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CAPS - The use of urine sodium to creatinine ratio as a marker of total body sodium in infants with intestinal failure - Sara Choi
With Dr. Sarah Choi & Dr. Paul Wales & Dr. Hannah Piper
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Infants with intestinal failure have compromised intestinal function, putting them at increased risk of malabsorption and electrolyte and fluid deficits.
Sodium depletion can go unrecognized, resulting in poor growth refractory to increased caloric intake.
Sodium supplementation has been shown to be associated with weight gain and overall growth in infants with intestinal failure.
Serum sodium does not reflect total sodium stores.
Fractional excretion of sodium is the optimum measure of total body sodium but is inconvenient in the pediatric population as it requires a paired urine and blood sample.
At BC Women's Hospital, urine sodium is used as a non-invasive marker to estimate total body sodium in infants with intestinal failure, with a value above 30 suggesting sodium sufficiency.
Urine sodium doesn't account for volume status, therefore can result in oversupplementation or under supplementation with sodium.
The urine sodium to urine creatinine ratio offers a non-invasive measure which accounts for variable urine flow and has shown to be strongly correlated with fractional excretion of sodium.
The use of the urine sodium to creatinine ratio has not yet been validated in the intestinal failure population.
In the study cohort of 22 infants, median gestational age was 31 weeks, median birth weight was 1.9 kg, and median age of enrollment was 8 days.
Gastroschisis was the most common etiology of intestinal failure in the study cohort.
There was no significant correlation between either urine sodium or the ratio with daily weight gain when evaluating the entire data set.
The ratio was more strongly associated with sodium intake when compared to urine sodium alone.
Urine sodium values above 29 and ratio values above 35 best predicted adequate weight gain.
The urine sodium threshold of 29 is similar to previous studies, as it is generally accepted that urine sodium values above 30 is suggestive of sodium sufficiency.
In the majority of urine sodium and ratio values, both markers were concordant, meaning that if urine sodium value met the threshold, then the ratio also met the threshold.
In 19% of the time, the urine sodium and ratio values were discordant.
Patients with stomas, even those without intestinal failure, run the risk of sodium depletion, which has a significant impact on their growth.
Stomas and high stool losses are a large source of sodium bicarbonate as well as magnesium loss.
Sodium status needs to be thought of, especially in the setting of a baby experiencing poor weight gain in the exposure to what is believed to be adequate calories.
When sodium is replaced, it helps restore growth, but it doesn't allow catch up growth.
It's important to track these patients serially so that a trend can be detected and sodium depletion can be avoided in the first place.
If it becomes part of practice to order urine electrolytes at the time that someone's doing their TPN blood work, it's easy to calculate the fractional excretion of sodium ratio.
Having potassium, chloride, and osmolality added to the urine electrolytes in addition to just the sodium gives a better picture of whether someone is truly sodium depleted.
If potassium level is higher than sodium level in urine, that often indicates the aldosterone pathway is turned on.