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1.10
Disorders of Water, Electrolytes, and Acid-Base
↑
ADH release or actionDrugsSyndrome of inappropriateantidiuretic hormonesecretion, etc.GFRdiminishedAgeRenal diseaseCongestive heart failureCirrhosisNephrotic syndromeVolume depletion
↓
Reabsorption of sodiumchloride in thick ascendinglimb of loop of HenleLoop diureticsOsmotic diureticsInterstitial disease
↓
Reabsorption of sodium chloridein distal convoluted tubuleThiazide diureticsNaCl
FIGURE 1-15
Pathogenesis of hyponatremia. Thenormal components of the renal dilutingmechanism are depicted in Figure 1-3.Hyponatremia results from disorders of this diluting capacity of the kidney in thefollowing situations:
1.
Intrarenal factors
such as a dimin-ished glomerular filtration rate(GFR), or an increase in proximaltubule fluid and sodium reabsorp-tion, or both, which decrease distaldelivery to the diluting segments of the nephron, as in volume depletion,congestive heart failure, cirrhosis, ornephrotic syndrome.2.
A defect in sodium chloride transport
out of the water-impermeable seg-ments of the nephrons (
ie
, in the thick ascending limb of the loop of Henle).This may occur in patients with inter-stitial renal disease and administra-tion of thiazide or loop diuretics.3.
Continued secretion of antidiuretichormone (ADH)
despite the presenceof serum hypo-osmolality mostlystimulated by nonosmotic mecha-nisms [12].
NaCl—sodium chloride.
UNa>20U
Na
>20U
Na
<20Assessment of volume status
Hypovolemia
•
Total body water
↓
•
Total body sodium
↓↓
Euvolemia (no edema)
•
Total body water
↑
•
Total body sodium
←→
Renal losses
Diuretic excessMineralcorticoid deficiencySalt-losing deficiencyBicarbonaturia withrenal tubal acidosis andmetabolic alkalosisKetonuriaOsmotic diuresisGlucocorticoid deficiencyHypothyroidismStressDrugsSyndrome of inappropriateantidiuretic hormonesecretion
Extrarenal losses
VomitingDiarrheaThird spacing of fluidsBurnsPancreatitisTraumaU
Na
>20U
Na
<20
Hypervolemia
•
Total body water
↑↑
•
Total body sodium
↑
Acute or chronicrenal failureNephrotic syndromeCirrhosisCardiac failure
FIGURE 1-16
Diagnostic algorithm for hyponatremia. The next step in the evalua-tion of a hyponatremic patient is to assess volume status and identifyit as hypovolemic, euvolemic or hypervolemic. The patient withhypovolemic hyponatremia has both total body sodium and waterdeficits, with the sodium deficit exceeding the water deficit. Thisoccurs with large gastrointestinal and renal losses of water andsolute when accompanied by free water or hypotonic fluid intake.In patients with hypervolemic hyponatremia, total body sodium isincreased but total body water is increased even more than sodium,causing hyponatremia. These syndromes include congestive heartfailure, nephrotic syndrome, and cirrhosis. They are all associatedwith impaired water excretion. Euvolemic hyponatremia is the mostcommon dysnatremia in hospitalized patients. In these patients, bydefinition, no physical signs of increased total body sodium aredetected. They may have a slight excess of volume but no edema[12]. (
Modified from
Halterman and Berl [12]; with permission.)
1.11
Diseases of Water Metabolism
DRUGSASSOCIATED WITH HYPONATREMIA
Antidiuretic hormone analoguesDeamino-D-arginine vasopressin (DDAVP)OxytocinDrugs that enhance release of antidiuretic hormoneChlorpropamideClofibrateCarbamazepine-oxycarbazepineVincristineNicotineNarcoticsAntipsychoticsAntidepressantsIfosfamideDrugs that potentiate renal action of antidiuretic hormoneChlorpropamideCyclophosphamideNonsteroidal anti-inflammatory drugsAcetaminophenDrugs that cause hyponatremia by unknown mechanismsHaloperidolFluphenazineAmitriptylineThioradazineFluoxetine
FIGURE 1-17
Drugs that cause hyponatremia. Drug-induced hyponatremia ismediated by antidiuretic hormone analogues like deamino-D-argi-nine-vasopressin (DDAVP), or antidiuretic hormone release, or bypotentiating the action of antidiuretic hormone. Some drugs causehyponatremia by unknown mechanisms [13]. (
From
Veis and Berl[13]; with permission.)
CAUSESOF THE SYNDROME OF INAPPROPRIATEDIURETIC HORMONE SECRETION
Carcinomas
BronchogenicDuodenalPancreaticThymomaGastricLymphomaEwing
’
s sarcomaBladderCarcinoma of theureterProstaticOropharyngeal
PulmonaryDisorders
Viral pneumoniaBacterial pneumoniaPulmonary abscessTuberculosisAspergillosisPositive-pressurebreathingAsthmaPneumothoraxMesotheliomaCystic fibrosis
Central Nervous System Disorders
Encephalitis (viral or bacterial)Meningitis (viral, bacterial, tuberculous,fungal)Head traumaBrain abscessBrain tumorGuillain-Barr
é
syndromeAcute intermittent porphyriaSubarachnoid hemorrhage or subduralhematomaCerebellar and cerebral atrophyCavernous sinus thrombosisNeonatal hypoxiaHydrocephalusShy-Drager syndromeRocky Mountain spotted feverDelirium tremensCerebrovascular accident (cerebralthrombosis or hemorrhage)Acute psychosisMultiple sclerosis
FIGURE 1-18
Causes of the syndrome of inappropriate antidiuretic hormonesecretion (SIADH). Though SIADH is the commonest cause of hyponatremia in hospitalized patients, it is a diagnosis of exclusion.It is characterized by a defect in osmoregulation of ADH in whichplasma ADH levels are not appropriately suppressed for the degreeof hypotonicity, leading to urine concentration by a variety of mech-anisms. Most of these fall into one of three categories (
ie
, malignan-cies, pulmonary diseases, central nervous system disorders) [14].
DIAGNOSTIC CRITERIA FOR THE SYNDROME OFINAPPROPRIATE ANTIDIURETIC HORMONESECRETION
Essential
Decreased extracellular fluid effective osmolality (< 270 mOsm/kg H
2
O)Inappropriate urinary concentration (> 100 mOsm/kg H
2
O)Clinical euvolemiaElevated urinary sodium concentration (U
[Na]
), with normal salt and H
2
O intakeAbsence of adrenal, thyroid, pituitary, or renal insufficiency or diuretic use
Supplemental
Abnormal H
2
O load test (inability to excrete at least 90%of a 20
–
mL/kg H
2
O loadin 4 hrs or failure to dilute urinary osmolality to < 100 mOsm/kg)Plasma antidiuretic hormone level inappropriately elevated relative to plasma osmolal-ityNo significant correction of plasma sodium with volume expansion, but improvementafter fluid restriction
FIGURE 1-19
Diagnostic criteria for the syndrome of inappropriate antidiuretichormone secretion (SIADH). Clinically, SIADH is characterized bya decrease in the effective extracellular fluid osmolality, with inap-propriately concentrated urine. Patients with SIADH are clinicallyeuvolemic and are consuming normal amounts of sodium andwater (H
2
O). They have elevated urinary sodium excretion. In theevaluation of these patients, it is important to exclude adrenal, thy-roid, pituitary, and renal disease and diuretic use. Patients withclinically suspected SIADH can be tested with a water load. Uponadministration of 20 mL/kg of H
2
O, patients with SIADH areunable to excrete 90% of the H
2
O load and are unable to dilutetheir urine to an osmolality less than 100 mOsm/kg [15]. (
Modified from
Verbalis [15]; with permission.)
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