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1.
BMJ Case Rep ; 12(7)2019 Jul 11.
Artigo em Inglês | MEDLINE | ID: mdl-31300598

RESUMO

A 61-year-old Caucasian woman with a history of hypertension presented with a week's history of confusion falls and back pain was found to have hyponatraemia from secretion of antidiuretic hormone and treated appropriately. Given her persistent symptoms, despite a normal CT head on presentation, an MRI head was obtained, showing vasogenic oedema in line with posterior reversible encephalopathy syndrome (PRES). Despite aggressive antihypertensives and supportive measures, unfortunately, her condition deteriorated, with increased confusion, new left-sided flaccid paresis, paraesthesias and worsening of the back pain. Following further testing including a cerebrospinal fluid analysis, finally diagnosed with an atypical presentation of Guillain-Barre syndrome (GBS), and prompt management with intravenous immunoglobulins was initiated. She recovered clinically and returned to near-normal function on follow-up. We use this case to suggest the importance of dysautonomia in GBS and various clinical manifestations it can present with, including PRES and hyponatraemia.


Assuntos
Síndrome de Guillain-Barré/diagnóstico , Hiponatremia/fisiopatologia , Imunoglobulinas Intravenosas/uso terapêutico , Fatores Imunológicos/uso terapêutico , Síndrome da Leucoencefalopatia Posterior/fisiopatologia , Acidentes por Quedas , Confusão/etiologia , Feminino , Síndrome de Guillain-Barré/tratamento farmacológico , Síndrome de Guillain-Barré/fisiopatologia , Humanos , Hiponatremia/tratamento farmacológico , Imagem por Ressonância Magnética , Pessoa de Meia-Idade , Síndrome da Leucoencefalopatia Posterior/tratamento farmacológico , Resultado do Tratamento
2.
Rinsho Shinkeigaku ; 59(8): 541-544, 2019 Aug 29.
Artigo em Japonês | MEDLINE | ID: mdl-31341131

RESUMO

We present a case of tuberculous meningitis (TBM), wherein pleural effusion developed as a manifestation of paradoxical reaction during anti-tuberculosis therapy. An 87-year-old diabetic man was referred to our clinic for fever and impaired consciousness. He did not obey vocal commands. No ocular motor deficit, facial palsy, or limb weakness was observed. He had hyponatremia due to inappropriate antidiuresis. Examination of the cerebrospinal fluid revealed lymphocytosis and high adenosine deaminase (ADA) activity, suggestive of TBM. He was treated with isoniazid, rifampicin, and pyrazinamide, after which his symptoms quickly resolved. Lymphocyte count, ADA activity, and protein concentration in the cerebrospinal fluid decreased. However, approximately 30 days after the initiation of therapy, he developed mild hypoxemia. A chest CT scan revealed pleural effusion. The pleural fluid was exudate with elevated ADA activity, which was consistent with tuberculous pleural effusion. Shortly after the use of a herbal medicine, Goreisan extract, hyponatremia and hypoproteinemia improved, and the pleural effusion was reduced. Approximately one-third of patients with TBM are reported to develop a paradoxical reaction, such as tuberculoma, hydrocephalus, and optochiasmatic and spinal arachnoiditis. The present case suggests that extra-central nervous system manifestations, including pleural effusion, should be considered when treating TBM.


Assuntos
Antituberculosos/efeitos adversos , Antituberculosos/uso terapêutico , Derrame Pleural/etiologia , Tuberculose Meníngea/complicações , Tuberculose Meníngea/tratamento farmacológico , Tuberculose Pleural/etiologia , Adenosina Desaminase/líquido cefalorraquidiano , Idoso de 80 Anos ou mais , Biomarcadores/líquido cefalorraquidiano , Medicamentos de Ervas Chinesas/uso terapêutico , Humanos , Hiponatremia/tratamento farmacológico , Hiponatremia/etiologia , Masculino , Medicina Kampo , Fitoterapia , Derrame Pleural/diagnóstico por imagem , Derrame Pleural/tratamento farmacológico , Radiografia Torácica , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Tuberculose Meníngea/diagnóstico , Tuberculose Pleural/diagnóstico por imagem , Tuberculose Pleural/tratamento farmacológico
3.
Medicine (Baltimore) ; 98(28): e16407, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31305453

RESUMO

RATIONALE: The misdiagnosis of hypopituitarism is common due to its rarity and its nonspecific clinical manifestations. Our case report highlights the importance of critical evaluation regarding hypopituitarism as a cause of recurrent hypoglycemia, hyponatremia, and gastrointestinal symptoms in patients with T1DM, as misdiagnosis might be fatal to the patient. PATIENT CONCERNS: We herein report the case of 35-year-old female patient who presented with 18 years of history of well-controlled type 1 diabetes mellitus and a 6-month history of recurrent nausea and vomiting, generalized weakness, hyponatremia, and severe hypoglycemia, despite a reduction in the dose of insulin. She was considered as having "type 1 diabetes and gastroparesis." Four months later, she was diagnosed with hypothyroidism, and 25 µg/d of levothyroxine was prescribed. However, the levothyroxine had to be discontinued 1 week later because of frequent vomiting by the patient. DIAGNOSIS: Further evaluation in our hospital revealed low-normal adrenocorticotropic hormone, low-normal serum cortisol, and low 24-hours urinary cortisol excretion. Secondary hypothyroidism and hypogonadotropic hypogonadism were also demonstrated. Based on the endocrinological findings, she was diagnosed with hypopituitarism possibly due to lymphocytic hypophysitis. Diabetic nephropathy was another diagnosis made after kidney biopsy. INTERVENTIONS: The patient was treated with 100 mg/d of hydrocortisone intravenously for 2 weeks. After that, she continued on 15 mg/d of prednisone, and then 25 µg/d of levothyroxine was administered. OUTCOMES: The patient's insulin requirement increased to a premorbid level, the severe hypoglycemia resolved, the physical discomforts were alleviated, and blood electrolytes returned to normal. LESSONS: This uncommon case reinforced the significance of a timely diagnosis and appropriate treatment of hypopituitarism. We recommend that physicians focus their awareness on this potentially life-threatening disease, as it is a condition potentially fatal to the patient if not recognized and treated.


Assuntos
Diabetes Mellitus Tipo 1/complicações , Hipoglicemia/etiologia , Hiponatremia/etiologia , Hipopituitarismo/complicações , Adulto , Nefropatias Diabéticas/complicações , Diagnóstico Diferencial , Feminino , Humanos , Hipoglicemia/diagnóstico , Hipoglicemia/tratamento farmacológico , Hiponatremia/diagnóstico , Hiponatremia/tratamento farmacológico , Hipopituitarismo/diagnóstico , Hipopituitarismo/tratamento farmacológico
4.
Probl Endokrinol (Mosk) ; 65(1): 39-45, 2019 05 14.
Artigo em Russo | MEDLINE | ID: mdl-31091049

RESUMO

We report a case of cerebral salt-wasting syndrome in a 12-year-old boy with severe traumatic brain injury. The child developed refractory intracranial hypertension at the time of injury, which required decompressive craniectomy on the 7th day after injury. Infusion of hypertonic sodium chloride solutions performed at the intensive care unit resulted in hypernatremia on the 5th day and polyuria and hypovolemia on the 11th day, which was regarded as manifestations of central diabetes insipidus. Persistent hyponatremia developed on the 17th day after injury; on the next day, the therapy was supplemented with Fludrocortisone at a dose of 100 µg/day, followed by an increase in the dose to 150 µg/day, which had no significant effect. Fludrocortisone was discontinued on the 30th day of therapy, but it was re-used at a dose of 400 µg/day from the 54th day. During this treatment, polyuria gradually decreased to 4 to 5 l/day, and the plasma sodium concentration remained within the reference values. The dose of Fludrocortisone was increased to 600 µg/day since the 66th day. The child was transferred to a specialized department on the 67th day after injury. At the Department of Neurosurgery, the dose of Cortineff was gradually reduced starting with the 94th day and completely discontinued on the 122nd day after injury. On day 132th of the post-traumatic period, the patient was transferred to another hospital for rehabilitation therapy.


Assuntos
Lesões Encefálicas Traumáticas/patologia , Hiponatremia/etiologia , Poliúria/etiologia , Sódio/sangue , Anti-Inflamatórios/administração & dosagem , Anti-Inflamatórios/uso terapêutico , Lesões Encefálicas Traumáticas/sangue , Lesões Encefálicas Traumáticas/complicações , Criança , Fludrocortisona/administração & dosagem , Fludrocortisona/análogos & derivados , Fludrocortisona/uso terapêutico , Humanos , Hiponatremia/tratamento farmacológico , Masculino , Poliúria/tratamento farmacológico
5.
J Med Case Rep ; 13(1): 40, 2019 Feb 23.
Artigo em Inglês | MEDLINE | ID: mdl-30795800

RESUMO

BACKGROUND: Hyponatremia is defined as a serum sodium level of less than 135 mEq/L in a patient. Although hyponatremia is not an uncommon laboratory finding, especially in the elderly, hunting for the etiology is a challenging issue for any clinician. The three first-line investigations that are required for further analysis are urine osmolality, serum osmolality, and urinary sodium levels in addition to clinical assessment of volume status. CASE PRESENTATION: A 69-year-old previously well Sinhalese man presented with lethargy, loss of appetite, vomiting, and altered behavior of 1 week's duration. An examination revealed Glasgow Coma Scale of 13/15 and marginally low blood pressure. Initial serum sodium level was 104 mmol/L, and plasma and urinary osmolalities were 251 mOsm/kg and 305 mOsm/kg, respectively. His urinary sodium level of 158 mmol/L was suggestive of a clinical picture of a syndrome of inappropriate secretion of antidiuretic hormone. Even after correction of hyponatremia with intravenously administered 3% saline, a persistent altered behavior necessitated cerebral imaging that confirmed the presence of pituitary macroadenoma. Meanwhile, his hormone profile showed very low serum cortisol and low free tetraiodothyronine levels. An ultrasound scan of his abdomen affirmed the presence of normal adrenal glands. With intravenously administered hydrocortisone and orally administered levothyroxine replacement, he showed marked clinical improvement that supported the diagnosis of hypopituitarism. CONCLUSION: Hyponatremia in the elderly is not an uncommon presentation. However, etiological diagnosis is a challenging task as there are multiple overlapping differential diagnoses.


Assuntos
Adenoma/complicações , Adenoma/diagnóstico por imagem , Hiponatremia/etiologia , Neoplasias Hipofisárias/complicações , Neoplasias Hipofisárias/diagnóstico por imagem , Adenoma/cirurgia , Idoso , Anti-Inflamatórios/uso terapêutico , Encéfalo/diagnóstico por imagem , Diagnóstico Diferencial , Humanos , Hidrocortisona/uso terapêutico , Hiponatremia/sangue , Hiponatremia/tratamento farmacológico , Masculino , Hipófise/diagnóstico por imagem , Hipófise/cirurgia , Neoplasias Hipofisárias/cirurgia , Tiroxina/uso terapêutico , Tomografia Computadorizada por Raios X
6.
Crit Care Clin ; 35(2): 187-200, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30784603

RESUMO

Diabetes insipidus and the syndrome of inappropriate antidiuretic hormone secretion lie at opposite ends of the spectrum of disordered renal handling of water. Whereas renal retention of water insidiously causes hypotonic hyponatremia in syndrome of inappropriate antidiuretic hormone secretion, diabetes insipidus may lead to free water loss, hypernatremia, and volume depletion. Hypernatremia and hyponatremia are associated with worse outcomes and longer intensive care stays. Moreover, pathologies causing polyuria and hyponatremia in patients in intensive care may be multiple, making diagnosis challenging. We provide an approach to the diagnosis and management of these conditions in intensive care patients.


Assuntos
Antidiuréticos/uso terapêutico , Cuidados Críticos/normas , Desamino Arginina Vasopressina/uso terapêutico , Diabetes Insípido/tratamento farmacológico , Hipernatremia/tratamento farmacológico , Hiponatremia/tratamento farmacológico , Síndrome de Secreção Inadequada de HAD/tratamento farmacológico , Diabetes Insípido/diagnóstico , Diabetes Insípido/fisiopatologia , Feminino , Humanos , Hipernatremia/diagnóstico , Hiponatremia/diagnóstico , Síndrome de Secreção Inadequada de HAD/diagnóstico , Síndrome de Secreção Inadequada de HAD/fisiopatologia , Masculino , Guias de Prática Clínica como Assunto , Equilíbrio Hidroeletrolítico/efeitos dos fármacos
7.
Intern Med ; 58(13): 1939-1942, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-30799365

RESUMO

A 77-year-old woman who had taken a single oral dose of duloxetine subsequently developed a headache and nausea. On the first day, her serum sodium level was 135 mEq/L. She became confused on the third day. Her serum sodium level was 119 mEq/L and her antidiuretic hormone level was 1.9 IU. We diagnosed her with acute hyponatremia from duloxetine-induced syndrome of inappropriate antidiuretic hormone secretion (SIADH). This case suggests that we must not rule out SIADH on the basis of normal serum sodium levels when a patient who has started serotonin-norepinephrine reuptake inhibitor (SNRI) treatment presents with symptoms similar to hyponatremia.


Assuntos
Cloridrato de Duloxetina/efeitos adversos , Hiponatremia/induzido quimicamente , Hiponatremia/tratamento farmacológico , Síndrome de Secreção Inadequada de HAD/induzido quimicamente , Síndrome de Secreção Inadequada de HAD/tratamento farmacológico , Solução Salina/uso terapêutico , Inibidores de Captação de Serotonina/efeitos adversos , Administração Intravenosa , Idoso , Feminino , Humanos , Hiponatremia/diagnóstico , Síndrome de Secreção Inadequada de HAD/diagnóstico , Solução Salina/administração & dosagem , Resultado do Tratamento
8.
Expert Rev Endocrinol Metab ; 14(1): 13-21, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30596344

RESUMO

INTRODUCTION: Hyponatremia is the most frequent electrolyte disorder in hospitalised patients. Acute and severe hyponatremia may be a life-threatening situation. However, also mild and chronic hyponatremia may negatively affect the health status (i.e. gait disturbances, attention deficits, falls and fractures, and bone loss) and may increase the risk of death. Therefore, it is of paramount importance for clinicians to have an in-depth knowledge on this topic, in order to appropriately manage patients affected by hyponatremia. AREAS COVERED: This review will cover different areas related to this electrolyte disorder. Because many pathologic conditions may be associated with hyponatremia, thorough investigations have to be performed in order to establish the underlying etiology. To establish the cause of hyponatremia is of great importance, because an appropriate therapeutic strategy is strictly dependent on a correct diagnosis. A description of the different available therapeutic approaches for the correction of hyponatremia, including vaptans, will follow. EXPERT COMMENTARY: Undoubtedly, the studies that have been published in recent years and the introduction of vaptans in clinical practice have contributed to increase the awareness on hyponatremia among clinicians. Nevertheless, additional studies are needed in order to clarify some partially uncovered areas.


Assuntos
Marcha/fisiologia , Hiponatremia/tratamento farmacológico , Hiponatremia/etiologia , Síndrome de Secreção Inadequada de HAD/diagnóstico , Animais , Antagonistas dos Receptores de Hormônios Antidiuréticos/uso terapêutico , Conscientização , Diagnóstico Diferencial , Eletrólitos/metabolismo , Feminino , Disparidades nos Níveis de Saúde , Humanos , Hiponatremia/diagnóstico , Hiponatremia/epidemiologia , Síndrome de Secreção Inadequada de HAD/induzido quimicamente , Síndrome de Secreção Inadequada de HAD/epidemiologia , Masculino , Modelos Animais , Mutação , Ratos , Receptores de Vasopressinas/efeitos dos fármacos , Receptores de Vasopressinas/genética , Tolvaptan/uso terapêutico
9.
J Clin Res Pediatr Endocrinol ; 11(2): 202-206, 2019 05 28.
Artigo em Inglês | MEDLINE | ID: mdl-30257818

RESUMO

Inappropriate antidiuretic hormone syndrome (SIADH) may develop after intracranial surgery. SIADH in the pediatric age group is usually encountered in patients with an intracranial mass both before and after surgery. Fluid restriction is the standard therapy in SIADH. However, a resistant, hyponatremic pattern may be encountered in some cases. Vaptans have been recently introduced for treatment of hyponatremia due to SIADH. There is inadequate data concerning tolvaptan treatment in pediatric patients. We present a 13 year-old female with SIADH of triphasic episode who was transferred to our clinic after surgery for craniopharyngioma. Resistant hyponatremia did not resolve despite fluid restriction and hypertonic saline support. The patient responded rapidly to a single dose of tolvaptan, with no adverse effect, which resulted in successful control of her SIADH.


Assuntos
Antagonistas dos Receptores de Hormônios Antidiuréticos/uso terapêutico , Craniofaringioma/cirurgia , Hiponatremia/tratamento farmacológico , Síndrome de Secreção Inadequada de HAD/complicações , Procedimentos Neurocirúrgicos/efeitos adversos , Complicações Pós-Operatórias/tratamento farmacológico , Tolvaptan/uso terapêutico , Adolescente , Craniofaringioma/patologia , Feminino , Humanos , Hiponatremia/etiologia , Hiponatremia/patologia , Síndrome de Secreção Inadequada de HAD/fisiopatologia , Neoplasias Hipofisárias/patologia , Neoplasias Hipofisárias/cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/patologia , Prognóstico
10.
Pigment Cell Melanoma Res ; 32(2): 326-331, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30387922

RESUMO

The incidence of malignant melanoma has increased over the past two decades. A combined BRAF/MEK inhibitor regimen has been shown to lead to prolonged survival and progression-free survival in patients with metastatic BRAF V600-mutant melanoma. Different nephrotoxic effects have been described, among them hyponatremia. The goal of the present narrative review was to understand the pathophysiological mechanisms driving hyponatremia when using selective BRAF inhibitors and/or MEK inhibitors in order to propose potential strategies to prevent or to treat this side effect. Several mechanisms of kidney injury have been suggested including changes in glomerular and tubular function. However, the precise mechanisms of hyponatremia remain unknown. Our hypothesis is that BRAF/MEK inhibitors lead to hyponatremia and water retention (so-called dilution hyponatremia) by activating aquaporin 2 (AQP2) trafficking from its intracellular compartment to the luminal cell membrane, and by activating ENaC channel. Therefore, we recommend treating the hyponatremia related to BRAF/MEK inhibitors with restriction of fluid intake.


Assuntos
Hiponatremia/tratamento farmacológico , Hiponatremia/fisiopatologia , Melanoma/tratamento farmacológico , Melanoma/fisiopatologia , Inibidores de Proteínas Quinases/uso terapêutico , Humanos , Hiponatremia/complicações , Hiponatremia/diagnóstico , Melanoma/complicações , Quinases de Proteína Quinase Ativadas por Mitógeno/antagonistas & inibidores , Quinases de Proteína Quinase Ativadas por Mitógeno/metabolismo , Modelos Biológicos , Proteínas Proto-Oncogênicas B-raf/antagonistas & inibidores , Proteínas Proto-Oncogênicas B-raf/metabolismo
11.
Am J Kidney Dis ; 73(3): 391-399, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30554800

RESUMO

When homeostatic regulatory systems are unable to maintain a normal serum sodium concentration, the organism must adapt to demands of a disordered internal environment, a process known as "allostasis." Human cells respond to osmotic stress created by an abnormal serum sodium level with the same adaptations used by invertebrate organisms that do not regulate body fluid osmolality. To avoid intolerable changes in their volume, cells export organic osmolytes when exposed to a low serum sodium concentration and accumulate these intracellular solutes when serum sodium concentration increases. The brain's adaptation to severe hyponatremia (serum sodium < 120 mEq/L) has been studied extensively. However, adaptive responses occur with less severe hyponatremia and other tissues are affected; the consequences of these adaptations are incompletely understood. Recent epidemiologic studies have shown that mild (sodium, 130-135 mEq/L) and moderate (sodium, 121-129 mEq/L) chronic hyponatremia, long thought to be inconsequential, is associated with adverse outcomes. Adaptations of the heart, bone, brain, and (possibly) immune system to sustained mild to moderate hyponatremia may adversely affect their function and potentially the organism's survival. This review explores what is known about the consequences of mild to moderate chronic hyponatremia and the potential benefits of treating this condition.


Assuntos
Alostase , Hiponatremia/diagnóstico , Hiponatremia/fisiopatologia , Doenças Ósseas/etiologia , Doença Crônica , Humanos , Hiponatremia/complicações , Hiponatremia/tratamento farmacológico , Índice de Gravidade de Doença
12.
G Ital Nefrol ; 35(6)2018 Dec.
Artigo em Italiano | MEDLINE | ID: mdl-30550035

RESUMO

ADH is a hormone secreted by neurohypophysis that plays different roles based on the target organ. At the renal level, this peptide is capable of causing electrolyte-free water absorption, thus playing a key role in the hydro-electrolytic balance. There are pathologies and disorders that jeopardize this balance and, in this field, ADH receptor inhibitors such as Vaptans could play a key role. By inhibiting the activation pathway of vasopressin, they are potentially useful in euvolemic and hypervolemic hypotonic hyponatremia. However, clinical trials in heart failure have not given favourable results on clinical outcomes. Even in SIADH, despite their wide use, there is no agreement by experts on their use. Since vaptans inhibit the cAMP pathway in tubular cells, their use has been proposed to inhibit cystogenesis. A clinical trial has shown favourable effects on ADPKD progression. Because vaptans have been shown to be effective in models of renal cysts disorders other than ADPKD, their use has been proposed in diseases such as nephronophthisis and recessive autosomal polycystic disease. Other possible uses of vaptans could be in kidney transplantation and cardiorenal syndrome. Due to the activity of ADH in coagulation and haemostasis, ADH's activation pathway by Desmopressin Acetate could be a useful strategy to reduce the risk of bleeding in biopsies in patients with haemorrhagic risk.


Assuntos
Antagonistas dos Receptores de Hormônios Antidiuréticos/uso terapêutico , Nefropatias/tratamento farmacológico , Terapia de Alvo Molecular , Neurofisinas/agonistas , Neurofisinas/antagonistas & inibidores , Precursores de Proteínas/agonistas , Precursores de Proteínas/antagonistas & inibidores , Receptores de Vasopressinas/efeitos dos fármacos , Vasopressinas/agonistas , Vasopressinas/antagonistas & inibidores , Desequilíbrio Hidroeletrolítico/tratamento farmacológico , Antagonistas dos Receptores de Hormônios Antidiuréticos/farmacologia , Cadáver , AMP Cíclico/fisiologia , Previsões , Humanos , Hiponatremia/tratamento farmacológico , Hiponatremia/fisiopatologia , Nefropatias/fisiopatologia , Doenças Renais Císticas/tratamento farmacológico , Transplante de Rim , Túbulos Renais Coletores/efeitos dos fármacos , Túbulos Renais Coletores/fisiologia , Neurofisinas/fisiologia , Rim Policístico Autossômico Dominante/tratamento farmacológico , Rim Policístico Autossômico Dominante/fisiopatologia , Precursores de Proteínas/fisiologia , Receptores de Vasopressinas/agonistas , Sistemas do Segundo Mensageiro/efeitos dos fármacos , Doadores de Tecidos , Vasopressinas/fisiologia
13.
BMJ Case Rep ; 20182018 Oct 21.
Artigo em Inglês | MEDLINE | ID: mdl-30344146

RESUMO

Osmotic demyelination syndrome commonly affects the pons and infrequently involves the extrapontine region. We report a patient with severe hyponatraemia who developed osmotic demyelination syndrome as a consequence of rapid sodium correction. The condition manifested as acute severe parkinsonism, bilateral ptosis and gaze impairment. MRI revealed typical features of central pontine and extrapontine myelinolysis. The patient improved gradually after treatment with a combination of levodopa, intravenous immunoglobulin and dexamethasone. However, it is important to emphasise that the improvement of neurological symptoms is not necessarily causal with these experimental therapies.


Assuntos
Blefaroptose/diagnóstico , Hiponatremia/diagnóstico , Mielinólise Central da Ponte/diagnóstico , Transtornos Parkinsonianos/diagnóstico , Blefaroptose/complicações , Blefaroptose/tratamento farmacológico , Diagnóstico Diferencial , Humanos , Hiponatremia/complicações , Hiponatremia/tratamento farmacológico , Levodopa/uso terapêutico , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Mielinólise Central da Ponte/complicações , Mielinólise Central da Ponte/diagnóstico por imagem , Mielinólise Central da Ponte/tratamento farmacológico , Transtornos Parkinsonianos/complicações , Transtornos Parkinsonianos/diagnóstico por imagem , Transtornos Parkinsonianos/tratamento farmacológico , Síndrome
14.
Clin J Am Soc Nephrol ; 13(11): 1627-1632, 2018 11 07.
Artigo em Inglês | MEDLINE | ID: mdl-30181129

RESUMO

BACKGROUND AND OBJECTIVES: Current therapies for hyponatremia have variable effectiveness and tolerability, and in certain instances, they are very expensive. We examined the effectiveness, safety, and tolerability of urea for the treatment of inpatient hyponatremia. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We identified all patients hospitalized at the University of Pittsburgh Medical Center between July 2016 and August 2017 with hyponatremia (plasma sodium <135 mEq/L) who received urea, including a subgroup of patients who received urea as the sole drug therapy for hyponatremia (urea-only treated). We matched urea only-treated patients to a group of patients with hyponatremia who did not receive urea (urea untreated) and compared changes in plasma sodium at 24 hours and the end of therapy as well as the proportion of patients who achieved plasma sodium ≥135 mEq/L. We abstracted data on adverse events and reported side effects of urea. RESULTS: Fifty-eight patients received urea (7.5-90 g/d) over a median of 4.5 (interquartile range, 3-8) days and showed an increase in plasma sodium from 124 mEq/L (interquartile range, 122-126) to 131 mEq/L (interquartile range, 127-134; P<0.001). Among 12 urea only-treated patients, plasma sodium increased from 125 mEq/L (interquartile range, 122-127) to 131 mEq/L (interquartile range, 129-136; P=0.001) by the end of urea therapy. There was a larger increase in plasma sodium at 24 hours in urea only-treated patients compared with urea-untreated patients (2.5 mEq/L; interquartile range, 0-4.5 versus -0.5 mEq/L; interquartile range, -2.5 to 1.5; P=0.04), with no difference in change in plasma sodium by the end of therapy (6 mEq/L; interquartile range, 3.5-10 versus 5.5 mEq/L; interquartile range, 3-7.5; P=0.51). A greater proportion of urea only-treated patients achieved normonatremia, but this difference was not statistically significant (33% versus 8%; P=0.08). No patients experienced overly rapid correction of plasma sodium, and no serious adverse events were reported. CONCLUSIONS: Urea seems effective and safe for the treatment of inpatient hyponatremia, and it is well tolerated.


Assuntos
Hiponatremia/tratamento farmacológico , Sódio/sangue , Ureia/uso terapêutico , Idoso , Feminino , Humanos , Hiponatremia/sangue , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Ureia/efeitos adversos
15.
BMC Gastroenterol ; 18(1): 137, 2018 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-30180806

RESUMO

BACKGROUND: Although tolvaptan treatment improves hyponatremia, only few studies have investigated whether tolvaptan actually benefits the survival of cirrhotic patients. This study evaluated the impact of tolvaptan on six-month survival of decompensated cirrhotic patients with and without hyponatremia. METHODS: Two hundred forty-nine decompensated cirrhotic patients with or without hyponatremia were enrolled in a multicenter cohort study. Patients were divided into two groups according to receiving either tolvaptan or placebo treatment for 7-day. Subsequently, the patients were followed up for 6 months. RESULTS: Two hundred thirty patients, including 98 with hyponatremia (tolvaptan vs. placebo: 69 vs. 29) finished the study. Tolvaptan did not alter serum sodium levels and survival outcome of decompensated cirrhotic patients without hyponatremia. However, tolvaptan treatment remarkably improved serum sodium levels and six-month survival in patients with hyponatremia. Following tolvaptan treatment, serum sodium levels were restored to normal in 63.8% of patients, whereas in patients receiving placebo, only 36.2% showed the same effect (P < 0.05). Compared to a six-month survival rate of 68.97% in patients receiving placebo, the survival rate in tolvapatan-treated patients was 89.94% (P < 0.05). Furthermore, six-month survival rate in the tolvaptan-treated hyponatremia patients with resolved serum sodium was 81.32%, whereas the survival in those with unresolved serum sodium was only 24% (P < 0.05). CONCLUSIONS: Tolvaptan improves short term survival in most decompensated cirrhotic hyponatremia patients with resolved serum sodium. TRIALS REGISTRATION: Clinical trial one: ClinicalTrials.gov ID: NCT00664014 , Registered on April 14, 2008. Clinical trial two: ClinicalTrials.gov ID: NCT01349335 , Registered on March 5, 2010. Clinical trial three: ClinicalTrials.gov ID: NCT01349348 , Registered on May 4, 2011.


Assuntos
Antagonistas dos Receptores de Hormônios Antidiuréticos/uso terapêutico , Ascite/tratamento farmacológico , Benzazepinas/uso terapêutico , Hiponatremia/tratamento farmacológico , Cirrose Hepática/tratamento farmacológico , Cirrose Hepática/mortalidade , Adulto , Ascite/etiologia , Método Duplo-Cego , Feminino , Humanos , Hiponatremia/etiologia , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sódio/sangue , Taxa de Sobrevida , Tolvaptan
16.
Intern Med ; 57(16): 2353-2357, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30111674

RESUMO

A 79-year-old woman without any cerebral hernia symptoms was hospitalized with hyponatremia. After syndrome of inappropriate antidiuretic hormone induced by drugs was diagnosed and water restriction implemented, the patient became comatose during overcorrection caused by the generation of a large volume of electrolyte-free urine. Once the serum sodium concentration was immediately relowered by the administration of desmopressin and 5% glucose solution, the patient's level of consciousness improved dramatically without osmotic demyelination syndrome (ODS) developing. This outcome suggests that, similar to the findings in rat models, relowering the serum sodium concentration as early as possible to counter a disturbance of consciousness during the overcorrection of hyponatremia prevents ODS.


Assuntos
Antidiuréticos/uso terapêutico , Estado de Consciência/efeitos dos fármacos , Desamino Arginina Vasopressina/efeitos adversos , Desamino Arginina Vasopressina/uso terapêutico , Hiponatremia/tratamento farmacológico , Sódio/sangue , Sódio/uso terapêutico , Idoso , Animais , Feminino , Humanos , Ratos , Resultado do Tratamento
17.
Expert Opin Pharmacother ; 19(12): 1337-1344, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30071178

RESUMO

INTRODUCTION: Hyponatremia is the most common electrolyte disorder with a prevalence of up to 30% in hospitalized patients. Furthermore, it is associated with increased morbidity and mortality. AREAS COVERED: This review discusses the efficacy and side effects of the currently available treatment options for hyponatremia and the differences in the pharmacological approach between the European and USA guidelines. Additionally, the authors provide their expert perspectives on current treatment strategies and what they expect from this field in the future. EXPERT OPINION: Several pharmacological options are available for the treatment of hyponatremia, but data from trials examining and comparing these treatments are missing. Regarding chronic hyponatremia, the role of vaptans should be further analyzed, focusing on comparisons with other active treatments on patient-relevant outcomes and not only on serum sodium concentration. Clinicians should be cautious to an overly rapid increase in serum sodium levels with all available treatment strategies. Finally, it is important to ascertain whether correction of serum sodium levels improves mortality in hyponatremic patients.


Assuntos
Hiponatremia/tratamento farmacológico , Doença Crônica , Humanos
18.
BMJ Case Rep ; 20182018 Aug 29.
Artigo em Inglês | MEDLINE | ID: mdl-30158258

RESUMO

Recreational drug use is a significant societal issue and remains a clinical challenge in emergency and critical care departments. We report on a 19-year-old woman admitted to hospital semiconscious and with severe hyponatraemia. Urinalysis was positive for methamphetamine and supported a diagnosis of hyponatraemia related to ecstasy use together with a syndrome of inappropriate antidiuretic hormone secretion (SIADH). The woman was transferred to an intensive care unit, where a hypertonic saline infusion was started. Three hours postadmission she developed polyuria. Follow-up urinalysis at this point was consistent with water intoxication. This case is a reminder that hyponatraemia is a potentially fatal complication after the ingestion of 3,4-methylenedioxymethamphetamine, illustrates the sequential nature of an SIADH and water intoxication and highlights the importance of considering the sequence of onset of hyponatraemia, as the patient may be admitted at any stage.


Assuntos
Hiponatremia/diagnóstico , Síndrome de Secreção Inadequada de HAD/diagnóstico , N-Metil-3,4-Metilenodioxianfetamina , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Intoxicação por Água/diagnóstico , Diagnóstico Diferencial , Feminino , Humanos , Hiponatremia/complicações , Hiponatremia/tratamento farmacológico , Síndrome de Secreção Inadequada de HAD/complicações , Síndrome de Secreção Inadequada de HAD/tratamento farmacológico , Solução Salina Hipertônica/uso terapêutico , Transtornos Relacionados ao Uso de Substâncias/complicações , Intoxicação por Água/complicações , Intoxicação por Água/tratamento farmacológico , Adulto Jovem
19.
Liver Transpl ; 24(11): 1612-1621, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30129266

RESUMO

Hyponatremia in cirrhosis is defined as a serum sodium level ≤130 mEq/L and occurs in approximately 22% of patients with cirrhosis. The appearance of hyponatremia in patients with cirrhosis portends a poor prognosis before liver transplantation (LT), independent of the Model for End-Stage Liver Disease (MELD) score. With the development of the MELD-sodium score, the management of hyponatremia has become more relevant than ever before. Overcorrection of hyponatremia before LT or perioperatively can lead to the devastating neurologic condition known as osmotic demyelination syndrome, which is often irreversible and fatal. Therefore, the most important tenet of hyponatremia is to avoid correcting the serum sodium by ≥8 mEq/L in a 24-hour period. Treatment of hyponatremia is highly challenging. The vast majority of patients with cirrhosis have chronic hypervolemic hyponatremia. Fluid restriction increases serum sodium levels, but tolerance and compliance are significant barriers. Diuretic withdrawal is helpful but contributes to worsening fluid overload. There are limited data to support use of intravenous concentrated albumin solutions. The use of the arginine vasopressin antagonists ("vaptans") is contentious; however, they may have a limited role. Risk factors for intraoperative overcorrection of serum sodium include increased utilization of packed red blood cell and fresh frozen plasma transfusions, which are often unavoidable. Intraoperative management is evolving, and more data are needed in regard to the use of sodium-reduced continuous venovenous hemofiltration and the use of trishydroxymethylaminomethane (Tris) to avoid excess sodium rebound. A thorough discussion of the current treatment options before and during LT is given in this review.


Assuntos
Hiponatremia/complicações , Cirrose Hepática/cirurgia , Transplante de Fígado , Mielinólise Central da Ponte/prevenção & controle , Assistência Perioperatória/métodos , Antagonistas dos Receptores de Hormônios Antidiuréticos/uso terapêutico , Diuréticos/efeitos adversos , Humanos , Hipernatremia/induzido quimicamente , Hipernatremia/complicações , Hiponatremia/sangue , Hiponatremia/tratamento farmacológico , Cirrose Hepática/sangue , Mielinólise Central da Ponte/etiologia , Prognóstico , Fatores de Risco , Sódio/sangue
20.
JAMA Neurol ; 75(11): 1383-1391, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-30105362

RESUMO

Importance: Tuberculous meningitis is associated with high frequency of cerebral salt wasting. There is a paucity of objective information regarding the best method of treatment of this condition. Objective: To evaluate the efficacy and safety of fludrocortisone in the treatment of cerebral salt wasting in patients with tuberculous meningitis. Design, Setting, and Participants: This is a single-center, open-label, randomized clinical trial conducted from October 2015 to April 2017 in India. Patients were randomized in a 1:1 ratio to arms receiving saline only or saline plus fludrocortisone, in addition to a standard treatment of 4 antitubercular drugs, prednisolone, and aspirin. The 2 arms were matched for demographic, clinical, and magnetic resonance imaging findings. The patients were followed up for at least 6 months. Interventions: Patients were randomized to a 0.9% solution of intravenous saline with 5 to 12 g per day of oral salt supplementation, with or without the addition of 0.1 to 0.4 mg of fludrocortisone per day. Main Outcomes and Measures: The primary end point was the time needed to correct serum sodium levels; secondary end points were in-hospital deaths, disability at 3 months, disability at 6 months, occurence of stroke, and serious adverse reactions. Results: Ninety-three patients with suspected tuberculous meningitis were recruited; 12 did not meet the inclusion criteria, including 4 with alternate diagnoses. A total of 37 patients with cerebral salt wasting were eligible for the study. One refused to participate, and therefore 36 patients were included, with 18 randomized to each group. The median (range) age was 30 (20-46) years, and 19 were male (52.8%). Those receiving fludrocortisone regained normal serum sodium levels after 4 days, significantly earlier than those receiving saline only (15 days; P = .004). In an intention-to-treat analysis, hospital mortality, disability at 3 months, and disability at 6 months did not differ significantly, but fewer infarcts occurred in the deep border zone in the group receiving fludrocortisone (1 of 18 [6%]) vs those in the control arm (6 of 18 [33%]; P = .04). Fludrocortisone was associated with severe hypokalemia and hypertension in 2 patients each, and pulmonary edema occurred in 1 patient. These adverse reactions necessitated discontinuation of fludrocortisone in 2 patients. Conclusions and Relevance: Fludrocortisone results in earlier normalization of serum sodium levels, but did not affect outcomes at 6 months. Fludrocortisone had to be withdrawn in 2 patients because of severe adverse effects. This study provides class II evidence on the role of fludrocortisone in treatment of hyponatremia associated with cerebral salt wasting in patients with tuberculous meningitis. Trial Registration: Clinical Trials Registry of India (ctri.nic.in) Identifier: CTRI/2017/10/010255.


Assuntos
Anti-Inflamatórios/farmacologia , Fludrocortisona/farmacologia , Hiponatremia/tratamento farmacológico , Solução Salina/farmacologia , Cloreto de Sódio/farmacologia , Tuberculose Meníngea/complicações , Adulto , Anti-Inflamatórios/administração & dosagem , Anti-Inflamatórios/efeitos adversos , Quimioterapia Combinada , Feminino , Fludrocortisona/administração & dosagem , Fludrocortisona/efeitos adversos , Humanos , Hiponatremia/sangue , Hiponatremia/etiologia , Masculino , Pessoa de Meia-Idade , Solução Salina/administração & dosagem , Cloreto de Sódio/administração & dosagem , Tuberculose Meníngea/sangue , Adulto Jovem
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