Severe Hyponatremia Research Articles

Salt Wasting Syndrome: Serial Cases

Hyponatremia is one of the electrolyte disturbances that can be found in patients with central nervous system disorders, the most cases of hyponatremia are the Syndrome of Inappropriate Antidiuretic Hormone/SIADH compared to hyponatremia in Cerebral Salt Wasting Syndrome/CSWS and it is not uncommon to also occur in patients undergoing chemotherapy treatment without accompanying head abnormalities are referred to as Renal Salt Wasting Syndrome (RSWS). There is difficulty differentiating these two conditions due to almost the same clinical symptoms. Evaluation of volume status and monitoring of urate excretion fraction can help differentiate SIADH from RSWS and CSWS. Management requiring prompt diagnosis is essential to prevent severe hyponatremia from substantially causing cerebral edema and thereby reducing the risk of seizures. Fluid resuscitation therapy and sodium restoration are important. This case series report injured 2 CSWS patients after head trauma with different treatments and hyponatremia due to cisplatin induced RSWS.

Point-of-care ultrasound is a useful adjunct tool to a clinician's assessment in the evaluation of severe hyponatraemia.

Hyponatraemia is the most common electrolyte disorder in inpatients resulting mainly from an imbalance in water homeostasis. Intravascular fluid status assessment is pivotal but is often challenging given multimorbidity, polypharmacy and diuretics use. We evaluated the utility of point-of-care ultrasound (POCUS) as an adjunct tool to standard practice for fluid assessment in severe hyponatraemia patients. Patients presenting with severe hyponatremia (Serum Sodium [Na] < 120 mmol/L; Normal range: 135-145 mol/L), managed by standard care were included. Hyponatraemia biochemistry work-up and POCUS examination were undertaken. Both clinician and POCUS independently assigned one of the three fluid status groups of hypovolaemia, hypervolaemia or euvolaemia. The final diagnosis of three fluid status groups at admission was made at the time of discharge by retrospective case review. Clinician's (standard of care) and POCUS fluid assessments were compared to that of the final diagnosis at the time of discharge. n = 19 patients were included. Median Na on admission was 113 mmol/L (109-116), improved to 129 ± 3 mmol/L on discharge. POCUS showed the higher degree of agreement with the final diagnosis (84%; n = 16/19), followed by the clinician (63%; n = 12/19). A trend towards higher accuracy of POCUS compared to clinician assessment of fluid status was noted (84% vs. 63%, p = 0.1611). Biochemistry was unreliable in 58% (n = 11/19) likely due to renal failure, polypharmacy or diuretic use. Inappropriate emergency fluid management was undertaken in 37% (n = 7/19) of cases based on initial clinician assessment. Thirst symptom correlated to hypovolaemia in 80% (4/5) cases. As subjective clinical and biochemistry assessments of fluid status are often unreliable due to co-morbidities and concurrent use of medications, POCUS can be a rapid objective diagnostic tool to assess fluid status in patients with severe hyponatraemia, to guide accurate emergency fluid management.

Gastroenteritis Rehydration Of children with Severe Acute Malnutrition (GASTROSAM): A Phase II Randomised Controlled trial: Trial Protocol.

Children hospitalised with severe acute malnutrition (SAM) are frequently complicated (>50%) by diarrhoea ( ≥3 watery stools/day) which is accompanied by poor outcomes. Rehydration guidelines for SAM are exceptionally conservative and controversial, based upon expert opinion. The guidelines only permit use of intravenous fluids for cases with advanced shock and exclusive use of low sodium intravenous and oral rehydration solutions (ORS) for fear of fluid and/or sodium overload. Children managed in accordance to these guidelines have a very high mortality. The proposed GASTROSAM trial will reappraise current recommendations with mortality as the primary outcome. We hypothesize that liberal rehydration strategies for both intravenous and oral rehydration in SAM children with diarrhoea may reduce adverse outcomes. An open Phase II trial, with a partial factorial design, enrolling children in Uganda, Kenya, Nigeria and Niger aged 6 months to 12 years with SAM hospitalised with gastroenteritis (>3 loose stools/day) and signs of moderate and severe dehydration. In Stratum A (severe dehydration) children will be randomised (1:1:2) to WHO plan C (100mls/kg Ringers Lactate (RL) with intravenous rehydration (IV) given over 3-6 hours according to age including boluses for shock), slow rehydration (100 mls/kg RL over 8 hours (no boluses)) or WHO SAM rehydration regime (ORS only (boluses for shock (standard of care)). Stratum B incorporates all children with moderate dehydration and severe dehydration post-intravenous rehydration and compares (1:1 ratio) standard WHO ORS given for non-SAM (experimental) versus WHO SAM-recommended low-sodium ReSoMal. The primary outcome for intravenous rehydration is mortality to 96 hours and for oral rehydration a change in sodium levels at 24 hours post-randomisation. Secondary outcomes include measures assessing safety (evidence of pulmonary oedema or heart failure); change in sodium from post-iv levels for those in Stratum A; perturbations of electrolyte abnormalities (severe hyponatraemia <125 mmols/L or hypokalaemia. If the trial shows that rehydration strategies for non-malnourished children are safe and improve mortality in SAM this could prompt revisions to the current treatment recommendations or may prompt future Phase III trials.

A Rare Presentation of a Common Disorder : Severe Hyponatremia Presenting as Reversible Unstable Bradyarrythmias

Severe hyponatraemia is defined as a sodium level of less than 120 mEq/L, and it is frequently accompanied by neurological symptoms like coma, convulsions, respiratory arrest, and death. Clinical cardiac toxicity from hyponatremia, such as bradyarrhythmia, is extremely rare. In this article, we present a case of acute severe hyponatraemia that induced unstable bradyarrhythmia and led to refractory bradycardia, which did not improve despite receiving treatment in accordance with the standard Advanced Cardiovascular Life Support protocol. The patient’s bradyarrhythmia has completely resolved with the administration of 3% hypertonic saline, which restored her sodium levels. Due to the possibility that severe hyponatremia may contribute to the aetiology of cardiac malfunction, this case raises awareness about the significance of closely monitoring electrocardiograms and telemetry in patients with severe hyponatremia.

Simultaneous Occurrence of Hyponatremia and Hypokalemia in a Patient with Herpes Zoster: A Case Report with a Review of the Literature.

We herein report a patient with herpes zoster (HZ), severe hyponatremia, and hypokalemia. Syndrome of inappropriate antidiuresis (SIAD) leads to euvolemic hyponatremia and hypoosmotic plasma due to inadequate diuresis. Hyponatremia in the current patient was caused by SIAD and associated with HZ of the trigeminal facial nerve (V1). The patient also had hypokalemia, with excessive urinary potassium excretion and elevated cortisol levels. Hypokalemia is caused by hypercortisolemia, which is stimulated by HZ pain. Adequate treatment for HZ and comprehensive pain control play pivotal roles in improving SIAD, cortisol hypersecretion, and the subsequent electrolyte abnormalities.

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.

Porphyria in an Adolescent Girl: A Clinician’s Quagmire

Abstract Background: Porphyrias are a group of potentially life-threatening, metabolic disorders resulting from defective heme biosynthesis. They have a myriad of multisystem manifestations and pose a diagnostic and management challenge. Acute intermittent porphyria (AIP) is a severe and the most common form of porphyria. Awareness of this uncommon entity and a high index of suspicion are warranted for a successful outcome. Clinical Description: A 12-year-old girl was referred to us with a history of severe pain in the abdomen and generalized tonic-clonic seizures. She had episodic abdominal pain for the past 6 months associated with abnormal menstrual cycles. She had acutely raised blood pressure. She had urine was orange-pink in color, which led us to suspect a diagnosis of AIP. A urine examination confirmed the presence of porphobilinogen. On genetic testing, a pathogenic missense variation (c.518G&gt;A) in exon 9 of the hydroxymethylbilane synthase (+) gene, which is autosomal dominant, was detected, which confirmed the diagnosis. Management: Seizures were treated with lorazepam and levetiracetam. Hypertension was managed with labetalol infusion followed by amlodipine. Tramadol was given for severe pain abdomen. Persistent severe hyponatremia (serum sodium 104 mEq/L) was initially managed with normal saline 3% saline and later, with fluids restriction. Conclusion: The diagnosis of AIP should be suspected, especially in pubertal girls who present more than once with persistent symptoms of acute abdomen, vomiting, hypertension, or symptoms linked to the menstrual cycle.

Hyponatremia in the Elderly Induced by Risperidone: A Case Report

Hyponatremia due to risperidone is a rare complication that can be associated with drowsiness, confusion to coma and seizures. We report a case of a 92-year-old female with delirium combined with pulmonary infection who developed severe hyponatremia after 30 days of risperidone treatment, and the patient’s blood sodium gradually increased to normal after administration of concentrated sodium chloride, tolvaptan and gradual reduction of risperidone dosage until discontinuation. Through clinical observation, the mechanism of hyponatremia caused by risperidone is related to the Syndrome of Inappropriate Antidiuretic Hormone (SIADH).

Prevalence, Risk Factors, and Mortality of Patients Presenting with Moderate and Severe Hyponatremia in Emergency Departments.

Hyponatremia is among the most common electrolyte disturbances encountered in clinical practice and is associated with a high rate of morbidity and mortality. However, there are very limited data on adult cases presenting to emergency departments with hyponatremia. This study aimed to evaluate the frequency, clinical characteristics, and outcomes in hyponatremic patients presenting to emergency departments. This retrospective study analyzed all patients older than 18 years who visited our institution's emergency department between October 2018 and October 2019 and has a serum sodium (Na) level <130 mmol/L. Among 24,982 patients who visited the emergency department and had a documented serum sodium level, 284 were included. Patients' median age was 67.13 ± 14.8 years. Younger patients are less likely to develop severe hyponatremia compared to older patients (adjusted odds ratio (AOR): 0.415; 95% confidence interval (CI): 0.231-0.743; p=0.003). Asymptomatic hyponatremia and gastrointestinal manifestations were the most common presenting hyponatremia symptoms (33.7% and 24.2%, respectively). Proton pump inhibitor (PPI) use, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACE/ARB) use, and spironolactone use (OR = 2.6 and 3.9, 2.3 with a p=0.02, 0.03, and 0.05, respectively) were associated with increased odds of severe hyponatremia. There is no difference in the overall mortality rate within 6 months of presentation between severe and moderate hyponatremia groups (11.1% versus 16.2%, p=0.163). Moderate and severe hyponatremia are not uncommon among patients presenting to emergency departments. Moderate hyponatremia can be asymptomatic with clinical significance. Older patients, use of PPI, use of ACEi/ARBs, and spironolactone use were associated with an increased risk of severe hyponatremia compared to moderate. Further prospective analysis of a larger population is needed to confirm our findings.

Panhypopituitarism due to Sheehan’s Syndrome in a Patient with Recurrent Hyponatremia: Case Report from Nepal

Introduction: Panhypopituitarism, deficiency of all pituitary hormones (anterior pituitary hormones: adrenocorticotropic hormone, thyroid-stimulating hormone, luteinizing hormone, follicle-stimulating hormone, prolactin, growth hormone; posterior pituitary hormones: oxytocin, vasopressin). Sheehan’s syndrome also known as postpartum hypopituitarism is one of the causes of panhypopituitarism, which is characterized by hypopituitarism due to necrosis of pituitary gland secondary to massive postpartum hemorrhage. In this case, a 50 years female presented with the history of vomiting and loss of appetite since 2 years with severe hyponatremia, and decreased pituitary hormones levels in laboratory findings with significant obstetric history is diagnosed with Sheehan’s Syndrome.

Characteristics and Frequency of Hyponatremia in Newborns

Background: Hyponatremia, defined as a serum sodium level below 135 meq/L, is a significant and often overlooked problem in neonatal intensive care unit. Local data on the severity and chronicity of hyponatremia in neonates is lacking. This study aimed to investigate the features, risk factors, and frequency of hyponatremia in infants admitted to our NICU. Objective: To determine the incidence, identifying potential risk factors, assessing its severity, as well as understanding the recovery period and the duration of hospital stay associated with hyponatremia in neonates. Study Design: Cross-sectional study. Settings: Study was conducted in Neonatal ICUs of Fatima Memorial Hospital, Lahore Pakistan. Duration: January to December 2022 (1 Year). Methods: Sample size was 300, calculated with 95% confidence interval, 10% margin of error and 5% level of significance. It was done by using formula; n=Zs (p)(1-p)/d2 by using consecutive, non-probability sampling technique. After IRB approval all neonates meeting the inclusion criteria were included in the study after seeking informed consent from parents and relevant data was collected on the predesigned proforma. Results: Among 300 neonates included in final study 42% had mild hyponatremia and 58% had moderate-severe hyponatremia. Risk of severe hyponatremia were GA 28-32+6 weeks, IUGR and APGAR-5&lt;7. PIH increased the risk of chronic hyponatremia. Conclusion: In our study population 58% neonates had moderate to severe hyponatremia. Among 73.1% neonates born at GA 28-32+6 had moderate to severe hyponatremia. APGAR-5 of &lt;7 and IUGR increases the risk of moderate-severe hyponatremia by 42374 and 200 times respectively. Whereas maternal PIH is associated with increased risk of chronic hyponatremia.

Retrospective analysis of patients diagnosed with severe hyponatraemia in the emergency department.

Background . We investigated the demographic, aetiological and clinical characteristics of patients who presented to the emergency department and had severe hyponatraemia. Methods . We retrospectively evaluated 1171 patients who presented to the emergency department and were diagnosed with severe hyponatraemia. Results . Over half the patients studied were women (53.5%). The mean age of women was higher (p<0.0001). The most common complaint was dyspnoea (16.8%) and 42.5% of the patients had an oral intake disorder. In addition, 22.3% of the patients were on loop diuretics. About 76.3% of patients were conscious, and the mean sodium level of these patients was higher than the mean sodium level of those who responded to verbal and painful stimuli (p<0.001). Severe isolated hyponatraemia was observed in 61.8% of the patients. The mortality rate was 12.8%. There was no difference between the mean sodium levels of the deceased and discharged patients (p=1.0). The mortality rate was higher in patients who had a history of cirrhosis and cancer, but was lower in patients with a history of coronary artery disease (p=0.0002, p<0.0001 and p=0.04, respectively). Conclusion . Severe hyponatraemia was more prevalent in women, serum sodium levels were higher in conscious patients, and the mortality rate was higher in patients who had a history of cirrhosis and cancer. We found that the mean serum sodium levels did not help in distinguishing between the deceased and discharged patients.

Hyponatremia: A Rare Complication of Gitelmans's Syndrome - Literature Review and Clinical Case

Abstract Gitelman's syndrome (GS) is a variant of classical Bartter's syndrome (BS) in adults characterized by hypokalemic metabolic alkalosis, hypocalciuria (daily excretion &lt;2.0 mg/kg body weight), hypomagnesaemia (&lt;1.5 mg/dl), together with a normal to low blood pressure. In 1996, Simon et al. reported complete linkage between the syndrome and the thiazide-sensitive sodium chloride coporter (TSC) on chromosome 16q13 (Human Gene Mapping Workshop-approved symbol: SLCA3). Other metabolic features of GS include normonatremia, hyperuricemia, normocalcemia, increased plasma renin and aldosterone/potassium ratio, and inappropriately high renal potassium, magnesium, and chloride excretion. In this paper, we describe two affected patients who developed severe hyponatremia and hypouricemia. To the best of our knowledge, this complication has not been described previously.

Hyponatremia and Identification of Seniors at Risk (ISAR) Score in Geriatric Patients: An Analytical Cross-Sectional Study.

Aim and objective Hyponatremia is the most common electrolyte abnormality in hospitalized patients. Age is an important, strong independent factor for hyponatremia. Geriatric at-risk groups are identified with six straightforward dichotomous questions. The research aims to determine the incidence of hyponatremia and correlate the identification of seniors at risk (ISAR) score with electrolytes in elderly individuals. Materials and methods The 334 geriatric population of elderly men and women were recruited based on age cut-off as more than 70 to 75, 76 to 80, and more than 80. Patients were categorized based on serum sodium levels as severe hyponatremia group A (< 125 mEq/L), moderate hyponatremia B (126 to 130 mEq/L), mild hyponatremia C (131 to 135 mEq/L) and normonatremia D (136 to 145 mEq/L). At the time of admission, the ISAR Tool was utilized to identify the participants with hyponatremia at risk. Electrolytes sodium, potassium, and chloride were analyzed in the Beckman Coulter AU480 autoanalyzer by indirect ISE method. The mean of the data was compared with ANOVA, and the ISAR risk score was correlated with electrolytes by Pearson correlation analysis; p < 0.5 is considered significant. Results and discussion About 16.76 % (56 patients) had severe hyponatremia (Serum sodium 119.14± 4.14 mEq/L) with a high ISARscore (6.0) and were reported as critical alert results by the central laboratory. Based on age-wise category, 70 to 75 yrs had serum sodium levels of 133.82 mEq/L, 76 to 80 yrs had 128.4 mEq/L, and more than 80 years had serum hyponatremia 119.17 mEq/L. Geriatrics with normonatremia had a 1.22 ISAR score, whereas geriatrics with severe hyponatremia had a 6.0 ISAR score. Correlation analysis of the ISAR score revealed a statistically significant negative correlation with sodium (r = - 0.53), potassium (r = - 0.34), and chloride (r = - 0.30) levels. Likewise, the length of hospital stay of the geriatrics with severe hyponatremia was prolonged (19 days), which contributed to the deterioration of health status; thereby, better healthcare follow-up is encouraged. Conclusion Hyponatremia is a critical alert analyte that is common in hospitalized geriatric patients. The ISAR score system points towards the individuals who are at risk and need immediate correction. Thereby, correction of sodium levels and close monitoring of the elderly patient enables quick recovery, and the consequences of hyponatremia are circumvented.

Incidence of postoperative hyponatremia after endoscopic endonasal pituitary transposition for skull base pathologies.

Pituitary transposition is a novel surgical approach to access the retroinfundibular space and interpeduncular cistern. Few studies have evaluated post-surgical outcomes, including incidence of hyponatremia, following pituitary transposition. This is a retrospective study including 72 patients who underwent endoscopic endonasal surgery involving pituitary transposition for non-pituitary derived tumors over a decade at the University of Pittsburgh Medical Center. Anterior pituitary deficiencies and replacement therapy, tumor pathology and pre-operative serum sodium (Na) were recorded. Na was assessed at postoperative day 1, 3, 5, 7, and 10. Anatomical/surgical parameters included sellar height, sellar access angle to approach the tumor, and cranial extension of the tumor above the sellar floor (B) compared to the height of the gland (A) (B/A). T-test (normally distributed variables) and Wilcoxon rank-sum test (not-normally distributed) were applied for mean comparison. Logistic regression analyzed correlations between anatomical/surgical parameters and postoperative hyponatremia. 55.6% of patients developed post-operative transient hyponatremia. Two patients (5%) developed severe hyponatremia (sodium level < 120 mmol/L). Eleven (15.3%) patients required desmopressin replacement immediately post-operatively, and 2 other patients needed desmopressin after discharge and after sodium nadir developed. Hyponatremia was inversely associated with sellar access angle (p = 0.02) and the tumor cranial extension above the sellar floor showing a trend towards significance (p = 0.09). More than half of patients who had pituitary transposition developed transient hyponatremia. Hyponatremia was more common in those with narrower sellar access angle and smaller cranial extension of the tumor above the sellar floor. Anatomical/surgical parameters may allow risk-stratification for post-operative hyponatremia following pituitary transposition.

Postpartum acute adrenal insufficiency of early-onset Sheehan syndrome: A case series study in a single center.

To identify the symptoms and relevant factors associated with acute adrenal insufficiency of early-onset Sheehan syndrome. We retrospectively reviewed the charts of 125 women admitted to our intensive care unit because of postpartum hemorrhage between January 2011 and December 2021. Three women developed acute adrenal insufficiency. We investigated the total blood loss, shock status, consciousness level upon arrival, and intensive care provided to the women. We also analyzed the symptoms and laboratory data that led to the diagnosis of acute adrenal insufficiency. Continuous variables were presented by median (minimum-maximum). The medians and ranges of age, total blood loss, and shock index [heart rate/systolic blood pressure] on admission were 33.1 (17.2-45.3) years, 3351 (595-20 260) g, and 0.94 (0.55-2.94), respectively. Seven women were older than 40 years, 28 experienced >5000 g blood loss, 17 had shock index >1.5, 27 had impaired consciousness upon arrival, and 15 underwent hysterectomy. Women who developed acute adrenal insufficiency were <40 years old and had a bleeding volume of over 5000 g, impaired consciousness upon arrival, and had undergone hysterectomy. They had experienced lactation failure, presented with hyponatremia-related symptoms onpostpartumdays 8-9, experienced general malaise, headache, and impaired consciousness, and showed severe hyponatremia. Massive postpartum hemorrhage over 5000 g, impaired consciousness upon arrival, and hysterectomy as a hemostatic measure were relevant factors associated with acute adrenal insufficiency of early-onset Sheehan syndrome. Hyponatremia-related symptoms occurring after lactation failure are indicative of the onset of acute adrenal insufficiency.

Eslicarbazepine-induced hyponatremia: A retrospective single-center real clinical practice study.

Hyponatremia is a typical side effect of antiseizure drugs from the dibenzazepine family. The study investigated the prevalence of hyponatremia in patients with epilepsy who were treated with eslicarbazepine. We aimed to determine the prevalence of hyponatremia, reveal the factors leading to the discontinuation of treatment, and identify possible risk factors for the development of hyponatremia including the dose dependency. The medical records of 164 patients with epilepsy taking eslicarbazepine in our center were analyzed. The overall prevalence of hyponatremia was 30.5%. The prevalence of mild hyponatremia, seen in 14%-20% of patients, was not dose dependent. The prevalence of moderate and severe hyponatremia was significantly dose dependent. The severity of hyponatremia was significantly dose dependent. Severe hyponatremia was found in 6.1% of patients. Hyponatremia was asymptomatic in the majority of cases, and in 48% did not require any management. Hyponatremia was the reason for discontinuation in 6.2% of patients. The major risk factor for developing hyponatremia was older age. The study shows that eslicarbazepine-induced hyponatremia is usually mild and asymptomatic. It usually does not require any management and seldom leads to treatment discontinuation. Hyponatremia is dose dependent. Another major risk for developing hyponatremia (besides dose) is older age.

Risk Factors of Under-Correction in Severe Hyponatremia: A Post Hoc Analysis of the SALSA Trial

Risk Factors of Under-Correction in Severe Hyponatremia: A Post Hoc Analysis of the SALSA Trial

Safety and Efficacy of Proactive vs. Reactive Administration of DDAVP in Severe Symptomatic Hyponatremia: A Randomized Controlled Trial

Safety and Efficacy of Proactive vs. Reactive Administration of DDAVP in Severe Symptomatic Hyponatremia: A Randomized Controlled Trial

Treatment of Severe Hyponatremia with Urea in Liver Cirrhosis

Treatment of Severe Hyponatremia with Urea in Liver Cirrhosis