Dysnatremias in Pediatric Patients with Earthquake Victims of 2023 Türkiye-Syria Earthquake

Dysnatremias in Pediatric Patients with Earthquake Victims of 2023 Türkiye-Syria Earthquake | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Dysnatremias in Pediatric Patients with Earthquake Victims of 2023 Türkiye-Syria Earthquake ulaş özdemir, tugba Kandemir Gülmez, Mehmet Deniz Erhan, ümit çelik, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6246916/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Jun, 2025 Read the published version in Pediatric Nephrology → Version 1 posted 5 You are reading this latest preprint version Abstract Background: Dysnatremia is a common electrolyte abnormality in children, but its prevalence and impact in pediatric earthquake victims are not well-established. This study aimed to define the frequency of dysnatremia in pediatric earthquake victims and evaluate its relationship with complications, mortality, and morbidity. Methods: We retrospectively analyzed data from 312 pediatric patients admitted to our hospital after the 2023 Türkiye-Syria earthquakes. Patients were categorized based on admission sodium levels: hyponatremic (145 mmol/L), and normal (135-145 mmol/L). Demographic, clinical, and laboratory data were analyzed. Results: Of the 312 patients, 36.2% were hyponatremic, 17.3% were hypernatremic, and 46.5% had normal sodium levels. Hyponatremic patients had a higher frequency of fasciotomy, crush syndrome, and acute kidney injury (AKI). Hypernatremic patients had longer times under rubble and increased rates of crush syndrome and AKI. Mortality was 5.4%, with no significant difference between dysnatremic and normonatremic patients. Conclusions: Dysnatremia is common in pediatric earthquake victims. Hyponatremia is associated with increased morbidity, including crush syndrome and AKI. Monitoring and management of sodium abnormalities are crucial in the care of pediatric earthquake survivors. INTRODUCTION The Marash-based earthquakes that took place on February 6 affected a very large area, causing great destruction in 11 provinces and causing more than 50 thousand deaths and more than 120 thousand injuries to our people. Due to the location of our hospital, many injured people from both the province where we are located and the surrounding provinces, especially from the province of Hatay, were brought to our hospital after the first intervention or directly removed from the wreckage. The risk of injury and death during earthquakes and other disasters is much higher in children than in adults. Considering that approximately 1 billion children under the age of 14 live in countries with high seismic activity and active earthquake faults, the magnitude of the current risk reaches frightening dimensions ( 1 , 2 ). The vast majority of deaths are sudden deaths due to severe injuries to vital organs caused by the direct impact of earthquake debris. Earthquake victims with severe brain or spinal cord trauma often cannot be saved. For other serious injuries, deaths occur within the first few hours after the earthquake unless urgent treatment is provided ( 2 , 3 ). Among other survivors, deaths occur days and weeks after the earthquake due to complications such as sepsis, MOD and disseminated intravascular coagulation. The greatest need for health care providers and hospitals arises in the first week ( 2 ). Natural disasters, especially earthquakes, not only cause a large number of deaths in a short period of time, but also lead to physical and psychological injuries that require longer and comprehensive medical treatment ( 2 ). Crush injury (CI) is the most important trauma encountered after earthquakes and is defined as prolonged compression of the extremities causing rhabdomyolysis with CK > 1000 U/L and/or tissue damage requiring fasciotomy/amputation. Acute kidney injury (AKI) is defined as an acute deterioration in renal function characterized by an acute increase in serum creatinine (sCr) or a decrease in urine output. Although myoglobinuric acute tubular necrosis due to rhabdomyolysis is the most common cause of AKI, AKI may also occur postrenal due to obstruction as a result of pelvic injury, ischemic prerenal due to prolonged exposure to debris and excessive dehydration or hypovolemic state in cases of major bleeding. Crush syndrome (CS) is defined as a systemic manifestation of CI accompanied by at least one of the following: a > 2-fold increase in creatinine, hyperkalemia (> 6mmol/l), elevated uric acid (> 8mg/dl), elevated serum phosphorus (> 8 mg/dL) or low serum calcium (< 8mg/dL). Crush syndrome and associated complications are seen as the most common cause of death after the destruction caused by the earthquake and the direct effect of trauma. There are very few studies evaluating the relationship between crush injuries and complications and dysnatremia, especially in the pediatric age group ( 4 , 5 ) The aim of this study was to define the frequency of dysnatremia in pediatric age group earthquake victims based on our experiences after these devastating earthquakes and to evaluate the relationship between dysnatremia and complications, mortality and morbidity due to crush injuries. MATERIAL-METHOD Earthquake victims who applied to Adana City Hospital Pediatric Emergency Service between 6/2/2023-17/2/2023, 1071 children were brought to our emergency department with injuries. Patients referred after initial treatment and stabilization and patients with missing file information were excluded from the study, 312 patients who were followed up as an inpatient in our hospital were included in the study. The demographic data of the patients, the duration of their stay under the rubble, laboratory characteristics at the time of admission, and clinical data such as trauma, pediatric intensive care unit (PICU) need, and the presence of multiple organ dysfunction (MOD) were analyzed retrospectively. To evaluate the effects of dysnatraemia on morbidity and mortality, patients were grouped as hyponatremic ( 145 mmol/l) and normal sodium (135–145 mmol/l) levels at admission. The aim of this study is to define the frequency of dysnatraemias in earthquake survivors, to evaluate the risk factors related to dysnatremia and the relationship between dysnatremia and mortality. Definitions Dysnatremia: Normal sodium level was defined as a sodium level of 135–145 mmol/l. Hyponatremia was defined as a sodium level of 145 mmol/l ( 6 , 7 ). Acute kidney injury (AKI) is defined as an acute decline in renal function characterised by an acute increase in serum creatinine (sCr) or a decrease in urine output ( 8 ). Crush injury (CI) is defined as prolonged limb compression resulting in rhabdomyolysis with CK > 1000 U/L and/or tissue damage requiring fasciotomy/amputation. Crush syndrome (CS) is defined as a systemic manifestation of CI accompanied by at least one of the following: a > 2-fold increase in creatinine, hyperkalemia (> 6mmol/l), elevated uric acid (> 8mg/dl), elevated serum phosphorus (> 8 mg/dL) or low serum calcium (< 8mg/dL) ( 9 ). Statistical Analysis Statistical analysis of the study was performed using the Statistical Package for Social Sciences” version 20 (IBM Corp., Armonk, NY, USA) program. Descriptive statistics of numerical data were calculated as mean ± standard deviation in parametric data and median (minimum-maximum) in non-parametric data. Categorical data were given as percentage (%). Chi-square analysis and Fisher’s exact test was used to compare categorical measures between groups. In the comparison of numerical measurements between the groups, the T test was used if the assumptions were met, and the Mann Whitney U test was used if the assumptions were not met. Mann-Whitney U test was used for continuous variables under parametric conditions and Student’s t-test under nonparametric conditions. The significance level used for these tests was p < 0.05. RESULTS Patient Characteristics 312 patients, 159 male and 153 female, who were hospitalized in Adana City Hospital Pediatrics Clinic, were included in the study. Mean age of the patients were 117± 63 months. 280 (89.7%) of 312 pediatric earthquake victims were admitting from Hatay, which is 2 hours away from our hospital by highway. The median time under the rubble (TUR) of the patients was 18 hours (minimum:1, maximum:248 hours). The most common trauma was extremity trauma with 286 patients (91.7%), followed by thoracic trauma in 55 (17.6%), abdominal trauma in 48 (15.4%), cranial trauma in 40 (12.8%), and pelvic trauma in 30 (9.6%). Median duration of hospitalization was 10 days (2-145 days). The clinical features of the patients are shown in Table 1. Of the patients 145 (46.5%) had normal sodium levels, 113 (36.2%) of them were hyponatremic and 54 (17.3%) of them were hypernatremic. Hyponatremic Patients Patients who were hyponatremic at admission and those with normal sodium levels were similar in terms of age, gender, and TUR. The frequency of fasciotomy, crush syndrome and AKI and dialysis treatment was significantly higher in the hyponatremic patient group compared to those with normal sodium levels. Extremity, thoracic, abdominal, cranial, and pelvic trauma frequencies were similar in patients with hyponatremia and normal sodium level. Considering the laboratory findings at the time of admission, hyponatremic patients were found to have higher levels of urea, creatinine, uric acid, creatinine kinase (CK), lactate dehydrogenase (LDH), AST, ALT, potassium, phosphorus, hemoglobin, and white blood count (WBC); and had lower levels of calcium, pH, and bicarbonate levels. The median hospital stay of hyponatremic patients was 15 (2-99) days and was longer than those without dysnatraemia and hypernatremic patients (p<0.001). Clinical and laboratory features of patients with normal sodium level and hyponatremia at the time of admission is shown in Table 2. Hypernatremic Patients The mean age of patients who were hypernatremic at admission was 92±73 months, and they were younger than those with normal sodium levels (119±74 months) (p=0.035). Hypernatremic patients also had a longer TUR with 121±64 hours, which is 35±41 hours in patients with normal sodium (p<0.001). The frequency of hypernatremia was higher in patients with thoracic trauma. There was no increased frequency of hypernatremia in the presence of extremity, abdominal, cranial, and pelvic trauma. CS and AKI was found more frequently in the hypernatremic patient group at admission, although the need for dialysis was not higher in this group. Presence of MOD, need for PICU hospitalization and amputation were found to be increased in the hypernatremic patient group compared to those with normal sodium. While urea, creatinine, uric acid, and phosphorus levels of hypernatremic patients were higher than the group with normal sodium, pH and HCO3 levels were lower. The median hospital stay of hypernatremic patients was 9 (2-145) days and was similar to those without dysnatraemia (p<0.116). Clinical and laboratory features of patients with normal sodium level and hypernatremia at the time of admission is shown in Table 3. Clinical course of patients with normal sodium, hyponatremia and hypernatremia on admission is shown in graph 1. Mortality A total of 17 patients (5.4%) died during the follow-up period. 13 patients died within the first 6 days. While 7 of the deceased patients were normonatremic at admission, 10 patients had dysnatremia and there was no statistically significant difference between the mortality rates. Clinical and laboratory characteristics of the deceased patients are summarized in Table 4. DISCUSSION Our study demonstrates that in pediatric patients presenting post-earthquake, the presence of dysnatremia, particularly hyponatremia, should prompt increased vigilance regarding the development of adverse clinical outcomes during follow-up, including fasciotomy, crush syndrome (CS), and acute kidney injury (AKI), all of which may carry a poor prognosis and necessitate complex treatment regimens. Dysnatremia is among the most common electrolyte abnormalities of childhood. Acute and rapid changes in plasma or serum sodium can lead to serious morbidity and mortality. A serum or plasma sodium level of less than 135 mEq/L is defined as hyponatremia and a level of more than 145 mEq/L is defined as hypernatremia ( 6 , 7 ). The incidence of pediatric hyponatremia is not known precisely due to the diversity of etiology and mechanisms of occurrence and the fact that most studies have been conducted in hospitalized children. The incidence of hyponatremia has been reported to vary between 17% and 45%. Hypovolemia may occur as a result of antidiuretic hormone (ADH) release due to diseases such as fever, head trauma, central nervous system (CNS) infections, pneumonia, bronchiolitis, etc. It may also occur due to drugs used in inpatients, intravenous/oral hypotonic fluid treatments ( 10 – 14 ). Hypernatremia is less common than hyponatremia. Hypernatremia is reported to occur in 0.04%-0.2% of children admitted to hospital. The most common cause of hypernatremia is excessive dehydration or inadequate fluid intake due to gastroenteritis or systemic infection, but it may also occur iatrogenically due to increased intracranial pressure, cerebral edema or hyperosmolar therapy for the treatment of acute liver failure ( 15 , 16 ). Various prevalences of hyponatremia and hypernatremia have been reported after major earthquakes. In a study evaluating 180 adult earthquake victims after the Wenchuane earthquake, the prevalence of hyponatremia was reported as 50.6% ( 5 ). After the 1999 Marmara earthquake, Dönmez et al. evaluated 20 pediatric patients and reported that serum sodium levels were between 135.4 and 133 mmol/l in children with one extremity and multiple extremity injuries, respectively, and hyponatremia developed in approximately 50% of the patients( 4 ). In another study in which the results of 118 earthquake victims over 15 years of age were evaluated, it was reported that hyponatremia was detected in 52.5% and hypernatremia in 6.9% of the patients on the first day of hospitalization( 17 ). The prevalence reported in other studies evaluating earthquake victims ranged between 14.5% and 75% ( 18 , 19 ). In our study, 36.2% of the patients had hyponatremia and 17.3% had hypernatremia at hospital admission, which is consistent with the literature. The TUR was longer in hypernatremic patients than in patients with normal sodium, and the younger mean age of hypernatremic patients at admission may have provided them with a smaller body mass, allowing them to remain relatively protected in the triangle of life under the rubble and to be exposed to less crush injury. In support of this, thoracic trauma was more common in hypernatremic patients and the frequency of hypernatremia was not increased in the presence of extremity abdominal, pelvic and cranial trauma. When the time spent under debris is prolonged, dehydration and hypernatremia are expected to increase due to the lack of fluid intake and fluid losses. Since the earthquake we experienced was in February, it may have caused less fluid loss. Nevertheless, it is necessary to consider the possibility that the people who could be reached during the rescue operations were given intravenous or oral fluid support while under the rubble, and that the children who were taken out of the rubble may have taken water/fruit juice to quench their thirst. Regretfully, no data could be recorded in the chaotic conditions of the earthquake, so it is not possible to draw any definitive conclusions. In literature, the prevalence of CS has been reported between 2% and 15%, while the prevalence of AKI has been reported between 4.9% and 31% ( 2 , 20 ). It has been reported that AKI develops in approximately half of patients with CS ( 2 , 3 , 21 – 23 ). In our study, 43.3% of the patients were followed up with a diagnosis of CS and 52.6% with a diagnosis of AKI, and these different rates compared to the literature were thought to be due to the difference in the definitions of CS and AKI and the fact that most of them have not been studied in the pediatric population. The presence of CS and the size of the crushed body surface area significantly increase the risk of AKI ( 24 ). The frequency of CS and AKI was higher in hyponatremic patients than in normonatremic and hypernatremic patients, suggesting that especially hyponatremia may be associated with the severity of crush in injured patients. Compartment syndrome is the result of increased tissue pressure in a closed osteofascial compartment, resulting in obstruction of capillary blood flow, leading to ischemia in muscle and nerve tissues and permanent loss of function. Crushing of the extremity with a high-energy trauma causes widespread edema in the tissues, and irreversible neural and muscular ischemia occurs after 6–8 hours. In compartment syndrome, urgent release of the tissue is important. Compartment syndrome is diagnosed by physical examination, stretching tests or direct tissue pressure measurement, but in earthquakes and natural disasters, when measurement facilities are not available, it is recommended that fasciotomy should be decided with reasonable clinical suspicion. If diagnosed within 8 hours, the only appropriate treatment is dermato-fasciotomy of all involved compartments. There is no conclusive evidence that the 6–8 hour period can be extended in children, but children are potentially capable of retaining viable muscle for longer. Especially late fasciotomy causes complications such as permanent functional impairment in peripheral nerves, increased risk of wound infection, prolonged hospitalization, and increased morbidity and mortality ( 25 , 26 ). The frequency of fasciotomy has been reported between 45% and 75% in various studies in the literature.( 4 , 5 , 15 , 27 ) In our study, the rate of fasciotomy was 36.3%. The studies in the literature mostly consist of adult patients. Since determining the indications for fasciotomy in children is more challenging and varies according to the clinical evaluation and experience of the physician, different results may have been reached with the literature. The prevalence of fasciotomy was significantly higher in hyponatremic patients than in patients without dysnatremia and hypernatremic patients (p < 0.001). The risk of fasciotomy was 3.97 times higher in hyponatremic patients (95% CI: 2.16–7.29). After crushing of the extremities, hyponatremia may occur as a result of pain, muscle damage due to compression and intracellular edema with reperfusion damage, intravascular volume decrease as a result of losses to the third spaces, renin angiotensin aldosterone system activation and vasopressin increase, and it has been shown that vasopressin is significantly increased in patients with multiple trauma ( 28 ). The length of hospital stay of hyponatremic patients was longer than that of patients without dysnatremia and hypernatremic patients. In addition to the higher rate of fasciotomy in hyponatremic patients, the increased incidence of CS and AKI was also associated with longer hospitalization. Zhang et al. reported that the mortality rate during hospitalization was 11% and more than 50% of these deaths were due to MOD caused by severe trauma and occurred within the first week, and that hyponatremia increased the probability of death up to 5.74 times in earthquake victims ( 5 ). In our study, a total of 17 patients (5.4%) died during the follow-up period. 13 patients died within the first 6 days. While 7 of the deceased patients were normonatremic at admission, 10 patients had dysnatremia and there was no statistically significant difference between the mortality rates. Due to the small number of patients who died in our study, we could not perform multiple regression analysis to determine risk factors. However, multiple trauma (abdominal, thoracic, pelvic and cranial traumas accompanying extremity trauma), presence of CS, MOD and dysnatremia were found to be more common in the deceased patient population. CONCLUSION This study, conducted within the pediatric patient group, represents one of the largest patient cohorts reported from a single center in the literature. It indicates that in cases of dysnatremia detected in children admitted post-earthquake especially in the presence of hyponatremia, it shows that one should be more careful in terms of clinical issues that may develop during follow-up such as fasciotomy, CS, AKI, which may have a poor prognosis and may require complicated treatments. Although it is impractical to prevent earthquakes, damage mitigation can be achieved through proactive measures and the formulation of comprehensive rescue and medical intervention plans for both the immediate and post-disaster phases. Enhancing individual and societal awareness, alongside the implementation of effective public institution and state policies, is crucial. Furthermore, research focused on identifying appropriate treatment methods and optimal timing for health service providers is essential for effective disaster preparedness and response. Limitations and Strengths The primary limitation of our study is its retrospective design. Our center served as a coordination hub, resulting in many patients being transferred from earthquake-affected areas, while a significant number were sent to other hospitals for ongoing monitoring and treatment after stabilization. Moreover, the chaotic circumstances of the disaster have led to deficiencies in data records, which may affect the representativeness of the study population concerning the demographic characteristics of all earthquake survivors. Nevertheless, a notable strength of our study is that it includes the largest cohort of pediatric patients evaluated for the relationship between dysnatremias, CI, and CS reported in the literature. Abbreviations EQ Earthquake CI Crush injury AKI Acute kidney injury CS Crush syndrome TUR Time under the rubble PICU Pediatric intensive care unit KRT Kidney replacement therapy CK Creatinine Kinase eGFR Estimated glomerular filtration rate MOD Multi-organ dysfunction LDH Lactate dehydrogenase CRP C-reactive protein IHD Intermittent hemodialysis CRRT Continuous renal replacement therapy HDF Hemodiafiltration Declarations Consent for Publication: On behalf of all the contributors I will act and guarantor and will correspond with the journal from this point onward. This work has not been published or submitted to any other journal. Each author listed on the manuscript has seen and approved the manuscript. We hereby transfer, assign, or otherwise convey all copyright ownership, including any and all rights incidental thereto, exclusively to the journal, in the event that such work is published by the journal. Funding: The authors did not receive support from any organization for the submitted work. Conflict of Interest: The authors have no conflicts of interest relevant to this article to disclose. Consent to Participate: Informed consent was obtained from all individual participants and their legal guards included in the study. Ethics Approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Adana City Education and Research Hospital (Date03.08.2023/No2738). Contributors Statement: Dr Ulas Ozdemir conceptualized and designed the study, coordinated and supervised data collection, carried out the initial analyses, drafted the initial manuscript, and critically reviewed and revised the manuscript. Dr Ulas Ozdemir and Dr Tugba Kandemir Gulmez designed the data collection instruments, collected data, carried out the initial analyses. Dr Mehmet Deniz Erhan designed the data collection instruments and critically reviewed and revised the manuscript. Dr Sevgin Taner designed the data collection instruments and critically reviewed and revised the manuscript Dr Umit Celik coordinated and supervised data collection, and critically reviewed and revised the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. References United Nations Children’s Fund (UNICEF). Children and disasters: Building resilience through education. https://www.unisdr.org/we/ inform/publications/24583. Accessed 20 March 2023 Bartels SA, VanRooyen MJ. Medical complications associated with earthquakes. Lancet. 2012 Feb 25;379(9817):748-57. doi: 10.1016/S0140-6736(11)60887-8. Epub 2011 Nov 4. Erratum in: Lancet. 2012 Feb 25;379(9817):712. PMID: 22056246 He Q, Wang F, Li G, Chen X, Liao C, Zou Y, Zhang Y, Kang Z, Yang X, Wang L. 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Supplementary Files dysnatremiagraphics.docx dysnatremiatables.docx Cite Share Download PDF Status: Published Journal Publication published 27 Jun, 2025 Read the published version in Pediatric Nephrology → Version 1 posted Editorial decision: Major Revisions Needed 03 Apr, 2025 Reviewers agreed at journal 23 Mar, 2025 Reviewers invited by journal 22 Mar, 2025 Editor assigned by journal 18 Mar, 2025 First submitted to journal 17 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6246916","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":432502268,"identity":"23950e61-2ff5-4861-93d0-07b9866eb797","order_by":0,"name":"ulaş özdemir","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYDACdjDJDEYMPBUgNnMDfi3MKFrOgNiMxGoBAd42EElAi8Fh5scfPvyxltNt53264e282mj+dqCWHxXb8GhhM5OcwZNubHaY3ezm3G3Hc2ccZmxg7DlzG48WBjNmHonDidsOs7Hd5t12LLcBqIWZsQ2fFvbPn3kMDtdDtMw5ljufsBYeA2mehMMJZmAtDTW5GwhpkTzMUyY540C6IciWm3OOHcjdCNRyEJ9f+I63bwaFmLzZ+WNsN97U1OXOO3/44IMfFbi1oIPDYPIA0eqBoI4UxaNgFIyCUTBCAAAy2lq/V5ImRQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-4498-6142","institution":"SBU Adana City Training and Research Hospital: TC Saglik Bakanligi Adana Sehir Egitim ve Arastirma Hastanesi","correspondingAuthor":true,"prefix":"","firstName":"ulaş","middleName":"","lastName":"özdemir","suffix":""},{"id":432502269,"identity":"8d4f92f1-a563-4a46-a296-4b8a0a3c8658","order_by":1,"name":"tugba Kandemir Gülmez","email":"","orcid":"","institution":"SBU Adana City Training and Research Hospital: TC Saglik Bakanligi Adana Sehir Egitim ve Arastirma Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"tugba","middleName":"Kandemir","lastName":"Gülmez","suffix":""},{"id":432502270,"identity":"163949ac-28cd-4896-b49c-d6dcb5a5c4d0","order_by":2,"name":"Mehmet Deniz Erhan","email":"","orcid":"","institution":"SBU Adana City Training and Research Hospital: TC Saglik Bakanligi Adana Sehir Egitim ve Arastirma Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"Deniz","lastName":"Erhan","suffix":""},{"id":432502271,"identity":"70051942-850e-4471-903b-d1aa5763f3ff","order_by":3,"name":"ümit çelik","email":"","orcid":"","institution":"SBÜ Adana Şehir Eğitim ve Araştırma Hastanesi: TC Saglik Bakanligi Adana Sehir Egitim ve Arastirma Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"ümit","middleName":"","lastName":"çelik","suffix":""},{"id":432502272,"identity":"c3eb4f42-55ba-4fbf-a22d-9dfba5219879","order_by":4,"name":"sevgin taner","email":"","orcid":"https://orcid.org/0000-0003-1578-789X","institution":"SBÜ Adana Şehir Eğitim ve Araştırma Hastanesi: TC Saglik Bakanligi Adana Sehir Egitim ve Arastirma Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"sevgin","middleName":"","lastName":"taner","suffix":""}],"badges":[],"createdAt":"2025-03-17 17:55:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6246916/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6246916/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00467-025-06843-w","type":"published","date":"2025-06-27T15:57:38+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85686177,"identity":"1db6902c-f1a9-434b-aee5-ce5ae56fa9d1","added_by":"auto","created_at":"2025-06-30 16:04:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":462147,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6246916/v1/ad560d55-7ae1-4c7f-9f34-7eb84441c586.pdf"},{"id":79557262,"identity":"d23200b4-065e-4b87-a21f-36585799b67a","added_by":"auto","created_at":"2025-03-31 07:52:13","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":25222,"visible":true,"origin":"","legend":"","description":"","filename":"dysnatremiagraphics.docx","url":"https://assets-eu.researchsquare.com/files/rs-6246916/v1/ccd7b00c8fa272b344f9f1a2.docx"},{"id":79557265,"identity":"10897bac-a43e-4008-9f47-f361ab80b3d5","added_by":"auto","created_at":"2025-03-31 07:52:13","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":27923,"visible":true,"origin":"","legend":"","description":"","filename":"dysnatremiatables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6246916/v1/b83f8971779eceb316336e05.docx"}],"financialInterests":"","formattedTitle":"Dysnatremias in Pediatric Patients with Earthquake Victims of 2023 Türkiye-Syria Earthquake","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe Marash-based earthquakes that took place on February 6 affected a very large area, causing great destruction in 11 provinces and causing more than 50 thousand deaths and more than 120 thousand injuries to our people. Due to the location of our hospital, many injured people from both the province where we are located and the surrounding provinces, especially from the province of Hatay, were brought to our hospital after the first intervention or directly removed from the wreckage.\u003c/p\u003e \u003cp\u003eThe risk of injury and death during earthquakes and other disasters is much higher in children than in adults. Considering that approximately 1\u0026nbsp;billion children under the age of 14 live in countries with high seismic activity and active earthquake faults, the magnitude of the current risk reaches frightening dimensions (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe vast majority of deaths are sudden deaths due to severe injuries to vital organs caused by the direct impact of earthquake debris. Earthquake victims with severe brain or spinal cord trauma often cannot be saved. For other serious injuries, deaths occur within the first few hours after the earthquake unless urgent treatment is provided (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Among other survivors, deaths occur days and weeks after the earthquake due to complications such as sepsis, MOD and disseminated intravascular coagulation. The greatest need for health care providers and hospitals arises in the first week (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNatural disasters, especially earthquakes, not only cause a large number of deaths in a short period of time, but also lead to physical and psychological injuries that require longer and comprehensive medical treatment (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Crush injury (CI) is the most important trauma encountered after earthquakes and is defined as prolonged compression of the extremities causing rhabdomyolysis with CK\u0026thinsp;\u0026gt;\u0026thinsp;1000 U/L and/or tissue damage requiring fasciotomy/amputation. Acute kidney injury (AKI) is defined as an acute deterioration in renal function characterized by an acute increase in serum creatinine (sCr) or a decrease in urine output. Although myoglobinuric acute tubular necrosis due to rhabdomyolysis is the most common cause of AKI, AKI may also occur postrenal due to obstruction as a result of pelvic injury, ischemic prerenal due to prolonged exposure to debris and excessive dehydration or hypovolemic state in cases of major bleeding. Crush syndrome (CS) is defined as a systemic manifestation of CI accompanied by at least one of the following: a\u0026thinsp;\u0026gt;\u0026thinsp;2-fold increase in creatinine, hyperkalemia (\u0026gt;\u0026thinsp;6mmol/l), elevated uric acid (\u0026gt;\u0026thinsp;8mg/dl), elevated serum phosphorus (\u0026gt;\u0026thinsp;8 mg/dL) or low serum calcium (\u0026lt;\u0026thinsp;8mg/dL).\u003c/p\u003e \u003cp\u003eCrush syndrome and associated complications are seen as the most common cause of death after the destruction caused by the earthquake and the direct effect of trauma. There are very few studies evaluating the relationship between crush injuries and complications and dysnatremia, especially in the pediatric age group (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe aim of this study was to define the frequency of dysnatremia in pediatric age group earthquake victims based on our experiences after these devastating earthquakes and to evaluate the relationship between dysnatremia and complications, mortality and morbidity due to crush injuries.\u003c/p\u003e"},{"header":"MATERIAL-METHOD","content":"\u003cp\u003eEarthquake victims who applied to Adana City Hospital Pediatric Emergency Service between 6/2/2023-17/2/2023, 1071 children were brought to our emergency department with injuries. Patients referred after initial treatment and stabilization and patients with missing file information were excluded from the study, 312 patients who were followed up as an inpatient in our hospital were included in the study. The demographic data of the patients, the duration of their stay under the rubble, laboratory characteristics at the time of admission, and clinical data such as trauma, pediatric intensive care unit (PICU) need, and the presence of multiple organ dysfunction (MOD) were analyzed retrospectively. To evaluate the effects of dysnatraemia on morbidity and mortality, patients were grouped as hyponatremic (\u0026lt;\u0026thinsp;135mmol/l), hypernatremic (\u0026gt;\u0026thinsp;145 mmol/l) and normal sodium (135\u0026ndash;145 mmol/l) levels at admission. The aim of this study is to define the frequency of dysnatraemias in earthquake survivors, to evaluate the risk factors related to dysnatremia and the relationship between dysnatremia and mortality.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDefinitions\u003c/strong\u003e \u003cp\u003eDysnatremia: Normal sodium level was defined as a sodium level of 135\u0026ndash;145 mmol/l. Hyponatremia was defined as a sodium level of \u0026lt;\u0026thinsp;135mmol/l and hypernatremia as a sodium level of \u0026gt;\u0026thinsp;145 mmol/l (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003eAcute kidney injury (AKI) is defined as an acute decline in renal function characterised by an acute increase in serum creatinine (sCr) or a decrease in urine output (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCrush injury (CI) is defined as prolonged limb compression resulting in rhabdomyolysis with CK\u0026thinsp;\u0026gt;\u0026thinsp;1000 U/L and/or tissue damage requiring fasciotomy/amputation.\u003c/p\u003e \u003cp\u003eCrush syndrome (CS) is defined as a systemic manifestation of CI accompanied by at least one of the following: a\u0026thinsp;\u0026gt;\u0026thinsp;2-fold increase in creatinine, hyperkalemia (\u0026gt;\u0026thinsp;6mmol/l), elevated uric acid (\u0026gt;\u0026thinsp;8mg/dl), elevated serum phosphorus (\u0026gt;\u0026thinsp;8 mg/dL) or low serum calcium (\u0026lt;\u0026thinsp;8mg/dL) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis of the study was performed using the Statistical Package for Social Sciences\u0026rdquo; version 20 (IBM Corp., Armonk, NY, USA) program. Descriptive statistics of numerical data were calculated as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation in parametric data and median (minimum-maximum) in non-parametric data. Categorical data were given as percentage (%). Chi-square analysis and Fisher\u0026rsquo;s exact test was used to compare categorical measures between groups. In the comparison of numerical measurements between the groups, the T test was used if the assumptions were met, and the Mann Whitney U test was used if the assumptions were not met. Mann-Whitney U test was used for continuous variables under parametric conditions and Student\u0026rsquo;s t-test under nonparametric conditions. The significance level used for these tests was p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePatient Characteristics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e312 patients, 159 male and 153 female, who were hospitalized in Adana City Hospital Pediatrics Clinic, were included in the study. Mean age of the patients were 117± 63 months. 280 (89.7%) of 312 pediatric earthquake victims were admitting from Hatay, which is 2 hours away from our hospital by highway. The median time under the rubble (TUR) of the patients was 18 hours (minimum:1, maximum:248 hours). The most common trauma was extremity trauma with 286 patients (91.7%), followed by thoracic trauma in 55 (17.6%), abdominal trauma in 48 (15.4%), cranial trauma in 40 (12.8%), and pelvic trauma in 30 (9.6%). Median duration of hospitalization was 10 days (2-145 days). The clinical features of the patients are shown in Table 1. Of the patients 145 (46.5%) had normal sodium levels, 113 (36.2%) of them were hyponatremic and 54 (17.3%) of them were hypernatremic.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHyponatremic Patients\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients who were hyponatremic at admission and those with normal sodium levels were similar in terms of age, gender, and TUR. The frequency of fasciotomy, crush syndrome and AKI and dialysis treatment was significantly higher in the hyponatremic patient group compared to those with normal sodium levels. Extremity, thoracic, abdominal, cranial, and pelvic trauma frequencies were similar in patients with hyponatremia and normal sodium level. Considering the laboratory findings at the time of admission, hyponatremic patients were found to have higher levels of urea, creatinine, uric acid, creatinine kinase (CK), lactate dehydrogenase (LDH), AST, ALT, potassium, phosphorus, hemoglobin, and white blood count (WBC); and had lower levels of calcium, pH, and bicarbonate levels. The median hospital stay of hyponatremic patients was 15 (2-99) days and was longer than those without dysnatraemia and hypernatremic patients (p\u0026lt;0.001). Clinical and laboratory features of patients with normal sodium level and hyponatremia at the time of admission is shown in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHypernatremic Patients\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean age of patients who were hypernatremic at admission was 92±73 months, and they were younger than those with normal sodium levels (119±74 months) (p=0.035). Hypernatremic patients also had a longer TUR with 121±64 hours, which is 35±41 hours in patients with normal sodium (p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eThe frequency of hypernatremia was higher in patients with thoracic trauma. There was no increased frequency of hypernatremia in the presence of extremity, abdominal, cranial, and pelvic trauma. CS and AKI was found more frequently in the hypernatremic patient group at admission, although the need for dialysis was not higher in this group. Presence of MOD, need for PICU hospitalization and amputation were found to be increased in the hypernatremic patient group compared to those with normal sodium. While urea, creatinine, uric acid, and phosphorus levels of hypernatremic patients were higher than the group with normal sodium, pH and HCO3 levels were lower. The median hospital stay of hypernatremic patients was 9 (2-145) days and was similar to those without dysnatraemia (p\u0026lt;0.116). Clinical and laboratory features of patients with normal sodium level and hypernatremia at the time of admission is shown in Table 3.\u003c/p\u003e\n\u003cp\u003eClinical course of patients with normal sodium, hyponatremia and hypernatremia on admission is shown in graph 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMortality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 17 patients (5.4%) died during the follow-up period. 13 patients died within the first 6 days. While 7 of the deceased patients were normonatremic at admission, 10 patients had dysnatremia and there was no statistically significant difference between the mortality rates. Clinical and laboratory characteristics of the deceased patients are summarized in Table 4.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur study demonstrates that in pediatric patients presenting post-earthquake, the presence of dysnatremia, particularly hyponatremia, should prompt increased vigilance regarding the development of adverse clinical outcomes during follow-up, including fasciotomy, crush syndrome (CS), and acute kidney injury (AKI), all of which may carry a poor prognosis and necessitate complex treatment regimens.\u003c/p\u003e \u003cp\u003eDysnatremia is among the most common electrolyte abnormalities of childhood. Acute and rapid changes in plasma or serum sodium can lead to serious morbidity and mortality. A serum or plasma sodium level of less than 135 mEq/L is defined as hyponatremia and a level of more than 145 mEq/L is defined as hypernatremia (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe incidence of pediatric hyponatremia is not known precisely due to the diversity of etiology and mechanisms of occurrence and the fact that most studies have been conducted in hospitalized children. The incidence of hyponatremia has been reported to vary between 17% and 45%. Hypovolemia may occur as a result of antidiuretic hormone (ADH) release due to diseases such as fever, head trauma, central nervous system (CNS) infections, pneumonia, bronchiolitis, etc. It may also occur due to drugs used in inpatients, intravenous/oral hypotonic fluid treatments (\u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHypernatremia is less common than hyponatremia. Hypernatremia is reported to occur in 0.04%-0.2% of children admitted to hospital. The most common cause of hypernatremia is excessive dehydration or inadequate fluid intake due to gastroenteritis or systemic infection, but it may also occur iatrogenically due to increased intracranial pressure, cerebral edema or hyperosmolar therapy for the treatment of acute liver failure (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVarious prevalences of hyponatremia and hypernatremia have been reported after major earthquakes. In a study evaluating 180 adult earthquake victims after the Wenchuane earthquake, the prevalence of hyponatremia was reported as 50.6% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). After the 1999 Marmara earthquake, D\u0026ouml;nmez et al. evaluated 20 pediatric patients and reported that serum sodium levels were between 135.4 and 133 mmol/l in children with one extremity and multiple extremity injuries, respectively, and hyponatremia developed in approximately 50% of the patients(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In another study in which the results of 118 earthquake victims over 15 years of age were evaluated, it was reported that hyponatremia was detected in 52.5% and hypernatremia in 6.9% of the patients on the first day of hospitalization(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The prevalence reported in other studies evaluating earthquake victims ranged between 14.5% and 75% (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In our study, 36.2% of the patients had hyponatremia and 17.3% had hypernatremia at hospital admission, which is consistent with the literature.\u003c/p\u003e \u003cp\u003eThe TUR was longer in hypernatremic patients than in patients with normal sodium, and the younger mean age of hypernatremic patients at admission may have provided them with a smaller body mass, allowing them to remain relatively protected in the triangle of life under the rubble and to be exposed to less crush injury. In support of this, thoracic trauma was more common in hypernatremic patients and the frequency of hypernatremia was not increased in the presence of extremity abdominal, pelvic and cranial trauma.\u003c/p\u003e \u003cp\u003eWhen the time spent under debris is prolonged, dehydration and hypernatremia are expected to increase due to the lack of fluid intake and fluid losses. Since the earthquake we experienced was in February, it may have caused less fluid loss. Nevertheless, it is necessary to consider the possibility that the people who could be reached during the rescue operations were given intravenous or oral fluid support while under the rubble, and that the children who were taken out of the rubble may have taken water/fruit juice to quench their thirst. Regretfully, no data could be recorded in the chaotic conditions of the earthquake, so it is not possible to draw any definitive conclusions.\u003c/p\u003e \u003cp\u003eIn literature, the prevalence of CS has been reported between 2% and 15%, while the prevalence of AKI has been reported between 4.9% and 31% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). It has been reported that AKI develops in approximately half of patients with CS (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In our study, 43.3% of the patients were followed up with a diagnosis of CS and 52.6% with a diagnosis of AKI, and these different rates compared to the literature were thought to be due to the difference in the definitions of CS and AKI and the fact that most of them have not been studied in the pediatric population.\u003c/p\u003e \u003cp\u003eThe presence of CS and the size of the crushed body surface area significantly increase the risk of AKI (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The frequency of CS and AKI was higher in hyponatremic patients than in normonatremic and hypernatremic patients, suggesting that especially hyponatremia may be associated with the severity of crush in injured patients.\u003c/p\u003e \u003cp\u003eCompartment syndrome is the result of increased tissue pressure in a closed osteofascial compartment, resulting in obstruction of capillary blood flow, leading to ischemia in muscle and nerve tissues and permanent loss of function. Crushing of the extremity with a high-energy trauma causes widespread edema in the tissues, and irreversible neural and muscular ischemia occurs after 6\u0026ndash;8 hours. In compartment syndrome, urgent release of the tissue is important. Compartment syndrome is diagnosed by physical examination, stretching tests or direct tissue pressure measurement, but in earthquakes and natural disasters, when measurement facilities are not available, it is recommended that fasciotomy should be decided with reasonable clinical suspicion. If diagnosed within 8 hours, the only appropriate treatment is dermato-fasciotomy of all involved compartments. There is no conclusive evidence that the 6\u0026ndash;8 hour period can be extended in children, but children are potentially capable of retaining viable muscle for longer. Especially late fasciotomy causes complications such as permanent functional impairment in peripheral nerves, increased risk of wound infection, prolonged hospitalization, and increased morbidity and mortality (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe frequency of fasciotomy has been reported between 45% and 75% in various studies in the literature.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) In our study, the rate of fasciotomy was 36.3%. The studies in the literature mostly consist of adult patients. Since determining the indications for fasciotomy in children is more challenging and varies according to the clinical evaluation and experience of the physician, different results may have been reached with the literature.\u003c/p\u003e \u003cp\u003eThe prevalence of fasciotomy was significantly higher in hyponatremic patients than in patients without dysnatremia and hypernatremic patients (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The risk of fasciotomy was 3.97 times higher in hyponatremic patients (95% CI: 2.16\u0026ndash;7.29). After crushing of the extremities, hyponatremia may occur as a result of pain, muscle damage due to compression and intracellular edema with reperfusion damage, intravascular volume decrease as a result of losses to the third spaces, renin angiotensin aldosterone system activation and vasopressin increase, and it has been shown that vasopressin is significantly increased in patients with multiple trauma (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe length of hospital stay of hyponatremic patients was longer than that of patients without dysnatremia and hypernatremic patients. In addition to the higher rate of fasciotomy in hyponatremic patients, the increased incidence of CS and AKI was also associated with longer hospitalization.\u003c/p\u003e \u003cp\u003eZhang et al. reported that the mortality rate during hospitalization was 11% and more than 50% of these deaths were due to MOD caused by severe trauma and occurred within the first week, and that hyponatremia increased the probability of death up to 5.74 times in earthquake victims (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In our study, a total of 17 patients (5.4%) died during the follow-up period. 13 patients died within the first 6 days. While 7 of the deceased patients were normonatremic at admission, 10 patients had dysnatremia and there was no statistically significant difference between the mortality rates. Due to the small number of patients who died in our study, we could not perform multiple regression analysis to determine risk factors. However, multiple trauma (abdominal, thoracic, pelvic and cranial traumas accompanying extremity trauma), presence of CS, MOD and dysnatremia were found to be more common in the deceased patient population.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study, conducted within the pediatric patient group, represents one of the largest patient cohorts reported from a single center in the literature. It indicates that in cases of dysnatremia detected in children admitted post-earthquake especially in the presence of hyponatremia, it shows that one should be more careful in terms of clinical issues that may develop during follow-up such as fasciotomy, CS, AKI, which may have a poor prognosis and may require complicated treatments.\u003c/p\u003e \u003cp\u003eAlthough it is impractical to prevent earthquakes, damage mitigation can be achieved through proactive measures and the formulation of comprehensive rescue and medical intervention plans for both the immediate and post-disaster phases. Enhancing individual and societal awareness, alongside the implementation of effective public institution and state policies, is crucial. Furthermore, research focused on identifying appropriate treatment methods and optimal timing for health service providers is essential for effective disaster preparedness and response.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLimitations and Strengths\u003c/strong\u003e \u003cp\u003eThe primary limitation of our study is its retrospective design. Our center served as a coordination hub, resulting in many patients being transferred from earthquake-affected areas, while a significant number were sent to other hospitals for ongoing monitoring and treatment after stabilization. Moreover, the chaotic circumstances of the disaster have led to deficiencies in data records, which may affect the representativeness of the study population concerning the demographic characteristics of all earthquake survivors. Nevertheless, a notable strength of our study is that it includes the largest cohort of pediatric patients evaluated for the relationship between dysnatremias, CI, and CS reported in the literature.\u003c/p\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEarthquake\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCrush injury\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAKI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcute kidney injury\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCrush syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTUR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTime under the rubble\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePediatric intensive care unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKRT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKidney replacement therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCreatinine Kinase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eeGFR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEstimated glomerular filtration rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMOD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMulti-organ dysfunction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLDH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLactate dehydrogenase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eC-reactive protein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIHD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntermittent hemodialysis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRRT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eContinuous renal replacement therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHDF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHemodiafiltration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e On behalf of all the contributors I will act and guarantor and will correspond with the journal from this point onward. This work has not been published or submitted to any other journal. Each author listed on the manuscript has seen and approved the manuscript. We hereby transfer, assign, or otherwise convey all copyright ownership, including any and all rights incidental thereto, exclusively to the journal, in the event that such work is published by the journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e The authors have no conflicts of interest relevant to this article to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate:\u003c/strong\u003e Informed consent was obtained from all individual participants and their legal guards included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval:\u003c/strong\u003e This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Adana City Education and Research Hospital (Date03.08.2023/No2738).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributors Statement:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDr Ulas Ozdemir conceptualized and designed the study, coordinated and supervised data collection, carried out the initial analyses, drafted the initial manuscript, and critically reviewed and revised the manuscript.\u003cbr\u003e\u0026nbsp;Dr Ulas Ozdemir and Dr Tugba Kandemir Gulmez designed the data collection instruments, collected data, carried out the initial analyses.\u003c/p\u003e\n\u003cp\u003eDr Mehmet Deniz Erhan\u0026nbsp;designed the data collection instruments and critically reviewed and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eDr Sevgin Taner designed the data collection instruments and critically reviewed and revised the manuscript\u003cbr\u003e\u0026nbsp;Dr Umit Celik coordinated and supervised data collection, and critically reviewed and revised the manuscript for important intellectual content.\u003cbr\u003e\u0026nbsp;All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUnited Nations Children\u0026rsquo;s Fund (UNICEF). Children and disasters: Building resilience through education. https://www.unisdr.org/we/ inform/publications/24583. Accessed 20 March 2023\u003c/li\u003e\n\u003cli\u003eBartels SA, VanRooyen MJ. Medical complications associated with earthquakes. Lancet. 2012 Feb 25;379(9817):748-57. doi: 10.1016/S0140-6736(11)60887-8. Epub 2011 Nov 4. Erratum in: Lancet. 2012 Feb 25;379(9817):712. PMID: 22056246\u003c/li\u003e\n\u003cli\u003eHe Q, Wang F, Li G, Chen X, Liao C, Zou Y, Zhang Y, Kang Z, Yang X, Wang L. Crush syndrome and acute kidney injury in the Wenchuan Earthquake. J Trauma. 2011 May;70(5):1213-7; discussion 1217-8. doi: 10.1097/TA.0b013e3182117b57. PMID: 21610435.\u003c/li\u003e\n\u003cli\u003eDonmez O, Meral A, Yavuz M, Durmaz O. Crush syndrome of children in the Marmara Earthquake, Turkey. Pediatrics international : official journal of the Japan Pediatric Society. 2001;43(6):678-82.\u003c/li\u003e\n\u003cli\u003eZhang L, Fu P, Wang L, Cai G, Zhang L, Chen D, et al. Hyponatraemia in patients with crush syndrome during the Wenchuan earthquake. Emergency medicine journal : EMJ. 2013;30(9):745-8. 10.\u003c/li\u003e\n\u003cli\u003eAmer BE, Abdelwahab OA, Abdelaziz A, Soliman Y, Amin AM, Mohamed MA, Albakri K, Zedan EM, Hamouda N. Efficacy and safety of isotonic versus hypotonic intravenous maintenance fluids in hospitalized children: an updated systematic review and meta-analysis of randomized controlled trials. Pediatr Nephrol. 2024 Jan;39(1):57-84. doi: 10.1007/s00467-023-06032-7. Epub 2023 Jun 26. PMID: 37365423; PMCID: PMC10673968.\u003c/li\u003e\n\u003cli\u003eBraun MM, Barstow CH, Pyzocha NJ. Diagnosis and management of sodium disorders: hyponatremia and hypernatremia. \u003cem\u003eAm Fam Physician\u003c/em\u003e. 2015;91(5):299-307.\u003c/li\u003e\n\u003cli\u003eKhwaja A (2012) KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract 120(4):c179\u0026ndash;c184.\u003c/li\u003e\n\u003cli\u003eBartels SA, VanRooyen MJ (2012) Medical complications associated with earthquakes. Lancet 379(9817):748\u0026ndash;757.\u003c/li\u003e\n\u003cli\u003eHasegawa H, Okubo S, Ikezumi Y, et al. Hyponatremia due to an excess of arginine vasopressin is common in children with febrile disease. Pediatr Nephrol 2009; 24:507.\u003c/li\u003e\n\u003cli\u003eDon M, Valerio G, Korppi M, Canciani M. Hyponatremia in pediatric community-acquired pneumonia. Pediatr Nephrol 2008; 23:2247.\u003c/li\u003e\n\u003cli\u003eChoong K, Arora S, Cheng J, et al. Hypotonic versus isotonic maintenance fluids after surgery for children: a randomized controlled trial. Pediatrics 2011; 128:857.\u003c/li\u003e\n\u003cli\u003eCarandang F, Anglemyer A, Longhurst CA, et al. Association between maintenance fluid tonicity and hospital-acquired hyponatremia. J Pediatr 2013; 163:1646.\u003c/li\u003e\n\u003cli\u003eBettinelli A, Longoni L, Tammaro F, et al. Renal salt-wasting syndrome in children with intracranial disorders. Pediatr Nephrol 2012; 27:733.\u003c/li\u003e\n\u003cli\u003eDidsbury M, See EJ, Cheng DR, Kausman J, Quinlan C. Correcting Hypernatremia in Children. \u003cem\u003eClin J Am Soc Nephrol\u003c/em\u003e. 2023;18(3):306-314.\u003c/li\u003e\n\u003cli\u003eForman S, Crofton P, Huang H, et al. The epidemiology of hypernatraemia in hospitalised children in Lothian: a 10-year study showing differences between dehydration, osmoregulatory dysfunction and salt poisoning. Arch Dis Child 2012; 97:502.\u003c/li\u003e\n\u003cli\u003eSafari S, Eshaghzade M, Najafi I, et al. Trends of Serum Electrolyte Changes in Crush syndrome patients of Bam Earthquake; a Cross sectional Study. Emerg (Tehran). 2017;5(1):e7.\u003c/li\u003e\n\u003cli\u003eOda Y, Shindoh M, Yukioka H, Nishi S, Fujimori M, Asada A. Crush syndrome sustained in the 1995 Kobe, Japan, earthquake; treatment and outcome. Annals of emergency medicine. 1997;30(4):507-12.\u003c/li\u003e\n\u003cli\u003eAdams D, de Jonge R, van der Cammen T, Zietse R, Hoorn EJ. Acute kidney injury in patients presenting with hyponatremia. Journal of nephrology. 2011;24(6):749-55.\u003c/li\u003e\n\u003cli\u003eAtmis B, Bayazit AK, Cagli Piskin C, Saribas E, Piskin FC, Bilen S, Ozgur Horoz O, Ekinci F, Turker I, Telefon HA, Unal I, Yilmaz HL, Narli N, Yildizdas D. Factors predicting kidney replacement therapy in pediatric earthquake victims with crush syndrome in the first week following rescue. Eur J Pediatr. 2023 Dec;182(12):5591-5598. doi: 10.1007/s00431-023-05250-3. Epub 2023 Oct 7. PMID: 37804325\u003c/li\u003e\n\u003cli\u003eZhang L, Fu P, Wang L, Cai G, Zhang L, Chen D, Guo D, Sun X, Chen F, Bi W, Zeng X, Li H, Liu Z, Wang Y, Huang S, Chen X. The clinical features and outcome of crush patients with acute kidney injury after the Wenchuan earthquake: differences between elderly and younger adults. Injury. 2012 Sep;43(9):1470-5. doi: 10.1016/j.injury.2010.11.036. Epub 2010 Dec 7. PMID: 21144512.\u003c/li\u003e\n\u003cli\u003eXiang B, Cheng W, Liu J, Huang L, Li Y, Liu L. Triage of pediatric injuries after the 2008 Wen-Chuan earthquake in China. J Pediatr Surg. 2009 Dec;44(12):2273-7. doi: 10.1016/j.jpedsurg.2009.07.068. PMID: 20006008.\u003c/li\u003e\n\u003cli\u003eSever MS, Vanholder R, Lameire N. Management of crush-related injuries after disasters. N Engl J Med. 2006;354:1052\u0026ndash;1063. 2006;354:1052\u0026ndash;1063.\u003c/li\u003e\n\u003cli\u003eHu Z, Zeng X, Fu P, Luo Z, Tu Y, Liang J, Tao Y, Qin W. Predictive factors for acute renal failure in crush injuries in the Sichuan earthquake. Injury. 2012 May;43(5):613-8. doi: 10.1016/j.injury.2010.08.025. Epub 2010 Sep 19. PMID: 20855068\u003c/li\u003e\n\u003cli\u003eArbeitsgemeinschaft f\u0026uuml;r Osteosynthesefragen Surgery Reference. 2024. Erişim adresi: http://www.aofoundation.org/icrchttps://surgeryreference.aofoundation.org/orthopedic-trauma/pediatric-trauma/proximal-forearm/further-reading/compartment-syndrome?searchurl=/searchresults\u003c/li\u003e\n\u003cli\u003eGuo J, Yin Y, Jin L, Zhang R, Hou Z, Zhang Y. Acute compartment syndrome: Cause, diagnosis, and new viewpoint. Medicine (Baltimore). 2019;98(27):e16260. doi:10.1097/MD.0000000000016260\u003c/li\u003e\n\u003cli\u003eErek E, Sever MS, Serdenge\u0026ccedil;ti K, et al. An overview of morbidity and mortality in patients with acute renal failure due to crush syndrome: the Marmara earthquake experience. Nephrol Dial Transplant. 2002;17(1):33-40. doi:10.1093/ndt/17.1.33\u003c/li\u003e\n\u003cli\u003eWestermann I, D\u0026uuml;nser MW, Haas T, et al. Endogenous vasopressin and copeptin response in multiple trauma patients. Shock. 2007;28(6):644-649. doi:10.1097/shk.0b013e3180cab33f\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section\u003c/p\u003e"},{"header":"Graph","content":"\u003cp\u003eGraph 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pnep","sideBox":"Learn more about [Pediatric Nephrology](http://link.springer.com/journal/467)","snPcode":"467","submissionUrl":"https://www.editorialmanager.com/pnep/default2.aspx","title":"Pediatric Nephrology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6246916/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6246916/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Dysnatremia is a common electrolyte abnormality in children, but its prevalence and impact in pediatric earthquake victims are not well-established. This study aimed to define the frequency of dysnatremia in pediatric earthquake victims and evaluate its relationship with complications, mortality, and morbidity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We retrospectively analyzed data from 312 pediatric patients admitted to our hospital after the 2023 Türkiye-Syria earthquakes. Patients were categorized based on admission sodium levels: hyponatremic (\u0026lt;135 mmol/L), hypernatremic (\u0026gt;145 mmol/L), and normal (135-145 mmol/L). Demographic, clinical, and laboratory data were analyzed. \u003cstrong\u003eResults:\u003c/strong\u003e Of the 312 patients, 36.2% were hyponatremic, 17.3% were hypernatremic, and 46.5% had normal sodium levels. Hyponatremic patients had a higher frequency of fasciotomy, crush syndrome, and acute kidney injury (AKI). Hypernatremic patients had longer times under rubble and increased rates of crush syndrome and AKI. Mortality was 5.4%, with no significant difference between dysnatremic and normonatremic patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Dysnatremia is common in pediatric earthquake victims. Hyponatremia is associated with increased morbidity, including crush syndrome and AKI. Monitoring and management of sodium abnormalities are crucial in the care of pediatric earthquake survivors.\u003c/p\u003e","manuscriptTitle":"Dysnatremias in Pediatric Patients with Earthquake Victims of 2023 Türkiye-Syria Earthquake","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-31 07:52:09","doi":"10.21203/rs.3.rs-6246916/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major Revisions Needed","date":"2025-04-03T12:13:21+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-03-23T07:13:31+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-22T15:22:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-18T08:09:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Nephrology","date":"2025-03-17T13:54:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pnep","sideBox":"Learn more about [Pediatric Nephrology](http://link.springer.com/journal/467)","snPcode":"467","submissionUrl":"https://www.editorialmanager.com/pnep/default2.aspx","title":"Pediatric Nephrology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2c74df5e-28aa-46d7-898c-59a4f3583dab","owner":[],"postedDate":"March 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-30T16:01:12+00:00","versionOfRecord":{"articleIdentity":"rs-6246916","link":"https://doi.org/10.1007/s00467-025-06843-w","journal":{"identity":"pediatric-nephrology","isVorOnly":false,"title":"Pediatric Nephrology"},"publishedOn":"2025-06-27 15:57:38","publishedOnDateReadable":"June 27th, 2025"},"versionCreatedAt":"2025-03-31 07:52:09","video":"","vorDoi":"10.1007/s00467-025-06843-w","vorDoiUrl":"https://doi.org/10.1007/s00467-025-06843-w","workflowStages":[]},"version":"v1","identity":"rs-6246916","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6246916","identity":"rs-6246916","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}