salt Wasting.

Our understanding of hyponatremic conditions has undergone major alterations. There is a tendency to treat all patients with hyponatremia because of common subtle symptoms that include unsteady gait that lead to increased falls and bone fractures and can progress to mental confusion, irritability, seizures, coma and even death. We describe a new approach that is superior to the ineffectual volume approach. Determination of fractional excretion (FE) of urate has simplified the diagnosis of a reset osmostat, Addison's disease, edematous causes such as congestive heart failure, cirrhosis and nephrosis, volume depletion from extrarenal salt losses with normal renal tubular function and the difficult task of differentiating the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) from cerebral/renal salt wasting (C/RSW). SIADH and C/RSW have identical clinical and laboratory parameters but have diametrically opposite therapeutic goals of water-restricting water-loaded patients with SIADH or administering salt water to dehydrated patients with C/RSW. In a study of nonedematous patients with hyponatremia, we utilized FEurate and response to isotonic saline infusions to differentiate SIADH from C/RSW. Twenty-four (38%) of 62 hyponatremic patients had C/RSW with 21 having no clinical evidence of cerebral disease to support our important proposal to change cerebral to renal salt wasting (RSW). Seventeen (27%) had SIADH and 19 (31%) had a reset osmostat. One each from hydrochlorothiazide and Addison's disease. We demonstrated natriuretic activity in the plasma of patients with neurosurgical and Alzheimer diseases (AD) in rat clearance studies and have now identified the natriuretic protein to be haptoglobin related protein without signal peptide (HPRWSP). We introduce a new syndrome of RSW in AD that needs further confirmation. Future studies intend to develop HPRWSP as a biomarker to simplify the diagnosis of RSW in hyponatremic and normonatremic patients and explore other clinical applications that can improve clinical outcomes.

Outcome of Hospitalized Cancer Patients with Hypernatremia: A Retrospective Case-Control Study.

Hypernatremia (&gt;145 mmol/L) is a relatively rare event, and the data regarding its role in the outcome of inpatients on an oncology ward are weak. The aim of this study was to describe the prevalence, prognosis, and outcome of hospitalized cancer patients with hypernatremia. We performed a retrospective case-control study of data obtained from inpatients with a solid tumor at the St. Claraspital, Basel, Switzerland, who were admitted between 2017 and 2020. The primary endpoint was overall survival. Hypernatremia was found in 93 (3.16%) of 2945 inpatients bearing cancer or lymphoma. From 991 eligible normonatremic control patients, 93 were matched according to diagnosis, age, and sex. The median overall survival time (OS) of patients with hypernatremia was 1.5 months compared to 11.7 months of the normonatremic controls (HR 2.69, 95% CI 1.85-3.90, p &lt; 0.0001). OS of patients with irreversible compared to reversible hypernatremia was significantly shorter (23 versus 88 days, HR 4.0, 95% CI 2.04-7.70, p &lt; 0.0001). The length of hospital stay was significantly longer for the hypernatremic than for the normonatremic group (p &lt; 0.0001). Significantly more patients with hypernatremia died in the hospital (30.1% versus 8.6%, p &lt; 0.001). These results suggest hypernatremia to be associated with an unfavorable outcome and a very short OS.

ODP325 Inverse Relationship Between IL-6 and Sodium Levels in Patients With COVID-19 and Other Respiratory Tract Infections

Abstract Background Hyponatremia is highly prevalent in patients with COVID-19. One of the most common causes of hyponatremia in these patients is the syndrome of inadequate antidiuresis (SIAD). Interleukin 6 (IL-6) is a key mediator of inflammation in COVID-19. We hypothesized that hyponatremia in COVID-19 is due to IL-6 mediated non-osmotic arginine vasopressin (AVP) secretion, and that the inverse association between IL-6 and plasma sodium concentration is stronger in COVID-19 compared to other respiratory infections. METHODS This is a secondary analysis of a prospective, observational, cohort study including patients with COVID-19 suspicion admitted to the Emergency Department, University Hospital of Basel, Switzerland, between March and July 2020. We included patients with PCR-confirmed COVID-19 and patients without COVID-19 but similar symptoms, further subclassified in bacterial and other viral respiratory infections. The primary objective was to investigate the association between plasma sodium levels and IL-6 levels. Results 500 patients were included, of whom 184 (37%) with COVID-19, 92 (18%) with bacterial respiratory infections, 224 (45%) with other viral respiratory infections. Hyponatremia prevalence was higher in patients with COVID-19 compared to patients with other viral respiratory infections (28% vs 12%, p&amp;lt;0. 01), and similar to patients with bacterial respiratory infections (28% vs 30%, p&amp;lt;0.41). In all three groups, median [IQR] IL-6 levels were significantly higher in hyponatremic compared to normonatremic patients (COVID-19: 43.4 [28.4, 59.8] vs 9.2 [2.8, 32.7] pg/ml, p&amp;lt;0. 0001; bacterial: 122.1 [63. 0, 282. 0] vs 67.1 [24.9, 252. 0] pg/ml, p&amp;lt;0. 05; viral: 14.1 [6.9, 84.7] vs 4.3 [2.1, 14.4] pg/ml, p&amp;lt;0. 05). IL-6 levels were negatively correlated with plasma sodium levels in COVID-19, whereas the correlation in bacterial and other viral infections was weaker (COVID-19: ρ = − 0.52, p &amp;lt; 0. 001; bacterial: ρ = − 0.24, p = 0. 056, viral: ρ = − 0.24, p &amp;lt; 0. 001). Conclusion IL-6 levels were inversely correlated with plasma sodium levels, with a stronger correlation in patients with COVID-19 compared to patients with bacterial and other viral infections. IL-6 might stimulate AVP secretion and lead to higher rates of hyponatremia due to the syndrome of inadequate antidiuresis in these patients. Presentation: No date and time listed

Neither the presence nor the severity of hyponatremia affected the outcome of the patients with small cell lung cancer.

Hyponatremia is the most common electrolyte disorder in lung cancer, and it particularly occurs in small cell lung cancer (SCLC) patients. The prognostic significance of hyponatremia has been reported in several studies with controversial results. We aimed in this study to investigate hyponatremia and evaluate its prognostic value in SCLC patients. The data of 373 SCLC patients were analyzed retrospectively. Serum sodium concentrations were measured from blood samples taken from all patients before treatment. Hyponatremia was defined as a serum sodium concentration below 135mmol/L and then assigned into two groups: mild (130 to 134mmol/L) and severe (below ≤ 129mmol/L) hyponatremia. Hyponatremia was detected in 85 (22.8%) patients (mild hyponatremia in 51 (13.7%) and severe hyponatremia in 34 (9.1%) patients). Furthermore, 26% (63 of 242) of ED-SCLC patients and 16.8% (22 of 131) of LD-SCLC patients had hyponatremia. While no clinical parameter was statistically associated with serum sodium concentrations in LD-SCLC patients, hyponatremic ED-SCLC patients were more frequently associated with weight loss (p = 0.04) and liver metastasis (p = 0.04). In LD-SCLC, the overall survival (OS) rates of patients with hyponatremia were similar to those with normonatremia (p = 0.6). Likewise, hyponatremic and normonatremic ED-SCLC patients had similar life expectancies (p = 0.1). Moreover, the severity of hyponatremia did not affect OS in either LD-SCLC (p = 0.3) or ED-SCLC (p = 0.1). Serum sodium concentration did not have an impact on survival in SCLC patients; thus, we concluded that neither the presence nor the severity of hyponatremia affected the outcome of these patients.

Inverse relationship between IL-6 and sodium levels in patients with COVID-19 and other respiratory tract infections: data from the COVIVA study.

ObjectiveHyponatremia in COVID-19 is often due to the syndrome of inadequate antidiuresis (SIAD), possibly mediated by interleukin-6 (IL-6)-induced non-osmotic arginine vasopressin (AVP) secretion. We hypothesized an inverse association between IL-6 and plasma sodium concentration, stronger in COVID-19 compared to other respiratory infections.DesignSecondary analysis of a prospective cohort study including patients with COVID-19 suspicion admitted to the Emergency Department, University Hospital of Basel, Switzerland, between March and July 2020.MethodsWe included patients with PCR-confirmed COVID-19 and patients with similar symptoms, further subclassified into bacterial and other viral respiratory infections. The primary objective was to investigate the association between plasma sodium and IL-6 levels.ResultsA total of 500 patients were included, 184 (37%) with COVID-19, 92 (18%) with bacterial respiratory infections, and 224 (45%) with other viral respiratory infections. In all groups, median (IQR) IL-6 levels were significantly higher in hyponatremic compared to normonatremic patients (COVID-19: 43.4 (28.4, 59.8) vs 9.2 (2.8, 32.7) pg/mL, P < 0.001; bacterial: 122.1 (63.0, 282.0) vs 67.1 (24.9, 252.0) pg/mL, P < 0.05; viral: 14.1 (6.9, 84.7) vs 4.3 (2.1, 14.4) pg/mL, P < 0.05). IL-6 levels were negatively correlated with plasma sodium levels in COVID-19, whereas the correlation in bacterial and other viral infections was weaker (COVID-19: R = −0.48, P < 0.001; bacterial: R = −0.25, P = 0.05, viral: R = −0.27, P < 0.001).ConclusionsIL-6 levels were inversely correlated with plasma sodium levels, with a stronger correlation in COVID-19 compared to bacterial and other viral infections. IL-6 might stimulate AVP secretion and lead to higher rates of hyponatremia due to the SIAD in these patients.

Electrolyte imbalances as poor prognostic markers in COVID-19: a systemic review and meta-analysis.

PurposeSerum electrolyte imbalances are highly prevalent in COVID-19 patients. However, their associations with COVID-19 outcomes are inconsistent, and of unknown prognostic value. We aim to systematically clarify the associations and prognostic accuracy of electrolyte imbalances (sodium, calcium, potassium, magnesium, chloride and phosphate) in predicting poor COVID-19 clinical outcome.MethodsPubMed, Embase and Cochrane Library were searched. Odds of poor clinical outcome (a composite of mortality, intensive-care unit (ICU) admission, need for respiratory support and acute respiratory distress syndrome) were pooled using mixed-effects models. The associated prognostic sensitivity, positive and negative likelihood ratios (LR + , LR-) and predictive values (PPV, NPV; assuming 25% pre-test probability), and area under the curve (AUC) were computed.ResultsWe included 28 observational studies from 953 records with low to moderate risk-of-bias. Hyponatremia (OR = 2.08, 95% CI = 1.48–2.94, I2 = 93%, N = 8), hypernatremia (OR = 4.32, 95% CI = 3.17–5.88, I2 = 45%, N = 7) and hypocalcemia (OR = 3.31, 95% CI = 2.24–4.88, I2 = 25%, N = 6) were associated with poor COVID-19 outcome. These associations remained significant on adjustment for covariates such as demographics and comorbidities. Hypernatremia was 97% specific in predicting poor outcome (LR + 4.0, PPV = 55%, AUC = 0.80) despite no differences in CRP and IL-6 levels between hypernatremic and normonatremic patients. Hypocalcemia was 76% sensitive in predicting poor outcome (LR- 0.44, NPV = 87%, AUC = 0.71). Overall quality of evidence ranged from very low to moderate.ConclusionHyponatremia, hypernatremia and hypocalcemia are associated with poor COVID-19 clinical outcome. Hypernatremia is 97% specific for a poor outcome, and the association is independent of inflammatory marker levels. Further studies should evaluate if correcting these imbalances help improve clinical outcome.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40618-022-01877-5.

Hypernatremia in Hospitalized Patients: A Large Population-Based Study.

Hypernatremia is a frequently encountered electrolyte disorder in hospitalized patients. Controversies still exist over the relationship between hypernatremia and its outcomes in hospitalized patients. This study examines the relationship of hypernatremia to outcomes among hospitalized patients and the extent to which this relationship varies by kidney function and age. We conducted an observational study to investigate the association between hypernatremia, eGFR, and age at hospital admission and in-hospital mortality, and discharge dispositions. We analyzed the data of 1.9 million patients extracted from the Cerner Health Facts databases (2000-2018). Adjusted multinomial regression models were used to estimate the relationship of hypernatremia to outcomes of hospitalized patients. Of all hospitalized patients, 3% had serum sodium (Na) >145 mEq/L at hospital admission. Incidence of in-hospital mortality was 12% and 2% in hyper- and normonatremic patients, respectively. The risk of all outcomes increased significantly for Na >155 mEq/L compared with the reference interval of Na=135-145 mEq/L. Odds ratios (95% confidence intervals) for in-hospital mortality and discharge to a hospice or nursing facility were 34.41 (30.59-38.71), 21.14 (17.53-25.5), and 12.21 (10.95-13.61), respectively (all P<0.001). In adjusted models, we found that the association between Na and disposition was modified by eGFR (P<0.001) and by age (P<0.001). Sensitivity analyses were performed using the eGFR equation without race as a covariate, and the inferences did not substantially change. In all hypernatremic groups, patients aged 76-89 and ≥90 had higher odds of in-hospital mortality compared with younger patients (all P<0.001). Hypernatremia was significantly associated with in-hospital mortality and discharge to a hospice or nursing facility. The risk of in-hospital mortality and other outcomes was highest among those with Na >155 mEq/L. This work demonstrates that hypernatremia is an important factor related to discharge disposition and supports the need to study whether protocolized treatment of hypernatremia improves outcomes.

Hyponatremia in elderly patients with fractures around the hip; role of glutamate (CSF glutamate study)

Background &amp; objective: Hyponatremia is the most common electrolyte disorder and is a predictor of osteoporosis, inflammation and cognitive dysfunction leading to falls in the elderly patients. We compared glutamate levels in normonatremic elderly patients with those with hyponatremia, admitted with osteoarthritis, to find correlation between the cognitive status with cerebrospinal fluid (CSF) glutamate as a biomarker for hyponatremia.&#x0D; Methodology: In an observational prospective study; 70 patients, more than 70 y of age, admitted to trauma unit of Assiut University Hospital with fractures around the hip, were investigated for the frequency of on-admission hyponatremia. The CSF glutamate level was determined using radio-immune assay. We compared glutamate level in 18 hyponatremic patients with 10 normonatremic elderly patients admitted with osteoarthritis for elective joint replacement (control group) to find correlation between the cognitive status assessed by Modified Mini-Mental State (3MS) examination and CSF glutamate as a biomarker for hyponatremia.&#x0D; Results: Hyponatremia is highly prevalent in elderly with fractures around the hip; we recorded it in 41.4% of the study sample. Most patients were females (62.86%). CSF glutamate was significantly increased in hyponatremic patients than the controls (P &lt; 0.001).&#x0D; Conclusion: Prevalence of hyponatremia is high in old aged patients probably due to due to prevalent hot weather in the south of Egypt. CSF glutamate level can be a marker for mild cognitive impairment caused by hyponatremia.&#x0D; Abbreviations: 3MS: Modified Mini-Mental State examination; CSF: cerebrospinal fluid; RPM: revolutions per minute; ELISA: enzyme-linked immunosorbent assay; SD: standard deviation&#x0D; Key words: Geriatric anesthesia; Chronic Disease; Cognition Disorders / blood; Cognition Disorders / etiology; Glutamic Acid / metabolism; Hyponatremia / blood; Hyponatremia / complications; Hyponatremia / psychology; Inappropriate ADH Syndrome / complications; 3MS&#x0D; Citation: Kotb HI, Hassan A, Sayed AA, Seddik MI, Maghraby HH, Kamel EZ. Hyponatremia in elderly patients with fractures around the hip; role of glutamate (CSF glutamate study). Anaesth. pain intensive care 2022;26(3):332-337&#x0D; DOI: 10.35975/apic.v26i3.1900&#x0D; Received: November 28, 2020; Reviewed: December 25, 2020; Accepted: April 25, 2022

Prognostic value of dysnatremia for survival in neuroendocrine neoplasm patients.

Hyponatremia and hypernatremia are common electrolyte abnormalities in patients with malignancy and have been independently associated with worse survival outcomes. To date, there are no data on the impact of dysnatremia on survival outcomes in patients with neuroendocrine neoplasms (NENs). This study involves retrospective cohort analysis from a tertiary care center of NEN patients treated with peptide receptor radionuclide therapy (PRRT) with a cumulative activity of at least 3.7 GBq 177Lu-DOTATATE between the years 2000 and 2015. Comparison of overall survival of patients with the occurrence of hyponatremia (serum sodium < 135 mmol/L) or hypernatremia (serum sodium > 145 mmol/L) before starting or during PRRT was perfomed. A total of 649 patients were included. Hyponatremia occurred in 57 patients during the observation period and was associated with a shorter median overall survival (95% CI) of 25 months (14-36) compared to 55 months (48-61) of the 512 normonatremic patients (P < 0.001), adjusted hazard ratio (HR): 1.48 (95% CI: 1.04-2.12). Overall survival time was reduced regardless of whether hyponatremia was present at baseline or during PRRT. In contrast, hypernatremia occurred in 80 patients and was associated with a longer median overall survival (95% CI) of 94 months (47-140) compared with the 512 normonatremic patients (P = 0.018), adjusted HR: 0.61 (95% CI: 0.40-0.92). This association was driven by the patients with hypernatremia during PRRT. No association between dysnatremia and progression-free survival after PRRT was observed. The occurrence of hypo- or hypernatremia in PRRT-treated NET patients is associated with opposing outcomes with regard to overall survival. Sodium levels might have a prognostic role in these patients.

Preoperative hyponatremia and survival after left ventricular assist device implantation.

Hyponatremia is associated with adverse outcomes in heart failure and after cardiac surgery. We hypothesized that hyponatremia is associated with poorer short-term and longer term survival in patients after continuous-flow left ventricular assist device (CF-LVAD) placement. We reviewed a single-center database of patients who received a CF-LVAD during 2012-2017. Sodium (Na) values obtained within 14 days before CF-LVAD insertion were averaged; patients (n=332) were divided into hyponatremia (mean Na <135 mEq/L; n=160; 48.2%) and normonatremia groups (mean Na 135-145 mEq/L; n=172; 51.8%). Patients requiring preoperative dialysis or pump exchange were excluded. We compared outcomes between preoperative hyponatremia and normonatremia groups. The two groups' baseline characteristics were similar, although hyponatremia patients more often had preoperative mechanical circulatory support (44.4% vs. 31.4%, p=0.002). Although hyponatremic and normonatremic patients did not differ in 30-day mortality (7.5% vs. 6.5%, p=0.7), preoperative hyponatremia was associated with greater 5-year mortality (61% vs. 44%, p=0.03). On binary logistic regression analysis, the strongest independent predictors of late mortality were hyponatremia (odds ratio [OR] 1.88, 95% CI [1.07-3.31], p=0.02), older age (OR 1.03, 95% CI [1.01-1.05], p=0.01), and elevated mean right atrial pressure/pulmonary capillary wedge pressure ratio (OR 4.69, 95% CI [1.76-12.47], p=0.002). Hyponatremia was not associated with greater early mortality but was associated with poorer late survival. The optimal timing of LVAD implantation in relation to hyponatremia, and whether correcting hyponatremia perioperatively improves long-term survival, should be investigated.