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.

Utility and Safety of Tolvaptan in Cirrhotic Patients with Hyponatremia: a Prospective Cohort Study

Abstract: Introduction and aim. Hyponatremia is common in patients with decompensated cirrhosis and is associated with increased mortality. Tolvaptan, a vasopressor V2 receptor antagonist, can increase free wáter excretion, but its efficacy and safety in cirrhotic patients remain unclear. Material and methods. We studied the usage and safety of tolvaptan in cirrhotic patients in a real-life, non-randomized, multicenter prospective cohort study. Forty-nine cirrhotic patients with hyponatremia were treated with tolvaptan 15 mg daily, and 48 patients not treated with tolvaptan in the same period served as controls. Improvement in serum sodium level was defined as an increase in serum sodium from < 125 to ≥ 125 mmol/L or from 125-134 to ≥ 135 mmol/L on day 7. Results. Twenty-three (47%) patients in the tolvaptan group and 17 (35%) in the control group had normal serum sodium on day 7 (p = 0.25). Serum sodium improved in 30 (61%) patients in the tolvaptan group and 17 (35%) patients in the control group (p = 0.011). Adverse events occurred in 46-47% of patients in both groups, and tolvaptan was not associated with worsened liver function. No patient with normal serum sodium on day 7 died within 30 days of treatment, whereas 16% of those with persistent hyponatremia died (p = 0.0019). Conclusion. In conclusion, short-term tolvaptan treatment is safe and can improve serum sodium level in cirrhotic patients with hyponatremia. Normalization of serum sodium level is associated with better survival.

Hyponatremia, acute kidney injury, and mortality in HIV-related toxoplasmic encephalitis

BACKGROUND: There are no reports on hyponatremia and acute kidney injury (AKI) involved in the course of HIV-related toxoplasmic encephalitis (TE). The main objective of this study was to describe the occurrence of hyponatremia and its relationship with AKI and mortality in HIV-related toxoplasmic encephalitis (TE). METHODS: This was a retrospective cohort study on patients with HIV-related TE. AKI was considered only when the RIFLE (risk, injury, failure, loss, end-stage) criterion was met, after the patient was admitted. RESULTS: A total of 92 patients were included, with a mean age of 36 ± 9 years. Hyponatremia at admission was observed in 43 patients (46.7%), with AKI developing in 25 (27.1%) patients during their hospitalization. Sulfadiazine was the treatment of choice in 81% of the cases. Death occurred in 13 cases (14.1%). Low serum sodium level correlated directly with AKI and mortality. Male gender (OR 7.89, 95% CI 1.22-50.90, p = 0.03) and hyponatremia at admission (OR 4.73, 95% CI 1.22-18.30, p = 0.02) were predictors for AKI. Independent risk factors for death were AKI (OR 8.3, 95% CI 1.4-48.2, p < 0.0001) and hyponatremia (or 9.9, 95% ci 1.2-96.3, p < 0.0001). CONCLUSION: AKI and hyponatremia are frequent in TE. Hyponatremia on admission is highly associated with AKI and mortality.

La hiponatremia al momento de ingreso como factor de riesgo de mortalidad hospitalaria / Hyponatremia on admission to the emergency room as a risk factor for hospital mortality

Background: Patients who develop hyponatremia during their hospitalization have higher hospital mortality. Aim: To determine if the presence of hyponatremia on admission to the emergency room is a risk factor for hospital mortality. Patients and Methods: Two hundred forty five patients consecutively admitted to the emergency room and then transferred to the Medicine Department, where they finally died, were matched for age and gender with 245 control subjects admitted to the emergency room and hospitalized in the Medicine Department at the same time, but survived. The dependent variable was death, and the exposure variable was hyponatremia. Admission diagnosis and Charlson comorbidity index was considered as confounding variables. Results: Hyponatremia at admission occurred in 30 and 17 percent of patients who died and survived, respectively, rendering an adjusted odds ratio for death of 2.13 (95 percent confidence intervals = 1.27-3.57). Charlson Comorbidity Index according to age score was higher in subjects with hyponatremia compared to those without hyponatremia (8.1 ± 3.1 and 7.2 ± 2.8; p = 0.01). Multivariate analysis showed that age, gender, length of stay, cause of hospitalization and chronic diseases did not significantly modify the effect of hyponatremia on hospital mortality. Conclusions: Hyponatremia on admission at emergency room had a significant association with hospital mortality. Subjects with hyponatremia had a higher Charlson Comorbidity Index score.

Aplicação do escore MELD em pacientes submetidos a transplante de fígado: análise retrospectiva da sobrevida e dos fatores preditivos a curto e longo prazo / The application of MELD score in patients submitted to liver transplantation: a retrospective analysis of survival and the predictive factors in the short and long term

RACIONAL: Utiliza-se o escore MELD (Model End-Stage Liver Disease) para o prognóstico da mortalidade em lista de espera para transplante de fígado e, em alguns estudos, para predição da sobrevida pós-operatória a longo prazo. OBJETIVO: Verificar a aplicação do escore MELD como predição da sobrevida após o transplante. MÉTODOS: Por intermédio de dados coletados prospectivamente efetuou-se um estudo de coorte longitudinal retrospectivo em 232 pacientes. Excluíram-se os retransplantes, insuficiência hepática aguda, crianças e enxertos duplos ou reduzidos. Avaliaram-se os dados dos doadores: idade, sexo, peso, creatinina, bilirrubina, sódio, aspartato aminotransferase, antecedentes pessoais, causa da morte, presença de esteatose, número de critérios expandidos do doador e índice de risco do doador. Em relação aos receptores, analisaram-se as variáveis: sexo, idade, peso, doença hepática, pontos de Child-Turcotte-Pugh, escore MELD, depuração de creatinina, sódio, tempos de isquemia e de hospitalização, quantidade de hemoderivados transfundidos, presença e grau de disfunção do enxerto. A análise estatística foi efetuada usando-se a análise de regressão univariada e/ou múltipla, estatística 'c', teste exato de Fisher, método de Kaplan-Meier (teste log-rank) para sobrevida, e análise de regressão de Cox para risco de óbito ajustado para as condições clínicas. RESULTADOS: O ponto de corte MELD para sobrevida foi 20 e de Child-Turcotte-Pugh foi 11,5. Para escore MELD maior ou igual a 20, os fatores preditivos de sobrevida foram: volume de sangue transfundido, disfunção do enxerto e o sódio do doador. Para os hiponatrêmicos os fatores preditivos de sobrevida foram: volume de sangue transfundido, disfunção do enxerto e sódio do doador. A sobrevida estimada para pacientes com escore MELD >25 foi menor ao final de 12 meses (68,86 por cento vs 39,13 por cento). A sobrevida estimada para os pacientes sem hiponatremia foi maior (65,16 por cento vs 44,44...

BACKGROUND: The model for end-stage liver disease (MELD) was developed to predict short-term mortality in patients with cirrhosis. There are few reports studying the correlation between MELD and long-term posttransplantation survival. AIM: To assess the value of pretransplant MELD in the prediction of posttransplant survival. METHODS: The adult patients (age >18 years) who underwent liver transplantation were examined in a retrospective longitudinal cohort of patients, through the prospective data base. We excluded acute liver failure, retransplantation and reduced or split-livers. The liver donors were evaluated according to: age, sex, weight, creatinine, bilirubin, sodium, aspartate aminotransferase, personal antecedents, brain death cause, steatosis, expanded criteria donor number and index donor risk. The recipients' data were: sex, age, weight, chronic hepatic disease, Child-Turcotte-Pugh points, pretransplant and initial MELD score, pretransplant creatinine clearance, sodium, cold and warm ischemia times, hospital length of stay, blood requirements, and alanine aminotransferase (ALT >1,000 UI/L = liver dysfunction). The Kaplan-Meier method with the log-rank test was used for the univariable analyses of posttransplant patient survival. For the multivariable analyses the Cox proportional hazard regression method with the stepwise procedure was used with stratifying sodium and MELD as variables. ROC curve was used to define area under the curve for MELD and Child-Turcotte-Pugh. RESULTS: A total of 232 patients with 10 years follow up were available. The MELD cutoff was 20 and Child-Turcotte-Pugh cutoff was 11.5. For MELD score > 20, the risk factors for death were: red cell requirements, liver dysfunction and donor's sodium. For the patients with hyponatremia the risk factors were: negative delta-MELD score, red cell requirements, liver dysfunction and donor's sodium. The regression univariated analyses came up with the following risk...

Hiponatremia como factor de riesgo de muerte en pacientes internados por neumonia adquirida en la comunidad / Hyponatremia as a risk factor of death in patients with community-acquired pneumonia requiring hospitalization

Investigamos si la hiponatremia es un factor de riesgo de muerte en pacientes internados por neumoníaadquirida en la comunidad (NAC) y estimamos el peso relativo de otros factores de riesgo de muerte por NAC, en un estudio de cohorte, prospectivo, multicéntrico, en 5 Servicios de Clínica Médica del Area Metropolitana de Buenos Aires. Evaluamos adultos con NAC ingresados entre 21 de marzo de 2000 y 21 de diciembre del mismo año. Los factores de riesgo que mostraron asociación con evolución por análisis univariado, fueron sometidos a análisis de regresión logística, con un nivel de significación de α de 0.05. En 9 meses seinternaron 238 pacientes con NAC: 150 (63%) varones y 88 (36%) mujeres, con edades medias 52.99 (±20.35)y 55.06 (±20.94) años, respectivamente. Fallecieron 25/238 (10.5%). En análisis multivariado, se asociaron significativamente con evolución: enfermedad vascular encefálica (EVE) (B: 2.614, p<0.001, RRE: 13.6, IC 95%: 3.7-49.6); hiponatremia al ingreso o durante la internación (B: 1.994, p<0.001, RRE: 7.3, IC 95%: 2.5-20.8); urea plasmática elevada (B: 0.016, p= 0.003, RRE: 1.016, IC 95%: 1.005-1.02). Desarrollamos una fórmula deprobabilidad de fallecer por NAC: P (óbito)= 1/1+ exp. – (-4.03 + 2.61x1 + 1.99x2 + 0.016x3), donde: x1= EVE(sí =1/no =0); x2= hiponatremia (sí =1/no =0); x3 = urea plasmática (mg/dl). La predictibilidad fue 91.1%. Elriesgo de fallecer por NAC fue significativamente mayor entre quienes presentaron EVE, hiponatremia y ureaplasmática elevada

We investigated whether hyponatremia is a risk factor of death in patients hospitalized with community-acquired pneumonia (CAP) and estimated the relative risk of death by CAP of otherrisk factors. The design was prospective multicentre cohort study. In 5 centers in Buenos Aires, Argentina, westudied adults hospitalized with CAP between March 21, 2000 and December 21, 2000. Using stepwise logisticregression, we analyzed risk factors that showed a univariate association with mortality; α significance level was0.05. During a 9-month period, 238 patients were admitted with CAP: 150 (63%) male and 88 (36%) female,mean age 52.99 (±20.35) and 55.06 (±20.94), respectively. Mortality was 10.5% (25/238). By multivariate analysis, the following variables were statistically associated with evolution: cerebrovascular disease (CD) (B: 2.614,p<0.001, RRE: 13.6, IC 95%: 3.7-49.6); hyponatremia at admission or during hospitalization (B: 1.994, p<0.001, RRE: 7.3, IC 95%: 2.5-20.8); and elevated blood urea (B: 0.016, p= 0.003, RRE: 1.016, IC 95%: 1.005-1.02). We developed a formula to predict mortality by CAP: P (death) = 1/1+ exp – (-4.03 + 2.61x1 + 1.99x2 + 0.016x3), where: x1= CD (yes=1/no =0); x2= hyponatremia (yes=1/no =0); x3 = blood urea (mg/dl). The predictability was 91.1%. The mortality risk by CAP was statistically higher in patients with CD, hyponatremia and elevated blood urea

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

Epidemiología de las hiponatremias en el Centro Médico Boliviano Belga / Epidemiology of hyponatremia at the Bolivian - Belgium Medical Center

Se revisan las historias clínicas de 139 pacientes con hiponatremia a fin de conocer la incidencia en pacientes ambulatorios hospitalarios, tanto médicos como quirúrgicos y críticos, las circunstancias en que se presenta y sus mecanismos responsables, evaluar la morbimortalidad asociada y el impacto de su corrección en el pronóstico de los pacientes. Se incluye en que es frecuente en hospitalizados de ambos sexos y mayores con las mas variadas patologías, por lo general leve a moderada pero asociada cuando no se la corrige a una mortalidad elevada dependiente de la enfermedad primaria.

Hiponatremia: estudo de sua epidemiologia e mortalidade / Hyponatremia: study of its epidemiology and mortality

Neste trabalho, 49 episódios de hiponatremia (0,78% dos casos internados no Hospital das Clínicas durante 90 dias) foram estudados. Mais de 90% dos casos foram intra-hospitalares e do tipo dilucional, sendo 34% classificados como hiponatremias graves (Na < 118 meq/1). Diuréticos, restriçäo de sal sem restriçäo de água foram os principais fatores desencadeantes. Sintomas neurológicos que poderiam ser explicados pela hiponatremia ocorreram em 10,8% dos casos, persistindo 4,3% com sintomas após o tratamento, sendo este feito com uma baixa velocidade de correçäo (0,16 ñ 0,004 meq/1 hora). Dez pacientes morreram, porém em apenas um caso o óbito poderia ter sido causado pelo distúrbio. Estes resusltados mostraram que a morbidade e a mortalidade da hiponatremia per si é baixa em nosso meio, que poucos pacientes tinham alteraçöes neurológicas e que a maioria se recuperou com o tratamento lento