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Al Zaman K, Alhebsi AA, Almheiri A, Alhosani H, Alshehhi NT, Alwheibi ES. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) in Chronic Respiratory Diseases: A Comprehensive Review. Cureus 2025; 17:e77407. [PMID: 39949461 PMCID: PMC11822327 DOI: 10.7759/cureus.77407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2025] [Indexed: 02/16/2025] Open
Abstract
The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a complex and often underdiagnosed disorder characterized by impaired water homeostasis, leading to hyponatremia and associated complications. This comprehensive review explores the intersection of SIADH with chronic respiratory diseases, including chronic obstructive pulmonary disease (COPD), pulmonary tuberculosis, cystic fibrosis, and interstitial lung disease. The review looks at current evidence on pathophysiology, diagnostic challenges, and treatment approaches, highlighting the need for specialized management strategies to improve patient outcomes. Through an analysis of clinical and observational studies, this review highlights the significant impact of SIADH on morbidity and mortality among patients with respiratory diseases. It illustrates the necessity for further research to refine diagnostic and therapeutic modalities.
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Affiliation(s)
- Khaled Al Zaman
- Internal Medicine, Cleveland Clinic Abu Dhabi, Abu Dhabi, ARE
| | | | | | - Hind Alhosani
- Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, ARE
| | - Nada T Alshehhi
- Internal Medicine, Cleveland Clinic Abu Dhabi, Abu Dhabi, ARE
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Acute hyponatremia after aneurysmal subarachnoid hemorrhage: Frequency, treatment, and outcome. J Clin Neurosci 2021; 88:237-242. [PMID: 33992191 DOI: 10.1016/j.jocn.2021.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/27/2021] [Accepted: 04/03/2021] [Indexed: 11/21/2022]
Abstract
We retrospectively examined the course of serum sodium levels in 180 patients with acute aneurysmal subarachnoid hemorrhage (SAH) who had been admitted to the anesthesiologic-neurosurgical intensive care unit of the University Medical Center Regensburg, Germany, between January 2014 and December 2018. Each patient file was analyzed regarding the frequency and intensity of hyponatremic episodes and the administered medication. At admission to the intensive care unit (ICU), 18patients had shown initial hyponatremia (<135 mmol/L) and 4 patients hypernatremia (greater than145 mmol/L). 88(48.9%) of the 158 patients with normal serum sodium levels developed at least one hyponatremic episode during ICU treatment. The number of hyponatremic episodes was similar between patients with higher-grade and lower-grade aneurysmal SAH (P = 0.848). At the end of ICU treatment, outcome did not differ between patients with and without hyponatremia (40/88, 45.5% vs. 38/70, 54.3%, P = 0.270). At 6 months after SAH, however, good outcome (Glasgow outcome scale, GOS 4-5) was more frequently observed in patients with hyponatremia (26/88, 29.5% vs. 32/70, 45.7%, P = 0.036). Medication with sodium chloride, fludrocortisone, or tolvaptan was initiated in 75.4% patients with mild hyponatremia (130-134 mmol/L) and in 92.9% with moderate hyponatremia (125-129 mmol/L). At 6 months after SAH, patients treated with tolvaptan had a lower rate of poor outcome than patients who had not received tolvaptan (1/14, 7.1% vs. 25/74, 33.8%, P = 0.045). In patients with acute aneurysmal SAH and hyponatremic episodes, consequent treatment of hyponatremia prevented impaired outcome. Because administration of tolvaptan rapidly normalized serum sodium levels, this therapy seems to be a promising treatment approach.
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Association of optic nerve sheath diameter measurement with hyponatremia in emergency department. Am J Emerg Med 2019; 37:1876-1879. [PMID: 30622006 DOI: 10.1016/j.ajem.2018.12.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/26/2018] [Accepted: 12/27/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Investigation of association of ONSD with hyponatremia in symptomatic patients. METHODS 89 patients who were diagnosed to have hyponatremia (Na + <135 mmol/L) were prospectively analyzed and compared with 72 patients who have normal serum sodium levels presented to ED at the same time interval. Subjects' demographic properties including age and sex were recorded, as were admission symptoms, serum Na + level, and pre-treatment and post-treatment optic nerve sheath diameter (ONSD). RESULTS The mean age of the study population was 62.3 ± 17.6 years, and the control group 55.1 ± 20.0 years (p < 0.05). There was a significant difference between the patient group's pre-treatment and post-treatment OSNDs compared to the controls (p < 0.05). There was a significant negative correlation between the admission sodium level and ONSD in the patient group (p < 0.05). In the pre-treatment period, patients with symptoms had a significantly greater mean ONSD than those without symptoms (0.546 ± 0.068 mm vs 0.448 ± 0.081 mm; p < 0.05). The area under the curve was 0.870; the cut-off level calculated for hyponatremia was 0.49 mm, which had a sensitivity of 81% and a specificity of 81.9%. CONCLUSION Ultrasonic imaging of ONSD measurement in the emergency department appears to reflect changes consistent with ICP changes in hyponatremia and change in serum sodium.
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Efthymiou C, Spyratos D, Kontakiotis T. Endocrine paraneoplastic syndromes in lung cancer. Hormones (Athens) 2018; 17:351-358. [PMID: 29968234 DOI: 10.1007/s42000-018-0046-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 03/04/2018] [Indexed: 12/25/2022]
Abstract
Paraneoplastic syndromes are defined as a combination of clinical disorders associated with malignant diseases that are caused by the secretion of various substances by the tumor without, however, being caused by the direct growth and infiltration of the primary tumor, or due to the development of distant metastases. Despite the fact that lung cancer represents the number one cause of death from cancer worldwide, the new methods of treatment increase patient survival and the incidence of paraneoplastic syndromes. The most important ones of these are humoral hypercalcemia of malignancy, syndrome of inappropriate antidiuretic hormone, hyponatremia of malignancy, ectopic Cushing's syndrome, carcinoid syndrome, and hypoglycemia and are usually a poor prognostic marker. Early diagnosis of those syndromes is achieved using specific criteria and may lead to early diagnosis of the underlying malignancy. It is essential to treat them with the overriding objective of improving the patients' quality of life.
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Affiliation(s)
- Christoforos Efthymiou
- Pulmonary Department, G. Papanikolaou Hospital, Aristotle University of Thessaloniki, Exohi, 570 10, Thessaloniki, Greece
| | - Dionisios Spyratos
- Pulmonary Department, G. Papanikolaou Hospital, Aristotle University of Thessaloniki, Exohi, 570 10, Thessaloniki, Greece.
| | - Theodore Kontakiotis
- Pulmonary Department, G. Papanikolaou Hospital, Aristotle University of Thessaloniki, Exohi, 570 10, Thessaloniki, Greece
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Rocha-Rivera HF, Javela-Rugeles JD, Barrios-Torres JC, Montalvo-Arce C, Tovar-Cardozo JH, Tejada-Perdomo JH. Incidence of postoperative hyponatremia in neurosurgical patients in a hospital in Southern Colombia. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2018. [DOI: 10.1097/cj9.0000000000000021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Al Mawed S, Pankratz VS, Chong K, Sandoval M, Roumelioti ME, Unruh M. Low serum sodium levels at hospital admission: Outcomes among 2.3 million hospitalized patients. PLoS One 2018; 13:e0194379. [PMID: 29566068 PMCID: PMC5864034 DOI: 10.1371/journal.pone.0194379] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 02/20/2018] [Indexed: 12/30/2022] Open
Abstract
Background Hyponatremia is the most common electrolyte disorder among hospitalized patients. Controversies still exist over the relationship between hyponatremia and outcomes of hospitalized patients. Methods To analyze the association of low serum sodium levels at hospital admission with in-hospital mortality and patient disposition and to compare the distribution of the risk of death associated with hyponatremia across the lifespan of hospitalized patients, we conducted an observational study of 2.3 million patients using data extracted from the Cerner Health Facts database between 2000 and 2014. Logistic regression models were used in the analyses. Results At hospital admission 14.4% of hospitalized patients had serum sodium levels [Na] <135 mEq/L. In adjusted multinomial logistic regression analysis, we found that the risk of in-hospital mortality significantly increases for [Na] levels < 135 or ≥143 to ≤145 mEq/L compared to the reference interval of 140 to <143 mEq/L (p<0.001). We observed similar trends for the relationship between [Na] levels and discharge to hospice or to a nursing facility. We demonstrated that younger age groups (18 to <45, 45 to <65) had a higher risk of in-hospital mortality compared to older age groups (65 to <75, ≥75) for [Na] levels <130 mEq/L or 143 to ≤145 mEq/L (p<0.001). Conclusions Hyponatremia is common among hospitalized patients and is significantly associated with in-hospital mortality, discharge to hospice or to a nursing facility. The risk of death and other outcomes was more evident for [Na] <135 mEq/L. The mortality associated with low [Na] was significantly higher in younger versus older patients.
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Affiliation(s)
- Saleem Al Mawed
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - V. Shane Pankratz
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - Kelly Chong
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - Matthew Sandoval
- University of New Mexico Clinical and Translational Science Center (CTSC), Albuquerque, New Mexico, United States of America
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - Mark Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
- * E-mail:
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Li B, Fang D, Qian C, Feng H, Wang Y. The Efficacy and Safety of Tolvaptan in Patients with Hyponatremia: A Meta-Analysis of Randomized Controlled Trials. Clin Drug Investig 2017; 37:327-342. [PMID: 27766511 DOI: 10.1007/s40261-016-0470-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND OBJECTIVES Comprehensive evaluations regarding the benefits of tolvaptan in the treatment of hyponatremia are lacking. The objective of this meta-analysis was to assess the efficacy and safety of tolvaptan in patients with hyponatremia. METHODS Pertinent studies were identified by searching PubMed, EMBASE, Web of Science, and the Cochrane Library for articles published between their respective inception dates and 31 April 2016. Summary relative risks (RRs) or weighted mean differences (WMDs) with their 95 % confidence intervals (CIs) were calculated using fixed-effects or randomized-effects models, depending on the degree of heterogeneity noted among the studies included in the analysis. RESULTS Eleven articles comprising 5209 patients were ultimately included in the analysis. Our pooled results showed that tolvaptan was more effective than control with respect to increasing serum sodium concentrations (WMD = 3.99 mEq/L), 95 % CI 2.80-5.19, Z = 6.56, P < 0.001), improving serum sodium correction rates (RR = 3.35, 95 % CI 1.93-5.82, Z = 4.31, P < 0.001), improving 24-h urine output (WMD = 987.64 mL, 95 % CI 850.71-1124.57, Z = 14.14, P < 0.001), and improving net fluid balance (WMD = 795.97 mL, 95 % CI 418.56-1173.38, Z = 4.13, P < 0.001). Tolvaptan treatment also resulted in increased incidences of adverse events compared with control treatment (RR = 1.05, 95 % CI 1.02-1.07, Z = 3.83, P < 0.001). These events included dry mouth (RR = 2.38, 95 % CI 1.41-4.04, Z = 3.23, P = 0.001), thirst (RR = 3.85, 95 % CI 1.96-7.57, Z = 3.92, P < 0.001), pollakiuria (RR = 2.47, 95 % CI 1.41-4.33, Z = 3.16, P = 0.002), and overly rapid hyponatremia correction (RR = 8.43, 95 % CI 1.06-66.96, Z = 2.02, P = 0.04). No significant differences in all-cause mortality (RR = 0.99, 95 % CI 0.90-1.10, Z = 0.17, P = 0.86), serious adverse event rate (RR = 1.01, 95 % CI 0.80-1.29, Z = 0.11, P = 0.92), systolic blood pressure (WMD = 0.1 mmHg, 95 % CI -1.04 to 1.23, Z = 0.17, P = 0.87), or heart rate (WMD = -0.16 bpm, 95 % CI -1.14 to 0.82, Z = 0.31, P = 0.76) were noted between the two groups, based on the results of our meta-analysis. CONCLUSION The results of this meta-analysis suggest that tolvaptan can increase serum sodium concentrations, serum sodium correction rates, 24-h urine output, net fluid balance, and total adverse event rates without significantly decreasing all-cause mortality rates or increasing serious adverse event rates in patients with hyponatremia.
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Affiliation(s)
- Benlei Li
- Department of Cardiology, Zhongnan Hospital of Wuhan University, No. 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Dong Fang
- Department of Cardiology, Zhongnan Hospital of Wuhan University, No. 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Cheng Qian
- Department of Cardiology, Zhongnan Hospital of Wuhan University, No. 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Hongliang Feng
- Department of Neurology, Zhongnan Hospital of Wuhan University, No. 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Yanggan Wang
- Department of Cardiology, Zhongnan Hospital of Wuhan University, No. 169 Donghu Road, Wuhan, 430071, Hubei, China.
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Aicale R, Tarantino D, Maffulli N. Prevalence of Hyponatremia in Elderly Patients with Hip Fractures: A Two-Year Study. Med Princ Pract 2017; 26:451-455. [PMID: 28810258 PMCID: PMC5757544 DOI: 10.1159/000480294] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 08/14/2017] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE This study investigated the prevalence of hyponatremia in elderly patients (≥65 years old) with hip fractures. SUBJECTS AND METHODS All records containing clinical and laboratory data on the 334 elderly patients admitted to the San Giovanni di Dio e Ruggi d'Aragona Hospital of Salerno, Italy, with hip fractures during 2014 and 2015, were retrieved from the hospital database. Patients were divided into 4 groups, according to their sex and the type of hip fracture. Sodium serum concentrations were retrieved from the medical records. Hyponatremia was defined as the presence of at least 1 episode of hyponatremia during the hospital stay. RESULTS Of 334 elderly patients, hyponatremia was found in 64 (19%). The prevalence of hyponatremia was 18% (28/157) for female patients with extracapsular proximal femoral fracture, 22% (17/79) for female patients with intracapsular proximal femoral fracture, 20% (12/60) for male patients with extracapsular proximal femoral fracture, and 18% (7/38) for male patients with intracapsular proximal femoral fracture. CONCLUSION There was a high prevalence of hyponatremia in the elderly patients with hip fractures. Hence, serum sodium concentrations should be regularly assessed to prevent occurrence of hyponatremia.
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Affiliation(s)
- Rocco Aicale
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Domiziano Tarantino
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Salerno, Italy
- Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Mile End Hospital, London, UK
- *Nicola Maffulli, MD, MS, PhD, FRCS (Orth), Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG (UK), E-Mail
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Edate S, Albanese A. Management of electrolyte and fluid disorders after brain surgery for pituitary/suprasellar tumours. Horm Res Paediatr 2016; 83:293-301. [PMID: 25677941 DOI: 10.1159/000370065] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 11/24/2014] [Indexed: 11/19/2022] Open
Abstract
Disturbances in salt and water balances are relatively common in children after brain surgeries for suprasellar and pituitary tumours, presenting diagnostic and therapeutic challenges. Although hypernatraemia associated with central diabetes insipidus is commonly encountered, it is hyponatraemia (HN) that poses more of a diagnostic dilemma. The main differential diagnoses causing HN are the syndrome of inappropriate antidiuretic hormone secretion, marked by inappropriate retention of water, and cerebral salt wasting, characterized by polyuria and natriuresis. Diagnosis and management can be even more difficult when these conditions precede or coexist with each other. These diagnostic and therapeutic dilemmas are discussed in detail in this review.
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Affiliation(s)
- Sujata Edate
- Paediatric Endocrinology Unit, St. George's Hospital, London, UK
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Singh A, Kamal R, Mudiam MKR, Gupta MK, Satyanarayana GNV, Bihari V, Shukla N, Khan AH, Kesavachandran CN. Heat and PAHs Emissions in Indoor Kitchen Air and Its Impact on Kidney Dysfunctions among Kitchen Workers in Lucknow, North India. PLoS One 2016; 11:e0148641. [PMID: 26871707 PMCID: PMC4752274 DOI: 10.1371/journal.pone.0148641] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 01/20/2016] [Indexed: 01/06/2023] Open
Abstract
Indoor air quality and heat exposure have become an important occupational health and safety concern in several workplaces including kitchens of hotels. This study investigated the heat, particulate matter (PM), total volatile organic compounds (TVOCs) and polycyclic aromatic hydrocarbons (PAHs) emissions in indoor air of commercial kitchen and its association with kidney dysfunctions among kitchen workers. A cross sectional study was conducted on 94 kitchen workers employed at commercial kitchen in Lucknow city, North India. A questionnaire-based survey was conducted to collect the personal and occupational history of the kitchen workers. The urine analysis for specific gravity and microalbuminuria was conducted among the study subjects. Indoor air temperature, humidity, wet/ dry bulb temperature and humidex heat stress was monitored during cooking activities at the kitchen. Particulate matter (PM) for 1 and 2.5 microns were monitored in kitchen during working hours using Hazdust. PAHS in indoor air was analysed using UHPLC. Urinary hydroxy-PAHs in kitchen workers were measured using GC/MS-MS. Higher indoor air temperature, relative humidity, PM1 and PM2.5 (p<0.001) was observed in the kitchen due to cooking process. Indoor air PAHs identified are Napthalene, fluorine, acenaphthene, phenanthrene, pyrene, chrysene and indeno [1,2,3-cd) pyrene. Concentrations of all PAHs identified in kitchen were above the permissible OSHA norms for indoor air. Specific gravity of urine was significantly higher among the kitchen workers (p<0.001) as compared to the control group. Also, the prevalence of microalbuminuria was higher (p<0.001) among kitchen workers. Urinary PAH metabolites detected among kitchen workers were 1-NAP, 9-HF, 3-HF, 9-PHN and 1-OHP. Continuous heat exposure in kitchens due to cooking can alter kidney functions viz., high specific gravity of urine in kitchen workers. Exposure to PM, VOCs and PAHs in indoor air and presence of urinary PAHs metabolites may lead to inflammation, which can cause microalbuminuria in kitchen workers, as observed in the present study.
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Affiliation(s)
- Amarnath Singh
- Epidemiology Division, CSIR-Indian Institute of Toxicology Research, PB No 80, MG Marg, Lucknow, 226001, U.P, India
- Department of Biochemistry, Babu Banarasi Das University, BBD City, Faizabad Road, Lucknow, Uttar Pradesh - 226 028, U.P, India
| | - Ritul Kamal
- Epidemiology Division, CSIR-Indian Institute of Toxicology Research, PB No 80, MG Marg, Lucknow, 226001, U.P, India
| | - Mohana Krishna Reddy Mudiam
- Analytical Chemistry Division, CSIR-Indian Institute of Toxicology Research, PB No 80, MG Marg, Lucknow, 226001, U.P, India
| | - Manoj Kumar Gupta
- Analytical Chemistry Division, CSIR-Indian Institute of Toxicology Research, PB No 80, MG Marg, Lucknow, 226001, U.P, India
| | | | - Vipin Bihari
- Epidemiology Division, CSIR-Indian Institute of Toxicology Research, PB No 80, MG Marg, Lucknow, 226001, U.P, India
| | - Nishi Shukla
- Environment Monitoring Division, CSIR-Indian Institute of Toxicology Research, PB No 80, MG Marg, Lucknow, 226001, U.P, India
| | - Altaf Hussain Khan
- Environment Monitoring Division, CSIR-Indian Institute of Toxicology Research, PB No 80, MG Marg, Lucknow, 226001, U.P, India
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Geoghegan P, Harrison AM, Thongprayoon C, Kashyap R, Ahmed A, Dong Y, Rabinstein AA, Kashani KB, Gajic O. Sodium Correction Practice and Clinical Outcomes in Profound Hyponatremia. Mayo Clin Proc 2015; 90:1348-55. [PMID: 26434962 DOI: 10.1016/j.mayocp.2015.07.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 07/16/2015] [Accepted: 07/20/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To assess the epidemiology of nonoptimal hyponatremia correction and to identify associated morbidity and in-hospital mortality. PATIENTS AND METHODS An electronic medical record search identified all patients admitted with profound hyponatremia (sodium <120 mmol/L) from January 1, 2008, through December 31, 2012. Patients were classified as having optimally or nonoptimally corrected hyponatremia at 24 hours after admission. Optimal correction was defined as sodium correction in 24 hours of 6 through 10 mmol/L. We investigated the association between sodium correction and demographic and outcome variables, including occurrence of osmotic demyelination syndrome (ODS). Baseline characteristics by correction outcome categories were compared using the Kruskal-Wallis test for continuous variables and the χ(2) test for categorical variables. Odds ratios for in-hospital mortality between groups were assessed using logistic regression. Adjusted differences in hospital length of stay (LOS) and intensive care unit (ICU) LOS were assessed using the Dunnett 2-tailed t test. RESULTS A total of 412 patients satisfied inclusion criteria of whom 174 (42.2%) were admitted to the ICU. A total of 211 (51.2%) had optimal correction of their hyponatremia at 24 hours, 87 (21.1%) had undercorrected hyponatremia, and 114 (27.9%) had overcorrected hyponatremia. Both patient factors and treatment factors were associated with nonoptimal correction. There was a single case of ODS. Overcorrection was not associated with in-hospital mortality or ICU LOS. When adjusted for patient factors, undercorrection of profound hyponatremia was associated with an increase in hospital LOS (9.3 days; 95% CI, 1.9-16.7 days). CONCLUSION Nonoptimal correction of profound hyponatremia is common. Fortunately, nonoptimal correction is associated with serious morbidity only infrequently.
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Affiliation(s)
- Pierce Geoghegan
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN.
| | - Andrew M Harrison
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Medical Scientist Training Program, Mayo Clinic, Rochester, MN
| | - Charat Thongprayoon
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN
| | - Rahul Kashyap
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Adil Ahmed
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Wichita Falls Family Practice Residency Program, North Central Texas Medical Foundation, Wichita Falls
| | - Yue Dong
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Alejandro A Rabinstein
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Department of Neurology, Mayo Clinic, Rochester, MN
| | - Kianoush B Kashani
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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Wiggins A, Balasubramanian T, Ferraro A. Hyponatraemia and confusion in a 70-year-old female when bupropion was added to dothiepin and escitalopram. Australas Psychiatry 2015; 23:507-9. [PMID: 26405241 DOI: 10.1177/1039856215597534] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Hyponatraemia secondary to syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a well-recorded adverse event observed in elderly patients on antidepressant treatment. Bupropion is an antidepressant agent usually reserved as an augmentation strategy for treatment-resistant depression. While hyponatraemia is not a documented side effect of bupropion, there are a few cases outside of Australia reported in the literature. We report on a case of hyponatraemia observed on bupropion initiation in a 70-year-old female patient with treatment-resistant depression. We present a discussion of the possible mechanism of action for the hyponatraemia observed in our case and prior reported cases. CONCLUSIONS Our case and review of the available literature highlights the dangers of polypharmacy in the management of treatment-resistant depression. Our findings suggest that the association of hyponatraemia with bupropion in our and subsequent cases was likely the result of medication interaction and not a direct side effect of bupropion. Where bupropion is being used as an augmenting agent in the treatment of depression we would suggest checking of serum sodium prior to commencement of bupropion, and monitoring thereafter. This is especially important in elderly patients where other risk factors for hyponatraemia are likely to be present.
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Affiliation(s)
- Aaron Wiggins
- Psychiatry Registrar, North West Area Mental Health Service, Melbourne Health, Parkville, VIC, Australia
| | | | - Angelo Ferraro
- Old Age Psychiatrist, North West Aged Persons Mental Health Program, Melbourne Health, Broadmeadows, VIC, Australia
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Synthesis and biological evaluation of novel phenothiazine derivatives as non-peptide arginine vasopressin V2 receptor antagonists. CHINESE CHEM LETT 2015. [DOI: 10.1016/j.cclet.2015.01.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Geoghegan P, Koch CD, Wockenfus AM, Harrison AM, Dong Y, Kashani KB, Karon BS. Agreement between whole blood and plasma sodium measurements in profound hyponatremia. Clin Biochem 2015; 48:525-8. [PMID: 25773258 DOI: 10.1016/j.clinbiochem.2015.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 03/02/2015] [Accepted: 03/03/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We compared two different methods of whole blood sodium measurement to plasma sodium measurement using samples in the profoundly hyponatremic range (Na < 120 mmol/L). DESIGN AND METHODS Whole blood pools with a range of low sodium values were generated using combinations and dilutions of pooled electrolyte-balanced lithium heparin samples submitted for arterial blood gas analysis. Each pool was analyzed five times on a Radiometer 827 blood gas analyzer and iSTAT analyzer. Pools were centrifuged to produce plasma, which was analyzed five times on a Roche Cobas c501 chemistry analyzer. An additional 40 fresh (analyzed on day of collection) excess lithium heparin arterial blood gas samples from 36 patients were analyzed on the Radiometer 827, iSTAT, and Cobas c501 as described above. The setting was a tertiary referral center. Blood samples were collected from a combination of patients in the intensive care unit, operating theaters and emergency room. RESULTS All methods demonstrated excellent precision, even in the profoundly hyponatremic measurement range (Na < 120 mmol/L using a plasma reference method). However, agreement between the methods varied with the degree of hyponatremia. In the profoundly hyponatremic range, Radiometer whole blood sodium values were nearly identical to plasma reference sodium, while iSTAT whole blood sodium showed a consistent positive bias relative to plasma sodium in this range. CONCLUSION If whole blood direct sodium measurements are compared with plasma sodium in profoundly hyponatremic patients consideration should be given to the use of Radiometer blood gas analyzers over iSTAT since the latter shows a positive bias relative to a plasma comparative method.
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Affiliation(s)
- Pierce Geoghegan
- Department of Anaesthesia and Critical Care, Tallaght Hospital, Dublin, Ireland; Multidisciplinary Epidemiology and Translational Research in Intensive Care (M.E.T.R.I.C.), Mayo Clinic, Rochester, MN, USA.
| | - Christopher D Koch
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Amy M Wockenfus
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Andrew M Harrison
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (M.E.T.R.I.C.), Mayo Clinic, Rochester, MN, USA; Medical Scientist Training Program, Mayo Clinic, Rochester, MN, USA
| | - Yue Dong
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (M.E.T.R.I.C.), Mayo Clinic, Rochester, MN, USA; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (M.E.T.R.I.C.), Mayo Clinic, Rochester, MN, USA; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Brad S Karon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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O'Connell JB, Alemayehu A. Hyponatremia, Heart Failure, and the Role of Tolvaptan. Postgrad Med 2015; 124:29-39. [DOI: 10.3810/pgm.2012.03.2534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Prevalence of hyponatremia in femur neck fractures: a one-year survey in an urban emergency department. Adv Orthop 2014; 2014:397059. [PMID: 25298896 PMCID: PMC4179951 DOI: 10.1155/2014/397059] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/26/2014] [Accepted: 09/02/2014] [Indexed: 01/16/2023] Open
Abstract
This study was aimed at investigating the prevalence of hyponatremia in patients with intracapsular femoral neck fracture. All records containing clinical and laboratory information of patients admitted with femoral neck fractures to the Academic Hospital of Parma (Italy) during the year 2013 were retrieved from the hospital database. The control population consisted of subjects admitted to the outpatient phlebotomy center during the same period. The final population consisted of 543 patients with femoral neck fractures and 700 outpatients. The category of elderly subjects (i.e., ≥65 years) included 491 patients and 380 controls. In both the entire population and elderly subjects, serum sodium was lower in patients than in controls (138 versus 139 mmol/L, P < 0.001). The prevalence of hyponatremia was also higher in cases than in controls, both in the entire population (19.5 versus 10.4%, P < 0.001) and in elderly subjects (20.8 versus 11.8%, P < 0.001). The odds ratio of hyponatremia for femoral neck fracture was 2.08 in the entire study population and 1.95 in those aged 65 years and older. In conclusion, we found that hyponatremia is significantly associated with femoral neck fracture. Serum sodium should hence be regularly assessed and hyponatremia eventually corrected.
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Spano SJ, Reagle Z, Evans T. In Reply to Symptomatic Hypotonic Hyponatremia Presenting at High Altitude. Wilderness Environ Med 2014; 25:363-4. [DOI: 10.1016/j.wem.2014.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 03/05/2014] [Indexed: 10/25/2022]
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Abstract
Hyponatremia is a common and often under-recogonised clinical problem in oncologic practice. The recogonition of the cause of hyponatremia and initiation of appropriate and timely intervention can prevent morbidity and improve treatment tolerance. This drug review aims at discussing the currently approved oral vaptanagent Tolvaptan. Vaptans including Tolvaptan act as "aquaretic" agents cousing excretion of water while retaining the sodium. Administration of this agent for prescribed periods result in improvement of serum sodium levels. The drug can be used in many clinical situations resulting in hyponatremia including congestive heart failure, cirrhosis and syndrome of inappropriate ADH secretion (SIADH) including SIADH related to malignancies.
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Affiliation(s)
- Bharath Rangarajan
- Department of Medical Oncology, Mazumdar Shaw Cancer Center, Bengaluru, Karnataka, India
| | - Vineetha Binoy
- Department of Medical Oncology, Mazumdar Shaw Cancer Center, Bengaluru, Karnataka, India
| | | | - Vanita Noronha
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
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Kanaji N, Watanabe N, Kita N, Bandoh S, Tadokoro A, Ishii T, Dobashi H, Matsunaga T. Paraneoplastic syndromes associated with lung cancer. World J Clin Oncol 2014; 5:197-223. [PMID: 25114839 PMCID: PMC4127595 DOI: 10.5306/wjco.v5.i3.197] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 04/12/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Paraneoplastic syndromes are signs or symptoms that occur as a result of organ or tissue damage at locations remote from the site of the primary tumor or metastases. Paraneoplastic syndromes associated with lung cancer can impair various organ functions and include neurologic, endocrine, dermatologic, rheumatologic, hematologic, and ophthalmological syndromes, as well as glomerulopathy and coagulopathy (Trousseau’s syndrome). The histological type of lung cancer is generally dependent on the associated syndrome, the two most common of which are humoral hypercalcemia of malignancy in squamous cell carcinoma and the syndrome of inappropriate antidiuretic hormone secretion in small cell lung cancer. The symptoms often precede the diagnosis of the associated lung cancer, especially when the symptoms are neurologic or dermatologic. The proposed mechanisms of paraneoplastic processes include the aberrant release of humoral mediators, such as hormones and hormone-like peptides, cytokines, and antibodies. Treating the underlying cancer is generally the most effective therapy for paraneoplastic syndromes, and treatment soon after symptom onset appears to offer the best potential for symptom improvement. In this article, we review the diagnosis, potential mechanisms, and treatments of a wide variety of paraneoplastic syndromes associated with lung cancer.
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20
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Smith CD, Robert S. 'Designer drugs': update on the management of novel psychoactive substance misuse in the acute care setting. Clin Med (Lond) 2014; 14:409-15. [PMID: 25099844 PMCID: PMC4952836 DOI: 10.7861/clinmedicine.14-4-409] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The use of novel psychoactive substances ('legal highs' or 'designer drugs') is increasing worldwide. Patients misusing such substances have been reported to experience severe or prolonged side effects requiring admission to acute or critical care wards. These complications can be life threatening if misdiagnosed or mismanaged. As physicians have traditionally had less involvement with the management of such patients compared with their colleagues in emergency departments an update in the management of such patients is indicated. Here we present a summary of the management of those novel substances with the potential for serious complications based on a review of current literature.
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Affiliation(s)
- Christopher D Smith
- Accident and Emergency Department, Whipps Cross Hospital, Barts Health NHS Trust, London, UK
| | - Stefanie Robert
- Homerton University Hospital NHS Foundation Trust, London, UK
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Abstract
Hyponatremia can be challenging to manage, especially in older adults. Acute severe hyponatremia can cause significant morbidity and mortality, but too-rapid reversal of chronic hyponatremia can cause serious neurologic issues or death. This article reviews the causes, presentations, and management of hyponatremia in adults.
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Harrington C, Grossman J, Richman K. Psychogenic adipsia presenting as acute kidney injury: case report and review of disorders of sodium and water metabolism in psychiatric illness. PSYCHOSOMATICS 2014; 55:289-295. [PMID: 24012289 DOI: 10.1016/j.psym.2013.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 06/14/2013] [Accepted: 06/17/2013] [Indexed: 06/02/2023]
Affiliation(s)
- Colin Harrington
- Department of Psychiatry, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI.
| | - Joseph Grossman
- Department of Medicine, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Katherine Richman
- Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
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Symptomatic Hypotonic Hyponatremia Presenting at High Altitude. Wilderness Environ Med 2014; 25:69-74. [DOI: 10.1016/j.wem.2013.09.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 06/13/2013] [Accepted: 09/19/2013] [Indexed: 10/25/2022]
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Dasta JF, Chiong JR, Christian R, Friend K, Lingohr-Smith M, Lin J, Cassidy IB. Update on tolvaptan for the treatment of hyponatremia. Expert Rev Pharmacoecon Outcomes Res 2014; 12:399-410. [DOI: 10.1586/erp.12.30] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Neurologic complications of electrolyte disturbances and acid-base balance. HANDBOOK OF CLINICAL NEUROLOGY 2014; 119:365-82. [PMID: 24365306 DOI: 10.1016/b978-0-7020-4086-3.00023-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Electrolyte and acid-base disturbances are common occurrences in daily clinical practice. Although these abnormalities can be readily ascertained from routine laboratory findings, only specific clinical correlates may attest as to their significance. Among a wide phenotypic spectrum, acute electrolyte and acid-base disturbances may affect the peripheral nervous system as arreflexic weakness (hypermagnesemia, hyperkalemia, and hypophosphatemia), the central nervous system as epileptic encephalopathies (hypomagnesemia, dysnatremias, and hypocalcemia), or both as a mixture of encephalopathy and weakness or paresthesias (hypocalcemia, alkalosis). Disabling complications may develop not only when these derangements are overlooked and left untreated (e.g., visual loss from intracranial hypertension in respiratory or metabolic acidosis; quadriplegia with respiratory insufficiency in hypermagnesemia) but also when they are inappropriately managed (e.g., central pontine myelinolisis when rapidly correcting hyponatremia; cardiac arrhythmias when aggressively correcting hypo- or hyperkalemia). Therefore prompt identification of the specific neurometabolic syndromes is critical to correct the causative electrolyte or acid-base disturbances and prevent permanent central or peripheral nervous system injury. This chapter reviews the pathophysiology, clinical investigations, clinical phenotypes, and current management strategies in disorders resulting from alterations in the plasma concentration of sodium, potassium, calcium, magnesium, and phosphorus as well as from acidemia and alkalemia.
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Hussain NS, Piper M, Ludlam WG, Ludlam WH, Fuller CJ, Mayberg MR. Delayed postoperative hyponatremia after transsphenoidal surgery: prevalence and associated factors. J Neurosurg 2013; 119:1453-60. [DOI: 10.3171/2013.8.jns13411] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Transient delayed postoperative hyponatremia (DPH) after transsphenoidal surgery (TSS) is common and can have potentially devastating consequences. However, the true prevalence of transient symptomatic and asymptomatic DPH has not been studied in a large patient cohort with close and accurate follow-up.
Methods
A retrospective analysis of a single-institution prospective database was conducted; all patients undergoing TSS for lesions involving the pituitary gland were followed up in a multidisciplinary neuroendocrine clinic, and demographic, imaging, and clinical data were prospectively collected. Patients were examined preoperatively and followed up postoperatively in a standardized fashion, and their postoperative sodium levels were measured at Weeks 1 and 2 postoperatively. Levels of hyponatremia were rated as mild (serum sodium concentration 130–134 mEq/L), moderate (125–129 mEq/L), or severe (< 125 mEq/L). Routine clinical questionnaires were administered at all postoperative office visits. Postoperative hyponatremia was analyzed for correlations with demographic and clinical features and with immediate postoperative physiological characteristics.
Results
Over a 4-year interval, 373 procedures were performed in 339 patients who underwent TSS for sellar and parasellar lesions involving the pituitary gland. The mean (± SD) age of patients was 48 ± 18 years; 61.3% of the patients were female and 46.1% were obese (defined as a body mass index [BMI] ≥ 30). The overall prevalence of DPH within the first 30 days postoperatively was 15.0%; 7.2% of the patients had mild, 3.8% moderate, and 3.8% severe hyponatremia. The incidence of symptomatic hyponatremia requiring hospitalization was 6.4%. The Fisher exact test detected a statistically significant association of DPH with female sex (p = 0.027) and a low BMI (p = 0.001). Spearman rank correlation detected a statistically significant association between BMI and nadir serum sodium concentration (r = 0.158, p = 0.002) and an inverse association for age (r = −0.113, p = 0.031). Multivariate analyses revealed a positive correlation between postoperative hyponatremia and a low BMI and a trend toward association with age; there were no associations between other preoperative demographic or perioperative risk factors, including immediate postoperative alterations in serum sodium concentration. Patients were treated with standardized protocols for hyponatremia, and DPH was not associated with permanent morbidity or mortality.
Conclusions
Delayed postoperative hyponatremia was a common result of TSS; a low BMI was the only clear predictor of which patients will develop DPH. Alterations in immediate postoperative sodium levels did not predict DPH. Therefore, an appropriate index of suspicion and close postoperative monitoring of serum sodium concentration should be maintained for these patients, and an appropriate treatment should be undertaken when hyponatremia is identified.
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Affiliation(s)
- Namath S. Hussain
- 1Seattle Pituitary Center, Swedish Neuroscience Institute, Seattle, Washington; and
| | - Mackenzie Piper
- 1Seattle Pituitary Center, Swedish Neuroscience Institute, Seattle, Washington; and
| | - W. Grant Ludlam
- 1Seattle Pituitary Center, Swedish Neuroscience Institute, Seattle, Washington; and
| | | | - Cindy J. Fuller
- 1Seattle Pituitary Center, Swedish Neuroscience Institute, Seattle, Washington; and
| | - Marc R. Mayberg
- 1Seattle Pituitary Center, Swedish Neuroscience Institute, Seattle, Washington; and
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Pharmacokinetics of intravenous conivaptan in subjects with hepatic or renal impairment. Clin Pharmacokinet 2013; 52:385-95. [PMID: 23456393 DOI: 10.1007/s40262-013-0047-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Conivaptan is a non-peptide dual antagonist of vasopressin V1A and V2 receptors that is approved in the United States as an intravenous formulation for the treatment of euvolemic and hypervolemic hyponatremia in hospitalized patients. The pharmacokinetics of intravenous conivaptan had not been studied in patients with hepatic or renal impairment. OBJECTIVE The objective of this study was to assess the pharmacokinetics and tolerability of intravenous conivaptan in subjects with mild or moderate hepatic or renal impairment compared with subjects with normal function. STUDY DESIGN These studies were phase I, open-label pharmacokinetic studies conducted at two sites in the US. PATIENTS Men and non-pregnant women 30-70 years of age were allocated to the mild (Child-Pugh classification score of 5-6) or moderate (Child-Pugh classification score of 7-9) hepatically impaired groups (n = 8-9 per group) based on their liver function assessed at screening. For the renal study, men and non-pregnant women between 18 and 70 years of age were assigned to renal function groups (n = 8-9 per group) based on estimated glomerular filtration rate (eGFR) assessed at screening. Normal renal function was defined as an eGFR >80 ml/min, mild renal impairment as 50-80 ml/min, and moderate renal impairment as 30-49 ml/min. Subjects with normal hepatic or renal function were selected to match the race, sex, age, and body mass index of subjects enrolled in the impaired groups. INTERVENTION Subjects were administered a 20-mg/30-min intravenous loading dose of conivaptan on day 1, followed by a 20-mg/23.5-h continuous conivaptan infusion. On day 2, immediately following the end of the day 1 infusion, a 20-mg/24-h continuous conivaptan infusion was administered. MAIN OUTCOME MEASURE Primary pharmacokinetic parameters estimated were the area under the plasma conivaptan concentration-time curve from time 0 to infinity (AUC∞), plasma conivaptan concentrations at the end of the 20-mg loading dose (C LD), and plasma conivaptan concentrations at the end of the second day 20-mg/24-h continuous infusion (C 48). RESULTS For each of C LD, C 48, and AUC∞, the mean values were similar for subjects with mild hepatic impairment and subjects with normal hepatic function. Subjects with moderate hepatic impairment had a 73 % higher C 48 and an 80 % higher AUC∞ compared with subjects with normal hepatic function. There were no clinically relevant changes in conivaptan exposure in the mild and moderate renal impairment groups compared with subjects with normal renal function. Intravenous conivaptan was generally well tolerated in subjects with mild or moderate hepatic or renal impairment. Infusion-site reaction was the most commonly reported adverse event. CONCLUSION Overall exposure to conivaptan increased in subjects with moderate hepatic impairment compared with subjects with normal hepatic function. Therefore, in patients with moderate hepatic impairment, conivaptan should be initiated with a loading dose of 10 mg over 30 min followed by 10 mg per day as a continuous infusion for 2-4 days, which is half the approved dose. No dose adjustment is necessary in patients with mild or moderate renal impairment and in patients with mild hepatic impairment.
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Abstract
Arginine vasopressin (AVP) plays an important role in water and sodium homeostasis. It acts via three receptor subtypes-V1a, V1b, and V2-distributed widely throughout the body. Vaptans are nonpeptide vasopressin receptor antagonists (VRA). By property of aquaresis, VRAs offer a novel therapy of water retention. Conivaptan is a V1a/V2 nonselective VRA approved for euvolemic and hypervolemic hyponatremia. Tolvaptan is the first oral VRA. Other potential uses of this new class of drugs include congestive heart failure (CHF), cirrhosis of liver, syndrome of inappropriate secretion of antidiuretic hormone, polycystic kidney disease, and so on. These novel drugs score over diuretics as they are not associated with electrolyte abnormalities. Though much remains to be elucidated before the VRAs are applied clinically, the future holds much promise.
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Affiliation(s)
- Suruchi Aditya
- Department of Pharmacology, Dr. Harvansh Singh Judge Institute of Dental Sciences, Chandigarh, India
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Outcome and frequency of sodium disturbances in neurocritically ill patients. Acta Neurol Belg 2013; 113:139-45. [PMID: 23055112 DOI: 10.1007/s13760-012-0137-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 09/13/2012] [Indexed: 10/27/2022]
Abstract
Sodium disturbances are frequent and serious complications in neurocritically ill patients. Hyponatremia is more common than hypernatremia, which is, however, prognostically worse. The aim of this study was to analyse outcome and frequency of sodium disturbances in relation to measured serum osmolality in neurologic-neurosurgical critically ill patients. A 5-year retrospective collection of patients (pts) and laboratory data were made from the Laboratory Information System database in the Clinical Biochemistry Department. The criteria for patients' inclusion was acute brain disease and serum sodium (SNa(+)) <135 mmol/l (hyponatremia) or SNa(+) >150 mmol/l (hypernatremia). Hypoosmolality was defined as measured serum osmolality (SOsm) <275 mmol/kg, hyperosmolality as SOsm >295 mmol/kg. We performed analysis of differences between hyponatremia and hypernatremia and subanalysis of differences between hypoosmolal hyponatremia and hypernatremia. From 1,440 pts with acute brain diseases there were 251 (17 %) pts with hyponatremia (mean SNa(+) 131.78 ± 2.89 mmol/l, SOsm 279.46 ± 11.84 mmol/kg) and 75 (5 %) pts with hypernatremia (mean SNa(+) 154.38 ± 3.76 mmol/l, SOsm 326.07 ± 15.93 mmol/kg). Hypoosmolal hyponatremia occurred in 50 (20 % of hyponatremic patients) pts (mean SNa(+) 129.62 ± 4.15 mmol/l; mean SOsm 267.35 ± 6.28 mmol/kg). Multiple logistic regression analysis showed that hypernatremia is a significant predictor of mortality during neurologic-neurosurgical intensive care unit (NNICU) stay (OR 5.3, p = 0.002) but not a predictor of bad outcome upon discharge from NNICU, defined as Glasgow Coma Scale 1-3. These results showed that hypernatremia occurred less frequently than all hyponatremias, but more often than hypoosmolal hyponatremia. Hypernatremia was shown to be a significant predictor of NNICU mortality compared to hyponatremia.
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Sakaida I, Yamashita S, Kobayashi T, Komatsu M, Sakai T, Komorizono Y, Okada M, Okita K. Efficacy and safety of a 14-day administration of tolvaptan in the treatment of patients with ascites in hepatic oedema. J Int Med Res 2013; 41:835-47. [PMID: 23685892 DOI: 10.1177/0300060513480089] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To investigate the efficacy and safety of 14 days' orally administered tolvaptan as adjunctive treatment for hepatic oedema in Japanese liver cirrhosis patients with insufficient response to conventional diuretics, with the option to increase dose in those who did not respond initially. METHODS This multicentre, single-arm, phase 3 study allocated patients with liver cirrhosis and persistent ascites to 7-day treatment with 7.5 mg/day tolvaptan followed by an additional 7 days' treatment. Responders at day 7 (achieving ≥ 1 kg body-weight reduction) continued on 7.5 mg/day tolvaptan; nonresponders (<1 kg body-weight reduction) received 15 mg/day tolvaptan. Conventional diuretic treatment continued throughout. The primary endpoint was change in body weight from baseline, as a marker of ascites volume. RESULTS A total of 51 patients received 7.5 mg/day tolvaptan for 7 days, which caused a significant reduction in mean body weight (55% response rate). During the second 7-day treatment period, 30 patients received 7.5 mg/day tolvaptan and 13 patients received tolvaptan 15 mg/day: response rates were 43% and 23%, respectively. Two serious adverse events were observed. Serum sodium was within normal range. CONCLUSIONS Tolvaptan therapy for 14 days (with possible dose increase as necessary), in combination with conventional diuretics, effectively reduced body weight in patients with hepatic oedema.
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Affiliation(s)
- Isao Sakaida
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan.
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Ost DE, Jim Yeung SC, Tanoue LT, Gould MK. Clinical and organizational factors in the initial evaluation of patients with lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e121S-e141S. [PMID: 23649435 PMCID: PMC4694609 DOI: 10.1378/chest.12-2352] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 11/30/2012] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND This guideline is intended to provide an evidence-based approach to the initial evaluation of patients with known or suspected lung cancer. It also includes an assessment of the impact of timeliness of care and multidisciplinary teams on outcome. METHODS The applicable current medical literature was identified by a computerized search and evaluated using standardized methods. Recommendations were framed using the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians. Data sources included MEDLINE and the Cochrane Database of Systematic Reviews. RESULTS Initial evaluation should include a thorough history and physical examination; CT imaging; pulmonary function tests; and hemoglobin, electrolyte, liver function, and calcium levels. Additional testing for distant metastases and paraneoplastic syndromes should be determined on the basis of these results. Paraneoplastic syndromes may have an adverse impact on cancer treatment, so they should be controlled rapidly with the goal of proceeding with definitive cancer treatment in a timely manner. Although the relationship between timeliness of care and survival is difficult to quantify, efforts to deliver timely care are reasonable and should be balanced with the need to attend to other dimensions of health-care quality (eg, safety, effectiveness, efficiency, equality, consistency with patient values and preferences). Quality care will require multiple disciplines. Although it is difficult to assess the impact, we suggest that a multidisciplinary team approach to care be used, particularly for patients requiring multimodality therapy. CONCLUSIONS The initial evaluation of patients with lung cancer should include a thorough history and physical examination, pulmonary function tests, CT imaging, basic laboratory tests, and selective testing for distant metastases and paraneoplastic syndromes.
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Affiliation(s)
- David E Ost
- Department of Pulmonary Medicine, MD Anderson Cancer Center, The University of Texas, Houston, TX.
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, MD Anderson Cancer Center, The University of Texas, Houston, TX; Department of Endocrine, Neoplasia & Hormonal Disorders, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Lynn T Tanoue
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, Yale University, New Haven, CT
| | - Michael K Gould
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
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AlZahrani A, Sinnert R, Gernsheimer J. Acute kidney injury, sodium disorders, and hypercalcemia in the aging kidney: diagnostic and therapeutic management strategies in emergency medicine. Clin Geriatr Med 2013. [PMID: 23177611 DOI: 10.1016/j.cger.2012.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This article summarizes the current literature regarding the structural and functional changes of the aging kidney and describes how these changes make the older patient more susceptible to acute kidney injury and fluid and electrolyte disorders. It discusses the clinical manifestations, evaluation, and management of hyponatremia and shows how the management of hypernatremia in geriatric patients involves addressing the underlying cause and safely correcting the hypernatremia. The current literature regarding evaluation and management of hypercalcemia in older patients is summarized. The management of severe hypercalcemia is discussed in detail. The evaluation and management of acute kidney injury is described.
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Affiliation(s)
- Abdullah AlZahrani
- Department of Emergency Medicine, SUNY Downstate College of Medicine, Brooklyn, NY 11203, USA
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Deitelzweig S, Amin A, Christian R, Friend K, Lin J, Lowe TJ. Health care utilization, costs, and readmission rates associated with hyponatremia. Hosp Pract (1995) 2013; 41:89-95. [PMID: 23466971 DOI: 10.3810/hp.2013.02.1014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
PURPOSE Hyponatremia is associated with higher morbidity and mortality rates among hospitalized patients. Our study evaluated health care utilization and associated costs of patients hospitalized with a primary diagnosis of hyponatremia. METHODS Hospitalized patients with a primary discharge diagnosis of hyponatremia (aged ≥ 18 years) were identified from the Premier Perspective™ database (January 1, 2007-March 31, 2010) and matched to non-hyponatremic (non-HN) patients using a combination of exact patient characteristic matching and propensity score matching. Univariate and multivariate statistics were used to compare hospital resource usage, costs, and 30-day readmission rates between cohorts. RESULTS Hospital length of stay (LOS) (± standard deviation) (3.78 ± 3.19 vs 3.54 ± 3.26 days; P < 0.001) and cost ($5396 ± $6500 vs $4979 ± $6152; P < 0.001 for the hyponatremic [HN] and non-HN patient cohorts, respectively) were greater for the HN cohort, but intensive care unit (ICU) costs ($3554 ± $6463 vs $3484 ± $8510; P = 0.828) and ICU LOS (2.37 ± 3.47 vs 2.52 ± 3.87; P = 0.345) did not differ between cohorts. The ICU admission rate (7.9% vs 4.4%; P < 0.001), as well as the 30-day readmission rate (12.1% vs 2.9%; P < 0.001) were greater for the HN cohort. After adjustment for key patient characteristics, hyponatremia was associated with a 7.6% increase in hospital LOS, an 8.9% increase in hospital costs, and a 9% increase in ICU costs. Hyponatremia was associated with an increased risk of ICU admission (odds ratio, 1.89, confidence limits, 1.72, 2.07; P < 0.001) and 30-day hospital readmission for hyponatremia (odds ratio, 4.76; confidence limits, 4.31, 5.26; P < 0.001). CONCLUSION Compared with non-HN patients, patients with a primary diagnosis of hyponatremia use a greater amount of hospital resources and represent a challenge to hospital profitability due to the increased likelihood of 30-day readmission.
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Yanagawa Y, Jo T, Yoshihara T, Kato H. A patient with demyelination, laminar cortical necrosis, and rhabdomyolysis associated with hypernatremia. Am J Emerg Med 2013; 31:269.e3-5. [DOI: 10.1016/j.ajem.2012.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 04/28/2012] [Indexed: 10/28/2022] Open
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Abraham WT, Hensen J, Gross PA, Bichet DG, Josiassen RC, Chafekar DS, Orlandi C. Lixivaptan safely and effectively corrects serum sodium concentrations in hospitalized patients with euvolemic hyponatremia. Kidney Int 2012; 82:1223-30. [DOI: 10.1038/ki.2012.275] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
Synthetic cathinones are synthetic derivatives of the natural cathinone, one of the psychoactive compounds present in Catha edulis (khat). There are at least 12 different types of synthetic cathinones, with mephedrone and 3,4-methylendioxypyrovalerone (MDPV) being the most commonly used by the purchasers. The legal control of these substances is especially difficult because when a specific compound is banned, a new slightly modified chemical variant is introduced into the market. It has been described that patients after taking synthetic cathinones may show signs and symptoms of the sympathicomimetic toxidrome, including agitation, psychosis, tachycardia, hypertension, and seizures. Furthermore, some cases of deaths related to their consumption have also been reported. Nowadays, there is no established treatment protocol for the clinical management of these intoxications. Because of this, we have developed some recommendations that may be useful to determine the treatment of these patients.
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Abstract
Hyponatremia (serum sodium <135 mEq/L) is the most common electrolyte disorder. The severity of symptoms is related to how rapidly the condition develops and the degree of cerebral edema that results from the low serum level of sodium. Hypertonic saline and the new vasopressin receptor antagonists are highly effective treatments for severe symptomatic hyponatremia, yet they can result in severe neurological complications if sodium levels are restored too quickly. Hyponatremia is classified as hypovolemic, euvolemic, and hypervolemic. Treatments include administration of high-risk medications and fluid restriction to restore fluid and electrolyte balance and relieve cerebral effects. Nursing care to ensure safe outcomes involves multidisciplinary collaboration, close monitoring of serum sodium levels and intake and output, and assessment for neurological changes.
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Amin A, Deitelzweig S, Christian R, Friend K, Lin J, Belk K, Baumer D, Lowe TJ. Evaluation of incremental healthcare resource burden and readmission rates associated with hospitalized hyponatremic patients in the US. J Hosp Med 2012; 7:634-9. [PMID: 22961813 DOI: 10.1002/jhm.1973] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Revised: 07/06/2012] [Accepted: 07/14/2012] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hyponatremia is a prevalent electrolyte disorder in hospitalized patients indicative of greater morbidity and mortality. A large-scale retrospective analysis was conducted to evaluate the incremental burden of hospitalized hyponatremic (HN) versus non-HN patients in terms of hospital resource utilization, costs, and hospital readmissions in the real-world setting. METHODS HN patients (≥18 years) were selected from the Premier Hospital Database between January 1, 2007 and March 31, 2010 and matched to a non-HN control cohort using propensity score matching. Bivariate and multivariate statistics were employed to evaluate the differences in healthcare resource utilization, costs, and hospital readmissions between patient cohorts. RESULTS Among the matched patient cohorts, length of stay (LOS) (8.8 ± 10.3 vs 7.7 ± 8.5 days, P < 0.001), hospital admission costs ($15,281 ± $24,054 vs $13,439 ± $22,198, P < 0.001), intensive care unit (ICU) LOS (5.5 ± 7.9 vs 4.9 ± 7.1 days, P < 0.001), and ICU costs ($8525 ± $13,342 vs $7597 ± $12,695, P < 0.001) were greater for the HN versus non-HN cohort, as were hospital readmission rates 30 days postdischarge. Multivariate regressions further demonstrated that hyponatremia was associated with an increase of 10.9% for LOS, 8.2% for total hospitalization costs, 10.2% for ICU LOS, and 8.9% for ICU costs. Additionally, after multivariate adjustment, hyponatremia was associated with a 15.0% increased chance for hospital readmission 30 days postdischarge (P < 0.0001). CONCLUSIONS Hyponatremia is an independent predictor of increased hospitalization LOS and cost, ICU admission and cost, and 30-day hospital readmission, and therefore represents a potential target for intervention to reduce healthcare expenditures for a large population of hospitalized hyponatremic patients.
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Affiliation(s)
- Alpesh Amin
- Department of Medicine, University of California, Irvine, Irvine, California, USA.
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Oral lixivaptan effectively increases serum sodium concentrations in outpatients with euvolemic hyponatremia. Kidney Int 2012; 82:1215-22. [PMID: 22932122 DOI: 10.1038/ki.2012.274] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hyponatremia is the most common electrolyte disorder in clinical practice. Its incidence increases with age and it is associated with increased morbidity and mortality. Recently, the vaptans, antagonists of the arginine vasopressin pathway, have shown promise for safe treatment of hyponatremia. Here we evaluated the efficacy, safety, and tolerability of oral lixivaptan, a selective vasopressin V2-receptor antagonist, for treatment of nonhospitalized individuals with euvolemic hyponatremia (sodium less than 135 mmol/l) in a multicenter, randomized, double-blind, placebo-controlled, phase III study. About half of the 206 patients were elderly in a chronic care setting. Of these patients, 52 were given a placebo and 154 were given 25-100 mg per day lixivaptan, titrated based on the daily serum sodium measurements. Compared with placebo (0.8 mmol/l), the serum sodium concentration significantly increased by 3.2 mmol/l from baseline to day 7 (primary efficacy endpoint) with lixivaptan treatment. A significantly greater proportion of patients that received lixivaptan achieved normal serum sodium (39.4%) by day 7 relative to placebo (12.2%). Overall, lixivaptan was considered safe and well-tolerated. Thus, oral lixivaptan can be safely initiated in the outpatient setting and effectively increases serum sodium concentrations in outpatients with euvolemic hyponatremia.
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Frouget T. [The syndrome of inappropriate antidiuresis]. Rev Med Interne 2012; 33:556-66. [PMID: 22884285 DOI: 10.1016/j.revmed.2012.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 06/11/2012] [Accepted: 07/05/2012] [Indexed: 11/26/2022]
Abstract
The syndrome of inappropriate antidiuresis (SIAD; formerly the syndrome of inappropriate secretion of antidiuretic hormone) is the most frequent cause of hyponatremia. A strong association exists between mortality and hyponatremia, which reflects the severity of the underlying disease. In SIAD, hyponatremia is associated with normovolaemia but the assessment of extracellular volume can be difficult. Clinical features are mainly neurological and can lead to death but mechanisms of adaptation can limit cerebral oedema. The notion of mild asymptomatic hyponatremia was questioned by the observation of subclinical neurocognitive impairment, a greater risk of falls and fractures. Aetiologies are classified into six groups: neurologic disorders, infections mainly cerebral, meningeal and pulmonary, drugs in particular antidepressants, tumors, genetic causes, and idiopathic. Symptomatic acute hyponatremia is a therapeutic emergency that is not specific of SIAD. When hyponatremia is asymptomatic, fluid restriction with salt intake is generally sufficient but urea can be an alternative. In chronic SIAD, there is currently no recommendation. Fluid restriction is not always feasible; urea has proved its efficacy, its good tolerance and its long-term harmlessness. Vaptans have demonstrated their good tolerance and their efficacy on the correction of hyponatremia from SIAD in studies subgroups, for moderate hyponatremia and asymptomatic patients. In the only study having compared vaptans and urea, efficacy and tolerance were similar. Because of the cost difference between vaptans and urea and while waiting for follow-up studies, urea appears at present as the first-line treatment of hyponatremia in SIAD.
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Affiliation(s)
- T Frouget
- Service de Néphrologie, CHU de Pontchaillou, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex 9, France.
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Gosch M, Joosten-Gstrein B, Heppner HJ, Lechleitner M. Hyponatremia in geriatric inhospital patients: effects on results of a comprehensive geriatric assessment. Gerontology 2012; 58:430-40. [PMID: 22722883 DOI: 10.1159/000339100] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 04/17/2012] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To study whether geriatric patients with mild-to-moderate hyponatremia (≤131 mmol/l) reveal different outcomes in structured tests for functional and cognitive impairments, depression and malnutrition compared to normonatremic patients. DESIGN Single-center, retrospective case control study. SETTING The study was conducted in a Geriatric Evaluation and Management Unit of a Department for Geriatrics and Internal Medicine. METHODS AND PARTICIPANTS We included 2,880 elderly patients (75.6% female, mean age 78.6 ± 6.98 years), consecutively admitted to the GEMU primarily or from another hospital or emergency department. Results were compared between a group of 129 patients with mild-to-moderate hyponatremia (118-131 mmol/l) and an age- and sex-matched control group of 129 patients with normal serum sodium values (>135 mmol/l). To assess functional and cognitive status, depression and malnutrition we used standardized tests of a geriatric assessment. RESULTS 16.7% (n = 477) of the total 2,880 patients were hyponatremic (≤135 mmol/l), 4.5% (n = 129) revealed moderate hyponatremia. Compared to the control group, these patients had significantly worse results in all tests of the Geriatric Assessment, including Activities of Daily Living, Mini Mental State Examination, Clock Completion Test, Geriatric Depression Score, Tinetti Mobility Test and the Timed Up&Go Test and the Mini Nutritional Assessment. Comorbidities were assessed by the Charlson Comorbidity Index and the Cumulative Illness Rating Scale with no significant difference between the two groups. The hyponatremic patients received significantly more medications than the normonatremic control group, but we could not find a significant difference with respect to the use of a distinct single drug therapy. CONCLUSION We were able to demonstrate that geriatric patients with mild-to-moderate hyponatremia revealed a significantly worse outcome in all standardized tests of the geriatric assessment compared to a normonatremic control group. Serum sodium levels should therefore be considered when interpreting common tests of geriatric assessment.
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Affiliation(s)
- Markus Gosch
- Department of Geriatrics and Internal Medicine, Hospital Hochzirl, Zirl, Austria.
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Abstract
BACKGROUND Asymptomatic or clinically mild hyponatremia commonly occurs in the setting of heart failure, especially among elderly and severely decompensated, fluid-overloaded patients, and is associated with increased morbidity and mortality. Successful detection and treatment of hyponatremia by cardiovascular and advanced practice nurses caring for patients with heart failure are part of multidisciplinary team care. Nurses should be able to detect signs and symptoms of hyponatremia and, even when patients are asymptomatic, initiate appropriate treatment promptly to prevent complications. PURPOSE In this review, the epidemiology and pathophysiology of hyponatremia in heart failure, and signs and symptoms are described. In patients with heart failure, challenges involved in determining the type of hyponatremia (hypervolemic, hypovolemic, or euvolemic) and in correctly managing hyponatremia to prevent serious complications are presented. Conventional treatment options and their limitations are reviewed, and the vasopressin-receptor antagonist tolvaptan, an emerging oral therapy option, is introduced and discussed. CONCLUSIONS Hyponatremia is a marker of morbidity and mortality in patients with heart failure. Nurses working collaboratively with other healthcare providers must be able to recognize the condition and understand treatment options, including potential adverse effects of current and emerging therapies. One emerging therapy--tolvaptan--can be used in hypervolemic and euvolemic hyponatremic patients with heart failure to correct serum sodium level without negatively affecting renal function. CLINICAL IMPLICATIONS Improved nurse understanding of hyponatremia in patients with heart failure may promote nurse-initiated or nurse-facilitated detection and management, which could decrease mortality and morbidity.
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Osama Hegazi M. Effect of Hypokalemia on the Clinical Impact of Hyponatremia. J Clin Hypertens (Greenwich) 2012; 14:656. [DOI: 10.1111/j.1751-7176.2012.00643.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hyponatremia in cirrhosis and end-stage liver disease: treatment with the vasopressin V₂-receptor antagonist tolvaptan. Dig Dis Sci 2012; 57:2774-85. [PMID: 22732834 PMCID: PMC3472061 DOI: 10.1007/s10620-012-2276-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 06/05/2012] [Indexed: 02/07/2023]
Abstract
Hyponatremia is common in patients with cirrhosis and portal hypertension, and is characterized by excessive renal retention of water relative to sodium due to reduced solute-free water clearance. The primary cause is increased release of arginine vasopressin. Hyponatremia is associated with increased mortality in cirrhotic patients, those with end-stage liver disease (ESLD) on transplant waiting lists, and, in some studies, posttransplantation patients. Clinical evidence suggests that adding serum sodium to model for ESLD (MELD) scoring identifies patients in greatest need of liver transplantation by improving waiting list mortality prediction. Hyponatremia is also associated with numerous complications in liver disease patients, including severe ascites, hepatic encephalopathy, infectious complications, renal impairment, increased severity of liver disease in cirrhosis, and increased hospital stay and neurologic/infectious complications posttransplant. Vasopressin receptor antagonists, which act to increase free water excretion (aquaresis) and thereby increase serum sodium concentration, have been evaluated in patients with hypervolemic hyponatremia (including cirrhosis and heart failure) and euvolemic hyponatremia (SIADH). Tolvaptan, a selective vasopressin V(2)-receptor antagonist, is the only oral agent in this class approved for raising sodium levels in hypervolemic and euvolemic hyponatremia. The SALT trials showed that tolvaptan treatment rapidly and effectively resolved hyponatremia in these settings, including cirrhosis, and it has been shown that this agent can be safely and effectively used in long-term treatment. Fluid restriction should be avoided during the first 24 h of treatment to prevent overly rapid correction of hyponatremia, and tolvaptan should not be used in patients who cannot sense/respond to thirst, anuric patients, hypovolemic patients, and/or those requiring urgent intervention to raise serum sodium acutely.
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Deitelzweig SB, McCormick L. Hyponatremia in hospitalized patients: the potential role of tolvaptan. Hosp Pract (1995) 2011; 39:87-98. [PMID: 21881396 DOI: 10.3810/hp.2011.08.584] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hyponatremia (typically defined as serum sodium level < 135 mEq/L) is a common electrolyte abnormality among hospitalized patients. Whether present at admission or acquired during hospitalization, hyponatremia is associated with higher mortality and longer hospital stays. Failure to adequately investigate and treat hyponatremia may also be associated with adverse outcomes. The presence and severity of clinical symptoms largely depend on the rate and extent of the decline in serum sodium; rapid or large decreases may cause serious neurologic complications. The approach to treatment depends on the presence and severity of symptoms, the timing of their onset, the underlying etiology, and the patient's volume status. Patients with euvolemic or hypervolemic hyponatremia usually have inappropriately elevated levels of arginine vasopressin, which stimulates water reabsorption even in the presence of low serum osmolality. Tolvaptan is an orally active, selective V2-receptor antagonist that blocks the effects of arginine vasopressin in the renal collecting duct to promote aquaresis without increasing sodium or potassium excretion; as a result, it increases serum sodium in a controlled manner. Tolvaptan offers a mechanism-based treatment option for patients with euvolemic or hypervolemic hyponatremia who have serum sodium levels < 125 mEq/L or persistent symptoms resistant to fluid restriction.
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Mishriki YY, Shariff N. Puzzles in Practice. Postgrad Med 2011; 123:191-4. [DOI: 10.3810/pgm.2011.03.2278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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