Asymptomatic Hyponatremia Research Articles

Prevalence and Patterns of Electrolyte Imbalance in Children Diagnosed with Acute Severe Malnutrition at a Nutritional Stabilization Center

Malnutrition accounts for around 35% of all fatalities in Pakistan among children under five, making it the primary cause of childhood mortality in that country. The most severe type of malnutrition, known as severe acute malnutrition (SAM), was frequently linked to electrolyte abnormalities. The purpose of this study was to ascertain how frequently electrolyte imbalance occurred in children with SAM who were admitted to a tertiary care facility. Objective: To Determine the Prevalence and Patterns of Electrolyte Imbalance in Children Diagnosed with Acute Severe Malnutrition at a Nutritional Stabilization Center”. Methods: A cross-sectional study was carried out in Nawabshah at the Department of Pediatrics, Peoples University of Medical and Health Sciences, from May 16 to August 15, 2024. This study comprised 92 patients with severe acute malnutrition, ranging in age from 2 to 60 months. Non purposive sampling technique was used for data collection. Children with secondary causes of wasting were excluded, including those with congenital heart disease, chronic renal or liver illness, TB, cancer, and hemolytic anaemia. Weight-for-height was calculated using measurements of weight, length, and height. When the weight-for-height ratio fell below the -3 standard deviation (SD), children were diagnosed with SAM. The lab received blood samples that were taken for serum electrolytes. The chi-square test was used for stratification, and descriptive statistics were computed. Results: Participants' average ages ranged from 23.63± 12.71 months. A total of 85 (93.4%) of the 92 SAM patients had an electrolyte imbalance. The prevalence of hypokalemia (70.08%), hypocalcemia (56.52%), hyponatremia (32.60%), and hypomagnesemia (28.26%), respectively. Conclusions: Children with SAM experience dyselectrolytemia both with and without problems. In all cases of SAM, serum electrolyte levels may need to be assessed in order to identify hyponatremia and hypokalemia in the absence of symptoms. This will facilitate the inpatient treatment triage process for patients with asymptomatic hyponatremia and hypokalemia.

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 500ml/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.

Etiology, Clinical Approach, and Therapeutic Consequences of Hyponatremia

A perturbation in the water balance rather than any change in salt content is the main cause of hyponatremia, the most frequent electrolyte abnormality, defined as a serum sodium concentration <135 mEq/L. Hyponatremia may be divided between mild (Na > 120 mEq/L) or severe (Na < 120 mEq/L) hyponatremia, and is most frequently observed in elderly ICU hospitalized patients. Based on tonicity, hyponatremia may be hypotonic (a decreased concentration of the solute), isotonic, and hypertonic (falsely low sodium). According to the volume of extracellular fluid (ECF), hyponatremia is further divided among hypovolemic, euvolemic, or hypervolemic hyponatremia. Finally, hyponatremia may develop rapidly as acute (<48 h), usually with severe symptoms, or slowly as chronic hyponatremia, usually being asymptomatic or with mild symptoms. Acute severe hyponatremia presents with severe CNS problems, increased hospitalization rates, and mortality. The treatment with 3% sodium chloride and a 100 mL IV bolus based on severity and persistence of symptoms needs careful monitoring. A non-severe hyponatremia may be treated with oral urea. In asymptomatic mild hyponatremia, an adequate solute intake with an initial fluid restriction of 500 mL/d adjusted according to the serum sodium levels is preferred. Vaptans could be considered in patients with high ADH activity regardless of whether they are euvolemic or hypervolemic. In general, the treatment of hyponatremia should be based on the underlying cause, the duration and degree of hyponatremia, the observed symptoms, and volume status of patient.

Prevalence, Risk Factors, and Mortality of Patients Presenting with Moderate and Severe Hyponatremia in Emergency Departments.

Hyponatremia is among the most common electrolyte disturbances encountered in clinical practice and is associated with a high rate of morbidity and mortality. However, there are very limited data on adult cases presenting to emergency departments with hyponatremia. This study aimed to evaluate the frequency, clinical characteristics, and outcomes in hyponatremic patients presenting to emergency departments. This retrospective study analyzed all patients older than 18 years who visited our institution's emergency department between October 2018 and October 2019 and has a serum sodium (Na) level <130 mmol/L. Among 24,982 patients who visited the emergency department and had a documented serum sodium level, 284 were included. Patients' median age was 67.13 ± 14.8 years. Younger patients are less likely to develop severe hyponatremia compared to older patients (adjusted odds ratio (AOR): 0.415; 95% confidence interval (CI): 0.231-0.743; p=0.003). Asymptomatic hyponatremia and gastrointestinal manifestations were the most common presenting hyponatremia symptoms (33.7% and 24.2%, respectively). Proton pump inhibitor (PPI) use, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACE/ARB) use, and spironolactone use (OR = 2.6 and 3.9, 2.3 with a p=0.02, 0.03, and 0.05, respectively) were associated with increased odds of severe hyponatremia. There is no difference in the overall mortality rate within 6 months of presentation between severe and moderate hyponatremia groups (11.1% versus 16.2%, p=0.163). Moderate and severe hyponatremia are not uncommon among patients presenting to emergency departments. Moderate hyponatremia can be asymptomatic with clinical significance. Older patients, use of PPI, use of ACEi/ARBs, and spironolactone use were associated with an increased risk of severe hyponatremia compared to moderate. Further prospective analysis of a larger population is needed to confirm our findings.

Real-world experience with selinexor-containing chemotherapy-free or low-dose chemotherapy regimens for patients with relapsed/refractory acute myeloid leukemia and myeloid sarcoma.

Introduction: Treatment of relapsed or refractory acute myeloid leukemia (R/R AML) and myeloid sarcoma (MS) has presented challenges for decades. Studies on selinexor in combination with various standard or intensive chemotherapy regimens for the treatment of R/R AML have demonstrated promising results. This study aimed to evaluate the efficacy and safety of chemotherapy-free or low-dose chemotherapy regimens with selinexor for R/R AML and MS patients. Methods: Ten patients with R/R AML or MS who received chemotherapy-free or low-dose chemotherapy regimens in combination with selinexor at Tongji Hospital from October 2021 to August 2022 were included in this study. The primary endpoint was overall response rate (ORR) and secondary endpoints included complete remission (CR), CR with incomplete hematological recovery (CRi), partial remission (PR), transplantation rate, and safety. Results: All patients were evaluable for response, achieving CR in four (40.0%) patients and CRi in two (20.0%) patients for a total CR/CRi of 60.0%. The ORR was 80.0% when patients with PR were included. Five (50.0%) patients underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT) after treatment with selinexor-containing regimens. At the end of the follow-up, seven (70.0%) patients were alive, and three patients died of transplant-related complications or disease progression. The most frequently reported nonhematologic adverse events (AEs) in patients were grade 1 or 2 asymptomatic hyponatremia. Conclusion: The chemotherapy-free or low-dose chemotherapy regimens in combination with selinexor for R/R AML are feasible and tolerable and provide an opportunity for patients to receive transplantation.

Evidence-based hyponatremia management in liver disease.

Hyponatremia is primarily a water balance disorder associated with high morbidity and mortality. The pathophysiological mechanisms behind hyponatremia are multifactorial, and diagnosing and treating this disorder remains challenging. In this review, the classification, pathogenesis, and step-by-step management approaches for hyponatremia in patients with liver disease are described based on recent evidence. We summarize the five sequential steps of the traditional diagnostic approach: 1) confirm true hypotonic hyponatremia, 2) assess the severity of hyponatremia symptoms, 3) measure urine osmolality, 4) classify hyponatremia based on the urine sodium concentration and extracellular fluid status, and 5) rule out any coexisting endocrine disorder and renal failure. Distinct treatment strategies for hyponatremia in liver disease should be applied according to the symptoms, duration, and etiology of disease. Symptomatic hyponatremia requires immediate correction with 3% saline. Asymptomatic chronic hyponatremia in liver disease is prevalent and treatment plans should be individualized based on diagnosis. Treatment options for correcting hyponatremia in advanced liver disease may include water restriction; hypokalemia correction; and administration of vasopressin antagonists, albumin, and 3% saline. Safety concerns for patients with liver disease include a higher risk of osmotic demyelination syndrome.

Predictors of Delayed Hyponatraemia After Surgery for Pituitary Tumour.

Delayed hyponatraemia(DH) is a common complication following trans-sphenoidal surgery(TSS) for pituitary tumour. We evaluated the prevalence of DH following TSS, and assessed the factors associated with DH, including early post-operative diabetes insipidus(EPDI). This retrospective study included 100 TSS for pituitary tumours in 98 patients, over a period of 26 months. Subjects were divided into two groups: those who developed hyponatraemia and those who did not develop hyponatraemia, during post-operative days 4 to 14. The clinical characteristics and peri-operative parameters were compared between the two groups, to identify factors predicting DH. The mean age of the patients was 42.0±13.6 years, 58 (59%) were females and 61 (61%) had functional tumours. Thirty-six patients(36%) developed DH following TSS of whom majority(58%) were diagnosed on post-operative days 7 and 8; only 8/36 (22%) were symptomatic. Syndrome of inappropriate antidiuretic hormone secretion(SIADH) was found to be the most common aetiology of DH. On logistic regression analysis, intra-operative cerebrospinal fluid(CSF) leak (OR 5.0; 95% CI 1.9-13.8; p=0.002), EPDI (OR 3.4; 95% CI 1.3-9.2; p=0.015) and peri-operative steroid use (OR 3.6; 95% CI 1.3-9.8; p=0.014) were found to be significantly associated with DH. In conclusion, EPDI, intra-operative CSF leak and peri-operative steroid use were significant predictors of DH. EPDI predicts moderate to severe hyponatraemia with 80% specificity but has low sensitivity(47%). As most patients have asymptomatic hyponatraemia, serum sodium measurement on POD 7 to 10 would be helpful to identify DH in patients at increased risk.

The Urine Calcium/Creatinine Ratio and Uricemia during Hyponatremia of Different Origins: Clinical Implications.

Chronic hyponatremia is known to be associated with osteoporosis. It has been shown that chronic hyponatremia increases bone resorption in an attempt to release body stores of exchangeable sodium by different mechanisms. We wanted to know the calciuria of patients with hyponatremia of different origins. We made a retrospective study of 114 consecutive patients with asymptomatic hyponatremia of different origins with the usual serum and urine chemistry. In hyponatremia due to SIADH, we had a high urine calcium/creatinine ratio of 0.23 ± 0.096 while in patients with salt depletion the UCa/UCr ratio was low (0.056 ± 0.038), in patients with hyponatremia secondary to thiazide intake the value was also low (0.075 ± 0.047) as in hypervolemic patients (0.034 ± 0.01). In hyponatremia due to polydipsia, the value was high (0.205 ± 0.10). Correction of hyponatremia in the euvolemic patients was associated with a significant decrease in the UCa/UCr ratio. In patients with hyponatremia secondary to thiazide intake, we noted that in the patients with low uric acid levels (&lt;4 mg/dL, suggesting euvolemia) we also observed a low UCa/UCr (&lt;0.10). In nine patients with chronic SIADH (SNa 125.1 ± 3.6 mEq/L), the 24 h urine calcium excretion was 275 ± 112 mg and decreased to 122 ± 77 mg (p &lt; 0.01) after at least 2 weeks of treatment. Patients with chronic hyponatremia due to SIADH usually have a high UCa/UCr ratio (&gt;0.15). This is also observed in hyponatremia secondary to polydipsia. Patients with thiazide-induced hyponatremia usually have low UCa/UCr levels and this is the case even among those with a biochemistry similar to that in SIADH (uric acid &lt; 4 mg/dL).

Standardized Oral Urea for the Treatment of Hyponatraemic Conditions: Pharmacological and Pharmacoeconomic Consideration

Standardized Oral Urea for the Treatment of Hyponatraemic Conditions: Pharmacological and Pharmacoeconomic Consideration

Hyponatremia in peritoneal dialysis patients

Hyponatremia is the most common disorder of body fluid and electrolyte balance encountered in clinical practice, and also in peritoneal dialysis (PD) population. Depending on the severity and the speed of drop in sodium concentration, the symptoms can vary from asymptomatic hyponatremia to mild and non-specific symptoms or severe and life-threatening situations. Hyponatremia is associated with high morbidity and mortality. Its pathophysiology is complex, specifically in patients undergoing PD. The etiological workup can be cumbersome but is of paramount importance for early and appropriate treatment. In this article, we review the clinical manifestations as well as the pathophysiology and the specific etiologies of hyponatremia in peritoneal dialysis patients, and we propose a diagnostic algorithm.

Hyponatraemia in elderly patient - significance, clarification and therapy

In the general population, the prevalence of mild, usually asymptomatic hyponatremia ranges from 1,7-7,7 %. With increasing age, it rises to 11,6 % in > 75-year-olds. The prevalence is much higher in nursing home residents and hospital patients. Hyponatremia thus represents the most common electrolyte disturbance in the elderly. Despite the existing evidence on the acute as well as chronic effects of hyponatremia, too little attention is paid to it in clinical practice. An algorithm has proven to be useful for the diagnosis of hyponatremia, which enables the cause to be identified in a few simple steps and at the same time leads to the correct therapeutic steps. The goal must be a serum sodium within the normal range. This is the only way to improve the prognosis and functionality of elderly patients. For SIADH, we have a potent substance available in tolvaptan. In order to be able to recognize the danger of overcorrection in time, the adjustment should take place in the inpatient setting.

Hyponatremia among Postoperative Children Administered with Hypotonic Fluids in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

Hypotonic solutions in postoperative children may cause hyponatremia. Considering humidity and temperatures in India, this study was conducted to find out the prevalence of hyponatremia among postoperative children who were administered with hypotonic solutions in a tertiary care hospital. A descriptive cross-sectional study was conducted at a tertiary care hospital. Ethical approval was taken from the institutional review board of Christian Medical College, Vellore, India (Reference number: 9177). Children aged less than 15 years undergoing elective surgery, requiring fasting for more than 12 hours post-operatively with normal preoperative electrolytes and renal functions were included. Hypotonic fluids were administered following existent protocol. Electrolytes were repeated immediate postoperatively and at 12-24 hours. Data was entered into and analyzed using the Statistical Package for the Social Sciences version 18.0. Point estimate at 90% Confidence Interval was calculated along with frequency and proportion for binary data. Among 109 participants, hyponatremia in the postoperative period was seen in 53 (48.6%) (40.7-56.5 at 90% Confidence Interval) children. Hyponatremia was found in the immediate postoperative period in 10 (9.2%) children. All received Ringer Lactate as maintenance intra-operatively and none were severe enough to need correction. In the 12-24-hour sample, 43 (39.41%) had hyponatremia and none in severe category. Asymptomatic hyponatremia was noted in normal children planned for elective surgery. Among children managed with the existing institutional perioperative (hypotonic) fluid management protocol, subclinical postoperative hyponatremia within 12-24 hours of surgery was noted in a significant proportion, which was more in the hot and warm months in tropics. There are grounds for switching to isotonic fluids for perioperative management.

A Prospective Study on the Degree of Hyponatremia in Transurethral Resection of Prostate

Background: Systemic uptake of hypotonic fluid during irrigation performed at the time of Transurethral Resection of the Prostate (TURP) may cause electrolyte changes including sodium, potassium and calcium. The present study was aimed to assess the degree of sodium changes during Transurethral Resection of Prostate (TURP).&#x0D; Methods: 50 males aged 54 to 86 years, presented for TURP, were enrolled in the study with ASA classification of I to IV grades. Glycine 1.5% was used with height of irrigation kept at 60 cm. One day preoperatively and one hour postoperative, levels of serum sodium were measured for all the patients.&#x0D; Results: Spinal anaesthesia was given in 31 patients, whereas 19 patients were managed under general anaesthesia, with mean duration time being 72.42 ± 24.77min. The mean size of the resected prostate was 54.82 ± 25.04g. 58% patients developed mild hyponatremia, 4% had asymptomatic moderate hyponatremia and no patient developed severe hyponatremia or TURP Syndrome. The systemic diseases like hypertension, DM, or IHD found to be insignificant.&#x0D; Conclusion: TURP was associated with a high incidence of asymptomatic mild hyponatremia. Duration of operation was one of the most important factors.

Syndrome of inappropriate antidiuretic hormone secretion in patients with brucellosis

Introduction: Syndrome of inappropriate antidiuretic hormone secretion (SIADH), is generally characterized by hyponatremia and hypo-osmolarity. Objectives: SIADH may develop following some infectious diseases including brucellosis, which regarding the severity of the disease may cause morbidity or mortality. Patients and Methods: In this case-control study, 110 patients with brucellosis and 110 healthy controls were enrolled. The case group was selected among patients having clinical signs and symptoms of brucellosis with a Wright test titer ≥1/160 and a 2ME test titer ≥1/80. About 10 cc blood sample was taken from each of them to test the blood sugar, thyroid stimulating hormone (TSH), serum sodium, serum potassium, blood urea nitrogen (BUN), creatinine, and serum cortisol. Random urine samples were also taken from participants to measure the urinary osmolarity and sodium. Results: The frequency of hyponatremia (Na &lt;135 mEq/L) in patients with brucellosis was significantly higher than the control group but there was no significant difference between the groups in the frequency of abnormal urinary sodium (more than 40 mEq/L). Meanwhile, the frequency of abnormal uric acid (less than 4 mg/dL) was significantly higher in patients than the control group. The frequency of abnormal urine osmolarity (above 300 mOsm/kg) was significantly higher in patients than the control group. In total, only 9 out of 110 patients had SIADH with asymptomatic mild hyponatremia and severe hyponatremia was seen only in one patient with prolonged Brucella meningitis. Conclusion: Based on the defined criteria, 8.2% of brucellosis patients were at the risk of SIADH, but the findings were in favor of asymptomatic SIADH without prominent hyponatremia.

Phase I/II Study of Liposomal Doxorubicin (DOX) in Combination with Selinexor (SEL) and Dexamethasone (Dex) for Relapsed and Refractory Multiple Myeloma (RRMM)

Background: SEL, an oral first-in-class inhibitor of XPO1 showed activity in clinical trials for hematologic malignancies. SEL inhibits DNA damage repair and exhibits marked synergy with doxorubicin in preclinical myeloma models. SEL/Dex results in a 20% response rate in penta-refractory myeloma patients. We report here the results of a phase I/II trial of SEL in combination with DOX and Dex in patients with RRMM.Methods: Eligible patients had RRMM and received ≥ 2 prior therapies including lenalidomide and a proteasome inhibitor. Treatment consisted of a loading phase with SEL and Dex for 1-2 weeks; an induction phase with DOX 20 mg/m2 IV D1, SEL and Dex (once weekly) and a maintenance phase of weekly SEL/Dex. Two loading phases were evaluated: A. SEL/Dex twice weekly for 2 weeks, B. One dose of SEL/Dex (table 1). Primary and secondary end points: maximum tolerated dose (MTD) / recommended phase II dose (RP2D) of the combination, and overall response rate (ORR) per International Myeloma Working Group (IMWG) criteria.Results: Twenty-seven patients were enrolled (median age of 62 years, median of 6 prior lines (range 2-10)). No dose limiting toxicities (DLT) were noted in dose level (DL) 1. Two patients experienced a DLT in DL2 (Gr4 thrombocytopenia and Gr 3 nausea). The loading phase was shortened to 1 dose of SEL (80mg) on day -7 (DL2m). 1/6 patients experienced a DLT on DL2m (Gr3 hyponatremia). Two patients experienced a DLT in dose level 3m (Grade 3 ALT and Grade 3 confusion). The recommended phase II dose was determined to be DL2m (SEL 80mg D1,8,15, DOX 20mg/m2 D1 and Dex 40 mg D1,8,15). Three patients died on study (1 from RSV pneumonia, one from pneumocystis Jiroveci and 1 from advanced myeloma). The most common Grade 3/4 at least possibly related adverse events are as follows: thrombocytopenia 33%, neutropenia 33%, asymptomatic hyponatremia 30%, anemia 26%, nausea / vomiting 11%, hyperglycemia 11%, diarrhea 7%, and fatigue 7% (table 2). Of the 14 patients treated at the RP2D, one was not evaluable (NE), one had a PR and 1 a MR at the time of this analysis. Per protocol, this current level of response does not justify proceeding with the second stage of the phase II study. Of the 27 total patients treated, we noted 2 VGPR, 2 PR, 3MR, 8SD, 4NE with an ORR of 15%, clinical benefit rate (MR and better) of 26% by intent to treat. There was increased nuclear localization of Ikβ post selinexor treatment in responders compared to non-responders (Nuclear / cytoplasmic ratio mean 1.15 ±0.06 versus 0.93 ±0.09; p=0.04).Conclusions: The addition of DOX to SEL/Dex, while reasonableywell tolerated, does not appear to improve the ORR noted with SEL/Dex in this heavily pretreated patient population. [Display omitted] DisclosuresBaz:BMS: Research Funding; celgene: Honoraria, Research Funding; karyopharm: Research Funding; takeda: Research Funding; merck: Research Funding; Sanofi: Research Funding. Zonder:Janssen: Consultancy; BMS: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; Takeda: Consultancy; Pharmacyclics: Other: Data Safety Monitoring Committee; Prothena: Consultancy.

Challenges of Managing and Diagnosing Reset Osmostat vs SIADH in a Patient With Personal and Family History of Chronic Hyponatremia

Background: Distinguishing between a reset osmostat and SIADH in a hyponatremic patient can prove to be challenging in certain circumstances. Reset osmostat is an uncommon and under recognized cause of hyponatremia. Thus, it is important to recognize it as it does not require any treatment. Clinical Case: A 48 year old male with history of chronic hyponatremia of unknown cause, fatty liver, hypertension, was in the hospital post operatively after resection of a meningioma along dura. Endocrine was consulted for management of his chronic hyponatremia. Had chronic hyponatremia for over 20 years and was always asymptomatic. Normally drank 6-7 L of water at home, mostly at night. Also found to have a spinal compression fracture of unknown cause. Both his father and brother had chronic hyponatremia of unknown cause as well, suggesting possible familial component. His baseline sodium levels were 129-133 mmol/L. In the hospital, serum sodium levels decreased to the 120s. TSH was 0.307mcunit/mL (0.27-4.2). Was also placed on 1.5 L fluid restriction. Urine osmolality was 900 mOsm/kg (500-800) with sodium of 123 mmol/L (136-145), consistent with SIADH. A rare inherited disorder, nephrogenic SIADH (NSIADH), was considered. However, it has an X-linked inheritance pattern. Fluid restriction was removed, then did fluid load with 2L of water and obtained urine sodium, serum sodium, urine osmolality, serum osmolality, Copeptin (pro-AVP) before fluid load and 1 hour after fluid load. Serum sodium level went from 127mmol/L before to 125 mmol/L after. Urine osmolality improved from 984 mOsm/kg prior to 575 mOsm/kg after. Urine sodium went from 183 mmol/L prior to 91 mmol/L after. Serum osmolality went from 278 mOsm/kg (270-310) to 268 mOsm/kg after. His co-peptin pro-AVP levels were 16.4 pmol/L (ref. <13.1). They are found to be low in NSIADH. It was decided that his chronic hyponatremia was likely due to reset osmostat. After discharge and follow up, his serum sodium was rechecked and was 128 mmol/L. It would have been challenging, but useful, to try a vaptan for diagnostic purposes and possibly to increase serum sodium. However, there are complications from overcorrection. Since patient had long standing asymptomatic chronic hyponatremia with family history, it was decided not to pursue aggressive measures just to “normalize” serum sodium. Otherwise, it would have been an example of treating the numbers and not the patient. Conclusions: Case demonstrates the importance of keeping the patient, their symptoms, and clinical picture in mind, and to not just follow numbers, as difficult as it may be, especially when managing conditions in which diagnosis may be uncertain or unclear. Sometimes no intervention is needed at all, however tempting it may be to do one, it is important to keep the former option in mind. An asymptomatic patient with longstanding chronic hyponatremia due to reset osmostat is an example of that.

Clinico-Biochemical Study of the Safety and Tolerability of Selective Serotonin Reuptake Inhibitors (SSRI) with Special Reference to SSRI Induced Hyponatremia in Humans and Animals

Introduction: Selective Serotonin Reuptake Inhibitors (SSRIs) are recommended as first-line anti-depressants in Major Depressive Disorder (MDD) because of their relatively benign safety profile. Hyponatremia is under reported and notorious adverse effect of SSRIs shown by few Randomised Clinical Trials (RCTs). There are only few published studies of SSRIs on serum sodium level in human and animal model. Aim: To determine SSRI induced hyponatremia in human and its correlation with age. Materials and Methods: The clinical part is a prospective cohort study whereas second part is experimental study involving animals. In clinical part-Patients of either sex, aged above 18 years, attending the Out-Patient Department (OPD) of Psychiatry of a tertiary hospital and diagnosed as MDD Diagnostic and Statistical Manual (DSM) V with the help of a senior psychiatrist, were screened and recruited in the study after satisfying the inclusion and exclusion criteria by consecutive sampling. Patients were prescribed fluoxetine (n=90), sertraline (n=55), paroxetine (n=30) and escitalopram (n=25). Parameters recorded (serum sodium) at baseline, 4th week, 8th week and 12th week. Symptoms due to hyponatremia and Adverse Drug Reactions (ADR) were also checked. Multiple group comparison at different visits for sodium level was done using one-way ANOVA and repeated measures ANOVA test and relationship of blood sodium level with age were estimated with bivariate correlation. Animal experiment was done in Pharmacology Department, animals were randomised into 5 groups control, fluoxetine, sertraline, paroxetine and escitalopram (n=6). Blood sodium checked at baseline, 2nd week and 4th week. Kruskal Wallis test and Friedman’s test done to detect changes in sodium level in follow-up period. Results: Mean age ranged between 40-50 years with equal gender distribution. Both within group and between group analysis revealed significant difference in blood sodium level (p-value&lt; 0.0001). Hyponatremia was strongly correlated with age (correlation coefficient &gt;-0.783). Most participants (184 out of 200) developed asymptomatic hyponatremia. Two among sertraline developed seizure leading to discontinuation to therapy. About 72 (38.09%) ADRs belonged to probable, mostly belonging to fluoxetine and sertraline group, developement of hyponatremia was 9 days (median) from starting SSRI. In animal part within group analysis revealed significant change of sodium from baseline in all drug treated animals (p-value&lt;0.0001). Conclusion: SSRI is associated with hyponatremia and is common in elderly patients. Monitoring of serum sodium is necessary for patients on SSRI.

Síndrome de secreción inadecuada de hormona antidiurética

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is the commonest form of normovolaemic or dilutional hyponatraemia, and it is caused by either excessive hormone excretion or dysregulated hormone action. Etiology is multifactorial, including drugs, neoplasms, brain and hypophysis lesions, benign lung lesions or human immunodeficiency virus. Clinical features depend on the severity and rate of fall of hyponatremia. Diagnosis demand a normal thyroid, adrenal, liver, renal and cardiovascular function, as well as to rule out diuretic intake. Hypertonic (3%) saline infusion is the treatment of choice of severe acute hyponatremia; whereas fluid restriction is the treatment of asymptomatic chronic hyponatremia. Other pharmacological alternatives are urea, demeclocycline or tolvaptan (the latter having aroused great interest in the last decade).

Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Induced by Long-Term Use of Citalopram and Short-Term Use of Naproxen

Patient: Female, 88-year-oldFinal Diagnosis: Syndrome of inappropriate antidiuretic hormone secretionSymptoms: Decreased appetite • malaise • nauseaMedication:—Clinical Procedure: LaboratorySpecialty: Endocrinology and Metabolic • Geriatrics • NephrologyObjective:Rare co-existance of disease or pathologyBackground:Use of selective serotonin reuptake inhibitors (SSRIs) has been reported to be associated with the syndrome of inappropriate antidiuretic hormone (SIADH), although it is uncommon. Nonsteroidal anti-inflammatory drugs (NSAIDs), as a sole agent, are an even rarer cause of SIADH. Despite being documented in the literature, the understanding of the mechanism of both agents is limited. Here, we report a case of a patient taking both of these medications, a dangerous combination that led to the development of SIADH.Case Report:An 88-year-old woman with a history of asymptomatic chronic hyponatremia presented to our facility with symptomatic acute-on-chronic hyponatremia after she started using naproxen in addition to her daily citalopram. Her hyponatremia symptoms resolved after discontinuing these 2 offending agents, along with administration of fluid restriction and oral sodium supplements.Conclusions:Naproxen is commonly prescribed and is often taken by elderly patients to control long-term or short-term pain. SSRIs, on the other hand, are a first-line treatment for depression and are usually prescribe by a psychiatrist. Hyponatremia is a rare medication adverse effect that should be kept in mind when treating these patients with either of these medications, and should especially be considered when combining them. Medication reconciliation should be done carefully by the provider to avoid adverse effects and drug interactions. When hyponatremia is encountered, options for future medication prescriptions include rechallenging with the same medication, switching to a different medication with the same mechanism of action, or using a medication from another class altogether. Monitoring of serum sodium level is warranted when titrating the offending agent.

Low-solute intake in chronic asymptomatic hyponatraemia related to syndrome of inappropriate secretion of ADH (SIADH): think about food beyond water intake!

Low-solute intake in chronic asymptomatic hyponatraemia related to syndrome of inappropriate secretion of ADH (SIADH): think about food beyond water intake!