Hypernatremia at admission predicts poor survival in patients with terminal cancer: a retrospective cohort study.

BACKGROUND: Although palliative care providers, patients, and their families rely heavily on accurate prognostication, the prognostic value of electrolyte imbalance has received little attention. METHODS: As a retrospective review, we screened inpatients with terminal cancer admitted between January 2017 and May 2019 to a single hospice-palliative care unit. Clinical characteristics and laboratory results were obtained from medical records for multivariable Cox regression analysis of independent prognostic factors. RESULTS: Of the 487 patients who qualified, 15 (3%) were hypernatremic upon admission. The median survival time was 26 days. Parameters associated with shortened survival included male sex, advanced age (> 70 years), lung cancer, poor performance status, elevated inflammatory markers, azotemia, impaired liver function, and hypernatremia. In a multivariable Cox proportional hazards model, male sex (hazard ratio [HR] = 1.53, 95% confidence interval [CI]: 1.15-2.04), poor performance status (HR = 1.45, 95% CI: 1.09-1.94), leukocytosis (HR = 1.98, 95% CI: 1.47-2.66), hypoalbuminemia (HR = 2.06, 95% CI: 1.49-2.73), and hypernatremia (HR = 1.55, 95% CI: 1.18-2.03) emerged as significant predictors of poor prognosis. CONCLUSION: Hypernatremia may be a useful gauge of prognosis in patients with terminal cancer. Further large-scale prospective studies are needed to corroborate this finding.

Possible association between dysnatremias and mortality during hospitalization in patients undergoing acute hemodialysis: analysis from a Peruvian retrospective cohort / Possível associação entre distúrbios do sódio e mortalidade hospitalar em pacientes submetidos a hemodiálise aguda: análise de uma coorte retrospectiva peruana

Abstract Objective: To evaluate the association between dysnatremias or dyschloremias and mortality during hospitalization in patients with acute kidney injury (AKI) or chronic kidney disease (CKD) undergoing acute hemodialysis. Methods: We carried out a retrospective cohort study on adult patients undergoing acute hemodialysis with AKI or CKD diagnosis at a public hospital in Lima, Peru. Dysnatremias were categorized as hyponatremia (Na < 135mmol/L) or hypernatremia (Na > 145mmol/L), and dyschloremias were defined as hypochloremia (Cl < 98 mmol/L) or hyperchloremia (Cl > 109mmol/L). The outcome of interest was mortality during hospitalization. We performed generalized lineal Poisson family models with bias-corrected and accelerated non-parametric bootstrap to estimate the risk ratios at crude (RR) and adjusted analysis (aRR) by gender, age, HCO3 (for all patients) and Liaño score (only for AKI) with CI95%. Results: We included 263 patients (mean age: 54.3 years, females: 43%): 191 with CKD and 72 with AKI. Mortality was higher in patients with AKI (59.7%) than in patients with CKD (14.1%). In overall, patients with hypernatremia had a higher mortality during hospitalization compared to those who had normal sodium values (aRR: 1.82, 95% CI: 1.17-2.83); patients with hyponatremia did not have different mortality (aRR: 0.19, 95% CI: 0.69-2.04). We also found that hyperchloremia (aRR: 1.35, 95% CI: 0.83-2.18) or hypochloremia (aRR: 0.66, 95% CI: 0.30-14.78) did not increase mortality in comparison to normal chloride values. No association between dysnatremias or dyschloremias and mortality during hospitalization was found in CKD and AKI subgroups. Conclusions: In our exploratory analysis, only hypernatremia was associated with mortality during hospitalization among patients with AKI or CKD undergoing acute hemodialysis.

Resumo Objetivo: Avaliar a associação entre distúrbios do sódio ou do cloro e mortalidade hospitalar de pacientes com insuficiência renal aguda (IRA) ou doença renal crônica (DRC) submetidos a hemodiálise aguda. Métodos: O presente estudo de coorte retrospectiva incluiu pacientes adultos submetidos a hemodiálise aguda com diagnóstico de IRA ou DRC em um hospital público de Lima, Peru. Os distúrbios do sódio foram classificados como hiponatremia (Na < 135mmol/L) ou hipernatremia (Na > 145mmol/L), enquanto os distúrbios do cloro foram classificados como hipocloremia (Cl < 98 mmol/L) ou hipercloremia (Cl > 109mmol/L). O desfecho de interesse foi mortalidade hospitalar. Utilizamos modelos de Poisson da família de modelos lineares generalizados com bootstrap não-paramétrico e correção de viés acelerado para estimar os riscos relativos na análise bruta (RR) e ajustada (RRa) para sexo, idade, HCO3 (para todos os pacientes) e escore de Liaño (apenas para IRA) com IC 95%. Resultados: Foram incluídos 263 pacientes (idade média 54,3 anos; 43% do sexo feminino), 191 com DRC e 72 com IRA. A mortalidade foi mais elevada nos pacientes com IRA (59,7%) do que nos indivíduos com DRC (14,1%). No geral, os pacientes com hipernatremia tiveram mortalidade hospitalar mais elevada do que os indivíduos com valores normais de sódio (RRa: 1,82; IC 95%: 1,17-2,83). Os pacientes com hiponatremia não apresentaram mortalidade diferente (RRa: 0,19; IC 95%: 0,69-2,04). Também identificamos que hipercloremia (RRa: 1,35; IC 95%: 0,83-2,18) e hipocloremia (RRa: 0,66; IC 95%: 0,30-14,78) não elevaram a mortalidade em comparação a indivíduos com níveis normais de cloro. Não foi encontrada associação entre distúrbios do sódio ou do cloro e mortalidade hospitalar nos subgrupos com DRC e IRA. Conclusões: Em nossa análise exploratória, apenas hipernatremia apresentou associação com mortalidade hospitalar em pacientes com IRA ou DRC submetidos a hemodiálise aguda.

The prevalence of sodium abnormalities in moderate to severe traumatic brain injury patients in a level 1 Trauma unit in Durban.

BACKGROUND: The prevalence of sodium abnormalities in the moderate to severe brain injury patient is not known in the South African population. METHOD: Patients admitted to the trauma intensive care unit between January 2013 and June 2015 with moderate to severe traumatic brain injury were included in the study. Descriptive statistics, tests of association and tests of differences were used. RESULTS: There were 184 patients with 143 (77.7%) males and 41 (22.3%) females. Abnormal sodium was present in 126 (68.4%), 61 of whom had hyponatremia and 65 hypernatremia, a prevalence of 33.1% and 35.3% respectively. Of the 65 patients with hypernatremia, 52 (80%) had dehydration, 7 (10.7%) had diabetes insipidus (DI) and 6 (9.3%) had hyperosmolar therapy as the cause. Of the 61 patients with hyponatremia, the commonest cause was fluid overload in 47 patients (77.1%) with SIADH in 11 (18%) and CSWS in 3 (4.9%). Death occurred in 34 (18.5%) patients and diagnosis was found to be significantly associated with mortality (p = 0.01), the most common diagnoses amongst those who died being dehydration (29.4%), fluid overload (17.7%) and DI (14.7%). CONCLUSION: The prevalence of sodium abnormalities was 126 (68.4%) patients of whom 61 (33.1%) had hyponatremia and 65 (35.3%) hypernatremia. In those patients who survived, a later onset was related to a better outcome. The GOS in DI tended to be worse.

Associations of dysnatremias with mortality in chronic kidney disease.

BACKGROUND: Hyponatremia and hypernatremia are associated with death in the general population and those with chronic kidney disease (CKD). We studied the associations between dysnatremias, all-cause mortality and causes of death in a large cohort of Stage 3 and 4 CKD patients. METHODS: We included 45 333 patients with Stage 3 and 4 CKDs followed in a large healthcare system. Associations between hyponatremia (<136 mmol/L) and hypernatremia (>145), and all-cause mortality and causes of death (cardiovascular, malignancy related and non-cardiovascular/non-malignancy related) were studied using Cox proportional hazards and competing risk models. RESULTS: Dysnatremias were found in 9.2% of the study population. In separate multivariable Cox proportional hazards models using baseline serum sodium levels and time-dependent repeated measures, both hyponatremia and hypernatremia were associated with all-cause mortality. In the competing risk analyses, hyponatremia was significantly associated with increased risk for various cause-specific mortality categories [cardiovascular (hazard ratio, HR 1.16, 95% confidence interval, CI: 1.04, 1.30), malignancy related (HR 1.48, 95% CI: 1.33, 1.65) and non-cardiovascular/non-malignancy deaths (HR 1.25, 95% CI: 1.13, 1.39)], while hypernatremia was significantly associated with higher non-cardiovascular/non-malignancy mortality only (HR 1.36, 95% CI: 1.08, 1.72). CONCLUSIONS: In those with CKD, hyponatremia was associated with all-cause mortality, cardiovascular, malignancy and non-cardiovascular/non-malignancy-related deaths. Hypernatremia was associated with all-cause and non-cardiovascular/non-malignancy-related deaths. Further studies are needed to elucidate the mechanisms of differences in cause-specific death among CKD patients with hyponatremia and hypernatremia.

Pediatric liver transplant outcome using severe hypernatremic donors.

INTRODUCTION: Pediatric liver transplantation is limited by donation. In the last 5 years, urgent conditions have forced transplant teams to accept donors with minor suboptimal conditions, termed "extended donor criteria." Among those, the risk of using severe hypernatremic donors (SHD) for liver transplant is not yet well established. The aim of this study is to report the outcome of pediatric patients receiving grafts from SHD. METHODS: Clinical records of patients transplanted in the last 3 years at Hospital Luis Calvo Mackenna, Santiago, Chile, were reviewed. Outcome was evaluated in terms of patient and graft survival and complications potentially associated to the donor condition. RESULTS: Five of 33 deceased donor transplants presented with SHD. All recipients were waiting transplant in an acute condition, one of them in acute liver failure (ALF). No living related donor was available. Donors' serum sodium was 169 to 193 mEq/L before medical management and between 157 and 172 mEq/L at procurement. One patient died from sepsis related to biliary complications, and the patient suffering ALF developed primary graft nonfunction, received a second transplant 2 weeks later, and recovered to stable medical condition. No other complication was registered in these patients. DISCUSSION: Our findings allow us to postulate that hypernatremic deceased donors may be used for pediatric liver transplant under special circumstances.

Preoperative hypernatremia predicts increased perioperative morbidity and mortality.

BACKGROUND: The prognostic implications of preoperative hypernatremia are unknown. We sought to determine whether preoperative hypernatremia is a predictor of 30-day perioperative morbidity and mortality. METHODS: We conducted a cohort study using the American College of Surgeons-National Surgical Quality Improvement Program and identified 908,869 adult patients undergoing major surgery from approximately 300 hospitals from the years 2005 to 2010. We followed the patients for 30-day perioperative outcomes, which included death, major coronary events, wound infections, pneumonia, and venous thromboembolism. Multivariable logistic regression was used to estimate the odds of 30-day perioperative outcomes. RESULTS: The 20,029 patients (2.2%) with preoperative hypernatremia (>144 mmol/L) were compared with the 888,840 patients with a normal baseline sodium (135-144 mmol/L). Hypernatremia was associated with a higher odds for 30-day mortality (5.2% vs 1.3%; adjusted odds ratio [aOR], 1.44; 95% confidence interval [CI], 1.33-1.56), and this finding was consistent in all subgroups. The odds increased according to the severity of hypernatremia (P < .001 for pairwise comparison for mild [145-148 mmol/L] vs severe [>148 mmol/L] categories). Furthermore, hypernatremia was associated with a greater odds for perioperative major coronary events (1.6% vs 0.7%; aOR, 1.16; 95% CI, 1.03-1.32), pneumonia (3.4% vs 1.5%; aOR, 1.23; 95% CI, 1.13-1.34), and venous thromboembolism (1.8% vs 0.9%; OR, 1.28; 95% CI, 1.14-1.42). CONCLUSION: Preoperative hypernatremia is associated with increased perioperative 30-day morbidity and mortality.

Intensive care-acquired hypernatremia after major cardiothoracic surgery is associated with increased mortality.

PURPOSE: Hypernatremia is common in the medical Intensive Care Unit (ICU) and has been described as an independent risk factor for mortality. Hypernatremia has not yet been studied in a collection of ICU patients after cardiothoracic surgery. Therefore, we wanted to determine the incidence of hypernatremia in a surgical ICU and its association with outcomes of critically ill surgical patients. METHODS: In this retrospective cohort study performed at a surgical ICU of a university hospital in Vienna, patients were admitted to the ICU after major cardiothoracic surgery between May 1999 and October 2007. Data on serum sodium in the ICU, ICU mortality, hospital mortality, and length of ICU stay were collected prospectively. RESULTS: 2,699 patients underwent surgery during the study period, and 2,314 patients were included in the study. Two hundred twenty-one (10%) patients acquired hypernatremia during their ICU stay. Median onset of hypernatremia was on day 4 (2-7). Patients with ICU-acquired hypernatremia had a higher ICU mortality (19%) compared to patients without hypernatremia (8%; p < 0.01). Length of ICU stay was increased in patients with hypernatremia (17 vs. 3 days; p < 0.01). In a multivariate Cox regression, ICU-acquired hypernatremia was an independent risk factor for ICU mortality within 28 days. CONCLUSIONS: Hypernatremia is a common event early in the course of critical illness after major cardiothoracic surgery and is independently associated with ICU mortality within 28 days. Future research should focus on the impact of hypernatremia on physiological functions as well as adequate and safe treatment of the electrolyte disorder.

Characterization of intensive care unit acquired hyponatremia and hypernatremia following cardiac surgery.

PURPOSE: Although intensive care unit (ICU) acquired sodium disturbances are common in critically ill patients, few studies have examined sodium disturbances in patients following cardiac surgery. The objective of this study was to describe the epidemiology of ICU-acquired hyponatremia and hypernatremia in patients following cardiac surgery. METHODS: We identified 6,727 adults (> or =18 yr) who were admitted consecutively to a regional cardiovascular intensive care unit (CVICU) from January 1, 2000 to December 31, 2006 and were documented as having normal serum sodium levels (133 to 145 mmol.L(-1)) during the first day of ICU admission. ICU-acquired hyponatremia and hypernatremia were defined as a change in serum sodium concentration to <133 mmol.L(-1) or >145 mmol.L(-1), respectively, following ICU day one. RESULTS: A first episode of ICU-acquired hyponatremia and hypernatremia developed in 785 (12%) and 242 (4%) patients, respectively, (95% confidence interval [CI] 11-12% and 95% CI 3-4%, respectively), with a respective incidence density of 4.2 and 1.3 patients per 100 days of ICU admission (95% CI 4.0-4.5 and 95% CI 1.2-1.5). The incidence of ICU-acquired sodium disturbances varied according to the patients' demographic and clinical variables for both hyponatremia (age, diabetes, Acute Physiology and Chronic Health Evaluation [APACHE II] score, mechanical ventilation, length of ICU stay, serum glucose level, and serum potassium level) and hypernatremia (APACHE II score, mechanical ventilation, length of hospital stay prior to ICU admission, length of ICU stay, serum glucose level, and serum potassium level). Compared with patients with normal serum sodium levels, hospital mortality was increased in patients with ICU-acquired hyponatremia (1.6% vs 10%, respectively; P < 0.001) and ICU-acquired hypernatremia (1.6% vs 14%, respectively; P < 0.001). CONCLUSION: ICU-acquired hyponatremia and hypernatremia are common complications in critically ill patients following cardiac surgery. They are associated with patient demographic and clinical characteristics and an increased risk of hospital mortality.

Hypo- and hypernatraemia in surgical patients: is there room for improvement?

BACKGROUND: Up to 30% of surgical inpatients develop complications related to fluid and electrolyte therapy. We sought to study the occurrence of hypo- and hypernatraemia in these patients to inform current standards of care. METHODS: This prospective audit took place over 80 days in a university hospital. Patients with a serum sodium concentration less than 130 or greater than 150 mmol/l were included. Daily intakes of Na(+), K(+) and Cl(-), and fluid balance were recorded before and after development of dysnatraemia. Fluid balance charts were assessed, as was the presence of documented patient weights. Patients were followed up until one of these milestones was reached: normonatraemia, death, or hospital discharge. RESULTS: During the study period 55 (4%) of the 1,383 surgical admissions met the inclusion criteria. Fifteen patients had hypernatraemia, 13 (87%) of whom were identified on ICU/HDU. In the days preceding the hypernatraemia, patients received (in mmol/day) a median (IQR) of 157 (76-344) Na(+), 38 (6-65) K(+), 157 (72-310) Cl(-), and 1.96 (1.13-2.96) L water. In the days preceding the hyponatraemia, patients received 50 (0-189) Na(+), 0 (0-10) K(+), 56 (0-188) Cl(-), and 1.45 (0-2.60) L water. Before the dysnatraemias only 28% of fluid balance charts were completed accurately. During the audit 42% of patients were not weighed. Dysnatraemic patients had a higher hospital mortality rate than those who did not develop dysnatraemia (12.7 vs. 2.3%, P < 0.001). CONCLUSIONS: Four percent of surgical inpatients developed dysnatraemias, which were associated with increased mortality. Fluid balance documentation was suboptimal and daily weights were not measured routinely, even in patients with severe electrolyte derangements.

¿Es frecuente la deshidratación hipernatrémica como causa de readmisión hospitalaria en recién nacidos? / Is hypernatremic dehydration a common readmission cause in newborns?

Objetivo: conocer la incidencia de deshidratación hipernatrémica (DH) asociada a ictericia así como sus características clínicas en neonatos ingresados a un hospital general. Material y Métodos: estudio exploratorio, prospectivo, descriptivo. Se incluyeron neonatos de término, ingresados por hiperbilirrubinemia, divididos en dos grupos, con y sin hipernatremia. Se compararon características perinatales, edad en la readmisión, pérdida de peso, fiebre, bilirrubina, manejo con antimicrobianos, presencia de alteraciones neurológicas y mortalidad. Resultados: se ingresaron 24 pacientes en un año, de los cuales 12 tuvieron sodio sérico elevado, con un promedio de 163,92 mmol/L. La incidencia fue de 5/1000 nacidos vivos. No se encontraron diferencias en cuanto a las características perinatales o cifras de bilirrubinas. La pérdida ponderal fue mayor en el grupo con DH. Dos pacientes presentaron alteraciones neurológicas y uno falleció. Conclusiones: la incidencia de la triada de deshidratación hipernatrémica, fiebre e ictericia puede ser mayor a la reportada.

Survival with serum sodium level of 180 mEq/L: permanent disorientation to place and time.

A 41-year-old woman who had undergone transfrontal craniotomy for a pituitary tumor 4 months before presentation was admitted with confusion and orientation only to self. She had a fever of 40 degrees C. Serum sodium and chloride levels on admission were 180 and 139 mEq/L, respectively. Measured serum osmolality was 380 mOsmol/L with a urine osmolality of 360 mOsmol/L. Magnetic resonance imaging revealed a 1.5-cm mass in the sella turcica, which was nonfunctioning on endocrine evaluation. The "bright spot" of a normal posterior pituitary was absent. Central diabetes insipidus was confirmed by a 300% increase in urine osmolality with desmopressin. The patient survived her severe hypernatremia, which has 70% mortality with a serum sodium level of 160 mEq/L or above. However, she developed permanent (6 months) disorientation to time and place even when hypernatremia was corrected, which has not been described previously.

Mortalidad asociada a hipo e hipernatremia en UCI / Mortality associated to hypo and hypernatremia in ICU

La hiponatremia y la hipernatremia son trastornos metabólicos frecuentes, de mayor incidencia en los pacientes más graves. En este estudio, en un total de 786 pacientes ingresados en la unidad de cuidados intensivos (UCI) del Hospital G. Fricke, durante un período de 27 meses, se encontró 22 sujetos con hiponatremia severa (2,8%) y 55 con hipernatremia (7%). Se analizaron las características de 74 pacientes con alteraciones de la natremia, principalmente orientadas hacia sus complicaciones y mortalidad. Los trastornos ocurrieron fundamentalmente en el hospital, siendo la hiponatremia más frecuente en las salas de cuidados convencionales y la hipernatremia más frecuente en la UCI. Dos tercios de los enfermos cursó con compromiso de conciencia. La hiponatremia se asoció la mayoría de las veces a un volumen extracelular normal y la hipernatremia, al aporte de sodio excesivo. Ambos compromisos de la natremia se relacionaron con fallas orgánicas importantes, siendo la insuficiencia respiratoria y la trombocitopenia más comunes en la hipernatremia. La mortalidad encontrada en los enfermos con hiponatremia (50%) y con hipernatremia (73%) fue significativamente mayor a la observada en aquéllos sin trastornos de la natremia en la UCI (22,5%), siendo mayor en la hipernatremia. Se concluye que, tanto la hiponatremia como la hipernatremia representan un elemento de gravedad en el pronóstico de los pacientes internados en la UCI

Hypernatremia in elderly patients. A heterogeneous, morbid, and iatrogenic entity.

The causes, therapy for, and consequences of hypernatremia in elderly patients are not well understood. We found that in 15,187 consecutive hospital admissions, 162 (1.1%) patients who were at least 60 years of age had serum sodium levels that measured greater than 148 meq/L. Of that 162, 57% had become hypernatremic in the hospital; the remaining 43% were hypernatremic at hospitalization. The mean peak serum sodium level was 154 meq/L (range, 149 to 182), and mean water deficit, 9% of total body water (range, 6% to 30%). The most frequent primary causes were complications of surgery (21%), febrile illness (20%), infirmity (11%), and diabetes mellitus (11%), with more than 40 causal factors identified. Depression of sensorium correlated with severity of hypernatremia (p less than 0.001). The mortality rate (42%) was seven times that of age-matched hospitalized patients, but was not predicted by severity of hypernatremia. Mortality increased with increasing rates of fluid replacement (p less than 0.008). Hypernatremia in elderly patients is usually iatrogenic and often a marker for severe associated systemic illness.