Hypernatremia due to Urea-Induced Osmotic Diuresis: Physiology at the Bedside

Vadi, Sonali; Yim, Kenneth K.

doi:10.4103/ijccm.ijccm_266_18

Cited by 7 publications

(7 citation statements)

References 9 publications

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“…A link between PICS and hypernatremia can be established in two ways. On the one hand, hyperosmolar cell stress has been shown to trigger protein metabolism, muscle degradation and immunomodulation [ 32 , 33 , 34 , 35 ], and on the other hand, excessive catabolism has been shown to cause hypernatremia via profuse urine urea excretion, leading to osmotic diuresis and concomitant loss of electrolyte-free water [ 26 , 27 , 28 , 29 , 30 , 31 ]. Despite conceptualizing a potential vicious cycle, of course, the complex physiology behind PICS and hypernatremia cannot be broken down to one simple cause.…”

Section: Discussionmentioning

confidence: 99%

“…The link back to hypernatremia is theoretically done in two ways. On the one hand, persistent catabolism with elevated ureagenesis can lead to profuse urine urea output and subsequently to urea-induced osmotic diuresis with loss of electrolyte-free water and resulting hypernatremia [ 26 , 27 , 28 , 29 , 30 , 31 ]. On the other hand, hypernatremia itself can again promote protein catabolism and also systemic inflammation, primarily via hyperosmolar cell stress [ 32 , 33 , 34 , 35 ].…”

Section: Introductionmentioning

confidence: 99%

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ICU-Acquired Hypernatremia Is Associated with Persistent Inflammation, Immunosuppression and Catabolism Syndrome

Rugg

Ströhle

Treml

et al. 2020

JCM

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Developing hypernatremia while on intensive care unit (ICU) is a common problem with various undesirable effects. A link to persistent inflammation, immunosuppression and catabolism syndrome (PICS) can be established in two ways. On the one hand, hypernatremia can lead to inflammation and catabolism via hyperosmolar cell stress, and on the other, profound catabolism can lead to hypernatremia via urea-induced osmotic diuresis. In this retrospective single-center study, we examined 115 patients with prolonged ICU stays (≥14 days) and sufficient renal function. Depending on their serum sodium concentrations between ICU day 7 and 21, allocation to a hypernatremic (high) and a nonhypernatremic group (low) took place. Distinct signs of PICS were detectable within the complete cohort. Thirty-three of them (28.7%) suffered from ICU-acquired hypernatremia, which was associated with explicitly higher signs of inflammation and ongoing catabolism as well as a prolonged ICU length of stay. Catabolism was discriminated better by the urea generation rate and the urea-to-creatinine ratio than by serum albumin concentration. An assignable cause for hypernatremia was the urea-induced osmotic diuresis. When dealing with ICU patients requiring prolonged treatment, hypernatremia should at least trigger thoughts on PICS as a contributing factor. In this regard, the urea-to-creatinine ratio is an easily accessible biomarker for catabolism.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

ICU-Acquired Hypernatremia Is Associated with Persistent Inflammation, Immunosuppression and Catabolism Syndrome

Rugg

Ströhle

Treml

et al. 2020

JCM

View full text Add to dashboard Cite

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“…In our cohort of severely burned patients we were able to link as much as 44% to this phenomenon. Additionally, there have only been a few case reports on this topic [9][10][11][12][13]. The corresponding pathophysiology is easily understandable but even more easily overseen.…”

Section: Electrolyte-free Water Clearancementioning

confidence: 99%

“…All state a similar pathophysiology: an excessive generation of urea, usually due to catabolism deriving from various causes (e.g., diabetes type I, corticosteroids, hypermetabolism, systemic inflammation) leads to a profuse urine urea output and therefore an increased fraction of urea and decreased fraction of electrolytes in osmole excretion. This raised loss of electrolyte-free water is often overlooked and leads to hypernatremia [9][10][11][12][13].…”

Section: Introductionmentioning

confidence: 99%

The Link between Hypermetabolism and Hypernatremia in Severely Burned Patients

et al. 2020

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Hypernatremia is common in critical care, especially in severely burned patients. Its occurrence has been linked to increased mortality. Causes of hypernatremia involve a net gain of sodium or a loss of free water. Renal loss of electrolyte-free water due to urea-induced osmotic diuresis has been described as causative in up to 10% of hypernatremic critical ill patients. In this context, excessive urea production due to protein catabolism acts as major contributor. In severe burn injury, muscle wasting occurs as result of hypermetabolism triggered by ongoing systemic inflammation. In this retrospective study, severely burned patients were analysed for the occurrence of hypernatremia and subsequent signs of hypermetabolism. The urea: creatinine ratio—as a surrogate for hypermetabolism—sufficiently discriminated between two groups. Four of nine hypernatremic burn patients (44%) had a highly elevated urea: creatinine ratio, which was clearly associated with an increased urea production and catabolic index. This hypermetabolism was linked to hypernatremia via an elevated urea- and reduced electrolyte-fraction in renal osmole excretion, which resulted in an increased renal loss of electrolyte-free water. In hypermetabolic severely burned patients, the electrolyte-free water clearance is a major contributor to hypernatremia. A positive correlation to serum sodium concentration was shown.

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“…Renal solute and water excretion determines the direction and magnitude of the change in serum sodium concentration resulting from renal losses [1][2][3][4][5][6][7][8]. The rates of renal solute and water excretion are expressed as osmolal clearance (C Osm ), solute-free water clearance (C H2O ), electrolyte (monovalent cation) clearance (C (e) ), and electrolyte-free water clearance (C H2O(e) ).…”

mentioning

confidence: 99%

Solute-free water excretion and electrolyte-free water excretion are better terms than solute-free water clearance and electrolyte-free water clearance

et al. 2021

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Hypernatremia due to Urea-Induced Osmotic Diuresis: Physiology at the Bedside

Abstract: Hypernatremia secondary to urea-induced solute diuresis is due to the renal excretion of electrolyte-free water. This concept is explained here step-wise physiologically with the help of a clinical vignette.

Cited by 7 publications

References 9 publications

ICU-Acquired Hypernatremia Is Associated with Persistent Inflammation, Immunosuppression and Catabolism Syndrome

ICU-Acquired Hypernatremia Is Associated with Persistent Inflammation, Immunosuppression and Catabolism Syndrome

The Link between Hypermetabolism and Hypernatremia in Severely Burned Patients

Solute-free water excretion and electrolyte-free water excretion are better terms than solute-free water clearance and electrolyte-free water clearance

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