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Bem RA, Lemson J. Evaluating fluid overload in critically ill children. Curr Opin Pediatr 2024; 36:266-273. [PMID: 38655808 DOI: 10.1097/mop.0000000000001347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW To review the evaluation and management of fluid overload in critically ill children. RECENT FINDINGS Emerging evidence associates fluid overload, i.e. having a positive cumulative fluid balance, with adverse outcome in critically ill children. This is most likely the result of impaired organ function due to increased extravascular water content. The combination of a number of parameters, including physical, laboratory and radiographic markers, may aid the clinician in monitoring and quantifying fluid status, but all have important limitations, in particular to discriminate between intra- and extravascular water volume. Current guidelines advocate a restrictive fluid management, initiated early during the disease course, but are hampered by the lack of high quality evidence. SUMMARY Recent advances in early evaluation of fluid status and (tailored) restrictive fluid management in critically ill children may decrease complications of fluid overload, potentially improving outcome. Further clinical trials are necessary to provide the clinician with solid recommendations.
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Affiliation(s)
- Reinout A Bem
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam Academic Medical Centers, location University of Amsterdam, Amsterdam
| | - Joris Lemson
- Department of Intensive Care, Radboud university medical center, Nijmegen, The Netherlands
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2
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Hay RE, Parsons SJ, Wade AW. The effect of dehydration, hyperchloremia and volume of fluid resuscitation on acute kidney injury in children admitted to hospital with diabetic ketoacidosis. Pediatr Nephrol 2024; 39:889-896. [PMID: 37733096 DOI: 10.1007/s00467-023-06152-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/18/2023] [Accepted: 08/23/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a recognized comorbidity in pediatric diabetic ketoacidosis (DKA), although the exact etiology is unclear. The unique physiology of DKA makes dehydration assessments challenging, and these patients potentially receive excessive amounts of intravenous fluids (IVF). We hypothesized that dehydration is over-estimated in pediatric DKA, leading to over-administration of IVF and hyperchloremia that worsens AKI. METHODS Retrospective cohort of all DKA inpatients at a tertiary pediatric hospital from 2014 to 2019. A total of 145 children were included; reasons for exclusion were pre-existing kidney disease or incomplete medical records. AKI was determined by change in creatinine during admission, and comparison to a calculated baseline value. Linear regression multivariable analysis was used to identify factors associated with AKI. True dehydration was calculated from patients' change in weight, as previously validated. Fluid over-resuscitation was defined as total fluids given above the true dehydration. RESULTS A total of 19% of patients met KDIGO serum creatinine criteria for AKI on admission. Only 2% had AKI on hospital discharge. True dehydration and high serum urea levels were associated with high serum creatinine levels on admission (p = 0.042; p < 0.001, respectively). Fluid over-resuscitation and hyperchloremia were associated with delayed kidney recovery (p < 0.001). Severity of initial AKI was associated with cerebral edema (p = 0.018). CONCLUSIONS Dehydration was associated with initial AKI in children with DKA. Persistent AKI and delay to recovery was associated with hyperchloremia and over-resuscitation with IVF, potentially modifiable clinical variables for earlier AKI recovery and reduction in long-term morbidity. This highlights the need to re-address fluid protocols in pediatric DKA.
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Affiliation(s)
- Rebecca E Hay
- Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Canada.
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada.
| | - Simon J Parsons
- Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Canada
- Section of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Calgary, Alberta Children's Hospital, Calgary, Canada
| | - Andrew W Wade
- Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Canada
- Section of Nephrology, Department of Pediatrics, Faculty of Medicine, University of Calgary, Alberta Children's Hospital, Calgary, Canada
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Larson NJ, Rogers FB, Feeken JL, Blondeau B, Dries DJ. Electrolyte Disorders: Causes, Diagnosis, and Initial Care-Part 1. Air Med J 2024; 43:80-83. [PMID: 38490789 DOI: 10.1016/j.amj.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/03/2024] [Indexed: 03/17/2024]
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Selewski DT, Barhight MF, Bjornstad EC, Ricci Z, de Sousa Tavares M, Akcan-Arikan A, Goldstein SL, Basu R, Bagshaw SM. Fluid assessment, fluid balance, and fluid overload in sick children: a report from the Pediatric Acute Disease Quality Initiative (ADQI) conference. Pediatr Nephrol 2024; 39:955-979. [PMID: 37934274 PMCID: PMC10817849 DOI: 10.1007/s00467-023-06156-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/14/2023] [Accepted: 08/29/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND The impact of disorders of fluid balance, including the pathologic state of fluid overload in sick children has become increasingly apparent. With this understanding, there has been a shift from application of absolute thresholds of fluid accumulation to an appreciation of the intricacies of fluid balance, including the impact of timing, trajectory, and disease pathophysiology. METHODS The 26th Acute Disease Quality Initiative was the first to be exclusively dedicated to pediatric and neonatal acute kidney injury (pADQI). As part of the consensus panel, a multidisciplinary working group dedicated to fluid balance, fluid accumulation, and fluid overload was created. Through a search, review, and appraisal of the literature, summative consensus statements, along with identification of knowledge gaps and recommendations for clinical practice and research were developed. CONCLUSIONS The 26th pADQI conference proposed harmonized terminology for fluid balance and for describing a pathologic state of fluid overload for clinical practice and research. Recommendations include that the terms daily fluid balance, cumulative fluid balance, and percent cumulative fluid balance be utilized to describe the fluid status of sick children. The term fluid overload is to be preserved for describing a pathologic state of positive fluid balance associated with adverse events. Several recommendations for research were proposed including focused validation of the definition of fluid balance, fluid overload, and proposed methodologic approaches and endpoints for clinical trials.
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Affiliation(s)
- David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Matthew F Barhight
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Erica C Bjornstad
- Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zaccaria Ricci
- Department of Emergency and Intensive Care, Pediatric Intensive Care Unit, Azienda Ospedaliero Universitaria Meyer, Florence, Italy.
- Department of Health Science, University of Florence, Florence, Italy.
| | - Marcelo de Sousa Tavares
- Pediatric Nephrology Unit, Nephrology Center of Santa Casa de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil
| | - Ayse Akcan-Arikan
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rajit Basu
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
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Starr MC, Voivodas M, Hains DS. Using aquapheresis with continuous hematocrit monitoring to guide ultrafiltration. Pediatr Nephrol 2024; 39:597-601. [PMID: 37661234 DOI: 10.1007/s00467-023-06143-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/15/2023] [Accepted: 08/15/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Management of edema and volume overload in patients with hypoalbuminemia, either due to nephrotic syndrome or other disease processes, can be extremely challenging. METHODS We describe the management of five patients with hypoalbuminemia and severe fluid overload using the Aquadex FlexFlow device with continuous hematocrit monitoring to guide ultrafiltration. RESULTS We report five pediatric patients ranging in age from 7 days to 11 years and in size from 2.7 to 65 kg with hypoalbuminemia due to a variety of etiologies treated with slow continuous ultrafiltration with continuous hematocrit monitoring to guide ultrafiltration using the Aquadex device. Treatment allowed successful fluid removal in all cases, without hypotension or other hemodynamic complications. CONCLUSIONS In a variety of clinical circumstances and in patients from infants to adolescence, we report that patients with diuretic-resistant fluid overload can be treated with Aquadex using continuous hematocrit monitoring to guide management to allow fluid removal without hemodynamic instability or other complications. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Michelle C Starr
- Division of Pediatric Nephrology, Department of Pediatrics, Indiana University School of Medicine, 410 W 10Th Street, Suite 2000A, Indianapolis, IN, 46202, USA.
- Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Michelle Voivodas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David S Hains
- Division of Pediatric Nephrology, Department of Pediatrics, Indiana University School of Medicine, 410 W 10Th Street, Suite 2000A, Indianapolis, IN, 46202, USA
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Sankar J, Muralidharan J, Lalitha AV, Rameshkumar R, Pathak M, Das RR, Nadkarni VM, Ismail J, Subramanian M, Nallasamy K, Dev N, Kumar UV, Kumar K, Sharma T, Jaravta K, Thakur N, Aggarwal P, Jat KR, Kabra SK, Lodha R. Multiple Electrolytes Solution Versus Saline as Bolus Fluid for Resuscitation in Pediatric Septic Shock: A Multicenter Randomized Clinical Trial. Crit Care Med 2023; 51:1449-1460. [PMID: 37294145 DOI: 10.1097/ccm.0000000000005952] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine if initial fluid resuscitation with balanced crystalloid (e.g., multiple electrolytes solution [MES]) or 0.9% saline adversely affects kidney function in children with septic shock. DESIGN Parallel-group, blinded multicenter trial. SETTING PICUs of four tertiary care centers in India from 2017 to 2020. PATIENTS Children up to 15 years of age with septic shock. METHODS Children were randomized to receive fluid boluses of either MES (PlasmaLyte A) or 0.9% saline at the time of identification of shock. All children were managed as per standard protocols and monitored until discharge/death. The primary outcome was new and/or progressive acute kidney injury (AKI), at any time within the first 7 days of fluid resuscitation. Key secondary outcomes included hyperchloremia, any adverse event (AE), at 24, 48, and 72 hours, and all-cause ICU mortality. INTERVENTIONS MES solution ( n = 351) versus 0.9% saline ( n = 357) for bolus fluid resuscitation during the first 7 days. MEASUREMENTS AND MAIN RESULTS The median age was 5 years (interquartile range, 1.3-9); 302 (43%) were girls. The relative risk (RR) for meeting the criteria for new and/or progressive AKI was 0.62 (95% CI, 0.49-0.80; p < 0.001), favoring the MES (21%) versus the saline (33%) group. The proportions of children with hyperchloremia were lower in the MES versus the saline group at 24, 48, and 72 hours. There was no difference in the ICU mortality (33% in the MES vs 34% in the saline group). There was no difference with regard to infusion-related AEs such as fever, thrombophlebitis, or fluid overload between the groups. CONCLUSIONS Among children presenting with septic shock, fluid resuscitation with MES (balanced crystalloid) as compared with 0.9% saline resulted in a significantly lower incidence of new and/or progressive AKI during the first 7 days of hospitalization.
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Affiliation(s)
- Jhuma Sankar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jayashree Muralidharan
- Division of Pediatric Critical Care, Department of Pediatrics, PGIMER, Chandigarh, India
| | - A V Lalitha
- Department of Pediatrics Intensive Care, St Johns' Medical College Bengaluru, India
| | | | - Mona Pathak
- Research and Development Department, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | | | - Vinay M Nadkarni
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Javed Ismail
- Pediatric Intensive Care Unit, NMC Royal Hospital Khalifa City, Abu Dhabi, United Arab Emirates
| | - Mahadevan Subramanian
- Division of Pediatric Critical Care, Department of Pediatrics, JIPMER, Puducherry, India
| | - Karthi Nallasamy
- Division of Pediatric Critical Care, Department of Pediatrics, PGIMER, Chandigarh, India
| | - Nishanth Dev
- Department of Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| | - U Vijay Kumar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kiran Kumar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Taniya Sharma
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kanika Jaravta
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Neha Thakur
- Division of Pediatric Critical Care, Department of Pediatrics, PGIMER, Chandigarh, India
| | | | - Kana Ram Jat
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - S K Kabra
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Neyra JA, Mehta RL, Murugan R. Fluid Management during Continuous Renal Replacement Therapy: A Case-Based Approach. Nephron Clin Pract 2023; 147:782-787. [PMID: 37793364 DOI: 10.1159/000534395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/05/2023] [Indexed: 10/06/2023] Open
Abstract
Continuous renal replacement therapy (CRRT) is frequently used for fluid management of critically ill patients with acute or chronic kidney failure. There is significant practice variation worldwide in fluid management during CRRT. Multiple clinical studies have suggested that both the magnitude and duration of fluid overload are associated with morbidity and mortality in critically ill patients. Therefore, timely and effective fluid management with CRRT is paramount in managing critically ill patients with fluid overload. While the optimal method of fluid management during CRRT is still unclear and warrants further investigation, observational data have suggested a U-shape relationship between net ultrafiltration rate and mortality. Furthermore, recent clinical data have underpinned a significant gap in prescribed versus achieved fluid balance during CRRT, which is also associated with mortality. This review uses a case-based approach to discuss two fluid management strategies based on net ultrafiltration rate and fluid balance goals during CRRT and harmonizes operational definitions.
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Affiliation(s)
- Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ravindra L Mehta
- Division of Nephrology, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Raghavan Murugan
- Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Gordon L, Grossmann KR, Guillet R, Steflik H, Harer MW, Askenazi DJ, Menon S, Selewski DT, Starr MC. Approaches to evaluation of fluid balance and management of fluid overload in neonates among neonatologists: a Neonatal Kidney Collaborative survey. J Perinatol 2023; 43:1314-1315. [PMID: 37481631 DOI: 10.1038/s41372-023-01738-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/06/2023] [Accepted: 07/18/2023] [Indexed: 07/24/2023]
Affiliation(s)
- Lindsey Gordon
- Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Katarina Robertsson Grossmann
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Division of Pediatrics, Karolinska Institutet, Stockholm, Sweden
| | - Ronnie Guillet
- Division of Neonatology, Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Heidi Steflik
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Matthew W Harer
- Division of Neonatology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WA, USA
| | - David J Askenazi
- Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shina Menon
- Division of Nephrology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Michelle C Starr
- Division of Nephrology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
- Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Regiroli G, Loi B, Pezza L, Sartorius V, Foti A, Barra PF, Centorrino R, Di Nardo M, De Luca D. Continuous Venovenous Hemofiltration Performed by Neonatologists With Cardio-Renal Pediatric Dialysis Emergency Machine to Treat Fluid Overload During Multiple Organ Dysfunction Syndrome: A Case Series. Pediatr Crit Care Med 2023; 24:e196-e201. [PMID: 36728157 DOI: 10.1097/pcc.0000000000003177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES A new device is available for neonates needing extracorporeal renal replacement therapy. We reviewed the use of this device (in continuous venovenous hemofiltration [CVVH] mode) in term or preterm neonates affected by multiple organ dysfunction syndrome (MODS) with fluid overload. DESIGN Case series. SETTING Academic specialized referral neonatal ICU (NICU) with expertise on advanced life support and monitoring. PATIENTS Neonates with MODS and fluid overload despite conventional treatments and receiving at least one CVVH session. INTERVENTION CVVH with the Cardio-Renal Pediatric Dialysis Emergency Machine. MEASUREMENTS AND MAIN RESULTS Ten (three preterm) neonates were treated using 18 consecutive CVVH sessions. All patients were in life-threatening conditions and successfully completed the CVVH treatments, which almost always lasted 24 hr/session, without major side effects. Three neonates survived and were successfully discharged from hospital with normal follow-up. CVVH reduced fluid overload (before versus after represented as a weight percentage: 23.5% [12-34%] vs 14.6% [8.2-24.1%]; p = 0.006) and lactate (before versus after: 4.6 [2.9-12.1] vs 2.9 mmol/L [2.3-5.5 mmol/L]; p = 0.001). CVVH also improved the Pa o2 to Fio2 (before vs after: 188 mm Hg [118-253 mm Hg] vs 240 mm Hg [161-309 mm Hg]; p = 0.003) and oxygenation index (before vs after: 5.9 [3.8-14.6] vs 4 [2.9-11]; p = 0.002). The average cost of CVVH in these patients was minor (≈3%) in comparison with the median total cost of NICU care per patient. CONCLUSIONS We have provided CVVH to critically ill term and preterm neonates with MODS. CVVH improved fluid overload and oxygenation. The cost of CVVH was minimal compared with the overall cost of neonatal intensive care.
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Affiliation(s)
- Giulia Regiroli
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Barbara Loi
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Lucilla Pezza
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Victor Sartorius
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Anna Foti
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Pasquale Fabio Barra
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Roberta Centorrino
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children Hospital-IRCCS, Rome, Italy
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
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Abstract
Excessive accumulation of fluid may result in interstitial edema and multiorgan dysfunction. Over the past few decades, the detrimental impact of fluid overload has been further defined in adult and pediatric populations. Growing evidence highlights the importance of monitoring, preventing, managing, and treating fluid overload appropriately. Translating this knowledge to neonates is difficult as they have different disease pathophysiologies, and because neonatal physiology changes rapidly postnatally in many of the organ systems (i.e., skin, kidneys, and cardiovascular, pulmonary, and gastrointestinal). Thus, evaluations of the optimal targets for fluid balance need to consider the disease state as well as the gestational and postmenstrual age of the infant. Integration of what is known about neonatal fluid overload with individual alterations in physiology is imperative in clinical management. This comprehensive review will address what is known about the epidemiology and pathophysiology of neonatal fluid overload and highlight the known knowledge gaps. Finally, we provide clinical recommendations for monitoring, prevention, and treatment of fluid overload.
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Affiliation(s)
| | - Colm P Travers
- University of Alabama at Birmingham, Birmingham, AL, USA.
| | | | - David Askenazi
- University of Alabama at Birmingham, Birmingham, AL, USA
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Ricci Z, Bjornstad E. Fluid balance in pediatric critically ill patients (with and without kidney dysfunction). Curr Opin Crit Care 2022; 28:583-589. [PMID: 36302194 PMCID: PMC10852033 DOI: 10.1097/mcc.0000000000000987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW The issues of fluid balance and fluid overload are currently considered crucial aspects of pediatric critically ill patients' care. RECENT FINDINGS This review describes current understanding of fluid management in critically ill children in terms of fluid balance and fluid overload and its effects on patients' outcomes. The review describes current evidence surrounding definitions, monitoring, and treatment of positive fluid balance. In particular, the review focuses on specific patient conditions, including perioperative cardiac surgery, severe acute respiratory failure, and extracorporeal membrane oxygenation therapy, as the ones at highest risk of developing fluid overload and poor clinical outcomes. Gaps in understanding include specific thresholds at which fluid overload occurs in all critically ill children or specific populations and optimal timing of decongestion of positive fluid balance. SUMMARY Current evidence on fluid balance in critically ill children is mainly based on retrospective and observational studies, and intense research should be recommended in this important field. In theory, active decongestion of patients with fluid overload could improve mortality and other clinical outcomes, but randomized trials or advanced pragmatic studies are needed to better understand the optimal timing, patient characteristics, and tools to achieve this.
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Affiliation(s)
- Zaccaria Ricci
- Pediatric Intensive Care Unit, Meyer Children's University Hospital
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
| | - Erica Bjornstad
- Department of Pediatrics, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Mullens W, Dauw J, Martens P, Verbrugge FH, Nijst P, Meekers E, Tartaglia K, Chenot F, Moubayed S, Dierckx R, Blouard P, Troisfontaines P, Derthoo D, Smolders W, Bruckers L, Droogne W, Ter Maaten JM, Damman K, Lassus J, Mebazaa A, Filippatos G, Ruschitzka F, Dupont M. Acetazolamide in Acute Decompensated Heart Failure with Volume Overload. N Engl J Med 2022; 387:1185-1195. [PMID: 36027559 DOI: 10.1056/nejmoa2203094] [Citation(s) in RCA: 155] [Impact Index Per Article: 77.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Whether acetazolamide, a carbonic anhydrase inhibitor that reduces proximal tubular sodium reabsorption, can improve the efficiency of loop diuretics, potentially leading to more and faster decongestion in patients with acute decompensated heart failure with volume overload, is unclear. METHODS In this multicenter, parallel-group, double-blind, randomized, placebo-controlled trial, we assigned patients with acute decompensated heart failure, clinical signs of volume overload (i.e., edema, pleural effusion, or ascites), and an N-terminal pro-B-type natriuretic peptide level of more than 1000 pg per milliliter or a B-type natriuretic peptide level of more than 250 pg per milliliter to receive either intravenous acetazolamide (500 mg once daily) or placebo added to standardized intravenous loop diuretics (at a dose equivalent to twice the oral maintenance dose). Randomization was stratified according to the left ventricular ejection fraction (≤40% or >40%). The primary end point was successful decongestion, defined as the absence of signs of volume overload, within 3 days after randomization and without an indication for escalation of decongestive therapy. Secondary end points included a composite of death from any cause or rehospitalization for heart failure during 3 months of follow-up. Safety was also assessed. RESULTS A total of 519 patients underwent randomization. Successful decongestion occurred in 108 of 256 patients (42.2%) in the acetazolamide group and in 79 of 259 (30.5%) in the placebo group (risk ratio, 1.46; 95% confidence interval [CI], 1.17 to 1.82; P<0.001). Death from any cause or rehospitalization for heart failure occurred in 76 of 256 patients (29.7%) in the acetazolamide group and in 72 of 259 patients (27.8%) in the placebo group (hazard ratio, 1.07; 95% CI, 0.78 to 1.48). Acetazolamide treatment was associated with higher cumulative urine output and natriuresis, findings consistent with better diuretic efficiency. The incidence of worsening kidney function, hypokalemia, hypotension, and adverse events was similar in the two groups. CONCLUSIONS The addition of acetazolamide to loop diuretic therapy in patients with acute decompensated heart failure resulted in a greater incidence of successful decongestion. (Funded by the Belgian Health Care Knowledge Center; ADVOR ClinicalTrials.gov number, NCT03505788.).
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Affiliation(s)
- Wilfried Mullens
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Jeroen Dauw
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Pieter Martens
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Frederik H Verbrugge
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Petra Nijst
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Evelyne Meekers
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Katrien Tartaglia
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Fabien Chenot
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Samer Moubayed
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Riet Dierckx
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Philippe Blouard
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Pierre Troisfontaines
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - David Derthoo
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Walter Smolders
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Liesbeth Bruckers
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Walter Droogne
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Jozine M Ter Maaten
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Kevin Damman
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Johan Lassus
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Alexandre Mebazaa
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Gerasimos Filippatos
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Frank Ruschitzka
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Matthias Dupont
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
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de-Madaria E, Buxbaum JL, Maisonneuve P, García García de Paredes A, Zapater P, Guilabert L, Vaillo-Rocamora A, Rodríguez-Gandía MÁ, Donate-Ortega J, Lozada-Hernández EE, Collazo Moreno AJR, Lira-Aguilar A, Llovet LP, Mehta R, Tandel R, Navarro P, Sánchez-Pardo AM, Sánchez-Marin C, Cobreros M, Fernández-Cabrera I, Casals-Seoane F, Casas Deza D, Lauret-Braña E, Martí-Marqués E, Camacho-Montaño LM, Ubieto V, Ganuza M, Bolado F. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med 2022; 387:989-1000. [PMID: 36103415 DOI: 10.1056/nejmoa2202884] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Early aggressive hydration is widely recommended for the management of acute pancreatitis, but evidence for this practice is limited. METHODS At 18 centers, we randomly assigned patients who presented with acute pancreatitis to receive goal-directed aggressive or moderate resuscitation with lactated Ringer's solution. Aggressive fluid resuscitation consisted of a bolus of 20 ml per kilogram of body weight, followed by 3 ml per kilogram per hour. Moderate fluid resuscitation consisted of a bolus of 10 ml per kilogram in patients with hypovolemia or no bolus in patients with normovolemia, followed by 1.5 ml per kilogram per hour in all patients in this group. Patients were assessed at 12, 24, 48, and 72 hours, and fluid resuscitation was adjusted according to the patient's clinical status. The primary outcome was the development of moderately severe or severe pancreatitis during the hospitalization. The main safety outcome was fluid overload. The planned sample size was 744, with a first planned interim analysis after the enrollment of 248 patients. RESULTS A total of 249 patients were included in the interim analysis. The trial was halted owing to between-group differences in the safety outcomes without a significant difference in the incidence of moderately severe or severe pancreatitis (22.1% in the aggressive-resuscitation group and 17.3% in the moderate-resuscitation group; adjusted relative risk, 1.30; 95% confidence interval [CI], 0.78 to 2.18; P = 0.32). Fluid overload developed in 20.5% of the patients who received aggressive resuscitation and in 6.3% of those who received moderate resuscitation (adjusted relative risk, 2.85; 95% CI, 1.36 to 5.94, P = 0.004). The median duration of hospitalization was 6 days (interquartile range, 4 to 8) in the aggressive-resuscitation group and 5 days (interquartile range, 3 to 7) in the moderate-resuscitation group. CONCLUSIONS In this randomized trial involving patients with acute pancreatitis, early aggressive fluid resuscitation resulted in a higher incidence of fluid overload without improvement in clinical outcomes. (Funded by Instituto de Salud Carlos III and others; WATERFALL ClinicalTrials.gov number, NCT04381169.).
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Affiliation(s)
- Enrique de-Madaria
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - James L Buxbaum
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Patrick Maisonneuve
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Ana García García de Paredes
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Pedro Zapater
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Lucía Guilabert
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Alicia Vaillo-Rocamora
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Miguel Á Rodríguez-Gandía
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Jesús Donate-Ortega
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Edgard E Lozada-Hernández
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Alan J R Collazo Moreno
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Alba Lira-Aguilar
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Laura P Llovet
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Rajiv Mehta
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Raj Tandel
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Pablo Navarro
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Ana M Sánchez-Pardo
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Claudia Sánchez-Marin
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Marina Cobreros
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Idaira Fernández-Cabrera
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Fernando Casals-Seoane
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Diego Casas Deza
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Eugenia Lauret-Braña
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Eva Martí-Marqués
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Laura M Camacho-Montaño
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Verónica Ubieto
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Mikel Ganuza
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
| | - Federico Bolado
- From the Departments of Gastroenterology (E.M., L.G., A.V.-R.) and Clinical Pharmacology (P.Z.), Dr. Balmis General University Hospital, ISABIAL (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, the Department of Clinical Medicine, Faculty of Medicine, Miguel Hernández University, Elche (E.M.), the Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá (A.G.G.P., M.Á.R.-G., J.D.-O.), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (P.Z., F.C.-S.), and the Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (F.C.-S.), Madrid, the Gastroenterology and Digestive Endoscopy Unit, Corporació Sanitària Parc Taulí, Sabadell (A.L.-A., L.P.L.), the Department of Gastroenterology, Hospital Clínico Universitario de Valencia, Valencia (P.N., A.M.S.-P.), the Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander (C.S.-M., M.C.), the Department of Gastroenterology, Hospital Dr. Negrín, Las Palmas (I.F.-C.), the Department of Gastroenterology, Miguel Servet University Hospital and Health Research Institute of Aragón, Zaragoza (D.C.D.), the Department of Gastroenterology, Central de Asturias University Hospital, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo (E.L.-B.), the Department of Gastroenterology, Lucus Augusti University Hospital, Lugo (E.M.-M.), the Department of Gastroenterology, Puerta del Mar University Hospital, Cadiz (L.M.C.-M.), and the Department of Gastroenterology, University Hospital of Navarre, Pamplona (V.U., M.G., F.B.) - all in Spain; the Division of Gastroenterology, University of Southern California, Los Angeles (J.L.B.); the Division of Epidemiology and Biostatistics, IRCSS European Institute of Oncology, Milan (P.M.); the General Surgery Unit, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajío, Leon, Mexico (E.E.L.-H., A.J.R.C.M.); and the Department of Gastroenterology, Surat Institute of Digestive Sciences Hospital and Research Center, Surat, India (R.M., R.T.)
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Abstract
IMPORTANCE Hyponatremia is the most common electrolyte disorder and it affects approximately 5% of adults and 35% of hospitalized patients. Hyponatremia is defined by a serum sodium level of less than 135 mEq/L and most commonly results from water retention. Even mild hyponatremia is associated with increased hospital stay and mortality. OBSERVATIONS Symptoms and signs of hyponatremia range from mild and nonspecific (such as weakness or nausea) to severe and life-threatening (such as seizures or coma). Symptom severity depends on the rapidity of development, duration, and severity of hyponatremia. Mild chronic hyponatremia is associated with cognitive impairment, gait disturbances, and increased rates of falls and fractures. In a prospective study, patients with hyponatremia more frequently reported a history of falling compared with people with normal serum sodium levels (23.8% vs 16.4%, respectively; P < .01) and had a higher rate of new fractures over a mean follow-up of 7.4 years (23.3% vs 17.3%; P < .004). Hyponatremia is a secondary cause of osteoporosis. When evaluating patients, clinicians should categorize them according to their fluid volume status (hypovolemic hyponatremia, euvolemic hyponatremia, or hypervolemic hyponatremia). For most patients, the approach to managing hyponatremia should consist of treating the underlying cause. Urea and vaptans can be effective treatments for the syndrome of inappropriate antidiuresis and hyponatremia in patients with heart failure, but have adverse effects (eg, poor palatability and gastric intolerance with urea; and overly rapid correction of hyponatremia and increased thirst with vaptans). Severely symptomatic hyponatremia (with signs of somnolence, obtundation, coma, seizures, or cardiorespiratory distress) is a medical emergency. US and European guidelines recommend treating severely symptomatic hyponatremia with bolus hypertonic saline to reverse hyponatremic encephalopathy by increasing the serum sodium level by 4 mEq/L to 6 mEq/L within 1 to 2 hours but by no more than 10 mEq/L (correction limit) within the first 24 hours. This treatment approach exceeds the correction limit in about 4.5% to 28% of people. Overly rapid correction of chronic hyponatremia may cause osmotic demyelination, a rare but severe neurological condition, which can result in parkinsonism, quadriparesis, or even death. CONCLUSIONS AND RELEVANCE Hyponatremia affects approximately 5% of adults and 35% of patients who are hospitalized. Most patients should be managed by treating their underlying disease and according to whether they have hypovolemic, euvolemic, or hypervolemic hyponatremia. Urea and vaptans can be effective in managing the syndrome of inappropriate antidiuresis and hyponatremia in patients with heart failure; hypertonic saline is reserved for patients with severely symptomatic hyponatremia.
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Affiliation(s)
- Horacio J Adrogué
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Division of Nephrology, Department of Medicine, Houston Methodist Hospital, Houston, Texas
| | - Bryan M Tucker
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Division of Nephrology, Department of Medicine, Houston Methodist Hospital, Houston, Texas
| | - Nicolaos E Madias
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
- Division of Nephrology, Department of Medicine, St Elizabeth's Medical Center, Boston, Massachusetts
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Chand R, Chand R, Goldfarb DS. Hypernatremia in the intensive care unit. Curr Opin Nephrol Hypertens 2022; 31:199-204. [PMID: 34939612 DOI: 10.1097/mnh.0000000000000773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Hypernatremia is a relatively frequent electrolyte disorder seen in critically ill patients. As many as 27% of patients in intensive care units (ICUs) develop hypernatremia of variable severity during an ICU stay. Debate among specialists often ensues as to whether to correct hypernatremia or not. Some practitioners, particularly intensivists, believe that correction of hypernatremia with fluids may cause expansion of the extracellular fluid volume (ECFV) thereby worsening ventilation and impeding extubation. Other practitioners, including many nephrologists, do not expect correction of hypernatremia to lead to clinically apparent ECFV expansion, and fear other deleterious effects of hypernatremia. In this review we address the controversy regarding appropriate practice. RECENT FINDINGS There are no randomized, clinical trials (RCTs) to guide the administration of electrolyte-free fluid administration in hypernatremic patients. However, there are associations, demonstrated in the literature, suggesting that hypernatremia of any severity will increase the mortality and length of stay in these patients. These associations generally support the practice of correction of hypernatremia. In addition, our knowledge of the distribution of total body water influences us towards correcting hypernatremia as an appropriate therapy. We do not expect that adequate RCTs addressing this question will be performed. SUMMARY Allowing persistence of any degree of hypernatremia is associated with increased mortality, length of stay (LOS) and postdischarge mortality. We expect that proper use of electrolyte-free water intake will avoid adverse outcomes.
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Affiliation(s)
- Raja Chand
- Nephrology Division, New York University Langone Health, NYU Grossman School of Medicine, and Nephrology Section, NY Harbor VA Healthcare System, New York, New York, USA
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de la Espriella R, Santas E, Zegri Reiriz I, Górriz JL, Cobo Marcos M, Núñez J. Quantification and treatment of congestion in heart failure: A clinical and pathophysiological overview. Nefrologia 2022; 42:145-162. [PMID: 36153911 DOI: 10.1016/j.nefroe.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/06/2021] [Indexed: 06/16/2023] Open
Abstract
Renal sodium and water retention with resulting extracellular volume expansion and redistribution are hallmark features of heart failure syndromes. However, congestion assessment, monitoring, and treatment represent a real challenge in daily clinical practice. This document reviewed historical and contemporary evidence of available methods for determining volume status and discuss pharmacological aspects and pathophysiological principles that underlie diuretic use.
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Affiliation(s)
- Rafael de la Espriella
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, Spain; Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Spain
| | - Enrique Santas
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, Spain; Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Spain
| | - Isabel Zegri Reiriz
- Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Spain; Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jose Luis Górriz
- Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Spain; Servicio de Nefrología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, Spain; Departamento de Medicina, Universidad de Valencia, Spain
| | - Marta Cobo Marcos
- Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Spain; Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain; CIBER Cardiovascular, Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Spain.
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Abstract
Novel immunotherapy drugs have changed the landscape of cancer medicine. Immune checkpoint inhibitors and chimeric antigen receptor T cells are being used and investigated in almost all solid cancers. Immune-related adverse events have been associated with immunotherapies. Acute kidney injury has been the most commonly associated kidney adverse event. In this review, we showcase the several associated electrolyte disorders seen with immunotherapy. Immune checkpoint inhibitors can lead to hyponatremia by several mechanisms, with the syndrome of inappropriate antidiuresis being the most common. Endocrine causes of hyponatremia are rare. Hypokalemia is not uncommon and is associated with both proximal and distal renal tubular acidosis. Hypercalcemia associated with immune checkpoint inhibitors has led to some interesting observations including immune checkpoint inhibitor-induced parathyroid hormone - related peptide production, sarcoid-like granulomas, and hyper-progression of the disease. Hypocalcemia and hyperphosphatemia may be seen with immune checkpoint inhibitor-induced tumor lysis syndrome. Chimeric antigen receptor T cell therapy-associated electrolyte disorders are also common. This is associated chiefly with hyponatremia, although other electrolyte abnormalities can occur. Early recognition and prompt diagnosis may help providers manage the mechanistically varied and novel electrolyte disorders associated with immunotherapy.
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Affiliation(s)
- Nupur N. Uppal
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, New York
| | - Biruh T. Workeneh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Helbert Rondon-Berrios
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, New York
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Abstract
Starvation ketoacidosis (SKA) is a rarer cause of ketoacidosis. Most patients will only have a mild acidosis, but if exacerbated by stress can result in a severe acidosis. We describe a 66-year-old man admitted with reduced consciousness and found to have a severe metabolic acidosis with raised anion gap. His body mass index (BMI) was noted to be within the healthy range at 23 kg/m2; however, it was last documented 1 year previously at 28 kg/m2 with no clear timeframe of weight loss. While his acidosis improved with intravenous fluids, he subsequently developed severe electrolyte imbalance consistent with refeeding during his admission. Awareness of SKA as a cause for high anion gap metabolic acidosis is important and knowledge of management including intravenous fluids, thiamine, dietetic input and electrolyte replacement is vital.
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Affiliation(s)
- Angela Heulwen Boal
- Department of Clinical Biochemistry, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Maurizio Panarelli
- Department of Clinical Biochemistry, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Caroline Millar
- Department of Clinical Biochemistry, NHS Greater Glasgow and Clyde, Glasgow, UK
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20
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Abstract
Fluid overload is a common and important complication encountered in the care of patients with end-stage kidney failure receiving hemodialysis. Fluid overload not only causes unpleasant symptomatology for patients on dialysis, but also leads to increased incidence of hospitalization and mortality. Given the association of fluid overload with adverse outcomes in patients with end-stage kidney failure on hemodialysis, it is paramount that we identify effective and reliable methods to determine fluid status in such patients.
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Affiliation(s)
- Tony Lopez
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK; Cardiology Clinical Academic Group, Translational and Research Institute, St George's, University of London, London, UK
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK; Cardiology Clinical Academic Group, Translational and Research Institute, St George's, University of London, London, UK.
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21
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Choi J, Booth G, Jung HY, Lapointe-Shaw L, Tang T, Kwan JL, Rawal S, Weinerman A, Verma A, Razak F. Association of diabetes with frequency and cost of hospital admissions: a retrospective cohort study. CMAJ Open 2021; 9:E406-E412. [PMID: 33863799 PMCID: PMC8084549 DOI: 10.9778/cmajo.20190213] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Acute inpatient hospital admissions account for more than half of all health care costs related to diabetes. We sought to identify the most common and costly conditions leading to hospital admission among patients with diabetes compared with patients without diabetes. METHODS We used data from the General Internal Medicine Inpatient Initiative (GEMINI) study, a retrospective cohort study, of all patients admitted to a general internal medicine service at 7 Toronto hospitals between 2010 and 2015. The Canadian Institute for Health Information (CIHI) Most Responsible Diagnosis code was used to identify the 10 most frequent reasons for admission in patients with diabetes. Cost of hospital admission was estimated using the CIHI Resource Intensity Weight. Comparisons were made between patients with or without diabetes using the Pearson χ2 test for frequency and distribution-free confidence intervals (CIs) for median cost. RESULTS Among the 150 499 hospital admissions in our study, 41 934 (27.8%) involved patients with diabetes. Compared with patients without diabetes, hospital admissions because of soft tissue and bone infections were most frequent (2.5% v. 1.9%; prevalence ratio [PR] 1.28, 95% CI 1.19-1.37) and costly (Can$8794 v. Can$5845; cost ratio [CR] 1.50, 95% CI 1.37-1.65) among patients with diabetes. This was followed by urinary tract infections (PR 1.16, 95% CI 1.11-1.22; CR 1.23, 95% CI 1.17-1.29), stroke (PR 1.13, 95% CI 1.07-1.19; CR 1.19, 95% CI 1.14-1.25) and electrolyte disorders (PR 1.11, 95% CI 1.03-1.20; CR 1.20, 95% CI 1.08-1.34). INTERPRETATION Soft tissue and bone infections, urinary tract infections, stroke and electrolyte disorders are associated with a greater frequency and cost of hospital admissions in patients with diabetes than in those without diabetes. Preventive strategies focused on reducing hospital admissions secondary to these disorders may be beneficial in patients with diabetes.
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Affiliation(s)
- Jin Choi
- Department of Medicine (Choi), University of Toronto; Li Ka Shing Knowledge Institute (Booth, Jung, Verma, Razak) and Department of Medicine, Division of Endocrinology (Booth), St. Michael's Hospital; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Verma, Razak), St. Michael's Hospital, Toronto, Ont
| | - Gillian Booth
- Department of Medicine (Choi), University of Toronto; Li Ka Shing Knowledge Institute (Booth, Jung, Verma, Razak) and Department of Medicine, Division of Endocrinology (Booth), St. Michael's Hospital; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Verma, Razak), St. Michael's Hospital, Toronto, Ont
| | - Hae Young Jung
- Department of Medicine (Choi), University of Toronto; Li Ka Shing Knowledge Institute (Booth, Jung, Verma, Razak) and Department of Medicine, Division of Endocrinology (Booth), St. Michael's Hospital; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Verma, Razak), St. Michael's Hospital, Toronto, Ont
| | - Lauren Lapointe-Shaw
- Department of Medicine (Choi), University of Toronto; Li Ka Shing Knowledge Institute (Booth, Jung, Verma, Razak) and Department of Medicine, Division of Endocrinology (Booth), St. Michael's Hospital; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Verma, Razak), St. Michael's Hospital, Toronto, Ont
| | - Terence Tang
- Department of Medicine (Choi), University of Toronto; Li Ka Shing Knowledge Institute (Booth, Jung, Verma, Razak) and Department of Medicine, Division of Endocrinology (Booth), St. Michael's Hospital; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Verma, Razak), St. Michael's Hospital, Toronto, Ont
| | - Janice L Kwan
- Department of Medicine (Choi), University of Toronto; Li Ka Shing Knowledge Institute (Booth, Jung, Verma, Razak) and Department of Medicine, Division of Endocrinology (Booth), St. Michael's Hospital; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Verma, Razak), St. Michael's Hospital, Toronto, Ont
| | - Shail Rawal
- Department of Medicine (Choi), University of Toronto; Li Ka Shing Knowledge Institute (Booth, Jung, Verma, Razak) and Department of Medicine, Division of Endocrinology (Booth), St. Michael's Hospital; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Verma, Razak), St. Michael's Hospital, Toronto, Ont
| | - Adina Weinerman
- Department of Medicine (Choi), University of Toronto; Li Ka Shing Knowledge Institute (Booth, Jung, Verma, Razak) and Department of Medicine, Division of Endocrinology (Booth), St. Michael's Hospital; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Verma, Razak), St. Michael's Hospital, Toronto, Ont
| | - Amol Verma
- Department of Medicine (Choi), University of Toronto; Li Ka Shing Knowledge Institute (Booth, Jung, Verma, Razak) and Department of Medicine, Division of Endocrinology (Booth), St. Michael's Hospital; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Verma, Razak), St. Michael's Hospital, Toronto, Ont
| | - Fahad Razak
- Department of Medicine (Choi), University of Toronto; Li Ka Shing Knowledge Institute (Booth, Jung, Verma, Razak) and Department of Medicine, Division of Endocrinology (Booth), St. Michael's Hospital; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Verma, Razak), St. Michael's Hospital, Toronto, Ont.
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22
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Abstract
AIM Diabetic ketoacidosis is a hyperglycaemic emergency that is often treated in intensive care units (ICUs) despite having a low mortality and good prognosis. Current risk stratification is based primarily on acidosis, but it has been suggested that hyperosmolarity may also be an important marker of increased severity. Our aim was to evaluate the relationship between raised serum osmolarity and adverse clinical outcomes in ICU admissions for ketoacidosis. METHODS Retrospective review of prospectively collected data for adult admissions with ketoacidosis in the Australian and New Zealand Intensive Care Society Adult Patient Database over a 15-year period (2004-2018). Exclusions were readmissions and records with critical missing data. Serum hyperosmolarity was defined as > 320 mosm/l. The primary outcome was hospital mortality; secondary outcomes were ICU mortality and other adverse clinical events. RESULTS Some 17 379 admissions were included in the study population. People with hyperosmolarity had fourfold increased mortality, a higher incidence of renal failure and need for mechanical ventilation, and prolonged ICU and hospital length of stay. The relationship with mortality remained highly significant even after adjusting for severity of acidosis, hospital type, year of admission, time to ICU, and a modified Australia and New Zealand Risk of Death propensity score. CONCLUSIONS Although adults with ketoacidosis have a good prognosis overall, hyperosmolarity was independently associated with a significantly higher incidence of multiple adverse outcomes including mortality. Whether or not this is directly causal, it may have practical applications to improve risk stratification and identify individuals at risk of adverse outcomes.
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Affiliation(s)
- S P Blank
- Emergency Medicine/Retrieval, Tamworth Base Hospital, Tamworth, NSW, Australia
- Adult Intensive Care Services, Prince Charles Hospital, Chermside, QLD, Australia
| | - R M Blank
- Queensland Anaesthetic Regional Training Scheme, Brisbane, QLD, Australia
| | - M D Ziegenfuss
- Adult Intensive Care Services, Prince Charles Hospital, Chermside, QLD, Australia
- Statewide Intensive Care Clinical Network QLD Health, Brisbane, QLD, Australia
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23
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Abstract
Assessment of urine concentrations of sodium, chloride, and potassium is a widely available, rapid, and low-cost diagnostic option for the management of critically ill patients. Urine electrolytes have long been suggested in the diagnostic workup of hypovolemia, kidney injury, and acid-base and electrolyte disturbances. However, due to the wide range of normal reference values and challenges in interpretation, their use is controversial. To clarify their potential role in managing critical patients, we reviewed existing evidence on the use of urine electrolytes for diagnostic and therapeutic evaluation and assessment in critical illness. This review will describe the normal physiology of water and electrolyte excretion, summarize the use of urine electrolytes in hypovolemia, acute kidney injury, acid-base, and electrolyte disorders, and suggest some practical flowcharts for the potential use of urine electrolytes in daily critical care practice.
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Affiliation(s)
- Michele Umbrello
- From the Struttura Complessa (SC) Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy
| | - Paolo Formenti
- From the Struttura Complessa (SC) Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy
| | - Davide Chiumello
- From the Struttura Complessa (SC) Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy
- Dipartimento di Scienze della Salute
- Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy
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24
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Abstract
In primary polydipsia pathologically high levels of water intake physiologically lower arginine vasopressin (AVP) secretion, and in this way mirror the secondary polydipsia in diabetes insipidus in which pathologically low levels of AVP (or renal responsiveness to AVP) physiologically increase water intake. Primary polydipsia covers several disorders whose clinical features and significance, risk factors, pathophysiology and treatment are reviewed here. While groupings may appear somewhat arbitrary, they are associated with distinct alterations in physiologic parameters of water balance. The polydipsia is typically unrelated to homeostatic regulation of water intake, but instead reflects non-homeostatic influences. Recent technological advances, summarized here, have disentangled functional neurocircuits underlying both homeostatic and non-homeostatic physiologic influences, which provides an opportunity to better define the mechanisms of the disorders. We summarize this recent literature, highlighting hypothalamic circuitry that appears most clearly positioned to contribute to primary polydipsia. The life-threatening water imbalance in psychotic disorders is caused by an anterior hippocampal induced stress-diathesis that can be reproduced in animal models, and involves phylogenetically preserved pathways that appear likely to include one or more of these circuits. Ongoing translational neuroscience studies in these animal models may potentially localize reversible pathological changes which contribute to both the water imbalance and psychotic disorder.
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Affiliation(s)
- Leeda Ahmadi
- Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA.
| | - Morris B Goldman
- Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA.
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25
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Bertocchio JP. [Decision making in fluid and electrolyte disorders]. Rev Prat 2020; 70:e238. [PMID: 33739739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Jean-Philippe Bertocchio
- Genitourinary Medical Oncology and Research, MD Anderson Cancer Center, 77030 Houston, TX, USA
- Explorations fonctionnelles rénales et métaboliques, Hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 75908 Paris, France
- Centre national de référence des maladies rares du métabolisme du calcium et du phosphate CaP - Filière maladies rares OSCAR
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26
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Gong S, Dong Y, Gunderson TM, Andrijasevic NM, Kashani KB. Elastic Bandage vs Hypertonic Albumin for Diuretic-Resistant Volume-Overloaded Patients in Intensive Care Unit: A Propensity-Match Study. Mayo Clin Proc 2020; 95:1660-1670. [PMID: 32605782 DOI: 10.1016/j.mayocp.2020.03.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 03/03/2020] [Accepted: 03/09/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To compare elastic bandage (EB) vs hypertonic albumin solution administration to increase fluid removal by enhancing loop diuretic efficiency (DE) in patients with volume overload and diuretic resistance. PATIENTS AND METHODS In this historic cohort study with propensity matching, we included diuretic-resistant adult (≥18 years) patients with volume overload after fluid resuscitation admitted in the intensive care unit from January 1, 2006, through June 30, 2017. Regression models and propensity matching were used to assess the associations of these interventions with changes in DE and other clinical outcomes. RESULTS Of 1147 patients (median age, 66; interquartile range [IQR], 56-76 years; 51% [n=590] men), 384 (33%) received EB and 763 (67%) received hypertonic albumin solution. In adjusted models, EB was significantly associated with higher DE compared with hypertonic albumin solution (odds ratio, 1.37; 95% CI, 1.04 to 1.81; P=.004). After propensity matching of 345 pairs, DE remained significantly different between the 2 groups (median, 2111; IQR, 1092 to 4665 mL for EB vs median, 1829; IQR, 1032 to 3436 mL for hypertonic albumin solution; P=.02). EB, male sex, lower baseline serum urea nitrogen level, lower Charlson Comorbidity Index score, and higher baseline left ventricular ejection fraction were DE determinants. The lowest DE quartile (<1073 mL/40-mg furosemide equivalent) following adjustment for known predictors of mortality remained independently associated with higher 90-day death rate (odds ratio, 1.64; 95% CI, 1.13 to 2.36; P=.009). CONCLUSION EB use is associated with greater DE than hypertonic albumin solution during the deescalation phase of sepsis resuscitation. Prospective clinical trials would validate the findings of this hypothesis-generating study.
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Affiliation(s)
- Shurong Gong
- Department of Surgical Critical Care Medicine, Fujian Provincial Hospital, Provincial Clinical College of Fujian Medical University, Fuzhou, China
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Tina M Gunderson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | - Kianoush B Kashani
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
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27
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Gorga SM, Sahay RD, Askenazi DJ, Bridges BC, Cooper DS, Paden ML, Zappitelli M, Gist KM, Gien J, Basu RK, Jetton JG, Murphy HJ, King E, Fleming GM, Selewski DT. Fluid overload and fluid removal in pediatric patients on extracorporeal membrane oxygenation requiring continuous renal replacement therapy: a multicenter retrospective cohort study. Pediatr Nephrol 2020; 35:871-882. [PMID: 31953749 PMCID: PMC7517652 DOI: 10.1007/s00467-019-04468-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 12/09/2019] [Accepted: 12/20/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of this study was to characterize continuous renal replacement therapy (CRRT) utilization on extracorporeal membrane oxygenation (ECMO) and to determine the association of both fluid overload (FO) at CRRT initiation and fluid removal during CRRT with mortality in a large multicenter cohort. METHODS Retrospective chart review of all children < 18 years of age concurrently treated with ECMO and CRRT from January 1, 2007, to December 31, 2011, at six tertiary care children's hospital. Children treated with hemodialysis or peritoneal dialysis were excluded from the FO analysis. MEASUREMENTS AND MAIN RESULTS A total of 756 of the 1009 children supported with ECMO during the study period had complete FO data. Of these, 357 (47.2%) received either CRRT or were treated with an in-line filter and thus entered into the final analysis. Survival to ECMO decannulation was 66.4% and survival to hospital discharge was 44.3%. CRRT initiation occurred at median of 1 day (IQR 0, 2) after ECMO initiation. Median FO at CRRT initiation was 20.1% (IQR 5, 40) and was significantly lower in ECMO survivors vs. non-survivors (15.3% vs. 30.5% p = 0.005) and in hospital survivors vs. non-survivors (13.5% vs. 25.9%, p = 0.004). Median FO at CRRT discontinuation was significantly lower in ECMO survivors (23% vs. 37.6% p = 0.002) and hospital survivors vs. non-survivors (22.6% vs. 36.1%, p = 0.002). In ECMO survivors, after adjusting for pH at CRRT initiation, non-renal complications, ECMO mode, support type, center, patient age and AKI, FO at CRRT initiation (p = 0.01), and FO at CRRT discontinuation (p = 0.0002) were independently associated with duration of ECMO. In a similar multivariable analysis, FO at CRRT initiation (adjusted adds ratio [aOR] 1.09, 95% CI 1.00-1.18, p = 0.045) and at CRRT discontinuation (aOR 1.11, 95% CI 1.03-1.19, p = 0.01) were independently associated with hospital mortality. CONCLUSIONS In a multicenter pediatric ECMO cohort, this study demonstrates that severe FO was very common at CRRT initiation. We found an independent association between the degree of FO at CRRT initiation with adverse outcomes including mortality and increased duration of ECMO support. The results suggest that intervening prior to the development of significant FO may be a clinical therapeutic target and warrants further evaluation.
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Affiliation(s)
- Stephen M Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Rashmi D Sahay
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - David J Askenazi
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Brian C Bridges
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - David S Cooper
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Matthew L Paden
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Zappitelli
- Department of Pediatrics, Toronto Hospital for Sick Children, Toronto, Canada and McGill University Health Centre, Montreal, Canada
| | - Katja M Gist
- Department of Pediatrics, Children's Hospital of Colorado University of Colorado Anschutz Medical Campus Aurora, Aurora, CO, USA
| | - Jason Gien
- Department of Pediatrics, Children's Hospital of Colorado University of Colorado Anschutz Medical Campus Aurora, Aurora, CO, USA
| | - Rajit K Basu
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Jennifer G Jetton
- Division of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa Children's Hospital, Iowa City, IA, USA
| | - Heidi J Murphy
- Department of Pediatric, Medical University of South Carolina, Charleston, SC, USA
| | - Eileen King
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, Alabama, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Geoffrey M Fleming
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - David T Selewski
- Department of Pediatric, Medical University of South Carolina, Charleston, SC, USA.
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28
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Tazmini K, Nymo SH, Louch WE, Ranhoff AH, Øie E. Electrolyte imbalances in an unselected population in an emergency department: A retrospective cohort study. PLoS One 2019; 14:e0215673. [PMID: 31022222 PMCID: PMC6483356 DOI: 10.1371/journal.pone.0215673] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 04/05/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although electrolyte imbalances (EIs) are common in the emergency department (ED), few studies have examined the occurrence of such conditions in an unselected population. OBJECTIVES To investigate the frequency of EI among adult patients who present to the ED, with regards to type and severity, and the association with age and sex of the patient, hospital length of stay (LOS), readmission, and mortality. METHODS A retrospective cohort study. All patients ≥18 years referred for any reason to the ED between January 1, 2010, and December 31, 2015, who had measured blood electrolytes were included. In total, 62 991 visits involving 31 966 patients were registered. RESULTS EIs were mostly mild, and the most common EI was hyponatremia (glucose-corrected) (24.6%). Patients with increasing severity of EI had longer LOS compared with patients with normal electrolyte measurements. Among all admitted patients, there were 12928 (20.5%) readmissions within 30 days from discharge during the study period. Hyponatremia (glucose-corrected) was associated with readmission, with an adjusted odds ratio (OR) of 1.25 (95% CI, 1.18-1.32). Hypomagnesemia and hypocalcemia (albumin-corrected) were also associated with readmission, with ORs of 1.25 (95% CI, 1.07-1.45) and 1.22 (95% CI, 1.02-1.46), respectively. Dysnatremia, dyskalemia, hypercalcemia, hypermagnesemia, and hyperphosphatemia were associated with increased in-hospital mortality, whereas all EIs except hypophosphatemia were associated with increased 30-day and 1-year mortality. CONCLUSIONS EIs were common and increasing severity of EIs was associated with longer LOS and increased in-hospital, 30-days and 1-year mortality. EI monitoring is crucial for newly admitted patients, and up-to-date training in EI diagnosis and treatment is essential for ED physicians.
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Affiliation(s)
- Kiarash Tazmini
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
- * E-mail:
| | - Ståle H. Nymo
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - William E. Louch
- Institute of Experimental Medical Research, Oslo University Hospital, Ullevål and University of Oslo, Oslo, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Anette H. Ranhoff
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Erik Øie
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
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Dasgupta I, Thomas GN, Clarke J, Sitch A, Martin J, Bieber B, Hecking M, Karaboyas A, Pisoni R, Port F, Robinson B, Rayner H. Associations between Hemodialysis Facility Practices to Manage Fluid Volume and Intradialytic Hypotension and Patient Outcomes. Clin J Am Soc Nephrol 2019; 14:385-393. [PMID: 30723164 PMCID: PMC6419273 DOI: 10.2215/cjn.08240718] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 12/14/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND OBJECTIVES Fluid overload and intradialytic hypotension are associated with cardiovascular events and mortality in patients on hemodialysis. We investigated associations between hemodialysis facility practices related to fluid volume and intradialytic hypotension and patient outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data were analyzed from 10,250 patients in 273 facilities across 12 countries, from phase 4 of the Dialysis Outcomes and Practice Patterns Study (DOPPS; 2009-2012). Cox regression models (shared frailty) were used to estimate associations between facility practices reported by medical directors in response to the DOPPS Medical Directors Survey and all-cause and cardiovascular mortality and hospitalization, and cardiovascular events, adjusting for country, age, sex, dialysis vintage, predialysis systolic BP, cardiovascular comorbidities, diabetes, body mass index, smoking, residual kidney function, dialysis adequacy, and vascular access type. RESULTS Of ten facility practices tested (chosen a priori), having a protocol that specifies how often to assess dry weight in most patients was associated with lower all-cause (hazard ratio [HR], 0.78; 99% confidence interval [99% CI], 0.64 to 0.94) and cardiovascular mortality (HR, 0.72; 99% CI, 0.55 to 0.95). Routine orthostatic BP measurement to assess dry weight was associated with lower all-cause hospitalization (HR, 0.86; 99% CI, 0.77 to 0.97) and cardiovascular events (HR, 0.85; 99% CI, 0.73 to 0.98). Routine use of lower dialysate temperature to limit or prevent intradialytic hypotension was associated with lower cardiovascular mortality (HR, 0.76; 99% CI, 0.58 to 0.98). Routine use of an online volume indicator to assess dry weight was associated with higher all-cause hospitalization (HR, 1.19; 99% CI, 1.02 to 1.38). Routine use of sodium modeling/profiling to limit or prevent intradialytic hypotension was associated with higher all-cause mortality (HR, 1.36; 99% CI, 1.14 to 1.63), cardiovascular mortality (HR, 1.34; 99% CI, 1.04 to 1.73), and cardiovascular events (HR, 1.21; 99% CI, 1.03 to 1.43). CONCLUSIONS Hemodialysis facility practices relating to the management of fluid volume and intradialytic hypotension are associated with patient outcomes.
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Affiliation(s)
- Indranil Dasgupta
- Department of Renal Medicine, Heartlands Hospital, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - G. Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Joanne Clarke
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alice Sitch
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- National Institute for Health Research, Birmingham Biomedical Research Centre, University Hospitals Birmingham National Health Service Foundation Trust and University of Birmingham, Birmingham, UK
| | - James Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Angelo Karaboyas
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Ronald Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Friedrich Port
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Bruce Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Hugh Rayner
- Department of Renal Medicine, Heartlands Hospital, Birmingham, UK
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Niu DG, Yang F, Tian WL, Zhao YZ, Li C, Ding LA, Fang HC, Huang Q. A technique to establish fistuloclysis for high-output jejunocutaneous fistula through percutaneous enterostomy: A case report. Medicine (Baltimore) 2019; 98:e14653. [PMID: 30855454 PMCID: PMC6417508 DOI: 10.1097/md.0000000000014653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Currently, fistucolysis helps to establish intestinal nutrition and succus entericus reinfusion in the case of controllable mature high-output enterocutaneous fistula. However, if the tube cannot reach the distal limb of a fistula, fistuloclysis is not achieved. We proposed a strategy to establish succus entericus reinfusion for intractable intestinal fistula through percutaneous enterostomy. PATIENT CONCERNS A 43-year-old man was transferred to our facility for postoperative enterocutaneous fistulae, sepsis, malnutrition, and electrolyte and fluid imbalance. The contrast X-ray demonstrated the breakdown of the primary anastomosis, with fistula output ranging from 1500 to 2000 mL/d, despite the administration of medications to reduce gastrointestinal secretions. DIAGNOSES The patient was diagnosed with high-output anastomosis fistula by gastrointestinal radiography. INTERVENTIONS We used percutaneous enterostomy to establish fistuloclysis. OUTCOMES Fistuloclysis was established by percutaneous enterostomy successfully. No complications were found during the past 4-month follow-up after percutaneous enterostomy. He is waiting for reconstruction surgery after 6 months' enteral nutrition (EN). LESSONS Fistuloclysis-assisted EN, if used appropriately, avoids the complications of long-term parenteral nutrition (PN) and may promote faster fistula healing.
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Affiliation(s)
- Dong-Guang Niu
- Gastrointestinal Surgery Department, Affiliated Hospital of Qingdao University, Shandong, China
| | - Fan Yang
- Department of General Surgery, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Wei-Liang Tian
- Department of General Surgery, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yun-Zhao Zhao
- Department of General Surgery, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Chen Li
- Oncology Department, Xintai People's Hospital, Tai’an, Shandong, China
| | - Lian-An Ding
- Gastrointestinal Surgery Department, Affiliated Hospital of Qingdao University, Shandong, China
| | - Hong-Chun Fang
- Gastrointestinal Surgery Department, Affiliated Hospital of Qingdao University, Shandong, China
| | - Qian Huang
- Department of General Surgery, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
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31
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Friedman S, Zac L, Cattan A, Ovadia D, Lebel DE, Matot I. Hyperchloremia and Diuresis in Children Undergoing Scoliosis Surgery: A Retrospective Cohort Study. Isr Med Assoc J 2019; 21:94-99. [PMID: 30772959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Hyperchloremia is frequent in adult surgical patients and is associated with renal dysfunction. Studies in surgical pediatric patients are lacking. OBJECTIVES To identify both the incidence of postoperative hyperchloremia in children undergoing surgery for idiopathic and non-idiopathic scoliosis, and the association of postoperative hyperchloremia with intraoperative fluid management and postoperative diuresis. METHODS The records of 74 children and adolescents who underwent elective scoliosis surgery were retrospectively evaluated. The primary endpoint was the incidence of serum chloride level ≥ 110 mEq/L at the end of surgery and 12 hours postoperatively. Secondary endpoints were the type and volume of administered fluids, 12 hours postoperative diuresis, and the incidence of postoperative oliguria. RESULTS Hyperchloremia occurred in 55% of the patients at the end of surgery and in 52% 12 hours postoperatively. Hyperchloremic patients received larger intraoperative volume of 0.9% NaCl diluted cell-saver blood and 10% HAES than did normochloremic patients [median (interquartile range) 6.8 (2.5-11.0) ml/kg vs. 0 (0-7.3), P = 0.003 and 10.0 (0-12.8) vs. 4.4 (0-9.8), P = 0.02, respectively]. Additionally, when compared with normochloremic patients, diuresis during the first 12 hours postoperatively was lower in hyperchloremic patients. Postoperative oliguria (urine output < 0.5 ml/kg/hr for 12 hours) was diagnosed in 7 children (9%), of whom 6 were hyperchloremic at the end of surgery. CONCLUSIONS Early postoperative hyperchloremia is common in children undergoing scoliosis repair surgery and may be attributed to the administration of 0.9% NaCl diluted cell-saver blood and 10% HAES. Postoperative hyperchloremia might be associated with postoperative oliguria.
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Affiliation(s)
- Shirley Friedman
- Department of Pediatric Intensive Care, Dana Dwek Childrens Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Lilach Zac
- Division of Anesthesiology, Critical Care and Pain Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Anat Cattan
- Division of Pediatric Orthopedics, Dana Dwek Childrens Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Dror Ovadia
- Division of Pediatric Orthopedics, Dana Dwek Childrens Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - David E Lebel
- Division of Pediatric Orthopedics, Dana Dwek Childrens Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Idit Matot
- Division of Anesthesiology, Critical Care and Pain Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Canlas JF, Ponmani C. Congenital adrenal hyperplasia with salt-wasting crisis and arrhythmia: a case study. BMJ Case Rep 2019; 12:12/1/e227565. [PMID: 30700462 PMCID: PMC6352754 DOI: 10.1136/bcr-2018-227565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We report a case of a 10-day-old male infant who presented to the emergency department with severe electrolyte imbalance and life-threatening arrhythmia. The parents reported a 3-day history of poor feeding and lethargy. On examination, he was bradycardic (heart rate of 65 beats/min) with signs of dehydration. His ECG showed broad complex bradycardia. Blood gas showed metabolic acidosis with hyponatraemia and hyperkalaemia. A probable diagnosis of congenital adrenal hyperplasia (CAH) with salt-wasting crisis was made and treatment was commenced. He was given saline bolus, nebulised salbutamol, calcium gluconate and hydrocortisone. Following the above interventions, his heart rate rose to 150 beats/min with a regular sinus rhythm within a period of 40 min. The diagnosis of CAH secondary to 21-hydroxylase deficiency with mutation in CYP21A2 was confirmed by genetic studies. He was discharged home with hydrocortisone, fludrocortisone and sodium chloride.
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Affiliation(s)
- Johnny Figueroa Canlas
- Department of Paediatrics, Barking Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - Caroline Ponmani
- Department of Paediatrics, Barking Havering and Redbridge University Hospitals NHS Trust, Romford, UK
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Odo KE, Odetunde OI, Chinawa JM, Okafor HU, Aronu AE, Adimora GN. Comparison of plasma electrolytes of perinatally asphyxiated and normal term babies. J Neonatal Perinatal Med 2019; 12:385-389. [PMID: 31282432 DOI: 10.3233/npm-1839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES The objective of this study is to document and compare plasma electrolytes of asphyxiated newborns of different degree within 48 hours of life. STUDY DISIGN A comparative cross-sectional study was conducted in the newborn special care unit at the University of Nigeria Teaching Hospital (UNTH), Enugu, South-East Nigeria. Sodium, potassium, bicarbonate and ionized calcium levels were estimated in the plasma samples of neonates with perinatal asphyxia of different degree and healthy newborns (control group) within 48 hours of birth. MAIN OUTCOME MEASURES The plasma sodium, potassium, bicarbonate and ionized calcium levels were estimated in both, the study subjects and controls. RESULTS Mean plasma sodium level was significantly lower (134.93±5.24 mmol/l vs 141.90±3.36 mmol/l; P < 0.05), mean plasma bicarbonate level was significantly lower (16.98±3.99 mmol/l vs 18.54±2.36 mmol/l; P < 0.05), and mean plasma ionized calcium level was significantly lower (1.10±0.14 mmol/l vs 1.25 0.11 mmol/l; P < 0.05) in subjects compared to controls while mean plasma potassium was significantly higher (5.07±0.93 mmol/l vs 4.65±0.51 mmol/l P < 0.05) in subjects compare to controls. CONCLUSION The tendency to have hyponatremia, hyperkalemia, acidosis and hypocalcemia is very high among the study subjects which underscores the need for great vigilance in electrolyte monitoring when managing an asphyxiated baby.
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Affiliation(s)
- K E Odo
- Department of Pediatrics, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - O I Odetunde
- Department of Pediatrics, College of Medicine, University of Nigeria and University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu, Nigeria
| | - J M Chinawa
- Department of Pediatrics, College of Medicine, University of Nigeria and University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu, Nigeria
| | - H U Okafor
- Department of Pediatrics, College of Medicine, University of Nigeria and University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu, Nigeria
| | - A E Aronu
- Department of Pediatrics, College of Medicine, University of Nigeria and University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu, Nigeria
| | - G N Adimora
- Department of Pediatrics, College of Medicine, University of Nigeria and University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu, Nigeria
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34
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Korkut S, Akin L, Hatipoglu N, Özdemir A, Gündüz Z, Dursun I, Korkmaz L, Dursun I, Kurtoglu S. A potential serious complication in infants with congenital obstructive uropathy: Secondary pseudohypoaldosteronism. J PAK MED ASSOC 2019; 69:108-112. [PMID: 30623923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Patients who have secondary pseudohypoaldosteronism (PHA) in addition to hyponatraemia, hyperpotassaemia and high serum aldosterone levels for the age were included in this retrospective study.Among eight patients, seven patients were diagnosed with PHA secondary to obstructive uropathy (OUP), whereas one patient had PHA secondary to ileostomy. Six patients with OUP had simultaneous urinary tract infection (UTI) and in all except one patient, secondary PHA recovered with only UTI treatment before applying surgical correction. All the patients were younger than 3 months age. In three patients with PUV diagnosis, salt wasting recurred in an UTI episode under 3 months of age.
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Affiliation(s)
- Sabriye Korkut
- Department of Neonatology, Erciyes University Medical Faculty, Turkey
| | - Leyla Akin
- Department of Pediatric Endocrinology, Erciyes University Medical Faculty, Turkey
| | - Nihal Hatipoglu
- Department of Pediatric Endocrinology, Erciyes University Medical Faculty, Turkey
| | - Ahmet Özdemir
- Department of Neonatology, Erciyes University Medical Faculty, Turkey
| | - Zübeyde Gündüz
- Department of Pediatric Nephrology, Erciyes University Medical Faculty, Turkey
| | - Ismail Dursun
- Department of Pediatric Nephrology, Erciyes University Medical Faculty, Turkey
| | - Levent Korkmaz
- Department of Neonatology, Erciyes University Medical Faculty, Turkey
| | - Ismail Dursun
- Department of Pediatric Nephrology, Erciyes University Medical Faculty, Turkey
| | - Selim Kurtoglu
- Department of Neonatology, Erciyes University Medical Faculty, Turkey
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Affiliation(s)
- Emilie Trinh
- Division of Nephrology, McGill University Health Center, Montreal, Quebec, Canada; and
| | - Jeffrey Perl
- Division of Nephrology and
- Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
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Abstract
Intravenous fluids are commonly prescribed but uncertainty remains about how to assess when fluids are required and how much to give, particularly in our multimorbid, polymedicated and ageing population. Furthermore, studies have noted that fluid resuscitation can be harmful even if clinical evidence of hypervolaemia is not present. Two recent guidelines have acknowledged a limited evidence base to guide fluid assessment. A recommended means to assess hypovolaemia includes assessment of fluid responsiveness. Fluid responsiveness is a rise in stroke volume following an increase in preload, achieved using a fluid challenge or a passive leg raise. However, the means of defining fluid responsiveness and its ability to identify patients who would benefit from fluid resuscitation is currently unclear. This review discusses the current guidelines about, and the evidence base for the provision of, intravenous fluids in the acutely unwell medical patient. It highlights how little evidence is available to guide medical practice.
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Affiliation(s)
- Adam Seccombe
- Acute Medicinal Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Sapey
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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37
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Braun K, Utech A, Velez ME, Walker R. Parenteral Nutrition Electrolyte Abnormalities and Associated Factors Before and After Nutrition Support Team Initiation. JPEN J Parenter Enteral Nutr 2018; 42:387-392. [PMID: 29443393 DOI: 10.1177/0148607116673186] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 09/02/2016] [Indexed: 10/13/2023]
Abstract
BACKGROUND Studied since the 1940s, refeeding syndrome still has no universal definition, thus making comparison of studies difficult. Negative outcomes (eg, metabolic abnormalities) may occur with the use of specialized nutrition, such as parenteral nutrition (PN). Less than half of medical institutions have a nutrition support team (NST) managing PN. Interdisciplinary team management of PN may reduce negative outcomes of PN. The objective of this study was to show the value of the NST by measuring differences in PN variables, especially electrolyte abnormalities (EAs), before and after NST initiation at a large medical center and to identify factors associated with EAs among adult subjects receiving PN. MATERIALS AND METHODS During this retrospective study, computerized medical charts (N = 735) from 2007-2010 were reviewed for electrolyte changes (particularly potassium, magnesium, and phosphorus) the first 3 days following PN initiation in hospitalized adults. Changes in EAs with other variables were compared before and after NST implementation. Equivalent samples sizes were collected to better evaluate the impact of the team. RESULTS Following the implementation of the NST, fewer EAs were seen in PN patients (53%; χ2 = 10.906, P = .004); significantly less potassium, phosphorus, and magnesium intravenous piggyback supplementation (88.8% vs 94%; χ2 = 5.05, P = .026) was used; and mortality within 30 days of PN cessation was significantly less (12.7% vs 10.6%, P = .012). CONCLUSION Our study complements existing research, finding that an NST was associated with a decreased occurrence of EAs and mortality in the hospitalized adult receiving PN.
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Affiliation(s)
- Katie Braun
- Michael E. DeBakey Medical Center, Houston, Texas, USA
| | - Anne Utech
- Department of Veterans Affairs, Veterans Health Administration, Washington, DC, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - Maria Eugenia Velez
- Michael E. DeBakey Medical Center, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - Renee Walker
- Michael E. DeBakey Medical Center, Houston, Texas, USA
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Abstract
Despite the gradual increased use of peritoneal dialysis (PD) globally around the world, it is recognized that a number of areas in PD as a renal-replacement therapy require attention and improvements. The current challenges in PD include how to tackle technique failure and sustain long-term PD, manage and prevent peritoneal infections, malnutrition and inflammation, cardiovascular mortality, volume overload, glucose exposure, adequacy of solute removal, peritoneal access, peritoneal physiology and changes with long-term PD, patient fatigue, psychosocial issues, and care of elderly patients on PD. Obviously, hemodialysis as another renal-replacement therapy modality also has its own areas that need attention and improvement by nephrologists and nurses. With more clinical and basic science research, outcome studies, and through better education and training, together with the implementation of global PD guidelines for enhancing care of PD patients, it is likely that such problem areas in PD gradually will be resolved and PD patient outcomes will be improved.
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Affiliation(s)
- Philip Kam-Tao Li
- CUHK Carol and Richard Yu PD Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong.
| | - Vickie Wai-Ki Kwong
- CUHK Carol and Richard Yu PD Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong
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40
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Abstract
Acute kidney injury (AKI) occurs frequently in the surgical intensive care unit and results in significant morbidity and mortality. AKI needs to be identified early and underlying causes treated or eliminated. Sepsis, major surgery such as coronary artery bypass, and hypovolemia are the most common causes and patients with underlying comorbidities have increased susceptibility. Treatment should begin by ensuring that patients are adequately resuscitated and all contributing causes are replaced or eliminated. After stabilization of hemodynamic status and elimination of contributing causes, treatment becomes largely supportive and may require the use of a renal replacement therapy.
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Affiliation(s)
- Robert A Maxwell
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, TN, USA.
| | - Christopher Michael Bell
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, TN, USA
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41
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Weiss BD. Electrolytes: Foreword. FP Essent 2017; 459:2. [PMID: 28806045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Barry D Weiss
- University of Arizona College of Medicine, 1450 North Cherry, Tucson, AZ 85719,
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Harris L, Braun M. Electrolytes: Oral Electrolyte Solutions. FP Essent 2017; 459:35-38. [PMID: 28806049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Oral electrolyte solutions are used widely for rehydration in diarrheal illness and to maintain hydration during vigorous exercise. In diarrheal illness, an oral rehydration solution (ORS) typically is preferred over intravenous fluids except for patients with severe dehydration. The preferred ORS is one similar to the glucose-containing reduced osmolarity World Health Organization ORS. There also are polymer-based solutions that use rice or wheat as the source of carbohydrates but these are not widely recommended. Use of other liquids, such as sport drinks, juice, soft drinks, and chicken broth is not recommended, though these can be considered for patients with no or mild dehydration. For maintaining hydration during exercise, particularly vigorous high-intensity exercise, recommendations are to consume fluids (ie, 5 to 7 mL/kg) and a sodium-containing snack at least 4 hours before. During exercise, individuals require 200 to 800 mL/hour of liquid that should contain 20 to 30 mEq/L of sodium. Carbohydrate intake is recommended during high-intensity exercise. Intake of excessive sodium-free fluids should be avoided to prevent exercise-induced hyponatremia. Additional fluids (ie, 1.5 L/kg of weight lost) can be consumed after exercise to restore hydration. Vitamin and mineral supplements are not recommended routinely for athletes unless known deficiencies exist.
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Affiliation(s)
- Lisa Harris
- Madigan Army Medical Center Family Medicine Residency, 9040 Jackson Ave, Tacoma, WA 98431
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Ripollés-Melchor J, Chappell D, Espinosa Á, Mhyten MG, Abad-Gurumeta A, Bergese SD, Casans-Francés R, Calvo-Vecino JM. Perioperative fluid therapy recommendations for major abdominal surgery. Via RICA recommendations revisited. Part I: Physiological background. Rev Esp Anestesiol Reanim 2017; 64:328-338. [PMID: 28364973 DOI: 10.1016/j.redar.2017.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 02/08/2017] [Accepted: 02/08/2017] [Indexed: 06/07/2023]
Affiliation(s)
- J Ripollés-Melchor
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España.
| | - D Chappell
- Departamento de Anestesia, Hospital Universitario LMU de Múnich, Múnich, Alemania
| | - Á Espinosa
- Departamento de Anestesia Cardiovascular y Torácica, y Cuidados Intensivos, Bahrain Defence Force Hospital, Riffa, Reino de Baréin
| | - M G Mhyten
- University College London Hospital, National Institute of Health Research, Biomedical Research Centre, Londres, Reino Unido
| | - A Abad-Gurumeta
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España
| | - S D Bergese
- Departamento de Anestesia y Neurocirugía, Wexner Medical Center, The Ohio State University, Columbus, OH, Estados Unidos
| | - R Casans-Francés
- Departamento de Anestesia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J M Calvo-Vecino
- Departamento de Anestesia, Complejo Asistencial de Salamanca, Universidad de Salamanca, Salamanca, España
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44
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Ripollés-Melchor J, Chappell D, Aya HD, Espinosa Á, Mhyten MG, Abad-Gurumeta A, Bergese SD, Casans-Francés R, Calvo-Vecino JM. Fluid therapy recommendations for major abdominal surgery. Via RICA recommendations revisited. Part III: Goal directed hemodynamic therapy. Rationale for maintaining vascular tone and contractility. Rev Esp Anestesiol Reanim 2017; 64:348-359. [PMID: 28343682 DOI: 10.1016/j.redar.2017.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 02/27/2017] [Accepted: 03/01/2017] [Indexed: 06/06/2023]
Affiliation(s)
- J Ripollés-Melchor
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España.
| | - D Chappell
- Departamento de Anestesia, Hospital Universitario LMU de Múnich, Múnich, Alemania
| | - H D Aya
- Departamento de Cuidados Intensivos, St George's University Hospitals, NHS Foundation Trust, Londres, Reino Unido
| | - Á Espinosa
- Departamento de Anestesia Cardiovascular y Torácica, y Cuidados Intensivos, Bahrain Defence Force Hospital, Riffa, Reino de Baréin
| | - M G Mhyten
- University College London Hospital, National Institute of Health Research, Biomedical Research Centre, Londres, Reino Unido
| | - A Abad-Gurumeta
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España
| | - S D Bergese
- Departamento de Anestesia y Neurocirugía, Wexner Medical Center, The Ohio State University, Columbus, OH, Estados Unidos
| | - R Casans-Francés
- Departamento de Anestesia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J M Calvo-Vecino
- Departamento de Anestesia, Complejo Asistencial Universitario de Salamanca, Universidad de Salamanca (CAUSA), Salamanca, España
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45
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Ripollés-Melchor J, Chappell D, Aya HD, Espinosa Á, Mhyten MG, Abad-Gurumeta A, Bergese SD, Casans-Francés R, Calvo-Vecino JM. Fluid therapy recommendations for major abdominal surgery. Via RICA recommendations revisited. Part II: Goal directed hemodynamic therapy. Rationale for optimising intravascular volume. Rev Esp Anestesiol Reanim 2017; 64:339-347. [PMID: 28343684 DOI: 10.1016/j.redar.2017.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 06/06/2023]
Affiliation(s)
- J Ripollés-Melchor
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España.
| | - D Chappell
- Departamento de Anestesia, Hospital Universitario LMU de Múnich, Múnich, Alemania
| | - H D Aya
- Departamento de Cuidados Intensivos, St George's University Hospitals, NHS Foundation Trust, Londres, Reino Unido
| | - Á Espinosa
- Departamento de Anestesia Cardiovascular y Torácica, y Cuidados Intensivos, Bahrain Defence Force Hospital, Riffa, Reino de Baréin
| | - M G Mhyten
- University College London Hospital, National Institute for Health Research, Biomedical Research Centre, Londres, Reino Unido
| | - A Abad-Gurumeta
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España
| | - S D Bergese
- Departamento de Anestesia y Neurocirugía, Wexner Medical Center, The Ohio State University, Columbus, OH, Estados Unidos
| | - R Casans-Francés
- Departamento de Anestesia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J M Calvo-Vecino
- Departamento de Anestesia, Complejo Asistencial Universitario de Salamanca, Universidad de Salamanca (CAUSA), Salamanca, España
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46
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Abstract
Electrolyte disturbances are frequently encountered in critically ill oncology patients. Hyponatremia and hypernatremia as well as hypocalcemia and hypercalcemia are among the most commonly encountered electrolyte abnormalities. In the intensive care unit, management of critical electrolyte disturbances is focused on initial evaluation and immediate treatment plan to prevent severe complications. A PubMed search was performed to identify best available evidence for evaluation and management of dysnatremias, hypocalcemia, and hypercalcemia. Current literature was reviewed regarding the management of electrolyte disturbances. The role of new therapeutic options, for example, vaptans for hyponatremia, teriparatide for hypocalcemia, and denosumab for hypercalcemia, is discussed. Early diagnosis and appropriate management are expected to reduce adverse outcomes.
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Affiliation(s)
- Maryam I Khan
- 1 Division of Endocrinology, Diabetes and Metabolism, Cooper University Health Care, Camden, NJ, USA
| | - R Phillip Dellinger
- 2 Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ, USA
| | - Steven G Waguespack
- 3 Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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47
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Ettrup-Christensen A, Amstrup-Hansen L, Zwisler ST. [Prehospital arterial blood gas analysis after collapse connected to triathlon participation]. Ugeskr Laeger 2017; 179:V09160668. [PMID: 28473024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Long-distance athletes are at risk of serious fluid and electrolyte disturbances, such as hypernatraemia (dehydration). Recently, cases of serious morbidity have been reported, due to acute exercise-associated hyponatraemia, which can advance to encephalopathy. An arterial blood gas analysis (ABG) was drawn from collapsed athletes at the championship of full-distance triathlon 2015, and different electrolyte imbalances were found. Our findings show that prehospital ABG can assist in differentiating the cause of collapse, and presumably, targeted treatment can be initiated already on scene.
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48
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Ashurst J, Sergent SR, Wagner BJ, Kim J. Evidence-based management of potassium disorders in the emergency department [digest]. Emerg Med Pract 2016; 18:S1-S2. [PMID: 28745843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Hypokalemia and hyperkalemia are the most common electrolyte disorders managed in the emergency department. The diagnosis of these potentially life-threatening disorders is challenging due to the often vague symptomatology a patient may express, and treatment options may be based upon very little data due to the time it may take for laboratory values to return. This review examines the most current evidence with regard to the pathophysiology, diagnosis, and management of potassium disorders. In this review, classic paradigms, such as the use of sodium polystyrene and the routine measurement of serum magnesium, are tested, and an algorithm for the treatment of potassium disorders is discussed. [Points & Pearls is a digest of Emergency Medicine Practice].
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Affiliation(s)
- John Ashurst
- Director of Emergency Medicine Residency Research, Duke Lifepoint Conemaugh Memorial Medical Center, Johnstown, PA
| | - Shane R Sergent
- Department of Emergency Medicine, Conemaugh Memorial Hospital, Johnstown, PA
| | - Benjamin J Wagner
- Department of Emergency Medicine, Conemaugh Memorial Hospital, Johnstown, PA
| | - Jeremy Kim
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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49
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Cooper DS, Basu RK, Price JF, Goldstein SL, Krawczeski CD. The Kidney in Critical Cardiac Disease: Proceedings From the 10th International Conference of the Pediatric Cardiac Intensive Care Society. World J Pediatr Congenit Heart Surg 2016; 7:152-63. [PMID: 26957397 DOI: 10.1177/2150135115623289] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The field of cardiac intensive care continues to advance in tandem with congenital heart surgery. The focus of intensive care unit care has now shifted to that of morbidity reduction and eventual elimination. Acute kidney injury (AKI) after cardiac surgery is associated with adverse outcomes, including prolonged intensive care and hospital stays, diminished quality of life, and increased long-term mortality. Acute kidney injury occurs frequently, complicating the care of both postoperative patients and those with heart failure. Patients who become fluid overloaded and/or require dialysis are at high risk of mortality, but even minor degrees of AKI portend a significant increase in mortality and morbidity. Clinicians continue to seek methods of early diagnosis and risk stratification of AKI to prevent its adverse sequelae. Previous conventional wisdom that survivors of AKI fully recover renal function without subsequent consequences may be flawed.
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Affiliation(s)
- David S Cooper
- The Heart Institute and the Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rajit K Basu
- Division of Critical Care and the Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jack F Price
- Division of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Stuart L Goldstein
- The Heart Institute and the Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Catherine D Krawczeski
- Dvision of Cardiology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
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50
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Ashurst J, Sergent SR, Sergent BR. Evidence-Based Management Of Potassium Disorders In The Emergency Department. Emerg Med Pract 2016; 18:1-24. [PMID: 27775507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 08/10/2016] [Indexed: 06/06/2023]
Abstract
Hypokalemia and hyperkalemia are the most common electrolyte disorders managed in the emergency department. The diagnosis of these potentially life-threatening disorders is challenging due to the often vague symptomatology a patient may express, and treatment options may be based upon very little data due to the time it may take for laboratory values to return. This review examines the most current evidence with regard to the pathophysiology, diagnosis, and management of potassium disorders. In this review, classic paradigms, such as the use of sodium polystyrene and the routine measurement of serum magnesium, are tested, and an algorithm for the treatment of potassium disorders is discussed.
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Affiliation(s)
- John Ashurst
- Director of Emergency Medicine Residency Research, Duke Lifepoint Conemaugh Memorial Medical Center, Johnstown, PA
| | - Shane R Sergent
- Department of Emergency Medicine, Conemaugh Memorial Hospital, Johnstown, PA
| | - Benjamin R Sergent
- Department of Emergency Medicine, Conemaugh Memorial Hospital, Johnstown, PA
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