Elevated tissue sodium deposition in patients with type 2 diabetes on hemodialysis detected by 23Na magnetic resonance imaging

Temporal Trends and Clinical Impact of Malnutrition on In-Hospital Outcomes Among Patients with Advanced Chronic Kidney Disease: A Nationwide Inpatient Analysis

BACKGROUND/OBJECTIVES

Malnutrition is a prevalent yet under-recognized condition in patients with advanced chronic kidney disease (CKD), contributing to increased morbidity, mortality, and healthcare burden. The aim of this study is to determine the prevalence and trends of malnutrition and investigate the impact of malnutrition on in-hospital outcomes, treatments, and resource utilization in hospitalized patients with advanced CKD.

METHODS

This study utilized the National Inpatient Sample (NIS) database to identify hospitalized patients with advanced CKD from 2016 to 2021. This study investigated temporal trends in the prevalence and in-hospital mortality across different degrees of malnutrition in advanced CKD patients. Multivariable regression models were used to assess the association between malnutrition and in-hospital outcomes.

RESULTS

Out of 1,244,415 advanced CKD patients, 67,587 (5.4%) had mild to moderate malnutrition, and 63,785 (5.1%) had severe malnutrition. Malnourished patients exhibited significantly higher in-hospital mortality, with adjusted odds ratios of 1.70 (95% confidence interval (CI), 1.64-1.75) for mild to moderate cases and 2.67 (95% CI, 2.60-2.75) for severe cases. Severely malnourished patients were associated with longer mean hospital stay by 7.0 days and higher hospitalization costs by $97,767 compared with non-malnourished patients. The prevalence of severe malnutrition showed a significant uptrend from 4.2% in 2016 to 5.5% in 2021 (p for trend < 0.001).

CONCLUSIONS

Malnutrition in advanced CKD is an increasingly prevalent condition linked to worsened in-hospital outcomes and heightened healthcare resource utilization. The rising trend of severe malnutrition underscores the need for early nutritional screening and the need for future interventional studies to mitigate adverse clinical outcomes in this high-risk population.

Sodium MRI of the skin using a surface coil to investigate and reduce signal loss and bias

PURPOSE

The purpose was to improve sodium MRI of human skin using a surface coil and twisted projection imaging with smaller, reshaped voxels.

METHODS

Calf skin sodium images were acquired in 14 healthy adults using twisted projection imaging with short TE ˜ 0.1 ms, first with a volume coil and voxels (1.5 × 1.5 × 15 = 34 mm3) reflecting the widely adopted skin imaging protocol (VolPencil). A 5-cm-diameter surface coil then facilitated 5× smaller (0.8 × 0.8 × 10 = 6.4 mm3) voxels with similar signal to noise ratio (SNR) in the same 12-min scan time (SurfPencil). "Pencil-shaped" voxels were then replaced with "pancake-shaped" (0.4 × 4 × 4 = 6.4 mm3) voxels, matching the anatomy of pressed flat skin (SurfPancake). Surface coil B1 was investigated with the novel use of spin-3/2 simulation. Protocol modifications were tested for signal increase (reduced loss) and correlation with (bias by) skin thickness.

RESULTS

Higher resolution SurfPencil yielded 44% ± 16% greater skin sodium image intensity than VolPencil, whereas SurfPancake yielded an additional 20% ± 9% (p < 1e-8), reflecting reduced signal loss. Over the 1.0 to 1.8 mm skin thickness across participants, sodium intensity significantly increased 56% ± 19% and 44% ± 12% for VolPencil and SurfPencil, respectively (p < 0.003), but not for SurfPancake, reflecting reduced bias. Imaging yielded skin sodium concentration of 34 ± 5 mM for SurfPancake. This is greater than the ˜20 mM measures from the widely adopted protocol, but simulation (matching experimental trends) identified a remaining 64% signal loss; compensation yields 95 ± 15 mM.

CONCLUSION

Surface coil imaging and "pancake" voxel reshaping increased skin sodium intensity and reduced bias by skin thickness. Simulated loss compensation yields skin sodium concentration similar to that measured by atomic absorption spectroscopy.

I Brazilian guideline on hypertension in dialysis of the Brazilian Society of Nephrology

Hypertension in dialysis patients (HTND) has a high prevalence, affecting at least 80% or more of patients, and its management in the nephrology practice is heterogeneous and often empirical. Knowing how to define, understand the pathophysiology, diagnose, monitor and treat with lifestyle changes, and adjust antihypertensive drugs to achieve the recommended blood pressure (BP) target - to reduce morbidity and mortality - requires specific knowl-edge and approaches within the contexts of hemodialysis (HD) and peritoneal dialysis (PD). This document is the first guideline of the Brazilian Society of Nephrology, developed by the departments of Hypertension and Dialysis. It aims to guide physicians who provide care in dialysis centers on how to manage patients with HTND, in a comprehensive and individualized manner, based on the critical appraisal of the best available scientific evidence. When such evidence is scarce or unavailable, the opinion of specialists should be recommended. The different topics covered include HTND definition (pre-HD BP ≥ 140/90 mmHg and post-HD BP ≥ 130/80 mmHg), epidemiology, and pathophysiology; diagnosis of HTND preferably with BP measurements outside the dialysis setting (BP ≥ 130/80 mmHg); complementary assessment; blood pressure targets; non-pharmacological treatment; use of the most appropriate antihypertensive medications; special situations; and complications of HTND, predominantly cardiovascular ones.

Prediction of plasma sodium changes in the acutely ill patients: the potential role of tissue sodium content

BACKGROUND

Rapid correction of dysnatremias can result in neurological complications. Therefore, various formulas are available to predict changes in plasma sodium concentration ([Na+]) after treatment, but these have been shown to be inaccurate. This could be explained by sodium acumulation in skin and muscle tissue, which is not explicitly considered in these formulas. We assessed the association between clinical and biochemical factors related to tissue sodium accumulation and the discrepancy between predicted and measured plasma [Na+].

METHODS

We used data from an intensive care unit (ICU) cohort with complete data on sodium, potassium, and water balance. The predicted plasma [Na+] was calculated using the Barsoum-Levine (BL) and the Nguyen-Kurtz (NK) formula. We calculated the discrepancy between predicted and measured plasma sodium and fitted a linear mixed-effect model to investigate its association with factors related to tissue sodium accumulation.

RESULTS

We included 594 ICU days of sixty-three patients in our analysis. The mean plasma [Na+] at baseline was 147±6 mmol/L. The median (IQR) discrepancy between predicted and measured plasma [Na+] was 3.14 mmol/L (1.48, 5.55) and 3.53 mmol/L (1.81, 6.44) for the BL and NK formulas, respectively. For both formulas, estimated total body water (p=0.027), initial plasma [Na+] (p<0.001) and plasma [Na+] change (p<0.001) were associated with the discrepancy between predicted and measured plasma [Na+].

CONCLUSION

In this ICU cohort, initial plasma [Na+], total body water, and plasma [Na+] changes, all factors that are related to tissue sodium accumulation, were associated with the inaccurateness of plasma [Na+] prediction.

Intermuscular adipose tissue accumulation is associated with higher tissue sodium in healthy individuals

BACKGROUND AND AIMS

High tissue sodium accumulation and intermuscular adipose tissue (IMAT) are associated with aging, type 2 diabetes, and chronic kidney disease. In this study, we aim to investigate whether high lower-extremity tissue sodium accumulation relates to IMAT quantity and whether systemic inflammatory mediators and adipocytokines contribute to such association.

METHODS

Tissue sodium content and IMAT accumulation (percentage of IMAT area to muscle area) were measured in 83 healthy individuals using sodium imaging (23Na-MRI) and proton (1H-MRI) imaging of the calf. Insulin sensitivity was assessed by glucose disposal rate (GDR) measured with the hyperinsulinemic-euglycemic clamp.

RESULTS

Median (interquartile range) muscle and skin sodium contents were 16.6 (14.9, 19.0) and 12.6 (10.9, 16.7) mmol/L, respectively. Median IMAT was 3.69 (2.80, 5.37) %. In models adjusted for age, sex, BMI, GDR, adiponectin, and high-sensitivity C-reactive protein, increasing tissue sodium content was significantly associated with higher IMAT quantity (p = 0.018 and 0.032 for muscle and skin tissue sodium, respectively). In subgroup analysis stratified by sex, skin sodium was significantly associated with IMAT only among men. In interaction analysis, the association between skin sodium and IMAT was greater with increasing levels of high-sensitivity C-reactive protein and interleukin-6 (p for interaction = 0.022 and 0.006, respectively).

CONCLUSIONS

Leg muscle and skin sodium are associated with IMAT quantity among healthy individuals. The relationship between skin sodium and IMAT may be mediated by systemic inflammation.

Modification of Dialysate Na+ Concentration but not Ultrafiltration or Dialysis Treatment Time Affects Tissue Na+ Deposition in Patients on Hemodialysis

Introduction

Tissue Na+ overload is present in patients receiving hemodialysis (HD) and is associated with cardiovascular mortality. Strategies to actively modify tissue Na+ amount in these patients by adjusting the HD regimen have not been evaluated.

Methods

In several substudies, including cross-sectional analyses (n = 75 patients on HD), a cohort study and a cross-over interventional study (n = 10 patients each), we assessed the impact of ultrafiltration (UF) volume, prolongation of dialysis treatment time, and modification of dialysate Na+ concentration on tissue Na+ content using 23Na magnetic resonance imaging (23Na-MRI).

Results

In the cross-sectional analysis of our patients on HD, differences in dialysate sodium concentration ([Na+]) were associated with changes in tissue Na+ content, whereas neither UF volume nor HD treatment time affected tissue Na+ amount. Skin Na+ content was lower in 17 patients on HD, with dialysate [Na+] of <138 mmol/l compared to 58 patients dialyzing at ≥138 mmol/l (20.7 ± 7.3 vs. 26.0 ± 8.8 arbitrary units [a.u.], P < 0.05). In the cohort study, intraindividual prolongation of HD treatment time was not associated with a reduction in tissue Na+ content. Corresponding to the observational data, intraindividual modification of dialysate [Na+] from 138 to 142 to 135 mmol/l resulted in concordant changes in skin Na+ (24.3 ± 7.6 vs. 26.3 ± 8.0 vs. 20.8 ± 5.6 a.u, P < 0.05 each), whereas no significant change in muscle Na+ occurred.

Conclusion

Solely adjustment of dialysate [Na+] had a reproducible impact on tissue Na+ content. 23Na-MRI could be utilized to monitor the effectiveness of dialysate [Na+] modifications in randomized-controlled outcome trials.

Tangram of Sodium and Fluid Balance

Homeostasis of fluid and electrolytes is a tightly controlled physiological process. Failure of this process is a hallmark of hypertension, chronic kidney disease, heart failure, and other acute and chronic diseases. While the kidney remains the major player in the control of whole-body fluid and electrolyte homeostasis, recent discoveries point toward more peripheral mechanisms leading to sodium storage in tissues, such as skin and muscle, and a link between this sodium and a range of diseases, including the conditions above. In this review, we describe multiple facets of sodium and fluid balance from traditional concepts to novel discoveries. We examine the differences between acute disruption of sodium balance and the longer term adaptation in chronic disease, highlighting areas that cannot be explained by a kidney-centric model alone. The theoretical and methodological challenges of more recently proposed models are discussed. We acknowledge the different roles of extracellular and intracellular spaces and propose an integrated model that maintains fluid and electrolyte homeostasis and can be distilled into a few elemental players: the microvasculature, the interstitium, and tissue cells. Understanding their interplay will guide a more precise treatment of conditions characterized by sodium excess, for which primary aldosteronism is presented as a prototype.

Why should we use a low sodium dialysis solution for peritoneal dialysis?

Overhydration is highly prevalent in patients on peritoneal dialysis (PD), with inappropriately high sodium load supposedly playing a central role in the pathophysiology of the conditions. Recent studies have revealed the novel role of the interstitium as a buffer system for sodium ions, and it has been reported that patients on dialysis, including PD, present increased levels of sodium in the interstitium, such as in subcutaneous tissue and muscle. Hence, therapy for correction of overhydration should target the excess extracellular volume and the excess sodium storage in the interstitium. The ultrafiltrate obtained using the currently available PD solutions is hypo- to isonatric as compared to serum, which is disadvantageous for prompt and efficient sodium removal from the body in patients with overhydration. In contrast, use of low sodium PD solutions is characterised by iso- to hypernatric ultrafiltrate, which may beneficial for reducing sodium storage in the interstitium. Trials of low sodium PD solutions have reported possible clinical merits, for example, decreased blood pressure, reduced dryness of mouth and decreased body water content as assessed using bioimpedance methods. Given these observations and the high prevalence of overhydration in current PD populations, it makes medical sense that low sodium solutions be positioned as the new standard solution in the future. However, for medical safety, that is, to avoid hyponatremia and excessive decreases in blood pressure, further studies are needed to establish the appropriate compositions and applications of low sodium solutions.

Effect of Dialysate and Plasma Sodium on Mortality in a Global Historical Hemodialysis Cohort

SIGNIFICANCE STATEMENT

This large observational cohort study aimed to investigate the relationship between dialysate and plasma sodium concentrations and mortality among maintenance hemodialysis patients. Using a large multinational cohort of 68,196 patients, we found that lower dialysate sodium concentrations (≤138 mmol/L) were independently associated with higher mortality compared with higher dialysate sodium concentrations (>138 mmol/L). The risk of death was lower among patients exposed to higher dialysate sodium concentrations, regardless of plasma sodium levels. These results challenge the prevailing assumption that lower dialysate sodium concentrations improve outcomes in hemodialysis patients. The study confirms that until robust evidence from randomized trials that are underway is available, nephrologists should remain cautious in reconsideration of dialysate sodium prescribing practices to optimize cardiovascular outcomes and reduce mortality in this population.

BACKGROUND

Excess mortality in hemodialysis (HD) patients is largely due to cardiovascular disease and is associated with abnormal fluid status and plasma sodium concentrations. Ultrafiltration facilitates the removal of fluid and sodium, whereas diffusive exchange of sodium plays a pivotal role in sodium removal and tonicity adjustment. Lower dialysate sodium may increase sodium removal at the expense of hypotonicity, reduced blood volume refilling, and intradialytic hypotension risk. Higher dialysate sodium preserves blood volume and hemodynamic stability but reduces sodium removal. In this retrospective cohort, we aimed to assess whether prescribing a dialysate sodium ≤138 mmol/L has an effect on survival outcomes compared with dialysate sodium >138 mmol/L after adjusting for plasma sodium concentration.

METHODS

The study population included incident HD patients from 875 Fresenius Medical Care Nephrocare clinics in 25 countries between 2010 and 2019. Baseline dialysate sodium (≤138 or >138 mmol/L) and plasma sodium (<135, 135-142, >142 mmol/L) concentrations defined exposure status. We used multivariable Cox regression model stratified by country to model the association between time-varying dialysate and plasma sodium exposure and all-cause mortality, adjusted for demographic and treatment variables, including bioimpedance measures of fluid status.

RESULTS

In 2,123,957 patient-months from 68,196 incident HD patients with on average three HD sessions per week dialysate sodium of 138 mmol/L was prescribed in 63.2%, 139 mmol/L in 15.8%, 140 mmol/L in 20.7%, and other concentrations in 0.4% of patients. Most clinical centers (78.6%) used a standardized concentration. During a median follow-up of 40 months, one third of patients ( n =21,644) died. Dialysate sodium ≤138 mmol/L was associated with higher mortality (multivariate hazard ratio for the total population (1.57, 95% confidence interval, 1.25 to 1.98), adjusted for plasma sodium concentrations and other confounding variables. Subgroup analysis did not show any evidence of effect modification by plasma sodium concentrations or other patient-specific variables.

CONCLUSIONS

These observational findings stress the need for randomized evidence to reliably define optimal standard dialysate sodium prescribing practices.

Muscle Sodium Accumulation in Kidney Failure: Physiological Impact and Mitigation Strategies

Skeletal muscle has recently been recognized as a nonosmotic sodium reservoir that buffers dietary sodium. The in-vivo quantification of muscle sodium is based on a novel technology, sodium magnetic resonance imaging. Studies using this technology have shown that muscle sodium accumulation may be a clinical complication of chronic kidney disease (CKD). This review aims to summarize existing evidence on muscle sodium accumulation in patients with CKD and to identify knowledge gaps and topics for further research. The literature examined in this review suggests that muscle sodium accumulation is associated with CKD progression and pathological conditions. However, the causalities between muscle sodium accumulation and its related pathological changes are still elusive mainly because it is still uncertain where and how sodium accumulates in the muscle. More research is needed to address these gaps and determine if muscle sodium is a new intervention target in CKD.

Recent technical developments and clinical research applications of sodium (23Na) MRI

Sodium is an essential ion that plays a central role in many physiological processes including the transmembrane electrochemical gradient and the maintenance of the body's homeostasis. Due to the crucial role of sodium in the human body, the sodium nucleus is a promising candidate for non-invasively assessing (patho-)physiological changes. Almost 10 years ago, Madelin et al. provided a comprehensive review of methods and applications of sodium (23Na) MRI (Madelin et al., 2014) [1]. More recent review articles have focused mainly on specific applications of 23Na MRI. For example, several articles covered 23Na MRI applications for diseases such as osteoarthritis (Zbyn et al., 2016, Zaric et al., 2020) [2,3], multiple sclerosis (Petracca et al., 2016, Huhn et al., 2019) [4,5] and brain tumors (Schepkin, 2016) [6], or for imaging certain organs such as the kidneys (Zollner et al., 2016) [7], the brain (Shah et al., 2016, Thulborn et al., 2018) [8,9], and the heart (Bottomley, 2016) [10]. Other articles have reviewed technical developments such as radiofrequency (RF) coils for 23Na MRI (Wiggins et al., 2016, Bangerter et al., 2016) [11,12], pulse sequences (Konstandin et al., 2014) [13], image reconstruction methods (Chen et al., 2021) [14], and interleaved/simultaneous imaging techniques (Lopez Kolkovsky et al., 2022) [15]. In addition, 23Na MRI topics have been covered in review articles with broader topics such as multinuclear MRI or ultra-high-field MRI (Niesporek et al., 2019, Hu et al., 2019, Ladd et al., 2018) [16-18]. During the past decade, various research groups have continued working on technical improvements to sodium MRI and have investigated its potential to serve as a diagnostic and prognostic tool. Clinical research applications of 23Na MRI have covered a broad spectrum of diseases, mainly focusing on the brain, cartilage, and skeletal muscle (see Fig. 1). In this article, we aim to provide a comprehensive summary of methodological and hardware developments, as well as a review of various clinical research applications of sodium (23Na) MRI in the last decade (i.e., published from the beginning of 2013 to the end of 2022).

Determinants of phase angle in Japanese patients with diabetes

Phase angle, obtained using bioelectrical impedance analysis, non-invasively reflects the whole-body cellular condition and nutritional status and may be helpful as a prognostic factor. Patients with diabetes had a smaller phase angle than healthy subjects. However, the clinical significance of phase angle has not yet been elucidated. Therefore, the purpose of this study was to clarify the relationship between phase angle and HbA1c in patients with diabetes and the clinical relevance of phase angle. A retrospective, multicenter, cross-sectional study was conducted with Japanese patients with diabetes. Body composition was determined with bioelectrical impedance analysis, and this was used to obtain phase angle. Phase angle was assessed in relation to clinical parameters, body composition parameters, and HbA1c levels. A total of 655 patients were enrolled (400 men and 255 women, aged 57.1 ± 14.8 years, body mass index 25.6 ± 5.2 kg/m2, HbA1c 8.1 ± 1.9%). Even in patients with diabetes, the phase angle was higher in men than in women and did not differ between the types of diabetes. Multiple regression analysis, performed with phase angle as the objective variable, and age, sex, diabetes type, HbA1c, albumin level, and body mass index as explanatory variables, revealed that phase angle was negatively affected by HbA1c (B = - 0.043, 95% Confidence interval: - 0.07 to - 0.02, p < 0.001). HbA1c, age, sex, albumin level, and body mass index were independent determinants of phase angle in participants with diabetes.

The damaging duo: Obesity and excess dietary salt contribute to hypertension and cardiovascular disease

Hypertension is a primary risk factor for cardiovascular disease. Cardiovascular disease is the leading cause of death among adults worldwide. In this review, we focus on two of the most critical public health challenges that contribute to hypertension-obesity and excess dietary sodium from salt (i.e., sodium chloride). While the independent effects of these factors have been studied extensively, the interplay of obesity and excess salt overconsumption is not well understood. Here, we discuss both the independent and combined effects of excess obesity and dietary salt given their contributions to vascular dysfunction, autonomic cardiovascular dysregulation, kidney dysfunction, and insulin resistance. We discuss the role of ultra-processed foods-accounting for nearly 60% of energy intake in America-as a major contributor to both obesity and salt overconsumption. We highlight the influence of obesity on elevated blood pressure in the presence of a high-salt diet (i.e., salt sensitivity). Throughout the review, we highlight critical gaps in knowledge that should be filled to inform us of the prevention, management, treatment, and mitigation strategies for addressing these public health challenges.

Free and bound sodium identification by skin dielectric properties separation algorithm of bioelectrical impedance spectroscopy (spa-BIS) in human skin model

Free and bound sodium in human skin models have been identified by two proposals: skin's phantom fabrication and skin's dielectric properties separation algorithm of bioelectrical impedance spectroscopy (spa-BIS). Thespa-BIS consist of conductivity-permittivity separation, contact impedance compensation, and a correlation score algorithm based on the vessel with a bipolar electrode. The skin phantom fabrication comprises a recipe combination with temperature-controlled protocol and sodium molarity calculation. In experiments, the human skin models are created to mimic the electrical properties of skin under1MHzwith several different sodium molarities. Based on five types of human skin models with five samples of each group, the free sodium type conductivity and concentration resultsR2=0.9903-following a linear trendline of concentration change in skin tissues theorems with the fRequency range from1kHzto1MHz,while the bound sodium type resultsR2=0.9061-.Thespa-BIS compensate7-16Ωof vessel contact impedance. The dielectric properties of each type have been extracted with less than 10% of the average standard deviation, which is considered an accurate identification method of dermis dielectric properties. The algorithm successfully identifies sodium type: free sodium has a negative, and bound sodium has a positive correlation score trend. As an additional discussion, the different time-dependent effects, the different water content, and different agar content analyses have been provided in this study. As a robust analysis method, thespa-BIS has a prominent performance to replace a²³Na-MRI in terms of free and bound sodium identification.

Sodium in the skin: a summary of the physiology and a scoping review of disease associations

A large and growing body of research suggests that the skin plays an important role in regulating total body sodium, challenging traditional models of sodium homeostasis that focused exclusively on blood pressure and the kidney. In addition, skin sodium may help to prevent water loss and facilitate macrophage-driven antimicrobial host defence, but may also trigger immune dysregulation via upregulation of proinflammatory markers and downregulation of anti-inflammatory processes. We performed a systematic search of PubMed for published literature on skin sodium and disease outcomes and found that skin sodium concentration is increased in patients with cardiometabolic conditions including hypertension, diabetes and end-stage renal disease; autoimmune conditions including multiple sclerosis and systemic sclerosis; and dermatological conditions including atopic dermatitis, psoriasis and lipoedema. Several patient characteristics are associated with increased skin sodium concentration including older age and male sex. Animal evidence suggests that increased salt intake results in higher skin sodium levels; however, there are conflicting results from small trials in humans. Additionally, limited data suggest that pharmaceuticals such as diuretics and sodium-glucose co-transporter-2 inhibitors approved for diabetes, as well as haemodialysis may reduce skin sodium levels. In summary, emerging research supports an important role for skin sodium in physiological processes related to osmoregulation and immunity. With the advent of new noninvasive magnetic resonance imaging measurement techniques and continued research on skin sodium, it may emerge as a marker of immune-mediated disease activity or a potential therapeutic target.

Recent Advances in Sodium Magnetic Resonance Imaging and Its Future Role in Kidney Disease

Sodium imbalance is a hallmark of chronic kidney disease (CKD). Excess tissue sodium in CKD is associated with hypertension, inflammation, and cardiorenal disease. Sodium magnetic resonance imaging (23Na MRI) has been increasingly utilized in CKD clinical trials especially in the past few years. These studies have demonstrated the association of excess sodium tissue accumulation with declining renal function across whole CKD spectrum (early- to end-stage), biomarkers of systemic inflammation, and cardiovascular dysfunction. In this article, we review recent advances of 23Na MRI in CKD and discuss its future role with a focus on the skin, the heart, and the kidney itself.

Practical implementation and clinical benefits of the new automated dialysate sodium control biosensor

Background

A key feature of dialysis treatment is the prescription of dialysate sodium (Na). This study aimed to describe the practical implementation of a new automated dialysate Na control biosensor and to assess its tolerance and the beneficial clinical effects of isonatraemic dialysis.

Methods

A prospective study was carried out in 86 patients who, along with their usual parameters, received the following five consecutive phases of treatment for 3 weeks each: phase 0: baseline 5008 machine; phases 1 and 2: 6008 machine without activation of the Na control biosensor and the same fixed individualized Na dialysate prescription or adjusted to obtain similar conductivity to phase 0; phases 3 and 4: activated Na control to isonatraemic dialysis (Na dialysate margins 135-141 or 134-142 mmol/L).

Results

When the Na control was activated, the few episodes of cramps or hypotension disappeared when the lower dialysate Na margin was increased by 1 or 2 mmol/L. The activated Na control module showed significant differences compared with baseline and the non-activated Na module in final serum Na values, diffusive Na balance, and changes in pre- to postdialysis plasma Na values. The mean predialysis systolic blood pressure value was significantly lower in phase 4 than in phase 1. There were no significant differences in total Na balance in the four 6008 phases evaluated.

Conclusions

The implementation of the automated dialysate Na control module is a useful new tool, which reduced the diffusive load of Na with good tolerance. The module had the advantages of reducing thirst, interdialytic weight gain and intradialytic plasma Na changes.

Sodium Magnetic Resonance Imaging Shows Impairment of the Counter-current Multiplication System in Diabetic Mice Kidney

Key Points

23Na MRI allows us to noninvasively assess sodium distribution. We propose the utility of 23Na MRI for evaluating functional changes in diabetic kidney disease and not as a marker reflecting structural damage. 23Na MRI may be an early marker for structures beyond the glomeruli, enabling prompt intervention with novel efficacious tubule-targeting therapies.

Background

Sodium magnetic resonance imaging can noninvasively assess sodium distribution, specifically sodium concentration in the countercurrent multiplication system in the kidney, which forms a sodium concentration gradient from the cortex to the medulla, enabling efficient water reabsorption. This study aimed to investigate whether sodium magnetic resonance imaging can detect changes in sodium concentrations under normal conditions in mice and in disease models, such as a mouse model with diabetes mellitus.

Methods

We performed sodium and proton nuclear magnetic resonance imaging using a 9.4-T vertical standard-bore superconducting magnet.

Results

A condition of deep anesthesia, with widened breath intervals, or furosemide administration in 6-week-old C57BL/6JJcl mice showed a decrease in both tissue sodium concentrations in the medulla and sodium concentration gradients from the cortex to the medulla. Furthermore, sodium magnetic resonance imaging revealed reductions in the sodium concentration in the medulla and in the gradient from the cortex to the medulla in BKS.Cg-Leprdb+/+ Leprdb/Jcl mice at very early type 2 diabetes mellitus stages compared with corresponding control BKS.Cg-m+/m+/Jcl mice.

Conclusions

The kidneys of BKS.Cg-Leprdb+/+ Leprdb/Jcl mice aged 6 weeks showed impairments in the countercurrent multiplication system. We propose the utility of 23Na MRI for evaluating functional changes in diabetic kidney disease and not as a marker that reflects structural damage. Thus, 23Na MRI may be a potentially very early marker for structures beyond the glomerulus; this may prompt intervention with novel efficacious tubule-targeting therapies.

Influence of reference tube location on the measured sodium concentrations in calf muscles using a birdcage coil at 3T

PURPOSE

To investigate the influence of the sodium (Na) reference tube location in a birdcage coil on the quantification of Na in the calf muscle. Two correction methods were also evaluated.

METHOD

Eight (4 × 20 mM, 4 × 30 mM Na) reference tubes were placed along the inner surface of the coil and one (30 mM Na) tube more centrally near the tibia. In two volunteers, four repeated UTE scans were acquired. In six calf muscles, the Na concentration was calculated based on each reference tube. Flip angle mapping of a homogenous Na phantom was used for correcting intensity values. Alternatively, a normalized intensity map was used for correcting the in vivo signal intensities. Results were given as range or SD of Na concentration measurements over the reference tubes.

RESULTS

For calf Na measurements, there was limited space for positioning reference tubes away from coil B₁ inhomogeneity. In both volunteers, the Na quantification depended greatly on the reference tube used with a range of up to 10 mM. The central tube location gave a Na quantification close to the mean of the other tubes. The flip angle and normalized signal intensity phantom-based correction methods decreased the quantification variation from 14.9% to 5.0% and 10.4% to 2.7%, respectively. Both correction methods had little influence (< 2.3%) on quantification based on the central tube.

CONCLUSION

Despite use of a birdcage coil, location of the reference tube had a great impact on Na quantification in the calf muscles. Although both correction methods did reduce this variation, placing the reference tube more centrally was found to give the most reliable results.

MR-Nucleomics: The study of pathological cellular processes with multinuclear magnetic resonance spectroscopy and imaging in vivo

Clinical medicine has experienced a rapid development in recent decades, during which therapies targeting specific cellular signaling pathways, or specific cell surface receptors, have been increasingly adopted. While these developments in clinical medicine call for improved precision in diagnosis and treatment monitoring, modern medical imaging methods are restricted mainly to anatomical imaging, lagging behind the requirements of precision medicine. Although positron emission tomography and single photon emission computed tomography have been used clinically for studies of metabolism, their applications have been limited by the exposure risk to ionizing radiation, the subsequent limitation in repeated and longitudinal studies, and the incapability in assessing downstream metabolism. Magnetic resonance spectroscopy (MRS) or spectroscopic imaging (MRSI) are, in theory, capable of assessing molecular activities in vivo, although they are often limited by sensitivity. Here, we review some recent developments in MRS and MRSI of multiple nuclei that have potential as molecular imaging tools in the clinic.

Revisiting the concept of constant tissue conductivities for volume estimation in dialysis patients using bioimpedance spectroscopy

RATIONALE

Current estimation of body fluid volumes in hemodialysis patients using bioimpedance analysis assumes constant specific electrical characteristics of biological tissues despite a large variation in plasma Na⁺ concentrations [Na⁺], ranging from 130 to 150 mmol/L. Here, we examined the potential effect of variable [Na⁺] on bioimpedance-derived volume overload.

METHOD

Volumes were calculated from published whole-body extra- and intracellular resistance data and relationships using either "standard" or "revised" specific electrical characteristics modeled as functions of [Na⁺].

RESULT

With "standard" assumptions, volumes increased with increasing [Na⁺]. The increase in volume overload was about 0.5 dm³ and 3% of extracellular volume per 10 mmol/dm³ of [Na⁺] in a 75 kg patient. This increase was abolished when the same bioimpedance data were analyzed under "revised" conditions.

DISCUSSION

The overestimation in extracellular volume overload in the range of 0.5 dm³ per 10 mmol/dm³ [Na⁺] perfectly matches the positive relationship determined in a large cohort of hemodialysis patients. The bias may be considered moderate when interpreting data of individual patients, but may become important when comparing data of larger patient groups. The bias disappears when analysis of bioimpedance data accounts for differences in tissue electrical properties, using individual [Na⁺].

Intercorrelated variability in blood and hemodynamic biomarkers reveals physiological network in hemodialysis patients

Increased intra-individual variability of a variety of biomarkers is generally associated with poor health and reflects physiological dysregulation. Correlations among these biomarker variabilities should then represent interactions among heterogeneous biomarker regulatory systems. Herein, in an attempt to elucidate the network structure of physiological systems, we probed the inter-variability correlations of 22 biomarkers. Time series data on 19 blood-based and 3 hemodynamic biomarkers were collected over a one-year period for 334 hemodialysis patients, and their variabilities were evaluated by coefficients of variation. The network diagram exhibited six clusters in the physiological systems, corresponding to the regulatory domains for metabolism, inflammation, circulation, liver, salt, and protein. These domains were captured as latent factors in exploratory and confirmatory factor analyses (CFA). The 6-factor CFA model indicates that dysregulation in each of the domains manifests itself as increased variability in a specific set of biomarkers. Comparison of a diabetic and non-diabetic group within the cohort by multi-group CFA revealed that the diabetic cohort showed reduced capacities in the metabolism and salt domains and higher variabilities of the biomarkers belonging to these domains. The variability-based network analysis visualizes the concept of homeostasis and could be a valuable tool for exploring both healthy and pathological conditions.

Fluid Overload and Tissue Sodium Accumulation as Main Drivers of Protein Energy Malnutrition in Dialysis Patients

Protein energy malnutrition is recognized as a leading cause of morbidity and mortality in dialysis patients. Protein-energy-wasting process is observed in about 45% of the dialysis population using common biomarkers worldwide. Although several factors are implicated in protein energy wasting, inflammation and oxidative stress mechanisms play a central role in this pathogenic process. In this in-depth review, we analyzed the implication of sodium and water accumulation, as well as the role of fluid overload and fluid management, as major contributors to protein-energy-wasting process. Fluid overload and fluid depletion mimic a tide up and down phenomenon that contributes to inducing hypercatabolism and stimulates oxidation phosphorylation mechanisms at the cellular level in particular muscles. This endogenous metabolic water production may contribute to hyponatremia. In addition, salt tissue accumulation likely contributes to hypercatabolic state through locally inflammatory and immune-mediated mechanisms but also contributes to the perturbation of hormone receptors (i.e., insulin or growth hormone resistance). It is time to act more precisely on sodium and fluid imbalance to mitigate both nutritional and cardiovascular risks. Personalized management of sodium and fluid, using available tools including sodium management tool, has the potential to more adequately restore sodium and water homeostasis and to improve nutritional status and outcomes of dialysis patients.

Correlation between Blood Oxygen Level-Dependent Magnetic Resonance Imaging Images and Prognosis of Patients with Multicenter Diabetic Nephropathy on account of Artificial Intelligence Segmentation Algorithm

This study was aimed to analyze the correlation between blood oxygen level-dependent magnetic resonance imaging (BOLD-MRI) images and prognosis of patients with diabetic nephropathy (DN) based on artificial intelligence (AI) segmentation algorithm, so as to provide references for diagnosis and treatment as well as prognosis analysis of patients DN. In this study, a kernel function-based fuzzy C-means algorithm (KFCM) model was proposed, and the FCM algorithm based on neighborhood pixel information (BCFCM) and the FCM algorithm based on efficiency improvement (EnFCM) were introduced for comparison to analyze the image segmentation effects of three algorithms. The results showed that the partition coefficient (V_pc) and partition entropy (V_pe) of the KFCM algorithm were 0.801 and 0.602, respectively, which were better than those of the traditional FCM, BCFCM, and EnFCM algorithm. At the same time, the effects of correlation between renal cortex R2∗ (RC-R2∗), renal medulla R2∗ (RM-R2∗), renal cortex D (RC-D), renal medulla D (RM-D) and renal function on the prognosis were compared. The results showed that the correlation coefficients between RC-R2∗, RM-R2∗, RC-D, RM-D and renal function were 0.57, 0.62, 0.49, and 0.38, respectively; among them, RC-R2∗ and RM-R2∗ were negatively correlated to the estimated glomerular filtration rate (eGFR), and the difference between the groups was statistically significant (P <0.05). Among the factors affecting the prognosis of DN patients, the GFR, hemoglobin (Hb), RC-R2∗, RM-R2∗, and RC-D were all related to the prognosis of DN, and the difference between groups was statistically obvious (P <0.05). It suggested that the KFCM algorithm proposed in this study showed the relatively best segmentation effect on BOLD-MRI images for DN patients; an increase in R2∗ indicated a poor prognosis, and an increase in the RC-D value indicated a better prognosis.

Sodium First Approach, to Reset Our Mind for Improving Management of Sodium, Water, Volume and Pressure in Hemodialysis Patients, and to Reduce Cardiovascular Burden and Improve Outcomes

New physiologic findings related to sodium homeostasis and pathophysiologic associations require a new vision for sodium, fluid and blood pressure management in dialysis-dependent chronic kidney disease patients. The traditional dry weight probing approach that has prevailed for many years must be reviewed in light of these findings and enriched by availability of new tools for monitoring and handling sodium and water imbalances. A comprehensive and integrated approach is needed to improve further cardiac health in hemodialysis (HD) patients. Adequate management of sodium, water, volume and hemodynamic control of HD patients relies on a stepwise approach: the first entails assessment and monitoring of fluid status and relies on clinical judgement supported by specific tools that are online embedded in the HD machine or devices used offline; the second consists of acting on correcting fluid imbalance mainly through dialysis prescription (treatment time, active tools embedded on HD machine) but also on guidance related to diet and thirst management; the third consist of fine tuning treatment prescription to patient responses and tolerance with the support of innovative tools such as artificial intelligence and remote pervasive health trackers. It is time to come back to sodium and water imbalance as the root cause of the problem and not to act primarily on their consequences (fluid overload, hypertension) or organ damage (heart; atherosclerosis, brain). We know the problem and have the tools to assess and manage in a more precise way sodium and fluid in HD patients. We strongly call for a sodium first approach to reduce disease burden and improve cardiac health in dialysis-dependent chronic kidney disease patients.

Novel perspectives of sodium handling in type 2 diabetes mellitus

INTRODUCTION

As a key regulator of body water, sodium homeostasis forms an essential component of human physiology. Type 2 Diabetes Mellitus (T2D)-associated sodium overload stems from chronic renal retention of sodium, contributing toward the development of adverse cardiovascular sequelae.

AREAS COVERED

Our traditional model of sodium regulation invokes two compartments: extracellular fluid (ECF [plasma and interstitial fluid]) and intracellular fluid (ICF). Data from the Mars program reveal inconsistencies with this two-space model, including mismatches between net body sodium and water. Recent data utilizing 23Na magnetic resonance imaging (MRI) show a preponderance of bound sodium within human dermis, consistent with a third space repository and providing compelling evidence to support a three-space model in which dermal sodium binding facilitates sodium homeostasis within the ECF and ICF. This buffer is impaired in T2D, with diminishment of dermal bound sodium that may promote deleterious sequelae of sodium overload within the ECF and ICF.

EXPERT OPINION

Future studies should focus on novel therapeutic opportunities for sodium regulation in T2D and other conditions of sodium dysregulation. The ratio of free:bound dermal sodium (reflecting sodium storage capacity) could be utilized as a clinical biomarker for salt and water balance, to improve diagnostic accuracy and facilitate clinical decision-making.

The modulatory effect of high salt on immune cells and related diseases

BACKGROUND

The adverse effect of excessive salt intake has been recognized in decades. Researchers have mainly focused on the association between salt intake and hypertension. However, studies in recent years have proposed the existence of extra-renal sodium storage and provided insight into the immunomodulatory function of sodium.

OBJECTIVES

In this review, we discuss the modulatory effects of high salt on various innate and adaptive immune cells and immune-regulated diseases.

METHODS

We identified papers through electronic searches of PubMed database from inception to March 2022.

RESULTS

An increasing body of evidence has demonstrated that high salt can modulate the differentiation, activation and function of multiple immune cells. Furthermore, a high-salt diet can increase tissue sodium concentrations and influence the immune responses in microenvironments, thereby affecting the development of immune-regulated diseases, including hypertension, multiple sclerosis, cancer and infections. These findings provide a novel mechanism for the pathology of certain diseases and indicate that salt might serve as a target or potential therapeutic agent in different disease contexts.

CONCLUSION

High salt has a profound impact on the differentiation, activation and function of multiple immune cells. Additionally, an HSD can modulate the development of various immune-regulated diseases.

Na+ is shifted from the extracellular to the intracellular compartment and is not inactivated by glycosaminoglycans during high salt conditions in rats

Recently, studies have emerged suggesting that the skin plays a role as major Na⁺ reservoir via regulation of the content of glycosaminoglycans and osmotic gradients. We investigated whether there were electrolyte gradients in skin and where Na⁺ could be stored to be inactivated from a fluid balance viewpoint. Na⁺ accumulation was induced in rats by a high salt diet (HSD) (8% NaCl and 1% saline to drink) or by implantation of a deoxycorticosterone acetate (DOCA) tablet (1% saline to drink) using rats on a low salt diet (LSD) (0.1% NaCl) on tap water as control. Na⁺ and K⁺ were assessed by ion chromatography in tissue eluates, and the extracellular volume by equilibration of ⁵¹ Cr-EDTA. By tangential sectioning of the skin, we found a low Na⁺ content and extracellular volume in epidermis, both parameters rising by ∼30% and 100%, respectively, in LSD and even more in HSD and DOCA when entering dermis. We found evidence for an extracellular Na⁺ gradient from epidermis to dermis shown by an estimated concentration in epidermis ∼2 and 4-5 times that of dermis in HSD and DOCA-salt. There was intracellular storage of Na⁺ in skin, muscle, and myocardium without a concomitant increase in hydration. Our data suggest that there is a hydration-dependent high interstitial fluid Na⁺ concentration that will contribute to the skin barrier and thus be a mechanism for limiting water loss. Salt stress results in intracellular storage of Na⁺ in exchange with K⁺ in skeletal muscle and myocardium that may have electromechanical consequences. KEY POINTS: Studies have suggested that Na⁺ can be retained or removed without commensurate water retention or loss, and that the skin plays a role as major Na⁺ reservoir via regulation of the content of glycosaminoglycans and osmotic gradients. In the present study, we investigated whether there were electrolyte gradients in skin and where Na⁺ could be stored to be inactivated from a fluid balance viewpoint. We used two common models for salt-sensitive hypertension: high salt and a deoxycorticosterone salt diet. We found a hydration-dependent high interstitial fluid Na⁺ concentration that will contribute to the skin barrier and thus be a mechanism for limiting water loss. There was intracellular Na⁺ storage in muscle and myocardium without a concomitant increase in hydration, comprising storage that may have electromechanical consequences in salt stress.

Tissue Sodium in Patients With Early Stage Hypertension: A Randomized Controlled Trial

Background

Sodium (Na⁺) stored in skin and muscle tissue is associated with essential hypertension. Sodium magnetic resonance imaging is a validated method of quantifying tissue stores of Na⁺. In this study, we evaluated tissue Na⁺ in patients with elevated blood pressure or stage I hypertension in response to diuretic therapy or low Na⁺ diet.

Methods and Results

In a double‐blinded, placebo‐controlled trial, patients with systolic blood pressure 120 to 139 mm Hg were randomized to low sodium diet (<2 g of sodium), chlorthalidone, spironolactone, or placebo for 8 weeks. Muscle and skin Na⁺ using sodium magnetic resonance imaging and pulse wave velocity were assessed at the beginning and end of the study. Ninety‐eight patients were enrolled to undergo baseline measurements and 54 completed randomization. Median baseline muscle and skin Na⁺ in 98 patients were 16.4 mmol/L (14.9, 18.9) and 13.1 mmol/L (11.1, 16.1), respectively. After 8 weeks, muscle Na⁺ increased in the diet and chlorthalidone arms compared with placebo. Skin sodium was decreased only in the diet arm compared with placebo. These associations remained significant after adjustment for age, sex, body mass index, systolic blood pressure, and urinary sodium. No changes were observed in pulse wave velocity among the different groups when compared with placebo.

Conclusions

Diuretic therapy for 8 weeks did not decrease muscle or skin sodium or improve pulse wave velocity in patients with elevated blood pressure or stage I hypertension.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02236520.

Dietary sodium and health: How much is too much for those with orthostatic disorders?

High dietary salt (NaCl) increases blood pressure (BP) and can adversely impact multiple target organs including the vasculature, heart, kidneys, brain, autonomic nervous system, skin, eyes, and bone. However, patients with orthostatic disorders are told to increase their NaCl intake to help alleviate symptoms. While there is evidence to support the short-term benefits of increasing NaCl intake in these patients, there are few studies assessing the benefits and side effects of long-term high dietary NaCl. The evidence reviewed suggests that high NaCl can adversely impact multiple target organs, often independent of BP. However, few of these studies have been performed in patients with orthostatic disorders. We conclude that the recommendation to increase dietary NaCl in patients with orthostatic disorders should be done with care, keeping in mind the adverse impact on dietary NaCl in people without orthostatic disorders. Modest, rather than robust, increases in NaCl intake may be sufficient to alleviate symptoms but also minimize any long-term negative effects.

Ode to Salt: Commentary on "Skin Sodium Accumulates in Psoriasis and Reflects Disease Severity"

"Skin Sodium Accumulates in Psoriasis and Reflects Disease Severity" (Maifeld et al., 2021) showed that skin sodium ion (Na+) is increased in patients with a PASI > 5. Na+ concentration as well as its content were increased in these patients, supporting the proposed mechanism that increased Na+ concentrations enhance IL-17 expression from CD4+ cells. These data initially were generated using a noninvasive technique, sodium (23Na) magnetic resonance imaging, and then were verified using 23Na spectroscopy and atomic absorption spectrometry in ashed-skin biopsies in humans and also using mouse models of psoriasis. These findings suggest a novel pathologic mechanism for psoriasis development and target for treatment.

From salt to hypertension, what is missed?

Excess salt intake is viewed as a major contributor to hypertension and cardiovascular disease, and dietary salt restriction is broadly recommended by public health guidelines. However, individuals can have widely varying physiological responses to salt intake, and a tailored approach to evaluation and intervention may be needed. The traditional sodium related concepts are challenging to assess clinically for two reasons: (1) spot and 24-hour urine sodium are frequently used to evaluate salt intake, but are more suitable for population study, and (2) some adverse effects of salt may be blood pressure-independent. In recent years, previously unknown mechanisms of sodium absorption and storage have been discovered. This review will outline the limitations of current methods to assess sodium balance and discuss new potential evaluation methods and treatment targets.

Tissue sodium content correlates with hypertrophic vascular remodeling in type 2 diabetes

BACKGROUND

Prospective studies describe a linkage between increased sodium intake and higher incidence of cardiovascular organ damage and end points. We analyzed whether tissue sodium content in the skin and muscles correlate with vascular hypertrophic remodeling, a risk factor for cardiovascular disease.

METHODS

In patients with type 2 diabetes we assessed tissue sodium content and vascular structural parameters of the retinal arterioles. The structural parameters of retinal arterioles assessed by Scanning Laser Doppler Flowmetry were vessel (VD) and lumen diameter (LD), wall thickness (WT), wall-to-lumen ratio (WLR) and wall cross sectional area (WCSA). Tissue sodium content was measured with a 3.0 T clinical ²³Sodium-Magnetic Resonance Imaging (²³Na-MRI) system.

RESULTS

In patients with type 2 diabetes (N = 52) we observed a significant correlation between muscle sodium content and VD (p = 0.005), WT (p = 0.003), WCSA (p = 0.002) and WLR (p = 0.013). With respect to skin sodium content a significant correlation has been found with VD (p = 0.042), WT (p = 0.023) and WCSA (p = 0.019). Further analysis demonstrated that tissue sodium content of skin and muscle is a significant determinant of hypertrophic vascular remodeling independent of age, gender, diuretic use and 24-hour ambulatory BP.

CONCLUSION

With the ²³Na-MRI technology we could demonstrate that high tissue sodium content is independently linked to hypertrophic vascular remodeling in type 2 diabetes.

TRIAL REGISTRATION

Trial registration number: NCT02383238 Date of registration: March 9, 2015.

Volume-Independent Sodium Toxicity in Peritoneal Dialysis: New Insights from Bench to Bed

Sodium overload is common in end-stage kidney disease (ESKD) and is associated with increased cardiovascular mortality that is traditionally considered a result of extracellular volume expansion. Recently, sodium storage was detected by Na23 magnetic resonance imaging in the interstitial tissue of the skin and other tissues. This amount of sodium is osmotically active, regulated by immune cells and the lymphatic system, escapes renal control, and, more importantly, is associated with salt-sensitive hypertension. In chronic kidney disease, the interstitial sodium storage increases as the glomerular filtration rate declines and is related to cardiovascular damage, regardless of the fluid overload. This sodium accumulation in the interstitial tissues becomes more significant in ESKD, especially in older and African American patients. The possible negative effects of interstitial sodium are still under study, though a higher sodium intake might induce abnormal structural and functional changes in the peritoneal wall. Interestingly, sodium stored in the interstial tissue is not unmodifiable, since it is removable by dialysis. Nevertheless, the sodium removal by peritoneal dialysis (PD) remains challenging, and new PD solutions are desirable. In this narrative review, we carried out an update on the pathophysiological mechanisms of volume-independent sodium toxicity and possible future strategies to improve sodium removal by PD.

7 Tesla and Beyond: Advanced Methods and Clinical Applications in Magnetic Resonance Imaging

ABSTRACT

Ultrahigh magnetic fields offer significantly higher signal-to-noise ratio, and several magnetic resonance applications additionally benefit from a higher contrast-to-noise ratio, with static magnetic field strengths of B0 ≥ 7 T currently being referred to as ultrahigh fields (UHFs). The advantages of UHF can be used to resolve structures more precisely or to visualize physiological/pathophysiological effects that would be difficult or even impossible to detect at lower field strengths. However, with these advantages also come challenges, such as inhomogeneities applying standard radiofrequency excitation techniques, higher energy deposition in the human body, and enhanced B0 field inhomogeneities. The advantages but also the challenges of UHF as well as promising advanced methodological developments and clinical applications that particularly benefit from UHF are discussed in this review article.

High Na+ Environments Impair Phagocyte Oxidase-Dependent Antibacterial Activity of Neutrophils

Infection and inflammation can augment local Na⁺ abundance. These increases in local Na⁺ levels boost proinflammatory and antimicrobial macrophage activity and can favor polarization of T cells towards a proinflammatory Th17 phenotype. Although neutrophils play an important role in fighting intruding invaders, the impact of increased Na⁺ on the antimicrobial activity of neutrophils remains elusive. Here we show that, in neutrophils, increases in Na⁺ (high salt, HS) impair the ability of human and murine neutrophils to eliminate Escherichia coli and Staphylococcus aureus. High salt caused reduced spontaneous movement, degranulation and impaired production of reactive oxygen species (ROS) while leaving neutrophil viability unchanged. High salt enhanced the activity of the p38 mitogen-activated protein kinase (p38/MAPK) and increased the interleukin (IL)-8 release in a p38/MAPK-dependent manner. Whereas inhibition of p38/MAPK did not result in improved neutrophil defense, pharmacological blockade of the phagocyte oxidase (PHOX) or its genetic ablation mimicked the impaired antimicrobial activity detected under high salt conditions. Stimulation of neutrophils with phorbol-12-myristate-13-acetate (PMA) overcame high salt-induced impairment in ROS production and restored antimicrobial activity of neutrophils. Hence, we conclude that high salt-impaired PHOX activity results in diminished antimicrobial activity. Our findings suggest that increases in local Na⁺ represent an ionic checkpoint that prevents excessive ROS production of neutrophils, which decreases their antimicrobial potential and could potentially curtail ROS-mediated tissue damage.

Animal, Human, and 23Na MRI Imaging Evidence for the Negative Impact of High Dietary Salt in Children

PURPOSE OF THE REVIEW

Conditions typically prevalent in adults such as hypertension, kidney stones, osteoporosis, and chronic kidney disease are increasing among adolescents and young adults (AYA). The purpose of this review is to describe the association of these conditions to a high salt diet among pediatric patients.

RECENT FINDINGS

We present animal, human, and 23Na MRI evidence associated with the negative impact of high dietary salt in children. Special focus is placed on novel 23Na MRI imaging which reveals the important concept of a third compartment for sodium storage in soft tissue. Finally, we make recommendations on who should not be on a low salt diet.

SUMMARY

A high salt intake predisposes children and AYA to considerable morbidity. We exhort the reader to engage in advocacy efforts to curve the incidence and prevalence of high salt-related life-limiting conditions.

Reduction of Tissue Na+ Accumulation After Renal Transplantation

Introduction

Chronic kidney disease (CKD) engenders salt-sensitive hypertension. Whether or not tissue Na⁺ accumulation is increased in CKD patients remains uncertain. How tissue Na⁺ is affected after renal transplantation has not been assessed.

Methods

We measured tissue Na⁺ amount in 31 CKD patients (stage 5) and prospectively evaluated tissue Na⁺ content at 3 and 6 months, following living-donor kidney transplantation. Additionally, pre- and post-transplantation data were compared to 31 age- and sex-matched control subjects. ²³Na-magnetic resonance imaging (²³Na-MRI) was used to quantify muscle and skin Na⁺ of the lower leg and water distribution was assessed by bioimpedance spectroscopy.

Results

Compared to control subjects, CKD patients showed increased muscle (20.7 ± 5.0 vs. 15.5 ± 1.8 arbitrary units [a.u.], P < 0.001) and skin Na⁺ content (21.4 ± 7.7 vs. 15.0 ± 2.3 a.u., P < 0.001), whereas plasma Na⁺ concentration did not differ between groups. Restoration of kidney function by successful renal transplantation was accompanied by mobilization of tissue Na⁺ from muscle (20.7 ± 5.0 vs. 16.8 ± 2.8 a.u., P < 0.001) and skin tissue (21.4 ± 7.7 vs. 16.8 ± 5.2 a.u., P < 0.001). The reduction of tissue Na⁺ after transplantation was associated with improved renal function, normalization of blood pressure as well as an increase in lymphatic growth-factor concentration (vascular endothelial growth factor C [VEGF-C] 4.5 ± 1.8 vs. 6.7 ± 2.7 ng/ml, P < 0.01).

Conclusions

Tissue Na⁺ accumulation in predialysis patients with CKD was almost completely reversed to the level of healthy controls after successful kidney transplantation.

Skin sodium is increased in male patients with multiple sclerosis and related animal models

Novel MRI techniques allow a noninvasive quantification of tissue sodium and reveal the skin as a prominent compartment of sodium storage in health and disease. Since multiple sclerosis (MS) immunopathology is initiated in the periphery and increased sodium concentrations induce proinflammatory immune cells, the skin represents a promising compartment linking high sodium concentrations and MS immunopathology. We used a 7-T sodium MRI (23Na-MRI) and inductively coupled plasma mass spectrometry to investigate the skin sodium content in two mouse models of MS. We additionally performed 3-T 23Na-MRI of calf skin and muscles in 29 male relapsing-remitting MS (RRMS) patients and 29 matched healthy controls. Demographic and clinical information was collected from interviews, and disease activity was assessed by expanded disability status scale scoring. 23Na-MRI and chemical analysis demonstrated a significantly increased sodium content in the skin during experimental autoimmune encephalomyelitis independent of active immunization. In male patients with RRMS, 23Na-MRI demonstrated a higher sodium signal in the area of the skin compared to age- and biological sex-matched healthy controls with higher sodium, predicting future disease activity in cranial MRI. In both studies, the sodium enrichment was specific to the skin, as we found no alterations of sodium signals in the muscle or other tissues. Our data add to the recently identified importance of the skin as a storage compartment of sodium and may further represent an important organ for future investigations on salt as a proinflammatory agent driving autoimmune neuroinflammation such as that in MS.

Skin Sodium Accumulates in Psoriasis and Reflects Disease Severity

Sodium can accumulate in the skin at concentrations exceeding serum levels. A high sodium environment can lead to pathogenic T helper 17 cell expansion. Psoriasis is a chronic inflammatory skin disease in which IL-17‒producing T helper 17 cells play a crucial role. In an observational study, we measured skin sodium content in patients with psoriasis and in age-matched healthy controls by Sodium-23 magnetic resonance imaging. Patients with PASI > 5 showed significantly higher sodium and water content in the skin but not in other tissues than those with lower PASI or healthy controls. Skin sodium concentrations measured by Sodium-23 spectroscopy or by atomic absorption spectrometry in ashed-skin biopsies verified the findings with Sodium-23 magnetic resonance imaging. In vitro T helper 17 cell differentiation of naive CD4⁺ cells from patients with psoriasis markedly induced IL-17A expression under increased sodium chloride concentrations. The imiquimod-induced psoriasis mouse model replicated the human findings. Extracellular tracer Chromium-51-EDTA measurements in imiquimod- and sham-treated skin showed similar extracellular volumes, rendering excessive water of intracellular origin. Chronic genetic IL-17A‒driven psoriasis mouse models underlined the role of IL-17A in dermal sodium accumulation and inflammation. Our data describe skin sodium as a pathophysiological feature of psoriasis, which could open new avenues for its treatment.

Sodium in the dermis colocates to glycosaminoglycan scaffold, with diminishment in type 2 diabetes mellitus

BACKGROUND

Dietary sodium intake mismatches urinary sodium excretion over prolonged periods. Our aims were to localize and quantify electrostatically bound sodium within human skin using triple-quantum-filtered (TQF) protocols for MRI and magnetic resonance spectroscopy (MRS) and to explore dermal sodium in type 2 diabetes mellitus (T2D).

METHODS

We recruited adult participants with T2D (n = 9) and euglycemic participants with no history of diabetes mellitus (n = 8). All had undergone lower limb amputations or abdominal skin reduction surgery for clinical purposes. We used 20 μm in-plane resolution 1H MRI to visualize anatomical skin regions ex vivo from skin biopsies taken intraoperatively, 23Na TQF MRI/MRS to explore distribution and quantification of freely dissolved and bound sodium, and inductively coupled plasma mass spectrometry to quantify sodium in selected skin samples.

RESULTS

Human dermis has a preponderance (>90%) of bound sodium that colocalizes with the glycosaminoglycan (GAG) scaffold. Bound and free sodium have similar anatomical locations. T2D associates with a severely reduced dermal bound sodium capacity.

CONCLUSION

We provide the first evidence to our knowledge for high levels of bound sodium within human dermis, colocating to the GAG scaffold, consistent with a dermal "third space repository" for sodium. T2D associates with diminished dermal electrostatic binding capacity for sodium.

Relationship between sodium removal, hydration and outcomes in peritoneal dialysis patients

BACKGROUND

Fluid overload (FO) in peritoneal dialysis (PD) patients is associated with mortality. We explore if low daily sodium removal is an independent risk factor for mortality. We examined severely FO PD patients established for >1 year in expectation that PD prescription would have been optimized for solute clearance and ultrafiltration. We also wish to determine the relationship between kt/v and sodium removal.

METHODS

Retrospective analysis of 231 PD patients with FO ≥2.0 L and compared with 218 PD patients who were euvolaemic throughout their PD treatment. Patients were followed up until death censored for transplantation.

RESULTS

Mean daily sodium removal in overhydrated patients was only 75 mmoles (=1.7 g). CAPD usage was more common in patients with the highest sodium removal. Achievement of UK guidelines for solute clearance and daily fluid removal were not independent predictors of mortality. Markers of sarcopenia (low serum albumin and high CRP) were associated with increased mortality, but these parameters were not independent predictors in a model that included functional assessment (Karnofsky score). Daily sodium removal was not predictive of mortality but the imprecision of clinically used sodium assay should be noted. The correlation between Na and kt/v is statistically significant but R² was weak at .07.

CONCLUSION

While diabetic males were more likely to become overhydrated, these factors did not increase mortality further. Traditional targets of 'dialysis adequacy' did not predict survival. Kt/v is not a good indicator of sodium removal which can be surprisingly low. Measuring sodium clearance may help clinicians optimize PD modality (CAPD vs. APD).

Sodium activates human monocytes via the NADPH oxidase and isolevuglandin formation

AIMS

Prior studies have focused on the role of the kidney and vasculature in salt-induced modulation of blood pressure; however, recent data indicate that sodium accumulates in tissues and can activate immune cells. We sought to examine mechanisms by which salt causes activation of human monocytes both in vivo and in vitro.

METHODS AND RESULTS

To study the effect of salt in human monocytes, monocytes were isolated from volunteers to perform several in vitro experiments. Exposure of human monocytes to elevated Na+ex vivo caused a co-ordinated response involving isolevuglandin (IsoLG)-adduct formation, acquisition of a dendritic cell (DC)-like morphology, expression of activation markers CD83 and CD16, and increased production of pro-inflammatory cytokines tumour necrosis factor-α, interleukin (IL)-6, and IL-1β. High salt also caused a marked change in monocyte gene expression as detected by RNA sequencing and enhanced monocyte migration to the chemokine CC motif chemokine ligand 5. NADPH-oxidase inhibition attenuated monocyte activation and IsoLG-adduct formation. The increase in IsoLG-adducts correlated with risk factors including body mass index, pulse pressure. Monocytes exposed to high salt stimulated IL-17A production from autologous CD4+ and CD8+ T cells. In addition, to evaluate the effect of salt in vivo, monocytes and T cells isolated from humans were adoptively transferred to immunodeficient NSG mice. Salt feeding of humanized mice caused monocyte-dependent activation of human T cells reflected by proliferation and accumulation of T cells in the bone marrow. Moreover, we performed a cross-sectional study in 70 prehypertensive subjects. Blood was collected for flow cytometric analysis and 23Na magnetic resonance imaging was performed for tissue sodium measurements. Monocytes from humans with high skin Na+ exhibited increased IsoLG-adduct accumulation and CD83 expression.

CONCLUSION

Human monocytes exhibit co-ordinated increases in parameters of activation, conversion to a DC-like phenotype and ability to activate T cells upon both in vitro and in vivo sodium exposure. The ability of monocytes to be activated by sodium is related to in vivo cardiovascular disease risk factors. We therefore propose that in addition to the kidney and vasculature, immune cells like monocytes convey salt-induced cardiovascular risk in humans.

Tolvaptan treatment in an adult Fontan patient with protein-losing enteropathy: a serial 23Na-MRI investigation

Background:

Protein-losing enteropathy (PLE) is a severe complication of the univentricular Fontan circulation and associated with disturbances in salt and water homeostasis. Fontan patients with PLE have a poor prognosis, with increased morbidity and mortality. Due to limited therapeutic strategies, patients are often treated only symptomatically.

Methods:

We report our first experience of Tolvaptan (TLV) treatment in a Fontan patient with PLE, severe volume retention and hyponatraemia, refractory to conventional diuretic therapy. In addition to clinical parameters, we monitored drug effects including tissue sodium and volume status via serial ²³Na-magnetic resonance imaging (²³Na-MRI) and bioimpedance spectroscopy compared with age-matched controls.

Results:

²³Na-MRI identified elevated tissue sodium, which decreased under TLV treatment, as well as volume status, while serum sodium increased and the patient’s symptoms improved. During long-term treatment, we were able to differentiate between sodium and volume status in our patient, suggesting that TLV uncoupled body sodium from water.

Conclusion:

TLV in addition to loop diuretics improved clinical symptoms of PLE and lowered tissue sodium overload. Long-term effects should be further evaluated in Fontan patients.

Cardiovascular benefits of sodium-glucose cotransporter 2 inhibitors in diabetic and nondiabetic patients

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) were developed as antidiabetic agents, but accumulating evidence has shown their beneficial effects on the cardiovascular system. Analyses of the EMPA-REG OUTCOME trial (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients) suggested that these benefits are independent of glycemic control. Several large-scale outcome trials of SGLT2i also showed cardiovascular benefits in nondiabetic patients, strengthening this perspective. Extensive animal and clinical studies have likewise shown that mechanisms other than the antihyperglycemic effect underlie the cardiovascular benefits. Recent clinical guidelines recommend the use of SGLT2i in patients with type 2 diabetes mellitus and cardiovascular diseases because of the proven cardiovascular protective effects. Since the cardiovascular benefits are independent of glycemic control, the therapeutic spectrum of SGLT2i will likely be extended to nondiabetic patients.

Whole body potassium as a biomarker for potassium uptake using a mouse model

Potassium is known for its effect on modifiable chronic diseases like hypertension, cardiac disease, diabetes (type-2), and bone health. In this study, a new method, neutron generator based neutron activation analysis (NAA), was utilized to measure potassium (K) in mouse carcasses. A DD110 neutron generator based NAA assembly was used for irradiation.Thirty-two postmortem mice (n= 16 males and 16 females, average weight [Formula: see text] and [Formula: see text] g) were employed for this study. Soft-tissue equivalent mouse phantoms were prepared for the calibration. All mice were irradiated for 10 minutes, and the gamma spectrum with 42K was collected using a high efficiency, high purity germanium (HPGe) detector. A lead shielding assembly was designed and developed around the HPGe detector to obtain an improved detection limit. Each mouse sample was irradiated and measured twice to reduce uncertainty. The average potassium concentration was found to be significantly higher in males [Formula: see text] compared to females [Formula: see text]. We also observed a significant correlation between potassium concentration and the weight of the mice. The detection limit for potassium quantification with the NAA system was 46 ppm. The radiation dose to the mouse was approximately 56 [Formula: see text] mSv for 10-min irradiation. In conclusion, this method is suitable for estimating individual potassium concentration in small animals. The direct evaluation of total body potassium in small animals provides a new way to estimate potassium uptake in animal models. This method can be adapted later to quantify potassium in the human hand and small animals in vivo. When used in vivo, it is also expected to be a valuable tool for longitudinal assessment, kinetics, and health outcomes.

Distinct osmoregulatory responses to sodium loading in patients with altered glycosaminoglycan structure: a randomized cross-over trial

Background

By binding to negatively charged polysaccharides called glycosaminoglycans, sodium can be stored in the body—particularly in the skin—without concurrent water retention. Concordantly, individuals with changed glycosaminoglycan structure (e.g. type 1 diabetes (DM1) and hereditary multiple exostosis (HME) patients) may have altered sodium and water homeostasis.

Methods

We investigated responses to acute (30-min infusion) and chronic (1-week diet) sodium loading in 8 DM1 patients and 7 HME patients in comparison to 12 healthy controls. Blood samples, urine samples, and skin biopsies were taken to investigate glycosaminoglycan sulfation patterns and both systemic and cellular osmoregulatory responses.

Results

Hypertonic sodium infusion increased plasma sodium in all groups, but more in DM1 patients than in controls. High sodium diet increased expression of nuclear factor of activated t-cells 5 (NFAT5)—a transcription factor responsive to changes in osmolarity—and moderately sulfated heparan sulfate in skin of healthy controls. In HME patients, skin dermatan sulfate, rather than heparan sulfate, increased in response to high sodium diet, while in DM1 patients, no changes were observed.

Conclusion

DM1 and HME patients show distinct osmoregulatory responses to sodium loading when comparing to controls with indications for reduced sodium storage capacity in DM1 patients, suggesting that intact glycosaminoglycan biosynthesis is important in sodium and water homeostasis.

Trial registration These trials were registered with the Netherlands trial register with registration numbers: NTR4095 (https://www.trialregister.nl/trial/3933 at 2013-07-29) and NTR4788 (https://www.trialregister.nl/trial/4645 at 2014-09-12).

Tissue sodium stores in peritoneal dialysis and hemodialysis patients determined by 23-sodium magnetic resonance imaging

BACKGROUND

Tissue sodium content in patients on maintenance hemodialysis (MHD) and peritoneal dialysis (PD) were previously explored using 23Sodium magnetic resonance imaging (23NaMRI). Larger studies would provide a better understanding of sodium stores in patients on dialysis as well as the factors influencing this sodium accumulation.

METHODS

In this cross-sectional study, we quantified the calf muscle and skin sodium content in 162 subjects (10 PD, 33 MHD patients, and 119 controls) using 23NaMRI. Plasma levels of interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hsCRP) were measured to assess systemic inflammation. Sixty-four subjects had repeat 23NaMRI scans that were analyzed to assess the repeatability of the 23NaMRI measurements.

RESULTS

Patients on MHD and PD exhibited significantly higher muscle and skin sodium accumulation compared to controls. African American patients on dialysis exhibited greater muscle and skin sodium content compared to non-African Americans. Multivariable analysis showed that older age was associated with both higher muscle and skin sodium. Male sex was also associated with increased skin sodium deposition. Greater ultrafiltration was associated with lower skin sodium in patients on PD (Spearman's rho=-0.68, P = 0.035). Higher plasma IL-6 and hsCRP levels correlated with increased muscle and skin sodium content in the overall study population. Patients with higher baseline tissue sodium content exhibited greater variability in tissue sodium stores on repeat measurements.

CONCLUSIONS

Our findings highlight greater muscle and skin sodium content in dialysis patients compared to controls without kidney disease. Tissue sodium deposition and systemic inflammation seen in dialysis patients might influence one another bidirectionally.