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

Abstract

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.

Keywords: PICS; catabolism; hypernatremia; inflammation; urea-to-creatinine ratio.

Figure A1

Inclusion criteria, steps of exclusion and group allocation.

Figure 1

Hypernatremia, catabolism and inflammation. Intensive care unit (ICU) day-dependent group analysis presented as daily median and interquartile range from admission to day 21 of (a) serum sodium, (b) urea-to-creatinine ratio, (c) urea generation rate, (d) leucocytes, (e) C-reactive protein (CRP) and (f) procalcitonin. The range of statistical interest (ICU day 7–21) is indicated by the gray-shaded area.

Figure 2

Electrolyte-free water clearance, fluid balance and sodium intake. ICU day-dependent group analysis presented as daily median and interquartile range from admission to day 21 of (a) urine output, (b) urine osmolality ratio (urea/not urea), (c) urine sodium output, (d) electrolyte-free water clearance (EFWC), (e) fluid balance and (f) sodium intake. The range of statistical interest (ICU day 7–21) is indicated by the gray-shaded area.