Sodium Intake and Chronic Kidney Disease.

In Chronic Kidney Disease (CKD) patients, elevated blood pressure (BP) is a frequent finding and is traditionally considered a direct consequence of their sodium sensitivity. Indeed, sodium and fluid retention, causing hypervolemia, leads to the development of hypertension in CKD. On the other hand, in non-dialysis CKD patients, salt restriction reduces BP levels and enhances anti-proteinuric effect of renin-angiotensin-aldosterone system inhibitors in non-dialysis CKD patients. However, studies on the long-term effect of low salt diet (LSD) on cardio-renal prognosis showed controversial findings. The negative results might be the consequence of measurement bias (spot urine and/or single measurement), reverse epidemiology, as well as poor adherence to diet. In end-stage kidney disease (ESKD), dialysis remains the only effective means to remove dietary sodium intake. The mismatch between intake and removal of sodium leads to fluid overload, hypertension and left ventricular hypertrophy, therefore worsening the prognosis of ESKD patients. This imposes the implementation of a LSD in these patients, irrespective of the lack of trials proving the efficacy of this measure in these patients. LSD is, therefore, a rational and basic tool to correct fluid overload and hypertension in all CKD stages. The implementation of LSD should be personalized, similarly to diuretic treatment, keeping into account the volume status and true burden of hypertension evaluated by ambulatory BP monitoring.

To salt or not to salt?-That is the question in cirrhosis.

Ascites is the most common complication of patients with cirrhosis, resulting from portal hypertension and vasodilatation. It is associated with an increased risk for the development of hyponatraemia and renal failure and has a high mortality rate of 20% per year. The development of ascites represents a baleful sign in the course of disease in cirrhosis. To prevent complications of cirrhosis and improve quality of life, an effective management of ascites is pivotal. Combined salt restriction and diuretic therapy is recommended as first-line therapy in numerous clinical practice guidelines. In contrast, there has been a debate on whether a strict salt-restricted diet for cirrhosis patients should be used at all since salt restriction may increase the risk for malnutrition which in turn may negatively impact on quality of life and survival. This review aims to summarize the current pros and cons regarding salt restriction in patients with cirrhosis and proposes the importance of achieving a sodium balance throughout different stages of cirrhosis.

Síndrome de realimentación en pediatría: clínica, diagnóstico, prevención y tratamiento / Refeeding syndrome in children: symptoms, diagnosis, prevention and management

El síndrome de realimentación es un proceso fisiopatológico asociado a trastornos de la glucosa y desequilibrio hidroelectrolítico que involucran principalmente a los iones intracelulares (fosfato, potasio y magnesio). Este síndrome se asocia con el soporte nutricional (oral, enteral o parenteral) en pacientes con riesgo de desnutrición o con desnutrición severa. Es muy importante valorar la presencia de factores de riesgo, estudiar los iones séricos e iniciar la alimentación de manera progresiva. El apoyo nutricional correcto es fundamental, con la supervisión diaria de los electrólitos séricos, los signos vitales y el equilibrio de líquidos, así como un correcto diseño del soporte nutricional (AU)

Refeeding syndrome (RFS) is a term that describes the metabolic and clinical changes that occur on aggressive nutritional rehabilitation of a malnourished patient. A shift from carbohydrate metabolism to fat and protein catabolism occurs. Hypophosphatemia is the hallmark of RFS. Other electrolyte abnormalities are associated with RFS, however, such as hypokalemia and hypomagnesemia. RFS is associated to any nutritional support (more frequently to parenteral nutrition) in malnourished patients'. A proper nutritional support is required to avoid RFS, checking daily liquid balance, electrolytes and vital signs (AU)

Applicability of nursing outcomes in patients with heart failure and fluid volume excessive. / Aplicabilidade dos resultados de enfermagem em pacientes com insuficiência cardíaca e volume de líquidos excessivo.

OBJECTIVE: The purpose of this study was to test the clinical applicability of the Nursing Outcomes Classification in patients with decompensated heart failure and the nursing diagnosis of fluid volume excess. METHODS: This is a longitudinal study conducted in two stages at a university hospital, in 2013. During the first stage the consensus of experts was used to select the nursing outcomes and the indicators related to diagnosing fluid volume excess. The longitudinal study was conducted in the second stage to clinically evaluate the patients using the instrument containing the results and indicators produced in the consensus. RESULTS: A total of 17 patients were assessed. The nursing outcomes were measured during the clinical evaluation by analysing their indicators. The scores increased in six of the results, in comparison with the average results of the first and last assessment. The Nursing Outcomes Classification during medical practice revealed a clinical improvement among the patient who were admitted following decompensated heart failure. CONCLUSION: The Nursing Outcomes Classification managed to detect changes in the clinical status of patients.

Sodium restriction in patients with cirrhotic ascites: a protocol for a systematic review.

BACKGROUND: Avid renal sodium and water retention among other mechanisms produce ascites in patients with cirrhosis. The main guidelines recommend sodium intake reduction in order to counteract this complication. However, some randomized controlled trials have suggested a lack of benefit with a sodium-restricted over an unrestricted diet, and even an increase in ascites and renal complications has been reported. There are no systematic reviews addressing this question. METHODS: A systematic review protocol has been designed and will be reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). We will search for randomized controlled trials evaluating a salt-restricted versus unrestricted regime in patients with cirrhosis and ascites in EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials. We will also try to identify literature by reviewing reference list of included studies and relevant reviews, screening main conference proceedings, and searching for unpublished and ongoing trials in the World Health Organization (WHO) International Clinical Trials Registry Platform. Two researchers will independently undertake selection of studies, data extraction, and assessment of the quality of included studies. We will estimate pooled risk ratios for dichotomous data and the mean difference or standardized mean difference for continuous outcomes. A random effect model will be used for meta-analyses. Data synthesis and other analyses will be conducted using RevMan software. ETHICS AND DISSEMINATION: no ethics approval is considered necessary. Results of this study will be disseminated via peer-reviewed publications and social networks DISCUSSION: Sodium restriction is a widely accepted coadjuvant therapy for ascites; however, this indication is based primarily on expert recommendations. As far as we know, this will be the first systematic review assessing the effects of a sodium-restricted diet for ascites in cirrhotic patients. Our systematic review will aim to provide a high-quality synthesis of current evidence for patients and clinicians about this question. The main limitation might result from the reduced number and quality of primary studies available. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015022161.

Aplicabilidade dos resultados de enfermagem em pacientes com insuficiência cardíaca e volume de líquidos excessivo / Aplicabilidad de los resultados de enfermería en pacientes con insuficiencia cardíaca y exceso de volumen de líquidos / Applicability of nursing outcomes in patients with heart failure and fluid volume excessive

RESUMO Objetivo Testar a aplicabilidade clínica da Nursing Outcomes Classification em pacientes com insuficiência cardíaca descompensada e Diagnóstico de Enfermagem Volume de Líquidos Excessivo. Métodos Estudo longitudinal conduzido em duas etapas em um hospital universitário no ano de 2013. Na primeira etapa, utilizou-se a validação por consenso de especialistas para selecionar os resultados de enfermagem e os indicadores relacionados ao diagnóstico de enfermagem; na segunda, foi realizado um estudo longitudinal para avaliação clínica dos pacientes, utilizando-se o instrumento contendo os resultados e indicadores produzidos no consenso. Resultados Foram realizadas avaliações em 17 pacientes. Na avaliação clínica, mensuraram-se os resultados de enfermagem através da avaliação de seus indicadores. Seis resultados apresentaram aumento nos escores, quando comparados às médias da primeira e da última avaliação. A utilização da Nursing Outcomes Classification na prática clínica demonstrou melhora dos pacientes internados por insuficiência cardíaca descompensada. Conclusão A Nursing Outcomes Classification foi sensível às alterações no quadro clínico dos pacientes.

RESUMEN Objetivo Testar la aplicabilidad clínica de la Nursing Outcomes Classification en pacientes con insuficiencia cardíaca descompensada y Diagnóstico de Enfermería Volumen de Líquidos Excesivo. Método Estudio longitudinal, realizado en dos etapas, en un hospital universitario, en 2013. En la primera etapa se utilizó la validación por consenso de especialistas para seleccionar los resultados de enfermería y los indicadores relaciones al diagnóstico de enfermería; en la segunda fue realizado un estudio longitudinal para evaluación clínica de los pacientes, utilizándose el instrumento que contiene los resultados y los indicadores producto del consenso. Resultados Fueron realizadas evaluaciones en 17 pacientes. Durante la evaluación clínica se midieron los resultados de enfermería a través de la evaluación de sus indicadores. Seis resultados mostraron un aumento en las puntuaciones, cuando se comparó las medias de los resultados de la primera y última evaluación. La utilización de la Nursing Outcomes Classification en la práctica clínica fue capaz de demostrar mejoría clínica de los pacientes internados por insuficiencia cardíaca descompensada. Conclusión La Clasificación de Resultados de Enfermería fue sensible a las alteraciones en el cuadro clínicos de los pacientes.

ABSTRACT Objective The purpose of this study was to test the clinical applicability of the Nursing Outcomes Classification in patients with decompensated heart failure and the nursing diagnosis of fluid volume excess. Methods This is a longitudinal study conducted in two stages at a university hospital, in 2013. During the first stage the consensus of experts was used to select the nursing outcomes and the indicators related to diagnosing fluid volume excess. The longitudinal study was conducted in the second stage to clinically evaluate the patients using the instrument containing the results and indicators produced in the consensus. Results A total of 17 patients were assessed. The nursing outcomes were measured during the clinical evaluation by analysing their indicators. The scores increased in six of the results, in comparison with the average results of the first and last assessment. The Nursing Outcomes Classification during medical practice revealed a clinical improvement among the patient who were admitted following decompensated heart failure. Conclusion The Nursing Outcomes Classification managed to detect changes in the clinical status of patients.

Use of a symbiotic supplement in a child with short bowel Syndrome; a case report / Uso de suplemento simbiótico en un niño con síndrome del intestino corto; caso clínico

The short bowel syndrome (SBS) is due to loss of bowel after surgery. Characterized by generalized nutrients malabsorption, its signs and symptoms include electrolyte imbalance, deficiency of vitamins, minerals and nutrients that can lead to death. Parenteral and enteral nutrition have a key role in its treatment. Objective: To describe the clinical course of a patient with SBS during continuous use of enteral nutrition supplemented with symbiotic. Case report: A seven-year-old male underwent an emergency laparotomy at 18 months old with a massive bowel resection, remaining about 20 cm of the small intestine and the entire colon. He was dependent of exclusive parenteral nutrition for over a year, leading to the occurrence of numerous infectious complications. Due to complications caused by prolonged use of central venous access, was unable to continue to receive the parenteral nutrition. Enteral nutrition by a nasogastric tube and supplemental symbiotic was the nutritional therapy option for him. The assessment of the volume of losses by the colostomy was measured daily. Results: There was a significant reduction of losses bycolostomy, especially in the first days after introduction of the enteral nutrition plus symbiotic supplementation, as well as significant decrease in gas production. Conclusion: Despite the lack of evidence for a formal recommendation on the use of symbiotic for SBS patients, its use in the nutritional therapy of this patient resulted in reduced electrolyte loss electrolyte and consequent improvement of his clinical and nutritional condition (AU)

El síndrome del intestino corto (SIC) se debe a una pérdida intestinal tras cirugía. Caracterizado por una mal absorción generalizada de nutrientes, sus signos y síntomas incluyen el desequilibrio electrolítico y la deficiencia de vitaminas, minerales y nutrientes que pueden acarrearla muerte. La nutrición parenteral y enteral tiene un papel clave en su tratamiento. Objetivo: Describir el curso clínico de un paciente con SIC durante el uso continuo de nutrición enteral suplementada con un simbiótico. Caso clínico: Un chico de siete años fue sometido a una laparotomía urgente a los 18 meses de edad con una resección intestinal masiva, quedando sólo 20 cm de intestino delgado y el colon al completo. Dependió de nutrición parenteral exclusiva durante más de un año, lo que le produjo numerosas complicaciones infecciosas. Debido a las complicaciones causadas por el uso prolongado de un acceso venoso central, no pudo continuar recibiendo la nutrición parenteral. La opción terapéutica para él fue la nutrición enteral a través de una sonda nasogástrica y un suplemento simbiótico. Se evaluaron a diario las pérdidas de volumen a través de la colostomía. Resultados: Hubo una reducción significativa de las pérdidas por la colostomía, especialmente en los primeros días de la introducción de la nutrición enteral y la suplementación simbiótica, así como un descenso significativo de la producción de gas. Conclusión: A pesar de la falta de evidencia de una recomendación formal para el uso de simbiótico en pacientes con SIC, su empleo en la terapia nutricional de este paciente produjo una reducción de la pérdida de electrolitos y la consiguiente mejoría de su situación clínica y nutricional (AU)

Hop (Humulus lupulus L.) extract inhibits obesity in mice fed a high-fat diet over the long term.

Hops (Humulus lupulus L.) are traditionally used to add bitterness and flavour to beer. Although the isomerised hop extracts produced by the brewing process have been thought to ameliorate lipid and glucose metabolism, the influence of untreated hop extracts on high-fat (HF) diet-induced obesity is unclear. The present study examined the anti-obesity effects of a hop extract in male C57BL/6J mice fed a HF diet, or HF diet plus 2 or 5 % hop extract for 20 weeks. The oral glucose tolerance test was performed at week 19. Furthermore, water excretion was evaluated in water-loaded Balb/c male mice. The effects of the extract on lipid accumulation and PPARγ expression in 3T3-L1 adipocytes were examined. The hop extract inhibited the increase in body and adipose tissue weight, adipose cell diameter and liver lipids induced by the HF diet. Furthermore, it improved glucose intolerance. The extract enhanced water excretion in water-loaded mice. Various fractions of the hop extract inhibited lipid accumulation and PPARγ expression in 3T3-L1 adipocytes. Hop extracts might be useful for preventing obesity and glucose intolerance caused by a HF diet.

'Refeeding syndrome' in a Kuwaiti child: clinical diagnosis and management.

OBJECTIVE: To report a case of refeeding syndrome in a Kuwaiti child, its clinical presentation and management. CLINICAL PRESENTATION AND INTERVENTION: A 13-month-old Kuwaiti boy presented with acute severe malnutrition in the form of marasmic kwashiorkor. On admission, blood sugar and serum electrolytes were normal but on the 3rd day he developed typical biochemical features of refeeding syndrome in the form of hyperglycemia, severe hypophosphatemia, hypokalemia, hypocalcemia and hypomagnesemia. The child then received treatment appropriate for refeeding syndrome in the form of lower calorie intake with gradual increase, as well as supplementation of electrolytes, thiamine and vitamins and he eventually made a safe recovery. CONCLUSION: This case showed that during rehabilitation of a malnourished child, a severe potentially lethal electrolyte disturbance (refeeding syndrome) can occur. Careful monitoring of electrolytes before and during the refeeding phase was needed and helped to detect this syndrome early. We suggest that slow and gradual calorie increase in the 'at-risk' patient can help prevent its occurrence.

Síndrome de realimentación / Refeeding syndrome

El síndrome de realimentación (SR) es un cuadro clínico complejo que ocurre como consecuencia de la reintroducción de la nutrición (oral, enteral o parenteral) en pacientes malnutridos. Los pacientes presentan trastornos en el balance de fl uidos, anomalías electrolíticas —como hipofosfatemia, hipopotasemia e hipomagnesemia— alteraciones en el metabolismo hidrocarbonado y déficits vitamínicos. Esto se traduce en la aparición de complicaciones neurológicas, respiratorias, cardíacas, neuromusculares y hematológicas. En este artículo se han revisado la patogenia y las características clínicas del SR, haciendo alguna sugerencia para su prevención y tratamiento. Lo más importante en la prevención del SR es identificar a los pacientes en riesgo, instaurar el soporte nutricional de forma prudente y realizar una corrección adecuada de los déficits de electrolitos y vitaminas (AU)

Refeeding syndrome is a complex syndrome that occurs as a result of reintroducing nutrition (oral, enteral or parenteral) to patients who are starved or malnourished. Patients can develop fluid-balance abnormalities, electrolyte disorders (hypophosphataemia, hypokalaemia and hypomagnesaemia), abnormal glucose metabolism and certain vitamin defi ciencies. Refeeding syndrome encompasses abnormalities affecting multiple organ systems, including neurological, pulmonary, cardiac, neuromuscular and haematological functions. Pathogenic mechanisms involved in the refeeding syndrome and clinical manifestations have been reviewed. We provide suggestions for the prevention and treatment of refeeding syndrome. The most important steps are to identify patients at risk, reintroduce nutrition cautiously and correct electrolyte and vitamin defi ciencies properly (AU)

Fluid and electrolyte balance in ultra-endurance sport.

It is well known that fluid and electrolyte balance are critical to optimal exercise performance and, moreover, health maintenance. Most research conducted on extreme sporting endeavour (>3 hours) is based on case studies and studies involving small numbers of individuals. Ultra-endurance sportsmen and women typically do not meet their fluid needs during exercise. However, successful athletes exercising over several consecutive days come close to meeting fluid needs. It is important to try to account for all factors influencing bodyweight changes, in addition to fluid loss, and all sources of water input. Increasing ambient temperature and humidity can increase the rate of sweating by up to approximately 1 L/h. Depending on individual variation, exercise type and particularly intensity, sweat rates can vary from extremely low values to more than 3 L/h. Over-hydration, although not frequently observed, can also present problems, as can inappropriate fluid composition. Over-hydrating or meeting fluid needs during very long-lasting exercise in the heat with low or negligible sodium intake can result in reduced performance and, not infrequently, hyponatraemia. Thus, with large rates of fluid ingestion, even measured just to meet fluid needs, sodium intake is vital and an increased beverage concentration [30 to 50 mmol/L (1.7 to 2.9 g NaCl/L) may be beneficial. If insufficient fluids are taken during exercise, sodium is necessary in the recovery period to reduce the urinary output and increase the rate of restoration of fluid balance. Carbohydrate inclusion in a beverage can affect the net rate of water assimilation and is also important to supplement endogenous reserves as a substrate for exercising muscles during ultra-endurance activity. To enhance water absorption, glucose and/or glucose-containing carbohydrates (e.g. sucrose, maltose) at concentrations of 3 to 5% weight/volume are recommended. Carbohydrate concentrations above this may be advantageous in terms of glucose oxidation and maintaining exercise intensity, but will be of no added advantage and, if hyperosmotic, will actually reduce the net rate of water absorption. The rate of fluid loss may exceed the capacity of the gastrointestinal tract to assimilate fluids. Gastric emptying, in particular, may be below the rate of fluid loss, and therefore, individual tolerance may dictate the maximum rate of fluid intake. There is large individual variation in gastric emptying rate and tolerance to larger volumes. Training to drink during exercise is recommended and may enhance tolerance.

Thermoregulation and marathon running: biological and environmental influences.

The extreme physical endurance demands and varied environmental settings of marathon footraces have provided a unique opportunity to study the limits of human thermoregulation for more than a century. High post-race rectal temperatures (Tre) are commonly and consistently documented in marathon runners, yet a clear divergence of thought surrounds the cause for this observation. A close examination of the literature reveals that this phenomenon is commonly attributed to either biological (dehydration, metabolic rate, gender) or environmental factors. Marathon climatic conditions vary as much as their course topography and can change considerably from year to year and even from start to finish in the same race. The fact that climate can significantly limit temperature regulation and performance is evident from the direct relationship between heat casualties and Wet Bulb Globe Temperature (WBGT), as well as the inverse relationship between record setting race performances and ambient temperatures. However, the usual range of compensable racing environments actually appears to play more of an indirect role in predicting Tre by acting to modulate heat loss and fluid balance. The importance of fluid balance in thermoregulation is well established. Dehydration-mediated perturbations in blood volume and blood flow can compromise exercise heat loss and increase thermal strain. Although progressive dehydration reduces heat dissipation and increases Tre during exercise, the loss of plasma volume contributing to this effect is not always observed for prolonged running and may therefore complicate the predictive influence of dehydration on Tre for marathon running. Metabolic heat production consequent to muscle contraction creates an internal heat load proportional to exercise intensity. The correlation between running speed and Tre, especially over the final stages of a marathon event, is often significant but fails to reliably explain more than a fraction of the variability in post-marathon Tre. Additionally, the submaximal exercise intensities observed throughout 42 km races suggest the need for other synergistic factors or circumstances in explaining this occurrence. There is a paucity of research on women marathon runners. Some biological determinants of exercise thermoregulation, including body mass, surface area-to-mass ratio, sweat rate, and menstrual cycle phase are gender-discrete variables with the potential to alter the exercise-thermoregulatory response to different environments, fluid intake, and exercise metabolism. However, these gender differences appear to be more quantitative than qualitative for most marathon road racing environments.

Fluid and electrolyte management in the pediatric surgical patient.

The following is a quick guide to the perioperative fluid program discussed 1. Always assess the state of fluid repletion in any patient presenting for surgical management (Note: This does not necessarily mean operative management). 2. If the patient is hypovolemic or if there is the possibility of hypovolemia and you are uncertain, restore volumes equal to 25% of the patient's blood volume with a fluid push made up of an osmotically active electrolyte solution modified for the additional requirements of red cell carrying capacity or clotting factors. If this results in a urine output and correction of hypoperfusion or hypotension, maintain an increased fluid administration program until a stable urine output and good perfusion are achieved. If the patient is normovolemic at the time of presentation, particularly if the patient is having an elective operative procedure and does not have an intravenous line in place, calculate the insensible losses that will occur during the time of fluid restriction before surgery and correct at least 50% of these during the operative procedure. 3. Develop the postoperative fluid program as a combination of 24-hour insensible loss replacement (maintenance fluid), restoration of measured losses, and an estimate (guess) as to the volume requirements for third-space fluid shifts. Restore blood losses if appropriate or administer additional volumes of balanced electrolyte solution at a 3-to-1 ratio to replace measured blood loss. 4. Total the insensible loss measurement, the measured losses, and the estimate of third-space requirement and divide this volume by 24 to get an initial hourly fluid administration rate. 5. Select the most osmotically active fluid that you intend to use and administer it first at the calculated rate. Carefully monitor the patient's urine output. 6. Increase or decrease the fluid administration rate to bring the hourly urine output within the guidelines for the appropriate hourly urine output (milliliters) for the particular patient based on size (kilograms). 7. When the urine output falls within the appropriate range, maintain that rate of fluid administration, and recalculate the volumes required because of insensible loss, measured loss, and third-space shifts by subtracting the amount of fluid already administered from the volume that will be required in the remainder of the 24 hours; this will yield the volumes of additional maintenance, measured loss, and third-space fluids that will make up the remainder of the fluids needed for the 24 hours.(ABSTRACT TRUNCATED AT 400 WORDS)