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Joseph G Verbalis - One of the best experts on this subject based on the ideXlab platform.
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correction Hyponatremia improvement is associated with a reduced risk of mortality evidence from a meta analysis
PLOS ONE, 2015Co-Authors: Giovanni Corona, Corinna Giuliani, Joseph G Verbalis, Gianni Forti, M Maggi, Alessandro PeriAbstract:Background Hyponatremia is the most common electrolyte disorder and it is associated with increased morbidity and mortality. However, there is no clear demonstration that the improvement of serum sodium concentration ([Na+]) counteracts the increased risk of mortality associated with Hyponatremia. Thus, we performed a meta-analysis that included the published studies that addressed the effect of Hyponatremia improvement on mortality. Methods and Findings A Medline, Embase and Cochrane search was performed to retrieve all English-language studies of human subjects published up to June 30th 2014, using the following words: “Hyponatremia”, “hyponatraemia”, “mortality”, “morbidity” and “sodium”. Fifteen studies satisfied inclusion criteria encompassing a total of 13,816 patients. The identification of relevant abstracts, the selection of studies and the subsequent data extraction were performed independently by two of the authors, and conflicts resolved by a third investigator. Across all fifteen studies, any improvement of Hyponatremia was associated with a reduced risk of overall mortality (OR=0.57[0.40-0.81]). The association was even stronger when only those studies (n=8) reporting a threshold for serum [Na+] improvement to >130 mmol/L were considered (OR=0.51[0.31-0.86]). The reduced mortality rate persisted at follow-up (OR=0.55[0.36-0.84] at 12 months). Meta-regression analyses showed that the reduced mortality associated with Hyponatremia improvement was more evident in older subjects and in those with lower serum [Na+] at enrollment. Conclusions This meta-analysis documents for the first time that improvement in serum [Na+] in hyponatremic patients is associated with a reduction of overall mortality.
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moderate Hyponatremia is associated with increased risk of mortality evidence from a meta analysis
PLOS ONE, 2013Co-Authors: Giovanni Corona, Corinna Giuliani, Joseph G Verbalis, Gianni Forti, M Maggi, Gabriele Parenti, Dario Norello, Alessandro PeriAbstract:Background Hyponatremia is the most common electrolyte disorder in clinical practice, and evidence to date indicates that severe Hyponatremia is associated with increased morbidity and mortality. The aim of our study was to perform a meta-analysis that included the published studies that compared mortality rates in subjects with or without Hyponatremia of any degree. Methods and Findings An extensive Medline, Embase and Cochrane search was performed to retrieve the studies published up to October 1st 2012, using the following words: “Hyponatremia” and “mortality”. Eighty-one studies satisfied inclusion criteria encompassing a total of 850222 patients, of whom 17.4% were hyponatremic. The identification of relevant abstracts, the selection of studies and the subsequent data extraction were performed independently by two of the authors, and conflicts resolved by a third investigator. Across all 81 studies, Hyponatremia was significantly associated with an increased risk of overall mortality (RR = 2.60[2.31–2.93]). Hyponatremia was also associated with an increased risk of mortality in patients with myocardial infarction (RR = 2.83[2.23–3.58]), heart failure (RR = 2.47[2.09–2.92]), cirrhosis (RR = 3.34[1.91–5.83]), pulmonary infections (RR = 2.49[1.44–4.30]), mixed diseases (RR = 2.59[1.97–3.40]), and in hospitalized patients (RR = 2.48[2.09–2.95]). A mean difference of serum [Na+] of 4.8 mmol/L was found in subjects who died compared to survivors (130.1±5.6 vs 134.9±5.1 mmol/L). A meta-regression analysis showed that the Hyponatremia-related risk of overall mortality was inversely correlated with serum [Na+]. This association was confirmed in a multiple regression model after adjusting for age, gender, and diabetes mellitus as an associated morbidity. Conclusions This meta-analysis shows for the first time that even a moderate serum [Na+] decrease is associated with an increased risk of mortality in commonly observed clinical conditions across large numbers of patients.
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diagnosis evaluation and treatment of Hyponatremia expert panel recommendations
The American Journal of Medicine, 2013Co-Authors: Joseph G Verbalis, Robert W. Schrier, Steven R Goldsmith, Arthur Greenberg, Cynthia A Korzelius, Richard H Sterns, C J ThompsonAbstract:Abstract Hyponatremia is a serious, but often overlooked, electrolyte imbalance that has been independently associated with a wide range of deleterious changes involving many different body systems. Untreated acute Hyponatremia can cause substantial morbidity and mortality as a result of osmotically induced cerebral edema, and excessively rapid correction of chronic Hyponatremia can cause severe neurologic impairment and death as a result of osmotic demyelination. The diverse etiologies and comorbidities associated with Hyponatremia pose substantial challenges in managing this disorder. In 2007, a panel of experts in Hyponatremia convened to develop the Hyponatremia Treatment Guidelines 2007: Expert Panel Recommendations that defined strategies for clinicians caring for patients with Hyponatremia. In the 6 years since the publication of that document, the field has seen several notable developments, including new evidence on morbidities and complications associated with Hyponatremia, the importance of treating mild to moderate Hyponatremia, and the efficacy and safety of vasopressin receptor antagonist therapy for hyponatremic patients. Therefore, additional guidance was deemed necessary and a panel of Hyponatremia experts (which included all of the original panel members) was convened to update the previous recommendations for optimal current management of this disorder. The updated expert panel recommendations in this document represent recommended approaches for multiple etiologies of Hyponatremia that are based on both consensus opinions of experts in Hyponatremia and the most recent published data in this field.
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Hyponatremia induced osteoporosis
Journal of Bone and Mineral Research, 2010Co-Authors: Joseph G Verbalis, Julianna Barsony, Yoshihisa Sugimura, Ying Tian, Douglas J Adams, Elizabeth A Carter, Helaine E ResnickAbstract:There is a high prevalence of chronic Hyponatremia in the elderly, frequently owing to the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Recent reports have shown that even mild Hyponatremia is associated with impaired gait stability and increased falls. An increased risk of falls among elderly hyponatremic patients represents a risk factor for fractures, which would be further amplified if Hyponatremia also contributed metabolically to bone loss. To evaluate this possibility, we studied a rat model of SIADH and analyzed data from the Third National Health and Nutrition Examination Survey (NHANES III). In rats, dual-energy X-ray absorptiometry (DXA) analysis of excised femurs established that Hyponatremia for 3 months significantly reduced bone mineral density by approximately 30% compared with normonatremic control rats. Moreover, micro-computed tomography (µCT) and histomorphometric analyses indicated that Hyponatremia markedly reduced both trabecular and cortical bone via increased bone resorption and decreased bone formation. Analysis of data from adults in NHANES III by linear regression models showed that mild Hyponatremia is associated with increased odds of osteoporosis (T-score –2.5 or less) at the hip [odds ratio (OR) = 2.85; 95% confidence interval (CI) 1.03–7.86; p < .01]; all models were adjusted for age, sex, race, body mass index (BMI), physical activity, history of diuretic use, history of smoking, and serum 25-hydroxyvitamin D [25(OH)D] levels. Our results represent the first demonstration that chronic Hyponatremia causes a substantial reduction of bone mass. Cross-sectional human data showing that Hyponatremia is associated with significantly increased odds of osteoporosis are consistent with the experimental data in rodents. Our combined results suggest that bone quality should be assessed in all patients with chronic Hyponatremia. © 2010 American Society for Bone and Mineral Research.
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Hyponatremia treatment guidelines 2007 expert panel recommendations
The American Journal of Medicine, 2007Co-Authors: Joseph G Verbalis, Robert W. Schrier, Steven R Goldsmith, Arthur Greenberg, Richard H SternsAbstract:Although Hyponatremia is a common, usually mild, and relatively asymptomatic disorder of electrolytes, acute severe Hyponatremia can cause substantial morbidity and mortality, particularly in patients with concomitant disease. In addition, overly rapid correction of chronic Hyponatremia can cause severe neurologic deficits and death, and optimal treatment strategies for such cases are not established. An expert panel assessed the potential contributions of aquaretic nonpeptide small-molecule arginine vasopressin receptor (AVPR) antagonists to Hyponatremia therapies. This review presents their conclusions, including identification of appropriate treatment populations and possible future indications for aquaretic AVPR antagonists.
Juan Carlos Ayus - One of the best experts on this subject based on the ideXlab platform.
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Hyponatremia and bone disease
Reviews in Endocrine & Metabolic Disorders, 2016Co-Authors: Armando Luis Negri, Juan Carlos AyusAbstract:Hip fractures represent a serious health risk in the elderly, causing substantial morbidity and mortality. There is now a considerable volume of literature suggesting that chronic Hyponatremia increases the adjusted odds ratio (OR) for both falls and fractures in the elderly. Hyponatremia appears to contribute to falls and fractures by two mechanisms. First, it produces mild cognitive impairment, resulting in unsteady gait and falls; this is probably due to the loss of glutamate (a neurotransmitter involved in gait function) as an osmolyte during brain adaptation to chronic Hyponatremia. Second, Hyponatremia directly contributes to osteoporosis and increased bone fragility by inducing increased bone resorption to mobilize sodium stores in bone. Low extracellular sodium directly stimulates osteoclastogenesis and bone resorptive activity through decreased cellular uptake of ascorbic acid and the induction of oxidative stress; these effects occur in a sodium level-dependent manner. Hyponatremic patients have elevated circulating arginine-vasopressin (AVP) levels, and AVP acting on two receptors expressed in osteoblasts and osteoclasts, Avpr1α and Avpr2, can increase bone resorption and decrease osteoblastogenesis. Should we be screening for low serum sodium in patients with osteoporosis or assessing bone mineral density (BMD) in patients with Hyponatremia? The answers to these questions have not been established. Definitive answers will require randomized controlled studies that allocate elderly individuals with mild Hyponatremia to receive either active treatment or no treatment for Hyponatremia, to determine whether correction of Hyponatremia prevents gait disturbances and changes in BMD, thereby reducing the risk of fractures. Until such studies are conducted, physicians caring for elderly patients must be aware of the association between Hyponatremia and bone disorders. As serum sodium is a readily available, simple, and affordable biochemical measurement, clinicians should look for Hyponatremia in elderly patients, especially in those receiving medications that can cause Hyponatremia. Furthermore, elderly patients with an unsteady gait and/or confusion should be evaluated for the presence of mild Hyponatremia, and if present, treatment should be initiated. Finally, elderly patients presenting with an orthopedic injury should have serum sodium checked and Hyponatremia corrected, if present.
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mild prolonged chronic Hyponatremia and risk of hip fracture in the elderly
Nephrology Dialysis Transplantation, 2016Co-Authors: Juan Carlos Ayus, Nora Fuentes, Armando Luis Negri, Michael L Moritz, Diego Giunta, Kamyar Kalantarzadeh, Sagar U Nigwekar, Ravi Thadhani, Alan S GoAbstract:Hip fractures are among the most serious bone fractures in the elderly, producing significant morbidity and mortality. Several observational studies have found that mild Hyponatremia can adversely affect bone, with fractures occurring as a potential complication. We examined if there is an independent association between prolonged chronic Hyponatremia (>90 days duration) and risk of hip fracture in the elderly.We performed a retrospective cohort study in adults >60 years of age from a prepaid health maintenance organization who had two or more measurements of plasma sodium between 2005 and 2012. The incidence of hip fractures was assessed in a very restrictive population: subjects with prolonged chronic Hyponatremia, defined as plasma sodium values 90 days. Multivariable Cox regression was performed to determine the hazard ratio (HR) for hip fracture risk associated with prolonged chronic Hyponatremia after adjustment for the propensity to have Hyponatremia, fracture risk factors and relevant baseline characteristics.Among 31 527 eligible patients, only 228 (0.9%) had prolonged chronic Hyponatremia. Mean plasma sodium was 132 ± 5 mmol/L in hyponatremic patients and 139 ± 3 mmol/L in normonatremic patients (P < 0.001). The absolute risk for hip fracture was 7/282 in patients with prolonged chronic Hyponatremia and 411/313 299 in normonatremic patients. Hyponatremic patients had a substantially elevated rate of hip fracture [adjusted HR 4.52 (95% CI 2.14-9.6)], which was even higher in those with moderate Hyponatremia (<130 mmol/L) [adjusted HR 7.61 (95% CI 2.8-20.5)].Mild prolonged chronic Hyponatremia is independently associated with hip fracture risk in the elderly population, although the absolute risk is low. However, proof that correcting Hyponatremia will result in a reduction of hip fractures is lacking.
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brain cell volume regulation in Hyponatremia role of sex age vasopressin and hypoxia
American Journal of Physiology-renal Physiology, 2008Co-Authors: Juan Carlos Ayus, Steven G Achinger, Allen I. ArieffAbstract:Hyponatremia is the most common electrolyte abnormality in hospitalized patients. When symptomatic (hyponatremic encephalopathy), the overall morbidity is 34%. Individuals most susceptible to death...
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hospital acquired Hyponatremia why are hypotonic parenteral fluids still being used
Nature Reviews Nephrology, 2007Co-Authors: Michael L Moritz, Juan Carlos AyusAbstract:Hospitalized patients have several stimuli for vasopressin production that increase the risk of their serum sodium concentration dropping to dangerous levels. Here, Moritz and Ayus elegantly present evidence to support their opinion that prevention and management of Hyponatremia are worryingly inadequate in many institutions. They assert that fundamental changes to long-standing, but erroneous, tenets of fluid therapy are needed to prevent unnecessary deaths. Hospital-acquired Hyponatremia can be lethal. There have been multiple reports of death or permanent neurological impairment in both children and adults. The main factor contributing to the development of hospital-acquired Hyponatremia is routine use of hypotonic fluids in patients in whom the excretion of free water, which is retained in response to excess arginine vasopressin (AVP), might be impaired. The practice of administering hypotonic parental fluids was established over 50 years ago, before recognition of the fact that there are numerous potential stimuli for AVP production in most hospitalized patients. Virtually all neurological morbidity resulting from hospital-acquired Hyponatremia has been associated with administration of hypotonic fluids. Multiple prospective studies have shown that 0.9% NaCl is effective prophylaxis against Hyponatremia. There is not a single report in the literature of neurological complications resulting from the use of 0.9% NaCl in non-neurosurgical patients. Patients at greatest risk of developing hyponatremic encephalopathy following hypotonic fluid administration are children, premenopausal females, postoperative patients, and those with brain injury or infection, pulmonary disease or hypoxemia. When hyponatremic encephalopathy develops, immediate administration of 3% NaCl is essential. In this Review, we discuss the question of why administering hypotonic fluids is unphysiologic and potentially dangerous, the settings in which isotonic fluids should be administered to prevent Hyponatremia, and the appropriate treatment of hyponatremic encephalopathy.
Ewout J Hoorn - One of the best experts on this subject based on the ideXlab platform.
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diagnosis and treatment of Hyponatremia compilation of the guidelines
Journal of The American Society of Nephrology, 2017Co-Authors: Ewout J Hoorn, Robert ZietseAbstract:Hyponatremia is a common water balance disorder that often poses a diagnostic or therapeutic challenge. Therefore, guidelines were developed by professional organizations, one from within the United States (2013) and one from within Europe (2014). This review discusses the diagnosis and treatment of Hyponatremia, comparing the two guidelines and highlighting recent developments. Diagnostically, the initial step is to differentiate hypotonic from nonhypotonic Hyponatremia. Hypotonic Hyponatremia is further differentiated on the basis of urine osmolality, urine sodium level, and volume status. Recently identified parameters, including fractional uric acid excretion and plasma copeptin concentration, may further improve the diagnostic approach. The treatment for Hyponatremia is chosen on the basis of duration and symptoms. For acute or severely symptomatic Hyponatremia, both guidelines adopted the approach of giving a bolus of hypertonic saline. Although fluid restriction remains the first-line treatment for most forms of chronic Hyponatremia, therapy to increase renal free water excretion is often necessary. Vasopressin receptor antagonists, urea, and loop diuretics serve this purpose, but received different recommendations in the two guidelines. Such discrepancies may relate to different interpretations of the limited evidence or differences in guideline methodology. Nevertheless, the development of guidelines has been important in advancing this evolving field.
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Hyponatremia and mortality moving beyond associations
American Journal of Kidney Diseases, 2013Co-Authors: Ewout J Hoorn, Robert ZietseAbstract:Acute Hyponatremia can cause death if cerebral edema is not treated promptly. Conversely, if chronic Hyponatremia is corrected too rapidly, osmotic demyelination may ensue, which also potentially is lethal. However, these severe complications of Hyponatremia are relatively uncommon and often preventable. More commonly, Hyponatremia predicts mortality in patients with advanced heart failure or liver cirrhosis. In these conditions, it generally is assumed that Hyponatremia reflects the severity of the underlying disease rather than contributing directly to mortality. The same assumption holds for the recently reported associations between Hyponatremia and mortality in patients with pulmonary embolism, pulmonary hypertension, pneumonia, and myocardial infarction. However, recent data suggest that chronic and mild Hyponatremia in the general population also are associated with mortality. In addition, Hyponatremia has been associated with mortality in long-term hemodialysis patients without residual function in whom the underlying disease cannot be responsible for Hyponatremia. These new data raise the question of whether Hyponatremia by itself can contribute to mortality or it remains a surrogate marker for other unknown risk factors. We review Hyponatremia and mortality and explore the possibility that Hyponatremia perturbs normal physiology in the absence of cerebral edema or osmotic demyelination.
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thiazide associated Hyponatremia a population based study
American Journal of Kidney Diseases, 2013Co-Authors: Eline M Rodenburg, Ewout J Hoorn, Rikje Ruiter, Jan J Lous, Albert Hofman, Andre G Uitterlinden, Bruno H Stricker, Loes E VisserAbstract:Background Hyponatremia is one of the most common adverse reactions to thiazide diuretics. In the present study, we analyzed differences in thiazide-associated Hyponatremia between men and women and between different categories of age, body mass index (BMI), daily thiazide dose, and estimated glomerular filtration rate. Study Design Population-based cohort study. Setting & Participants 13,325 individuals 45 years and older living in a suburb of Rotterdam, as part of the Rotterdam Study. Predictor Exposure to thiazide diuretics. Outcomes The association between thiazide exposure and Hyponatremia (defined as sodium level ≤135 mmol/L; mild Hyponatremia, 130-≤135 mmol/L; moderate, >125- Results 718 participants used thiazides at baseline, and 2,738 participants started on thiazide therapy during follow-up. 522 participants developed Hyponatremia, of whom 32.4% were exposed to thiazide diuretics at the time of Hyponatremia. Thiazide exposure was associated with an almost 5 times higher risk of Hyponatremia than no exposure (HR, 4.95; 95% CI, 4.12-5.96). The risk of mild Hyponatremia was more than 4.5 times higher in thiazide-exposed individuals; risks of moderate and severe Hyponatremia were both 8 times higher in individuals exposed to thiazides. Age and BMI (but not sex [ P = 0.8] or estimated glomerular filtration rate [ P = 0.2]) significantly modified this risk of thiazide-associated Hyponatremia ( P Limitations Some cases of severe Hyponatremia may have been missed if patients were admitted to the hospital without assessment of serum sodium in the general practitioner's laboratory. Nonproportionality of hazards in the first period was explained as possible "depletion of susceptibles" in this closed cohort. Conclusions Thiazide use is associated with a substantially increased risk of Hyponatremia. Age and BMI significantly influenced the thiazide-associated risk of Hyponatremia.
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mild Hyponatremia as a risk factor for fractures the rotterdam study
Journal of Bone and Mineral Research, 2011Co-Authors: Ewout J Hoorn, Robert Zietse, Albert Hofman, Andre G Uitterlinden, Bruno H Stricker, Fernando Rivadeneira, Joyce B J Van Meurs, Gijsbertus Ziere, Huibert A P Pols, Carola M ZillikensAbstract:Recent studies suggest that mild Hyponatremia is associated with fractures, but prospective studies are lacking. We studied whether Hyponatremia is associated with fractures, falls, and/or bone mineral density (BMD). A total of 5208 elderly subjects with serum sodium assessed at baseline were included from the prospective population-based Rotterdam Study. The following data were analyzed: BMD, vertebral fractures (mean follow-up 6.4 years), nonvertebral fractures (7.4 years), recent falls, comorbidity, medication, and mortality. Hyponatremia was detected in 399 subjects (7.7%, 133.4 ± 2.0 mmol/L). Subjects with Hyponatremia were older (73.5 ± 10.3 years versus 70.0 ± 9.0 years, p < .001), had more recent falls (23.8% versus16.4%, p < .01), higher type 2 diabetes mellitus prevalence (22.2% versus 10.3%, p < .001), and more often used diuretics (31.1% versus 15.0%, p < .001). Hyponatremia was not associated with lower BMD but was associated with increased risk of incident nonvertebral fractures [hazard ratio (HR) =1.39, 95% confidence interval (CI) 1.11–1.73, p = .004] after adjustment for age, sex, and body mass index. Further adjustments for disability index, use of diuretics, use of psycholeptics, recent falls, and diabetes did not modify results. In the fully adjusted model, subjects with Hyponatremia also had increased risk of vertebral fractures at baseline [odds ratio (OR) = 1.78, 95% CI 1.04–3.06, p = .037] but not at follow-up. Finally, all-cause mortality was higher in subjects with Hyponatremia (HR = 1.21, 95% CI 1.03–1.43, p = .022). It is concluded that mild Hyponatremia in the elderly is associated with an increased risk of vertebral fractures and incident nonvertebral fractures but not with BMD. Increased fracture risk in Hyponatremia also was independent of recent falls, pointing toward a possible effect on bone quality. © 2011 American Society for Bone and Mineral Research
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Hyponatremia and inflammation the emerging role of interleukin 6 in osmoregulation
Nephron Physiology, 2011Co-Authors: Reinout M Swart, Ewout J Hoorn, Michiel G H Betjes, Robert ZietseAbstract:Although Hyponatremia is a recognized complication of several inflammatory diseases, its pathophysiology in this setting has remained elusive until recently. A growing body of evidence now points to an important role for interleukin-6 in the non-osmotic release of vasopressin. Here, we review this evidence by exploring the immuno-neuroendocrine pathways connecting interleukin-6 with vasopressin. The importance of these connections extends to several clinical scenarios of Hyponatremia and inflammation, including hospital-acquired Hyponatremia, postoperative Hyponatremia, exercise-associated Hyponatremia, and Hyponatremia in the elderly. Besides insights in pathophysiology, the recognition of the propensity for antidiuresis during inflammation is also important with regard to monitoring patients and selecting the appropriate intravenous fluid regimen, for which recommendations are provided.
Richard H Sterns - One of the best experts on this subject based on the ideXlab platform.
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diagnosis evaluation and treatment of Hyponatremia expert panel recommendations
The American Journal of Medicine, 2013Co-Authors: Joseph G Verbalis, Robert W. Schrier, Steven R Goldsmith, Arthur Greenberg, Cynthia A Korzelius, Richard H Sterns, C J ThompsonAbstract:Abstract Hyponatremia is a serious, but often overlooked, electrolyte imbalance that has been independently associated with a wide range of deleterious changes involving many different body systems. Untreated acute Hyponatremia can cause substantial morbidity and mortality as a result of osmotically induced cerebral edema, and excessively rapid correction of chronic Hyponatremia can cause severe neurologic impairment and death as a result of osmotic demyelination. The diverse etiologies and comorbidities associated with Hyponatremia pose substantial challenges in managing this disorder. In 2007, a panel of experts in Hyponatremia convened to develop the Hyponatremia Treatment Guidelines 2007: Expert Panel Recommendations that defined strategies for clinicians caring for patients with Hyponatremia. In the 6 years since the publication of that document, the field has seen several notable developments, including new evidence on morbidities and complications associated with Hyponatremia, the importance of treating mild to moderate Hyponatremia, and the efficacy and safety of vasopressin receptor antagonist therapy for hyponatremic patients. Therefore, additional guidance was deemed necessary and a panel of Hyponatremia experts (which included all of the original panel members) was convened to update the previous recommendations for optimal current management of this disorder. The updated expert panel recommendations in this document represent recommended approaches for multiple etiologies of Hyponatremia that are based on both consensus opinions of experts in Hyponatremia and the most recent published data in this field.
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hypertonic saline for Hyponatremia risk of inadvertent overcorrection
Clinical Journal of The American Society of Nephrology, 2007Co-Authors: Hashim K Mohmand, Dany Issa, Zubair Ahmad, Joseph D Cappuccio, Ruth Kouides, Richard H SternsAbstract:Background and objectives: Data regarding dosage–response relationships for using hypertonic saline in treatment of Hyponatremia are extremely limited. Objectives of this study were to assess adherence to previously published guidelines (limiting correction to Design, setting, participants & measurements: A retrospective review was conducted of all 62 adult, hyponatremic patients who were treated with hypertonic saline during 5 yr at a 528-bed, acute care, teaching hospital. Results: Median infusion rate was 0.38 ml/kg per h, increasing serum sodium concentration by 0.47 ± 0.05 mEq/L per h, 7.1 ± 0.6 mEq/L per 24 h, and 11.3 ± 0.7 mEq/L per 48 h. In 11.3% of cases, the increase was >12 mEq/L per 24 h and in 9.7% was >18 mEq/L per 48 h. No patient9s rate was corrected by >25 mEq/L per 48 h. Among patients with serum sodium Conclusions: The Adrogue-Madias formula underestimates increase in sodium concentration after hypertonic saline therapy. Unrecognized hypovolemia and other reversible causes of water retention pose a risk for inadvertent overcorrection. Hypertonic saline should be infused at rates lower than those predicted by formulas with close monitoring of serum sodium and urine output.
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Hyponatremia treatment guidelines 2007 expert panel recommendations
The American Journal of Medicine, 2007Co-Authors: Joseph G Verbalis, Robert W. Schrier, Steven R Goldsmith, Arthur Greenberg, Richard H SternsAbstract:Although Hyponatremia is a common, usually mild, and relatively asymptomatic disorder of electrolytes, acute severe Hyponatremia can cause substantial morbidity and mortality, particularly in patients with concomitant disease. In addition, overly rapid correction of chronic Hyponatremia can cause severe neurologic deficits and death, and optimal treatment strategies for such cases are not established. An expert panel assessed the potential contributions of aquaretic nonpeptide small-molecule arginine vasopressin receptor (AVPR) antagonists to Hyponatremia therapies. This review presents their conclusions, including identification of appropriate treatment populations and possible future indications for aquaretic AVPR antagonists.
Michael L Moritz - One of the best experts on this subject based on the ideXlab platform.
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mild prolonged chronic Hyponatremia and risk of hip fracture in the elderly
Nephrology Dialysis Transplantation, 2016Co-Authors: Juan Carlos Ayus, Nora Fuentes, Armando Luis Negri, Michael L Moritz, Diego Giunta, Kamyar Kalantarzadeh, Sagar U Nigwekar, Ravi Thadhani, Alan S GoAbstract:Hip fractures are among the most serious bone fractures in the elderly, producing significant morbidity and mortality. Several observational studies have found that mild Hyponatremia can adversely affect bone, with fractures occurring as a potential complication. We examined if there is an independent association between prolonged chronic Hyponatremia (>90 days duration) and risk of hip fracture in the elderly.We performed a retrospective cohort study in adults >60 years of age from a prepaid health maintenance organization who had two or more measurements of plasma sodium between 2005 and 2012. The incidence of hip fractures was assessed in a very restrictive population: subjects with prolonged chronic Hyponatremia, defined as plasma sodium values 90 days. Multivariable Cox regression was performed to determine the hazard ratio (HR) for hip fracture risk associated with prolonged chronic Hyponatremia after adjustment for the propensity to have Hyponatremia, fracture risk factors and relevant baseline characteristics.Among 31 527 eligible patients, only 228 (0.9%) had prolonged chronic Hyponatremia. Mean plasma sodium was 132 ± 5 mmol/L in hyponatremic patients and 139 ± 3 mmol/L in normonatremic patients (P < 0.001). The absolute risk for hip fracture was 7/282 in patients with prolonged chronic Hyponatremia and 411/313 299 in normonatremic patients. Hyponatremic patients had a substantially elevated rate of hip fracture [adjusted HR 4.52 (95% CI 2.14-9.6)], which was even higher in those with moderate Hyponatremia (<130 mmol/L) [adjusted HR 7.61 (95% CI 2.8-20.5)].Mild prolonged chronic Hyponatremia is independently associated with hip fracture risk in the elderly population, although the absolute risk is low. However, proof that correcting Hyponatremia will result in a reduction of hip fractures is lacking.
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hospital acquired Hyponatremia why are hypotonic parenteral fluids still being used
Nature Reviews Nephrology, 2007Co-Authors: Michael L Moritz, Juan Carlos AyusAbstract:Hospitalized patients have several stimuli for vasopressin production that increase the risk of their serum sodium concentration dropping to dangerous levels. Here, Moritz and Ayus elegantly present evidence to support their opinion that prevention and management of Hyponatremia are worryingly inadequate in many institutions. They assert that fundamental changes to long-standing, but erroneous, tenets of fluid therapy are needed to prevent unnecessary deaths. Hospital-acquired Hyponatremia can be lethal. There have been multiple reports of death or permanent neurological impairment in both children and adults. The main factor contributing to the development of hospital-acquired Hyponatremia is routine use of hypotonic fluids in patients in whom the excretion of free water, which is retained in response to excess arginine vasopressin (AVP), might be impaired. The practice of administering hypotonic parental fluids was established over 50 years ago, before recognition of the fact that there are numerous potential stimuli for AVP production in most hospitalized patients. Virtually all neurological morbidity resulting from hospital-acquired Hyponatremia has been associated with administration of hypotonic fluids. Multiple prospective studies have shown that 0.9% NaCl is effective prophylaxis against Hyponatremia. There is not a single report in the literature of neurological complications resulting from the use of 0.9% NaCl in non-neurosurgical patients. Patients at greatest risk of developing hyponatremic encephalopathy following hypotonic fluid administration are children, premenopausal females, postoperative patients, and those with brain injury or infection, pulmonary disease or hypoxemia. When hyponatremic encephalopathy develops, immediate administration of 3% NaCl is essential. In this Review, we discuss the question of why administering hypotonic fluids is unphysiologic and potentially dangerous, the settings in which isotonic fluids should be administered to prevent Hyponatremia, and the appropriate treatment of hyponatremic encephalopathy.
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Preventing neurological complications from dysnatremias in children
Pediatric Nephrology, 2005Co-Authors: Michael L Moritz, J. Carlos AyusAbstract:Dysnatremias are among the most common electrolyte abnormalities encountered in hospitalized patients. In most cases, a dysnatremia results from improper fluid management. Dysnatremias can occasionally result in death or permanent neurological damage, a tragic complication that is usually preventable. In this manuscript, we discuss the epidemiology, pathogenesis and prevention and treatment of dysnatremias in children. We report on over 50 patients who have suffered death or neurological injury from hospital-acquired Hyponatremia. The main factor contributing to hyponatremic encephalopathy in children is the routine use of hypotonic fluids in patients who have an impaired ability to excrete free-water, due to such causes as the postoperative state, volume depletion and pulmonary and central nervous system diseases. The appropriate use of 0.9% sodium chloride in parenteral fluids would likely prevent most cases of hospital-acquired hyponatremic encephalopathy. We report on 15 prospective studies in over 500 surgical patients that demonstrate that normal saline effectively prevents postoperative Hyponatremia, and hypotonic fluids consistently result in a fall in serum sodium. Hyponatremic encephalopathy is a medical emergency that should be treated with hypertonic saline, and should never be managed with fluid restriction alone. Hospital-acquired hypernatremia occurs in patients who have restricted access to fluids in combination with ongoing free-water losses. Hypernatremia could largely be prevented by providing adequate free-water to patients who have ongoing free-water losses or when mild hypernatremia (Na>145 mE/l) develops. A group at high-risk for neurological damage from hypernatremia in the outpatient setting is that of the breastfed infant. Breastfed infants must be monitored closely for insufficient lactation and receive lactation support. Judicious use of infant formula supplementation may be called for until problems with lactation can be corrected.
