Osmolality- and Na+-dependent effects of hyperosmotic NaCl solution on contractile activity and Ca2+ cycling in rat ventricular myocytes

The U-shaped relationship between serum osmolality and the risk of sepsis-associated delirium development: a retrospective study

OBJECTIVE

We aim to investigate the association between serum osmolality and the risk of developing delirium in septic patients.

METHODS

Adult septic patients meeting the Sepsis-3 definition were included. Delirium was screened according to the Confusion Assessment Method for the ICU (CAM-ICU) tool. Patients lacked of serum osmolality results and those with delirium prior to sepsis occurrence were excluded. The association between osmolality and delirium was visualized using both restricted cubic splines (RCS) and local weighted scatter plot smoothing (LOWESS) methods. Logistic regression, subgroup and sensitivity analysis were performed to determine the predictive value of osmolality on delirium.

RESULTS

A total of 17,171 septic patients were included. A U-shaped pattern was observed between serum osmolality and delirium risk (P for non-linear < 0.001). Compared with intermediate range (286-301 mmol/L), patients in the low and high osmolality groups had an increased percentage of delirium. Compared with intermediate osmolality, low and high osmolality could increase the risk of delirium by 21.6-34.5% (OR 1.216-1.345) and 18.4-53.3% (OR 1.184-1.533). All subgroups analysis supported that abnormal osmolality is an independent risk factor for delirium (OR > 1), and a more significant association was found in SOFA < 6 subgroup. In sensitivity analysis, the presence of comorbidities made no influence on this U-shaped relationship. After balancing the baseline information by propensity score matching (PSM), patients in the intermediate range still had a lower incidence of delirium.

CONCLUSION

There was a U-shaped association between serum osmolality and the risk of sepsis-associated delirium. Further high-quality research is needed to verify our findings.

CLINICAL TRIAL NUMBER

Not applicable.

Association between osmolality trajectories and mortality in patients with sepsis: a group-based trajectory model in large ICU open access databases

Objective

The regulation of osmolality levels is controlled by the endocrine system, reflecting the body's water and electrolyte balance. However, the relationship between dynamic osmolality trajectories and the prognosis of septic patients has not yet been reported. This study aims to investigate the predictive value of dynamic osmolality trajectories on mortality among patients with sepsis.

Methods

A retrospective analysis was performed using the MIMIC IV and eICU-CRD databases. A total of 19,502 patients were included, 10,263 from MIMIC IV and 9,239 from eICU-CRD. Group-based trajectory modeling (GBTM) analysis was performed to identify distinct osmolality trajectories. The association between these trajectories and in-hospital mortality was assessed by logistic regression analysis and further adjusted for potential confounders. Subgroup analysis was used to identify potential interactive factors and to assess the robustness of the present findings.

Results

Five distinct osmolality trajectories were identified. Patients in the persistent hyperosmolality trajectory (Trajectory-5) had significantly higher in-hospital mortality compared to other trajectories, with an increased risk of in-hospital mortality of 233% (OR 3.33, 95% CI 2.71-4.09) and 150% (OR 2.50, 95% CI 1.97-3.17) in MIMIC IV and eICU-CRD respectively, with Trajectory-2 as reference. A dynamic increase in osmolality (Trajectory-4) was also associated with a 68% (OR 1.68, 95% CI 1.39-2.03) and a 68% (OR 1.68, 95% CI 1.44-1.97) increase in the risk of death, compared with Trajectory-2. Conversely, maintaining osmolality in the range of 290-300 mOsm/L (Trajectory-1 and Trajectory-2) was associated with a lower risk of death. Our results remained stable in the IPWRA and subgroup analyses.

Conclusion

Our findings suggest that dynamic changes in plasma osmolality are significantly associated with in-hospital mortality in septic patients. Osmolality trajectory model provides a potentially effective, easily accessible and cost-effective biomarker for the prognostic assessment and clinical management of sepsis.

Analysis of the correlation between the group-based trajectory modeling of serum osmolality and prognosis in patients with sepsis-associated encephalopathy at 72 h after admission

BACKGROUND

This study aimed to identify distinct trajectories of serum osmolality within the first 72 h for patients with sepsis-associated encephalopathy (SAE) in the MIMIC-IV and eICU-CRD databases and assess their impact on mortality and adverse clinical outcomes.

METHODS

In this retrospective cohort study, patients with SAE from the MIMIC-IV database were included. Group-based trajectory modeling (GBTM) was used to categorize distinct patterns of serum osmolality changes over 72 h in ICU patients. Differences in survival across the trajectory groups were compared using Kaplan-Meier (K-M) survival curves.

RESULTS

A total of 11,376 patients with SAE were included in the analysis, with a median age of 65.6 ± 16.5 years. The in-hospital mortality rate at 30 days was 12.8%. Based on model-defined criteria, three distinct osmolality trajectory groups were identified: Group 1 (59.6%), Group 2 (36.4%), and Group 3 (4.0%). Kaplan-Meier survival analysis indicated that patients with relatively lower serum osmolality within the normal range (Group 1) had a lower 30-day mortality rate compared to those in the other groups (Group 2 and 3). Subgroup analysis demonstrated significant interactions (P < 0.05) between osmolality trajectories and covariates such as the Sequential Organ Failure Assessment (SOFA), vasopressor use and renal replacement therapy (RRT).

CONCLUSION

Identifying distinct serum osmolality trajectories may help recognize SAE patient subgroups with varying risks of adverse outcomes, providing clinically meaningful stratification.

The U-shaped association between serum osmolality and 28-day mortality in patients with sepsis: a retrospective cohort study

BACKGROUND

Sepsis is a recognized global health challenge that places a considerable disease burden on countries. Although there has been some progress in the study of sepsis, the mortality rate of sepsis remains high. The relationship between serum osmolality and the prognosis of patients with sepsis is unclear.

METHOD

Patients with sepsis who met the criteria in the Medical Information Mart for Intensive Care IV database were included in the study. Hazard ratios (HRs) and 95% confidence intervals (CIs) were determined using multivariable Cox regression. The relationship between serum osmolality and the 28-day mortality risk in patients with sepsis was investigated using curve fitting, and inflection points were calculated.

RESULTS

A total of 13,219 patients with sepsis were enrolled in the study; the mean age was 65.1 years, 56.9 % were male, and the 28-day mortality rate was 18.8 %. After adjusting for covariates, the risk of 28-day mortality was elevated by 99% (HR 1.99, 95%CI 1.74-2.28) in the highest quintile of serum osmolality (Q5 >303.21) and by 59% (HR 1.59, 95%CI 1.39-1.83) in the lowest quintile (Q1 ≤285.80), as compared to the reference quintile (Q3 291.38-296.29). The results of the curve fitting showed a U-shaped relationship between serum osmolality and the risk of 28-day mortality, with an inflection point of 286.9 mmol/L.

CONCLUSION

There is a U-shaped relationship between serum osmolality and the 28-day mortality risk in patients with sepsis. Higher or lower serum osmolality is associated with an increased risk of mortality in patients with sepsis. Patients with sepsis have a lower risk of mortality when their osmolality is 285.80-296.29 mmol/L.

Potentially Detrimental Effects of Hyperosmolality in Patients Treated for Traumatic Brain Injury

Hyperosmotic therapy is commonly used to treat intracranial hypertension in traumatic brain injury patients. Unfortunately, hyperosmolality also affects other organs. An increase in plasma osmolality may impair kidney, cardiac, and immune function, and increase blood-brain barrier permeability. These effects are related not only to the type of hyperosmotic agents, but also to the level of hyperosmolality. The commonly recommended osmolality of 320 mOsm/kg H2O seems to be the maximum level, although an increase in plasma osmolality above 310 mOsm/kg H2O may already induce cardiac and immune system disorders. The present review focuses on the adverse effects of hyperosmolality on the function of various organs.

Hyperosmotic stress promotes endoplasmic reticulum stress-dependent apoptosis in adult rat cardiac myocytes

In different pathological situations, cardiac cells undergo hyperosmotic stress and cell shrinkage. This change in cellular volume has been associated with contractile dysfunction and cell death. However, the intracellular mechanisms involved in hyperosmotic stress-induced cell death have not been investigated in depth in adult cardiac myocytes. Given that osmotic stress has been shown to promote endoplasmic reticulum stress (ERS), a recognized trigger for apoptosis, we examined whether hyperosmotic stress triggers ERS in adult cardiac myocytes and if so whether this mechanism mediates hyperosmotic stress-induced cell death. Adult rat cardiomyocytes cultured overnight in a hypertonic solution (HS) containing mannitol as the osmolite, showed increased expression of ERS markers, GRP78, CHOP and cleaved-Caspase-12, compared with myocytes in isotonic solution (IS), suggesting that hyperosmotic stress induces ERS. In addition, HS significantly reduced cell viability and increased TUNEL staining and the expression of active Caspase-3, indicative of apoptosis. These effects were prevented with the addition of the ERS inhibitor, 4-PBA, indicating that hyperosmotic stress-induced apoptosis is mediated by ERS. Hyperosmotic stress-induced apoptosis was also prevented when cells were cultured in the presence of a Ca²⁺-chelating agent (EGTA) or the CaMKII inhibitor (KN93), suggesting that hyperosmotic stress-induced ERS is mediated by a Ca²⁺ and CaMKII-dependent mechanism. Similar results were observed when hyperosmotic stress was induced using glucose as the osmolite. We conclude that hyperosmotic stress promotes ERS by a CaMKII-dependent mechanism leading to apoptosis of adult cardiomyocytes. More importantly, we demonstrate that hyperosmotic stress-triggered ERS contributes to hyperglycemia-induced cell death.

Hypertonic sodium resuscitation after hemorrhage improves hemodynamic function by stimulating cardiac, but not renal, sympathetic nerve activity

Small volume hypertonic saline resuscitation can be beneficial for treating hemorrhagic shock, but the mechanism remains poorly defined. We investigated the effects of hemorrhagic resuscitation with hypertonic saline on cardiac (CSNA) and renal sympathetic nerve activity (RSNA) and the resulting cardiovascular consequences. Studies were performed on conscious sheep instrumented with cardiac ( n = 7) and renal ( n = 6) sympathetic nerve recording electrodes and a pulmonary artery flow probe. Hemorrhage (20 ml/kg over 20 min) caused hypotension and tachycardia followed by bradycardia, reduced cardiac output, and abolition of CSNA and RSNA. Resuscitation with intravenous hypertonic saline (1.2 mol/l at 2 ml/kg) caused rapid, dramatic increases in mean arterial pressure, heart rate, and CSNA, but had no effect on RSNA. In contrast, isotonic saline resuscitation (12 ml/kg) had a much delayed and smaller effect on CSNA, less effect on mean arterial pressure, no effect on heart rate, but stimulated RSNA, although the plasma volume expansion was similar. Intracarotid infusion of hypertonic saline (1 ml/min bilaterally, n = 5) caused similar changes to intravenous administration, indicating a cerebral component to the effects of hypertonic saline. In further experiments, contractility (maximum change in pressure over time), heart rate, and cardiac output increased significantly more with intravenous hypertonic saline (2 ml/kg) than with Gelofusine (6 ml/kg) after hemorrhage; the effects of hypertonic saline were attenuated by the β-receptor antagonist propranolol ( n = 6). These results demonstrate a novel neural mechanism for the effects of hypertonic saline resuscitation, comprising cerebral stimulation of CSNA by sodium chloride to improve cardiac output by increasing cardiac contractility and rate and inhibition of RSNA.

The negative inotropic action of canrenone is mediated by L-type calcium current blockade and reduced intracellular calcium transients

BACKGROUND AND PURPOSE

Adding spironolactone to standard therapy in heart failure reduces morbidity and mortality, but the underlying mechanisms are not fully understood. We analysed the effect of canrenone, the major active metabolite of spironolactone, on myocardial contractility and intracellular calcium homeostasis.

EXPERIMENTAL APPROACH

Left ventricular papillary muscles and cardiomyocytes were isolated from male Wistar rats. Contractility of papillary muscles was assessed with force transducers, Ca(2+) transients by fluorescence and Ca(2+) fluxes by electrophysiological techniques.

KEY RESULTS

Canrenone (300-600 micromol L(-1)) reduced developed tension, maximum rate of tension increase and maximum rate of tension decay of papillary muscles. In cardiomyocytes, canrenone (50 micromol L(-1)) reduced cell shortening and L-type Ca(2+) channel current, whereas steady-state activation and inactivation, and reactivation curves were unchanged. Canrenone also decreased the Ca(2+) content of the sarcoplasmic reticulum, intracellular Ca(2+) transient amplitude and intracellular diastolic Ca(2+) concentration. However, the time course of [Ca(2+)](i) decline during transients evoked by caffeine was not affected by canrenone.

CONCLUSION AND IMPLICATIONS

Canrenone reduced L-type Ca(2+) channel current, amplitude of intracellular Ca(2+) transients and Ca(2+) content of sarcoplasmic reticulum in cardiomyocytes. These changes are likely to underlie the negative inotropic effect of canrenone.