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Etiology of discharge hyponatremia in decompensated heart failure and normal admission Na+: Effect of diuretics

Published:December 21, 2017DOI:https://doi.org/10.1016/j.ejim.2017.12.007
      Hyponatremia is the commonest electrolyte abnormality in hospitalized patients [
      • Mohan S.
      • Gu S.
      • Parikh A.
      • Radhakrishnan J.
      Prevalence of hyponatremia and association with mortality: results from NHANES.
      ]. Patients with decompensated heart failure (HF) commonly have electrolyte abnormalities, due to the activation of several neurohumoral mechanisms, in addition to effect of drugs especially diuretics [
      • Oster J.R.
      • Preston R.A.
      • Materson B.J.
      Fluid and electrolyte disorders in congestive heart failure.
      ]. Hyponatremia is evident on hospital admission in ~15–25% of patients with decompensated HF [
      • Gheorghiade M.
      • Abraham W.T.
      • Albert N.M.
      • Gattis Stough W.
      • Greenberg B.H.
      • O'Connor C.M.
      • et al.
      Relationship between admission serum sodium concentration and clinical outcomes in patients hospitalized for heart failure: an analysis from the OPTIMIZE-HF registry.
      ,
      • Gheorghiade M.
      • Rossi J.S.
      • Cotts W.
      • Shin D.D.
      • Hellkamp A.S.
      • Pina I.L.
      • et al.
      Characterization and prognostic value of persistent hyponatremia in patients with severe heart failure in the ESCAPE Trial.
      ,
      • Milo-Cotter O.
      • Cotter G.
      • Weatherley B.D.
      • Adams K.F.
      • Kaluski E.
      • Uriel N.
      • et al.
      Hyponatraemia in acute heart failure is a marker of increased mortality but not when associated with hyperglycaemia.
      ,
      • DY Lu
      • Cheng H.M.
      • Cheng Y.L.
      • Hsu P.F.
      • Huang W.M.
      • Guo C.Y.
      • et al.
      Hyponatremia and worsening sodium levels are associated with long-term outcome in patients hospitalized for acute heart failure.
      ], and to a similar extent throughout hospitalization [
      • Konishi M.
      • Haraguchi G.
      • Ohigashi H.
      • Sasaoka T.
      • Yoshikawa S.
      • Inagaki H.
      • et al.
      Progression of hyponatremia is associated with increased cardiac mortality in patients hospitalized for acute decompensated heart failure.
      ,
      • Shchekochikhin D.Y.
      • Schrier R.W.
      • Lindenfeld J.
      • Price L.L.
      • Jaber B.L.
      • Madias N.E.
      Outcome differences in community- versus hospital-acquired hyponatremia in patients with a diagnosis of heart failure.
      ]. Although extensively studied in HF, the majority of research focused on the prognostic value of hyponatremia on admission [
      • Gheorghiade M.
      • Abraham W.T.
      • Albert N.M.
      • Gattis Stough W.
      • Greenberg B.H.
      • O'Connor C.M.
      • et al.
      Relationship between admission serum sodium concentration and clinical outcomes in patients hospitalized for heart failure: an analysis from the OPTIMIZE-HF registry.
      ], behavior of sodium (Na+) level from admission to discharge [
      • DY Lu
      • Cheng H.M.
      • Cheng Y.L.
      • Hsu P.F.
      • Huang W.M.
      • Guo C.Y.
      • et al.
      Hyponatremia and worsening sodium levels are associated with long-term outcome in patients hospitalized for acute heart failure.
      ], and decreasing Na+ after discharge [
      • Madan V.D.
      • Novak E.
      • Rich M.W.
      Impact of change in serum sodium concentration on mortality in patients hospitalized with heart failure and hyponatremia.
      ], and in those instances, hyponatremia was found to be associated with worse outcomes. We have recently studied the prognostic value of discharge hyponatremia in patients with decompensated HF and normal admission Na+, and found that in those subset of patients, discharge hyponatremia is apparently benign; limiting our conclusion to subjects with mild hyponatremia since their median discharge Na+ was 132 meq/L [
      • Omar H.R.
      • Charnigo R.
      • Guglin M.
      Prognostic significance of discharge hyponatremia in heart failure patients with normal admission sodium (from the ESCAPE Trial).
      ]. We speculated that this is due to effect of Na+-wasting diuretics since the “discharge hyponatremia” group had evidence of a significantly higher weight loss, greater reduction in inferior vena cava diameter and higher blood urea nitrogen (BUN)/creatinine, compared with “discharge normonatremia” group [
      • Omar H.R.
      • Charnigo R.
      • Guglin M.
      Prognostic significance of discharge hyponatremia in heart failure patients with normal admission sodium (from the ESCAPE Trial).
      ]. We also found that in decompensated HF, subjects with hospital-acquired hyponatremia (hyponatremia that develops in-hospital in those with normal admission Na+) had better outcomes than those with community-acquired hyponatremia (hyponatremia on presentation) [
      • Omar H.R.
      • Guglin M.
      Community acquired versus hospital acquired hyponatremia in acute heart failure: association with clinical characteristics and outcomes.
      ]. Herein, we aim to confirm our speculation of the association between discharge hyponatremia and diuretic therapy in subjects with normal Na+ on admission.

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