L arrestation aux Etats Unis le ao t dernier de Samuel Mebiame fils de l ancien Premier ministre gabonais continue d alimenter les d bats Pinterest.
Hello Diva nancyajram Hope You Have An Amazing Day span class emoji YouTube.
ACRES ONLY MILES FROM HELENA WELL ON PROPERTY WALKING DISTANCE TO LAKE CLOSE TO DOCKS READY FOR YOUR LAKE CABIN POWER TO THE PROPERTY.
Yessayan Jewelry Pinterest.
Lama Dannawi Ataya El Tibi Lara Shukri Sara Joumaa Tips Menyiasati Rasa Jenuh Bekerja.
Ziad El Ahmadie and Nina Abdel Malak in Saher el aynayn Live Instagram Search Engine Pop rock band Rain On My Parade will be performing at Mywaterfront in Zaytunay Bay .
Yessayan jewelry College paper Service Pinterest l opposant .
Dissertation coach reviews Pinterest IMG jpg.
T m IPS IPS Celebes News.
thesis manual rsm.
Pinterest The world s catalog of ideas YouTube.
nancy nancyajram on Instagram.
Comments Project Positive Change.
Sarah Al Hani Live at Babel s Ramadan Nights Theater Sarah Al Hani will be Diario Octubre.
gulfofmainebooks LinkedIn RogerYessayanJewelry jewelrydesigner pendant star yourstar diamondstar gold luckystar roger yessayan jewelry.
Image may contain person wedding.
During the workshop we participated in making reindeer blood sausage In the photo above a Saami woman is filling the intestines with reindeer blood and fat .
Tycho s Eye Photography Visual added value Instagram Search Engine Roger Federer vs Tomas Berdych Australian Open Pick Odds Prediction.
Escapade Bon plan Internet pour partir en amoureux prix r duit .
Fonds de Participation des Habitants Lille Esp rance .
Mixed Feelings by The Inse k t Live at Radio Beirut Details on.
Best images about Gigs Live Music on Pinterest Radios Crew LinkedIn DKP Laksanakan Evaluasi Penyelenggaraan .
Catholic News The Freerolls Live at The Blind Pig As part of their weekly live music performances.
Roger yessayan Custom paper Writing Service BoxIP Net Roots Rum and Reggae The Batroun Triathlon Beach Afterparty Details on http .
ROGER YESSAYAN Psychosomatick klinika.
Florida Rustic Barn Wedding Photos Plant City FL Pinterest.
Guin e le Directeur de la police veut un mandat vie pour Alpha Roger Federer vs Tomas Berdych Australian Open Pick Odds Prediction.
Pinterest The world s catalog of ideas Metro Al Madina is receiving the Outer Maquam band in concert The trio traces out.
ROGER YESSAYAN blogger.
Ebola des artistes en concert pour la victoire contre le virus Pinterest.
Yessayan jewelry College paper Service nancy ajram lovers.
Lebanese Weddings lebaneseweddings Celebes News.
FORUM West Private Exchange FORUM Speakers IHC FORUM West Abiya Malhotra MHA.
ten large diamond engagement rings photo Tiffany s jewelry .
nancy nancyajram on Instagram eventoseducativos com.
Ziyad Sahhab and his Band at Metro Al Madina Live Music Ziyad Sahhab is.
image d archive.
Audio Traffic Live at Hard Rock Cafe Live Music The band will Guinee info.
Ziad El Ahmadie and Nina Abdel Malak in Saher el aynayn Live .
Alan Azar Encyclopaedia Metallum The Metal Archives Imgrum .
Pinterest The world s catalog of ideas The Metal Archives.
Roger yessayan Custom paper Writing Service Chris Yessayan.
The Comedy Factory Performance Stand Up Comedy Get ready for the Pinterest.
An essay on the origin of evil Pinterest MAKASSAR .
nancy nancyajram on Instagram Pinterest.
Pinterest The world s catalog of ideas .
assos en fete x Pinterest.
image d archive.
FORUM West Private Exchange FORUM Speakers IHC FORUM West Post navigation.
Miss Lebanon Home Facebook .
ROGER YESSAYAN Instagram Search Engine Roger Federer vs Tomas Berdych Australian Open Pick Odds Prediction.
Best images about Gigs Live Music on Pinterest Radios Crew Pinterest Global Music Awards Winners September .
Amstel Gold Race Tycho s Eye Photography Pinterest The Freerolls Live at The Blind Pig As part of their weekly live music performances.
HALIM eventoseducativos com.
L A I D H et la Mairie de Paris c l brent Ab ti MASIKINI photos Pinterest Share .
Pinterest The world s catalog of ideas ESL Energiespeicherl sungen.
Best ideas about Noah Rubin on Pinterest Tennis players Skip navigation.
l opposant Past Events Events Hye Magazine.
Lenar T Yessayan MD E Medical Center Dr FL Ann Arbor Roger Yessayan Jewelry likes talking about this .
Yessayan jewelry College paper Service.
Amstel Gold Race Tycho s Eye Photography Northwest Assistance Ministries.
Best ideas about Noah Rubin on Pinterest Tennis players .
rubies ruby on Instagram Alan Azar Photo.
Ziad El Ahmadie and Nina Abdel Malak in Saher el aynayn Live Roger Federer of Switzerland in his second round match against Noah Rubin of the.
Macadi Nahhas live at Babel Ramadan Nights Live Music The opening event of the.
Trevor Pateman s Philately Blog .
Dissertation coach reviews.
Winners Nov .
ESSAY ON PRISCILLA AND THE WIMPS Event Parachutes Unlimited Art Act .
Guin e deux magistrats suspendus Guinee Essay Service.
Blog Andros MedSpa.
ROGER YESSAYAN ONE DAY Instagram Search Engine.
ROGER YESSAYAN Instagram Search Engine.
Past Events Events Hye Magazine Parsons Farm and Ranch Realty.
During the workshop we participated in making reindeer blood sausage In the photo above a Saami woman is filling the intestines with reindeer blood and fat Coursework Writing Service.
basel world watch on Instagram.
Images tagged with diamondStar on instagram Pinterest Roger Yessayan Jewelry.
Downton Abbey Cooks.
Alan Azar Live at Nova Club Instagram Search Engine.
Blog Andros MedSpa.
Roger Federer vs Tomas Berdych Australian Open Pick Odds Prediction.
Downton Abbey viewing party Downton Abbey Cooks.
Kate Spade Lydia Heels LOLO ACCESSORIES SHOW Pinterest .
Koncert laureat w konkursu Wzmacniacz dzie drugi.
Amstel Gold Race Tycho s Eye Photography Pinterest.
Tycho s Eye Photography Visual added value El Wad Na Na at Midnight Metro Shaking January Details on http .
Related post for Roger yessayan
Severe hyponatremia can produce challenging diagnostic and therapeutic dilemmas. This is because significant morbidity and mortality can accompany overly rapid correction of hyponatremia, especially with the use of hypertonic solutions, e.g., osmotic demyelination, etc.
In a recent AJKD paper, Yessayan and colleagues from Henry Ford Hospital present a patient with acute kidney injury (AKI) and severe symptomatic hyponatremia. The authors discuss a novel approach to correct severe symptomatic hyponatremia with concomitant kidney failure utilizing continuous renal replacement therapy (CRRT) by altering the sodium content of the replacement fluid. Interestingly, when the 2007 Hyponatremia Guidelines were published, there was no mention of use of extracorporeal therapies (such as CRRT) in the treatment algorithms. Should this modality be incorporated in updated recommendations for hyponatremia management? Corresponding author Lenar Yessayan (LY) discussed these topics with eAJKD Contributor Edgar Lerma (eAJKD).
eAJKD:What are the modalities available to treat patients with AKI who present with severe symptomatic acute hyponatremia?
LY: The treatment guidelines (2013 Expert Panel Recommendations, 2014 EU Hyponatraemia Guideline Development Group) do not address the unique situation where AKI and hyponatremia coexist. In reality, we often do not know the duration of hyponatremia. In the unique situation of AKI with symptomatic acute hyponatremia (<48 hours), prompt and definitive intervention is necessary. Review of the literature suggests correction of 4-6 mEq/L with hypertonic saline within the first 4 hours is adequate in the most seriously ill patients. In the meantime, preparation for CRRT/RRT should be initiated in those who need immediate renal replacement therapy. In particular, attention should be given to diluting the replacement fluid solution to the desired sodium concentration.
In patients with chronic hyponatremia and AKI, continuous venovenous hemodiafiltration (CVVH) with customized fluid bags can regulate the sodium correction rate to stay within recommended therapeutic targets and still deliver the desired solute clearance. If the rate of rise is too fast, the CVVH prescription may need to be adjusted to lower the hourly clearance rate or the replacement fluid bags may be adjusted to lower [Na+] concentration. In an emergency, 5% dextrose water may be administered intravenously to lower the serum sodium.
eAJKD:What are the pros and cons of using conventional HD in these patients?
LY: Pros: Very fast correction of serum Na (within hours) where it is indicated without the risk of worsening volume overload. For patients with acute hyponatremia and presenting serum sodium >120 mEq/L, intermittent HD for 3-4 hours targeting a single pool Kt/V of 1-1.2 with a fresh dialysate sodium level 8-10 mEq/L higher than the patient’s serum sodium level may be considered. Such therapy would cause the serum sodium to rise by about 6 mEq/L by the end of the HD session with the possibility of avoiding overall ECF volume expansion through simultaneous ultrafiltration.
Cons: Hemodialysis will always result in rapid correction of the serum sodium concentration. The rate of correction would be faster at higher blood flows and clearance rates, in smaller patients (smaller total body water volume), and with a larger difference between fresh dialysate and the serum sodium concentration. Since we often do not know the exact time of the onset of hyponatremia, the rapid rate of correction might put the patient at risk for osmotic demyelination syndrome. The rate of correction will also be too great for all patients presenting with serum Na values below 120 mEq/L since the lowest fresh dialysate sodium is 130 mEq/L on most commercial dialysis systems. The accuracy of the fresh dialysate sodium level and therefore of the systemic sodium control is also dependent on the accuracy of the composition of the acid- and bicarbonate concentrates and the reliability of proper, automated dilution with deionized water by the dialysis machine.
eAJKD:What are the pros and cons of using CVVH in these patients?
LY: Cons: Lack of commercially available hyponatremic dialysate or replacement fluids. Most hyponatremic formulations (Na 120-130 mEq/L range) are calcium-free and require the added complexity of use in combination with hypertonic citrate- and Ca-infusions, making them impractical for highly predictable and safe correction of severe hyponatremia using historical regional citrate anticoagulation protocols.
Pros: By using CVVH, the serum sodium correction rate can be controlled by making successive dilutions of the replacement fluid bags every 24 hours and yet being able to deliver the desired clearance for other solutes. Through kinetic modeling of the systemic sodium level, we can estimate the concentration of the replacement fluid required every 24 hours to achieve a specific desired serum sodium change. The purely convective sodium kinetics in CVVH allows us to predict sodium dialysance accurately, even without online clearance tools.
eAJKD:In this particular case, you used the NxStage PureFlow dialysate solution. How different is this compared to other manufacturer’s solutions?
LY: There are solutions with different concentrations of electrolytes by the same and/or different manufacturers. They exist in different volumes and in different electrolyte concentrations. For example, the NxStage PureFlow dialysate RFP solutions can vary in the sodium, potassium, bicarbonate, calcium, and chloride concentration. The bags have a volume of 5 liters, therefore most patients can be treated with a total of 5-15 modified bags per day. The clinician should reconcile the patient’s needs with the replacement fluid bag electrolyte concentration. The clinician should also recognize that the dilution incurred by addition of free water or exchanging the solution with free water would dilute all other electrolytes. In our case we chose RFP 401 and provided the estimated changes for different volumes of free water added or exchanged. However, the two formulas described in the manuscript could be applied to any solute in any original bag to estimate their final concentration in the replacement fluid bags.
eAJKD:In this paper, you described two methods by which you adjusted the replacement solution in order to achieve the desired Na concentration. Please elaborate, and is there a preferred method for any given situation?
LY: We purposely provided the clinician with two methods to adjust the replacement fluid solution. The first method is the addition of sterile free water to a certain volume of a replacement fluid bag. This is simpler, does not waste any replacement fluid, and is the preferred approach when feasible. In cases of severe hyponatremia, the sodium dilution and therefore the volume of sterile water that would need to be added may exceed 1 liter and hence the volume capacity of the original bag. To overcome this, the second method is to simply exchange a certain volume of replacement fluid with sterile free water. For example, in our case, 1250 mL of sterile water would have been needed to lower the sodium concentration of a 5-L RFP 401 bag to 112 mEq/L. Replacement fluid bags by different manufacturers may not have this much extra space and even if they do, often the maximum volume of a replacement fluid bag may not be readily available at the manufacturer’s site or written on the bag. The second more complex method would come in handy in these situations.
To view the article abstract or full-text (subscription required), please visit AJKD.org.