Hyponatremia, Cerebral Edema, and Noncardiogenic Pulmonary Edema in Marathon Runners

Ayus, Juan Carlos; Varon, Joseph; Arieff, Allen I.

doi:10.7326/0003-4819-132-9-200005020-00005

Cited by 267 publications

(236 citation statements)

References 13 publications

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“…In this study, the incidence of NSAID use in athletes was 30%, and NSAID use was highly associated with the development of hyponatremia (P ϭ 0.0002), as well as higher plasma potassium and creatinine levels. Several other, smaller studies and case reports also have suggested a potentiating role for NSAID use (11,12,52). Therefore, the role of NSAID in the development of EAH remains controversial but in some runners likely is a potentiating factor.…”

Section: Risk Factorsmentioning

confidence: 99%

“…During this period, military recruits were encouraged to ingest 1.8 L of fluid for every hour they were exposed to temperatures above 30°C (30). At least four other deaths have been attributed to EAH in the United States (5,10,11,26,31). It is interesting that two of these deaths occurred in doctors (31).…”

Section: Incidencementioning

confidence: 99%

“…As is discussed later, the majority of these athletes are asymptomatic or mildly symptomatic (nausea, lethargy). However, severe manifestations such as cerebral edema, noncardiogenic pulmonary edema, and death can occur (11)(12)(13)(14).…”

Section: Incidencementioning

confidence: 99%

“…It seems that the majority of runners with EAH have mild (weakness, dizziness, headache, nausea/vomiting) or no symptoms (usually associated with serum sodium values ranging from 134 to 128 mmol/L) (1,9 -13,15). In athletes with serum sodium values Ͻ126 mmol/L, there is a higher likelihood of severe clinical manifestations such as cerebral edema, altered mental status, seizures, pulmonary edema, coma, and death (11,17,19,20,24). However, a systematic survey of symptoms that are associated with hyponatremia in athletes has not been performed.…”

Section: Clinical Featuresmentioning

confidence: 99%

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Exercise-Associated Hyponatremia

Rosner

Kirven

2007

Clinical Journal of the American Society of Nephrology

168

165

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Exercise-associated hyponatremia has been described after sustained physical exertion during marathons, triathlons, and other endurance athletic events. As these events have become more popular, the incidence of serious hyponatremia has increased and associated fatalities have occurred. The pathogenesis of this condition remains incompletely understood but largely depends on excessive water intake. Furthermore, hormonal (especially abnormalities in arginine vasopressin secretion) and renal abnormalities in water handling that predispose individuals to the development of severe, life-threatening hyponatremia may be present. This review focuses on the epidemiology, pathogenesis, and therapy of exercise-associated hyponatremia.

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Section: Risk Factorsmentioning

confidence: 99%

Section: Incidencementioning

confidence: 99%

Section: Incidencementioning

confidence: 99%

Section: Clinical Featuresmentioning

confidence: 99%

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Exercise-Associated Hyponatremia

Rosner

Kirven

2007

Clinical Journal of the American Society of Nephrology

168

165

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“…EAH can be severe and life threatening as a result of cerebral edema and noncardiogenic pulmonary edema. 33,94 Prevention is paramount. Guidelines for appropriate fluid ingestion during marathons are available.…”

Section: Siadhmentioning

confidence: 99%

Hyponatremia Treatment Guidelines 2007: Expert Panel Recommendations

Verbalis

Goldsmith

Greenberg

et al. 2007

The American Journal of Medicine

519

498

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Although hyponatremia is a common, usually mild, and relatively asymptomatic disorder of electrolytes, acute severe hyponatremia can cause substantial morbidity and mortality, particularly in patients with concomitant disease. In addition, overly rapid correction of chronic hyponatremia can cause severe neurologic deficits and death, and optimal treatment strategies for such cases are not established. Hyponatremia is the most common disorder of electrolytes encountered in clinical practice, occurring in up to 15% to 30% of both acutely and chronically hospitalized patients. 1 Although most cases are mild and relatively asymptomatic, hyponatremia is important clinically because: (1) acute severe hyponatremia can cause substantial morbidity and mortality; (2) mortality is higher in patients with hyponatremia who have a wide range of underlying diseases; and (3) overly rapid correction of chronic hyponatremia can cause severe neurologic deficits and death.Despite knowledge of hyponatremia since the mid-20th century, this common disorder remains incompletely understood in many basic areas because of its association with a plethora of underlying disease states, and its multiple etiologies with differing pathophysiologic mechanisms. 2 Optimal treatment strategies have not been well defined, both for these reasons and because of marked differences in symptomatology and clinical outcomes based on the acuteness or chronicity of the hyponatremia. 3 Vasopressin receptor antagonists have long been anticipated as a more effective method to treat hyponatremia by virtue of their unique aquaretic effect to selectively increase solute-free water excretion by the kidneys. 4 The recent approval of the first such agent, conivaptan, for clinical use by the US Food and Drug Administration (FDA) heralds the beginning of a new era in the management of hyponatremic disorders. However, effective therapy with these agents will require intelligent guidelines for their use. To this end, a panel of experts in hyponatremia convened to review current therapies for hyponatremia and to evaluate the situations in which aquaretic agents should be considered as alternatives or supplements to accepted current therapies. This review is a summary of the conclusions of this panel.

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Risk of Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion Therapies of Hypertonic Saline for Patients With Symptomatic Hyponatremia

Baek

Ahn

et al. 2021

JAMA Intern Med

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IMPORTANCEFew high-quality studies have clarified whether hypertonic saline is best administered as slow continuous infusion (SCI) therapy or rapid intermittent bolus (RIB) therapy for symptomatic severe hyponatremia.OBJECTIVE To compare the risk of overcorrection in RIB and SCI with hypertonic saline in patients with symptomatic hyponatremia. DESIGN, SETTING, AND PARTICIPANTS This prospective, investigator-initiated, multicenter, open-label, randomized clinical trial enrolled 178 patients older than 18 years with moderately severe to severe hyponatremia and glucose-corrected serum sodium (sNa) levels of 125 mmol/L or less. Recruitment took place from August 24, 2016, until August 21, 2019, across emergency departments and wards of 3 general hospitals in the Republic of Korea.INTERVENTIONS Either RIB or SCI of hypertonic saline, 3%, for 24 to 48 hours stratified by the severity of clinical symptoms. MAIN OUTCOME AND MEASURESThe primary outcome was overcorrection at any given period, defined as increase in the sNa level by greater than 12 or 18 mmol/L within 24 or 48 hours, respectively. Secondary and post hoc outcomes included efficacy and safety of the treatment approaches. The sNa concentrations were measured every 6 hours for 2 days. RESULTSThe 178 patients (mean [SD] age, 73.1 [12.2] years; 80 (44.9%) male; mean [SD] sNa concentrations, 118.2 [5.0] mmol/L) were randomly assigned to the RIB group (n = 87) or the SCI group (n = 91). Overcorrection occurred in 15 of 87 (17.2%) and 22 of 91 (24.2%) patients in the RIB and SCI groups, respectively (absolute risk difference, −6.9% [95% CI, −18.8% to 4.9%]; P = .26). The RIB group showed lower incidence of relowering treatment than the SCI group (36 of 87 [41.4%] vs 52 of 91 [57.1%] patients, respectively; absolute risk difference, −15.8% [95% CI, −30.3% to −1.3%]; P = .04; number needed to treat, 6.3). Groups did not differ in terms of efficacy in increasing sNa concentrations nor improving symptoms, but RIB, when compared with SCI, showed better efficacy in achieving target correction rate within 1 hour (intention-to-treat analysis: 28 of 87 (32.2%) vs 16 of 91 (17.6%) patients, respectively; absolute risk difference, 14.6% [95% CI, 2%-27.2%]; P = .02; number needed to treat, 6.8; per-protocol analysis: 21 of 72 (29.2%) vs 12 of 73 (16.4%) patients, respectively; absolute risk difference, 12.7% [95% CI, −0.8% to 26.2%]; P = .07). The statistical significance of the intention-to-treat and per-protocol analyses were similar for all outcomes except for achieving the target correction rate within 1 hour.CONCLUSIONS AND RELEVANCE This randomized clinical trial found that both RIB and SIC therapies of hypertonic saline for treating hyponatremia were effective and safe, with no difference in the overcorrection risk. However, RIB had a lower incidence of therapeutic relowering treatment and tended to have a better efficacy in achieving sNa within 1 hour than SCI. RIB could be suggested as the preferred treatment of symptomatic hyponatremia, which is consistent with the cu...

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Hyponatremia, Cerebral Edema, and Noncardiogenic Pulmonary Edema in Marathon Runners

Abstract: In healthy marathon runners, noncardiogenic pulmonary edema can be associated with hyponatremic encephalopathy. The condition may be fatal if undiagnosed and can be successfully treated with hypertonic NaCl.

Cited by 267 publications

References 13 publications

Exercise-Associated Hyponatremia

Exercise-Associated Hyponatremia

Hyponatremia Treatment Guidelines 2007: Expert Panel Recommendations

Risk of Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion Therapies of Hypertonic Saline for Patients With Symptomatic Hyponatremia

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