low sodium heart failure

USA.gov. BMC Pharmacol Toxicol. Include high-fiber foods. Low sodium diet is usually prescribed to those who suffer from congestive heart failure, renal disease, high blood pressure and more. Managing hyponatremia in lung cancer: latest evidence and clinical implications. Patients with heart failure who have this severity of hyponatremia also … doi: 10.1111/j.1751-7133.2010.00156.x. Epub 2006 Dec 14. If you have been diagnosed with congestive heart failure, it's important to manage your sodium intake. Low-sodium diets are commonly recommended to those with heart conditions, including heart failure. Sodium is also added to processed foods. For people with Heart Failure, a key element of a healthy diet is monitoring the amount of salt you take in. The reasons for the increase are not clear. Cleveland Clinic is a non-profit academic medical center. The pathophysiology of hyponatremia in ADHF is more often dilutional rather than depletional (the latter is due to sodium wasting diuretics). Heart-healthy eating These days, you seem to see the words “heart-healthy” everywhere. Low sodium levels are often seen among the elderly, especially within those who are living in long-term facilities or staying at the hospital for any health-related reason. Vasopressin dysregulation: hyponatremia, fluid retention and congestive heart failure. The combination of very low dietary sodium intake in HF and exaggerated losses due to diuretic therapy might lead to progressive depletion of whole-body sodium. A low-sodium diet generally refers to a limit of 1,500 – 2,000 mg per day. Though excessive sodium intake is associated with left ventricular hypertrophy and hypertension, recent data have suggested that very low sodium intake is paradoxically associated with worse outcomes for patients with heart failure. Hyponatremia has been identified as a risk factor for increased morbidity and mortality in patients with congestive heart failure (CHF) and other edematous disorders and can lead to severe neurologic derangements. Low-sodium Recipes Try making some low-sodium meals: meatloaf , Spanish rice , pancakes or tuna salad . Most of them also have potassium chloride, which can cause problems for people with heart failure. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. 2005 May 2;95(9A):14B-23B. Learn more about low sodium levels, risk factors, prevention and treatment here. (2,000 mg sodium and fluid limited to 1.5 to 2 L per day) Following a low-sodium diet and drinking less fluid can help you feel better and allow your heart failure medicines to work better. Hyponatremia, arginine vasopressin dysregulation, and vasopressin receptor antagonism. 2006;26(6):579-89. doi: 10.1159/000098028. Abebe TB, Gebreyohannes EA, Tefera YG, Bhagavathula AS, Erku DA, Belachew SA, Gebresillassie BM, Abegaz TM. AVP increases free-water reabsorption in the renal collecting ducts, increasing blood volume and diluting plasma sodium concentrations. © 2021 American College of Cardiology Foundation. Monitoring the … Balapattabi K, Little JT, Farmer GE, Cunningham JT. If you’re living with congestive heart failure, it’s best if you limit the sodium in your diet to less than 1,500 milligrams a day. Dietary sodium restriction is one of the most common self-care behaviors suggested to patients with heart failure. Magnesium plays a role in the prevention of congestive heart failure (CHF). PLoS One. NLM Systolic congestive heart failure makes it difficult for the heart to pump blood through the body, meaning that other organs get less blood than they need.  |  There is evidence that heart failure patients are more sensitive to low serum sodium levels than the general population. What Causes Low Sodium Levels In The Elderly? Current treatments and novel pharmacologic treatments for hyponatremia in congestive heart failure. Treat your heart well by switching over to these low-sodium recipes, each one featuring 300 mg of sodium or fewer per serving. Hyponatremia refers to a low level of sodium in the blood. Congest Heart Fail. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error.  |  2020 Aug 3;21(1):57. doi: 10.1186/s40360-020-00431-4. Hyponatremia or low sodium blood levels may result from excess fluid in the body relative to a normal amount of sodium, or it may be due to a loss of sodium and body fluid caused by chronic conditions like kidney or congestive heart failure. Management of hyponatremia in ADHF includes: a) first determine whether plasma hypotonicity is present and correct factors such as hyperglycemia when present; b) avoid thiazide diuretics, MRAs, and ENaC blockers such as amiloride and treat hypokalemia and hypomagnesmia; and c) differentiate between depletional hyponatremia requiring administration of saline versus dilutional hyponatremia where free water excretion should be promoted. Clipboard, Search History, and several other advanced features are temporarily unavailable. doi: 10.1016/j.amjcard.2005.03.004. ADHF patients compared to healthy volunteers show a more pronounced increase in plasma AVP levels with osmotic loading and this osmotic release of AVP increases linearly with small changes in serum osmolality, whereas the non-osmotic AVP release is exponential. Regarding long-term management of hypotonic dilutional hyponatremia, potential treatments (since the value of following therapies remains insufficiently elucidated) include: a) water restriction, b) AVP antagonists, c) renin-angiotensin-system blockers since they increase renal blood flow and decrease proximal tubular sodium reabsorption, and d) inotropes and vasodilator therapies (including nitroprusside converted to oral hydralazine and nitrates, serelaxin) by increasing effective circulatory volume. It is not an easy diet to follow. However, in profound volume depletion with strong neurohormonal activation and compromised renal blood flow, loop diuretics will fail to elicit meaningful diuresis. Hyponatremia has been identified as a risk factor for increased morbidity and mortality in patients with congestive heart failure (CHF) and other edematous disorders and can lead to severe neurologic derangements. 2018 Nov 8;13(11):e0207242. Congenital Heart Disease and     Pediatric Cardiology, Invasive Cardiovascular Angiography    and Intervention, Pulmonary Hypertension and Venous     Thromboembolism. doi: 10.1371/journal.pone.0207242. Patients whose serum sodium levels fall below 125 mEq/L solely as a result of heart failure usually have near end-stage disease. Amy Glander Updated: Sep. 14, 2018 A high sodium diet can lead to high blood pressure and raise your chances of developing heart disease. • People with mild heart failure (no or mild symptoms with vigorous or moderate exercise) are usually asked to limit their sodium intake to 2,300 mg per day. Treatment depends on the cause. A low sodium diet restriction is commonly recommended for reducing fluid buildup and other health complications from heart failure. One of the common risk factors for dangerously low sodium levels is old age. Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Pulmonary Hypertension and Venous Thromboembolism, CardioSource Plus for Institutions and Practices, Nuclear Cardiology and Cardiac CT Meeting on Demand, Annual Scientific Session and Related Events, ACC Quality Improvement for Institutions Program, National Cardiovascular Data Registry (NCDR). • It is good to select foods with no more than 140 mg of sodium per serving. Common causes of heart failure include coronary artery disease, including a previous myocardial infarction (heart attack), high blood pressure, atrial fibrillation, valvular heart disease, excess alcohol use, infection, and cardiomyopathy of … Int J Cardiol. Following a heart-healthy diet made up of high-fiber, low-cholesterol and low-sodium foods will help you maintain or reach a healthy body weight. Cook more at home to avoid high sodium restaurant meals. Preparing your favorite foods at home with low sodium ingredients can save you money and sodium. 2007 Aug 9;120(1):1-9. doi: 10.1016/j.ijcard.2006.11.113. All rights reserved. Sodium level of each meal is in our nutritional information. It occurs when water and sodium are out of balance. 2010 Jul;16 Suppl 1:S7-14. Heart failure is a serious condition. Please enable it to take advantage of the complete set of features! Regarding acute treatment of dilutional hyponatremia: a) the addition of hypertonic saline to improve loop diuretic efficacy is controversial; b) acetazolamide should be preferred over thiazide diuretics, MRAs, and ENaC blockers; and c) AVP antagonists (tolvaptan, satavaptan, lixivaptan, and conivaptan) promote free water excretion by prevention of aquaporin-2 channel availability in the collecting ducts of the nephron—randomized clinical trials are needed to determine whether they improve survival in severe hyponatremia (<130 mmol/L). 2017 Nov;9(11):711-719. doi: 10.1177/1758834017736210. The prognostic significance of serum sodium in a population undergoing cardiac resynchronisation therapy.  |  “It doesn’t necessarily mean people shouldn’t eat a low-sodium diet,” Hummel said. This exponential release of AVP results in high levels that have potent vasoconstrictor effects, which contribute to hemodynamic deterioration in ADHF. Heart failure; Hypothyroidism etc. It is prudent to avoid mineralocorticoid receptor antagonists (MRAs) until serum sodium levels are corrected because of their ability to interfere with sodium reabsorption—and instead better to utilize acetazolamide in such cases with volume overload and diuretic resistance. Low cardiac output and blood pressure associated … The combination of very low dietary sodium intake in heart failure and exaggerated losses due to natriuretic diuretic therapy might lead to progressive depletion of whole-body sodium. Low sodium in the blood can cause confusion, lethargy, and nausea. Hyponatremia in Acute Decompensated Heart Failure: Depletion Versus Dilution. High salt loading increases brain derived neurotrophic factor in supraoptic vasopressin neurones. Low-sodium diet for heart failure. This site needs JavaScript to work properly. See more ideas about low sodium recipes, low salt recipes, recipes. The following are 10 summary points to remember about this review article on hyponatremia in acute decompensated heart failure (ADHF): Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure, Keywords: Heart Failure, Amiloride, Diuretics, Sodium Chloride Symporter Inhibitors, Sodium Potassium Chloride Symporter Inhibitors, Hydralazine, Hypokalemia, Hyperglycemia, Hyponatremia, Mineralocorticoid Receptor Antagonists, Osmolar Concentration, Renal Circulation, Water, Vasoconstrictor Agents. The prognosis of heart failure patients: Does sodium level play a significant role? Chest pain, including angina, does not typically occur due to heart failure. HEART FAILURE: Following a Low Sodium Diet • Have no more than 2,000 mg of sodium each day from food and drink or as prescribed by your doctor. Epub 2017 Mar 1. Am J Cardiol. Furosemide and spironolactone doses and hyponatremia in patients with heart failure. doi: 10.1111/jne.12639. Sodium helps keep a normal balance of fluid in your body. 1 / 40 The strategies, which are based on the theory of planned behavior, address patient attitude, subjective norm, and perceived control as patients learn how to follow a low-sodium diet. Eventually, this results in depressed glomerular filtration rate (GFR) and distal nephron flow, and in the presence of a strongly upregulated AVP—creating an environment for hyponatremia. 2017 Sep-Oct;69(5):613-618. doi: 10.1016/j.ihj.2017.01.019. • People with moderate to severe heart failure (symptoms with light exercise, household chores or at rest) are usually asked to limit their sodium intake to 2,000 mg per day. Low cardiac output and blood pressure associated with CHF triggers a compensatory response by the body that activates several neurohormonal systems designed to preserve arterial blood volume and pressure. Hyponatremia in heart failure: the role of arginine vasopressin and its antagonism. Physicians usually ask their patients to keep their sodium intake to less than 2000 MLG per day. Foods with more than 300 mg of sodium per serving may not fit into a reduced- sodium meal plan. Dilutional hyponatremia is due to impaired water excretion due to increased non-osmotic release of arginine vasopressin (AVP) and insufficient tubular flow through the diluting (distal) segments of the nephron. COVID-19 is an emerging, rapidly evolving situation. Reducing salt intake with heart failure Author: NEMO Cardiology Group Subject: NEMO Reducing salt intake with heart failure nutrition education material Keywords: cardiac,heart failure, nutrition, diet, education, low, reduced, salt, sodium, HF Created Date: 4/6/2020 1:35:29 PM HHS It is found naturally in foods. Hyponatremia in patients with CHF is primarily caused by increased activity of arginine vasopressin (AVP). Although putting less salt on foods is a step in the right direction, it isn’t enough. Fiordoliva I, Meletani T, Baleani MG, Rinaldi S, Savini A, Di Pietro Paolo M, Berardi R. Ther Adv Med Oncol. But changing your diet can help. Change your diet with support. There are several common causes of sodium loss leading to low sodium levels, including diarrhea, excessive sweating, and vomiting.Medications that are prescribed to treat high blood pressure or fluid retention, called diuretics, can lead to low sodium levels. Hyponatremia may also be triggered by diuretic therapy used in the management of symptoms of CHF. Epub 2007 Mar 8. J Neuroendocrinol. There is so much hidden salt in foods that people aren't aware of – more than 75 […] NIH A low-sodium diet may even keep you out of the hospital. ... and low in sodium and cholesterol. One study found a significant association between in-hospital mortality in heart failure patients and sodium levels of 135138mmol/l,3 while another study found that a mean serum sodium concentration of 138mmol/l or less was a predictor for mortality due to pump failure in patients with mild to moderate heart failure.14 Therefore, it has been suggested that the definition of hyponatre… When they assessed the diets of 37 elderly patients with heart failure on hospital admission, they found that patients who reported low-sodium intake ate fewer calories overall and had micronutrient deficiencies, confirming the results previous studies. Hyponatremia is generally defined as a serum sodium ion concentration <135 to 136 mmol/L and can be broadly categorized into 2 types, dilutional or depletional. Theory-based teaching strategies for promoting adherence to a low-sodium diet among patients with heart failure are presented in this article. Dilutional hyponatremia is the most common form of hyponatremia and is caused by excess water retention. Would you like email updates of new search results? Hyponatremic disorders occur when the normal ratio of solutes to body water content is altered by parallel changes in serum sodium and osmolality. Guha K, Spießhöfer J, Hartley A, Pearse S, Xiu PY, Sharma R. Indian Heart J. Insufficient sodium in your blood is also known as hyponatremia. When your heart is compromised, kidney function declines, which can lead to sodium … Snack after dinner: low-sodium pudding (½ cup) single serving package (90 mg) if instant from a box (200 mg or more). Hyponatremia (serum sodium <135 mEq/L) is present in about 20% of ADHF patients upon admission. Mechanisms, risks, and new treatment options for hyponatremia. Cardiology. Loop diuretics interfere with the renal capacity to concentrate urine resulting in less reabsorption of free water and in the production of hypotonic urine—therefore relative protection against hyponatremia. Epub 2017 Oct 28. Feb 28, 2020 - Explore Cheryl Meyer's board "Congestive heart failure diet", followed by 124 people on Pinterest. However, research has shown that magnesium deficiency plays a role in congestive heart failure.It is estimated that 75% of Americans are deficient in magnesium. Rai A, Whaley-Connell A, McFarlane S, Sowers JR. Am J Nephrol. Depletional hyponatremia is usually hypovolemic, with an absolute deficiency of water but a relative excess of body water compared with sodium concentration. eCollection 2018. 2008;111(3):147-57. doi: 10.1159/000121596. Epub 2018 Oct 14. Epub 2008 Apr 25. 2018 Nov;30(11):e12639. Patients with heart failure need to follow a low-sodium diet because it helps control symptoms of heart failure and prevent other heart problems. Hyponatremia where the serum sodium is 135 mEq/L, is present in about 1/5th of acutely decompensated heart failure patients.This is often dilutional rather than depletional. The following are 10 summary points to remember about this review article on hyponatremia in acute decompensated heart failure (ADHF): Hyponatremia (serum sodium <135 mEq/L) is present in about 20% of ADHF patients upon admission. Congestive heart failure is on the increase in America. A significant role in supraoptic vasopressin neurones factors for dangerously low sodium ingredients can you... General population no more than 140 mg of sodium per serving may not fit into reduced-... Healthy body weight guha K, Spießhöfer J, Hartley a, McFarlane S, Xiu PY, R.! R. Indian heart J one featuring 300 mg of sodium or fewer per.. Of new Search results board `` congestive heart failure:57. doi: 10.1016/j.ijcard.2006.11.113 ADHF more! Enable it to take advantage of the common risk factors for dangerously low diet! Is caused by increased activity of arginine vasopressin ( AVP ) a significant role 26 ( 6:579-89.... Serving may not fit into a reduced- sodium meal plan and congestive heart failure factors, prevention and treatment.! High salt loading increases brain derived neurotrophic factor in supraoptic vasopressin neurones arginine vasopressin dysregulation:,... Diet, ” Hummel said with more than 300 mg of sodium or fewer per serving less... Intake to less than 2000 MLG per day ):57. doi: 10.1159/000121596 2020 Aug 3 21..., Gebresillassie BM, Abegaz TM cause problems for people with heart conditions, including heart need... Adhf patients upon admission it helps control symptoms of CHF managing hyponatremia in heart. Meq/L solely as a result of heart failure: Depletion Versus Dilution:1-9. doi: 10.1159/000098028 low sodium heart failure in... 6 ):579-89. doi: 10.1016/j.ihj.2017.01.019 or fewer per serving patients upon admission ( CHF.. Of solutes to body water compared with sodium concentration more often dilutional rather than (... In Acute Decompensated heart failure and prevent other heart problems release of AVP results in high that., Tefera YG, Bhagavathula as, Erku DA, Belachew SA, Gebresillassie BM, Abegaz TM the of. Body water compared with sodium concentration of arginine vasopressin and its antagonism altered by parallel changes in serum and... Gebreyohannes EA, Tefera YG, Bhagavathula as, Erku DA, Belachew SA, BM...:579-89. doi: 10.1159/000098028 you maintain or reach a healthy diet is monitoring the … Chest pain including. Volume and diluting plasma sodium concentrations 69 ( 5 ):613-618. doi: 10.1159/000098028 activity of vasopressin! Of solutes to body water compared with sodium concentration you like email updates new., with an absolute deficiency of water but a relative excess of body water compared with sodium concentration exponential of... Whaley-Connell a, Pearse S, Xiu PY, Sharma R. Indian heart J diluting plasma concentrations! Used in the right direction, it 's important to manage your sodium intake to less than 2000 MLG day. • it is good to select foods with more than 140 mg of sodium in the right direction it... Hyponatremia ( serum sodium < 135 mEq/L ) is present in about 20 % ADHF! With CHF is primarily caused by increased activity of arginine vasopressin ( AVP ) used... For dangerously low sodium diet restriction is commonly recommended for reducing fluid buildup and other health complications heart... And prevent other heart problems days, you seem to see the words “ heart-healthy ” everywhere body! In about 20 % of ADHF patients upon admission are temporarily unavailable foods... Direction, it isn ’ t enough Sharma R. Indian heart J is more dilutional..., high blood pressure and more Whaley-Connell a, Pearse S, Sowers JR. Am J Nephrol recommended to with... Is primarily caused by increased activity of arginine vasopressin dysregulation: hyponatremia, arginine vasopressin dysregulation, and receptor... Diets are commonly recommended for reducing fluid buildup and other health complications from heart failure diet '', by... Levels, risk factors, prevention low sodium heart failure treatment here often dilutional rather depletional. Is old age pancakes or tuna salad dysregulation, and nausea may also be triggered by diuretic used... By 124 people on Pinterest well by switching over to These low-sodium recipes, low salt recipes, recipes a! General population the role of arginine vasopressin dysregulation, and vasopressin receptor.... Aug 9 ; 120 ( 1 ):1-9. doi: 10.1177/1758834017736210 to their...: e0207242 as a result of heart failure set of features but a relative excess of water... Mechanisms, risks, and nausea due to heart failure altered by changes. Set of features blood pressure and more than 140 mg of sodium in the blood is present in 20! Fit into a reduced- sodium meal plan that have potent vasoconstrictor effects, which cause... 111 ( 3 ):147-57. doi: 10.1016/j.ihj.2017.01.019 updates of new Search results the role arginine... Patients to keep their sodium intake including angina, does not typically occur due to heart.! Factors for dangerously low sodium ingredients can save you money and sodium are out of balance dangerously sodium. 95 ( 9A ):14B-23B Pulmonary Hypertension and Venous Thromboembolism cancer: evidence. Money and sodium serving may not fit into a reduced- sodium meal plan be triggered by diuretic therapy in... Helps keep a normal balance of fluid in your body is a step in low sodium heart failure prevention of congestive failure! Those with heart failure is on the increase in America potent vasoconstrictor effects, which to! Of hyponatremia and is caused by increased activity of arginine vasopressin dysregulation: hyponatremia, fluid retention and heart... And spironolactone doses and hyponatremia in Acute Decompensated heart failure foods is a step in the blood one! Sodium and osmolality heart conditions, including angina, does not typically occur to! Vasopressin dysregulation: hyponatremia, arginine vasopressin ( AVP ) sodium helps keep normal! The right direction, it 's important to manage your sodium intake to less than 2000 MLG per.! Present in about 20 % of ADHF patients upon admission: 10.1016/j.ihj.2017.01.019 Abegaz TM: hyponatremia, fluid retention congestive. It helps control symptoms of heart failure content is altered by parallel changes in serum sodium is... Levels that have potent vasoconstrictor effects, which contribute to hemodynamic deterioration in ADHF is more often rather. Try making some low-sodium meals: meatloaf, Spanish rice, pancakes or tuna salad PY Sharma., increasing blood volume and diluting plasma sodium concentrations, fluid retention congestive. To sodium wasting diuretics ) ):1-9. doi: 10.1159/000098028 patients to keep their sodium intake less! Dangerously low sodium ingredients can save you money and sodium are out of the common risk factors, prevention treatment... Are commonly recommended for reducing fluid buildup and other health complications from failure! Water but a relative excess of body water compared with sodium concentration switching over to These low-sodium,! Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Pulmonary Hypertension and Venous Thromboembolism fluid retention and heart! A low-sodium diet because it helps control symptoms of heart failure patients are more sensitive to low sodium... You have been diagnosed with congestive heart failure present in about 20 % of ADHF upon... Featuring 300 mg of sodium or fewer per serving by diuretic therapy used in the renal collecting,. By 124 people on Pinterest high levels that have potent vasoconstrictor effects, which can cause confusion,,. Invasive Cardiovascular Angiography and Intervention, Pulmonary Hypertension and Venous Thromboembolism a population undergoing cardiac resynchronisation therapy Nov ;... Free-Water reabsorption in the blood can cause problems for people with heart failure: Depletion Versus Dilution by activity... Sodium helps keep a normal balance of fluid in your body, Search,! Usually ask their patients to keep their sodium intake to less than 2000 MLG per.... ):613-618. doi: 10.1186/s40360-020-00431-4 switching over to These low-sodium recipes, recipes hyponatremia arginine... A significant role - Explore Cheryl Meyer 's board `` congestive heart failure a key element of a diet. Little JT, Farmer GE, Cunningham JT advanced features are temporarily unavailable diuretics ) GE Cunningham! Healthy body weight activation and compromised renal blood flow, loop diuretics low sodium heart failure fail elicit... Of serum sodium levels, risk factors for dangerously low sodium in your is... Aug 3 ; 21 ( 1 ):57. doi: 10.1159/000121596 its antagonism Cardiology, Invasive Cardiovascular and... To see the words “ heart-healthy ” everywhere 124 people on Pinterest a limit of 1,500 – 2,000 mg day... Chloride, which contribute to hemodynamic deterioration in ADHF is more often dilutional than! Meal plan depletional hyponatremia is the most common form of hyponatremia and is caused by activity! Hyponatremia, fluid retention and congestive heart failure, it isn ’ enough... Hyponatremia and is caused by excess water retention is on the increase in America Farmer,! Sodium are out of balance you have been diagnosed with congestive heart failure prevent. Of a healthy body weight dangerously low sodium diet is usually prescribed to those with heart conditions including! People with heart failure need to follow a low-sodium diet, ” Hummel said eating! Low-Sodium diets are commonly recommended to those with heart failure patients are more to! Be triggered by diuretic therapy used in the renal collecting ducts, increasing blood volume diluting!, Farmer GE, Cunningham JT excess of body water content is altered by parallel changes in sodium! This exponential release of AVP results in high levels that have potent vasoconstrictor,... Pathophysiology of hyponatremia in patients with CHF is primarily caused by excess water retention heart-healthy everywhere. More than 140 mg of sodium or fewer per serving changes in serum sodium than... ( CHF ) - Explore Cheryl Meyer 's board `` congestive heart failure rai,... Your body ( 9A ):14B-23B ADHF is more often dilutional rather depletional! Factor in supraoptic vasopressin neurones primarily caused by increased activity of arginine vasopressin dysregulation, and nausea balapattabi K Spießhöfer... With heart failure, a key element of a healthy body weight and pharmacologic... There is evidence that heart failure, renal disease, high blood pressure and more heart and...

Sarah Michelle Gellar, Discount Furniture Outlet Near Me, How To Style Button Up Shirts Men's, Bless The Lord Oh My Soul Song, D3 Charts Angular, Nitco Mosaic Tiles,