Thread by @NephJC

1/ #Tweetorial #NephJC #Hypernatremia Reviews and guidelines say to correct hypernatremia in adults by no more than 10 mmol/L per day. This is based on little hard data, has little support in literature and may be harmful nejm.org/doi/full/10.10…

2/ What rate do you target for the correction of chronic (>48 hours or present on admission) hypernatremia #NephJC

3/ The rapid lowering of serum sodium will lower the tonicity of the extracellular compartment. Water will then be osmotically drawn into relatively hypertonic intracellular compartment. This can cause cerebral edema and increased intracranial pressure. #NephJC

4/ We see this in patients who get acute hyponatremia and it causes seizures, respiratory failure and uncal herniation from cerebral edema. #NephJC latimes.com/archives/la-xp…

5/ If the drop in sodium is slow, the intracellular compartment will eject intracellular osmolytes to prevent movement of water into the brain, preventing increases in intracranial pressure. #NephJC

6/ Which clinical scenario doesn’t typically develop acute hyponatremia #NephJC

7/ The lessons from developing acute hyponatremia were adopted for the treatment of chronic hypernatremia with experts saying not to correct sodium faster than 10 mmol/d to avoid cerebral edema. #NephJC nejm.org/doi/full/10.10…

8/ The only empiric data was from a few series of infants and babies where rapid fluid resuscitation, lowered Na and reductions over 0.6 mmol/L/hour were associated with seizures. Note the pH, BUN and tCO2 in the 3 groups. Not your typical hypernatremics ncbi.nlm.nih.gov/pubmed/35558

9/ That bring us to this week’s #NephJC chat:

Rate of Correction of Hypernatremia and Health Outcomes in Critically Ill Patients.
PMID: 30948456 Full text at CJASN (free from May 13 to 20, 2019) #NephJC

cjasn.asnjournals.org/content/14/5/6…

10/ This is a retrospective observational study from a single-center tertiary care hospital (Beth Israel Deaconess in Boston, MA) from 2001 to 2012.
The data was abstracted from from the MIMIC-III database. #NephJC mimic.physionet.org/about/mimic/

11/ They included patients with a sodium over 155 and calculated the rate of correction of sodium using this definition #NephJC

12/ They divided patients by speed of correction. Fast patients were corrected > 0.5 mmol/L/hr, slow patients ≤ 0.5 mmol/L/hr

Chronic hypernatremia defined as people who presented to the hospital with Na ≥ 155 and as inpatients w/ Na > 145 for at least 48 hours. #NephJC

13/ They enrolled 449 patients with about three quarter being hospital acquired hypernatremia. #NephJC

14/ Initial sodium and the time course of sodium correction for the cohort #NephJC

15/ The top line result here is that rapid correction did not appear to be harmful...Let me repeat that for the people in the back of the room, "NO ONE WAS HARMED BY RAPID CORRECTION OF HYPERNATREMIA" #NephJC

16/ The authors did manual chart review to look for indications of cerebral edema and reviewed all neural imaging and couldn’t find one case of cerebral edema or seizure due to the rapid treatment of hypernatremia. #NephJC

17/ There was a high mortality rate and there was a signal that depending on how you sliced the data that the mortality was decreased by faster sodium correction in patients admitted with hypernatremia. #NephJC

18/ There has never been a case report of cerebral edema from the treatment of hypernatremia in adults. When the sodium is high, fix it and stop worrying about inducing cerebral edema. Per Richard Sterns (from his well written editorial) #NephJC
cjasn.asnjournals.org/content/14/5/6…

fin/ So are you convinced? Do you still fear rapid correction of hypernatremia #NephJC