irreverent MD

First I recall time served on the inpatient Cardiology service in residency. Then we review the evidence for salt and fluid restriction in acute and chronic heart failure. 

 Aliti GB, Rabelo ER, Clausell N, Rohde LE, Biolo A, Beck-da-Silva L. Aggressive fluid and sodium restriction in acute decompensated heart failure: a randomized clinical trial. JAMA Intern Med. 2013 Jun 24;173(12):1058-64. 

Herrmann JJ, Brunner-La Rocca HP, Baltussen LEHJM, Beckers-Wesche F, Bekkers SCAM, Bellersen L, van Eck JWM, Hassing HC, Jaarsma T, Linssen GCM, Pisters R, Sanders-van Wijk S, Verdijk MHI, Handoko ML, van der Meer P, Verbrugge FH, Januzzi JL Jr, Bayés-Genís A, Nieuwlaat R, Rodwell L, Gommans DHF, van Kimmenade RRJ. Liberal fluid intake versus fluid restriction in chronic heart failure: a randomized clinical trial. Nat Med. 2025 Jun;31(6):2062-2068. 

Hsu SM, Lin YH, Lin YC, Liu SJ, Liu CJ, Hung CL, Wang TJ. Fluid intake impact on heart failure: Systematic review and meta-analysis with trial sequential analysis. J Formos Med Assoc. 2025 Jul;124(7):650-659. 

Mullens W, Damman K, Dhont S, Banerjee D, Bayes-Genis A, Cannata A, Chioncel O, Cikes M, Ezekowitz J, Flammer AJ, Martens P, Mebazaa A, Mentz RJ, Miró Ò, Moura B, Nunez J, Ter Maaten JM, Testani J, van Kimmenade R, Verbrugge FH, Metra M, Rosano GMC, Filippatos G. Dietary sodium and fluid intake in heart failure. A clinical consensus statement of the Heart Failure Association of the ESC. Eur J Heart Fail. 2024 Apr;26(4):730-741. 

Urban S, Fułek M, Błaziak M, Fułek K, Iwanek G, Jura M, Grzesiak M, Szymański O, Stańczykiewicz B, Ptaszkowski K, Zymlinski R, Ponikowski P, Biegus J. Role of dietary sodium restriction in chronic heart failure: systematic review and meta-analysis. Clin Res Cardiol. 2024 Sep;113(9):1331-1342. 

Episode 10 to download: Let's get salty 3

More salt! Wait, less salt. Or at least the management of less salt. Let's review the evidence supporting the management of hyponatremia (or not)...

Aegisdottir H, Cooray C, Wirdefeldt K, Piehl F, Sveinsson O. Incidence of osmotic demyelination syndrome in Sweden: A nationwide study. Acta Neurol Scand. 2019 Nov;140(5):342-349.

Ayus JC, Moritz ML, Fuentes NA, Mejia JR, Alfonso JM, Shin S, Fralick M, Ciapponi A. Correction Rates and Clinical Outcomes in Hospitalized Adults With Severe Hyponatremia: A Systematic Review and Meta-Analysis. JAMA Intern Med. 2025 Jan 1;185(1):38-51. 

Chander S, Kumari R, Lohana AC, Rahaman Z, Parkash O, Shiwlani S, Mohammed YN, Wang HY, Chi H, Tan W, Kumar SK, Sindhu F. Urea to Treat Hyponatremia Due to Syndrome of Inappropriate Antidiuretic Hormone Secretion: A Systematic Review and Meta-Analysis. Am J Kidney Dis. 2025 Mar;85(3):303-319. 

Falhammar H, Andersson Franko M, Lindh JD, Skov J, Mannheimer B. Neurologic and psychiatric disorders following correction of profound hyponatremia - A cohort study. Eur J Intern Med. 2025 Oct;140:106394.

Krisanapan P, Vongsanim S, Pin-On P, Ruengorn C, Noppakun K. Efficacy of Furosemide, Oral Sodium Chloride, and Fluid Restriction for Treatment of Syndrome of Inappropriate Antidiuresis (SIAD): An Open-label Randomized Controlled Study (The EFFUSE-FLUID Trial). Am J Kidney Dis. 2020 Aug;76(2):203-212. 

Refardt J, Imber C, Sailer CO, Jeanloz N, Potasso L, Kutz A, Widmer A, Urwyler SA, Ebrahimi F, Vogt DR, Winzeler B, Christ-Crain M. A Randomized Trial of Empagliflozin to Increase Plasma Sodium Levels in Patients with the Syndrome of Inappropriate Antidiuresis. J Am Soc Nephrol. 2020 Mar;31(3):615-624. 

Refardt J, Imber C, Nobbenhuis R, Sailer CO, Haslbauer A, Monnerat S, Bathelt C, Vogt DR, Berres M, Winzeler B, Bridenbaugh SA, Christ-Crain M. Treatment Effect of the SGLT2 Inhibitor Empagliflozin on Chronic Syndrome of Inappropriate Antidiuresis: Results of a Randomized, Double-Blind, Placebo-Controlled, Crossover Trial. J Am Soc Nephrol. 2023 Feb 1;34(2):322-332. 

Rondon-Berrios H. Diagnostic and Therapeutic Strategies to Severe Hyponatremia in the Intensive Care Unit. J Intensive Care Med. 2024 Nov;39(11):1039-1054.

Seethapathy H, Zhao S, Ouyang T, Passos C, Sarang A, Cheung PW, Waikar SS, Steele DJR, Kalim S, Allegretti AS, Ayus JC, Nigwekar SU. Severe Hyponatremia Correction, Mortality, and Central Pontine Myelinolysis. NEJM Evid. 2023 Oct;2(10):EVIDoa2300107.

Schrier RW, Gross P, Gheorghiade M, Berl T, Verbalis JG, Czerwiec FS, Orlandi C; SALT Investigators. Tolvaptan, a selective oral vasopressin V2-receptor antagonist, for hyponatremia. N Engl J Med. 2006 Nov 16;355(20):2099-112. 

Spasovski G, Vanholder R, Allolio B, Annane D, Ball S, Bichet D, Decaux G, Fenske W, Hoorn EJ, Ichai C, Joannidis M, Soupart A, Zietse R, Haller M, van der Veer S, Van Biesen W, Nagler E; Hyponatraemia Guideline Development Group. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Eur J Endocrinol. 2014 Feb 25;170(3):G1-47. 

Verbalis JG, Goldsmith SR, Greenberg A, Korzelius C, Schrier RW, Sterns RH, Thompson CJ. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. Am J Med. 2013 Oct;126(10 Suppl 1):S1-42. 

Episode 9 to download: Let's get salty 2

This spring is all about salt!!! In part 1 I relive the saltiness of the emergency department while I was in residency and then get super nerdy about the pathophysiology of hyponatremia. 

Verbalis JG, Goldsmith SR, Greenberg A, Korzelius C, Schrier RW, Sterns RH, Thompson CJ. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. Am J Med. 2013 Oct;126(10 Suppl 1):S1-42. 

Spasovski G, Vanholder R, Allolio B, Annane D, Ball S, Bichet D, Decaux G, Fenske W, Hoorn EJ, Ichai C, Joannidis M, Soupart A, Zietse R, Haller M, van der Veer S, Van Biesen W, Nagler E; Hyponatraemia Guideline Development Group. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Eur J Endocrinol. 2014 Feb 25;170(3):G1-47. 

Episode 8 to download: Let's get salty 1

First there is more fun on the Oncology service to be had by all. Then we discuss a landmark trial assessing the benefit of exercise as adjunctive therapy for colon cancer.

Most pertinent articles:

Bozzetti F. Potential Benefits from Physical Exercise in Advanced Cancer Patients Undergoing Systemic Therapy? A Narrative Review of the Randomized Clinical Trials. Curr Oncol. 2024 Dec 1;31(12):7631-7646. 

Courneya KS, Vardy JL, O'Callaghan CJ, Gill S, Friedenreich CM, Wong RKS, Dhillon HM, Coyle V, Chua NS, Jonker DJ, Beale PJ, Haider K, Tang PA, Bonaventura T, Wong R, Lim HJ, Burge ME, Hubay S, Sanatani M, Campbell KL, Arthuso FZ, Turner J, Meyer RM, Brundage M, O'Brien P, Tu D, Booth CM; CHALLENGE Investigators. Structured Exercise after Adjuvant Chemotherapy for Colon Cancer. N Engl J Med. 2025 Jul 3;393(1):13-25. 

Feng Y, Feng X, Wan R, Luo Z, Qu L, Wang Q. Impact of exercise on cancer: mechanistic perspectives and new insights. Front Immunol. 2024 Sep 13;15:1474770. 

Zylstra J, Whyte GP, Beckmann K, Pate J, Santaolalla A, Gervais-Andre L, Russell B, Maisey N, Waters J, Tham G, Lagergren J, Green M, Kelly M, Baker C, Van Hemelrijck M, Goh V, Gossage J, Browning M, Davies A. Exercise prehabilitation during neoadjuvant chemotherapy may enhance tumour regression in oesophageal cancer: results from a prospective non-randomised trial. Br J Sports Med. 2022 Apr;56(7):402-409. 

Episode 7 to download: You can't outrun cancer…