Incidence and Predictors of Cerebral Salt Wasting Syndrome in Stroke Patients – Results of a Prospective Observational Study

BackgroundCerebral salt wasting syndrome (CSWS) and Syndrome of Inappropriate Anti Diuretic Hormone secretion (SIADH) are the most common aetiological factors for developing hyponatremia following stroke. The differentiation of these two entities is crucial as the treatment options are completely different. Hence the knowledge on predictors of CSWS is important to make a more accurate diagnosis of CSWS. MethodsTwo hundred and fourty six patients with confirmed stroke were prospectively observed throughout the hospital stay in a tertiary referral center in Sri Lanka to identify the possible predictors of CSWS. Hyponatremia was defined as serum Na+ level less than 131mmo/l. Serum osmolality, urine osmolality, urinary Na+, serum cortisol and thyroid function tests were performed on all the hyponatremic patients. Differentiation of the CSWS and SIADH was based on physical examination findings and laboratory parameters. ResultsThe incidence of hyponatremia in our study population was 19.1% (95% Confidence Interval 14.39-24.58). The majority of patients (24, 51%) were attributed to CSWS. SIADH group comprised of 17 (36.2%) patients and 6 (12.7%) patients had other undetermined causes. There was a significant statistical difference between the aetiologies of hyponatremia and laboratory investigations like urinary Na+, urinary osmolality and serum osmolality. Demographic characteristics, comorbidities, imaging findings and clinical parameters like systolic blood pressure, diastolic blood pressure, on admission GCS were considered in the multivariable logistic regression model and the overall model was not significant. Conclusion The incidence of CSWS is higher than the incidence of SIADH. The demographic characteristics, comorbidities, imaging and clinical parameters like blood pressure, on admission GCS could not predict the occurrence of CSWS

Carboplatin-induced Renal Salt Wasting Syndrome in Paediatric Patients with Intracranial Germ Cell Tumours and Concomitant Diabetes Insipidus

We report the first case series of 14 children with intracranial germ cell tumour (iGCT) and concomitant central diabetes insipidus (DI), who developed hyponatremia secondary to renal salt wasting syndrome (RSWS) following the administration of carboplatin. Clinicians prescribing platinum-based chemotherapy for this group of patients should be alert to the risk of RSWS. Regular monitoring should be performed as hyponatraemia can be asymptomatic until it is severe.

The Novel Bone Alkaline Phosphatase Isoform B1x Is Associated with Improved 5-Year Survival in Chronic Kidney Disease

Circulating alkaline phosphatase (ALP) is an independent cardiovascular risk marker. Serum bone ALP (BALP) isoforms indicate bone turnover and comprise approximately 50% of total circulating ALP. In chronic kidney disease (CKD), mortality is highest in patients with increased ALP and BALP and low bone turnover. However, not all low bone turnover states are associated with increased mortality. Chronic inflammation and oxidative stress, features of protein energy wasting syndrome, induce cardiovascular BALP activity and fibro-calcification, while bone turnover is suppressed. Circulating BALP isoform B1x is associated with low ALP and low bone turnover and has been exclusively detected in CKD. We investigated the association of serum B1x with survival, abdominal aortic calcification (AAC) score, and aortic pulse wave velocity (PWV) in CKD. Serum ALP, BALP isoforms, parathyroid hormone (PTH), PWV, and AAC were measured repeatedly over 2 years in 68 prevalent dialysis patients. Mortality was assessed after 5 years. B1x was detected in 53 patients. A competing risk analysis revealed an association of B1x with improved 5-year survival; whereas, baseline PWV, but not AAC score, predicted mortality. However, PWV improved in 26 patients (53%), and B1x was associated with variation of PWV over time (p = 0.03). Patients with B1x had lower PTH and total ALP, suggesting an association with lower bone turnover. In conclusion, B1x is associated with time-varying PWV, lower circulating ALP, and improved survival in CKD, and thus may be an indicator of a reduced cardiovascular risk profile among patients with low bone turnover.

The Role of Obesity in Frailty Incidence: The San Antonio Longitudinal Study of Aging

Background Although initially conceptualized as a wasting syndrome, obesity has been associated with frailty in prior studies. The goal of this study was to examine the associations of obesity and waist circumference with frailty and determine whether they predict incident frailty in an ethnically diverse population of older Mexican Americans (MAs) and European Americans (EAs). Methods 749 MA and EA community-dwelling older adults (65+) participated in the baseline examination of the San Antonio Longitudinal Study of Aging (SALSA), and 474 participants completed the first follow up approximately 6 years later. Frailty was classified using Fried criteria. Baseline characteristics, including body mass index (BMI) and waist circumference (WC) were summarized by frailty category (non-frail, pre-frail, frail) using ANOVA. The odds of becoming frail at follow-up by baseline BMI and WC were estimated using separate logistic regression models, adjusting for age, sex, ethnicity, diabetes, comorbidity (presence of ≥2 chronic diseases not including diabetes), baseline frailty score, and follow-up time. Results At baseline, participants were 69 ±3 years old, 61% female, and 50% MA. BMI and WC increased with increasing frailty category (p <0.01 for both). BMI was a significant predictor of incident frailty (OR=1.08, 95% confidence interval [CI]: 1.02-1.14, p=0.011). WC also predicted frailty (OR=1.03, 95% CI: 1.01-1.05, p =0.017). Conclusion These results demonstrate that BMI and WC are significant predictors of frailty. Interventions which target obesity may reduce the incidence of frailty; however, more research in this area is needed.

Pengelolaan Diabetes Insipidus dengan Cerebral Salt Wasting Syndrome dan Tension Pneumocephalus pada Pasien Pascabedah Eksisi Tumor Pineal

Electrolyte imbalance is an often incident in patients underwent neurosurgery and it potentially induces secondary brain injury, leading to a worse outcome, despite successful surgery. Diabetes insipidus is a frequent hypernatremic condition, commonly caused by abnormalities in the hypophysis; but rarely happens due to pineal tumor. A 21-year-old male with preoperative diabetes insipidus experienced episodes of diabetes insipidus complicated by cerebral salt wasting syndrome and tension pneumocephalus after a successful pineal tumor removal surgery. Closed observation on volume status, plasma glucose and electrolyte, along with optimal dose of desmopressin were keys of successful postoperative management in this patient in order to avoid the patient from secondary brain injury. An intensivist plays a key role, mainly in the understanding of intracranial pathophysiology and its implications to fluid and electrolyte balance.