|
1
|
Arzhan S, Lew SQ, Ing TS, Tzamaloukas AH, Unruh ML. Dysnatremias in Chronic Kidney Disease: Pathophysiology, Manifestations, and Treatment. Front Med (Lausanne) 2021; 8:769287. [PMID: 34938749 PMCID: PMC8687113 DOI: 10.3389/fmed.2021.769287] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/04/2021] [Indexed: 12/29/2022] Open
Abstract
The decreased ability of the kidney to regulate water and monovalent cation excretion predisposes patients with chronic kidney disease (CKD) to dysnatremias. In this report, we describe the clinical associations and methods of management of dysnatremias in this patient population by reviewing publications on hyponatremia and hypernatremia in patients with CKD not on dialysis, and those on maintenance hemodialysis or peritoneal dialysis. The prevalence of both hyponatremia and hypernatremia has been reported to be higher in patients with CKD than in the general population. Certain features of the studies analyzed, such as variation in the cut-off values of serum sodium concentration ([Na]) that define hyponatremia or hypernatremia, create comparison difficulties. Dysnatremias in patients with CKD are associated with adverse clinical conditions and mortality. Currently, investigation and treatment of dysnatremias in patients with CKD should follow clinical judgment and the guidelines for the general population. Whether azotemia allows different rates of correction of [Na] in patients with hyponatremic CKD and the methodology and outcomes of treatment of dysnatremias by renal replacement methods require further investigation. In conclusion, dysnatremias occur frequently and are associated with various comorbidities and mortality in patients with CKD. Knowledge gaps in their treatment and prevention call for further studies.
Collapse
Affiliation(s)
- Soraya Arzhan
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Susie Q. Lew
- Department of Medicine, George Washington University, Washington, DC, United States
| | - Todd S. Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, United States
| | - Antonios H. Tzamaloukas
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
- Research Service, Raymond G. Murphy Veteran Affairs (VA) Medical Center, Albuquerque, NM, United States
| | - Mark L. Unruh
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
- Medicine Service, Division of Nephrology, Raymond G. Murphy Veteran Affairs (VA) Medical Center, Albuquerque, NM, United States
| |
Collapse
|
|
2
|
Brennan M, Mulkerrin L, Wall D, O'Shea PM, Mulkerrin EC. Suboptimal management of hypernatraemia in acute medical admissions. Age Ageing 2021; 50:990-995. [PMID: 33765147 DOI: 10.1093/ageing/afab056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hypernatraemia arises commonly in acute general medical admissions. Affected patients have a guarded prognosis with high rates of morbidity and mortality. Age-related physiology and physical/cognitive barriers to accessing water predispose older patients to developing hypernatraemia. This study sought to perform a descriptive retrospective review of hypernatraemic patients admitted under acute general medicine teams. METHODS A retrospective cross-sectional study of a sample of acute medical in-patients with serum[sodium]>145 mmol/L was conducted. Patients were exclusively older(>69 years) and admitted from Nursing homes (NH)(41%) and non-NH pathways(59%). A comparison of management of NH /non-NH patients including clinical presentation, comorbidities, laboratory values, [sodium] monitoring, intravenous fluid regimes and patient outcomes was performed. RESULTS In total, 102 consecutive patients (males, n=69(67.6%)) were included. Dementia and reduced mobility were more common in NH residents and admission serum [Sodium] higher (148 vs 142 mmol/L/p=0.003). Monitoring was inadequate: no routine bloods within the first 12h in >80% of patients in both groups. No patient had calculated free water deficit documented. More NH patients received correct fluid management (60% vs 33%/p%0.015). Incorrect fluid regimes occurred in both groups (38% vs 58%/p=0.070). Length of stay in discharged patients was lower in NH, (8(4-20) vs 20.5(9.8-49.3 days)/p=0.003). Time to death for NH residents was shorter (9(5.5-11.5) vs 16 (10.25-23.5) days/p=0.011). CONCLUSION This study highlights suboptimal management of hypernatraemia. Implementation of hypernatraemia guidelines for general medical older inpatients are clearly required with mechanisms to confirm adherence. Health care workers require further education on diagnostic challenges of dehydration in older people and the importance of maintaining adequate hydration.
Collapse
Affiliation(s)
- Michelle Brennan
- Department of Geriatric Medicine, Saolta University Health Care Group (SUHCG), University Hospital Galway, Galway, Ireland
| | - Lorcan Mulkerrin
- Department of Geriatric Medicine, Saolta University Health Care Group (SUHCG), University Hospital Galway, Galway, Ireland
| | - Deirdre Wall
- School of Mathematics, Statistics and Applied Mathematics, National University of Ireland Galway, Galway, Ireland
| | - Paula M O'Shea
- Department of Clinical Biochemistry, Saolta University Health Care Group (SUHCG), Galway University Hospitals, Galway, Ireland
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Eamon C Mulkerrin
- Department of Geriatric Medicine, Saolta University Health Care Group (SUHCG), University Hospital Galway, Galway, Ireland
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| |
Collapse
|
|
3
|
Overgaard-Steensen C, Poorisrisak P, Heiring C, Schmidt LS, Voldby A, Høi-Hansen C, Langkilde A, Sterns RH. Fatal case of hospital-acquired hypernatraemia in a neonate: lessons learned from a tragic error. Clin Kidney J 2020; 14:1277-1283. [PMID: 33841873 PMCID: PMC8023185 DOI: 10.1093/ckj/sfaa108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Indexed: 11/28/2022] Open
Abstract
A 3-week-old boy with viral gastroenteritis was by error given 200 mL 1 mmol/mL hypertonic saline intravenously instead of isotonic saline. His plasma sodium concentration (PNa) increased from 136 to 206 mmol/L. Extreme brain shrinkage and universal hypoperfusion despite arterial hypertension resulted. Treatment with glucose infusion induced severe hyperglycaemia. Acute haemodialysis decreased the PNa to 160 mmol/L with an episode of hypoperfusion. The infant developed intractable seizures, severe brain injury on magnetic resonance imaging and died. The most important lesson is to avoid recurrence of this tragic error. The case is unique because a known amount of sodium was given intravenously to a well-monitored infant. Therefore the findings give us valuable data on the effect of fluid shifts on the PNa, the circulation and the brain’s response to salt intoxication and the role of dialysis in managing it. The acute salt intoxication increased PNa to a level predicted by the Edelman equation with no evidence of osmotic inactivation of sodium. Treatment with glucose in water caused severe hypervolaemia and hyperglycaemia; the resulting increase in urine volume exacerbated hypernatraemia despite the high urine sodium concentration, because electrolyte-free water clearance was positive. When applying dialysis, caution regarding circulatory instability is imperative and a treatment algorithm is proposed.
Collapse
Affiliation(s)
| | - Porntiva Poorisrisak
- Department of Neonatology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Christian Heiring
- Department of Neonatology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Lisbeth Samsø Schmidt
- Department of Pediatrics, Herlev Hospital, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Anders Voldby
- Department of Pediatrics, Herlev Hospital, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Christina Høi-Hansen
- Department of Pediatrics, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Annika Langkilde
- Department of Radiology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Richard H Sterns
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.,Rochester General Hospital, Rochester, NY, USA
| |
Collapse
|
|
4
|
Tomarelli G, Arriagada D, Donoso A, Diaz F. Extreme Neonatal Hypernatremia and Acute Kidney Injury Associated with Failure of Lactation. J Pediatr Intensive Care 2020; 9:124-127. [PMID: 32351767 PMCID: PMC7186027 DOI: 10.1055/s-0039-3400469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 10/20/2019] [Indexed: 01/31/2023] Open
Abstract
Hypoalimentation is an important cause of hypernatremic dehydration in neonates; however, extreme values of plasma sodium make it necessary to investigate the differential diagnosis. We report the case of a 20-day-old newborn who was admitted with severe hypernatremic dehydration, with plasma sodium of 213 mEq/L and oliguric acute renal failure. The patient was treated with intravenous fluids for correction of dehydration and peritoneal dialysis for adequate sodium correction. During the etiological study, a 10-fold increase in the concentration of sodium in breast milk was detected. Peritoneal dialysis was an effective therapy in the management of the extreme hypernatremia with sodium correction within the recommended rate. At the 1-year follow-up appointment, the child had normal renal function, normal for age psychomotor development, and neurological physical was unremarkable. In conclusion, we report a case of an unusual extreme hypernatremia with discussion of the underlying pathophysiology and, more importantly, the effective treatment with a mixed approach with intravenous fluids and peritoneal dialysis.
Collapse
Affiliation(s)
- Gianfranco Tomarelli
- Pediatric Intensive Care Unit, Hospital Clínico Metropolitano La Florida, Santiago, Chile
| | - Daniela Arriagada
- Pediatric Intensive Care Unit, Hospital Clínico Metropolitano La Florida, Santiago, Chile
| | - Alejandro Donoso
- Pediatric Intensive Care Unit, Hospital Clínico Metropolitano La Florida, Santiago, Chile
| | - Franco Diaz
- Pediatric Intensive Care Unit, Hospital Clínico Metropolitano La Florida, Santiago, Chile
| |
Collapse
|
|
5
|
Blohm E, Goldberg A, Salerno A, Jenny C, Boyer E, Babu K. Recognition and Management of Pediatric Salt Toxicity. Pediatr Emerg Care 2018; 34:820-824. [PMID: 29095382 DOI: 10.1097/pec.0000000000001340] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Immediate recognition of salt toxicity and aggressive resuscitative measures are critical in the treatment of this lethal poisoning. Despite heroic measures, pediatric deaths due to salt toxicity still occur from irreversible neurological damage. The objective of this article is to review the relevant literature and offer a therapeutic algorithm for the management of pediatric patients presenting with salt toxicity. METHODS A literature search for cases of salt toxicity was conducted. Articles in English that were available electronically through PubMed and Google Scholar were reviewed. RESULTS Nineteen cases and case series of salt toxicity were located using our search strategy. Salt poisoning has a distinct pathophysiology compared with hypernatremia, most notable for the lack of formation of idiogenic osmoles. CONCLUSIONS The approach to treatment differs between salt toxicity and hypernatremia, focusing on rapid correction of serum osmolality rather than gradual normalization of serum sodium concentrations. Consultation of nephrology and child protection services are strongly recommended in the comprehensive treatment approach.
Collapse
Affiliation(s)
| | | | - Ann Salerno
- Division of Nephrology, Department of Medicine, University of Massachusetts
| | - Carole Jenny
- Department of Pediatrics, University of Washington
| | - Edward Boyer
- Division of Toxicology, Department of Emergency Medicine, Brigham and Women's Hospital
| | | |
Collapse
|
|
6
|
Rondon-Berrios H, Argyropoulos C, Ing TS, Raj DS, Malhotra D, Agaba EI, Rohrscheib M, Khitan ZJ, Murata GH, Shapiro JI, Tzamaloukas AH. Hypertonicity: Clinical entities, manifestations and treatment. World J Nephrol 2017; 6:1-13. [PMID: 28101446 PMCID: PMC5215203 DOI: 10.5527/wjn.v6.i1.1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/17/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023] Open
Abstract
Hypertonicity causes severe clinical manifestations and is associated with mortality and severe short-term and long-term neurological sequelae. The main clinical syndromes of hypertonicity are hypernatremia and hyperglycemia. Hypernatremia results from relative excess of body sodium over body water. Loss of water in excess of intake, gain of sodium salts in excess of losses or a combination of the two are the main mechanisms of hypernatremia. Hypernatremia can be hypervolemic, euvolemic or hypovolemic. The management of hypernatremia addresses both a quantitative replacement of water and, if present, sodium deficit, and correction of the underlying pathophysiologic process that led to hypernatremia. Hypertonicity in hyperglycemia has two components, solute gain secondary to glucose accumulation in the extracellular compartment and water loss through hyperglycemic osmotic diuresis in excess of the losses of sodium and potassium. Differentiating between these two components of hypertonicity has major therapeutic implications because the first component will be reversed simply by normalization of serum glucose concentration while the second component will require hypotonic fluid replacement. An estimate of the magnitude of the relative water deficit secondary to osmotic diuresis is obtained by the corrected sodium concentration, which represents a calculated value of the serum sodium concentration that would result from reduction of the serum glucose concentration to a normal level.
Collapse
|
|
7
|
Carlberg DJ, Borek HA, Syverud SA, Holstege CP. Survival of acute hypernatremia due to massive soy sauce ingestion. J Emerg Med 2013; 45:228-31. [PMID: 23735849 DOI: 10.1016/j.jemermed.2012.11.109] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 10/25/2011] [Accepted: 11/29/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intentional massive sodium chloride ingestions are rare occurrences and are often fatal. OBJECTIVES There are a variety of treatment recommendations for hypernatremia, ranging from dialysis to varying rates of correction. We report a case of acute severe hypernatremia corrected with rapid free-water infusions that, to our knowledge, has not been previously reported. CASE REPORT A 19-year-old man presented to the Emergency Department in a comatose state with seizure-like activity 2 hours after ingesting a quart of soy sauce. He was administered 6 L of free water over 30 min and survived neurologically intact without clinical sequelae. Corrected for hyperglycemia, the patient's peak serum sodium was 196 mmol/L, which, to our knowledge, is the highest documented level in an adult patient to survive an acute sodium ingestion without neurologic deficits. CONCLUSION Emergency physicians should consider rapidly lowering serum sodium with hypotonic intravenous fluids as a potential management strategy for acute severe hypernatremia secondary to massive salt ingestion.
Collapse
Affiliation(s)
- David J Carlberg
- Department of Emergency Medicine, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | | | | | | |
Collapse
|
|
8
|
Imashuku S, Kudo N, Kubo K. Severe hypernatremia and hyperchloremia in an elderly patient with IgG-kappa-type multiple myeloma. J Blood Med 2013; 4:43-7. [PMID: 23700375 PMCID: PMC3660129 DOI: 10.2147/jbm.s44091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 77-year-old male was admitted to hospital after suffering a pelvic bone fracture in a road traffic accident and was incidentally found to have IgG-kappa-type multiple myeloma with hypercalcemia. The patient was also noted to be hypokalemic and had low HCO3−, with possible damage to the distal tubules in the kidneys. When the treatment was begun with bortezomib/dexamethasone/elcatonin and sodium bicarbonate (NaHCO3) in normal saline (equivalent to a daily sodium dose of 200 millimoles per liter [mmol/L]), the patient was in a state of poor oral fluid intake. The patient developed hypernatremia and hyperchloremia, with a peak serum sodium and chloride levels of 183 mmol/L and 153 mmol/L, respectively, at the sixth day after the start of treatment. Following the switch of the intravenous infusions from normal saline to soldem 1 and soldem 3 solutions, these high-electrolyte levels gradually returned to normal over the next 7 days. Although the patient showed disturbed consciousness (Japan Coma Scale = JCS-I-3) during the period of electrolyte abnormality, he eventually fully recovered without sequelae. In this patient, we successfully managed the severe hypernatremia/hyperchloremia, caused by the combined effects of intravenous saline burden in a state of poor oral fluid intake, during the treatment for IgG-kappa type multiple myeloma.
Collapse
|
|
9
|
Yildiz N, Erguven M, Yildiz M, Ozdogan T, Turhan P. Acute peritoneal dialysis in neonates with acute kidney injury and hypernatremic dehydration. Perit Dial Int 2012; 33:290-6. [PMID: 23123669 DOI: 10.3747/pdi.2011.00211] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We aimed to evaluate the efficacy of acute peritoneal dialysis (PD) and clinical outcomes in neonates with acute kidney injury (AKI) and hypernatremic dehydration. ♢ METHODS The medical records of 15 neonates with AKI and hypernatremic dehydration who were treated with acute PD were reviewed. The diagnoses were AKI with hypernatremic dehydration with or without sepsis in 13 patients and AKI with hypernatremia and congenital nephropathy in 2 patients. The main indications for PD were AKI with some combination of oligoanuria, azotemia, hyperuricemia, and metabolic acidosis unresponsive to initial intensive medical treatment. ♢ RESULTS The mean age of the patients at dialysis initiation was 11.9 ± 9 days, and the mean duration of PD was 6.36 ± 4.8 days. In 7 patients (46.7%), hypotension required the use of vasopressors, and in 6 patients (40%), mechanical ventilation was required. Peritoneal dialysis-related complications occurred in 7 patients (46.7%), the most common being catheter malfunction (n = 6). Four episodes of peritonitis occurred in the 15 patients (26.7%), 2 episodes in patients with congenital renal disease and 2 episodes in patients with sepsis and multiorgan failure, who did not survive. Congenital renal disease, septicemia, and the need for mechanical ventilation were important factors influencing patient survival. All patients with no pre-existing renal disease or sepsis recovered their renal function and survived. ♢ CONCLUSIONS In neonates with AKI and hypernatremic dehydration, PD is safe and successful, and in patients without congenital renal disease or sepsis, the prognosis is good. Peritoneal dialysis should be the treatment of choice in neonates with AKI and hypernatremic dehydration who do not respond to appropriate medical treatment.
Collapse
Affiliation(s)
- Nurdan Yildiz
- Department of Pediatric Nephrology, Göztepe Teaching and Research Hospital, Istanbul, Turkey.
| | | | | | | | | |
Collapse
|
|
10
|
|
|
11
|
McBryde KD, Bunchman TE, Kudelka TL, Pasko DA, Brophy PD. Hyperosmolar solutions in continuous renal replacement therapy for hyperosmolar acute renal failure: a preliminary report. Pediatr Crit Care Med 2005; 6:220-5. [PMID: 15730613 DOI: 10.1097/01.pcc.0000154954.24129.f7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To demonstrate the efficacy of hyperosmolar dialysis and prefilter replacement fluid solutions for continuous renal replacement therapies in the correction of hyperosmolar disorders in acute renal failure. DATA SOURCE An Institutional Review Board-approved pediatric acute renal failure database at the University of Michigan C. S. Mott Children's Hospital. STUDY SELECTION Three patients were identified meeting the inclusion criteria. The mean serum sodium concentration and plasma osmolality were 158 mmol/L and 357 mOsm/kg, respectively, at the time of initiation of renal replacement therapy. The sodium and/or dextrose concentrations of the dialysate or replacement fluids initially were increased and subsequently decreased to affect the solutions' calculated osmolalities in an effort to control the rate of decline of the patients' measured plasma osmolalities. DATA EXTRACTION The case patients' serum sodium concentrations and plasma osmolalities were measured. Additionally, the sodium and dextrose concentrations of the dialysate or replacement fluid were recorded and the solutions' osmolalities calculated. DATA SYNTHESIS The three patients experienced a mean rate of reduction of their serum sodium concentration and plasma osmolality of 0.5 mmol/L/hr and 1.6 mOsm/kg/hr, respectively. CONCLUSIONS Hyperosmolar dialysis or prefilter replacement fluid solutions can affect a slow decline in both the serum sodium and plasma osmolality in cases of hyperosmolar acute renal failure.
Collapse
Affiliation(s)
- Kevin D McBryde
- Department of Pediatrics, Children's National Medical Center, The George Washington University, Washington, DC, USA
| | | | | | | | | |
Collapse
|
|
12
|
Abstract
The clinical features of 12 children who incurred non-accidental salt poisoning are reported. The children usually presented to hospital in the first six months of life with unexplained hypernatraemia and associated illness. Most of the children suffered repetitive poisoning before detection. The perpetrator was believed to the mother for 10 children, the father for one, and either parent for one. Four children had serum sodium concentrations above 200 mmol/l. Seven children had incurred other fabricated illness, drug ingestion, physical abuse, or failure to thrive/neglect. Two children died; the other 10 remained healthy in alternative care. Features are described that should lead to earlier detection of salt poisoning; the importance of checking urine sodium excretion, whenever hypernatraemia occurs, is stressed.
Collapse
Affiliation(s)
- R Meadow
- Department of Paediatrics and Child Health, St James's University Hospital, Leeds
| |
Collapse
|