Skip to main content
SpringerLink
Log in

Improving the diagnostic workup of hyponatremia in the setting of kidney disease: a continuing medical education (CME) initiative

  • Nephrology - Original Paper
  • Published:
International Urology and Nephrology Aims and scope Submit manuscript

Abstract

Purpose

Hyponatremia is a common electrolyte disorder and is associated with mortality. We examined the frequency of appropriate testing in response to an episode of inpatient hyponatremia in a large urban hospital to better inform our educational intervention. We then evaluated the impact of a live CME activity with a focus on CKD- and ESRD-associated hyponatremia physiology, on diagnostic practices of audience hospitalist attendings.

Methods

We performed a retrospective database analysis of all patients admitted to Montefiore Medical Center in 2014 to examine the performance of hospital staff in response to hyponatremia across all CKD stages. We then did a comparative analysis of diagnostic workup orders for hyponatremic patients admitted to audience members of a live CME activity in the 4 months prior as compared to the 4 months after the activity.

Results

The prevalence of hyponatremia was 27% in a cohort of hospitalized patients: 41% of these hyponatremia inpatients had CKD, and 11.4% had ESRD. Overall less than 10% of patients had orders written for serum and urine osmolality without a differential pattern based on CKD or ESRD diagnosis. Among the patients admitted to the CME audience hospitalists, urine/serum osmolality and urine sodium orders occurred infrequently overall and did not differ after vs. before the lecture.

Discussion

The frequency of appropriate diagnostic orders written in response to an episode of hyponatremia was very low and did not vary based on degree of CKD. A CME activity with an emphasis on the role of CKD/ESRD in diagnostic accuracy did not improve the order quality in a group of audience hospitalists. Efforts to improve the diagnostic workup of hyponatremia with concomitant kidney disease are crucial to proper management of these patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Hoorn EJ, Zietse R (2013) Hyponatremia and mortality: moving beyond associations. Am J Kidney Dis 62(1):139–149

    Article  CAS  PubMed  Google Scholar 

  2. Wald R, Jaber BL, Price LL, Upadhyay A, Madias NE (2010) Impact of hospital-associated hyponatremia on selected outcomes. Arch Intern Med 170(3):294–302

    Article  CAS  PubMed  Google Scholar 

  3. Waikar SS, Mount DB, Curhan GC (2009) Mortality after hospitalization with mild, moderate, and severe hyponatremia. Am J Med 122(9):857–865

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Chiu DY, Kalra PA, Sinha S, Green D (2016) Association of serum sodium levels with all-cause and cardiovascular mortality in chronic kidney disease: results from a prospective observational study. Nephrology (Carlton) 21(6):476–482

    Article  CAS  Google Scholar 

  5. Han DS, Cho BS (2002) Therapeutic approach to hyponatremia. Nephron 92(Suppl 1):9–13

    Article  PubMed  Google Scholar 

  6. Zhang R, Wang S, Zhang M, Cui L (2016) Hyponatremia in patients with chronic kidney disease. Hemodial Int. doi:10.1111/hdi.12447

  7. Kovesdy CP, Lott EH, Lu JL, Malakauskas SM, Ma JZ, Molnar MZ et al (2012) Hyponatremia, hypernatremia, and mortality in patients with chronic kidney disease with and without congestive heart failure. Circulation 125(5):677–684

    Article  PubMed  PubMed Central  Google Scholar 

  8. Waikar SS, Curhan GC, Brunelli SM (2011) Mortality associated with low serum sodium concentration in maintenance hemodialysis. Am J Med 124(1):77–84

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Rhee CM, Ravel VA, Ayus JC, Sim JJ, Streja E, Mehrotra R et al (2016) Pre-dialysis serum sodium and mortality in a national incident hemodialysis cohort. Nephrol Dial Transplant 31(6):992–1001

    Article  PubMed  Google Scholar 

  10. Nigwekar SU, Wenger J, Thadhani R, Bhan I (2013) Hyponatremia, mineral metabolism, and mortality in incident maintenance hemodialysis patients: a cohort study. Am J Kidney Dis 62(4):755–762

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Hecking M, Karaboyas A, Saran R, Sen A, Horl WH, Pisoni RL et al (2012) Predialysis serum sodium level, dialysate sodium, and mortality in maintenance hemodialysis patients: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 59(2):238–248

    Article  CAS  PubMed  Google Scholar 

  12. Combs S, Berl T (2014) Dysnatremias in patients with kidney disease. Am J Kidney Dis 63(2):294–303

    Article  CAS  PubMed  Google Scholar 

  13. Macias Nunez JF, Garcia Iglesias C, Bondia Roman A, Rodriguez Commes JL, Corbacho Becerra L, Tabernero Romo JM et al (1978) Renal handling of sodium in old people: a functional study. Age Ageing 7(3):178–181

    Article  CAS  PubMed  Google Scholar 

  14. Bricker NS, Dewey RR, Lubowitz H, Stokes J, Kirkensgaard T (1959) Observations on the concentrating and diluting mechanisms of the diseased kidney. J Clin Invest 38(3):516–523

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Nagler EV, Vanmassenhove J, van der Veer SN, Nistor I, Van Biesen W, Webster AC et al (2014) Diagnosis and treatment of hyponatremia: a systematic review of clinical practice guidelines and consensus statements. BMC Med 12:1

    Article  PubMed  PubMed Central  Google Scholar 

  16. Verbalis JG, Goldsmith SR, Greenberg A, Schrier RW, Sterns RH (2007) Hyponatremia treatment guidelines 2007: expert panel recommendations. Am J Med 120(11 Suppl 1):S1–S21

    Article  CAS  PubMed  Google Scholar 

  17. Spasovski G, Vanholder R, Allolio B, Annane D, Ball S, Bichet D et al (2014) Clinical practice guideline on diagnosis and treatment of hyponatraemia. Intensive Care Med 40(3):320–331

    Article  PubMed  Google Scholar 

  18. Spasovski G, Vanholder R, Allolio B, Annane D, Ball S, Bichet D et al (2014) Clinical practice guideline on diagnosis and treatment of hyponatraemia. Nephrol Dial Transplant 29(Suppl 2):i1–i39

    Article  PubMed  Google Scholar 

  19. Spasovski G, Vanholder R, Allolio B, Annane D, Ball S, Bichet D et al (2014) Clinical practice guideline on diagnosis and treatment of hyponatraemia. Eur J Endocrinol 170(3):G1–G47

    Article  CAS  PubMed  Google Scholar 

  20. Mandai S, Kuwahara M, Kasagi Y, Kusaka K, Tanaka T, Shikuma S et al (2013) Lower serum sodium level predicts higher risk of infection-related hospitalization in maintenance hemodialysis patients: an observational cohort study. BMC Nephrol 14:276

    Article  PubMed  PubMed Central  Google Scholar 

  21. Tzoulis P, Evans R, Falinska A, Barnard M, Tan T, Woolman E et al (1070) Multicentre study of investigation and management of inpatient hyponatraemia in the UK. Postgrad Med J 2014(90):694–698

    Google Scholar 

  22. Miller A, Kuehl B, Tennankore K, Soroka S (2016) Approach to hyponatremia in congestive heart failure: a survey of Canadian specialist physicians and trainees. Can J Kidney Health Dis 3:4

    Article  PubMed  PubMed Central  Google Scholar 

  23. Giuliani C, Cangioli M, Beck-Peccoz P, Faustini-Fustini M, Fiaccadori E, Peri A (2013) Awareness and management of hyponatraemia: the Italian Hyponatraemia Survey. J Endocrinol Invest 36(9):693–698

    CAS  PubMed  Google Scholar 

  24. Hoorn EJ, Bouloux PM, Burst V (2012) Perspectives on the management of hyponatraemia secondary to SIADH across Europe. Best Pract Res Clin Endocrinol Metab 26(Suppl 1):S27–S32

    Article  PubMed  Google Scholar 

  25. William JH, Huang GC (2014) How we make nephrology easier to learn: computer-based modules at the point-of-care. Med Teach 36(1):13–18

    Article  PubMed  Google Scholar 

  26. Leaphart CL, Gonwa TA, Mai ML, Prendergast MB, Wadei HM, Tepas JJ 3rd et al (2012) Formal quality improvement curriculum and DMAIC method results in interdisciplinary collaboration and process improvement in renal transplant patients. J Surg Res 177(1):7–13

    Article  PubMed  Google Scholar 

  27. Davis DA, Thomson MA, Oxman AD, Haynes RB (1995) Changing physician performance. a systematic review of the effect of continuing medical education strategies. JAMA 274(9):700–705

    Article  CAS  PubMed  Google Scholar 

  28. Jerardi KE, Elkeeb D, Weiser J, Brinkman WB (2013) Rapid implementation of evidence-based guidelines for imaging after first urinary tract infection. Pediatrics 132(3):e749–e755

    Article  PubMed  PubMed Central  Google Scholar 

  29. Langsjoen J, Goodell C, Castro E, Thomas J, Kuehl TJ, Wehbe-Janek H et al (2015) Improving compliance with cervical cancer screening guidelines. Proc (Bayl Univ Med Cent) 28(4):450–453

    Google Scholar 

  30. Calderon-Margalit R, Mor-Yosef S, Mayer M, Adler B, Shapira SC (2005) An administrative intervention to improve the utilization of laboratory tests within a university hospital. Int J Qual Health Care 17(3):243–248

    Article  PubMed  Google Scholar 

  31. Gnanasampanthan V, Porten L, Bissett I (2014) Improving surgical intravenous fluid management: a controlled educational study. ANZ J Surg 84(12):932–936

    Article  PubMed  Google Scholar 

  32. Bhatia RS, Dudzinski DM, Milford CE, Picard MH, Weiner RB (2014) Educational intervention to reduce inappropriate transthoracic echocardiograms: the need for sustained intervention. Echocardiography 31(8):916–923

    Article  PubMed  Google Scholar 

  33. Leiba A, Dreiman N, Weiss G, Adini B, Bar-Dayan Y (2010) The effectiveness of an educational intervention on clinicians’ knowledge of pandemic influenza. Isr Med Assoc J 12(8):460–462

    PubMed  Google Scholar 

Download references

Acknowledgements

We would like to acknowledge the Montefiore CME office with their help with the live CME activity. The research described was supported by NIH/National Center for Advancing Translational Science (NCATS) Einstein-Montefiore CTSA Grant No. ULT1TR001073. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Author information

Authors and Affiliations

  1. Montefiore Medical Center, Albert Einstein College of Medicine, 3450 Wayne AveSuite 5H, Bronx, NY, 10467, USA

    Ladan Golestaneh, Joel Neugarten, William Southern, Faraj Kargoli & Amanda Raff

Authors
  1. Ladan Golestaneh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Joel Neugarten
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. William Southern
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Faraj Kargoli
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Amanda Raff
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ladan Golestaneh.

Ethics declarations

Conflict of interest

The corresponding author and another author received funds from the CME office for their participation in preparing the live lecture. There were no funding and no competing interests in gathering the data, analyzing it or preparing it for submission. Dr Golestaneh taught the CME activity, gathered all data, analyzed the data and wrote part of the manuscript. Drs Joel Neugarten and Amanda Raff helped to write the manuscript. Drs Kargoli and Southern helped with conceptual design of the study and the interpretation of the findings.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Golestaneh, L., Neugarten, J., Southern, W. et al. Improving the diagnostic workup of hyponatremia in the setting of kidney disease: a continuing medical education (CME) initiative. Int Urol Nephrol 49, 491–497 (2017). https://doi.org/10.1007/s11255-017-1501-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11255-017-1501-6

Keywords

Search

Navigation