Association of serum sodium levels with all-cause and cardiovascular mortality in chronic kidney disease: Results from a prospective observational study.

AIMS: The prevalence of hyponatraemia in the outpatient setting has not been thoroughly explored, and little is known about the prognostic implication of dysnatraemia in chronic kidney disease (CKD) patients, in particular accommodating the effect of concurrent medications. METHODS: This is a prospective observational study of non-dialysis-dependent CKD patients managed in a nephrology clinic. Patients enrolled between 2002 and 2012 in the Chronic Renal Insufficiency Standards Implementation Study were assessed. Survival analyses were performed using baseline sodium and 12-month time-averaged sodium, with adjustment for co-morbid diseases, laboratory findings and concurrent medications. RESULTS: At baseline (n = 2093), mean estimated glomerular filtration rate was 32.8 ± 15.9 ml/min per 1.73 m(2) , median age was 67 (interquartile range 56-75) years and median serum sodium concentration was 140 (138-142) mmol/l. After a follow up of 41 (18-67) months, there were 684 deaths, 174 from cardiovascular causes; 1925 time-averaged sodium values were analysed. In the Cox multivariate adjusted regression, baseline hyponatraemia, but not hypernatraemia, was independently associated with all-cause mortality (hazard ratio (HR) 1.35, 95% confidence interval (CI) 1.02-1.78, P = 0.04, and HR 1.15, 95% CI 0.84-1.57, P = 0.39, respectively). This was similarly the case for time-averaged hyponatraemia and hypernatraemia (HR 2.15, 95% CI 1.59-2.91, P < 0.01, and HR 1.47, 95% CI 0.93-2.38, P = 0.10, respectively). However, the association of baseline and time-averaged hyponatraemia with cardiovascular mortality was not significant. CONCLUSION: Hyponatraemia in the ambulatory setting is associated with all-cause but not cardiovascular mortality in CKD, independent of concomitant medications and co-morbidities.

Three-Dimensional Imaging of a Central Venous Dialysis Catheter Related Infected Thrombus.

Three-dimensional (3D) echocardiography is becoming widely available and with novel applications. We report an interesting case of a 68-year-old lady with a central venous thrombosis coincident with both a dialysis catheter infection and a recent pacemaker insertion. Two-dimensional transesophageal echocardiography was unable to delineate whether the thrombosis was involved with the pacemaker wire or due to the tunneled catheter infection. The use of 3D echocardiography was able to produce distinct images aiding diagnosis. This circumvented the need for invasive investigations and inappropriate, high-risk removal of the pacing wire. This case highlights the emerging application of 3D echocardiography in routine nephrology practice.

Sudden cardiac death in haemodialysis patients: preventative options.

Sudden cardiac death (SCD) is the most common cause of death in haemodialysis patients, accounting for 25% of all-cause mortality. There are many potential pathological precipitants as most patients with end-stage renal disease have structurally or functionally abnormal hearts. For example, at initiation of dialysis, 74% of patients have left ventricular hypertrophy. The pathophysiological and metabolic milieu of patients with end-stage renal disease, allied to the regular stresses of dialysis, may provide the trigger to a fatal cardiac event. Prevention of SCD can be seen as a legitimate target to improve survival in this patient group. In the general population, this is most effective by reducing the burden of ischaemic heart disease. However, the aetiology of SCD in haemodialysis patients appears to be different, with myocardial fibrosis, vascular calcification and autonomic dysfunction implicated as possible causes. Thus, the range of therapies is different to the general population. There are potential preventative measures emerging as our understanding of the underlying mechanisms progresses. This article aims to review the evidence for therapies to prevent SCD effective in the general population when applied to dialysis patients, as well as promising new treatments specific to this population group.