Fatal voluntary salt intake resulting in the highest ever documented sodium plasma level in adults (255 mmol L-1): a disorder linked to female gender and psychiatric disorders

Extreme Hypernatremia due to Dehydration

Hypernatremia is defined as having a serum sodium concentration exceeding 145 mmol/L (normal range is 136 - 145 mmol/L). When the serum sodium level surpasses 160 mmol/L and 190 mmol/L, it is classified as severe and extreme hypernatremia, respectively. Extreme hypernatremia is an uncommon occurrence and is associated with significant risks of mortality and morbidity. The most frequently reported causes of extreme hypernatremia are accidental or intentional salt ingestion and diabetes insipidus, while dehydration due to poor water intake as a trigger for extreme hypernatremia is rarely documented. Here, we present a case study of an elderly patient who experienced extreme hypernatremia with a serum sodium level of 191 mmol/L due to dehydration and had altered mental status and ventriculomegaly as a complication.

Salt and Water: A Review of Hypernatremia

Serum sodium disorders are generally a marker of water balance in the body. Thus, hypernatremia is most often caused by an overall deficit of total body water. Other unique circumstances may lead to excess salt, without an impact on the body's total water volume. Hypernatremia is commonly acquired in both the hospital and community. As hypernatremia is associated with increased morbidity and mortality, treatment should be initiated promptly. In this review, we will discuss the pathophysiology and management of the main types of hypernatremia, which can be categorized as either a loss of water or gain of sodium that can be mediated by renal or extrarenal mechanisms.

Multiscale real time and high sensitivity ion detection with complementary organic electrochemical transistors amplifier

Ions are ubiquitous biological regulators playing a key role for vital processes in animals and plants. The combined detection of ion concentration and real-time monitoring of small variations with respect to the resting conditions is a multiscale functionality providing important information on health states. This multiscale functionality is still an open challenge for current ion sensing approaches. Here we show multiscale real-time and high-sensitivity ion detection with complementary organic electrochemical transistors amplifiers. The ion-sensing amplifier integrates in the same device both selective ion-to-electron transduction and local signal amplification demonstrating a sensitivity larger than 2300 mV V-1 dec-1, which overcomes the fundamental limit. It provides both ion detection over a range of five orders of magnitude and real-time monitoring of variations two orders of magnitude lower than the detected concentration, viz. multiscale ion detection. The approach is generally applicable to several transistor technologies and opens opportunities for multifunctional enhanced bioelectronics.

Acute Dysnatremias - a dangerous and overlooked clinical problem

Background

Dysnatremias are common electrolyte disturbances with significant morbidity and mortality. In chronic dysnatremias a slow correction rate (<10 mmol/L/24 h) is indicated to avoid neurological complications. In acute dysnatremias (occurring <48 h) a rapid correction rate may be indicated. Most guidelines do not differ between acute and chronic dysnatremias. In this review, we focus on the evidence-based treatment of acute dysnatremias.

Methods

A literary search in PubMed and Embase. A total of 72 articles containing 79 cases were included, of which 12 cases were excluded due to lack of information.

Results

Of 67 patients (70% women) with acute dysnatremia, 60 had hypo- and 7 had hypernatremia. All patients with hyper- and 88% with hyponatremia had a rapid correction rate (> 10 mmol/L/24 h). The median time of correction was 1 day in patients with hypo- and 2.5 days in patients with hypernatremia. The mortality was 7% in patients with hypo- and 29% in patients with hypernatremia.

Interpretation

Severe acute dysnatremias have significant mortality and require immediate treatment. A rapid correction rate may be lifesaving and is not associated with neurological complications. Chronic dysnatremias, on the other hand, are often compensated and thus less severe. In these cases a rapid correction rate may lead to severe cerebral complications.

Electronic supplementary material

The online version of this article (10.1186/s13049-019-0633-3) contains supplementary material, which is available to authorized users.

Conflicting Evidence on Health Effects Associated with Salt Reduction Calls for a Redesign of the Salt Dietary Guidelines

Ninety-five percent of the World's populations have a mean salt intake between 6 and 12 g, which is much lower than the tolerated daily level of up to 55 g/d. In spite of this, the recommended upper level by many health institutions is as low as 5.8 g/day. When reviewing the evidence for an upper level of 5.8 g/day, it becomes apparent that neither the supporting studies selected by the health institutions, nor randomized controlled trials and prospective observational studies disregarded by the health institutions, document that a salt intake below this 5.8 g, has beneficial health effects. Although there is an association between salt intake and blood pressure, both in randomized controlled trials and in observational studies, this association is weak, especially in non-obese individuals with normal blood pressure. Furthermore a salt intake below 5.8 g is associated with the activation of the renin-angiotensin-aldosteron system, an increase in plasma lipids and increased mortality. A redesign of the salt dietary guidelines, therefore, seems to be needed.

The neural basis of homeostatic and anticipatory thirst

Water intake is one of the most basic physiological responses and is essential to sustain life. The perception of thirst has a critical role in controlling body fluid homeostasis and if neglected or dysregulated can lead to life-threatening pathologies. Clear evidence suggests that the perception of thirst occurs in higher-order centres, such as the anterior cingulate cortex (ACC) and insular cortex (IC), which receive information from midline thalamic relay nuclei. Multiple brain regions, notably circumventricular organs such as the organum vasculosum lamina terminalis (OVLT) and subfornical organ (SFO), monitor changes in blood osmolality, solute load and hormone circulation and are thought to orchestrate appropriate responses to maintain extracellular fluid near ideal set points by engaging the medial thalamic-ACC/IC network. Thirst has long been thought of as a negative homeostatic feedback response to increases in blood solute concentration or decreases in blood volume. However, emerging evidence suggests a clear role for thirst as a feedforward adaptive anticipatory response that precedes physiological challenges. These anticipatory responses are promoted by rises in core body temperature, food intake (prandial) and signals from the circadian clock. Feedforward signals are also important mediators of satiety, inhibiting thirst well before the physiological state is restored by fluid ingestion. In this Review, we discuss the importance of thirst for body fluid balance and outline our current understanding of the neural mechanisms that underlie the various types of homeostatic and anticipatory thirst.

Increased levels of sodium chloride directly increase osteoclastic differentiation and resorption in mice and men

To better understand the association between high salt intake and osteoporosis, we investigated the effect of sodium chloride (NaCl) on mice and human osteoclastogenesis. The results suggest a direct, activating role of NaCl supplementation on bone resorption.

INTRODUCTION

High NaCl intake is associated with increased urinary calcium elimination and parathyroid hormone (PTH) secretion which in turn stimulates the release of calcium from the bone, resulting in increased bone resorption. However, while calciuria after NaCl loading could be shown repeatedly, several studies failed to reveal a significant increase in PTH in response to a high-sodium diet. Another possible explanation that we investigated here could be a direct effect of high-sodium concentration on bone resorption.

METHODS

Mouse bone marrow macrophage and human peripheral blood mononuclear cells (PBMC) driven towards an osteoclastogenesis pathway were cultivated under culture conditions mimicking hypernatremia environments.

RESULTS

In this study, a direct effect of increased NaCl concentrations on mouse osteoclast differentiation and function was observed. Surprisingly, in a human osteoclast culture system, significant increases in the number of tartrate-resistant acid phosphatase (TRAP)-positive osteoclasts, calcitonin receptor (CTR)-positive osteoclasts, nuclear factor-activated T cells c1 (NFATc1) gene expression, and areal and volumetric resorptions were observed for increasing concentrations of NaCl. This suggests a direct, activating, cell-mediated effect of increased concentrations of NaCl on osteoclasts.

CONCLUSIONS

The reported that enhanced bone resorption after high-sodium diets may not only be secondary to the urinary calcium loss but may also be a direct, cell-mediated effect on osteoclastic resorption. These findings allow us to suggest an explanation for the clinical findings independent of a PTH-mediated regulation.

A Systematic Review of Fatalities Related to Acute Ingestion of Salt. A Need for Warning Labels?

There are sporadic cases of fatalities from acutely eating salt. Yet, on social media, there are "challenges to" and examples of children and some adults acutely eating salt, and recently a charity advocated eating small amounts of salt to empathize with Syrian refugees. We performed a systematic review of fatalities from ingesting salt to assess if relatively moderate doses of salt could be fatal. In 27 reports, there were 35 fatalities documented (19 in adults and 16 in children). The lethal dose was estimated to be less than 10 g of sodium (<5 teaspoons of salt) in two children, and less than 25 g sodium in four adults (<4 tablespoons of salt). The frequency of fatal ingestion of salt is not able to be discerned from our review. If investigation of the causes of hypernatremia in hospital records indicates salt overdose is relatively common, consideration could be given to placing warning labels on salt containers and shakers. Such warning labels can have the added advantage of reducing dietary salt consumption.

Severe Hypernatremia Caused by Acute Exogenous Salt Intake Combined with Primary Hypothyroidism

This report describes a case of severe hypernatremia with a serum sodium concentration of 188.1mmol/L caused by exogenous salt intake. A 26-year-old man diagnosed with Crohn's disease 5 years previously visited our clinic due to generalized edema and personality changes, with aggressive behavior. He had compulsively consumed salts, ingesting approximately 154 g of salt over the last 4 days. Despite careful fluid management that included not only hypotonic fluid therapy for 8 hours but also hypertonic saline administration, his serum sodium level decreased sharply at 40.6 mmol/L; however, it returned to normal within 72-hour of treatment without any neurological deficits. Primary hypothyroidism was also diagnosed. He was discharged after 9 days from admission, with a stable serum sodium level. We have described the possibility of successful treatment in a patient with hypernatremia caused by acute salt intoxication without sustained hypotonic fluid therapy.

Pseudohypernatremia secondary to trisodium citrate (Citra-LockTM)

INTRODUCTION

Hypernatremia is common among hospitalized patients especially in the intensive care units and presents an independent risk factor for mortality. Mild hypernatremia is often asymptomatic but severe hypernatremia causes central nervous system dysfunction with initial non-specific symptoms of encephalopathy that may progress to seizures, coma and death, if left untreated. Severe hypernatremia is a medical emergency and requires emergent medical attention.

MATERIALS AND METHODS

A haemodialysis patient who arrived for his scheduled haemodialysis treatment had monthly blood work drawn and was reported to have severe hypernatremia with serum sodium concentration of 183 mmol/L. The possibility of technique or laboratory error was considered and systematically evaluated.

RESULTS

The serum sodium measurement using another analyser showed similar value of 182 mmolL. A repeat serum sodium level on a sample drawn 2 h later showed normal value of 139-140 mmol/L. A step-wise evaluation of the complete procedure from blood collection to analysis of the sample revealed this to be spuriously elevated serum sodium concentration secondary to contamination of the sample during sample collection with trisodium citrate, a catheter-lock solution, commonly used in dialysis units to maintain patency of dialysis catheters.

CONCLUSIONS

Spuriously elevated plasma sodium concentration (pseudohypernatremia) of mild degree is common but severe pseudohypernatremia is rare and the possibility of sample contaminations or laboratory error should be considered. Vigilance is required by both the medical and the laboratory staff to resolve such issues in a timely fashion to avoid unintended consequences.

Hyperosmolar sodium chloride is toxic to cultured neurons and causes reduction of glucose metabolism and ATP levels, an increase in glutamate uptake, and a reduction in cytosolic calcium

Elevation of serum sodium, hypernatremia, which may occur during dehydration or treatment with sodium chloride, may cause brain dysfunction and damage, but toxic mechanisms are poorly understood. We found that exposure to excess NaCl, 10-100mmol/L, for 20h caused cell death in cultured cerebellar granule cells (neurons). Toxicity was due to Na(+), since substituting excess Na(+) with choline reduced cell death to control levels, whereas gluconate instead of excess Cl(-) did not. Prior to cell death from hyperosmolar NaCl, glucose consumption and lactate formation were reduced, and intracellular aspartate levels were elevated, consistent with reduced glycolysis or glucose uptake. Concomitantly, the level of ATP became reduced. Pyruvate, 10mmol/L, reduced NaCl-induced cell death. The extracellular levels of glutamate, taurine, and GABA were concentration-dependently reduced by excess NaCl; high-affinity glutamate uptake increased. High extracellular [Na(+)] caused reduction in intracellular free [Ca(2+)], but a similar effect was seen with mannitol, which was not neurotoxic. We suggest that inhibition of glucose metabolism with ensuing loss of ATP is a neurotoxic mechanism of hyperosmolar sodium, whereas increased uptake of extracellular neuroactive amino acids and reduced intracellular [Ca(2+)] may, if they occur in vivo, contribute to the cerebral dysfunction and delirium described in hypernatremia.

Risk Prediction of One-Year Mortality in Patients with Cardiac Arrhythmias Using Random Survival Forest

Existing models for predicting mortality based on traditional Cox proportional hazard approach (CPH) often have low prediction accuracy. This paper aims to develop a clinical risk model with good accuracy for predicting 1-year mortality in cardiac arrhythmias patients using random survival forest (RSF), a robust approach for survival analysis. 10,488 cardiac arrhythmias patients available in the public MIMIC II clinical database were investigated, with 3,452 deaths occurring within 1-year followups. Forty risk factors including demographics and clinical and laboratory information and antiarrhythmic agents were analyzed as potential predictors of all-cause mortality. RSF was adopted to build a comprehensive survival model and a simplified risk model composed of 14 top risk factors. The built comprehensive model achieved a prediction accuracy of 0.81 measured by c-statistic with 10-fold cross validation. The simplified risk model also achieved a good accuracy of 0.799. Both results outperformed traditional CPH (which achieved a c-statistic of 0.733 for the comprehensive model and 0.718 for the simplified model). Moreover, various factors are observed to have nonlinear impact on cardiac arrhythmias prognosis. As a result, RSF based model which took nonlinearity into account significantly outperformed traditional Cox proportional hazard model and has great potential to be a more effective approach for survival analysis.

Hypernatremia: correction rate and hemodialysis

Severe hypernatremia is defined as serum sodium levels above 152 mEq/L, with a mortality rate ≥60%. 85-year-old gentleman was brought to the emergency room with altered level of consciousness after refusing to eat for a week at a skilled nursing facility. On admission patient was nonverbal with stable vital signs and was responsive only to painful stimuli. Laboratory evaluation was significant for serum sodium of 188 mmol/L and water deficit of 12.0 L. Patient was admitted to medicine intensive care unit and after inadequate response to suboptimal fluid repletion, hemodialysis was used to correct hypernatremia. Within the first fourteen hours, sodium concentration only changed 1 mEq/L with a fluid repletion; however, the concentration dropped greater than 20 mEq/L within two hours during hemodialysis. Despite such a drastic drop in sodium concentration, patient did not develop any neurological sequela and was at baseline mental status at the time of discharge.

Osmotic homeostasis

Alterations in water homeostasis can disturb cell size and function. Although most cells can internally regulate cell volume in response to osmolar stress, neurons are particularly at risk given a combination of complex cell function and space restriction within the calvarium. Thus, regulating water balance is fundamental to survival. Through specialized neuronal "osmoreceptors" that sense changes in plasma osmolality, vasopressin release and thirst are titrated in order to achieve water balance. Fine-tuning of water absorption occurs along the collecting duct, and depends on unique structural modifications of renal tubular epithelium that confer a wide range of water permeability. In this article, we review the mechanisms that ensure water homeostasis as well as the fundamentals of disorders of water balance.

Severe hypernatremia by excessive bamboo salt ingestion in healthy young woman

Severe hypernatremia is an important electrolyte disorder that has serious effects. The patient had no medical history. A. 20-year-old ingested bamboo salt for digestion and weight reduction according to the folk remedies posted on an internet website. She presented with vomiting and diarrhea over ten times per day. Her initial serum sodium concentration was 174mEq/L. Her symptoms improved rapidly with hypotonic saline infusion. She recovered completely without any sequelae in three days. Severe hypernatremia in a normal young adult with clear consciousness and normal renal function has not been reported in Korea yet. So we report a case of severe hypernatremia by excessive bamboo salt ingestion in healthy young woman.

Survival of acute hypernatremia due to massive soy sauce ingestion

BACKGROUND

Intentional massive sodium chloride ingestions are rare occurrences and are often fatal.

OBJECTIVES

There are a variety of treatment recommendations for hypernatremia, ranging from dialysis to varying rates of correction. We report a case of acute severe hypernatremia corrected with rapid free-water infusions that, to our knowledge, has not been previously reported.

CASE REPORT

A 19-year-old man presented to the Emergency Department in a comatose state with seizure-like activity 2 hours after ingesting a quart of soy sauce. He was administered 6 L of free water over 30 min and survived neurologically intact without clinical sequelae. Corrected for hyperglycemia, the patient's peak serum sodium was 196 mmol/L, which, to our knowledge, is the highest documented level in an adult patient to survive an acute sodium ingestion without neurologic deficits.

CONCLUSION

Emergency physicians should consider rapidly lowering serum sodium with hypotonic intravenous fluids as a potential management strategy for acute severe hypernatremia secondary to massive salt ingestion.

Metabolic encephalopathies

Kinnier Wilson coined the term metabolic encephalopathy to describe a clinical state of global cerebral dysfunction induced by systemic stress that can vary in clinical presentation from mild executive dysfunction to deep coma with decerebrate posturing; the causes are numerous. Some mechanisms by which cerebral dysfunction occurs in metabolic encephalopathies include focal or global cerebral edema, alterations in transmitter function, the accumulation of uncleared toxic metabolites, postcapillary venule vasogenic edema, and energy failure. This article focuses on common causes of metabolic encephalopathy, and reviews common causes, clinical presentations and, where relevant, management.

Spirituality and aging

Interest in spirituality and aging has increased recently, owing to overwhelming evidence of positive health outcomes linked to spirituality and religious participation. Increasing longevity in modern society puts spiritual needs of older adults at the forefront of societal priorities. Understanding individual spiritual perspectives becomes increasingly important, given the issues of loss, physical illness and mortality that are confronted in old age. There are multiple barriers to the proper assessment of spirituality in clinical practice and research (e.g., the lack of professional training for healthcare professionals, shortage of time and comfort for healthcare providers when discussing spiritual issues and needs). Integrating an individual’s spiritual practice into their healthcare can help shape personalized medical care for older adults and improve health outcomes. This article reviews literature and research on spirituality, as well as spiritual interventions and their putative neurobiological mechanisms in relation to aging, mental and physical health, and coping with death and dying.

The potential significance of elevated vitreous sodium levels at autopsy

Elevated levels of sodium that may be detected in the analysis of post-mortem fluid samples may arise from a wide variety of organic illnesses and environmental factors that have caused either water depletion or solute gain. When hypernatraemia is suspected at autopsy a careful history is required with particular emphasis on pre-existing medical conditions such as renal or gastrointestinal disease. In addition, detailed information is required on the circumstances of death, including any clinical symptoms and signs that the deceased may have manifested, or medical procedures such as dialysis, colonoscopy or intravenous fluid replacement. Reduced intake of fluid may be associated with cognitive or physical impairment or may result from environmental depletion (the latter may be a manifestation of inflicted injury). Both central and nephrogenic diabetes insipidus may result in the loss of excessive amounts of hypotonic fluid. This may also occur following diuretic use, or be due to gastroenteritis or burns. Hypernatraemia may be a marker of excessive salt/saline ingestion and/or administration and may occur accidentally or as a manifestation of child abuse. Given the range of possible etiologies, hypernatraemia may be a significant autopsy finding that requires explanation.

A review of drug-induced hypernatraemia

Drug-induced electrolyte abnormalities have been increasingly reported and may be associated with considerable morbidity and/or mortality. In clinical practice, hypernatraemia (serum sodium higher than 145 mmol/L) is usually of multifactorial aetiology and drug therapy not infrequently is disregarded as a contributing factor for increased serum sodium concentration. Strategies to prevent this adverse drug effect involve careful consideration of risk factors and clinical and laboratory evaluation in the course of treatment. Herein, we review evidence-based information via PubMed and EMBASE and the relevant literature implicating pharmacologic treatment as an established cause of hypernatraemia and discuss its incidence and the underlying pathophysiologic mechanisms.

Central mechanisms of osmosensation and systemic osmoregulation

Systemic osmoregulation is a vital process whereby changes in plasma osmolality, detected by osmoreceptors, modulate ingestive behaviour, sympathetic outflow and renal function to stabilize the tonicity and volume of the extracellular fluid. Furthermore, changes in the central processing of osmosensory signals are likely to affect the hydro-mineral balance and other related aspects of homeostasis, including thermoregulation and cardiovascular balance. Surprisingly little is known about how the brain orchestrates these responses. Here, recent advances in our understanding of the molecular, cellular and network mechanisms that mediate the central control of osmotic homeostasis in mammals are reviewed.

Electrolyte and salt disturbances in older people: causes, management and implications

Salt and electrolyte disturbances are commonly encountered in older patients. A sound understanding of the underlying physiological and pathological mechanisms underpinning the predisposition of older people to the common electrolyte imbalances can help clinicians minimize their considerable associated morbidity and mortality. This review focuses on the more common and clinically relevant salt and electrolyte disorders of older people. The epidemiology, causes, symptoms, diagnosis and treatment of hyponatraemia, hypernatraemia, hyperkalaemia, hypokalaemia and calcium and phosphate imbalance in old age are covered from a clinician's perspective.

Hypernatremia and intravenous fluid resuscitation in collapsed ultramarathon runners

OBJECTIVE

To determine if a return to normonatremia is required for symptomatology to resolve in collapsed hypernatremic runners and if intravenous (IV) administration of an isotonic solution would adversely affect serum sodium concentration ([Na+]) in collapsed normonatremic runners.

DESIGN

Observational study.

SETTING

2006 Comrades Marathon.

PARTICIPANTS

103 collapsed runners.

MAIN OUTCOME MEASURE

Final serum [Na] upon discharge.

RESULTS

58% of all collapsed runners were hypernatremic. Hypernatremic runners reported significantly more vomiting than normonatremic runners (79 versus 34%; P < 0.001). A significant decrease in serum [Na] in hypernatremic collapsed runners occurred after the IV administration of either 1 L of 0.45% normal saline (150.5 +/- 3.5 versus 148.0 +/- 4.6; P < 0.05) or Ringers lactate solution (147.7 +/- 2.2 versus 146.2 +/- 2.1; P < 0.05). One liter of IV fluid administration caused an increase in plasma volume that was not significantly different between (1) hypernatremic runners receiving a hypotonic solution (13.5 +/- 12.7%) and (2) normonatremic runners receiving an isotonic solution (15.6 +/- 11.3%). The final serum [Na+] of hypernatremic runners was above the range for normonatremia upon discharge (>145 mmol/L).

CONCLUSIONS

A return to normonatremia was not required for hypernatremic runners to "recover" and be discharged from the medical tent. Vomiting either aggravated and/or facilitated the development of hypernatremia. IV administration of 1 L of either (1) a hypotonic solution to hypernatremic runners or (2) an isotonic solution to both normonatremic and hypernatremic runners did not produce any adverse biochemical or cardiovascular changes and can therefore be considered a safe and effective treatment for collapsed runners if used in this context.

Severe rhabdomyolysis due to adipsic hypernatremia after craniopharyngioma surgery

The association of diabetes insipidus and adipsia after craniopharyngioma surgery has high morbidity. Hypernatremia can be caused by adipsia and be aggravated by diabetes insipidus. Rhabdomyolysis rarely occurs. DASE REPORT: This is the first report of a diabetic patient with craniopharyngioma who developed diabetes insipidus and adipsia after surgery, evolving with severe hypernatremia that caused considerable rhabdomyolysis. CONCLUSION: The importance of the evaluation of muscle integrity when under hypernatremic states is pointed out. Although adipsia may have a simple solution through volunteer water ingestion, serious consequences such as repeated severe hypernatremia episodes and intense rhabdomyolysis with high morbidity could occur, if adipsia is not diagnosed.

Spiritual issues in psychiatric care

This article differentiates between the concepts of spirituality and religion and analyzes the strengths and weaknesses of the research findings related to spirituality, religion, and mental health. To discuss the importance of clarifying values and becoming self-aware in relation to implementing spiritual and religious interventions. The components of spiritual assessment are presented as well as spiritual coping practices and interventions the nurse might use when working with clients. Review of literature from MEDLINE, CINAHL, and current texts. Spirituality and religion are too often neglected foci of psychiatric mental health assessment and intervention. In order to maximize therapeutic effectiveness, nurses should be aware that for many patients spirituality is a critical life factor. Accordingly, they should screen patients and strive to meet patient needs for spiritual expression, while recognizing that there are important boundary and ethical issues in psychiatric mental health settings.