Severe Hyponatremia In Patients Research Articles

Comparison of severe hyponatremia in patients with and without psychiatric diseases: A single-center retrospective study.

Hyponatremia is a common electrolyte disorder. The severe hyponatremia has a mortality rate of 4%-40%. Psychiatric patients are likely to develop the condition because of polydipsia or the adverse effects of antipsychotics. We investigated the characteristics of patients with and without psychiatric diseases who developed severe hyponatremia. We retrospectively investigated cases admitted to our hospital (all departments) between October 2012 and November 2015 with a serum sodium concentration of ≤125 mmol/l on admission. We compared patient characteristics, etiology, and clinical course between psychiatric and nonpsychiatric patients. In total, 123 cases (62 female) were analyzed. Psychiatric disorders were present in 69 cases (56%), including schizophrenia (n = 19), anorexia (n = 16), mood disorders (n = 14), and organic mental disorders (n = 9). The mean patient age was 63 years. The mean serum sodium concentration on admission was 119 mmol/l, and the main causes of hyponatremia were polydipsia (20%), insufficient sodium intake (18%), and syndrome of inappropriate antidiuretic hormone secretion (16%). Compared with the nonpsychiatric group, the psychiatric group was significantly younger (55 vs. 74 years), was more likely to have polydipsia (30% vs. 6%), and had a lower in-hospital mortality (0% vs. 17%). Our study found differences in the clinical picture between psychiatric and nonpsychiatric patients with severe hyponatremia. Clinicians need to monitor serum sodium because the symptoms of hyponatremia can mimic those of psychiatric diseases.

1082: SPIKE IN CRITICAL CARE ADMISSIONS FOR SEVERE HYPONATREMIA IN PATIENTS RECEIVING PAXLOVID

Introduction: Paxlovid (nirmatrelvir-ritonavir) received Emergency Use Authorization (EUA) for mild to moderate COVID-19 among those at high risk for severe disease. Hyponatremia is not yet listed as an adverse reaction to either Paxlovid or ritonavir alone in UpToDate. The package insert lists hyponatremia if Paxlovid is administered with finerenone, due to the increased concentration of finerenone caused by a drug-drug interaction. The EUA lists one case of mild hyponatremia in a patient with 10 other adverse events, none of which thought to be related to Paxlovid. The Liverpool COVID-19 website allows review of concomitant medications for drug interaction prior to prescribing, although it is unclear how widespread its use is among prescribers. The objective of this case series is to review 4 cases of severe hyponatremia in patients receiving Paxlovid that required intensive care unit (ICU) admission. Description: During a 6-week period from June to July 2022, our community hospital treated 7 adult patients in the ICU for severe hyponatremia, defined as sodium (Na) less than 120 mEq/L. Of those 7, three patients did not have COVID-19. The remaining four patients had been prescribed and were taking Paxlovid for COVID-19, with Na levels upon admission ranging from 112 to 115 mEq/L. Weakness, nausea and dehydration were all common side effects upon presentation. Use of the Liverpool COVID-19 interaction checker revealed a potential weak interaction in only 1 of 4 patients that venlafaxine concentrations could potentially be increased and venlafaxine has been associated with hyponatremia. With cessation of the drug and conventional treatment measures for severe hyponatremia including hypertonic saline, the hyponatremia corrected appropriately in all four cases. Discussion: COVID-19 itself has been associated with hyponatremia of unclear mechanism, however two large studies of 1099 & 5700 patients hospitalized for COVID-19 showed average Na levels of 138 & 136 mEq/L, respectively. We admitted 4 patients to the ICU in a 6-week period for severe hyponatremia while taking Paxlovid. Although the mechanism is unknown, this could be a signal that warrants further investigation. Vigilant review of concomitant medications when prescribing Paxlovid using the Liverpool interaction checker is needed.

Severe hyponatremia in an infant with epidermolysis bullosa: a case report

BackgroundEpidermolysis bullosa is a rare inherited connective tissue disorder compromising cellular junctions. Blister formation is the first manifestation of epidermolysis bullosa. As cellular adhesion is affected, it can affect many organs. Due to compromised skin integrity, water loss and electrolyte imbalances are prevalent in these patients. However, hypernatremia is the usual observed sodium imbalance rather than hyponatremia.Case presentationThe patient was a 48-day-old Iranian male infant born near term. He was diagnosed with epidermolysis bullosa at 1 month of age. The patient was brought to the pediatrics center with apnea and respiratory distress, and was intubated and admitted to the pediatric intensive care unit. His symptoms started 4 days before the admission with vomiting and poor feeding, and the patient later developed loss of consciousness. Vital signs revealed a pulse rate of 154 beats per minute, respiratory rate of 70 per minute, a temporal temperature of 36.5 °C, nondetectable blood pressure, and oxygen saturation of 96%. The patient was anuric at presentation and was rehydrated. Physical examination showed bolus eruptions all over the body but not in mucosal membranes. Important laboratory findings were white blood cell count of 41,000/mm3 with 68% neutrophils, hemoglobin of 10.8 g/dL, platelet count of 856,000/mm2, negative C-reactive protein (CRP), blood sugar of 514 mg/dL, urea of 129 mg/dL, sodium of 98 mg/dL, corrected sodium of 105 mg/dL, potassium of 5.5 mg/dL, serum creatinine of 1.7 mg/dL, and serum procalcitonin of more than 75 ng/mL. Urine analysis revealed many red blood cells. Brain computed tomography demonstrated loss of differentiation between gray and white matter and effacement of cortical sulci suggesting severe cytotoxic edema.We administered 3% hypertonic saline and corrected the plasma sodium levels, and provided the patient with multiple doses of mannitol as well as antibiotics due to the leukocytosis. Subsequently, after 3 days in pediatric intensive care unit, the symptoms of brain edema resolved, and after 4 days, he was weaned from the ventilator and extubated. Later he was discharged from the pediatric intensive care unit.ConclusionThis study illustrates the possibility of severe hyponatremia in patients with epidermolysis bullosa to clinicians. Although uncommon, knowledge on such possibilities is vital due to the possible detrimental outcomes for patients.

Metabolic Acidosis and Hyponatremia in a Patient With Metastatic Melanoma

Metabolic Acidosis and Hyponatremia in a Patient With Metastatic Melanoma

A study of etio-pathogenesis of moderate to severe hyponatremia in patients admitted to MICU in a tertiary care hospital, Nandyal

A study of etio-pathogenesis of moderate to severe hyponatremia in patients admitted to MICU in a tertiary care hospital, Nandyal

Study of moderate to severe hyponatremia in patients admitted to medical intensive care units (MICU) in a tertiary care hospital

Study of moderate to severe hyponatremia in patients admitted to medical intensive care units (MICU) in a tertiary care hospital

Risk Factors for Severe Hyponatremia Related to Cisplatin: A Retrospective Case-Control Study.

Onset of severe hyponatremia following cisplatin (CDDP) administration has been previously reported. However, the risk factors associated with hyponatremia still remain unclear. We conducted a retrospective, single-center, case-control study to identify independent risk factors of severe hyponatremia in patients with various types of cancers. Adult patients who received intravenous CDDP administration between January 2012 and December 2017 met the inclusion criteria. The investigators recorded patients' demographics and clinical information retrospectively, and assessed the lowest serum sodium level within 21 d of the first CDDP administration. Risk factors for grade ≥3 hyponatremia were examined via a logistic regression analysis. Among a total of 472 patients, fifty patients (10.6%) developed grade ≥3 hyponatremia. Univariate analysis revealed that age (≥65 years), presence of small cell lung or esophageal cancer, and lower sodium concentrations in the serum (<138 mEq/L) were significantly associated with grade 3 and 4 hyponatremia. Additionally, multivariable logistic regression analysis showed that the presence of small cell lung cancer (adjusted odds ratio, 3.26; 95% confidence interval (CI), 1.07-10.00) and lower sodium concentrations in the serum (<138 mEq/L) (adjusted odds ratio, 6.18; 95%CI, 3.21-11.90) were independent risk factors of grade 3 and 4 hyponatremia. Thus, serum sodium concentrations in patients with these risk factors should be closely monitored after CDDP administration.

A Multidisciplinary Approach for the Management of Severe Hyponatremia in Patients Requiring Continuous Renal Replacement Therapy

IntroductionHyponatremia is a common electrolyte disorder in critically ill patients. Rapid correction of chronic hyponatremia may lead to osmotic demyelination syndrome. Management of severe hyponatremia in patients with acute or chronic kidney disease who require continuous renal replacement therapy (CRRT) is limited by the lack of commercially available hypotonic dialysate or replacement fluid solutions.MethodsThis was a single-center quality improvement project that consisted of the development and implementation of a multidisciplinary protocol for gradual correction of severe hyponatremia in patients who were admitted to the intensive care unit (ICU) and required CRRT. The protocol utilized a simplified method based on single-pool urea kinetic modeling and a hybrid technique of volume exchange, and addition of sterile water for sodium dilution of commercially available dialysate and replacement fluid solutions.ResultsWe report data of the first 3 ICU patients who required CRRT for acute kidney injury management, had severe hyponatremia (serum sodium <120 mEq/l), and were treated under the protocol. Targeted and gradual hyponatremia correction was achieved in all 3 patients. The observed versus the predicted serum sodium correction in each patient was concordant. No complications related to the protocol were reported. We detailed facilitators of and hindrances to the development and successful implementation of our multidisciplinary protocol.ConclusionWe demonstrated gradual and individualized rates of severe hyponatremia correction utilizing customized (sodium dilution) dialysate/replacement fluid solutions in ICU patients who required CRRT. It is not known whether the use of customized solutions to prevent hyponatremia overcorrection has a significant impact on patient outcomes. Further research in this susceptible population is needed.

Practical Protocol for Management of Severe Hyponatremia in Patients Undergoing Liver Transplant Surgery

Practical Protocol for Management of Severe Hyponatremia in Patients Undergoing Liver Transplant Surgery

Severe Symptomatic Hyponatremia Due to Syndrome of Inappropriate Antidiuretic Hormone From Mild Closed Head Trauma and Concussion

We report the first published case of severe, symptomatic hyponatremia resulting from syndrome of inappropriate antidiuretic hormone (SIADH) incurred as the result of a blow to the head inducing a concussion without any additional signs of head injury. A 38-year-old male in excellent health suffered a fall from a tree causing a right leg fracture and blunt trauma to the head with concussion but no other signs of head injury. The patient was discharged several days after surgery for repair of his leg fracture and subsequently became severely ill with nausea, vomiting, headache, and seizures. He was readmitted with a serum sodium of 114 mEq/L (mmol/L) with a presumed diagnosis of dehydration. After several days of saline administration he was discharged, but within 24 hours he again experienced severe, symptomatic hyponatremia and was admitted for the third time with a serum sodium of 110 mEq/L (mmol/L). A diagnosis of SIADH was made, and the patient was successfully treated with fluid restriction, intravenous saline, and demeclocycline resulting in a full recovery without further incident. This case emphasizes the need to consider SIADH as a possible cause of severe hyponatremia in patients sustaining relatively minor closed head trauma. J Med Cases. 2015;6(1):27-29 doi: http://dx.doi.org/10.14740/jmc2001w

High plasma exposure to pemetrexed leads to severe hyponatremia in patients with advanced non small cell lung cancer receiving pemetrexed-platinum doublet chemotherapy.

BackgroundPemetrexed-platinum doublet therapy is a standard treatment for stage IIIb/IV nonsquamous non small cell lung cancer (NSCLC). While the regimen is associated with several grade ≥3 toxicities, hyponatremia is not a commonly reported adverse effect. Here we report an unusually high incidence of grade ≥3 hyponatremia in Indian patients receiving pemetrexed-platinum doublet, and the pharmacological basis for this phenomenon.MethodsForty-six patients with advanced NSCLC were enrolled for a bioequivalence study of two pemetrexed formulations. All patients received the pemetrexed-platinum doublet for six cycles followed by single-agent pemetrexed maintenance until progression. Pharmacokinetic blood samples were collected at predefined time points during the first cycle and the concentration-time profile of pemetrexed was investigated by noncompartmental analysis. Hyponatremic episodes were investigated with serum electrolytes, serum osmolality, urinary sodium, and urine osmolality.ResultsSixteen of 46 patients (35%) had at least one episode of grade ≥3 hyponatremia. Twenty-four episodes of grade ≥3 hyponatremia were observed in 200 cycles of doublet chemotherapy. Plasma exposure to pemetrexed was significantly higher in patients with high-grade hyponatremia than in those with low-grade or no hyponatremia (P=0.063 and P=0.001, respectively). Pemetrexed clearance in high-grade hyponatremia was quite low compared with normal and low-grade hyponatremia (P=0.001 and P=0.055, respectively). Median pemetrexed exposure in this cohort was much higher than that reported in the literature from Western studies.ConclusionHigher exposure to pemetrexed is associated with grade ≥3 hyponatremia. The pharmacogenetic basis for higher exposure to pemetrexed in Indian patients needs further investigation.

Treatment of Severe Hyponatremia in Patients With Kidney Failure: Role of Continuous Venovenous Hemofiltration With Low-Sodium Replacement Fluid

Patients with hypervolemic hyponatremia and kidney failure pose a special therapeutic challenge. Hemodialysis to correct volume overload, azotemia, and abnormal electrolyte levels will result in rapid correction of serum sodium concentration and place the patient at risk for osmotic demyelination syndrome. We present a patient with acute kidney injury and severe hypervolemic hypotonic hyponatremia (serum sodium<100 mEq/L) who was treated successfully with continuous venovenous hemofiltration. This teaching case illustrates the limitations of hemodialysis and demonstrates how to regulate the sodium correction rate by single-pool sodium kinetic modeling during continuous venovenous hemofiltration. Two methods to adjust the replacement fluid to achieve the desired sodium concentration are outlined.

Carbamazepine-Induced Hyponatremia: Assessment of Risk Factors

To report a case of carbamazepine-induced acute hyponatremia resulting in seizures. A 44-year-old white woman developed acute hyponatremia and 2 subsequent tonic-clonic seizures after ingesting twice her evening dose of carbamazepine (usual evening dose 600 mg). On admission, her serum sodium level was 122 mEq/L. An infusion of NaCl 0.9% was begun and, within 24 hours, the serum sodium level had returned to her previous level of 136 mEq/L. The woman's preadmission carbamazepine concentration was 8.6 microg/mL, and it was 11.3 micorg/mL on admission. Carbamazepine was withheld and, the following day, the concentration was 5.6 microg/mL. The woman had experienced a similar event 6 months earlier when she also took a large dose of carbamazepine. We attributed the acute hyponatremia and seizures to the large increase in dose of carbamazepine in the presence of other risk factors for hyponatremia. Hyponatremia associated with carbamazepine has been well described. The incidence ranges from 1.8% to 40% depending on the patient population studied. Severe hyponatremia in patients treated with monotherapy is uncommon. Several risk factors have been reported to increase the risk of hyponatremia including age >40 years, concomitant use of medications associated with hyponatremia, menstruation, psychiatric condition, surgery, psychogenic polydipsia, and female gender. Treatment is focused on removal of the precipitating factors or discontinuation of carbamazepine therapy. Use of the Naranjo probability scale indicated a highly probable relationship between acute hyponatremia and carbamazepine in our patient. Hyponatremia with carbamazepine is well known. The factors associated with increased risk are less understood. An increased awareness of these risks, careful monitoring, and patient education are important in the prevention of neurologic complications.

Clinical Picture of Severe Hyponatremia in Patients with Hypopituitarism Including Secondary Adrenal Insufficiency

Clinical Picture of Severe Hyponatremia in Patients with Hypopituitarism Including Secondary Adrenal Insufficiency