We conclude that intravenous conivaptan is an effective aquaretic to treat hyponatraemia caused by SIADH, as evidenced by a simultaneous increase in serum sodium and decrease in urine osmolality. Baseline values of serum sodium, blood urea nitrogen and estimated glomerular filtration rate may help predicting the magnitude of response to therapy.

Background: The efficacy of vasoconstrictors in hepatorenal syndrome (HRS) is variable. We hypothesized that the effectiveness of vasoconstrictor therapy in improving kidney function ultimately relates to the magnitude of the achieved mean arterial pressure (MAP) increase. Methods: A retrospective study was conducted to identify cirrhotic individuals treated with vasoconstrictors for acute kidney injury (AKI) presumably caused by HRS to examine the relationship between change in MAP and change in serum creatinine (sCr) using multivariate mixed linear regression. Results: Among 73 patients treated with midodrine/octreotide, change in MAP inversely correlated with change in sCr (p = 0.0005). The quartile with the greatest increase in MAP (+15.9 to +29.4 mm Hg) was associated with a subsequent absolute decrease in sCr. The strength of the correlation increased when the analysis was restricted to those who met the HRS criteria (n = 27, p = 0.002), where the third (+5.3 to +15.6 mm Hg) and fourth (+15.9 to +20.9 mm Hg) quartiles of MAP change were associated with a decrease in sCr. A similar but stronger correlation was found among 14 patients treated with norepinephrine either after failing midodrine/octreotide (n = 10) or de novo (n = 4; p = 0.002), where a rise in MAP of +19.2 to 25 mm Hg was associated with a larger reduction in sCr. Associations remained significant after adjustment for baseline parameters. Conclusions: The magnitude of MAP rise during HRS therapy with midodrine/octreotide or norepinephrine correlated with a reduction in sCr concentration. Our results suggest that achieving a pre-specified target of MAP increase might improve renal outcomes in hepatorenal AKI.

Objective: To identify the incidence of and risk factors for hypoglycemia in patients with chronic kidney disease (CKD) stage III-V or end stage renal disease (ESRD) treated with intravenous (IV) insulin for hyperkalemia. Design: Single-center, retrospective, cohort study. Setting: Large academic tertiary care medical center. Patients: Adults with a diagnosis of CKD stage III-V or ESRD who had a serum potassium ≥ 5 mmol/L and were treated with regular insulin for hyperkalemia between October 1, 2015 and August 16, 2016. Measurements and main results: The primary outcome was the incidence of hypoglycemia during the hospitalization after the administration of insulin for hyperkalemia. Key secondary outcomes included incidence of hypoglycemia within 24 hours of insulin administration and identification of risk factors associated with hypoglycemia. Data collected included patient age, sex, race, history of diabetes, stage of CKD, weight, body mass index (BMI), baseline blood glucose, inciting serum potassium concentration, units of regular insulin administered, and grams of dextrose given with insulin. A total of 235 hospitalizations were included in the final analysis. Sixty-six patients (28.1%) experienced a hypoglycemic event during their hospital encounter. Fifty-three patients (22.6%) had hypoglycemia within 24 hours of insulin administration. The average time to onset of hypoglycemia was 21.2 hours in all patients who experienced hypoglycemia and 6.4 hours in the subset of patients who experienced hypoglycemia within 24 hours of insulin administration. Inciting potassium was significantly higher and baseline blood glucose was significantly lower in the group that experienced hypoglycemia (P = 0.01, P = 0.02, respectively). Conclusion: Hypoglycemia following treatment for hyperkalemia with IV regular insulin was common in this patient population. Consideration should be given to the development of a comprehensive order set for insulin use in hyperkalemia to include protocol driven glucose monitoring with dextrose administration tailored to baseline glucose levels.

Background: Acute chest syndrome (ACS) is an acute complication of sickle cell disease (SCD). Historically, the most common pathogens were Chlamydophila pneumoniae, Mycoplasma pneumoniae, and respiratory syncytial virus. Pediatric patients receiving guideline-adherent therapy experienced fewer ACS-related and all-cause 30-day readmissions compared with those receiving nonadherent therapy. This has not been evaluated in adults. Objectives: The primary objectives were to characterize antibiotic use and pathogens. The secondary objective was to assess the occurrence of readmissions associated with guideline-adherent and clinically appropriate treatment compared with regimens that did not meet those criteria. Methods: A retrospective cohort analysis was conducted for adults with SCD hospitalized between August 1, 2014, and July 31, 2017, with pneumonia (PNA) or ACS. The study was approved by the institutional review board. Results: A total of 139 patients with 255 hospitalizations were reviewed. Among 41 respiratory cultures, 3 organisms were isolated: Cryptococcus neoformans, Pseudomonas aeruginosa, and budding yeast. Respiratory panels were collected on 121 admissions, with 17 positive for 1 virus; all were negative for Chlamydophila pneumoniae and M pneumoniae. There were significantly more ACS-/PNA-related 7-day readmissions from patients on guideline-adherent regimens compared with nonadherent regimens (3.7% vs 0%; P = 0.04). Conclusion and Relevance: These findings challenge existing knowledge regarding the most common pathogens in adults with SCD with ACS or PNA. Routine inclusion of a macrolide may not be necessary. Future studies focused on pathogen characterization with standardized assessment are necessary to determine appropriate empirical therapy in this population.