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preparing him for dialysis every visit we did modality education and discussion he decided on home therapy and we referred to our general surgeon dr meguid who has really taken a deep interest in pd and become a valued partner in june of 2021 norris received a pd catheter and he began dialysis the following september we did the whole process as an outpatient so by unos rules even though he wasn t listed until 2022 his wait time was backdated to the start of dialysis september 2021 but something else happened in 2021 the nephrology community abandoned race in the calculation of egfr while this change helped black patients going forward it did nothing for people whose transplant evaluations had already been delayed by the old race adjusted equation so in january 2023 the organ procurement and transplantation network optn required transplant programs to review black kidney transplant candidates and determine whether earlier creatinine values would have made them eligible for listing using the race free equation norris had exactly that creatinine from a year before he presented to my service this creatinine of 3 4 gave him a gfr of 21 by the 2009 formula but with the 2021 race free egfr it was 19 ml min low enough for him to be eligible for transplant listing with the stroke of a pen his wait time moved from late 2021 to early 2018 an additional three years this was enough to thrust him near the top of the waitlist in september of 2024 norris got his kidney and three days later he was home with a falling creatinine feeling better than he had in years a lot of people worked hard to remove race from egfr equations it can feel like an abstract policy debate but sometimes it looks like this posted on march 11 2026 proactive vs reactive ddavp the clamp finally faces an rct note this was one of my first posts on roon com if you are an american physician who likes to chat about medicine you should sign up there are so few prospective randomized trials in hyponatremia that we cherish every one even the quirky underpowered ones so let s take our hats off and salute the royal thai air force for putting the ddavp clamp under the rct microscope safety and efficacy of proactive versus reactive administration of desmopressin in severe symptomatic hyponatremia a randomized controlled trial https www nature com articles s41598 024 57657 z the trial is underpowered their power calculation called for 66 patients but they enrolled 49 still i love that they had the courage to test something many of us including me have accepted without prospective data given the scarcity of trials this is very much the hyponatremia way the investigators randomized patients to a proactive strategy a ddavp clamp versus reactive ddavp and they had the courage to enroll people who were actually sick many hyponatremia trials enroll patients with relatively mild disease but this cohort had an average sodium of 115 meq l which is impressive just look at the high risk of osmotic demyelination syndrome and the clinical presentation in this population these are the bad actors in hyponatremia the patients who actually need randomized trials the hit trial would have benefited from enrolling a cohort like this the results though were similar to the hit there was no difference in overcorrection 24 hour sodium change or length of stay the sodium rose more in the proactive group at 48 hours but given multiple comparisons in a small trial that signal should be ignored the overcorrection rate was 16 7 in the proactive group vs 28 in the reactive group p 0 54 that s remarkably consistent with macmillan s toronto data where about 18 of all comers overcorrected it s also far better than the 40 overcorrection rate reported by george et al in western pennsylvania interestingly pakchotanon enrolled patients with na 125 meq l neatly splitting the difference between the 130 threshold used by macmillan and the 120 used by george honestly i expected better sodium control than they achieved my suspicion is that the 3 saline dosing protocol in this trial was relatively aggressive i know i tend to be more conservative with hypertonic saline when managing severe hyponatremia still this study is welcome it s part of a growing trend in hyponatremia research toward prospective data rather than retrospective dogma and in hyponatremia every randomized trial moves the field forward posted on march 9 2026 saline doesn t ruin hyponatremia labs it might help one of the challenges in the assessment of hyponatremia is we rarely get to assess patients fresh from the community by the time the nephrologist is called patients have usually received a liter or two of 0 9 normal saline i call these sneaky iv fluids because they often don t even get documented somewhere between triage and the nephrology consult a liter of saline appears no order no note just a bag that quietly happened rare picture of sneaky saline so when the emergency department or ward gets around to collecting the urine for biochemical analysis the urine has been contaminated can we trust those altered specimens can they reliably distinguish hypovolemic hyponatremia from siad well dr chienwichai of thailand designed a study to answer that very question and he did it prospectively with a well designed rigorous trial he took patients with a sodium less than 130 and eliminated anyone with fluid overload he also eliminated people where the urine sodium cannot be trusted nobody who received fluids before he got a chance to assess urine and blood nobody on diuretics nobody with adrenal insufficiency nobody with metabolic alkalosis or even just a serum bicarbonate over 30 nobody with an egfr less than 60 and then after checking basic urine and serum biochemical profiles ran everyone through protocolized fluid resuscitation if the serum sodium failed to rise or fell with saline patients were categorized as siad if the sodium corrected with fluids and remained corrected when fluids were stopped they were categorized as hypovolemic hyponatremia the protocol looked something like this so at the end of the protocol they had the cohort convincingly divided into siad or hypovolemic hyponatremia and they had a record of their initial urine and serum biochemical profile time zero their urine and biochemical profile after 500 ml time one after one liter time two after two liters time three and after four liters time four and so now we can see if that sneaky liter of saline ruins the biochemical tests and you know what it actually does the opposite it makes the difference between siad and hypovolemic hyponatremia more stark here is table two with the averages so it is pretty clear that the numbers don t meaningfully change with saline infusion but what i ve been trying to explain in my recent lectures the urine sodium isn t the window to truth we sometimes expect it to be this question can be seen in figure 2 look at the overlap in urine sodium between hypovolemic hyponatremia and siad though the numbers don t lose information and actually gain separation with fluid resuscitation there remains tremendous overlap with the urine na between hypovolemic hyponatremia and siad this is beautifully shown with the roc curves the authors provide while an auc of 0 75 is quite a bit better than 0 61 it s helpful but far from diagnostic one of the findings of the study was that patients who ultimately are diagnosed with siad often had an initial positive response to saline infusions however our study showed that urine osmolality also decreases in siad from before saline infusion to after saline infusion we hypothesize that this may be due to the vasopressin escape mechanism a defense response characterized by increased urine volume and decreased urine osmolality furthermore concurrent hypovolemia in hospitalized patients may have contributed to the observed decrease in urine osmolality although a decrease in the serum sodium level after saline administration is used as supportive criteria for diagnosis of siad25 approximately 30 of patients with siad have been reported to experience an increase in serum sodium by 5 mmol l after receiving 2 l of 0 9 saline in our study this was observed in 38 of patients with siad i ve seen this many times siad can give a head fake by initially responding to saline the sodium rises everyone relaxes and we think we were just treating volume depletion only for siad to reappear a day later it was satisfying to see that this was a real phenomenon rather than an undocumented spook the last finding i want to highlight is uric acid i m a fan of serum uric acid and some of my fellows have been waving the flag for fractional excretion of uric acid feua however in the baseline labs there was no significant difference in serum uric acid between hypovolemic hyponatremia and siad feua did show a difference but there was still substantial overlap you can see this in how high the 75th percentile of feua was in hypovolemic hyponatremia 13 9 even though the commonly cited cutoff for siad is only 12 the take home message don t panic if the urine studies were drawn after a liter of saline the saline doesn t destroy the diagnostic signal if anything it may accentuate the physiologic differences between hypovolemia and siad and most importantly urine sodium is helpful but it is never the whole story posted on march 6 2026 finally the hyponatremia intervention trial is published the hyponatremia interventional trial hit has been published in nejm evidence the results were unveiled at the late breaking and high impact clinical trials session at asn kidney week 2024 in san diego and we ve been waiting 15 months for the manuscript to drop last week it finally did https evidence nejm org doi full 10 1056 evidoa2500086 the nejm evidence journal has now published three of the most important articles on hyponatremia in the last few years first with macmillan et al that showed that cpm was quite a bit rarer than previously thought then the nejm evidence struck again with seethapathy et al who showed that patients with hyponatremia who corrected at the slowest rate had higher hospital mortality and now the hit the premise of the hit was straightforward and compelling hyponatremia has long been associated with worse outcomes higher mortality more rehospitalizations longer lengths of stay but association is not causation so the investigators asked what if we deliberately and systematically corrected hyponatremia if we do a better job at improving hyponatremia in one arm of a randomized trial and outcomes improve in that arm that would go a long way to prove that hyponatremia is directly responsible for those adverse outcomes to test this they randomized 2 100 patients to either standard care or a strategy of multifaceted targeted correction of hyponatremia i would describe the intervention if it was describable but what it essentially comes down to is consult nephro and have them run the hyponatremia playbook as described in verbalis 2013 us guidelines and spasovski s 2014 european guidelines take a look at figure 1 in the supplement give yourself more than a few minutes it s a lot the intervention worked but only modestly the mean increase in serum sodium during the treatment period was 10 0 mmol l 5 6 in the intervention group 8 7 mmol l 5 6 in the control group normal sodium levels 135 145 mmol l were achieved in 60 of the intervention arm 46 of the control arm editorial side bar it is depressing that the most current guidelines have not been updated for over a decade and fail to correct the sodium in 40 of patients what are we doing here back to the study so yes sodium moved more with the protocolized care but the difference was modest and clinically the primary outcome death or rehospitalization at 30 days occurred in 20 of the intervention group 22 of the control group p 0 45 little separation no signal the authors essentially randomized patients to either standard care or a protocol that essentially looked a lot like standard of care we should not be surprised that there was not separation if we want to get separation it is time to move on from being afraid of rapid correction in low risk patients and crack the whip after decades of observational data linking hyponatremia to poor outcomes hit delivers a sobering message correcting the number does not correct the prognosis or it is just a type 2 error due to the lack of separation between groups posted on january 28 2026 why aren t you prescribing fish oil to your dialysis patients so the belle of the ball at last year s kidney week was the pisces trial which reported a striking 50 reduction in cardiovascular outcomes with fish oil in hemodialysis patients that is an extraordinary signal if you re unaware or skeptical i suggest d strongly encourage you to check out nephjc s coverage or listen to the freely filtered episode the data look clean internally consistent and genuinely impressive one of the practical sticking points however has been how to translate pisces into practice specifically what fish oil actually matches the intervention used in the trial the investigators are working with their supplier to bring the study formulation to market but in the meantime clinicians are left asking what if anything can reasonably substitute earlier this year i was invited to the medical university of south carolina to give grand rounds and during the discussion ruth campbell mentioned that she has been using the fda regulated prescription omega 3 product lovaza for her patients as it turns out that choice is quite defensible lovaza is fairly similar to the fish oil used in pisces both in formulation omega 3 ethyl esters and dose differing mainly in the epa dha ratio because lovaza is an fda approved prescription drug it fits cleanly into most ehr workflows and patients are far more likely to receive what the label says they re getting than with unregulated over the counter fish oil supplements that reliability matters when you re trying to reproduce a trial signal as strong as pisces i like it i ve started prescribing it what are you using for your patients posts pagination page 1 page 2 page 115 next page who is joel topf there are many ways to describe me in bullet point form board certified nephrologist partner at st clair nephrology associate clinical professor at oakland university william beaumont school of medicine associate program director for the ascension saint john nephrology fellowship program medical director of st clair nephrology research i see patients at henry ford st johns roseville and troy conflicts of interest are available at the about page search search for search precious bodily fluids by email email address subscribe 2026 august 2 ouwb question about siadh and volume status occam denied july 1 may 2 march 4 january 1 2025 october 1 september 2 august 4 february 3 january 2 2024 december 2 november 4 october 4 september 5 august 1 july 1 june 1 may 1 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