Summary
Background
Hyponatremia has prognostic implications in patients with cirrhosis, and thus, has been incorporated in the 2016 MELD‐UNOS update. Changes in serum chloride are commonly perceived ...as ‘just’ parallel to changes in serum sodium. However, these are less well studied in the context of cirrhosis.
Aims
To investigate whether serum chloride independently predicts outcomes in patients with advanced chronic liver disease (ACLD) and stable clinical course or with critical illness.
Methods
891 patients with ACLD (defined by hepatic venous pressure gradient HVPG ≥6 mm Hg) were followed after HVPG measurement between 2003 and 2020 (ACLD cohort). 181 critically ill patients with cirrhosis admitted to the ICU between 2004 and 2007 were recruited for the ICU cohort. Hypo−/hypernatremia (normal: 136–145 mmol/L) and hypo−/hyperchloremia (normal: 98–107 mmol/L) at baseline were assessed.
Results
ACLD cohort: 68% of male patients with a median MELD (adjusted for Na) of 11 (9–17) were included (Child‐Pugh‐stages‐A/B/C: 46%/38%/16%) and followed for a median of 60 months. Lower serum chloride (adjusted average HR per mmol/L: 0.965 95% confidence interval (95% CI): 0.945–0.986, p = 0.001) showed a significant association with hepatic decompensation/liver‐related mortality on multivariable Cox regression analysis adjusted for age, HVPG, albumin and MELD. In line, hypochloremia was significantly associated with hepatic decompensation/liver‐related mortality (adjusted average HR: 1.656 95% CI:1.267–2.163, p < 0.001).
ICU cohort: 70% of patients were male, median MELD was 31(22–39) at ICU admission (92% with Child‐Pugh‐stage‐C). After adjusting for hypo−/hypernatremia, MELD, and blood pH, hypochloremia remained independently associated with ICU‐mortality (aOR Cl: 3.200 95%CI: 1.209–8.829, p = 0.021).
Conclusion
Hypochloremia is associated with increased mortality in clinically stable and critically ill patients with cirrhosis independently of MELD including serum sodium.
Graphical summarizing the study design as well as the main findings.
Thiazide diuretics are a mainstay in the management of hypertension and often associated with dyselectrolytemias. We investigated the prevalence of and risk factors for hyponatremia and hypokalemia ...in thiazide users, substance-specific differences, and the association of thiazides with syncope and falls.
In this cross-sectional analysis all patients admitted to an interdisciplinary emergency department in Switzerland between January 1, 2017, and December 31, 2018, with measurements of serum sodium and potassium were included. Data regarding serum electrolytes and creatinine were analyzed to classify for dysnatremias, dyskalemias, and acute kidney injury. Chart reviews were performed to screen for syncope or falls.
A total of 1604 patients (7.9%) took thiazides. Acute kidney injury was significantly more common in thiazide users (22.1 vs 7%, P < .0001). Hyponatremia (22.1 vs 9.8%, P < .0001) and hypokalemia (19 vs 11%, P < .0001) were more frequent with thiazides. Thiazide use together with higher age and female sex were independent predictors of hyponatremia and hypokalemia. A dose-dependent effect was found for electrolyte disorders, and there was a variance in risk between the investigated substances with chlorthalidone bearing the highest and hydrochlorothiazide the lowest risk. Patients taking thiazide diuretics had significantly more episodes of syncope and falls.
Thiazide use is a clear risk factor for hyponatremia and hypokalemia. The effect appears to be dose-dependent and highly variable depending on the substance. Syncope and falls seem to be causally related to thiazide use. Especially in patients who are elderly, female, and prone to falls, the use of thiazide diuretics should be thoroughly questioned.
Abstract Objective Dysnatremias are common in critically ill patients and associated with adverse outcomes, but their incidence, nature, and treatment rarely have been studied systematically in the ...population presenting to the emergency department. We conducted a study in patients presenting to the emergency department of the University of Bern. Methods In this retrospective case series at a university hospital in Switzerland, 77,847 patients admitted to the emergency department between April 1, 2008, and March 31, 2011, were included. Serum sodium was measured in 43,911 of these patients. Severe hyponatremia was defined as less than 121 mmol/L, and severe hypernatremia was defined as less than 149 mmol/L. Results Hypernatremia (sodium > 145 mmol/L) was present in 2% of patients, and hyponatremia (sodium < 135 mmol/L) was present in 10% of patients. A total of 74 patients had severe hypernatremia, and 168 patients had severe hyponatremia. Some 38% of patients with severe hypernatremia and 64% of patients with hyponatremia had neurologic symptoms. The occurrence of symptoms was related to the absolute elevation of serum sodium. Somnolence and disorientation were the leading symptoms in hypernatremic patients, and nausea, falls, and weakness were the leading symptoms in hyponatremic patients. The rate of correction did not differ between symptomatic and asymptomatic patients. Patients with symptomatic hypernatremia showed a further increase in serum sodium concentration during the first 24 hours after admission. Corrective measures were not taken in 18% of hypernatremic patients and 4% of hyponatremic patients. Conclusions Dysnatremias are common in the emergency department. Hyponatremia and hypernatremia have different symptoms. Contrary to recommendations, serum sodium is not corrected more rapidly in symptomatic patients.
Acid-base disorders in liver disease Scheiner, Bernhard; Lindner, Gregor; Reiberger, Thomas ...
Journal of hepatology,
November 2017, 2017-11-00, 20171101, Letnik:
67, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Alongside the kidneys and lungs, the liver has been recognised as an important regulator of acid-base homeostasis. While respiratory alkalosis is the most common acid-base disorder in chronic liver ...disease, various complex metabolic acid-base disorders may occur with liver dysfunction. While the standard variables of acid-base equilibrium, such as pH and overall base excess, often fail to unmask the underlying cause of acid-base disorders, the physical–chemical acid-base model provides a more in-depth pathophysiological assessment for clinical judgement of acid-base disorders, in patients with liver diseases.
Patients with stable chronic liver disease have several offsetting acidifying and alkalinising metabolic acid-base disorders. Hypoalbuminaemic alkalosis is counteracted by hyperchloraemic and dilutional acidosis, resulting in a normal overall base excess. When patients with liver cirrhosis become critically ill (e.g., because of sepsis or bleeding), this fragile equilibrium often tilts towards metabolic acidosis, which is attributed to lactic acidosis and acidosis due to a rise in unmeasured anions. Interestingly, even though patients with acute liver failure show significantly elevated lactate levels, often, no overt acid-base disorder can be found because of the offsetting hypoalbuminaemic alkalosis.
In conclusion, patients with liver diseases may have multiple co-existing metabolic acid-base abnormalities. Thus, knowledge of the pathophysiological and diagnostic concepts of acid-base disturbances in patients with liver disease is critical for therapeutic decision making.
Background
No data concerning the prevalence and risk factors of dyskalemia in acute kidney injury (AKI) exist. We investigated (a) prevalence rates, (b) risk factors and (c) outcome of hypo‐ and ...hyperkalemia in emergency patients.
Methods
In this cross‐sectional analysis, all patients admitted to the emergency department of a large public hospital in Switzerland between January 1st 2017 and December 31st 2018 with measurements of creatinine and potassium were included. Baseline characteristics, medication and laboratory data were extracted. Chart reviews were performed to identify patients with a diagnosis of chronic kidney disease (CKD) and to extract their baseline creatinine. For all other patients, the ADQI backformula was used in order to calculate baseline creatinine. AKI was graduated using creatinine criteria of the acute kidney injury network. Binary logistic regression analysis was used to identify risk factors for appearance of hyperkalemia and outcome.
Results
AKI was found in 8% of patients. Hyperkalemia was present in 13% and hypokalemia in 11% of patients with AKI. AKI stage, potassium‐sparing diuretics, ACE inhibitors and underlying CKD were the strongest risk factors for hyperkalemia. Hyperkalemia as well as profound hypokalemia were independently associated with prolonged length of stay and in‐hospital mortality. The study is limited by its dependency on chart review data in order to identify patients with chronic kidney disease and by limitations of the ADQI backformula to calculate baseline creatinine.
Conclusions
Dyskalemias are common in emergency patients with AKI and are independent risk factors for adverse outcomes. Potassium‐sparing diuretics, ACE‐inhibitors, AKIN stage and CKD are predictors of hyperkalemia in AKI.
Background Hypernatremia is common in the intensive care unit (ICU). We assessed the prevalence of hypernatremia and its impact on mortality and ICU length of stay (LOS). Study Design Retrospective ...analysis. Setting & Participants All patients admitted to a medical ICU of a university hospital during a 35-month observation period. Predictor Hypernatremia (serum sodium > 149 mmol/L) after admission to the ICU. Outcomes & Measurements Main outcomes were 28-day hospital mortality and ICU LOS. Demographic factors, main diagnosis, and severity of illness. Cox proportional hazards regression models were used for data analysis. Results Of 981 patients, 90 (9%) had hypernatremia, on admission to the ICU in 21 (2%) and developed during the ICU stay in 69 patients (7%). Of these 981 patients, 235 (24%) died; LOS was 8 ± 9 (SD) days. Mortality rates were 39% and 43% in patients with hypernatremia on admission or that developed after admission compared with 24% in patients without hypernatremia ( P < 0.01). LOS was 20 ± 16 days in patients with hypernatremia compared with 8 ± 10 days in patients without hypernatremia ( P < 0.001). In multivariable analysis, hypernatremia was an independent risk factor for mortality (relative risk, 2.1; 95% confidence interval, 1.4 to 3.3). Limitations Retrospective design, absence of data for long-term mortality. Conclusions Most cases of hypernatremia in the ICU developed after admission, suggesting an iatrogenic component in its evolution. Hypernatremia is associated with increased mortality. Strategies for preventing hypernatremia in the ICU should be encouraged.
Elderly people, defined by age 65 years and older, made up 18.45% of the Swiss Population in 2018 and their number is projected to rise continuously. Data investigating specific characteristics of ...this patient subgroup, especially in the emergency setting, is scarce.
Demographic data of admission records from all patients aged 65 years or older admitted to our emergency department (ED) between January 1st 2015 and December 31st 2018 were investigated. Retrospective chart reviews of patients admitted in 2018 were conducted. Comorbidity burden was assessed by Charlson Comorbidity Index. Risk factors for death, longer hospitalization and placement in a nursing facility were identified by multivariate regression.
The prevalence of elderly patients (≥65 years) admitted to the ED between 2015 and 2018 was rising from 33% in 2015 to 37.8% in 2018. In 2018 709 patients were 90 years and older (3.6%).
Age above 90 years and high comorbidity burden were identified as independent risk factors for death. Polypharmacy, hyponatremia and high comorbidity burden were independent risk factors for longer hospitalizations. Advanced age and high comorbidity burden were independent risk factors for placement in a nursing facility.
The number of elderly patients admitted to our ED is continuously rising. There was no difference in overall disease burden, number of medications and hospital length of stay between octogenarians and nonagenarians. We identified risk factors for mortality, long hospitalizations and need of placement in a nursing facility.
We aimed to investigate the prevalence, risk factors and outcome of hypo- and hypernatremia in emergency patients with acute kidney injury (AKI).
In this cross-sectional analysis all emergency ...patients between January 1st 2017 and December 31st 2018 with measurements of creatinine and sodium were included. Baseline characteristics, medication and laboratory data were gathered. Chart reviews were performed to identify patients with a diagnosis of chronic kidney disease (CKD) and to extract baseline creatinine. For all other patients the ADQI backformula was used to calculate baseline creatinine. AKI was graduated using creatinine criteria of the acute kidney injury network. Binary logistic regression analysis was used to identify risk factors for appearance of dysnatremias and outcome.
AKI was found in 8% of patients. 392 patients (23.16%) had hyponatremia, 24 (1.4%) had hypernatremia. Use of potassium sparing diuretics, a medical cause for emergency referral, use of thiazide diuretics and AKI stage were the strongest risk factors for hyponatremia. Loop diuretics, a medical cause for emergency referral and AKI stage were risk factors for hypernatremia. In patients with all classes of hyponatremia, length of hospital stay was significantly longer compared to patients with a normal serum sodium. In the binary logistic regression analysis with death as outcome, hyponatremia as well as severe hypernatremia were independent risk factors for mortality.
Dysnatremias are common in emergency patients with AKI. Diuretic medication is a major risk factor for hypo- and hypernatremia. Both hyponatremia and severe hypernatremia were independent risk factors for adverse outcome.
We propose an integrated and adaptable approach to improve patient care and clinical outcomes through analgesia and light sedation, initiated early during an episode of critical illness and as a ...priority of care. This strategy, which may be regarded as an evolution of the Pain, Agitation and Delirium guidelines, is conveyed in the mnemonic eCASH—early Comfort using Analgesia, minimal Sedatives and maximal Humane care. eCASH aims to establish optimal patient comfort with minimal sedation as the default presumption for intensive care unit (ICU) patients in the absence of recognised medical requirements for deeper sedation. Effective pain relief is the first priority for implementation of eCASH: we advocate flexible multimodal analgesia designed to minimise use of opioids. Sedation is secondary to pain relief and where possible should be based on agents that can be titrated to a prespecified target level that is subject to regular review and adjustment; routine use of benzodiazepines should be minimised. From the outset, the objective of sedation strategy is to eliminate the use of sedatives at the earliest medically justifiable opportunity. Effective analgesia and minimal sedation contribute to the larger aims of eCASH by facilitating promotion of sleep, early mobilization strategies and improved communication of patients with staff and relatives, all of which may be expected to assist rehabilitation and avoid isolation, confusion and possible long-term psychological complications of an ICU stay. eCASH represents a new paradigm for patient-centred care in the ICU. Some organizational challenges to the implementation of eCASH are identified.
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