Hyponatraemia-treatment standard 2024.

Hyponatraemia is the most common electrolyte disorder in hospital patients associated with increased morbidity, mortality, hospital stay and financial burden. The speed of a correction with 3% sodium chloride as a 100- to 150-ml intravenous bolus or continuous infusion depends on the severity and persistence of the symptoms and needs frequent biochemical monitoring. The rapid intermittent administration of hypertonic saline is preferred for treatment of symptomatic hyponatraemia. In asymptomatic mild hyponatraemia, an adequate solute intake with an initial fluid restriction (FR) of 500 ml/day adjusted according to the serum sodium (sNa) levels is preferred. Almost half of the syndrome of inappropriate antidiuretic hormone (SIADH) patients do not respond to FR as first-line therapy. At present, urea and tolvaptan are considered the most effective second-line therapies in SIADH. However, the evidence for guidance on the choice of second-line therapy of hypotonic hyponatraemia is lacking. Oral urea is considered to be a very effective and safe treatment. Mild and asymptomatic hyponatraemia is treated with adequate solute intake (salt and protein) and initial FR with adjustments based on sNa levels. Specific treatment with vaptans may be considered in either euvolaemic or hypervolaemic patients with high ADH activity. In order to ensure optimal patient outcome, close monitoring and readiness for administration of either hypotonic fluids or desmopressin may be crucial in the decision-making process for specific treatment and eventual overcorrection consequences. According to the guidelines, gradual correction and clinical evaluation is preferable over rapid normalization of sNa towards the laboratory reference ranges.

Reporte de caso: síndrome de absorción intravascular en histeroscopia, intoxicación por glicina / Case report: Intravascular absorption syndrome in hysteroscopy, glycine intoxication

El síndrome de absorción intravascular en histeroscopia se origina por la rápida absorción vascular de soluciones isotónicas e hipotónicas utilizadas en irrigación intrauterina, ocasionando hipervolemia y dilución de electrolitos, especialmente hiponatremia. Cuando este síndrome es debido a intoxicación por glicina al 1,5% causa acidosis severa y neurotoxicidad. La incidencia de este síndrome es baja pero puede aumentar por factores como: falta de control de altura de bolsas de irrigación, ausencia de equilibrio de fluidos de soluciones de irrigación, tejidos altamente vascularizados como miomas uterinos y uso de sistema de electrocirugía monopolar. Se reporta el caso de una paciente con miomas uterinos, programada para resección mediante histeroscopia que cursa con síndrome de absorción intravascular por glicina, el temprano diagnóstico y rápido tratamiento intraoperatorio y postoperatorio permitió una evolución favorable. El manejo se basó en el uso de diuréticos, restricción de fluidos y soluciones hipertónicas de sodio.

Intravascular absorption syndrome in hysteroscopy is caused by rapid vascular absorption of isotonic and hypotonic solutions used in intrauterine irrigation, causing hypervolemia and electrolyte dilution, especially hyponatremia. When this syndrome is due to 1.5% glycine toxicity, it causes severe acidosis and neurotoxicity. The incidence of this syndrome is low but may increase due to factors such as: lack of control of the height of irrigation bags, lack of fluid balance in irrigation solutions, highly vascularized tissues such as uterine myomas and use of a monopolar electrosurgery system. The case of a patient with uterine myomas, scheduled for resection by hysteroscopy, who presents with intravascular glycine absorption syndrome, is reported. Early diagnosis and rapid intraoperative and postoperative treatment allowed a favorable evolution. Management was based on the use of diuretics, fluid restriction, and hypertonic sodium solutions.

[Hyponatremia and Electrolyte Disorders in Cancer Patients].

Onconephrology is a rising and rapidly expanding field of medicine in which nephrology and oncology meet each other. Besides multidisciplinary meetings, oncologists and nephrologists often discuss on timing of the treatment, dosage, and side effects management. Cancer patients often encounter different electrolyte disorders. They are mostly secondary to the tumor itself or consequences of its treatment. In the last years, the great efforts to find new therapies like targeted, immune, and cell-based led us to many new side effects. Hyponatremia, hypokalemia, hyperkalemia, hypercalcemia, and hypomagnesemia are among the most common electrolyte disorders. Data have shown a worse prognosis in patients with electrolytic imbalances. Additionally, they cause a delay in chemotherapy or even an interruption. It is important to diagnose promptly these complications and treat them. In this review, we provide a special focus on hyponatremia and its treatment as the most common electrolytes disorder in cancer patients, but also on newly described cases of hypo- and hyperkalemia and metabolic acidosis.

Effect of controlled hypotensive hemorrhage on plasma sodium levels in anesthetized pigs: An exploratory study.

Perioperative hyponatremia, due to non-osmotic release of the antidiuretic hormone arginine vasopressin, is a serious electrolyte disorder observed in connection with many types of surgery. Since blood loss during surgery contributes to the pathogenesis of hyponatremia, we explored the effect of bleeding on plasma sodium using a controlled hypotensive hemorrhage pig model. After 30-min baseline period, hemorrhage was induced by aspiration of blood during 30 min at mean arterial pressure <50 mmHg. Thereafter, the animals were resuscitated with retransfused blood and a near-isotonic balanced crystalloid solution and monitored for 180 min. Electrolyte and water balances, cardiovascular response, renal hemodynamics, and markers of volume regulation and osmoregulation were investigated. All pigs (n = 10) developed hyponatremia. All animals retained hypotonic fluid, and none could excrete net-free water. Urinary excretion of aquaporin 2, a surrogate marker of collecting duct responsiveness to antidiuretic hormone, was significantly reduced at the end of the study, whereas lysine vasopressin, i.e., the pig antidiuretic hormone remained high. In this animal model, hyponatremia developed due to net positive fluid balance and generation of electrolyte-free water by the kidneys. A decreased urinary aquaporin 2 excretion may indicate an escape from antidiuresis.

Pituitary Apoplexy-associated Cerebral Salt Wasting Syndrome: A Case Report and Literature Review.

PURPOSE: This is a case report of a patient experiencing hyponatremia who was ultimately diagnosed with pituitary apoplexy-associated cerebral salt wasting syndrome (CSWS). METHODS: Laboratory tests, clinical evaluations, and magnetic resonance imaging were performed by specialists. FINDINGS: The patient presented with severe headache, thirst, and polyuria. Results of laboratory tests indicated hyponatremia, decreased plasma osmolality, and elevated urine osmolality. Fluid restriction worsened the situation, and normal saline treatment helped return serum sodium and chloride levels to normal. Pituitary apoplexy-associated CSWS was finally considered. IMPLICATIONS: Pituitary apoplexy is a rare but reasonable etiology for CSWS with hyponatremia. Saline therapy is usually effective.

[Hyponatremia : Etiology, diagnosis and acute therapy]. / Hyponatriämie : Ätiologie, Diagnostik und Akuttherapie.

Hyponatremia is one of the most common electrolyte disorders in emergency departments and hospitalized patients. Serum sodium concentration is controlled by osmoregulation and volume regulation. Both pathways are regulated via the release of antidiuretic hormone (ADH). Syndrome of inappropriate release of ADH (SIADH) may be caused by neoplasms or pneumonia but may also be triggered by drug use or drug abuse. Excessive fluid intake may also result in a decrease in serum sodium concentration. Rapid alteration in serum sodium concentration leads to cell swelling or cell shrinkage, which primarily causes neurological symptoms. The dynamics of development of hyponatremia and its duration are crucial. In addition to blood testing, a clinical examination and urine analysis are essential in the differential diagnosis of hyponatremia.

[Hyponatraemia in palliative care regarding a case report]. / Hyponatraemia a palliatív ellátásban egy esetbemutatás kapcsán.

Hyponatremia is a very common abnormality in palliative care which can cause a sudden decline in the patient's general condition. The diagnostic and therapeutic procedures are based on the patient's symptoms and life-expectancy. The inadequate diagnostic and therapeutic interventions result in an unnecessary burden, while the adequate treatment could improve the quality of life. In palliative care, acute hyponatremia is very rare, the chronic form without any symptoms or mild complaints is more common. Asymptomatic patients should be observed. In patients with mild symptoms and months or years plus prognosis contributing factors should be discontinued. The electrolyte abnormality of patients with moderate or severe symptoms and at least weeks prognosis should be treated. Patients with day prognosis needs no treatment. This case report of an early palliative care patient with moderate symptoms caused by chronic, severe hyponatremia aims to give a suggestion for the management of the most common electrolyte abnormality in everyday palliative care. Orv Hetil. 2023; 164(18): 713-717.

[Reversible central pontine myelinolysis without hyponatremia in a child with acute lymphoblastic leukemia: a case report]. / Myélinolyse centropontine réversible sans hyponatrémie chez un enfant atteint de leucémie aigüe lymphoblastique: à propos d'un cas.

Central pontine myelinolysis is a demyelinating disorder mainly affecting the central pons. In some cases, it is associated with extrapontine myelinolysis. It is usually caused by rapid correction of hyponatremia and osmotic shock. We here report the case of a 3.5-year-old girl diagnosed with acute lymphoblastic leukemia admitted to our Oncology Unit with neutropenic fever and diarrhea. Laboratory tests showed mild neutropenia, normochromic normocytic anemia. Electrolyte tests were normal without hyponatremia. She received antibiotic therapy with Metronidazole. Five days later, she developed flaccid quadriparesis with mutism. Computerized tomography (CT) scan was normal, cerebrospinal fluid (CSF) examination was normal (there was no evidence of leukemic cells) and ophthalmological examination did not show any abnormalities. Brain MRI found hyperintense signal in the pons. The child improved without specific treatment, and clinical and complete neurological recovery was noted. This case highlights that myelinolysis can occur under some circumstances not related with hyponatremia such as malignancy, chemotherapy.

Late-Onset Hyponatremia in Premature Infants.

Late-onset hyponatremia (LOH) frequently affects premature infants 2 or more weeks of age due to inadequate sodium intake and excessive kidney loss. Late-onset hyponatremia typically occurs in infants who are physiologically stable and is defined as serum sodium of 132 mEq/L or less or between 133 and 135 mEq/L if receiving sodium supplementation. Recent evidence suggests that spot urine sodium levels may improve the recognition of LOH, as low levels of excreted urine reflect a total body sodium deficit and negative balance. Untreated LOH may result in poor somatic growth, neurodevelopmental delay, higher incidence of bronchopulmonary dysplasia, and more severe retinopathy of prematurity. The primary prevention of LOH is to maintain serum sodium between 135 and 145 mEq/L; however, there are currently no formal protocols guiding sodium supplementation. The purpose of this article is to present on overview of LOH pathophysiology and its effect on somatic growth, neurodevelopment outcomes, and other related sequelae. We further discuss general management strategies and describe a protocol for sodium supplementation that is presently undergoing an evaluation for effectiveness.

Initiating Continuous Renal Replacement Therapy in Patients With Transurethral Resection of Prostate Syndrome: A Case Report.

With advances and developments in hysteroscopy, cystoscopy, transurethral resection of bladder tumor, and arthroscopy, transurethral resection of prostate (TURP) syndrome has been increasingly reported. TURP syndrome is often accompanied by severe hyponatremia, fluid overload, and a plasma hypotonic state, resulting in heart failure and pulmonary and cerebral edema. Conventional treatment methods, such as intravenous infusion of hyperosmotic saline, can rapidly reverse the downward trend of serum sodium levels in efforts to prevent and treat cerebral edema. However, this may not be suitable for patients with cardiac and renal insufficiency and may induce central pontine myelinolysis due to the possibility of worsening volume load and difficulty in controlling the correction rate of serum sodium. The patient described in this report presented with severe hyponatremia (sodium<100 mmol/L) combined with intraoperative pulmonary edema; his cardiac function and oxygenation status deteriorated after an intravenous infusion of 3% hypertonic saline. He underwent continuous renal replacement therapy (CRRT) to prevent the progression of multiple-organ edema and cardiac insufficiency. CRRT has demonstrated efficacy in the treatment of chronic hyponatremia in patients with renal failure, and can slowly and continuously correct water-electrolyte imbalance, acid-base imbalance, and volume overload. TURP syndrome with severe hyponatremia and pulmonary edema was diagnosed; accordingly, the patient was treated with 3% hypertonic saline, furosemide, and CRRT, without the development of overt neurological sequelae.

Human herpesvirus 6 (HHV-6) associated permanent hyponatremia in umbilical cord blood transplant recipient.

Long-term neurocognitive deficits after human herpesvirus-6 (HHV-6) infection are common in stem-cell transplant recipients, but SIADH (Syndrome of inappropriate antidiuretic hormone secretion) with persistent hyponatremia is rare. A 51-year-old woman presented with somnolence, hyponatremia (121 mmol/L) and HHV-6 viremia (80,330 copies/ml) on day +22 post umbilical cord blood transplant (UCBT). With waterrestriction, tolvaptan and combination of foscarnet and ganciclovir, patient's hyponatremia and HHV-6 viremia improved. On day +94 UCBT, hyponatremia and HHV-6 viremia recurred. Foscarnet was restarted and continued until day +269 UCBT due to multiple HHV-6 recurrences with persistent hyponatremia. At day +712, patient remains on water-restriction, tolvaptan for continuous hyponatremia from SIADH.

Risk factors and mortality in elderly patients with severe hyponatremia admitted to the emergency department.

BACKGROUND: This study was aimed at determining the risk factors associated with mortality in elderly patients with severe hyponatremia admitted to the emergency department. MATERIALS AND METHODS: The data of patients aged ≥ 65 years who were admitted to the emergency department and whose serum sodium levels were < 125 mEq/L were retrospectively collected. RESULTS: Mortality was associated with chronic liver disease/cirrhosis (p = 0.036), metastatic tumor (p = 0.007) and solid tumor (p = 0.013) cancers, antiarrhythmic drug use (p = 0.003), potassium-sparing diuretic use (p = 0.044), antineoplastic drug use (p = 0.0029), and dialysis treatment (p = 0.015). The following cutoff values were determined to be predictive of mortality: urea > 63.6 (AUC: 0.771; p = 0.0001), creatinine > 1.39 (AUC: 0.675; p = 0.0003), potassium > 4.64 (AUC: 0.711; p = 0.0001), C-reactive protein > 44 (AUC: 0.765; p = 0.0001), white blood cell count > 12.21 (AUC: 0.688; p = 0.0001), hemoglobin < 11.2 (AUC: 0.611; p = 0.0103), and Charlson comorbidity index > 2 (AUC: 0.739; p = 0.0001). The use of antineoplastic drugs (OR: 4.502; p = 0.010) and increased values of the following were associated with an increased risk of mortality: urea (OR: 1.007; p = 0.024), C-reactive protein (OR: 1.005; p = 0.026), glucose (OR: 1.008; p = 0.001), and Charlson comorbidity index (OR: 1.198; p = 0.025). CONCLUSION: Malignancy; liver cirrhosis; dialysis treatment; increased Charlson comorbidity index, urea, and C-reactive protein values and the use of antineoplastic drugs are associated with mortality.

Rapid correction of severe hyponatremia and control of subsequent overcorrection in operative hysteroscopy intravascular absorption syndrome: A case report.

RATIONALE: Operative hysteroscopy intravascular absorption syndrome (OHIAS) results from systemic absorption of hypotonic solution during hysteroscopy, which may induce severe hyponatremia within hours. Depending on the serum sodium (Na+) level, this can be life-threatening and requires prompt and careful remedial treatment. PATIENT CONCERNS AND DIAGNOSES: A 53-year-old woman underwent hysteroscopic myomectomy for submucosal leiomyoma. Approximately 3 hours postoperatively, the serum Na+ level decreased to 82 mM/L, accompanied by pulmonary edema and lactic acidosis. The patient was strongly suspicious of OHIAS. INTERVENTIONS AND OUTCOMES: A rapid correction was made using 3% NaCl to prevent brain edema as an initial response. After the serum Na+ level reached 120 mM/L, gradual correction was performed considering osmotic demyelination syndrome, and desmopressin was administered to prevent overcorrection caused by excessive water diuresis. Serum Na+ level normalized in 4 days and the patient recovered without any specific sequelae. LESSONS: The detection of OHIAS may be delayed under general anesthesia, and prior vigilance is important if the operation time is prolonged. In severe hyponatremia with an apparently rapid onset, such as OHIAS, a two-step correction process may be safe and useful: rapid correction followed by more gradual correction.

Disorders of Salt and Water Balance After Pituitary Surgery.

Transsphenoidal surgery is the first-line treatment for many clinically significant pituitary tumors and sellar lesions. Although complication rates are low when performed at high-volume centers, disorders of salt and water balance are relatively common postoperatively. Both, or either, central diabetes insipidus (recently renamed arginine vasopressin deficiency - AVP-D), caused by a deficiency in production and/or secretion of arginine vasopressin, and hyponatremia, most commonly secondary to the syndrome of inappropriate antidiuresis, may occur. These conditions can extend hospital stay and increase the risk of readmission. This article discusses common presentations of salt and water balance disorders following pituitary surgery, the pathophysiology of these conditions, and their diagnosis and management.

Syndrome of inappropriate antidiuretic hormone secretion. / Síndrome de secreción inadecuada de hormona antidiurética.

Hyponatremia is the most frequent electrolytic disorder in hospitalized patients, and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), the most frequent cause of hiponatremia with clinically normal extracellular volume. It consists of a disorder of the regulation of body water that obeys to different causes, mainly cancer, pulmonary illnesses, disorders of the central nervous system and diverse drugs. As in any hiponatremia it a physiological knowledge of the regulation of body water and sodium is essential as well as the application of precise diagnostic criteria in order to manage the problem with an effective treatment. The available data until the moment show that the clinical diagnosis of SIADH made by professionals is mainly not supported on the established criteria drawn by experts and this lack of accuracy probably hits in the therapeutic result. The basis of the treatment of the SIADH is to correct its cause, water restriction, solutes (sodium chloride) and the use of vaptans in case of failure of the previous measures.

An observational study on clinico aetiological profile and response to treatment and outcome of patients diagnosed with severe hyponatremia in medicine intensive care unit of a tertiary care centre.

Hyponatremia is defined as serum sodium concentration less than 135meq/l. More severe symptoms are seen when serum sodium falls below 120 meq/l. Hyponatremia in ICU is a very common scenario. Treatment strategy is decided after thorough history taking and clinical examination. Judicious treatment is necessary as rapid correction and delayed correction both can lead to various neurological sequelae. This study was done on critically ill patients who had hyponatremia on the day of admission and clinical and aetiological profile was studied. MATERIAL: An observational study was conducted between March 2020 to July 2021. With in this period of time 210 patients got admitted in medical ICU with serum sodium value less than 120meq/L on the day of admission. Clinico aetiological profile in terms of age, gender, symptoms, co morbidities, response to standard treatment approach, time taken for correction and complications were studied. OBSERVATION: Mean age was 65.5 years. 52.3 % of patients were male. SYMPTOMS: 92.3% had generalised weakness. 89.5% had confusion. 83.8% had nausea and vomiting. 23.8% had body swelling. 26.1% had restlessness. 9% had loss of consciousness and 7.6% had diarrhoea. Comorbidities: Hypertension was present in 41.4% of the patients. Diabetes was present in 24.7%. Hypothyroidism was present in 14.2%. Heart failure, cirrhosis or chronic kidney disease was present in 22.8%. Known pulmonary disease was present in 11.9%. 11.9% patients had history of taking diuretic drugs along with other factors. 1.1% patients were taking other SIADH causing drugs. 94.2% patients had history of low solute intake. In 93.3% Patients hyponatremia was multifactorial. 70.4% patients had hyponatremia due to increased renal excretion of sodium. 82.8% patients were having SIADH. 12.3 % patients had hypokalemia too. DIAGNOSIS: 35.7% patients had intracerebral pathology like CVA, meningitis or SOL. 32.3% had sepsis or underlying infection. 21.9% had dilutional hyponatremia due to underlying CKD/HF/CLD. 7.1% had adrenal insufficiency. 3% patients had other causes of hyponatremia like SIADH causing drugs and malignancy. Mean time to correction of hyponatremia with standard treatment methods was observed to be 3.5 days after admission. COMPLICATIONS: 20.9% patients died in ICU stay. One Patient presenting with Acute liver failure, sepsis developed locked in syndrome. Two Patients developed rest tremor. CONCLUSION: Hyponatremia in ICU in seen in elderly patients more commonly. Hyponatremia remains associated with diseases involving every organ system. Treatment strategies differ with clinical presentation of the patient. Prompt diagnosis and correction at proper pace prevents dreaded complications.

Hyponatraemic seizure secondary to primary polydipsia following urological surgery.

An 82-year-old man presented to the emergency department with delirium, vomiting and an initial hyponatraemia of 112 mmol/L the day after successful transurethral vaporisation of the prostate. He had a tonic-clonic seizure in the acute surgical unit and was managed subsequently in the intensive care unit with a controlled rate of hypertonic saline. Initial work-up for the cause of hyponatraemia revealed a low urine osmolality, suggestive of relative excess water intake. Detailed examination of the operation notes revealed no discrepancy between intraoperative irrigating fluid input and output. Careful collateral history revealed that the patient had drunk 8 L of water in the 24 hours following the operation, after taking advice to 'drink plenty of water' literally. This case highlights the importance of conveying specific advice to patient, the lower incidence of transurethral resection syndrome in resections using saline as an irrigation fluid and outlines the pathway for investigation and management for hyponatraemia.

The management and outcome of hyponatraemia following transsphenoidal surgery: a retrospective observational study.

PURPOSE: Hyponatraemia is a common complication following transsphenoidal surgery. However, there is sparse data on its optimal management and impact on clinical outcomes. The aim of this study was to evaluate the management and outcome of hyponatraemia following transsphenoidal surgery. METHODS: A prospectively maintained database was searched over a 4-year period between January 2016 and December 2019, to identify all patients undergoing transsphenoidal surgery. A retrospective case-note review was performed to extract data on hyponatraemia management and outcome. RESULTS: Hyponatraemia occurred in 162 patients (162/670; 24.2%) with a median age of 56 years. Female gender and younger age were associated with hyponatraemia, with mean nadir sodium being 128.6 mmol/L on postoperative day 7. Hyponatraemic patients had longer hospital stay than normonatraemic group with nadir sodium being inversely associated with length of stay (p < 0.001). In patients with serum sodium ≤ 132 mmol/L, syndrome of inappropriate antidiuretic hormone secretion (SIADH) was the commonest cause (80/111; 72%). Among 76 patients treated with fluid restriction as a monotherapy, 25 patients (25/76; 32.9%) did not achieve a rise in sodium after 3 days of treatment. Readmission with hyponatraemia occurred in 11 cases (11/162; 6.8%) at a median interval of 9 days after operation. CONCLUSION: Hyponatraemia is a relatively common occurrence following transsphenoidal surgery, is associated with longer hospital stay and risk of readmission and the effectiveness of fluid restriction is limited. These findings highlight the need for further studies to better identify and treat high-risk patients, including the use of arginine vasopressin receptor antagonists.