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Lamarche F, Ammann H, Dallaire G, Deslauriers L, Troyanov S. The risk of sodium overcorrections in severe hyponatremia and the utility of desmopressin: a large retrospective study. Clin Kidney J 2025; 18:sfae386. [PMID: 40235629 PMCID: PMC11997796 DOI: 10.1093/ckj/sfae386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Indexed: 04/17/2025] Open
Abstract
Background The suggested narrow rate of serum sodium (sNa) correction in hyponatremia can be difficult to respect, leading to overcorrections. Our ability to anticipate the rapidity of correction according to the mechanism of hyponatremia is uncertain. While desmopressin is often used to pause a rapid rise in sNa, its dose-related effect is also not well described. We studied the rate of hyponatremia overcorrections, its prediction and the utility of desmopressin in its management. Methods We retrospectively reviewed all cases of severe hyponatremia (sNa <120 mmol/L) in a large university hospital that occurred over 10 years. We assessed investigations, causes and treatments. We compared all sNa separated by at least 8 h and calculated correction rates. Significant overcorrection rates were defined by any rise of sNa >9 mmol/L per day sustained over at least 24 h. Results After exclusions, we found 355 episodes of severe hyponatremia. Low, appropriate and inappropriate antidiuretic hormone (ADH)-defined mechanisms accounted for 17%, 24% and 29% of etiologies, respectively, with the remaining 25% secondary to diuretics and 5% of uncertain causes. First urinary sodium and osmolality were consistent with the final diagnosis in 73%. Significant overcorrections were seen in 45% and were frequent in the setting of low ADH. Desmopressin was given in 82 episodes, more often as a rescue than a preventive measure, with the subsequent sNa dropping by ≥5 mmol/L by 12 h in eight instances. The dose of desmopressin (≥2 µg versus 1 µg) and a higher volume of intravenous free-water coadministration resulted in a clinically meaningful greater reduction in sNa in the following 12 h. Conclusions Overcorrections in severe hyponatremia are common, mainly when ADH is low. Initial urinary measurements anticipate this risk. Desmopressin effectively halted the rate of correction in a dose-dependent manner. Caution should be given when coadministrating water, which can significantly lower the sNa.
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Affiliation(s)
- Florence Lamarche
- Department of Medicine, Nephrology Service, Hôpital du Sacré-Coeur de Montréal, University of Montréal, Montréal, Quebec, Canada
| | - Hélène Ammann
- Department of Medicine, Biochemistry Service, Hôpital du Sacré-Coeur de Montréal, University of Montréal, Montréal, Quebec, Canada
| | - Gabriel Dallaire
- Department of Pharmacy, Hôpital du Sacré-Coeur de Montréal, University of Montréal, Montréal, Quebec, Canada
| | - Louis Deslauriers
- Department of Pharmacy, Hôpital du Sacré-Coeur de Montréal, University of Montréal, Montréal, Quebec, Canada
| | - Stéphan Troyanov
- Department of Medicine, Nephrology Service, Hôpital du Sacré-Coeur de Montréal, University of Montréal, Montréal, Quebec, Canada
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2
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Wernicke C, Bachmann U, Mai K. Hyponatremia in the emergency department: an overview of diagnostic and therapeutic approach. Biomarkers 2024; 29:244-254. [PMID: 38853611 DOI: 10.1080/1354750x.2024.2361074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/16/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION Hyponatremia, defined as a serum sodium concentration <135 mmol/l, is a frequent electrolyte disorder in patients presenting to an emergency department (ED). In this context, appropriate diagnostic and therapeutic management is rarely performed and challenging due to complex pathophysiologic mechanisms and a variety of underlying diseases. OBJECTIVE To implement a feasible pathway of central diagnostic and therapeutic steps in the setting of an ED. METHODS We conducted a narrative review of the literature, considering current practice guidelines on diagnosis and treatment of hyponatremia. Underlying pathophysiologic mechanisms and management of adverse treatment effects are outlined. We also report four cases observed in our ED. RESULTS Symptoms associated with hyponatremia may appear unspecific and range from mild cognitive deficits to seizures and coma. The severity of hyponatremia-induced neurological manifestation and the risk of poor outcome is mainly driven by the rapidity of serum sodium decrease. Therefore, emergency treatment of hyponatremia should be guided by symptom severity and the assumed onset of hyponatremia development, distinguishing acute (<48 hours) versus chronic hyponatremia (>48 hours). CONCLUSIONS Especially in moderately or severely symptomatic patients presenting to an ED, the application of a standard management approach appears to be critical to improve overall outcome. Furthermore, an adequate work-up in the ED enables further diagnostic and therapeutic evaluation during hospitalization.
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Affiliation(s)
- Charlotte Wernicke
- Department of Endocrinology and Metabolism, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ulrike Bachmann
- Department of Emergency and Acute Medicine, Charité-Universitätsmedizin Berlin Campus Mitte and Virchow, Berlin, Germany
| | - Knut Mai
- Department of Endocrinology and Metabolism, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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3
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Zieg J, Narla D, Gonsorcikova L, Raina R. Fluid management in children with volume depletion. Pediatr Nephrol 2024; 39:423-434. [PMID: 37452205 DOI: 10.1007/s00467-023-06080-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
Volume depletion is a common condition and a frequent cause of hospitalization in children. Proper assessment of the patient includes a detailed history and a thorough physical examination. Biochemical tests may be useful in selected cases. Understanding the pathophysiology of fluid balance is necessary for appropriate management. A clinical dehydration scale assessing more physical findings may help to determine dehydration severity. Most dehydrated children can be treated orally; however, intravenous therapy may be indicated in patients with severe volume depletion, in those who have failed oral therapy, or in children with altered consciousness or significant metabolic abnormalities. Proper management consists of restoring circulatory volume and electrolyte balance. In this paper, we review clinical aspects, diagnosis, and management of children with volume depletion.
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Affiliation(s)
- Jakub Zieg
- Department of Pediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Deepti Narla
- Department of Pediatric Nephrology, Akron Children's Hospital, Cleveland, OH, USA
| | - Lucie Gonsorcikova
- Department of Pediatrics, First Faculty of Medicine, Charles University in Prague and Thomayer University Hospital, Prague, Czech Republic
| | - Rupesh Raina
- Department of Pediatric Nephrology, Akron Children's Hospital, Cleveland, OH, USA.
- Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
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Pelouto A, Refardt JC, Christ-Crain M, Zandbergen AAM, Hoorn EJ. Overcorrection and undercorrection with fixed dosing of bolus hypertonic saline for symptomatic hyponatremia. Eur J Endocrinol 2023; 188:322-330. [PMID: 36881992 DOI: 10.1093/ejendo/lvad028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/13/2023] [Accepted: 03/06/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVE Current guidelines recommend treating symptomatic hyponatremia with rapid bolus-wise infusion of fixed volumes of hypertonic saline regardless of body weight. We hypothesize that this approach is associated with overcorrection and undercorrection in patients with low and high body weight. DESIGN Single-center, retrospective cohort study. METHODS Data were collected on patients treated with ≥1 bolus 100 or 150 mL 3% NaCl for symptomatic hyponatremia between 2017 and 2021. Outcomes were overcorrection (plasma sodium rise > 10 mmol/L/24 h, > 18 mmol/L/48 h, or relowering therapy) and undercorrection (plasma sodium rise < 5 mmol/L/24 h). Low body weight and high body weight were defined according to the lowest (≤60 kg) and highest (≥80 kg) quartiles. RESULTS Hypertonic saline was administered to 180 patients and caused plasma sodium to rise from 120 mmol/L to 126.4 mmol/L (24 h) and 130.4 mmol/L (48 h). Overcorrection occurred in 32 patients (18%) and was independently associated with lower body weight, weight ≤ 60 kg, lower baseline plasma sodium, volume depletion, hypokalemia, and less boluses. In patients without rapidly reversible causes of hyponatremia, overcorrection still occurred more often in patients ≤ 60 kg. Undercorrection occurred in 52 patients (29%) and was not associated with body weight or weight ≥ 80 kg but was associated with weight ≥ 100 kg and lean body weight in patients with obesity. CONCLUSION Our real-world data suggest that fixed dosing of bolus hypertonic saline may expose patients with low and high body weight to more overcorrection and undercorrection, respectively. Prospective studies are needed to develop and validate individualized dosing models.
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Affiliation(s)
- Anissa Pelouto
- Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, PO Box 2040, Room Ns403, 3000 CA Rotterdam, The Netherlands
| | - Julie C Refardt
- Departments of Endocrinology, Diabetology and Metabolism University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Mirjam Christ-Crain
- Departments of Endocrinology, Diabetology and Metabolism University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Adrienne A M Zandbergen
- Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, PO Box 2040, Room Ns403, 3000 CA Rotterdam, The Netherlands
| | - Ewout J Hoorn
- Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, PO Box 2040, Room Ns403, 3000 CA Rotterdam, The Netherlands
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5
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El-Moussa A, Mohsin SU, Alrawi O, Yaseen O, Osman Malik Y. Recurrent Hyponatremia in the Setting of Autoimmune Disease with Sicca Syndrome: A Case Report. Case Rep Nephrol Dial 2023; 13:45-50. [PMID: 37384122 PMCID: PMC10294280 DOI: 10.1159/000530491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 03/27/2023] [Indexed: 06/30/2023] Open
Abstract
Sjogren's syndrome is an autoimmune disease associated with xerostomia and xerophthalmia. The association of Sjogren's with hyponatremia has rarely been reported and has been attributed to syndrome of inappropriate antidiuretic hormone secretion. Here, we report a case of polydipsia secondary to xerostomia as a cause of chronic hyponatremia in the setting of Sjogren's syndrome. Analysis of the patient's medical record, including medication reconciliation and dietary habits, revealed several underlying causes of her recurrent hyponatremia. A thorough review of the patient's clinical history and good bedside examination may reduce prolonged hospitalizations and improve the quality of life of a hyponatremic population of patients who are predominantly elderly.
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Affiliation(s)
- Ahmad El-Moussa
- Department of Internal Medicine, Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - Syed Umer Mohsin
- Department of Internal Medicine, Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - Omer Alrawi
- Department of Internal Medicine, Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - Obead Yaseen
- Department of Internal Medicine, Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - Yahya Osman Malik
- Department of Internal Medicine, Detroit Medical Center, Wayne State University, Detroit, MI, USA
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6
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Yang H, Yoon S, Kim EJ, Seo JW, Koo JR, Oh YK, Jo YH, Kim S, Baek SH. Risk factors for overcorrection of severe hyponatremia: a post hoc analysis of the SALSA trial. Kidney Res Clin Pract 2022; 41:298-309. [PMID: 35286796 PMCID: PMC9184842 DOI: 10.23876/j.krcp.21.180] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 11/21/2021] [Indexed: 11/25/2022] Open
Abstract
Background Hyponatremia overcorrection can result in irreversible neurologic impairment such as osmotic demyelination syndrome. Few prospective studies have identified patients undergoing hypertonic saline treatment with a high risk of hyponatremia overcorrection. Methods We conducted a post hoc analysis of a multicenter, prospective randomized controlled study, the SALSA trial, in 178 patients aged above 18 years with symptomatic hyponatremia (mean age, 73.1 years; mean serum sodium level, 118.2 mEq/L). Overcorrection was defined as an increase in serum sodium levels by >12 or 18 mEq/L within 24 or 48 hours, respectively. Results Among the 178 patients, 37 experienced hyponatremia overcorrection (20.8%), which was independently associated with initial serum sodium level (≤110, 110–115, 115–120, and 120–125 mEq/L with 7, 4, 2, and 0 points, respectively), chronic alcoholism (7 points), severe symptoms of hyponatremia (3 points), and initial potassium level (<3.0 mEq/L, 3 points). The NASK (hypoNatremia, Alcoholism, Severe symptoms, and hypoKalemia) score was derived from four risk factors for hyponatremia overcorrection and was significantly associated with overcorrection (odds ratio, 1.41; 95% confidence interval, 1.24–1.61; p < 0.01) with good discrimination (area under the receiver-operating characteristic [AUROC] curve, 0.76; 95% CI, 0.66–0.85; p < 0.01). The AUROC curve of the NASK score was statistically better compared with those of each risk factor. Conclusion In treating patients with symptomatic hyponatremia, individuals with high hyponatremia overcorrection risks were predictable using a novel risk score summarizing baseline information.
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Affiliation(s)
- Huijin Yang
- Division of Nephrology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Songuk Yoon
- Division of Nephrology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Eun Jung Kim
- Division of Nephrology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Jang Won Seo
- Division of Nephrology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Ja-Ryong Koo
- Division of Nephrology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Yun Kyu Oh
- Division of Nephrology, Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sejoong Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Center for Artificial Intelligence in Healthcare, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Sejoong Kim Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Republic of Korea. E-mail:
| | - Seon Ha Baek
- Division of Nephrology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
- Correspondence: Seon Ha Baek Division of Nephrology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, 7 Keunjaebong-gil, Hwaseong 18450, Republic of Korea. E-mail: ,
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7
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Ling KHS, Wu P, Chan KC. Correction of severe hyponatremia by continuous veno-venous hemodialysis with regional citrate anticoagulation: A case series. Ther Apher Dial 2022; 26:1114-1120. [PMID: 35114071 DOI: 10.1111/1744-9987.13808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/30/2022] [Accepted: 02/01/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Hyponatremia is a common electrolyte disturbance in critically ill patients. Management of Intensive Care Unit (ICU) patients with concurrent hyponatremia and renal failure requiring dialysis is challenging especially with regional citrate anticoagulation which may cause excessive rise of serum [Na+ ]. We described the first and successful modified continuous veno-venous hemodialysis (CVVHD) regimen using regional citrate anticoagulation. METHOD A mathematical model was developed to predict serum [Na+ ] change during CVVHD. Our in-house CVVHD regimen using regional citrate anticoagulation was modified to slow down the rise of serum [Na+ ] by both modifying the dialysate solution and modifying the circuit. RESULT Five out of six patients had gradual serum [Na+ ] correction not exceeding the daily limit. None of them developed osmotic demyelination syndrome. CONCLUSION We concluded that regional citrate anticoagulation, with proper modification, is safe and effective for patients with severe hyponatremia requiring hemodialysis.
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Affiliation(s)
| | - Ping Wu
- Department of Intensive Care, Tuen Mun Hospital, Hong Kong
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Lippold C, Patel A. Correction of hyponatremia by infusing D5W (5% dextrose in water solution) prefilter in patients receiving continuous renal replacement therapy: A case series. Hemodial Int 2020; 24:E27-E32. [DOI: 10.1111/hdi.12819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 12/01/2019] [Accepted: 01/12/2020] [Indexed: 01/24/2023]
Affiliation(s)
- Cassiopia Lippold
- Department of Nephrology, Baltimore VA Medical Center Baltimore Maryland USA
- Department of Nephrology, University of Maryland School of Medicine Baltimore Maryland USA
| | - Ami Patel
- Department of Nephrology, Baltimore VA Medical Center Baltimore Maryland USA
- Department of Nephrology, University of Maryland School of Medicine Baltimore Maryland USA
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9
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Sojar SH, Goldner JSV, Krishnamoorthy K, Murphy SA, Masiakos PT, Klig JE. A 17-Year-Old Boy With High-Functioning Autism, Gastrointestinal Illness, and Seizures. Pediatrics 2019; 143:peds.2017-3964. [PMID: 30545828 DOI: 10.1542/peds.2017-3964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2018] [Indexed: 11/24/2022] Open
Abstract
A healthy 17-year-old boy with a high-functioning pervasive developmental disorder presented to the emergency department after having a 4-minute episode of seizure-like activity in the setting of presumed viral gastroenteritis. Within an hour of emergency department arrival, he developed a forehead-sparing facial droop, right-sided ptosis, and expressive aphasia, prompting stroke team assessment and urgent neuroimaging. Laboratory results later revealed a serum sodium of 119 mmol/L. Neurologic deficits self-resolved, and a full physical examination revealed diffuse abdominal tenderness in the lower abdomen with rebound tenderness in the right-lower quadrant. The patient was admitted to the PICU for electrolyte management and monitoring. A computed tomography (CT) scan of the abdomen obtained the following morning revealed the patient's final diagnosis.
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Affiliation(s)
- Sakina H Sojar
- Massachusetts General Hospital, Boston, Massachusetts; and
| | | | | | - Sarah A Murphy
- Massachusetts General Hospital, Boston, Massachusetts; and
| | | | - Jean E Klig
- Massachusetts General Hospital, Boston, Massachusetts; and
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10
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Dreyfuss D, Gaudry S. Quelle étrange idée : utiliser un analogue de l’hormone antidiurétique au cours du traitement d’une hyponatrémie ? MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Laureno R, Lamotte G, Mark AS. Sequential MRI in pontine and extrapontine myelinolysis following rapid correction of hyponatremia. BMC Res Notes 2018; 11:707. [PMID: 30290836 PMCID: PMC6173859 DOI: 10.1186/s13104-018-3816-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 10/03/2018] [Indexed: 02/01/2023] Open
Abstract
Objective This study describes the MRI changes associated with pontine and extrapontine myelinolysis secondary to rapid correction of hyponatremia in dogs. The authors discuss the relevance of the results for theories of pathogenesis and for diagnosis of patients. Results MRI changes associated with pontine and extrapontine myelinolysis first occur on diffusion-weighted imaging. As a generalization, gadolinium enhancement, flair image change and T2 weighted image abnormality appear sequentially.
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Affiliation(s)
- Robert Laureno
- Department of Neurology, Medstar Washington Hospital Center, Washington, DC, USA.,Department of Neurology, Medstar Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC, 20007, USA
| | - Guillaume Lamotte
- Department of Neurology, Medstar Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC, 20007, USA.
| | - Alexander S Mark
- Department of Radiology, Medstar Washington Hospital Center, Washington, DC, USA.,Bethesda MRI & CT, Rockville, MD, USA
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Abstract
Patients with severe (serum sodium ≤120 mEq/L), symptomatic hyponatremia can develop life-threatening or fatal complications from cerebral edema if treatment is inadequate and permanent neurologic disability from osmotic demyelination if treatment is excessive. Unfortunately, as is true of all electrolyte disturbances, there are no randomized trials to guide the treatment of this challenging disorder. Rather, therapeutic decisions rest on physiologic principles, animal models, observational studies, and single-patient reports. European guidelines and recommendations of an American Expert panel have come to similar conclusions on how much correction of hyponatremia is enough and how much is too much, but there are important differences. We review the evidence supporting these recommendations, identifying areas that rest on relatively solid ground and highlighting areas in greatest need of additional data.
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Affiliation(s)
- Richard H Sterns
- University of Rochester School of Medicine and Dentistry, Rochester General Hospital, Rochester, New York
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13
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Shah MK, Mandayam S, Adrogué HJ. Osmotic Demyelination Unrelated to Hyponatremia. Am J Kidney Dis 2018; 71:436-440. [DOI: 10.1053/j.ajkd.2017.10.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 10/06/2017] [Indexed: 02/07/2023]
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14
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Olde Engberink RH, Rorije NM, van den Born BJH, Vogt L. Quantification of nonosmotic sodium storage capacity following acute hypertonic saline infusion in healthy individuals. Kidney Int 2017; 91:738-745. [DOI: 10.1016/j.kint.2016.12.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 11/17/2016] [Accepted: 12/01/2016] [Indexed: 10/20/2022]
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15
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Goldwasser P, Roche-Recinos A, Barth RH. Graded interference with the direct potentiometric measurement of sodium by hemoglobin. Clin Biochem 2017; 50:440-443. [PMID: 28065682 DOI: 10.1016/j.clinbiochem.2016.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 12/23/2016] [Accepted: 12/23/2016] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Sodium concentration is measured by either indirect (INa) or direct potentiometry (DNa), on chemistry and gas panels, respectively. A spurious difference between these methods (ΔNa=INa-DNa) can be confusing to the clinician. For example, variation in serum total protein (TP) is well known to selectively interfere with INa. Red cells have been suggested to interfere with DNa, but both positive and negative interference have been reported. In this study, the effect of gas panel hemoglobin (Hb) on ΔNa was examined. METHODS ΔNa was calculated in 772 pairs of closely-timed chemistry and gas panels (median: 4min. apart), retrospectively collected from our critical care units, with 1 pair per patient. Hb was treated as a categorical or continuous variable and tested for linear and non-linear effects, with adjustment for 3 known influences on ΔNa-TP, bicarbonate (tCO2), and the chemistry-gas panel glucose difference (ΔGlu). RESULTS Hb ranged from 3.5 to 22.0g/dL [35-220g/L]. In categorical analysis, ΔNa increased with Hb, and the effect was essentially linear. By simple regression, ΔNa rose 0.06±0.03[SE]mmol/L per 1g/dL [10g/L] increase in Hb (p<0.05), but confounding was suspected because Hb also correlated (p<10-3) with TP, tCO2, and ΔGlu. Using multiple regression to adjust for the confounders, ΔNa rose 0.15±0.03mmol/L per 1g/dL [10g/L] rise in Hb (p<10-6). CONCLUSIONS Increasing Hb spuriously decreases DNa and increases ΔNa. A linear correction for this artifact can reduce the discordance between INa and DNa, promoting their interchangeable use.
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Affiliation(s)
- Philip Goldwasser
- Department of Medicine, Veterans Affairs New York Harbor Healthcare System, 800 Poly Place, Brooklyn, NY 11209, USA.
| | - Andrea Roche-Recinos
- State University of New York, Downstate Medical Center, 450 Clarkson Ave., Brooklyn, NY 11203, USA
| | - Robert H Barth
- Department of Medicine, Veterans Affairs New York Harbor Healthcare System, 800 Poly Place, Brooklyn, NY 11209, USA
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16
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Sánchez-Ferrer ML, Prieto-Sánchez MT, Orozco-Fernández R, Machado-Linde F, Nieto-Diaz A. Central pontine myelinolysis during pregnancy: Pathogenesis, diagnosis and management. J OBSTET GYNAECOL 2016; 37:273-279. [DOI: 10.1080/01443615.2016.1244808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- María Luisa Sánchez-Ferrer
- Obstetrics and Gynaecology Department, Virgen de la Arrixaca Clinical Hospital, University of Murcia, Murcia, Spain
| | - María Teresa Prieto-Sánchez
- Obstetrics and Gynaecology Department, Virgen de la Arrixaca Clinical Hospital, University of Murcia, Murcia, Spain
| | - Rodrigo Orozco-Fernández
- Obstetrics and Gynaecology Department, Virgen de la Arrixaca Clinical Hospital, University of Murcia, Murcia, Spain
| | - Francisco Machado-Linde
- Obstetrics and Gynaecology Department, Virgen de la Arrixaca Clinical Hospital, University of Murcia, Murcia, Spain
| | - Anibal Nieto-Diaz
- Obstetrics and Gynaecology Department, Virgen de la Arrixaca Clinical Hospital, University of Murcia, Murcia, Spain
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Filippatos TD, Liamis G, Elisaf MS. Ten pitfalls in the proper management of patients with hyponatremia. Postgrad Med 2016; 128:516-22. [DOI: 10.1080/00325481.2016.1186488] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
| | - George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Moses S. Elisaf
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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Hourly oral sodium chloride for the rapid and predictable treatment of hyponatremia. Clin Nephrol 2016; 82:397-401. [PMID: 23816479 PMCID: PMC4750111 DOI: 10.5414/cn108014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2014] [Indexed: 01/16/2023] Open
Abstract
Hypertonic NaCl is first-line therapy for acute, severe and symptomatic hyponatremia; however, its use is often restricted to the intensive care unit (ICU). A 35-year-old female inpatient with an optic chiasm glioma and ventriculoperitoneal shunt for hydrocephalus developed acute hyponatremia (sodium 122 mEq/l) perhaps coinciding with haloperidol treatment. The sum of her urinary sodium and potassium concentrations was markedly hypertonic vis-à-vis plasma; it was inferred that serum sodium concentration would continue to fall even in the complete absence of fluid intake. Intravenous (i.v.) 3% NaCl was recommended; however, a city-wide public health emergency precluded her transfer to the ICU. She was treated with hourly oral NaCl tablets in a dose calculated to deliver the equivalent of 0.5 ml/kg/h of 3% NaCl with an objective of increasing the serum sodium concentration by 6 mEq/l. She experienced a graded and predictable increase in serum sodium concentration. A slight overshoot to 129 mEq/l was rapidly corrected with 0.25 l of D5W, and she stabilized at 127 mEq/l. We conclude that hourly oral NaCl, in conjunction with careful monitoring of the serum sodium concentration, may provide an attractive alternative to i.v. 3% NaCl for selected patients with severe hyponatremia.
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Rafat C, Flamant M, Gaudry S, Vidal-Petiot E, Ricard JD, Dreyfuss D. Hyponatremia in the intensive care unit: How to avoid a Zugzwang situation? Ann Intensive Care 2015; 5:39. [PMID: 26553121 PMCID: PMC4639545 DOI: 10.1186/s13613-015-0066-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 09/02/2015] [Indexed: 12/11/2022] Open
Abstract
Hyponatremia is a common
electrolyte derangement in the setting of the intensive care unit. Life-threatening neurological complications may arise not only in case of a severe (<120 mmol/L) and acute fall of plasma sodium levels, but may also stem from overly rapid correction of hyponatremia. Additionally, even mild hyponatremia carries a poor short-term and long-term prognosis across a wide range of conditions. Its multifaceted and intricate physiopathology may seem deterring at first glance, yet a careful multi-step diagnostic approach may easily unravel the underlying mechanisms and enable physicians to adopt the adequate measures at the patient’s bedside. Unless hyponatremia is associated with obvious extracellular fluid volume increase such as in heart failure or cirrhosis, hypertonic saline therapy is the cornerstone of the therapeutic of profound or severely symptomatic hyponatremia. When overcorrection of hyponatremia occurs, recent data indicate that re-lowering of plasma sodium levels through the infusion of hypotonic fluids and the cautious use of desmopressin acetate represent a reasonable strategy. New therapeutic options have recently emerged, foremost among these being vaptans, but their use in the setting of the intensive care unit remains to be clarified.
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Affiliation(s)
- Cédric Rafat
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,AP-HP, Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Paris, France.
| | - Martin Flamant
- AP-HP, Service de Physiologie Rénale, Hôpital Bichat, Paris, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,INSERM, U1149, Centre de Recherche sur l'Inflammation, Paris, France.
| | - Stéphane Gaudry
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,ECEVE UMR 1123, ECEVE, Paris, France.
| | - Emmanuelle Vidal-Petiot
- AP-HP, Service de Physiologie Rénale, Hôpital Bichat, Paris, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,INSERM, U1149, Centre de Recherche sur l'Inflammation, Paris, France.
| | - Jean-Damien Ricard
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,INSERM UMR 1137, IAME, Paris, France.
| | - Didier Dreyfuss
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,INSERM UMR 1137, IAME, Paris, France.
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Risk factors, complication and measures to prevent or reverse catastrophic sodium overcorrection in chronic hyponatremia. Am J Med Sci 2015; 349:170-5. [PMID: 25163018 DOI: 10.1097/maj.0000000000000324] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Hyponatremia is the most common electrolyte disorder encountered in clinical practice. Patients who develop this condition for more than 48 hours are at risk for severe neurological sequelae if correction of the serum sodium occurs too rapidly. Certain medical disorders are known to place patients at an increased risk for rapid correction of serum sodium concentration. Large-volume polyuria in this setting is an ominous sign. For these patients, early identification of risk factors, close monitoring of serum sodium correction and the use of 5% dextrose with or without desmopressin to prevent or reverse overcorrection are important components of treatment.
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The relevance of hyponatraemia to perioperative care of surgical patients. Surgeon 2014; 13:163-9. [PMID: 25523069 DOI: 10.1016/j.surge.2014.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 09/16/2014] [Accepted: 09/22/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Hyponatraemia is the most common electrolyte disturbance in hospitalized patients. There is an increasing awareness of the impact of hyponatraemia on the perioperative management of surgical patients. METHODS We performed a literature review. We have included relevant data from different surgical disciplines for analysis. In this review we discuss the differential diagnosis of hyponatraemia, and explain the specific relevance of hyponatraemia to pre-, peri- and post-operative care. RESULTS Hyponatraemia is common during the preoperative period and is associated with an increase in subsequent peri-operative complications, such as wound infection, pneumonia, higher mortality rate and higher direct and indirect costs. Furthermore, data shows poorer surgical outcomes when plasma sodium concentration drops. Careful preoperative evaluation of the hyponatraemic patient enables assessment of surgical risk and individualization of the management of hyponatraemia. CONCLUSIONS We outline a practical guide to the assessment of the cause of hyponatraemia, which dictates the correct management of hyponatraemia and the correct selection of perioperative fluids. Finally, for the therapeutic role of the new vasopressin antagonist drugs in the treatment of surgical hyponatraemia is discussed in two illustrative surgical clinical cases.
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Gencpinar P, Tekguc H, Senol AU, Duman O, Dursun O. Extrapontine myelinolysis in an 18-month-old boy with diabetic ketoacidosis: case report and literature review. J Child Neurol 2014; 29:1548-53. [PMID: 24563474 DOI: 10.1177/0883073813520496] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Extrapontine myelinolysis is characterized by symmetric demyelination following rapid shifts in serum osmolality in the supratentorial compartment. Extrapontine myelinolysis in children is rare compared to adults. The most common underlying pathophysiology is rapid correction of hyponatremia. Only 2 cases were published after diabetic ketoacidosis without electrolyte imbalance in the English literature. This study presents an unusual and possibly the youngest case of extrapontine myelinolysis that occurred in the setting of diabetic ketoacidosis and complicated cerebral edema without electrolyte imbalance, along with a review of the literature.
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Affiliation(s)
- Pinar Gencpinar
- Department of Child Neurology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Hakan Tekguc
- Department of Pediatric Intensive Care, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - A Utku Senol
- Department of Radiology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Ozgur Duman
- Department of Child Neurology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Oguz Dursun
- Department of Pediatric Intensive Care, Faculty of Medicine, Akdeniz University, Antalya, Turkey
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Goldwasser P, Ayoub I, Barth RH. Pseudohypernatremia and pseudohyponatremia: a linear correction. Nephrol Dial Transplant 2014; 30:252-7. [DOI: 10.1093/ndt/gfu298] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Takagi H, Sugimura Y, Suzuki H, Iwama S, Izumida H, Fujisawa H, Ogawa K, Nakashima K, Ochiai H, Takeuchi S, Kiyota A, Suga H, Goto M, Banno R, Arima H, Oiso Y. Minocycline prevents osmotic demyelination associated with aquaresis. Kidney Int 2014; 86:954-64. [PMID: 24759153 DOI: 10.1038/ki.2014.119] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 02/07/2014] [Accepted: 03/06/2014] [Indexed: 11/09/2022]
Abstract
Overly rapid correction of chronic hyponatremia can cause osmotic demyelination syndrome (ODS). Minocycline protects ODS associated with overly rapid correction of chronic hyponatremia with hypertonic saline infusion in rats. In clinical practice, inadvertent rapid correction frequently occurs due to water diuresis, when vasopressin action suddenly ceases. In addition, vasopressin receptor antagonists have been applied to treat hyponatremia. Here the susceptibility to and pathology of ODS were evaluated using rat models developed to represent rapid correction of chronic hyponatremia in the clinical setting. The protective effect of minocycline against ODS was assessed. Chronic hyponatremia was rapidly corrected by 1 (T1) or 10 mg/kg (T10) of tolvaptan, removal of desmopressin infusion pumps (RP), or administration of hypertonic saline. The severity of neurological impairment in the T1 group was significantly milder than in other groups and brain hemorrhage was found only in the T10 and desmopressin infusion removal groups. Minocycline inhibited demyelination in the T1 group. Further, immunohistochemistry showed loss of aquaporin-4 (AQP4) in astrocytes before demyelination developed. Interestingly, serum AQP4 levels were associated with neurological impairments. Thus, minocycline can prevent ODS caused by overly rapid correction of hyponatremia due to water diuresis associated with vasopressin action suppression. Increased serum AQP4 levels may be a predictive marker for ODS.
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Affiliation(s)
- Hiroshi Takagi
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihisa Sugimura
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Haruyuki Suzuki
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shintaro Iwama
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hisakazu Izumida
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Haruki Fujisawa
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Koichiro Ogawa
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kotaro Nakashima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Ochiai
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Seiji Takeuchi
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Atsushi Kiyota
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidetaka Suga
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Motomitsu Goto
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryoichi Banno
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yutaka Oiso
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Yen HW, Wang JP, Lin PY, Lai MY, Lirng JF, Chao Y. Osmotic demyelination syndrome caused by normal saline correction in a patient admitted for gastric ulcer bleeding. Acta Clin Belg 2014; 69:149-51. [PMID: 24724762 DOI: 10.1179/0001551214z.00000000027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
A 61-year-old male had osmotic demyelination syndrome caused by rapid correction of gastric ulcer bleeding and vomiting related hyponatraemia with normal saline. It is rare to see severe hyponatraemia caused by gastric ulcer bleeding and vomiting. Hypokalaemia may be the determinant predisposing factor. There was no specific brain image finding until 17 days after the initial clinical presentation of this disease. Brain diffusion weighted MRI series did not help for the early diagnosis in this case. Outcome of this case may be more favourable if we corrected his hyponatraemia with half-saline or other hypotonic saline and close monitored serum sodium level, and relowered with dextrose water and desmopressin once we observed that the correction rate of hyponatraemia was beyond the recommended rate.
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Abstract
Hyponatremia is common in critical care units. Avoidance of neurologic injury requires a clear understanding of why the serum sodium (Na) concentration falls and why it rises, how the brain responds to a changing serum Na concentration, and what the goals of therapy should be. A 4 to 6 mEq/L increase in serum Na concentration is sufficient to treat life-threatening cerebral edema caused by acute hyponatremia. In chronic (> 48 h), severe (< 120 mEq/L) hyponatremia, correction by > 8 to 10 mEq/L/d risks iatrogenic osmotic demyelination syndrome (ODS); therefore, a 4 to 6 mEq/L daily increase in serum Na concentration should be the goal in most patients. With the possible exception of hyponatremia caused by heart failure or hepatic cirrhosis, a rapid initial increase in serum Na for severe symptoms and avoidance of overcorrection are best achieved with 3% saline given in either a peripheral or central vein. Inadvertent overcorrection can be avoided in high-risk patients with chronic hyponatremia by administration of desmopressin to prevent excessive urinary water losses. In patients with hyponatremia with oliguric kidney failure, controlled correction can be achieved with modified hemodialysis or continuous renal replacement therapies. ODS is potentially reversible, even in severely affected patients who are quadriplegic, unresponsive, and ventilator dependent. Supportive care should be offered several weeks before concluding that the condition is hopeless.
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Affiliation(s)
- Richard H Sterns
- Department of Medicine, Rochester General Hospital, Rochester, NY; Nephrology Division, University of Rochester School of Medicine, Rochester, NY.
| | - John K Hix
- Department of Medicine, Rochester General Hospital, Rochester, NY; Nephrology Division, University of Rochester School of Medicine, Rochester, NY
| | - Stephen M Silver
- Department of Medicine, Rochester General Hospital, Rochester, NY; Nephrology Division, University of Rochester School of Medicine, Rochester, NY
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Rafat C, Schortgen F, Gaudry S, Bertrand F, Miguel-Montanes R, Labbé V, Ricard JD, Hajage D, Dreyfuss D. Use of desmopressin acetate in severe hyponatremia in the intensive care unit. Clin J Am Soc Nephrol 2013; 9:229-37. [PMID: 24262506 DOI: 10.2215/cjn.00950113] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND OBJECTIVES Excessive correction of chronic and profound hyponatremia may result in central pontine myelinolysis and cause permanent brain damage. In the case of foreseeable or established hyponatremia overcorrection, slowing down the correction rate of sodium plasma levels (PNa) or reinducing mild hyponatremia may prevent this neurologic complication. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This retrospective and observational study was performed with 20 consecutive patients admitted to two intensive care units for severe hyponatremia, defined by PNa <120 mmol/L and/or neurologic complications ascribable to hyponatremia and subsequently treated by desmopressin acetate (DDAVP) during correction of hyponatremia when the rate of correction was overtly or predictably excessive. The primary endpoint was the effectiveness of DDAVP on PNa control. RESULTS DDAVP dramatically decreased the rate of PNa correction (median 0.81 mmol/L per hour [interquartile range, 0.46, 1.48] versus -0.02 mmol/L per hour [-0.16, 0.22] before and after DDAVP, respectively; P<0.001) along with a concurrent decrease in urine output (650 ml/h [214, 1200] versus 93.5 ml/h [43, 143]; P=0.003), and a rise in urine osmolarity (86 mmol/L [66, 180] versus 209 mmol/L [149, 318]; P=0.002). The maximal magnitude of PNa variations was also markedly reduced after DDAVP administration (11.5 mmol/L [8.25, 14.5] versus 5 mmol/L [4, 6.75]; P<0.001). No patient developed seizures after DDAVP or after subsequent relowering of PNa that occurred in 11 patients. CONCLUSIONS Desmopressin acetate is effective in curbing the rise of PNa in patients admitted in the intensive care unit for severe hyponatremia, when the initial rate of correction is excessive.
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Affiliation(s)
- Cédric Rafat
- Medical-Surgical Intensive Care Unit, Louis Mourier Hospital, Assistance Publique-Hôpitaux de Paris, Colombes, France;, †Diderot University of Paris, Sorbonne Paris Cité, Paris, France;, ‡Medical Intensive Care Unit, Henri Mondor Hospital, Public Assistance Hospitals of Paris, Créteil, France;, §Institut National de la Santé et de la Recherche Médicale U722, Paris, France, ‖Department of Public Health, Epidemiology, and Clinical Research, Bichat hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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Gharaibeh KA, Craig MJ, Koch CA, Lerant AA, Fülöp T, Csongrádi &E. Desmopression is an effective adjunct treatment for reversing excessive hyponatremia overcorrection. World J Clin Cases 2013; 1:155-158. [PMID: 24303490 PMCID: PMC3845948 DOI: 10.12998/wjcc.v1.i5.155] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 04/09/2013] [Accepted: 05/19/2013] [Indexed: 02/05/2023] Open
Abstract
We report a case of a 50-year-old malnourished African American male with hiccups, nausea and vomiting who was brought to the Emergency Department after repeated seizures at home. Laboratory evaluations revealed sodium (Na+) 107 mmol/L, unmeasurably low potassium, chloride < 60 mmol/L, bicarbonate of 38 mmol/L and serum osmolality 217 mOsm/kg. Seizures were controlled with 3% saline IV. Once nausea was controlled with iv antiemetics, he developed large volume free water diuresis with 6 L of dilute urine in 8 h (urine osmolality 40-60 mOsm/kg) and serum sodium rapidly rose to 126 mmol/L in 12 h. Both intravenous desmopressin and 5% dextrose in water was given to achieve a concentrated urine and to temporarily reverse the acute rise of sodium, respectively. Serum Na+ was gradually re-corrected in 2-3 mmol/L daily increments from 118 mmol/L until 130 mmol/L. Hypokalemia was slowly corrected with resultant auto-correction of metabolic alkalosis. The patient discharged home with no neurologic sequaele on the 11th hospital day. In euvolemic hyponatremic patients, controlling nausea may contribute to unpredictable free water diuresis. The addition of an antidiuretic hormone analog, such as desmopressin can limit urine output and prevent an unpredictable rise of the serum sodium.
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Tzamaloukas AH, Malhotra D, Rosen BH, Raj DSC, Murata GH, Shapiro JI. Principles of management of severe hyponatremia. J Am Heart Assoc 2013. [PMID: 23525443 DOI: 101161/jaha.112.005199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Antonios H Tzamaloukas
- Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM, USA
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Tzamaloukas AH, Malhotra D, Rosen BH, Raj DSC, Murata GH, Shapiro JI. Principles of management of severe hyponatremia. J Am Heart Assoc 2013; 2:e005199. [PMID: 23525443 PMCID: PMC3603260 DOI: 10.1161/jaha.112.005199] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Antonios H Tzamaloukas
- Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM, USA
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Tarakji AG, Tarakji AR, Shaheen U. Central pontine and extrapontine myelinolysis secondary to fast correction of severe hyponatremia and hypokalemia in an alcoholic patient. Int Urol Nephrol 2012. [PMID: 23180443 DOI: 10.1007/s11255-012-0329-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Frouget T. [The syndrome of inappropriate antidiuresis]. Rev Med Interne 2012; 33:556-66. [PMID: 22884285 DOI: 10.1016/j.revmed.2012.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 06/11/2012] [Accepted: 07/05/2012] [Indexed: 11/26/2022]
Abstract
The syndrome of inappropriate antidiuresis (SIAD; formerly the syndrome of inappropriate secretion of antidiuretic hormone) is the most frequent cause of hyponatremia. A strong association exists between mortality and hyponatremia, which reflects the severity of the underlying disease. In SIAD, hyponatremia is associated with normovolaemia but the assessment of extracellular volume can be difficult. Clinical features are mainly neurological and can lead to death but mechanisms of adaptation can limit cerebral oedema. The notion of mild asymptomatic hyponatremia was questioned by the observation of subclinical neurocognitive impairment, a greater risk of falls and fractures. Aetiologies are classified into six groups: neurologic disorders, infections mainly cerebral, meningeal and pulmonary, drugs in particular antidepressants, tumors, genetic causes, and idiopathic. Symptomatic acute hyponatremia is a therapeutic emergency that is not specific of SIAD. When hyponatremia is asymptomatic, fluid restriction with salt intake is generally sufficient but urea can be an alternative. In chronic SIAD, there is currently no recommendation. Fluid restriction is not always feasible; urea has proved its efficacy, its good tolerance and its long-term harmlessness. Vaptans have demonstrated their good tolerance and their efficacy on the correction of hyponatremia from SIAD in studies subgroups, for moderate hyponatremia and asymptomatic patients. In the only study having compared vaptans and urea, efficacy and tolerance were similar. Because of the cost difference between vaptans and urea and while waiting for follow-up studies, urea appears at present as the first-line treatment of hyponatremia in SIAD.
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Affiliation(s)
- T Frouget
- Service de Néphrologie, CHU de Pontchaillou, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex 9, France.
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Ranger AM, Chaudhary N, Avery M, Fraser D. Central pontine and extrapontine myelinolysis in children: a review of 76 patients. J Child Neurol 2012; 27:1027-37. [PMID: 22647485 DOI: 10.1177/0883073812445908] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study aimed to identify the causes and contributing factors, neurologic presentation, and outcomes of central pontine and extrapontine myelinolysis and to examine any trends in the presentation and course of these disorders over the past 50 years. Seventy-six pediatric cases were identified in the literature. Age, sex, decade of diagnosis, neurologic presentation, outcome, and attributed causes were extracted. The results showed that the diagnosis, course, and outcomes of central pontine and extrapontine myelinolysis clearly have changed over the past few decades. Early cases generally were diagnosed at autopsy as opposed to computed tomography or magnetic resonance imaging more recently. Ninety-four percent of cases prior to 1990 and only 7% of cases from 1990 onward resulted in patient mortality. The decade in which the case was reported was the strongest predictor of outcome (P < .001), followed by sodium dysregulation (P = .045) and dehydration (P = .07).
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Affiliation(s)
- Adrianna M Ranger
- Department of Clinical Neurological Sciences, Pediatric Neurosurgery, London, Ontario, Canada.
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Abstract
BACKGROUND Asymptomatic or clinically mild hyponatremia commonly occurs in the setting of heart failure, especially among elderly and severely decompensated, fluid-overloaded patients, and is associated with increased morbidity and mortality. Successful detection and treatment of hyponatremia by cardiovascular and advanced practice nurses caring for patients with heart failure are part of multidisciplinary team care. Nurses should be able to detect signs and symptoms of hyponatremia and, even when patients are asymptomatic, initiate appropriate treatment promptly to prevent complications. PURPOSE In this review, the epidemiology and pathophysiology of hyponatremia in heart failure, and signs and symptoms are described. In patients with heart failure, challenges involved in determining the type of hyponatremia (hypervolemic, hypovolemic, or euvolemic) and in correctly managing hyponatremia to prevent serious complications are presented. Conventional treatment options and their limitations are reviewed, and the vasopressin-receptor antagonist tolvaptan, an emerging oral therapy option, is introduced and discussed. CONCLUSIONS Hyponatremia is a marker of morbidity and mortality in patients with heart failure. Nurses working collaboratively with other healthcare providers must be able to recognize the condition and understand treatment options, including potential adverse effects of current and emerging therapies. One emerging therapy--tolvaptan--can be used in hypervolemic and euvolemic hyponatremic patients with heart failure to correct serum sodium level without negatively affecting renal function. CLINICAL IMPLICATIONS Improved nurse understanding of hyponatremia in patients with heart failure may promote nurse-initiated or nurse-facilitated detection and management, which could decrease mortality and morbidity.
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Abstract
Treatment of hypotonic hyponatremia often challenges clinicians on many counts. Despite similar serum sodium concentrations, clinical manifestations can range from mild to life threatening. Some patients require active management, whereas others recover without intervention. Therapeutic measures frequently yield safe correction, yet the same measures can result in osmotic demyelination. To address this challenge, we present a practical approach to managing hyponatremia that centers on two elements: a diagnostic evaluation directed at the pathogenesis and putative causes of hyponatremia, the case-specific clinical and laboratory features, and the associated clinical risk; and a management plan tailored to the diagnostic findings that incorporates quantitative projections of fluid therapy and fluid losses on the patient's serum sodium, balances potential benefits and risks, and emphasizes vigilant monitoring. These principles should enable the clinician to formulate a management plan that addresses expeditiously three critical questions: Which of the determinants of the serum sodium are deranged and what is the underlying culprit? How urgent is the need for intervention? What specific therapy should be instituted and which are the associated pitfalls?
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Affiliation(s)
- Horacio J Adrogué
- Department of Medicine, Baylor College of Medicine, Methodist Hospital, Houston, Texas, USA
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Tomlin SC, Williams R, Riley S. Preventing overcorrection of hyponatraemia with desmopressin. BMJ Case Rep 2011; 2011:bcr.07.2011.4512. [PMID: 22674100 DOI: 10.1136/bcr.07.2011.4512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 61-year-old woman was admitted with history of vomiting, diarrhoea and severe hyponatraemia (Na(+) 109). The cause of the hyponatraemia was due to intravascular volume depletion resulting in a non-osmotic release of antidiuretic hormone (ADH) with the added effects of a thiazide diuretic. She was also on fluoxetine which may induce inappropriate secretion of ADH. Despite cautious fluid replacement, the patient's serum sodium increased by 12 mmol/l over the first 18 h (and by 10 mmol/l over 12 h). This trajectory, coupled with the rapid decrease in urine osmolality, suggested that this patient was at risk of significant brain injury due to rapid correction of serum sodium. The use of desmopressin slowed the rise in serum sodium allowing brain adaptive mechanisms time to protect against osmotic demyelination.
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Elhassan EA, Schrier RW. The use of vasopressin receptor antagonists in hyponatremia. Expert Opin Investig Drugs 2011; 20:373-80. [PMID: 21320003 DOI: 10.1517/13543784.2011.553186] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Considerable data have recently characterized hyponatremia as fairly common in the intensive care and general hospital settings. Moreover, mounting evidence suggests the association of mild degrees of hyponatremia with untoward neurocognitive and musculoskeletal outcomes. A key development in our ability to treat hyponatremia was the introduction and approval of aquaretics (vaptans). These vasopressin receptor antagonists work by increasing electrolyte-free water excretion and thus raising serum sodium concentration. AREAS COVERED This review presents a diagnostic approach for hyponatremia and discusses some therapeutic considerations. It displays new evidence linking mild chronic hyponatremia with unfavorable outcomes and examines the available treatment options and their limitations and strengths. New data on vaptans and their potential role to treat hyponatremia in different clinical settings are reviewed. EXPERT OPINION Vaptans are likely to play an important role in treating hyponatremia, given their clinical efficacy and tolerability. High cost remains an impediment for vaptans, and more studies are needed to further define their best use in hyponatremic patients.
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Affiliation(s)
- Elwaleed A Elhassan
- Division of Renal Diseases and Hypertension, University of Colorado-Denver, 12700 East 19th Avenue, Aurora, CO 80045, USA
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Hyponatremia: diagnosis, complications, and management including V2 receptor antagonists. Curr Opin Nephrol Hypertens 2011; 20:161-8. [PMID: 21252664 DOI: 10.1097/mnh.0b013e3283436f14] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Recent studies have consistently demonstrated the common prevalence of hyponatremia in the hospital and intensive care settings, and how it correlates with untoward outcomes. This review discusses the classification, diagnosis, and pathophysiology of hyponatremia and how these agents may influence its management, and also examines the available treatment options and their weaknesses and strengths. RECENT FINDINGS This review is timely and relevant, as mild degrees of serum sodium lowering may be associated with adverse neurologic and musculoskeletal effects. These findings have the potential to transform our approach to managing hyponatremia. A major advance in our ability to treat hyponatremia was the introduction and approval of aquaretics (vaptans). Emerging data on vaptans and their potential role to treat hyponatremia in the settings of the syndrome of inappropriate antidiuretic hormone secretion, congestive heart failure, and liver cirrhosis are presented. SUMMARY Vaptans will likely play an important role in treating hyponatremia, given their clinical effectiveness and tolerability. Cost remains a hindrance for vaptans, and more studies are needed to further define their best utilization in hyponatremic patients.
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Vaghasiya RP, DeVita MV, Michelis MF. Serum and urine responses to the aquaretic agent tolvaptan in hospitalized hyponatremic patients. Int Urol Nephrol 2011; 44:865-71. [DOI: 10.1007/s11255-011-9996-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 05/06/2011] [Indexed: 01/08/2023]
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Sterns RH, Hix JK, Silver S. Treating profound hyponatremia: a strategy for controlled correction. Am J Kidney Dis 2010; 56:774-9. [PMID: 20709440 DOI: 10.1053/j.ajkd.2010.04.020] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 04/20/2010] [Indexed: 01/18/2023]
Abstract
An alcoholic patient presented with profound hyponatremia (serum sodium concentration, 96 mEq/L) caused by the combined effects of a thiazide diuretic, serotonin reuptake inhibitor, beer potomania, and hypovolemia. A computed tomographic scan of the brain was indistinguishable from one obtained 3 weeks earlier when he was normonatremic. Concurrent administration of 3% saline solution and desmopressin controlled the rate of correction to an average of 6 mEq/L daily and resulted in full neurologic recovery without evidence of osmotic demyelination. This case illustrates the value of controlled correction of profound hyponatremia.
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Affiliation(s)
- Richard H Sterns
- Rochester General Hospital, Nephrology Division, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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Abstract
The osmotic demyelination syndrome (ODS) has been a recognized complication of the rapid correction of hyponatremia for decades. However, in recent years, a variety of other medical conditions have been associated with the development of ODS, independent of changes in serum sodium. This finding suggests that the pathogenesis of ODS may be more complex and involve the inability of brain cells to respond to rapid changes in osmolality of the interstitial (extracellular) compartment of the brain, leading to dehydration of energy-depleted cells with subsequent axonal damage that occurs in characteristic areas. Features of the syndrome include quadriparesis and neurocognitive changes in the presence of characteristic lesions found on magnetic resonance imaging of the brain. Although slow correction of hyponatremia seems to be the best way to prevent development of the syndrome, there are new data that suggest reintroduction of hyponatremia in those patients who have undergone inadvertent rapid correction of the serum sodium and corticosteroids may play a role in prevention of ODS.
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Abstract
Conivaptan is the first dual vasopressin V1a/V2 receptor antagonist approved by the US FDA for the treatment of euvolemic and hypervolemic hyponatremia in hospitalized patients. Short-term use of intravenous conivaptan has been shown to promote effective free-water duresis and resolution of hyponatremia in several clinical trials. Adverse effects reported with short-term use mostly include infusion site reactions. However, they may also include serious effects including unexpectedly rapid serum Na+ correction, hypokalemia and orthostatic hypotension. Despite its proven efficacy in hospitalized patients, the development of oral conivaptan has been discontinued due to its shared hepatic clearance with many commonly used drugs. Thus, data is lacking on the long-term efficacy of conivaptan in patients with chronic hyponatremia. The decision to use conivaptan in addition to conventional therapy for euvolemic or hypervolemic hyponatremic patients must be carefully considered according to the patient history and response to conventional treatment.
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Affiliation(s)
- David Zeltser
- a Internal Medicine 'D' Department, Tel-Aviv Souraski Medical Center, 6 Weizman Street, Tel-Aviv, Israel
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| | - Arie Steinvil
- a Internal Medicine 'D' Department, Tel-Aviv Souraski Medical Center, 6 Weizman Street, Tel-Aviv, Israel
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