Markers of potassium homeostasis in salt losing tubulopathies- associations with hyperaldosteronism and hypomagnesemia.

BACKGROUND: Renal loss of potassium (K+) and magnesium (Mg2+) in salt losing tubulopathies (SLT) leads to significantly reduced Quality of Life (QoL) and higher risks of cardiac arrhythmia. The normalization of K+ is currently the most widely accepted treatment target, however in even excellently designed RCTs the increase of K+ was only mild and rarely normalized. These findings question the role of K+ as the ideal marker of potassium homeostasis in SLT. Aim of this hypothesis-generating study was to define surrogate endpoints for future treatment trials in SLT in terms of their usefulness to determine QoL and important clinical outcomes. METHODS: Within this prospective cross-sectional study including 11 patients with SLTs we assessed the biochemical, clinical and cardiological parameters and their relationship with QoL (RAND SF-36). The primary hypothesis was that QoL would be more dependent of higher aldosterone concentration, assessed by the transtubular-potassium-gradient (TTKG). Correlations were evaluated using Pearson's correlation coefficient. RESULTS: Included patients were mainly female (82%, mean age 34 ± 12 years). Serum K+ and Mg2+ was 3.3 ± 0.6 mmol/l and 0.7 ± 0.1 mmol/l (mean ± SD). TTKG was 9.5/3.4-20.2 (median/range). While dimensions of mental health mostly correlated with serum Mg2+ (r = 0.68, p = 0.04) and K+ (r = 0.55, p = 0.08), better physical health was associated with lower aldosterone levels (r = -0.61, p = 0.06). TTKG was neither associated with aldosterone levels nor with QoL parameters. No relevant abnormalities were observed in neither 24 h-ECG nor echocardiography. CONCLUSIONS: Hyperaldosteronism, K+ and Mg2+ were the most important parameters of QoL. TTKG was no suitable marker for hyperaldosteronism or QoL. Future confirmatory studies in SLT should assess QoL as well as aldosterone, K+ and Mg2+.

A mixed methods study of symptom perception in patients with chronic heart failure.

BACKGROUND: Early heart failure (HF) symptoms are frequently unrecognized for reasons that are unclear. We explored symptom perception in patients with chronic HF. METHODS: We enrolled 36 HF out-patients into a longitudinal sequential explanatory mixed methods study. We used objectively measured thoracic fluid accumulation and daily reports of signs and symptoms to evaluate accuracy of detected changes in fluid retention. Patterns of symptom interpretation and response were explored in telephone interviews conducted every 2 weeks for 3-months. RESULTS: In this sample, 44% had a mismatch between objective and subjective fluid retention; younger persons were more likely to have mismatch. In interviews, two patterns were identified: those able to interpret and respond appropriately to symptoms were higher in decision-making skill and the quality of social support received. CONCLUSION: Many HF patients were poor at interpreting and managing their symptoms. These results suggest a subgroup of patients to target for intervention.

Nutritional Problems Affecting Older Adults.

Nutritional problems, such as malnutrition, dehydration, and electrolyte imbalance, are multifaceted and complex issues for older adults. This article describes these potential nutritional problems and then discusses evidence-based assessment strategies and treatment modalities that target these problems. Micronutrient deficiency is explored and evidence-based supplementation discussed. Many factors contribute to weight loss and malnutrition in older adults. These factors are classified as social, psychological, and/or biological. Addressing these issues and the influence of oral health on food intake are imperative to enhancing the overall quality of life for older adults.

A 40-day water-only fast by a Pentecostal woman: clinical and religious observations.

A 57-year-old woman presented to the hospital after a 40-day acaloric (water-only) fast, which was motivated by her Christian beliefs and Pentecostal affiliation. She exhibited hyponatremia on admission, and developed hypokalemia, hypophosphatemia and hypomagnesemia during refeeding. The authors are unaware of other published case reports describing medical and religious aspects of prolonged fasting by Christians for spiritual reasons. Nevertheless, this practice is advocated by some Pentecostal and non-Pentecostal sources, and may be more common than is widely recognized.

Is salt, vitamin, or endocrinopathy causing this encephalopathy? A review of endocrine and metabolic causes of altered level of consciousness.

Altered level of consciousness describes the reason for 3% of critical emergency department (ED) visits. Approximately 85% will be found to have a metabolic or systemic cause. Early laboratory studies such as a bedside glucose test, serum electrolytes, or a urine dipstick test often direct the ED provider toward endocrine or metabolic causes. This article examines common endocrine and metabolic causes of altered mentation in the ED via sections dedicated to endocrine-, electrolyte-, metabolic acidosis-, and metabolism-related causes.

Hydration and the physiological responses to acute normobaric hypoxia.

OBJECTIVE: The effect hydration status has on exposure to hypoxia is unclear. The purpose of the study was to identify how hydration status, above and below euhydrated levels, affects the physiological responses and onset of acute mountain sickness symptoms during acute normobaric hypoxia. METHODS: Eight males completed intermittent walking tests under normobaric hypoxic conditions (FIo2 = 0.13) after controlled hyperhydration, hypohydration, and euhydration protocols. A range of physiological, psychological, and altitude illness markers were monitored throughout the 125-minute exposure. RESULTS: Heart rate, core temperature, peripheral arterial oxygen saturation, urine osmolality, and mean self-reported Lake Louise Questionnaire acute mountain sickness scores were significantly different between euhydration, hypohydration, and hyperhydration, respectively, and closely correlated with environmental symptoms questionnaire, Lake Louise questionnaire, and headache scores (P < .05). Other measures of ventilation and lung function were also significantly different between hydration conditions (P < .05). CONCLUSIONS: Hydration state above and below euhydration has detrimental consequences on physiological strain and onset of acute mountain sickness symptoms when exposed to acute normobaric hypoxia.

Weight restoration in a patient with anorexia nervosa on dialysis.

OBJECTIVE: We report a case of weight restoration in a patient with anorexia nervosa, end-stage renal disease (ESRD) requiring dialysis, and cardiac insufficiency. METHOD: The technical challenges and ethical issues involved in her clinical management are reviewed. Renal insufficiency is a common complication of more severe anorexia nervosa. RESULTS: Progression to renal failure, when it occurs, is most typically a terminal event. There are currently no published guidelines for monitoring the weight gain of patients undergoing dialysis. CONCLUSION: We present a case of a patient who progressed from renal insufficiency to renal failure while in treatment for anorexia nervosa, and who was ultimately successfully weight restored while on renal dialysis.

Salt preference in adolescence is predicted by common prenatal and infantile mineralofluid loss.

We investigated early determinants of salt preference in humans. In animals, physiological events, among them perinatal mineralofluid loss, contribute to long-term salt intake. Recent findings suggest that in humans prenatal mineralofluid loss (high levels of maternal vomiting) may increase the lifelong avidity for salt in offspring. Here we report that commonly occurring events that cause mild fluid loss and electrolyte imbalance in infancy, as well as prenatally, predict the avidity for salt in adolescents. Using questionnaires, 50 mothers recalled incidence and severity of infantile diarrhea and vomiting in their adolescent offspring. The adolescents' avidity for salt was determined by testing the preferred concentration of salt in soup, voluntary consumption of salty snack items, and by self report of salt use habits, and a dietary questionnaire. A reported history of mineralofluid loss including maternal vomiting and infantile vomiting and diarrhea increases the avidity for salt but not for sweet. Thus, commonly occurring early mineralofluid loss may contribute to lifelong salt intake. The findings raise the possibility that other causes of mineralofluid loss such as hemorrhage, exercise-induced dehydration, or neonatal diuretic therapy may also increase the avidity for salt, and its attendant health risks.

Psychogenic polydipsia after traumatic brain injury. A case report.

Electrolyte abnormalities are common medical complications of traumatic brain injury (TBI). Hyponatremia is the most common of these disorders. The syndrome of inappropriate antidiuretic hormone and cerebral salt-wasting are the most well known causes of hyponatremia following TBI. In the presence of polydipsia and polyuria, psychogenic polydipsia should be included in the differential diagnosis. It is important to distinguish among these entities because treatment differs to such an extent that improper diagnosis may lead to a worsening of the patient's condition. We present a patient who presented with a new onset of polyuria and polydipsia after sustaining a TBI. Evaluation, including monitoring of fluid intake and output, serum and urine sodium and osmolarity, as well as a fluid deprivation test revealed the cause to be psychogenic polydipsia. The patient's symptoms improved after institution of a behavioral program and fluid restriction. Various models of drinking behavior have been used to identify the site of dysregulation. Dopaminergic, cholinergic, and hippocampal etiologies have been implicated in this abnormality of fluid homeostasis. If disorders of these systems can lead to psychogenic polydipsia, it is reasonable to believe that a person who has sustained a TBI would be at higher risk of developing psychogenic polydipsia.

Elderly female patients in continuing care: why are they hyperosmolar?

We have shown that the majority of elderly female patients in continuing care are in a hyperosmolar state. Thirty-two out of thirty-nine subjects had an osmolality greater than 295 mosm/kg and the mean osmolality was 302 +/- 8 mosm/kg (range 280-317 mosm/kg). No significant relationship was found with the degree of confusion (rs = 0.31; p greater than 0.05). In the second part of the study neither the measured degree of hydration, or any acute, small increases in fluid input influenced the plasma osmolality.