The burden of hyponatremia and 30-day outcomes among adults admitted with stroke at a large tertiary teaching hospital in Northwestern Tanzania

So you did absolutely nothing? Described a problem, BUT DID NOTHING TO SOLVE IT! I'd fire everyone involved in this!

Telling us appropriately managing hyponatremia is useless; survivors want prevention! GET THERE!

Where the fuck are the EXACT PROTOCOLS that prevent this problem? You're all fired for incompetence!

The burden of hyponatremia and 30-day outcomes among adults admitted with stroke at a large tertiary teaching hospital in Northwestern Tanzania

Johari Katanga^1†Igembe Nkandala^1†Joshua Ngimbwa²Lilian Andrew Mwamba³Innocent Kitandu Paul¹Sospeter Berling¹Gladness Xavier¹Matilda K. Basinda¹Sophia Kagoye⁴Karim Mahawish⁵Sarah Shali Matuja^1*

• ¹Department of Internal Medicine, Catholic University of Health and Allied Sciences-Weill Bugando School of Medicine, Mwanza, Tanzania
• ²Department of Internal Medicine, Aga Khan University, Dar es Salaam, Tanzania
• ³Department of Internal Medicine-Neurology, Jinzhou Medical University, Jinzhou, China
• ⁴National Institute for Medical Research, Mwanza Research Centre, Dar es Salaam, Tanzania
• ⁵Department of Stroke Medicine, Counties Manukau Health, Auckland, New Zealand

Background: The most frequent electrolyte derangement in adults with stroke is hyponatremia, which is associated with increased morbidity, mortality, and prolonged hospital stay. The study aimed to investigate the hyponatremia incidence and 30-day outcomes among adults admitted with stroke at a large tertiary teaching hospital in Northwestern Tanzania.

Methods: This cohort study recruited adults presenting with first-ever stroke (as defined by the World Health Organization) between November 2023 to May 2024. Data were collected on demographics, the degree of neurological impairment at admission using the National Institutes of Health Stroke Scale (NIHSS), and laboratory workup, including sodium levels, on admission; the modified Rankin Scale was used to assess stroke outcomes. We used modified Poisson and logistic regressions to examine factors associated with hyponatremia and 30-day outcomes, respectively.

Results: In total, 167 adults were enrolled, of which 56.9% (n = 95) were female, with a median age of 60 years (interquartile range [IQR] 40–74), and 71.2% (n = 119) had hypertension and heart failure. The hyponatremia incidence was 29.3% (n = 49), and among these participants, 53% (n = 26) had mild hyponatremia. Factors associated with hyponatremia were the use of mannitol on admission (adjusted prevalence ratio [aPR] 3.14, 95% CI [1.81, 5.44], p < 0.001) and increasing NIHSS scores (aPR 1.03, 95% CI [1.00, 1.06], p < 0.05). There were no differences in 30-day mortality between those with and without hyponatremia (respectively, 38.3% vs. 36.7%, p = 0.79). The presence of leukocytosis was independently associated with 30-day mortality (adjusted odds ratio [aOR] = 2.7, 95% CI [1.39, 5.36], p = 0.004), and the median length of hospital stay was significantly higher in those with hyponatremia compared to those without: 7 days (IQR 4–9) vs. 5 days (IQR 3–9), p = 0.032.

Conclusion: Hyponatremia, which is associated with increased stroke severity, probable infections, and prolonged hospital stays, is prevalent among adults with stroke in Northwestern Tanzania. The high prevalence of hypertension and heart failure underscores the need for targeted preventive strategies(WHERE THE FUCK ARE THEY?). Early detection and appropriately managing hyponatremia are essential to improve stroke outcomes in this region.

Introduction

Stroke is the third-leading cause of death and the fourth-leading cause of disability-adjusted life years (DALYs) globally, with the majority of this burden (over 90% of deaths and DALYs) observed in low- and middle-income countries, particularly sub-Saharan Africa (SSA) (Feigin et al., 2022, 2021). The incidence and mortality rates of stroke in SSA are rising, largely due to the high prevalence of both modifiable and non-modifiable risk factors, such as age, gender, hypertension, and diabetes (Zhang et al., 2010; Abissegue et al., 2024). Studies in SSA indicate a growing burden of stroke, with crude incidence rates increasing from an average of 53 cases per 100,000 between 1973 and 1991 to 88 cases per 100,000 between 2003 and 2011 (Chukwudelunzu, 2024). Notably, in this region, stroke disproportionately affects younger individuals and is often associated with poor outcomes due to infections and other medical complications during the acute phase (Matuja et al., 2020, 2023). Among these complications, electrolyte imbalances are particularly common and can significantly worsen clinical outcomes (Hossain et al., 2023). Common causes of hyponatremia include the syndrome of inappropriate antidiuretic hormone secretion and the use of certain anti-hypertensive medications, such as diuretics and dietary salt restrictions for hypertension management, with cerebral salt wasting syndrome being the least common (Atila et al., 2021; Karunanandham et al., 2018; Ehtesham et al., 2019). Furthermore, serum creatinine levels play a crucial role in differentiating between hypervolemic hyponatremia and euvolemic hyponatremia. Research indicates that even small percentage changes in serum creatinine, specifically changes of ≥10% or ≤ -3%, can accurately classify hyponatremic patients (Gabriel Ruiz-Sánchez et al., 2022).

Tanzania, a country in SSA, has reported a high stroke burden in both community- and hospital-based studies. A large community-based study conducted between 2004 and 2006 identified an age-adjusted stroke incidence of 315.9 per 100,000 person-years in urban areas, with a 28-day mortality of 24% (Walker et al., 2010, 2013). Moreover, hospital-based studies have documented 30-day stroke mortality rates ranging from 40.8% to 61.3%, with the highest mortality occurring within the first week of hospital admission (Matuja et al., 2020; Okeng'o et al., 2017). Despite these alarming statistics, data addressing the burden and impact of hyponatremia on stroke outcomes in SSA, including Tanzania, are limited. This study aimed to investigate the hyponatremia incidence and 30-day outcomes among adults admitted with stroke at a large tertiary teaching hospital in Northwestern Tanzania.

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