1
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Kettritz R. [Dysnatremias - concepts and clinical work-up]. Dtsch Med Wochenschr 2024; 149:86-92. [PMID: 38262402 DOI: 10.1055/a-2055-3486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Osmotic gradients over cell membranes lead to water movement into or out of cells. An intact osmoregulation prevents osmotic gradients, thereby protecting cells from swelling or shrinking. Na+ is the major cation in the extracellular fluid (ECF) and the major determinant of the osmolarity in the ECF, including plasma. Therefore, the plasma-Na+ concentration needs to be tightly regulated. An excess of electrolyte-free water decreases the concentration of osmolytes leading to hyponatremia. In contrast, a free water deficit increases the osmolyte concentration leading to hypernatremia. Pathophysiology-oriented approaches to dysnatremic patients help both clinicians and patients. Therapeutic interventions depend on the differentiation between acute and chronic, asymptomatic, and symptomatic dysnatremia, and on the patient's extracellular volume status. The therapeutic armamentarium for hyponatremia consists of water restriction, hypertonic infusions, urea, V2 receptor-blockers, and sodium-glucose cotransporter 2 (SGLT2) inhibitors. Patients with hypernatremia are treated with electrolyte-free water or hypotonic sodium-containing solutions depending on their volume status. Basic concepts in the management of dysnatremic patients are discussed.
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Bastos AP, Rocha PN. Osmotic demyelination as a complication of hyponatremia correction: a systematic review. J Bras Nefrol 2024; 46:47-55. [PMID: 37523718 PMCID: PMC10962407 DOI: 10.1590/2175-8239-jbn-2022-0114en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 05/31/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Rapid correction of hyponatremia, especially when severe and chronic, can result in osmotic demyelination. The latest guideline for diagnosis and treatment of hyponatremia (2014) recommends a correction limit of 10 mEq/L/day. Our aim was to summarize published cases of osmotic demyelination to assess the adequacy of this recommendation. METHOD Systematic review of case reports of osmotic demyelination. We included cases confirmed by imaging or pathology exam, in people over 18 years of age, published between 1997 and 2019, in English or Portuguese. RESULTS We evaluated 96 cases of osmotic demyelination, 58.3% female, with a mean age of 48.2 ± 12.9 years. Median admission serum sodium was 105 mEq/L and > 90% of patients had severe hyponatremia (<120 mEq/L). Reports of gastrointestinal tract disorders (38.5%), alcoholism (31.3%) and use of diuretics (27%) were common. Correction of hyponatremia was performed mainly with isotonic (46.9%) or hypertonic (33.7%) saline solution. Correction of associated hypokalemia occurred in 18.8%. In 66.6% of cases there was correction of natremia above 10 mEq/L on the first day of hospitalization; the rate was not reported in 22.9% and in only 10.4% was it less than 10 mEq/L/day. CONCLUSION The development of osmotic demyelination was predominant in women under 50 years of age, with severe hyponatremia and rapid correction. In 10.4% of cases, there was demyelination even with correction <10 mEq/L/day. These data reinforce the need for conservative targets for high-risk patients, such as 4-6 mEq/L/day, not exceeding the limit of 8 mEq/L/day.
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3
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Wu H, Li X, Zhao L, Yuan J, Xing Y, Bai M, Sun S. Risk factors for mortality in brain injury patients who have severe hypernatremia and received continuous venovenous hemofiltration. Heliyon 2023; 9:e21792. [PMID: 38027977 PMCID: PMC10663868 DOI: 10.1016/j.heliyon.2023.e21792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 10/06/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Background and objectives The mortality rate for people with brain injuries is increased when hypernatremia is present. Patients with severe hypernatremia, who have a significant short-term mortality rate, were shown to benefit from continuous venovenous hemofiltration (CVVH), which has been indicated to be successful. Exploring the risk factors for short-term mortality in brain injury patients who underwent CVVH and had severe hypernatremia was the aim of the current study. Materials and methods Retrospective screening was performed on patients with brain injuries who underwent CVVH at Xijing Hospital between 1 December 2010 and 31 December 2021 and who have a diagnosis of severe hypernatremia. The outcomes included 28-day patient mortality and hospital stay duration. The patient survival rate was examined using the Kaplan-Meier survival curve. To determine the risk factors for short-term death for patients, univariate and multivariate Cox regression analysis models were used. Results Our current study included a total of 83 individuals. The included patients had a median age of 49 (IQR 35-59) years. Of the included patients, 58 patients (69.9 %) died within 28 days. The median length of hospital stay for the patient was 13 (IQR 7-21) days. The APACHE II score, SOFA score, GCS, PLT count, INR, stroke, mechanical ventilation, and vasopressor reliance were related to 28-day mortality according to the univariate Cox analysis. INR (HR = 1.004, 95 % Cl: 1.001-1.006, P = 0.008), stroke (HR = 1.971, 95 % Cl: 1.031-3.768, P = 0.04), mechanical ventilation (HR = 3.948, 95 % Cl: 1.090-14.294, P = 0.036), and vasopressor dependency (HR = 2.262, 95 % Cl: 1.099-4.655, P = 0.027) were independently associated with the risk of 28-day death rates, according to multivariate Cox regression analysis. Conclusions Brain injuries who have severe hypernatremia requires CVVH, which has high short-term patient mortality. Mechanical ventilation, INR increase, stroke, and vasopressor dependence are independently associated with increased patient mortality risk.
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Affiliation(s)
- Hao Wu
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, Shanxi, 710032, China
- Xi'an Medical University, Xi 'an, Shanxi, China
| | - Xiayin Li
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, Shanxi, 710032, China
- Xi'an Medical University, Xi 'an, Shanxi, China
| | - Lijuan Zhao
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, Shanxi, 710032, China
| | - Jinguo Yuan
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, Shanxi, 710032, China
| | - Yan Xing
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, Shanxi, 710032, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, Shanxi, 710032, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, Shanxi, 710032, China
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4
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Murt A, Kalantar-Zadeh K. Treating hyponatremia fast but modestly: counterbalancing risks and the fear of osmotic demyelination syndrome. Clin Kidney J 2023; 16:1553-1554. [PMID: 37779847 PMCID: PMC10539246 DOI: 10.1093/ckj/sfad158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Indexed: 10/03/2023] Open
Affiliation(s)
- Ahmet Murt
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Internal Medicine/Nephrolgy, Istanbul, Turkey
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, CA, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
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5
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An Exchange about "Osmotic Demyelination Syndrome in Patients Hospitalized with Hyponatremia". NEJM EVIDENCE 2023; 2:EVIDe2300228. [PMID: 38320188 DOI: 10.1056/evide2300228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
In Volume 2, Number 4 of NEJM Evidence, we published an article entitled, "Osmotic Demyelination Syndrome in Patients Hospitalized with Hyponatremia" by MacMillan et al. The article was accompanied by an editorial entitled "Hyponatremia Treatment Guidelines - Have They Gone Too Far?" by Ayus and Moritz. After these articles were published, a group of readers shared feedback about the data presented and the conclusions drawn; their comments are detailed as "Remarks from Readers." We relayed these points to the authors of the original article and the editorial; their responses follow.
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6
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Kinoshita T, Mlodzinski E, Xiao Q, Sherak R, Raines NH, Celi LA. Effects of correction rate for severe hyponatremia in the intensive care unit on patient outcomes. J Crit Care 2023; 77:154325. [PMID: 37187000 PMCID: PMC10524223 DOI: 10.1016/j.jcrc.2023.154325] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 03/19/2023] [Accepted: 05/04/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE Limited evidence exists regarding outcomes associated with different correction rates of severe hyponatremia. MATERIALS AND METHODS This retrospective cohort analysis employed a multi-center ICU database to identify patients with sodium ≤120 mEq/L during ICU admission. We determined correction rates over the first 24 h and categorized them as rapid (> 8 mEq/L/day) or slow (≤ 8 mEq/L/day). The primary outcome was in-hospital mortality. Secondary outcomes included hospital-free days, ICU-free days, and neurological complications. We used inverse probability weighting for confounder adjustment. RESULTS Our cohort included 1024 patients; 451 rapid and 573 slow correctors. Rapid correction was associated with lower in-hospital mortality (absolute difference: -4.37%; 95% CI, -8.47 to -0.26%), longer hospital-free days (1.80 days; 95% CI, 0.82 to 2.79 days), and longer ICU-free days (1.16 days; 95% CI, 0.15 to 2.17 days). There was no significant difference in neurological complications (2.31%; 95% CI, -0.77 to 5.40%). CONCLUSION Rapid correction (>8 mEq/L/day) of severe hyponatremia within the first 24 h was associated with lower in-hospital mortality and longer ICU and hospital-free days without an increase in neurological complication. Despite major limitations, including the inability to identify the chronicity of hyponatremia, the results have important implications and warrant prospective studies.
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Affiliation(s)
| | - Eric Mlodzinski
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
| | - Qian Xiao
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Raphael Sherak
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA; Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, CT 06510, USA
| | - Nathan H Raines
- Division of Nephrology, Department of Medicine Beth Israel Deaconess Medical Center, Boston, MA 02115, USA
| | - Leo A Celi
- MIT Critical Data, Laboratory for Computational Physiology, Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
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7
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Seethapathy H, Zhao S, Ouyang T, Passos C, Sarang A, Cheung PW, Waikar SS, Steele DJR, Kalim S, Allegretti AS, Ayus JC, Nigwekar SU. Severe Hyponatremia Correction, Mortality, and Central Pontine Myelinolysis. NEJM EVIDENCE 2023; 2:EVIDoa2300107. [PMID: 38320180 DOI: 10.1056/evidoa2300107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: In clinical practice, sodium correction rates are frequently limited in patients with severe hyponatremia to prevent neurologic complications. The implications of correction rates on overall mortality and length of hospital stay are unclear. METHODS: In this multicenter observational study, we evaluated the association of sodium correction rates with mortality, length of stay, and central pontine myelinolysis (CPM) in patients hospitalized with severe hyponatremia (admission serum sodium level less than 120 mEq/l). RESULTS: The cohort included 3274 patients. A correction rate of less than 6 mEq/l/24 hours was observed in 38%, 6 to 10 mEq/l/24 hours was observed in 29%, and greater than 10 mEq/l/24 hours was observed in 33%. Compared with 6 to 10 mEq/l/24 hours, a correction rate of less than 6 mEq/l/24 hours exhibited higher in-hospital mortality in multivariable-adjusted and propensity score–weighted analyses. Compared with 6 to 10 mEq/l/24 hours, a correction rate of greater than 10 mEq/l/24 hours was associated with lower in-hospital mortality and shorter length of stay in multivariable analyses. Seven patients with CPM were identified, with five of seven developing CPM despite a sodium correction rate of less than or equal to 8 mEq/l/24 hours. Six of seven patients who developed CPM had alcohol use disorder, malnutrition, hypokalemia, or hypophosphatemia. CONCLUSIONS: Limiting the sodium correction rate was associated with higher mortality and longer length of stay. Whether the sodium correction rate influences neurologic complications needs further evaluation.
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Affiliation(s)
- Harish Seethapathy
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Sophia Zhao
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Tianqi Ouyang
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Christie Passos
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Adviti Sarang
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Pui W Cheung
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston
| | - David J R Steele
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Sahir Kalim
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Juan Carlos Ayus
- Department of Nephrology and Hypertension, University of California, Irvine, CA
| | - Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
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8
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Perschinka F, Köglberger P, Klein SJ, Joannidis M. [Hyponatremia : Etiology, diagnosis and acute therapy]. Med Klin Intensivmed Notfmed 2023; 118:505-517. [PMID: 37646802 PMCID: PMC10501960 DOI: 10.1007/s00063-023-01049-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 05/09/2023] [Accepted: 05/15/2023] [Indexed: 09/01/2023]
Abstract
Hyponatremia is one of the most common electrolyte disorders in emergency departments and hospitalized patients. Serum sodium concentration is controlled by osmoregulation and volume regulation. Both pathways are regulated via the release of antidiuretic hormone (ADH). Syndrome of inappropriate release of ADH (SIADH) may be caused by neoplasms or pneumonia but may also be triggered by drug use or drug abuse. Excessive fluid intake may also result in a decrease in serum sodium concentration. Rapid alteration in serum sodium concentration leads to cell swelling or cell shrinkage, which primarily causes neurological symptoms. The dynamics of development of hyponatremia and its duration are crucial. In addition to blood testing, a clinical examination and urine analysis are essential in the differential diagnosis of hyponatremia.
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Affiliation(s)
- Fabian Perschinka
- Gemeinsame Einrichtung Internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - Paul Köglberger
- Gemeinsame Einrichtung Internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
- Institut für Anästhesiologie und Intensivmedizin, Klinikum Wels, Grieskirchnerstraße 42, 4600, Wels, Österreich
| | - Sebastian J Klein
- Gemeinsame Einrichtung Internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - Michael Joannidis
- Gemeinsame Einrichtung Internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
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9
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Ghosal A, Qadeer HA, Nekkanti SK, Pradhan P, Okoye C, Waqar D. A Conspectus of Euvolemic Hyponatremia, Its Various Etiologies, and Treatment Modalities: A Comprehensive Review of the Literature. Cureus 2023; 15:e43390. [PMID: 37700952 PMCID: PMC10495223 DOI: 10.7759/cureus.43390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2023] [Indexed: 09/14/2023] Open
Abstract
Hyponatremia is the most prevalent electrolyte imbalance encountered among hospitalized patients, athletes, the elderly, patients with chronic ailments, postoperative patients, and a few asymptomatic individuals. Clinical manifestations of hyponatremia can be diverse, with characteristic neurological symptoms. Depending on in-depth medical history, physical examination (including volume status assessment), laboratory investigation, and drug history, patients can be classified broadly as undergoing hypervolemic, euvolemic, or hypovolemic hyponatremia. However, patients with hypervolemic hyponatremia often present with distinctive signs such as edema or ascites, and the clinical presentation of hypovolemic and euvolemic hyponatremia poses significant challenges for clinicians. The convolution in clinical manifestations of patients is due to the varied etiologies of euvolemic hyponatremia, such as syndrome of inappropriate antidiuretic hormone secretion (SIADH), adrenocortical insufficiency, hypothyroidism, psychogenic polydipsia, different classes of drugs (chemotherapeutics, antipsychotics, antidepressants), endurance exercise events, and reset osmostat syndrome (ROS). The management of hyponatremia depends on the rate of hyponatremia onset, duration, severity of symptoms, levels of serum sodium, and underlying comorbidities. Over the last decade, the clinical understanding of hyponatremia has been scattered due to the introduction of innovative laboratory markers and new drugs. This article will be a conspectus of all the recent advancements in the field of diagnosis, investigations, management, and associations of hyponatremia, along with traditional clinical practices. Subsequently, a holistic overview has been laid out for the clinicians to better understand and identify knowledge deficiencies on this topic.
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Affiliation(s)
- Anit Ghosal
- Internal Medicine, Kolkata Medical College and Hospital, Kolkata, IND
| | - Hafiza Amna Qadeer
- Internal Medicine, Foundation University Medical College, Islamabad, PAK
| | | | | | - Chiugo Okoye
- Internal Medicine, Igbinedion University, Okada, NGA
| | - Danish Waqar
- Internal Medicine/Nephrology, Loyola University Medical Center, Chicago, USA
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10
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Hussain F, Ebeling-Koning NE, Carlson J, Beauchamp GA. From Crashing Waves to Crashing Sodium: A Rare Case of Nearly Asymptomatic Severe Hyponatremia. Cureus 2023; 15:e41474. [PMID: 37546107 PMCID: PMC10404146 DOI: 10.7759/cureus.41474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 08/08/2023] Open
Abstract
Hyponatremia refers to an abnormally low serum sodium level, and it is the most common electrolyte disorder encountered in the clinical setting. Despite its prevalence, hyponatremia can be challenging to clinically identify in some cases due to non-specific symptom presentation. In this case report, we illustrate the rare clinical course of a nearly asymptomatic patient with severe hyponatremia and discuss potential explanations for this uncommon presentation.
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Affiliation(s)
- Fawaz Hussain
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | | | - Joshua Carlson
- Department of Pulmonary and Critical Care Medicine, Lehigh Valley Health Network, Allentown, USA
| | - Gillian A Beauchamp
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, Allentown, USA
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11
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Sterns RH, Rondon-Berrios H, Adrogué HJ, Berl T, Burst V, Cohen DM, Christ-Crain M, Cuesta M, Decaux G, Emmett M, Garrahy A, Gankam-Kengne F, Hix JK, Hoorn EJ, Kamel KS, Madias NE, Peri A, Refardt J, Rosner MH, Sherlock M, Silver SM, Soupart A, Thompson CJ, Verbalis JG. Treatment Guidelines for Hyponatremia: Stay the Course. Clin J Am Soc Nephrol 2023; 19:01277230-990000000-00180. [PMID: 37379081 PMCID: PMC10843202 DOI: 10.2215/cjn.0000000000000244] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/22/2023] [Indexed: 06/29/2023]
Abstract
International guidelines designed to minimize the risk of complications that can occur when correcting severe hyponatremia have been widely accepted for a decade. On the basis of the results of a recent large retrospective study of patients hospitalized with hyponatremia, it has been suggested that hyponatremia guidelines have gone too far in limiting the rate of rise of the serum sodium concentration; the need for therapeutic caution and frequent monitoring of the serum sodium concentration has been questioned. These assertions are reminiscent of a controversy that began many years ago. After reviewing the history of that controversy, the evidence supporting the guidelines, and the validity of data challenging them, we conclude that current safeguards should not be abandoned. To do so would be akin to discarding your umbrella because you remained dry in a rainstorm. The authors of this review, who represent 20 medical centers in nine countries, have all contributed significantly to the literature on the subject. We urge clinicians to continue to treat severe hyponatremia cautiously and to wait for better evidence before adopting less stringent therapeutic limits.
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Affiliation(s)
- Richard H. Sterns
- University of Rochester School of Medicine and Dentistry, Rochester, New York
- Rochester General Hospital, Rochester, New York
| | | | | | - Tomas Berl
- University of Colorado Aschutz School of Medicine, Aurora, Colorado
| | - Volker Burst
- University of Cologne Faculty of Medicine, Cologne, Germany
| | | | | | | | - Guy Decaux
- Erasmus University Hospital, Brussels, Belgium
| | | | | | | | - John K. Hix
- Rochester General Hospital, Rochester, New York
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12
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Gankam Kengne F. Adaptation of the Brain to Hyponatremia and Its Clinical Implications. J Clin Med 2023; 12:jcm12051714. [PMID: 36902500 PMCID: PMC10002753 DOI: 10.3390/jcm12051714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/12/2023] [Accepted: 02/17/2023] [Indexed: 02/25/2023] Open
Abstract
Hyponatremia is the most common electrolyte disorder, occurring in up to 25% of hospitalized patients. Hypo-osmotic hyponatremia when severe and left untreated invariably results in cell swelling, which can lead to fatal consequences, especially in the central nervous system. The brain is particularly vulnerable to the consequences of decreased extracellular osmolarity; because of being encased in the rigid skull, it cannot withstand persistent swelling. Moreover, serum sodium is the major determinant of extracellular ionic balance, which in turn governs crucial brain functions such as the excitability of neurons. For these reasons, the human brain has developed specific ways to adapt to hyponatremia and prevent brain edema. On the other hand, it is well known that rapid correction of chronic and severe hyponatremia can lead to brain demyelination, a condition known as osmotic demyelination syndrome. In this paper, we will discuss the mechanisms of brain adaptation to acute and chronic hyponatremia and the neurological symptoms of these conditions as well as the pathophysiology and prevention of osmotic demyelination syndrome.
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13
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Harris S, Dupanloup A, Liao PT, Jukier T. Case report: Recovery and sequential imaging of a patient with osmotic demyelination syndrome. Front Vet Sci 2023; 10:1146091. [PMID: 37187927 PMCID: PMC10175592 DOI: 10.3389/fvets.2023.1146091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/05/2023] [Indexed: 05/17/2023] Open
Abstract
A 4-year-old neutered-male Australian Shepherd was presented to an emergency and referral hospital for an acute onset of neurologic signs and abnormal mentation. Seven days prior, the patient had been diagnosed with hypoadrenocorticism and was treated accordingly at another hospital. Based on recent clinical history, the neurologic signs were consistent with thalamic and brainstem deficits and suspected to be caused by osmotic demyelination syndrome secondary to rapid correction of hyponatremia. A brain MRI confirmed lesions consistent with osmotic demyelination syndrome. The patient's clinical signs initially worsened, and he required intensive nursing care with multimodal sedation, close monitoring of electrolytes and tailored fluid therapy. The patient recovered and was discharged on day seven of hospitalization. Four and a half months later, re-evaluation of the patient showed complete resolution of the neurological deficits with a now unremarkable neurological exam, and follow-up MRI revealed still present, yet improved bilateral thalamic lesions. This is the first known veterinary case report of sequential brain imaging of a dog that has recovered from osmotic demyelination syndrome. In humans, patients can have evidence of near to full clinical recovery, yet imaging findings may still be abnormal several months after recovery. This report details similar imaging findings in a canine with improved clinical signs, despite persistent lesions on brain MRI. Prognosis of canines with osmotic demyelination syndrome may be better than previously perceived, despite the severity of clinical signs and brain lesions apparent on MRI.
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Affiliation(s)
- Stephanie Harris
- Department of Clinical Sciences, Auburn University College of Veterinary Medicine, Auburn, AL, United States
| | - Adrien Dupanloup
- Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Pen-Ting Liao
- Department of Clinical Sciences, Auburn University College of Veterinary Medicine, Auburn, AL, United States
| | - Tom Jukier
- Department of Clinical Sciences, Auburn University College of Veterinary Medicine, Auburn, AL, United States
- *Correspondence: Tom Jukier
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14
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Wu H, Bai M, Li X, Xing Y, Sun S. Diagnosis and treatment of brain injury complicated by hypernatremia. Front Neurol 2022; 13:1026540. [PMID: 36518191 PMCID: PMC9743987 DOI: 10.3389/fneur.2022.1026540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/14/2022] [Indexed: 12/01/2023] Open
Abstract
Hypernatremia is a common electrolyte disorder in patients with brain injury. The mortality of brain injury patients with severe hypernatremia may be as high as 86.8%. The efficacy of conventional treatment for hypernatremia is limited. Continuous renal replacement therapy (CRRT) can slowly, controllably, and continuously reduce the blood sodium concentration and gradually become an important treatment for severe hypernatremia patients. This review aims to provide important information for clinicians and clinical researchers by describing the etiology, diagnosis, hazards, conventional treatment, and CRRT treatment of hypernatremia in patients with traumatic brain injury.
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Affiliation(s)
- Hao Wu
- Department for Postgraduate Students, Xi'an Medical University, Xi'an, China
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiayin Li
- Department for Postgraduate Students, Xi'an Medical University, Xi'an, China
| | - Yan Xing
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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15
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Ahmed M, Moffett P. Osmotic Demyelination Syndrome in a Patient With Tremors. Cureus 2022; 14:e30076. [PMID: 36381866 PMCID: PMC9639865 DOI: 10.7759/cureus.30076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2022] [Indexed: 11/07/2022] Open
Abstract
Osmotic demyelination syndrome is a neurological disorder caused by damage to the myelin sheath of brain cells secondary to rapid correction of hyponatremia. Clinical features are variable depending on the location of demyelination, with diagnosis confirmed by MRI. Once diagnosed, treatment is supportive. We present a 49-year-old female recently discharged from an outside hospital who presented with symptoms of tremors, ataxia, slurred speech, and confusion. The patient was diagnosed with osmotic demyelination syndrome based on the classic trident sign on MRI imaging. A review of her records showed rapid correction of serum sodium during her initial hospital visit.
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16
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Incidence and risk factors of overcorrection in patients presenting with severe hyponatremia to the emergency department. Clin Exp Nephrol 2022; 26:1086-1091. [DOI: 10.1007/s10157-022-02252-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/27/2022] [Indexed: 11/03/2022]
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17
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Baba M, Alsbrook D, Williamson S, Soman S, Ramadan AR. Approach to the Management of Sodium Disorders in the Neuro Critical Care Unit. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00723-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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18
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Poch E, Molina A, Piñeiro G. Syndrome of inappropriate antidiuretic hormone secretion. Med Clin (Barc) 2022; 159:139-146. [PMID: 35659417 DOI: 10.1016/j.medcli.2022.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 10/18/2022]
Abstract
Hyponatremia is the most frequent electrolytic disorder in hospitalized patients, and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), the most frequent cause of hiponatremia with clinically normal extracellular volume. It consists of a disorder of the regulation of body water that obeys to different causes, mainly cancer, pulmonary illnesses, disorders of the central nervous system and diverse drugs. As in any hiponatremia it a physiological knowledge of the regulation of body water and sodium is essential as well as the application of precise diagnostic criteria in order to manage the problem with an effective treatment. The available data until the moment show that the clinical diagnosis of SIADH made by professionals is mainly not supported on the established criteria drawn by experts and this lack of accuracy probably hits in the therapeutic result. The basis of the treatment of the SIADH is to correct its cause, water restriction, solutes (sodium chloride) and the use of vaptans in case of failure of the previous measures.
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Affiliation(s)
- Esteban Poch
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, España; IDIBAPS; Departamento de Medicina, Universidad de Barcelona, Barcelona, España.
| | - Alicia Molina
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, España
| | - Gastón Piñeiro
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, España
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19
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Murphy PT, Auger S, Nandoskar A. Osmotic demyelination syndrome despite appropriate gradual correction of moderate hyponatraemia. Pract Neurol 2022; 22:practneurol-2022-003369. [PMID: 35577547 DOI: 10.1136/practneurol-2022-003369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2022] [Indexed: 11/04/2022]
Abstract
Osmotic demyelination syndrome characteristically follows rapid correction of hyponatraemia. We present a young woman with a subacute progressive brainstem syndrome and diffuse pontine signal abnormality on MR imaging, diagnosed as osmotic demyelination syndrome. The case posed a diagnostic challenge due to comorbid Behçet's disease and the absence of significant fluctuation in her serum sodium concentration. Osmotic demyelination syndrome is not limited to patients with rapidly corrected hyponatraemia, especially when there are other risk factors. These factors, all present in this patient, include hypokalaemia, hypophosphataemia, malnutrition, harmful alcohol use and liver dysfunction.
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Affiliation(s)
| | - Stephen Auger
- Department of Neurology, Imperial College Healthcare NHS Trust, London, UK
| | - Ashwini Nandoskar
- Department of Neurology, Imperial College Healthcare NHS Trust, London, UK
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20
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Zurnuq S, Aljurfi M, Albekery M, Shawaqfeh MS, Elmubark A, Vasudevan S, Alharbi S, Alkatheri M, Albekairy AM, Al Katheri AA. Hyponatremia management among patients admitted to tertiary hospital: A retrospective evaluation. SAGE Open Med 2022; 10:20503121221095333. [PMID: 35509952 PMCID: PMC9058361 DOI: 10.1177/20503121221095333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 03/31/2022] [Indexed: 11/20/2022] Open
Abstract
Objective: The aim of this study is to compare the adherence to the guidelines in patients presenting with hyponatremia defined as a sodium (Na) level ⩽120 mEq/L, treated with 3% hypertonic saline or normal saline. The comparison included 3% hypertonic saline use, safe serum sodium increases within 24 and 48 h, frequency of hyponatremia-related complications, and length of stay. Methods: This retrospective observational study enrolled 122 patients with serum sodium ⩽120 mEq/L admitted to the Internal Medicine Department, King Abdulaziz Medical City, National Guard-Health Affairs (NGHA), Riyadh, Saudi Arabia, from January 2016 to December 2017. The patients were treated with either 3% hypertonic saline or normal saline. Results: Of the 122 patients, 105 (83.3%) received normal saline, and 17 (13.5%) received hypertonic saline. In the normal saline group, the mean serum sodium increase at 24 h was lower (6.60 ± 4.75) compared to the hypertonic saline group (9.24 ± 5.04). The length of stay was longer in the normal saline group (10.35 ± 13.90) compared to the hypertonic saline group (4.35 ± 3.39). A small proportion (8.7%) of the normal saline group had a serum sodium increase >12 mg/dL at 24 h compared to 29.4% for the hypertonic saline group, and the difference was statistically significant (p value = 0.013). Almost one-third of the sample (36%) presented with complications, the majority (77.3%, n = 34) had a serum sodium of ⩽115 mg/dL, and 22.7% (n = 10) with a serum sodium of 116–120 mg/dL (p value = 0.041). Conclusion: Despite the strong recommendation for 3% hypertonic saline use in severe hyponatremia, many practitioners still use normal saline, even in patients with serum sodium ⩽120 mEq/L. Normal saline showed some efficacy in managing hyponatremia in asymptomatic cases; however, severe cases may have a delayed correction, hyponatremia-related complications, and an extended length of stay.
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Affiliation(s)
- Sultan Zurnuq
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mahmoud Aljurfi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Mohammad S Shawaqfeh
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ahmed Elmubark
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Senthilvel Vasudevan
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Shmeylan Alharbi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Abdulkareem M Albekairy
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulmalik A Al Katheri
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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21
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Yang H, Yoon S, Kim EJ, Seo JW, Koo JR, Oh YK, Jo YH, Kim S, Baek SH. Risk factors for overcorrection of severe hyponatremia: a post hoc analysis of the SALSA trial. Kidney Res Clin Pract 2022; 41:298-309. [PMID: 35286796 PMCID: PMC9184842 DOI: 10.23876/j.krcp.21.180] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 11/21/2021] [Indexed: 11/25/2022] Open
Abstract
Background Hyponatremia overcorrection can result in irreversible neurologic impairment such as osmotic demyelination syndrome. Few prospective studies have identified patients undergoing hypertonic saline treatment with a high risk of hyponatremia overcorrection. Methods We conducted a post hoc analysis of a multicenter, prospective randomized controlled study, the SALSA trial, in 178 patients aged above 18 years with symptomatic hyponatremia (mean age, 73.1 years; mean serum sodium level, 118.2 mEq/L). Overcorrection was defined as an increase in serum sodium levels by >12 or 18 mEq/L within 24 or 48 hours, respectively. Results Among the 178 patients, 37 experienced hyponatremia overcorrection (20.8%), which was independently associated with initial serum sodium level (≤110, 110–115, 115–120, and 120–125 mEq/L with 7, 4, 2, and 0 points, respectively), chronic alcoholism (7 points), severe symptoms of hyponatremia (3 points), and initial potassium level (<3.0 mEq/L, 3 points). The NASK (hypoNatremia, Alcoholism, Severe symptoms, and hypoKalemia) score was derived from four risk factors for hyponatremia overcorrection and was significantly associated with overcorrection (odds ratio, 1.41; 95% confidence interval, 1.24–1.61; p < 0.01) with good discrimination (area under the receiver-operating characteristic [AUROC] curve, 0.76; 95% CI, 0.66–0.85; p < 0.01). The AUROC curve of the NASK score was statistically better compared with those of each risk factor. Conclusion In treating patients with symptomatic hyponatremia, individuals with high hyponatremia overcorrection risks were predictable using a novel risk score summarizing baseline information.
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Affiliation(s)
- Huijin Yang
- Division of Nephrology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Songuk Yoon
- Division of Nephrology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Eun Jung Kim
- Division of Nephrology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Jang Won Seo
- Division of Nephrology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Ja-Ryong Koo
- Division of Nephrology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Yun Kyu Oh
- Division of Nephrology, Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sejoong Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Center for Artificial Intelligence in Healthcare, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Sejoong Kim Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Republic of Korea. E-mail:
| | - Seon Ha Baek
- Division of Nephrology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
- Correspondence: Seon Ha Baek Division of Nephrology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, 7 Keunjaebong-gil, Hwaseong 18450, Republic of Korea. E-mail: ,
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22
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Lim KY, Chia YK, Khoo CS, Tan HJ. Case Series of Osmotic Demyelination Syndrome Treated With Plasmapheresis: Experience From Two Tertiary Hospitals. J Clin Neurol 2022; 18:117-119. [PMID: 35021290 PMCID: PMC8762491 DOI: 10.3988/jcn.2022.18.1.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/10/2021] [Accepted: 09/10/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Kuan Yee Lim
- Neurology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Yuen Kang Chia
- Neurology Unit, Department of Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Ching Soong Khoo
- Neurology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia.
| | - Hui Jan Tan
- Neurology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
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23
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Rondon-Berrios H, Sterns RH. Hypertonic Saline for Hyponatremia: Meeting Goals and Avoiding Harm. Am J Kidney Dis 2021; 79:890-896. [PMID: 34508830 DOI: 10.1053/j.ajkd.2021.07.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/25/2021] [Indexed: 12/22/2022]
Abstract
Hypertonic saline has been used for the treatment of hyponatremia for nearly a century. There is now general consensus that hypertonic saline should be used in patients with hyponatremia associated with moderate or severe symptoms to prevent neurological complications. However, much less agreement exists among experts regarding other aspects of its use. Should hypertonic saline be administered as a bolus injection or continuous infusion? What is the appropriate dose? Is a central venous line necessary? Should desmopressin be used concomitantly and for how long? This article considers these important questions, briefly explores the historical origins of hypertonic saline use for hyponatremia, and reviews recent evidence behind its indications, dosing, administration modality and route, combined use with desmopressin to prevent rapid correction of serum sodium, and other considerations such as the need and degree for fluid restriction. The authors conclude by offering some practical recommendations for the use of hypertonic saline.
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Affiliation(s)
- Helbert Rondon-Berrios
- Renal-Electrolyte Division. Department of Medicine. University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Richard H Sterns
- Rochester General Hospital and University of Rochester School of Medicine and Dentistry, Rochester, New York.
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24
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Mello BSF, Chaves Filho AJM, Custódio CS, Rodrigues PDA, Carletti JV, Vasconcelos SMM, Sousa FCFD, Sanders LLO, Macedo DS. Doxycycline at subantimicrobial dose combined with escitalopram reverses depressive-like behavior and neuroinflammatory hippocampal alterations in the lipopolysaccharide model of depression. J Affect Disord 2021; 292:733-745. [PMID: 34161892 DOI: 10.1016/j.jad.2021.05.083] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 05/06/2021] [Accepted: 05/30/2021] [Indexed: 12/27/2022]
Abstract
Doxycycline (DOXY) is a second-generation tetracycline with anti-inflammatory and neuroprotective effects. A proinflammatory profile seems to predict the severity of depressive symptoms. In the present study, we aimed at determining whether the anti-inflammatory action of subantimicrobial-dose doxycycline (SDD) (DOXY, 10mg/kg), alone or combined with the antidepressant escitalopram (ESC), could revert lipopolysaccharide-induced depressive-like alterations in mice. Male Swiss mice received saline or lipopolysaccharide (LPS) for ten consecutive days. From the 6th day of LPS exposure, they were treated with DOXY 10 mg/kg, ESC 4 mg/kg, DOXY 10 mg/kg plus ESC 4 mg/kg (DOXY+ESC), or saline. On the 10th day, we assessed behavioral despair (forced swimming test), anhedonia (sucrose preference test), brain oxidative stress markers, and inflammatory and protective pathways related to depression, such as NF-kB and phospho-CREB. Our results showed that DOXY alone or combined with ESC reduced hippocampal Iba-1 expression and interleukin (IL)-1β levels. Only DOXY+ESC successfully reversed the LPS-induced increase in NF-kBp65 expression and TNFα levels. DOXY caused a marked increase in the hippocampal expression of phospho-CREB and GSH concentrations. DOXY and DOXY+ESC showed a tendency to modulate the functional status of mitogen-activated kinase p42-44 (Phospho-p44/42 MAPK) and of the phosphorylated form of glycogen synthase kinase 3 beta (GSK3β), revealing a protective profile against inflammation. In conclusion, SDD, combined with ESC, seems to be a good strategy for reverting inflammatory changes and protecting against depression.
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Affiliation(s)
- Bruna Stefânia Ferreira Mello
- Neuropharmacology Laboratory, Drug Research and Development Center, Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - Adriano José Maia Chaves Filho
- Neuropharmacology Laboratory, Drug Research and Development Center, Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - Charllyany Sabino Custódio
- Neuropharmacology Laboratory, Drug Research and Development Center, Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - Patrícia de Araújo Rodrigues
- Laboratory of Neuroscience and Behavior, Drug Research and Development Center, Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - Jaqueline V Carletti
- Neuropharmacology Laboratory, Drug Research and Development Center, Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - Silvânia Maria Mendes Vasconcelos
- Neuropharmacology Laboratory, Drug Research and Development Center, Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - Francisca Cléa Florenço de Sousa
- Neuropharmacology Laboratory, Drug Research and Development Center, Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - Lia Lira Olivier Sanders
- Neuropharmacology Laboratory, Drug Research and Development Center, Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - Danielle S Macedo
- Neuropharmacology Laboratory, Drug Research and Development Center, Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil; National Institute for Translational Medicine (INCT-TM, CNPq), Ribeirão Preto, SP, Brazil.
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25
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Bose P. Central pontine myelinolysis and the osmotic demyelination syndromes: an open and shut case? Acta Neurol Belg 2021; 121:849-858. [PMID: 33713026 DOI: 10.1007/s13760-021-01634-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 02/16/2021] [Indexed: 12/01/2022]
Abstract
Central pontine myelinolysis and extrapontine myelinolysis are collectively called the osmotic demyelination syndromes. Despite being described in 1959, there are several aspects of the disorder that remain an enigma. Animal models and neuroimaging techniques have allowed us to understand the condition better. From being a universally fatal disorder that was diagnosed post mortem, increased awareness, neuroimaging techniques and supportive care have enabled us to make the diagnosis ante-mortem. This has also led to a significant drop in associated mortality. The aim of this review is to highlight the clinical spectrum, neuroimaging findings, and recent developments.
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Affiliation(s)
- Pyari Bose
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand.
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26
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Lee JH, Kim CS, Bae EH, Kim SW, Ma SK. Osmotic Demyelination Syndrome Associated with Hypernatremia Caused by Lactulose Enema in a Patient with Chronic Alcoholism. Electrolyte Blood Press 2021; 19:15-18. [PMID: 34290820 PMCID: PMC8267071 DOI: 10.5049/ebp.2021.19.1.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 12/03/2022] Open
Abstract
A 44-year-old man with chronic alcoholism presented with seizure and loss of consciousness. He was diagnosed with alcoholic hepatic encephalopathy, and his neurologic symptoms recovered after lactulose enema treatment. His initial serum sodium level was 141mEq/L. However, his mental state became confused after treatment with lactulose enema for five days, and his serum sodium level increased to 178mEq/L. After five days of gradual correction of serum sodium level from 178mEq/L to 140mEq/L, the patient's mental state recovered, but motor weakness in both limbs remained. Therefore, magnetic resonance imaging of the brain was performed. T2-weighted brain images showed bilateral symmetrical hyperintensities in the central pons, basal ganglia, thalami, hippocampi and unci, which were consistent with central pontine and extrapontine myelinolysis. We report a rare case of osmotic demyelination syndrome that occurred as a result of a rapid increase from a normal sodium level to hypernatremia caused by lactulose enema administered to treat alcoholic hepatic encephalopathy.
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Affiliation(s)
- Jeong Ho Lee
- Department of Internal Medicine, Gwangju Veterans Hospital, Gwangju, Republic of Korea
| | - Chang Seong Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Eun Hui Bae
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Seong Kwon Ma
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
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27
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Go S, Kim S, Son HE, Ryu JY, Yang H, Choi SR, Seo JW, Jo YH, Koo JR, Baek SH. Association between copeptin levels and treatment responses to hypertonic saline infusion in patients with symptomatic hyponatremia: a prospective cohort study. Kidney Res Clin Pract 2021; 40:371-382. [PMID: 34233437 PMCID: PMC8476303 DOI: 10.23876/j.krcp.20.233] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/28/2021] [Indexed: 11/05/2022] Open
Abstract
Background Copeptin is secreted in equimolar amounts as arginine vasopressin, main hormone regulating body fluid homeostasis. A recent study reported a copeptin-based classification of osmoregulatory defects in syndromes of inappropriate antidiuresis that may aid in prediction of therapeutic success. We investigated usefulness of copeptin for differentiating etiologies of hyponatremia and predicting efficacy and safety of hypertonic saline treatment in hyponatremic patients. Methods We performed a multicenter, prospective cohort study of 100 inpatients with symptomatic hyponatremia (corrected serum sodium [sNa] ≤ 125 mmol/L) treated with hypertonic saline. Copeptin levels were measured at baseline and 24 hours after treatment initiation, and patients were classified as being below or above median of copeptin at baseline or at 24 hours, respectively. Correlations between target, under correction, and overcorrection rates of sNa within 24 hours/24–48 hours and copeptin levels at baseline/24 hours were analyzed. Results Mean sNa and median copeptin levels were 117.9 and 16.9 pmol/L, respectively. Ratio of copeptin-to-urine sodium allowed for an improved differentiation among some (insufficient effective circulatory volume), but not all hyponatremia etiologic subgroups. Patients with below-median copeptin levels at baseline achieved a higher target correction rate in 6/24 hours (odds ratio [OR], 2.97; p = 0.02/OR, 6.21; p = 0.006). Patients with below-median copeptin levels 24 hours after treatment showed a higher overcorrection rate in next 24 hours (OR, 18.00, p = 0.02). Conclusion There is a limited diagnostic utility of copeptin for differential diagnosis of hyponatremia. However, copeptin might be useful for predicting responses to hypertonic saline treatment in hyponatremic patients.
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Affiliation(s)
- Suryeong Go
- Department of Internal Medicine, Armed Forces Yangju Hospital, Yangju, Republic of Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyung-Eun Son
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ji-Young Ryu
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Huijin Yang
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Sun Ryoung Choi
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Jang-Won Seo
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ja-Ryong Koo
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
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28
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Hellman T, Uusalo P, Järvisalo MJ. Continuous hemodialysis with citrate anticoagulation and standard dialysate for managing acute kidney injury in patients with moderate to severe hyponatremia-A retrospective study. Acta Anaesthesiol Scand 2021; 65:778-784. [PMID: 33595109 DOI: 10.1111/aas.13798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/23/2020] [Accepted: 02/02/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The safety of continuous veno-venous hemodialysis (CVVHD) with citrate-calcium anticoagulation for acute kidney injury (AKI) with coincident hyponatremia remains unclear. We aimed to explore the feasibility of CVVHD with standard dialysate and citrate-calcium anticoagulation in hyponatremic critically ill AKI patients. METHODS Thirty-seven of the 493 critically ill AKI patients requiring CVVHD and admitted to our intensive care unit during a 10-year period had hyponatremia (<130 mmol/L) and were included in this retrospective study. All patients received CVVHD with citrate-calcium anticoagulation and standard commercial dialysate and plasma sodium concentrations were frequently controlled until death or CVVHD discontinuation. Clinical data, mortalities and cases of central pontine myelinolysis within one-year follow-up were recorded. RESULTS Median plasma sodium concentration was 127 (IQR 124-129) mmol/L at CVVHD initiation. CVVHD duration was median 3 (IQR 1.5-5.5) days and the mean daily sodium load of the trisodium citrate solution during the first 3 days of CVVHD was 1754 (SD 730) mmol. The plasma sodium concentration increased a median 8 (IQR 5-10) mmol/L during the first 24 hours of CVVHD and excessively high plasma sodium correction (>8 mmol/L/24 h) was observed in 18 (48.6%) patients. However, increased mortality in association to rapid plasma sodium correction was not observed in this study. CONCLUSIONS CVVHD using standard citrate-calcium anticoagulation effectively increased plasma sodium concentration in this study. However, excessively high plasma sodium correction was observed in half of the patients and the sodium load provided by the standard citrate anticoagulation solutions was substantial.
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Affiliation(s)
- Tapio Hellman
- Kidney Center Turku University Hospital and University of Turku Turku Finland
| | - Panu Uusalo
- Department of Anaesthesiology and Intensive Care Turku University Hospital and University of Turku Turku Finland
- Perioperative Services, Intensive Care and Pain Medicine Turku University Hospital and University of Turku Turku Finland
| | - Mikko J. Järvisalo
- Kidney Center Turku University Hospital and University of Turku Turku Finland
- Department of Anaesthesiology and Intensive Care Turku University Hospital and University of Turku Turku Finland
- Perioperative Services, Intensive Care and Pain Medicine Turku University Hospital and University of Turku Turku Finland
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Abd Ur Rehman M, Abdulrahman AF, Zainab A, Paksoy Y, Kharma N. Hyponatremia and extrapontine myelinolysis in a patient with COVID-19: A case report. Clin Case Rep 2021; 9:e04463. [PMID: 34267918 PMCID: PMC8271216 DOI: 10.1002/ccr3.4463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/25/2021] [Accepted: 05/31/2021] [Indexed: 11/08/2022] Open
Abstract
Until we have strong evidence to the contrary, symptomatic hyponatremia should be treated with extra caution in COVID-19 co-infection patients as the latter could be another risk factor for the development of extrapontine myelinolysis.
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Affiliation(s)
| | | | - Aariz Zainab
- Radiology DepartmentHamad Medical CorporationDohaQatar
| | - Yahya Paksoy
- Radiology DepartmentHamad Medical CorporationDohaQatar
| | - Nadir Kharma
- Critical Care MedicineHamad Medical CorporationDohaQatar
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Annangi S, Nutalapati S, Naramala S, Yarra P, Bashir K. Uremia Preventing Osmotic Demyelination Syndrome Despite Rapid Hyponatremia Correction. J Investig Med High Impact Case Rep 2021; 8:2324709620918095. [PMID: 32410468 PMCID: PMC7232043 DOI: 10.1177/2324709620918095] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hyponatremia is the most common electrolyte abnormality encountered both in the
inpatient and outpatient clinical settings in the United States. Rapid
correction leads to a deranged cerebral osmotic gradient causing osmotic
demyelination syndrome. Coexisting azotemia is considered to be protective
against osmotic demyelination syndrome owing to its counteractive effect on
osmolarity change that occurs with rapid hyponatremia correction. In this
article, we report the case of a 37-year-old male who presented with altered
mentation, acute azotemia, and severe electrolyte derangements, with serum blood
urea nitrogen 160 mg/dL, creatinine 8.4 mg/dL, sodium 107 mEq/L, potassium 6.1
mEq/L, bicarbonate 7 mEq/L, and anion gap of 33. Given refractory hyperkalemia
with electrocardiogram changes, emergent dialysis was performed. Despite our
efforts to avoid rapid correction, serum sodium was corrected to 124 mEq/L and
blood urea nitrogen decreased to 87 mg/dL at the end of the 5-hour dialysis
session. Fortunately, hospital course and 4-week post-discharge clinic
follow-ups were uncomplicated with no neurological sequela confirmed by
neurological examination and magnetic resonance imaging.
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Rezaei B, Ramazani E, Amiri R, Sanaei Z. A cross-sectional study on the prevalence of electrolyte abnormalities in multiple trauma patients in Hamedan, Iran. Health Sci Rep 2021; 4:e239. [PMID: 33732893 PMCID: PMC7944545 DOI: 10.1002/hsr2.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 12/17/2020] [Accepted: 12/30/2020] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Evaluation of electrolyte status and homeostasis is one of the most important components of evaluation and treatment of critically ill patients, especially those with multiple trauma. Electrolyte imbalance can be associated with a bad prognosis and the need of specialized consultancy. AIM The aim of this study was to evaluate and determine the electrolyte status of patients with multiple trauma and evaluate the relationship of electrolyte disorders with patient outcome. METHODS In this cross-sectional study, 370 patients who were referred to the emergency department of Besat Hospital in Hamadan, Iran with multiple trauma were studied. Demographic parameters clinical characteristics such as blood pressure, heart rate, respiratory rate, consciousness score and body temperature, paraclinical characteristics including radiographic status, ultrasound, and electrocardiography and serum levels of sodium, potassium, creatinine, hemoglobin, hematocrit, and BUN and urine analysis was performed. Data regarding the discharge from emergency department or referral to other units were also complete in a questionnaire for each patient. Statistical analyses were performed using SPSSv24. RESULTS Three hundred seventy patients with multiple trauma were studied where 73% of patients were men and 27% were women. One hundred ninety-six patients were discharged from the emergency department, and 174 patients were referred to other units of the hospital. The most common electrolyte abnormalities were hypotension (62.7%), hypernatremia (9.5%), hypokalemia (6.8%), and hypercreatinine (4.6%). The results of independent t-test showed that heart rate and potassium level were significantly higher in patients referred to other units than in patients discharged from the emergency department and respiratory rate and hematocrit were significantly lower in patients referred to other units. CONCLUSION Hypotension, hypernatremia, hypokalemia, hypercreatinine, and abnormal urine analysis were more frequent in patients referred to other units than in patients discharged from the emergency department. These variables can be considered in predicting patient status for referral to other units and delayed hospital discharge.
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Affiliation(s)
- Bareza Rezaei
- Department of Emergency, Faculty of Medicine, Taleghani HospitalKermanshah University of Medical SciencesKermanshahIran
- Clinical Research Development Center of TaleghaniKermanshah University of Medical SciencesKermanshahIran
| | - Einaz Ramazani
- Department of Emergency, Besat HospitalHamedan University of Medical SciencesHamedanIran
| | - Rahimpour Amiri
- Department of Pediatrics, Faculty of Medicine, Besat HospitalHamedan University of Medical SciencesHamedanIran
| | - Zahra Sanaei
- Department of Community Medicine, Education Development OfficeHamedan University of Medical SciencesHamedanIran
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Wijayabandara M, Appuhamy S, Weerathunga P, Chang T. Effective treatment of osmotic demyelination syndrome with plasmapheresis: a case report and review of the literature. J Med Case Rep 2021; 15:6. [PMID: 33430956 PMCID: PMC7798224 DOI: 10.1186/s13256-020-02573-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 11/03/2020] [Indexed: 11/21/2022] Open
Abstract
Background Treatment options for chronic osmotic demyelination syndrome are limited to case reports and only a very few show complete recovery. We report a case of complete recovery of chronic osmotic demyelination syndrome with plasmapheresis. Case presentation A 43-year-old Sri Lankan man presented with fever, repeated vomiting, unsteady gait, increased tonicity of his right upper limb and paucity of speech for three days. He was treated in the local hospital with antibiotics and antivirals as per central nervous system infection. He had hyponatraemia, which was rapidly corrected with hypertonic saline from 97 to 119 mmol/L. He was transferred to our hospital because of progressive reduction of consciousness, rapidly worsening rigidity and bradykinesia of all four limbs and worsening dysarthria and bradyphrenia. Magnetic resonance imaging of the brain was compatible with osmotic demyelination syndrome. He was commenced on plasmapheresis twenty-two days after rapid correction of sodium. He regained independent mobility with complete resolution of rigidity, bradykinesia and speech dysfunction after five cycles of alternate day plasmapheresis. Conclusion Plasmapheresis can be considered as an effective treatment modality in chronic osmotic demyelination syndrome.
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Affiliation(s)
| | - Shenal Appuhamy
- University Medical Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Praveen Weerathunga
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Thashi Chang
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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Rajakumar A, Appuswamy E, Kaliamoorthy I, Rela M. Renal Dysfunction in Cirrhosis: Critical Care Management. Indian J Crit Care Med 2021; 25:207-214. [PMID: 33707901 PMCID: PMC7922436 DOI: 10.5005/jp-journals-10071-23721] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Cirrhotic patients with manifestations of the end-stage liver disease have a high risk for developing renal dysfunction even with minor insults. The development of renal dysfunction increases the morbidity and mortality of these patients. Causes of renal dysfunction in cirrhotics can be due to hepatorenal syndrome (HRS) or acute kidney injury (AKI) resulting from prerenal, renal, and postrenal causes. Development of pretransplant renal dysfunction has been shown to affect post-liver transplantation outcomes. Early detection and aggressive strategies for the prevention of further progression of renal dysfunction seem to decrease the morbidity and improve survival in this group of patients. This article aims to outline the pathogenesis of renal dysfunction in cirrhosis, etiological factors, and evaluation of renal dysfunction, strategies for aggressive therapy for renal dysfunction, the indications of renal replacement therapy (RRT) in this group of patients, and the various modalities of RRT with their merits and demerits. A thorough understanding of the pathogenesis, early detection, and aggressive corrective measures for AKI can prevent further progression. In conclusion, a good knowledge of treatment modalities available for renal dysfunction in cirrhosis and institution of timely interventions can significantly improve survival in this group of patients.
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Affiliation(s)
- Akila Rajakumar
- Department of Liver Anaesthesia and Intensive Care, Dr. Rela Institute and Medical Centre, Chennai, Tamil Nadu, India
| | - Ellango Appuswamy
- Department of Liver Anaesthesia and Intensive Care, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Ilankumaran Kaliamoorthy
- Department of Liver Anaesthesia and Intensive Care, Dr. Rela Institute and Medical Centre, Chennai, Tamil Nadu, India
| | - Mohamed Rela
- Department of Liver Transplantation and HPB Surgery, Dr. Rela Institute and Medical Centre, Chennai, Tamil Nadu, India
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Baek SH, Jo YH, Ahn S, Medina-Liabres K, Oh YK, Lee JB, Kim S. Risk of Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion Therapies of Hypertonic Saline for Patients With Symptomatic Hyponatremia: The SALSA Randomized Clinical Trial. JAMA Intern Med 2021; 181:81-92. [PMID: 33104189 PMCID: PMC7589081 DOI: 10.1001/jamainternmed.2020.5519] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Few high-quality studies have clarified whether hypertonic saline is best administered as slow continuous infusion (SCI) therapy or rapid intermittent bolus (RIB) therapy for symptomatic severe hyponatremia. OBJECTIVE To compare the risk of overcorrection in RIB and SCI with hypertonic saline in patients with symptomatic hyponatremia. DESIGN, SETTING, AND PARTICIPANTS This prospective, investigator-initiated, multicenter, open-label, randomized clinical trial enrolled 178 patients older than 18 years with moderately severe to severe hyponatremia and glucose-corrected serum sodium (sNa) levels of 125 mmol/L or less. Recruitment took place from August 24, 2016, until August 21, 2019, across emergency departments and wards of 3 general hospitals in the Republic of Korea. INTERVENTIONS Either RIB or SCI of hypertonic saline, 3%, for 24 to 48 hours stratified by the severity of clinical symptoms. MAIN OUTCOME AND MEASURES The primary outcome was overcorrection at any given period, defined as increase in the sNa level by greater than 12 or 18 mmol/L within 24 or 48 hours, respectively. Secondary and post hoc outcomes included efficacy and safety of the treatment approaches. The sNa concentrations were measured every 6 hours for 2 days. RESULTS The 178 patients (mean [SD] age, 73.1 [12.2] years; 80 (44.9%) male; mean [SD] sNa concentrations, 118.2 [5.0] mmol/L) were randomly assigned to the RIB group (n = 87) or the SCI group (n = 91). Overcorrection occurred in 15 of 87 (17.2%) and 22 of 91 (24.2%) patients in the RIB and SCI groups, respectively (absolute risk difference, -6.9% [95% CI, -18.8% to 4.9%]; P = .26). The RIB group showed lower incidence of relowering treatment than the SCI group (36 of 87 [41.4%] vs 52 of 91 [57.1%] patients, respectively; absolute risk difference, -15.8% [95% CI, -30.3% to -1.3%]; P = .04; number needed to treat, 6.3). Groups did not differ in terms of efficacy in increasing sNa concentrations nor improving symptoms, but RIB, when compared with SCI, showed better efficacy in achieving target correction rate within 1 hour (intention-to-treat analysis: 28 of 87 (32.2%) vs 16 of 91 (17.6%) patients, respectively; absolute risk difference, 14.6% [95% CI, 2%-27.2%]; P = .02; number needed to treat, 6.8; per-protocol analysis: 21 of 72 (29.2%) vs 12 of 73 (16.4%) patients, respectively; absolute risk difference, 12.7% [95% CI, -0.8% to 26.2%]; P = .07). The statistical significance of the intention-to-treat and per-protocol analyses were similar for all outcomes except for achieving the target correction rate within 1 hour. CONCLUSIONS AND RELEVANCE This randomized clinical trial found that both RIB and SIC therapies of hypertonic saline for treating hyponatremia were effective and safe, with no difference in the overcorrection risk. However, RIB had a lower incidence of therapeutic relowering treatment and tended to have a better efficacy in achieving sNa within 1 hour than SCI. RIB could be suggested as the preferred treatment of symptomatic hyponatremia, which is consistent with the current consensus guidelines. TRIAL REGISTRATION ClinicalTrials.org Identifier: NCT02887469.
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Affiliation(s)
- Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Soyeon Ahn
- Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kristianne Medina-Liabres
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yun Kyu Oh
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Jung Bok Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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Ruiz-Sánchez JG, Meneses D, Álvarez-Escolá C, Cuesta M, Calle-Pascual AL, Runkle I. The Effect of the Dose of Isotonic Saline on the Correction of Serum Sodium in the Treatment of Hypovolemic Hyponatremia. J Clin Med 2020; 9:E3567. [PMID: 33167557 PMCID: PMC7694500 DOI: 10.3390/jcm9113567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/27/2020] [Accepted: 11/03/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Overcorrection of serum sodium (SNa) during therapy of hyponatremia can result in osmotic demyelination syndrome. Our aim was to determine the relationship between the isotonic saline solution dose (ISSD) administered and the 24-h SNa increase (24SNa) in patients with hypovolemic hyponatremia (HH). METHODS Retrospective study of HH patients treated with ISS in a tertiary hospital of Madrid, Spain, between 1 January-30 May 2019. The 24-h ISSD received and corresponding 24SNa were calculated. The latter was classified as 3 groups: ≥8 mmol/L, ≥6 mmol/L, or <4 mmol/L. Multivariate regression analyses were performed and ROC curves calculated to study the relationship between ISSD and 24SNa. RESULTS Thirty patients were included, age 72 years (60-80), 50% were women. 24SNa was ≥8 mmol/L/24 h in 33%, ≥6 mmol/L/24 h in 50%, and <4 mmol/L/24 h in 30%. Median ISSD in each group was: 32 mL/kg/24 h (29-37), 31 mL/kg/24 h (25-33), and 20 mL/kg/24 h (14-22), respectively. An ISSD ≥ 30 mL/kg/24 h had an odds ratio (OR) of 16 (95% CI: 2.5-95.1; p = 0.004) for a 24SNa ≥8 mmol/L, with a sensitivity and specificity of 80%. CONCLUSIONS The 24SNa depends on ISSD. An ISSD between 23-30 mL/kg/24 h seems to be safe and effective.
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Affiliation(s)
- Jorge Gabriel Ruiz-Sánchez
- Servicio de Endocrinología y Nutrición, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (M.C.); (A.L.C.-P.); (I.R.)
| | - Diego Meneses
- Departamento de Endocrinología, Hospital Universitario Fundación Jiménez Díaz, 28040 Madrid, Spain;
| | | | - Martin Cuesta
- Servicio de Endocrinología y Nutrición, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (M.C.); (A.L.C.-P.); (I.R.)
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), 28029 Madrid, Spain
| | - Alfonso Luis Calle-Pascual
- Servicio de Endocrinología y Nutrición, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (M.C.); (A.L.C.-P.); (I.R.)
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), 28029 Madrid, Spain
| | - Isabelle Runkle
- Servicio de Endocrinología y Nutrición, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (M.C.); (A.L.C.-P.); (I.R.)
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Lambeck J, Hieber M, Dreßing A, Niesen WD. Central Pontine Myelinosis and Osmotic Demyelination Syndrome. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:600-606. [PMID: 31587708 DOI: 10.3238/arztebl.2019.0600] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 07/30/2018] [Accepted: 05/29/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Osmotic demyelination syndrome (ODS), which embraces central pontine myelinolysis (CPM) and extrapontine myelinosis (EPM), is often underdiagnosed in clinical practice, but can be fatal. In this article, we review the etiology, patho- physiology, clinical features, diagnosis, treatment, and prognosis of ODS. METHODS Pertinent publications from the years 1959 to 2018 were retrieved by a selective search in PubMed. RESULTS The most common cause of ODS is hyponatremia; particular groups of patients, e.g., liver transplant recipients, are also at risk of developing ODS. The pathophysiology of ODS consists of cerebral apoptosis and loss of myelin due to osmotic stress. Accordingly, brain areas that are rich in oligodendrocytes and myelin tend to be the most frequently affected. Patients with ODS often have a biphasic course, the first phase reflecting the underlying predisposing illness and the second phase reflecting ODS itself, with pontine dysfunction, impaired vigilance, and movement disorders, among other neurological abnormalities. The diagnostic modality of choice is magnetic resonance imaging (MRI) of the brain, which can also be used to detect oligosymptomatic ODS. The current mainstay of management is prevention; treatment strategies for manifest ODS are still experimental. The prognosis has improved as a result of MRI-based diagnosis, but ODS can still be fatal (33% to 55% of patients either die or remain permanently dependent on nursing care). CONCLUSION ODS is a secondary neurological illness resulting from a foregoing primary disease. Though rare overall, it occurs with greater frequency in certain groups of patients. Clinicians of all specialties should therefore be familiar with the risk constellations, clinical presentation, and prevention of ODS. The treatment of ODS is still experimental at present, as no evidence-based treatment is yet available.
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Affiliation(s)
- Johann Lambeck
- Department of Neurology and Neurophysiology, University Medical Center Freiburg, Germany
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Tandukar S, Kim C, Kalra K, Verma S, Palevsky PM, Puttarajappa C. Severe Hyponatremia and Continuous Renal Replacement Therapy: Safety and Effectiveness of Low-Sodium Dialysate. Kidney Med 2020; 2:437-449. [PMID: 32775984 PMCID: PMC7406832 DOI: 10.1016/j.xkme.2020.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
RATIONALE & OBJECTIVE In patients with severe hyponatremia in the setting of acute kidney injury or end-stage kidney disease, continuous renal replacement therapy (CRRT) using standard-sodium (140 mEq/L) fluids may lead to excessively rapid correction of plasma sodium concentration. Use of dialysate and replacement fluids with reduced sodium concentrations can provide a controlled rate of correction of plasma sodium concentration. STUDY DESIGN We performed a single-center retrospective analysis of the safety and effectiveness of this approach in patients with plasma sodium concentrations ≤ 126 mEq/L who underwent CRRT for 24 or more hours using low-sodium (119 or 126 mEq/L) dialysate and replacement fluids. Change in plasma sodium level was assessed at 24 and 48 hours after initiation of low-sodium CRRT and at the end of treatment. SETTING & PARTICIPANTS Between January 2016 and June 2018, a total of 23 hyponatremic patients underwent continuous venovenous hemodiafiltration using low-sodium dialysate and replacement fluids; 4 patients were excluded from analysis because of CRRT duration less than <24 hours. RESULTS The 19 patients included in the study had a mean age of 56 years, 11 (58%) were men, and 15 (79%) were white. The initial mean plasma sodium level was 121 mEq/L and the initial CRRT effluent dose was 27 mL/kg/h. Only 2 (11%) patients had an increase in plasma sodium concentration > 6 mEq/L at 24 hours. Mean changes in plasma sodium levels at 24 and 48 hours and at the time of CRRT discontinuation were 3, 3, and 6 mEq/L, respectively. None of the patients developed osmotic demyelination syndrome. LIMITATIONS Key limitations were small sample size and lack of a control group. CONCLUSIONS Use of low-sodium dialysate and replacement fluids is a safe strategy for the prevention of overly rapid correction of plasma sodium levels in hyponatremic patients undergoing CRRT.
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Affiliation(s)
| | - Catherine Kim
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kartik Kalra
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Siddharth Verma
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Paul M. Palevsky
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA
- Renal Section, Medical Service, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Chethan Puttarajappa
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA
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Hanna RM, Velez JC, Rastogi A, Nguyen MK, Kamgar MK, Moe K, Arman F, Hasnain H, Nobakht N, Selamet U, Kurtz I. Equivalent Efficacy and Decreased Rate of Overcorrection in Patients With Syndrome of Inappropriate Secretion of Antidiuretic Hormone Given Very Low-Dose Tolvaptan. Kidney Med 2019; 2:20-28. [PMID: 32734225 PMCID: PMC7380356 DOI: 10.1016/j.xkme.2019.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Rationale & Objective Euvolemic hyponatremia often occurs due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Vasopressin 2 receptor antagonists may be used to treat SIADH. Several of the major trials used 15 mg of tolvaptan as the lowest effective dose in euvolemic and hypervolemic hyponatremia. However, a recent observational study suggested an elevated risk for serum sodium level overcorrection with 15 mg of tolvaptan in patients with SIADH. Study Design A retrospective chart review study comparing outcomes in patients with SIADH treated with 15 versus 7.5 mg of tolvaptan. Settings & Participants Patients with SIADH who were treated with a very low dose of tolvaptan (7.5 mg) at a single center compared with patients using a 15-mg dose from patient-level data from the observational study described previously. Predictors Tolvaptan dose of 7.5 versus 15 mg daily. Outcomes Appropriate response to tolvaptan, defined as an initial increase in serum sodium level > 3 mEq/L, and overcorrection of serum sodium level (>8 mEq/L per day, and >10 mEq/L per day in sensitivity analyses). Analytical Approach Descriptive study with additional outcomes compared using t tests and F-tests (Fischer's Exact χ2 Test). Results Among 18 patients receiving 7.5 mg of tolvaptan, the mean rate of correction was 5.6 ± 3.1 mEq/L per day and 2 (11.1%) patients corrected their serum sodium levels by >8 mEq/L per day, with 1 of these increasing by >12 mEq/L per day. Of those receiving tolvaptan 7.5 mg, 14 had efficacy, with increases ≥ 3 mEq/L; similar results were seen with the 15-mg dose (21 of 28). There was a statistically significant higher chance of overcorrection with the use of 15 versus 7.5 mg of tolvaptan (11 of 28 vs 2 of 18; P = 0.05; and 10 of 28 vs 1 of 18; P = 0.03, for >8 mEq/L per day and >10 mEq/L per day, respectively). Limitations Small sample size, retrospective, and nonrandomized. Conclusions Tolvaptan, 7.5 mg, daily corrects hyponatremia with similar efficacy and less risk for overcorrection in patients with SIADH versus 15 mg of tolvaptan.
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Affiliation(s)
- Ramy M Hanna
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.,Division of Nephrology, Department of Medicine, University of California Irvine School of Medicine, Irvine, CA
| | - Juan Carlos Velez
- Department of Nephrology, Ochsner School of Medicine, New Orleans, LA
| | - Anjay Rastogi
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Minhtri K Nguyen
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Mohammad K Kamgar
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Kyaw Moe
- Lakewood Regional Medical Center, Lakewood, CA
| | - Farid Arman
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Huma Hasnain
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Niloofar Nobakht
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Umut Selamet
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.,Division of Nephrology, Department of Medicine, Brigham Women's and Children's Hospital, Boston, MA
| | - Ira Kurtz
- Division of Nephrology, Department of Medicine, UCLA Brain Research Center, Los Angeles, CA
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Aegisdottir H, Cooray C, Wirdefeldt K, Piehl F, Sveinsson O. Incidence of osmotic demyelination syndrome in Sweden: A nationwide study. Acta Neurol Scand 2019; 140:342-349. [PMID: 31343728 DOI: 10.1111/ane.13150] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/16/2019] [Accepted: 07/20/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To report the incidence rate of osmotic demyelination syndrome (ODS), associated risk factors, treatment, and long-term outcomes in a nationwide cohort. METHODS We conducted a retrospective study of individuals diagnosed with central pontine myelinolysis (ICD-10 code G37.2) in the Swedish National Patient Register during 1997-2011. RESULTS During the study period, we identified 83 individuals with ODS, 47 women and 36 men. Median age at diagnosis was 55 years. The incidence rate of ODS for the entire study period was 0.611 (95% CI: 0.490-0.754) per million person-years and increased during the study period from 0.271 (95% CI: 0.147-0.460) in 1997-2001 to 0.945 (95% CI: 0.677-1.234) individuals per million person-years in 2007-2011. Most cases (86.7%) were hyponatremic with a median sodium level at admission of 104 mmol/L. All hyponatremic cases were chronic. The cause of hyponatremia was multifactorial, including drugs (56.9%), polydipsia (31.9%), and vomiting or diarrhea (41.7%). A majority of patients (69.9%) were alcoholics. Hyponatremic patients were predominantly treated with isotonic saline (93.1%) and only 4.2% with hypotonic fluids. The median correction rate was 0.72 mmol/L/h. Only six patients were corrected in accordance with national guidelines (≤8 mmol/L/24/h). At three months, 7.2% had died and 60.2% were functionally independent (modified Rankin Scale 0-2). INTERPRETATION We found an increasing incidence during the study period, which could partly be explained by increased access to magnetic resonance imaging. ODS occurs predominantly in patients with extreme chronic hyponatremia which is corrected too fast with isotonic saline. Most patients survived and became functionally independent.
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Affiliation(s)
- Hildur Aegisdottir
- Department of Neurology The National University Hospital of Iceland Reykjavik Iceland
| | - Charith Cooray
- Department of Neurology Karolinska University Hospital Stockholm Sweden
- Department of Clinical Neuroscience Karolinska Institutet Stockholm Sweden
| | - Karin Wirdefeldt
- Department of Neurology Karolinska University Hospital Stockholm Sweden
- Department of Medical Epidemiology and Biostatistics Karolinska Institutet Stockholm Sweden
| | - Fredrik Piehl
- Department of Neurology Karolinska University Hospital Stockholm Sweden
- Department of Clinical Neuroscience Karolinska Institutet Stockholm Sweden
| | - Olafur Sveinsson
- Department of Neurology The National University Hospital of Iceland Reykjavik Iceland
- Department of Neurology Karolinska University Hospital Stockholm Sweden
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40
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Tandukar S, Rondon‐Berrios H. Treatment of severe symptomatic hyponatremia. Physiol Rep 2019; 7:e14265. [PMID: 31691515 PMCID: PMC6831993 DOI: 10.14814/phy2.14265] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 09/17/2019] [Accepted: 09/19/2019] [Indexed: 12/31/2022] Open
Abstract
Hyponatremia is the most common electrolyte abnormality seen in the hospital. Severe symptomatic hyponatremia is associated with grave consequences including cerebral edema, brain herniation, seizures, obtundation, coma, and respiratory arrest. However, rapid correction of chronic severe hyponatremia may lead to osmotic demyelination syndrome (ODS) and even death. Given the serious consequences of severe hyponatremia or its inadvertent overcorrection, it is of paramount importance for the clinician to be aware of the various scenarios in which hyponatremic patients can present and tailor the management strategies accordingly. We present here a case of severe hyponatremia of unknown duration with the presenting plasma sodium level of 95 mmol/L and use it to illustrate the various treatment strategies - proactive, reactive, or rescue therapy - along with the physiological basis to support these approaches.
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Affiliation(s)
- Srijan Tandukar
- Division of Transplant NephrologyThomas E. Starzl Transplant InstituteUniversity of Pittsburgh Medical CenterPittsburghPennsylvania
- Renal‐Electrolyte DivisionUniversity of Pittsburgh Medical CenterPittsburghPennsylvania
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41
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Burton AG, Hopper K. Hyponatremia in dogs and cats. J Vet Emerg Crit Care (San Antonio) 2019; 29:461-471. [DOI: 10.1111/vec.12881] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/04/2017] [Accepted: 09/06/2017] [Indexed: 01/10/2023]
Affiliation(s)
| | - Kate Hopper
- Department of Veterinary Surgical and Radiological SciencesUniversity of California Davis CA
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42
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Clinical Resolution of Osmotic Demyelination Syndrome following Overcorrection of Severe Hyponatremia. Case Rep Nephrol 2019; 2019:1757656. [PMID: 31016055 PMCID: PMC6446114 DOI: 10.1155/2019/1757656] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/07/2019] [Indexed: 01/06/2023] Open
Abstract
Osmotic Demyelination Syndrome (ODS) occurs after rapid overcorrection of severe chronic hyponatremia usually in those with a predisposition such as chronic alcoholism, malnutrition, or liver disease. Rarely, do patients make a full recovery. We report a case of ODS secondary to overcorrection of severe hyponatremia with pathognomonic clinical and radiologic signs making a complete neurological recovery. A detailed course of events, review of literature, and optimal and aggressive management strategies are discussed. There is some controversy in the literature regarding the prognosis of these patients. Our aim here is to show that, with aggressive therapy and long-term care, recovery is possible in these patients.
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43
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Harrois A, Anstey JR. Diabetes Insipidus and Syndrome of Inappropriate Antidiuretic Hormone in Critically Ill Patients. Crit Care Clin 2019; 35:187-200. [PMID: 30784603 DOI: 10.1016/j.ccc.2018.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Diabetes insipidus and the syndrome of inappropriate antidiuretic hormone secretion lie at opposite ends of the spectrum of disordered renal handling of water. Whereas renal retention of water insidiously causes hypotonic hyponatremia in syndrome of inappropriate antidiuretic hormone secretion, diabetes insipidus may lead to free water loss, hypernatremia, and volume depletion. Hypernatremia and hyponatremia are associated with worse outcomes and longer intensive care stays. Moreover, pathologies causing polyuria and hyponatremia in patients in intensive care may be multiple, making diagnosis challenging. We provide an approach to the diagnosis and management of these conditions in intensive care patients.
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Affiliation(s)
- Anatole Harrois
- Intensive Care Unit, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050, Australia; Department of Anesthesiology and Surgical Intensive Care, Hôpitaux Universitaires Paris Sud, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Sud, Université Paris Saclay, 78 rue du Général Leclerc, 94270 Le Kremlin Bicêtre, France.
| | - James R Anstey
- Intensive Care Unit, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050, Australia
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44
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Schuster M, Diekmann S, Klingebiel R, Volk T. Central Pontine Myelinolysis despite Slow Sodium Rise in a Case of Severe Community-acquired Hyponatraemia. Anaesth Intensive Care 2019; 37:117-20. [DOI: 10.1177/0310057x0903700120] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- M. Schuster
- Departments of Anesthesiology and Intensive Care and Neuroradiology, Chanté – University Hospital Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Berlin, Germany
- Department of Anesthesiology and Intensive Care
| | - S. Diekmann
- Departments of Anesthesiology and Intensive Care and Neuroradiology, Chanté – University Hospital Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Berlin, Germany
- Department of Neuroradiology
| | - R. Klingebiel
- Departments of Anesthesiology and Intensive Care and Neuroradiology, Chanté – University Hospital Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Berlin, Germany
- Department of Neuroradiology
| | - T. Volk
- Departments of Anesthesiology and Intensive Care and Neuroradiology, Chanté – University Hospital Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Berlin, Germany
- Department of Anesthesiology and Intensive Care
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45
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Sheikh AB, Afzal RM, Sagheer S, Bukhari MM, Javed A, Nasrullah A, Tariq U, Athar F, Saleem MS. The Dilemma of Inadvertent Pontine Demyelinosis: A Review of Literature. Cureus 2018; 10:e3174. [PMID: 30357070 PMCID: PMC6197531 DOI: 10.7759/cureus.3174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Osmotic demyelination syndrome is classically associated with a swift adjustment of previously low serum sodium levels which lead to cellular dehydration and subsequent neurological insult. We also review the epidemiology, different postulations to explain the underlying pathophysiology, current diagnostic modalities, subsequent therapeutic interventions used to manage this phenomenon, and the resultant prognosis of this ailment.
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Affiliation(s)
| | - Rao M Afzal
- Internal Medicine, Shifa College of Medicine, Islamabad, PAK
| | - Shazib Sagheer
- Internal Medicine, University of New Mexico Hospital, Albuquerque, USA
| | - Marvi M Bukhari
- Internal Medicine, Shifa College of Medicine, Islamabad, PAK
| | - Anam Javed
- Internal Medicine, College of Medicine and Dentistry, University of Lahore, Lahore, PAK
| | - Adeel Nasrullah
- Internal Medicine, Allegheny General Hospital, Pittsburgh, USA
| | - Usman Tariq
- Research Assistant, Yale University School of Medicine, New Haven, USA
| | - Fahad Athar
- Other, Albert Einstein Medical Center , Philadelphia, USA
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46
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George JC, Zafar W, Bucaloiu ID, Chang AR. Risk Factors and Outcomes of Rapid Correction of Severe Hyponatremia. Clin J Am Soc Nephrol 2018; 13:984-992. [PMID: 29871886 PMCID: PMC6032596 DOI: 10.2215/cjn.13061117] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 03/15/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Rapid correction of severe hyponatremia can result in serious neurologic complications, including osmotic demyelination. Few data exist on incidence and risk factors of rapid correction or osmotic demyelination. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a retrospective cohort of 1490 patients admitted with serum sodium <120 mEq/L to seven hospitals in the Geisinger Health System from 2001 to 2017, we examined the incidence and risk factors of rapid correction and osmotic demyelination. Rapid correction was defined as serum sodium increase of >8 mEq/L at 24 hours. Osmotic demyelination was determined by manual chart review of all available brain magnetic resonance imaging reports. RESULTS Mean age was 66 years old (SD=15), 55% were women, and 67% had prior hyponatremia (last outpatient sodium <135 mEq/L). Median change in serum sodium at 24 hours was 6.8 mEq/L (interquartile range, 3.4-10.2), and 606 patients (41%) had rapid correction at 24 hours. Younger age, being a woman, schizophrenia, lower Charlson comorbidity index, lower presentation serum sodium, and urine sodium <30 mEq/L were associated with greater risk of rapid correction. Prior hyponatremia, outpatient aldosterone antagonist use, and treatment at an academic center were associated with lower risk of rapid correction. A total of 295 (20%) patients underwent brain magnetic resonance imaging on or after admission, with nine (0.6%) patients showing radiologic evidence of osmotic demyelination. Eight (0.5%) patients had incident osmotic demyelination, of whom five (63%) had beer potomania, five (63%) had hypokalemia, and seven (88%) had sodium increase >8 mEq/L over a 24-hour period before magnetic resonance imaging. Five patients with osmotic demyelination had apparent neurologic recovery. CONCLUSIONS Among patients presenting with severe hyponatremia, rapid correction occurred in 41%; nearly all patients with incident osmotic demyelination had a documented episode of rapid correction. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_06_05_CJASNPodcast_18_7_G.mp3.
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Affiliation(s)
- Jason C George
- Department of Nephrology, Geisinger Medical Center, Danville, Pennsylvania; and
| | - Waleed Zafar
- Kidney Health Research Institute, Geisinger, Danville, Pennsylvania
| | - Ion Dan Bucaloiu
- Department of Nephrology, Geisinger Medical Center, Danville, Pennsylvania; and
| | - Alex R Chang
- Department of Nephrology, Geisinger Medical Center, Danville, Pennsylvania; and
- Kidney Health Research Institute, Geisinger, Danville, Pennsylvania
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47
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Boehm E, Kumar S, Nankervis A, Colman P. Managing hyponatraemia secondary to primary polydipsia: beware too rapid correction of hyponatraemia. Intern Med J 2018; 47:956-959. [PMID: 28782208 DOI: 10.1111/imj.13507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 01/26/2017] [Accepted: 01/26/2017] [Indexed: 11/29/2022]
Abstract
We describe three cases of severe hyponatraemia in the setting of primary polydipsia that were managed in our centre in 2016. Despite receiving different solute loads, large volume diuresis and rapid correction of serum sodium occurred in all cases. Given the potentially catastrophic consequence of osmotic demyelination, we highlight the judicious use of desmopressin and hypotonic fluid infusion to mitigate sodium overcorrection in this setting.
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Affiliation(s)
- Emma Boehm
- Diabetes and Endocrinology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Shanal Kumar
- Diabetes and Endocrinology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alison Nankervis
- Diabetes and Endocrinology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Peter Colman
- Diabetes and Endocrinology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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48
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Abstract
Patients with severe (serum sodium ≤120 mEq/L), symptomatic hyponatremia can develop life-threatening or fatal complications from cerebral edema if treatment is inadequate and permanent neurologic disability from osmotic demyelination if treatment is excessive. Unfortunately, as is true of all electrolyte disturbances, there are no randomized trials to guide the treatment of this challenging disorder. Rather, therapeutic decisions rest on physiologic principles, animal models, observational studies, and single-patient reports. European guidelines and recommendations of an American Expert panel have come to similar conclusions on how much correction of hyponatremia is enough and how much is too much, but there are important differences. We review the evidence supporting these recommendations, identifying areas that rest on relatively solid ground and highlighting areas in greatest need of additional data.
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Affiliation(s)
- Richard H Sterns
- University of Rochester School of Medicine and Dentistry, Rochester General Hospital, Rochester, New York
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49
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MacMillan TE, Cavalcanti RB. Outcomes in Severe Hyponatremia Treated With and Without Desmopressin. Am J Med 2018; 131:317.e1-317.e10. [PMID: 29061503 DOI: 10.1016/j.amjmed.2017.09.048] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 09/25/2017] [Accepted: 09/30/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Overcorrection of plasma sodium in severe hyponatremia is associated with osmotic demyelination syndrome. Desmopressin (DDAVP) can prevent overcorrection of plasma sodium in hyponatremia. The objective of this study was to compare outcomes in hyponatremia according to DDAVP usage. METHODS This was a retrospective observational study including all admissions to internal medicine with hyponatremia (plasma sodium concentration <123 mEq/L) from 2004 to 2014 at 2 academic hospitals in Toronto, Canada. The primary outcome was safe sodium correction (≤12 mEq/L in any 24-hour and ≤18 mEq/L in any 48-hour period). RESULTS We identified 1450 admissions with severe hyponatremia; DDAVP was administered in 254 (17.5%). Although DDAVP reduced the rate of change of plasma sodium, fewer patients in the DDAVP group achieved safe correction (174 of 251 [69.3%] vs 970 of 1164 [83.3%]); this result was driven largely by overcorrection occurring before DDAVP administration in the rescue group. Among patients receiving DDAVP, most received it according to a reactive strategy, whereby DDAVP was given after a change in plasma sodium within correction limits (174 of 254 [68.5%]). Suspected osmotic demyelination syndrome was identified in 4 of 1450 admissions (0.28%). There was lower mortality in the DDAVP group (3.9% vs 9.4%), although this is likely affected by confounding. Length of stay in hospital was longer in those who received DDAVP according to a proactive strategy. CONCLUSIONS Although observational, these data support a reactive strategy for using DDAVP in patients at average risk of osmotic demyelination syndrome, as well as a more stringent plasma sodium correction limit of 8 mEq/L in any 24-hour period for high-risk patients. Further studies are urgently needed on DDAVP use in treating hyponatremia.
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Affiliation(s)
- Thomas E MacMillan
- Division of General Internal Medicine, University Health Network, Toronto, ON, Canada; Division of General Internal Medicine, Department of Medicine, University of Toronto, ON, Canada; HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, ON, Canada.
| | - Rodrigo B Cavalcanti
- Division of General Internal Medicine, University Health Network, Toronto, ON, Canada; Division of General Internal Medicine, Department of Medicine, University of Toronto, ON, Canada; HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, ON, Canada
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50
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Lien YHH. How to Use Desmopressin to Manage Severe Chronic Hyponatremia? Am J Med 2018; 131:220-221. [PMID: 29157653 DOI: 10.1016/j.amjmed.2017.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 11/06/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Yeong-Hau H Lien
- Department of Medicine, College of Medicine, University of Arizona, Tucson; Arizona Kidney Disease and Hypertension Center, Tucson.
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