Episodes Of Hyponatremia Research Articles

Recurrent hyponatremia in neonate: a case of renal salt wasting syndrome

BackgroundRenal salt wasting (RSW) is primarily seen with central nervous disorders and is characterized by hyponatremia, elevated urinary sodium excretion, increased urine output, and hypovolemia. Although there have been reports of RSW in children, it has not been reported in newborns.Case presentationA term (38 weeks 2 days) female weighing 2060 g, born via normal vaginal delivery, to a primi-gravida mother, was admitted to our neonatal intensive care unit. At birth, the baby was non-vigorous, had aspirated meconium, and required bag-and-mask ventilation following which the baby cried. The child was put on CPAP and inotropes for respiratory distress and shock, respectively, along with first-line antibiotics. Over the next few days, the child was weaned off CPAP, inotropes were stopped, and feeds were started. On postnatal day (PND) 8, the baby developed repeated episodes of seizures requiring two-antiepileptics followed by midazolam infusion, had shock requiring inotropes, and also had a tense anterior fontanelle with altered sensorium and tone changes, for which mannitol and 3% saline were given. Antibiotics were upgraded, and neuroimaging (MRI) revealed left basal-ganglia bleed with intraventricular extension and cerebral venous thrombosis. The baby showed gradual clinical improvement with the above measures and was restarted on feeds. However, from PND-19 onwards the baby had repeated episodes of hyponatremia requiring 3% saline infusions, progressive weight loss, and polyuria. Considering RSW, urine sodium was done which was high (110 mmol/L). For polyuria and weight loss, feed volume was increased, whereas, for hyponatremia, table salt was added to the expressed breast milk (1 gm × tds). Subsequently, all the serum sodium values remained within normal limits, and the baby started gaining weight and was discharged on similar advice (PND 38). On further follow-up, table salt was gradually decreased in the feeds and was stopped after 1 month of discharge with normal serum sodium values.ConclusionManagement of recurrent hyponatremia in a neonate is challenging. Despite its rarity, RSW in newborns should be considered a differential.

Pituitary metastasis from a high grade serous ovarian carcinoma presenting as hyponatremia with masked diabetes insipidus: A case report

BackgroundPituitary metastasis is a rare entity, with majority of the primary tumors reported from breast or lung origins. We present a case with pituitary metastasis as the first clinical presentation of underlying ovarian carcinoma. CaseA 48-year-old female presented with visual disturbances and hyponatremic episodes. After management of her hyponatremia and resulting diabetes insipidus, detailed imaging was carried out which revealed a 35 mm x 35 mm x 20 mm (TS x CC x AP) pituitary mass, extending into the cavernous sinuses and suprasellar compartment, causing compression of the optic chiasma. Debulking was performed via the endoscopic trans-sphenoidal approach, and biopsy was consistent with metastatic high-grade ovarian serous carcinoma (WT1 + and estrogen receptor+). A CT chest-abdomen-pelvis revealed a 10 cm right ovarian mass with bilateral adrenal nodules. Postoperatively, patient developed CSF rhinorrhea and meningitis. Despite, reconstructive efforts, the patient continued to decline and was referred to palliation. She succumbed to her illness during her hospital admission. ConclusionOur case underscores the importance of considering pituitary metastasis when encountering DI or pituitary insufficiency in a middle-aged patient with a sellar mass.

Episodic Hyponatremia in Acute Intermittent Porphyria: A Case Report

Background: Acute intermittent porphyria (AIP) is an uncommon, ubiquitously distributed autosomal dominant disorder with low penetrance characterized by decreased enzyme activity of hydroxymethylbilane synthase (HMBS) an enzyme of heme synthesis pathway. It is often an elusive diagnosis due to rarity and non-specific signs and symptoms. Case report: A 28 years old female from Nawalparasi (district in central Nepal) presented with history of recurrent episodes of abdominal pain and vomiting. Her current episode began two weeks before presentation to our center. Abdominal pain was diffuse, colicky in nature without exacerbating or relieving factor. There was no postural or diurnal variation. On examination, there was no tenderness and abdominal examination findings were unremarkable. Her biochemical investigations were unremarkable except for severe hyponatremia (S. Na of 100mmol/L) which was SIADH/SIADH like presentation (Table 1 and Table 2). Severe episodic hyponatremia, port-wine color of urine, gastrointestinal symptoms and previous hospital stay two years back with similar episode of hyponatremia and abdominal pain were valuable clues for suspicion of acute porphyria. On further evaluation, patient was found to have presence of porphyrogenic precursors in urine and diagnosis of acute intermittent porphyria was confirmed. After diagnosis, she was managed conservatively with carbohydrate loading with intravenous dextrose, opioids and pregabalin as analgesics. Her symptoms gradually improved, hyponatremia subsided and was discharged in normal condition. Conclusion: Acute intermittent porphyria has signs and symptoms common to several clinical, neurological, psychiatric and gastroenterological pathologies, which complicate diagnosis. In young patients with hyponatremia (with SIADH –like picture), AIP should be considered in differential diagnosis.

Vasopressin in newborns with refractory acute pulmonary hypertension.

Acute pulmonary hypertension (aPH) in newborns can be life threatening and challenging to manage. In newborns with refractory aPH, there is currently limited therapeutic agents. Retrospective single-center cohort study in newborns less than one month old who were treated with vasopressin for a minimum of one hour in the context of refractory aPH in the neonatal and pediatric intensive care units of a tertiary university center between 2016 and 2022. The objective was to evaluate the efficacy and safety of vasopressin in newborns as an adjuvant treatment for refractory aPH. Twenty-five patients met inclusion criteria. In patients who received vasopressin, oxygenation index improved from 28.4 to 14.4 (p = 0.004) after twelve hours of continuous infusion. Oxygen requirements (FiO2) decreased from 0.91 to 0.50 (p = 0.004) and mean arterial pressure increased from 41 to 51 mmHg (p = 0.001). In our cohort, 68% of patients presented an episode of hyponatremia (serum sodium <130 mmol/L). The use of vasopressin may be associated with improvement in oxygenation and hemodynamic status of neonatal patients with aPH refractory to initial therapy. Further prospective studies are needed to establish the safety profile of vasopressin in newborns, particularly in preterm infants. Vasopressin may be an effective cardiotropic agent to improve oxygenation and hemodynamic status in newborns with acute pulmonary hypertension. Careful monitoring of serum sodium levels are warranted in newborns who are receiving vasopressin infusion. This provides additional evidence for the consideration of vasopressin in newborns with acute pulmonary hypertension refractory to inhaled nitric oxide.

Hyponatremia due to preserved non-osmotic arginine vasopressin secretion in adipsic diabetes insipidus: a case report with review of literature.

Adipsic diabetes insipidus (ADI) is characterized by central diabetes insipidus and an impaired thirst response to hyperosmolality, leading to hypernatremia. Hyponatremia observed in patients with ADI has been considered a complication of desmopressin therapy. Herein, we present a case of impaired thirst sensation and arginine vasopressin (AVP) secretion without desmopressin therapy, in which hyponatremia developed due to preserved non-osmotic AVP secretion. A 53-year-old woman with hypopituitarism, receiving hydrocortisone and levothyroxine, experienced hyponatremia three times over 5 months without desmopressin treatment. The first hyponatremic episode (120 mEq/L) was complicated by a urinary tract infection with a plasma AVP level of 33.8 pg/mL. Subsequent hyponatremia episodes occurred after administration of antipsychotic (124 mEq/L) and spontaneously (125 mEq/L) with unsuppressed plasma AVP levels (1.3 and 1.8 pg/mL, respectively). Hypertonic saline infusion did not affect AVP or copeptin levels. Regulating water intake using a sliding scale based on body weight prevented the recurrence of hyponatremia without the use of desmopressin. Except during infection, plasma AVP levels (1.3 ± 0.4 pg/mL) were not significantly correlated with serum sodium levels (rs = -0.04, p = 0.85). In conclusion, we present a unique case of impaired thirst sensation and AVP secretion in which hyponatremia developed without desmopressin therapy. Preserved non-osmotic AVP secretion, possibly stimulated by glucocorticoid deficiency, may contribute to the development of hyponatremia in patients with ADI.

Pagophagia-Induced Hyponatremia: An Unusual Case

Hyponatremia occurs when the serum sodium level is below 135 mmol/L. The symptoms include nausea, vomiting, confusion, headache, cardiorespiratory symptoms, profound somnolence or coma, and seizures are observed. Iron deficiency anemia can also cause pagophagia, a Pica subspecies. Although it has been emphasized that electrolyte disturbance may develop due to pagophagia, only a dearth of cases was reported. A 59-year-old male patient was brought to the emergency department with complaints of incoherent speech that started at night, disorientated movements (such as fluttering and climbing), insomnia, restlessness, and confusion. In 2017, he experienced hyponatremia due to pagophagia and a salt-free diet. At the index episode of hyponatremia, he experienced confusion, drowsiness, and sleepiness. It was learned that the patient enjoyed these symptoms.For this purpose, the patient made a habit of eating a completely salt-free diet and consumed plenty of water. Although pagophagia is considered to cause hyponatremia because it causes excessive water intake, there are not enough cases reported. It is to be noted that people develop habits or addiction to things they like.

The therapeutic effect of oral desmopressin lyophilisate formulation in children with central diabetes insipidus.

We aimed to assess the efficacy of oral use of oral desamino-D-arginine-8-vasopressin lyophilisate (OLD) in children with central diabetes insipidus (CDI). Clinical, laboratory, and imaging characteristics of twenty-five children with CDI treated with OLD were evaluated. Fourteen boys and eleven girls with a mean age of 52.37 months were evaluated. These children (mean weight and height at admission, 26.81±14.8 kg vs. 92.52±30 cm) presented with failure to thrive, irritability, prolonged fever, polyuria and hypernatremia (mean sodium level, 143.12±8.6 mEq/L). At the time of hypernatremia, mean serum and urine osmolality were 298.2±18 mOsm/kg and 160.20±8.7 mOsm/kg, respectively. ADH levels were undetectable (<0.5 pmol/L) at admission in all cases. Oral administration of desmopressin lyophilisate (120 µg/tablet) was initiated at a dose of 5 μg/kg/day in two divided doses together with controlled water intake to avoid hyponatremia. Serum sodium levels normalised in a mean durationof 15.2±16.4 h with a mean decline rate of 0.12±0.04 mEq/L/h. Nine children needed rehospitalization because of hypernatremia due to non-compliance. Four episode of hyponatremia was observed. Weight gain and growth were normal during the mean follow-up duration of 37.79±48.2 months. Administration of OLD was practical and safe in the treatment of CDI in children with CNS malformations in this small retrospective series.

Epidemiology and predictors of hyponatremia in a contemporary cohort of patients with malignancy: a retrospective cohort study.

Hyponatremia is associated with worse outcomes among patients with malignancy. However, contemporary cohort data on epidemiology and risk factors are lacking. In this single-centre, retrospective cohort study, patients who received intravenous antineoplastic agents from 2018 to 2020 at Nagoya City University Hospital were enrolled. Associations of demographics, antineoplastic agents, types of malignancy and concomitant medications with hyponatremia, defined as serum sodium concentration ≤130mmol/l, were analysed by mixed-effects logistic regression and the machine learning-based LightGBM model artificial intelligence technology. Among 2644 patients, 657 (24.8%) developed at least one episode of hyponatremia. Approximately 80% of hyponatremia was due to sodium wasting from the kidneys. Variables associated with hyponatremia both by mixed-effects logistic regression and the LightGBM model were older age, hypoalbuminemia and higher estimated glomerular filtration rate. Among antineoplastic agents, cisplatin {odds ratio [OR] 1.52 [95% confidence interval (CI) 1.18-1.96]}, pembrolizumab [OR 1.42 (95% CI 1.02-1.97)] and bortezomib [OR 3.04 (95% CI 1.96-4.71)] were associated with hyponatremia and these variables also had a positive impact on predicted hyponatremia in the LightGBM model. Hyponatremia was common among patients with malignancy. In addition to older age and poor nutritional status, novel antineoplastic agents, including immune checkpoint inhibitors and bortezomib, should be recognized as risk factors for hyponatremia.

Recurrent Hyponatremia: Levetiracetam - An Uncommon Cause.

Dear Editor, Hyponatremia can be an adverse drug reaction with the use of some of the anti-seizure medications (ASM). Carbamazepine and oxcarbazepine are the most common ASMs which induce hyponatremia. Rarely sodium valproate, eslicarbazepine, lamotrigine, levetiracetam, and gabapentin have also been reported to cause hyponatremia.[1] We report a case of Levetiracetam induced hyponatremia and review the English literature of similar cases. A 50-year-old male had traumatic brain injury in November 2015 and neuroimaging was normal. He was started on prophylactic levetiracetam at another facility. Since then, he had three admissions for hyponatremia: First admission was for acute symptomatic seizures due to hyponatremia, serum sodium of 118 mmol/L; second admission in February 2016 for dizziness, serum sodium 131 mmol/L; and third admission during April 2016 for drowsiness, serum sodium 108 mmol/L [Table 1]. During the latter two admissions, the work-up for hyponatremia was suggestive of syndrome of inappropriate antidiuretic hormone secretion (SIADH). During the first admission, patient was on levetiracetam 500 mg q12h and the dose was escalated to 1000 mg q12h at discharge. Patient was started on tolvaptan 15 mg q24h at discharge in the first admission (25.12.2015). During his subsequent admissions, workup for other causes of hyponatremia was negative. He was continued with tolvaptan intermittently. Review of the case records and drug chart suggested possible relation between hyponatremia and levetiracetam, a diagnosis of levetiracetam induced hyponatremia was considered and levetiracetam was discontinued. Since then, he had no further episode of hyponatremia. Patient was not started on any ASM as it is not our practice to use ASMs for primary prophylaxis in traumatic brain injury.Table 1: Admission profile of the patientIn this patient, diagnostic workup suggested that SIADH was the possible mechanism for hyponatremia. He had a mild closed traumatic brain injury and normal brain imaging. This clinical scenario is very unlikely to cause SIADH. Workup for other causes of hyponatremia was negative. When levetiracetam was discontinued patient had no further episodes of hyponatremia. On Naranjo Adverse Drug Reaction Probability Scale[2] this patient had a score of 7 suggesting levetiracetam being the “probable” culprit responsible for hyponatremia. Review of English literature revealed report of four patients with levetiracetam induced hyponatremia [Table 2]. In four patients, including the present case SIADH was the mechanism of hyponatremia. There are no specific clinical characteristics which are common among these 5 cases. In all the patients, hyponatremia was corrected after withdrawing levetiracetam. In patient “3” in addition to levetiracetam, hydrochlorothiazide would have added to the misery of hyponatremia.Table 2: Characteristics of the patientsIn conclusion this case illustrates that chronic hyponatremia in a patient with epilepsy on ASMs, one should check the ASM list to exclude the possible drug that can be associated with hyponatremia. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Anti LGI-1 positive encephalitis in an octogenarian: a curious case of recurrent hyponatremia in elderly- a case report

LGI-1 is mainly expressed in the limbic areas involving temporal cortices and hippocampus. Anti -LGI-1 encephalitis is an autoimmune encephalitis which manifests with cognitive impairment, seizures which are mostly faciobrachial dystonic type and recurrent hyponatremia. We present an 82 year old octogenarian with similar such presentation with recurrent episodes of hyponatremia and cognitive decline having an excellent response to immunotherapy. There has been no mention of a similar presentation in this age group in literature, to the best of our knowledge.

Nosocomial meningitis laboratory criteria in ICU patients: 5-year surveillance

Introduction. Nosocomial meningitis (NM) is one of the leading complications in neurosurgery due to high mortality and disability rates.Objective. The study was aimed to determine the reference values of laboratory parameters to diagnose NM in neurosurgical patients in the intensive care unit (ICU).Results. The incidence of NM in neurosurgical patients in ICU was 8.4 (95% CI 6.8–10. 0) per 100 patients. The dominant microbial agents of NM were coagulase-negative staphylococci, A. baumannii, and K. pneumoniae. We revealed the increase in leukocytosis, C-reactive protein, and blood procalcitonin in patients with infectious complications of other systems, regardless of NM presence. Episodes of hyponatremia and an increase in body temperature ≥ 38.0 occurred signifcantly more often in patients with NM. Changes in cerebrospinal fluid (CSF) cytosis, glucose, lactate, and the CSF/blood glucose ratio can serve as reliable criteria in the NM diagnosis.Conclusions. The diagnosis of NM is most likely when the increase in CSF cytosis &gt; 65 cells/μL, CSF lactate &gt; 4.2 mmol/L is observed, the decrease in the CSF glucose &lt; 2.6 mmol, and CSF/blood glucose ratio &lt; 0.45 is found.

Sodium Variability and Probability of Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage

ObjectivesVasospasm is a well-known complication of aneurysmal subarachnoid hemorrhage (aSAH) that generally occurs 4–14 days post-hemorrhage. Based on American Heart Association guidelines, the current understanding is that hyponatremic episodes may lead to vasospasm. Therefore, we sought to determine the association between repeated serum sodium levels of aSAH patients and its relationship to radiographic vasospasm. Materials and methodsA single-center retrospective analysis from 2007–2016 was conducted of aSAH patients. Daily serum sodium levels were recorded up to day 14 post-admission. Hyponatremia was defined as a serum sodium value of < 135 mEq/L. We evaluated the relationship to radiologic vasospasm, neurologic deterioration, functional status at discharge, and mortality. A repeated measures analysis using a mixed-effect regression model was performed to assess the interindividual relationship between serum sodium trends and outcomes. ResultsA total of 271 aSAH patients were included. There were no significant differences in interindividual serum sodium values over time and occurrence of radiographic vasospasm, neurologic deterioration, functional, or mortality outcomes (p = .59, p = .42, p = .94, p = .99, respectively) using the mixed-effect regression model. However, overall mean serum sodium levels were significantly higher in patients who had neurologic deterioration, poor functional outcome (mRS 3-6), and mortality. ConclusionsSerum sodium level variations are not associated with subsequent development of cerebral vasospasm in aSAH patients. These findings indicate that serum sodium may not have an impact on vasospasm, and avoiding hypernatremia may provide a neurologic, functional and survival benefit.

Management of a patient with Sheehan's syndrome and diabetes insipidus complicated by recurrent hyponatremia.

SummaryA 38-year-old female was initially seen in the intensive care unit after severe postpartum hemorrhage. She was initially diagnosed to have Sheehan’s syndrome and after discharge, she was diagnosed to have a vesicovaginal fistula which initially caused a delay in diagnosing diabetes insipidus in the patient because she was having urinary incontinence. The patient had the vesicovaginal fistula repaired and was on replacement with levothyroxine, prednisone, and desmopressin. Years after her diagnosis, the patient experienced recurrent episodes of hyponatremia in the setting of desmopressin therapy. This case highlights the challenges of diagnosing diabetes insipidus in a patient with Sheehan’s syndrome and a vesicovaginal fistula, as well as the long-term management of central diabetes insipidus in a resource-limited setting.Learning pointsSheehan’s syndrome is rarely associated with diabetes insipidus, and in our patient, it was initially missed due to a vesicovaginal fistula which caused urinary incontinence.Water intoxication is more common in young children and older adults but can occur years after initiating treatment with desmopressin in adults and should be kept in mind when treating patients with hyponatremia who have hypopituitarism associated with diabetes insipidus.Water intoxication is much more common in patients with diabetes insipidus being treated with intranasal desmopressin than in those using the oral preparations.

Hyponatraemia monitoring in those prescribed antidepressants - an audit from an inpatient older adult ward

AimsTo assess follow-up of sodium levels for in-patients prescribed antidepressants in practice compare to the standard of 3 monthly sodium levels for all patients who are prescribed antidepressants and at risk of hyponatraemiaMethodA list of the 20 most recently discharged patients from Meridian Ward, an older-adult functional inpatient ward, was prepared by the team administrator on 6th May 2020.We audited the entire duration of our patient's stay on Meridian Ward (we did not include periods of their admission when they were on other wards) using the electronic notes system, Carenotes.We also checked the electronic biochemistry results system, ICE, for sodium results, and the discharge summary for mentions of fluid restriction, medications and handover to GP of sodium-checking. We also checked scanned drug charts to see if they were on antidepressants and other implicated drugs.For people with episodes of hyponatraemia, in order to retrieve further info we looked at discharge summary and searched the activity notes for the following terms“Hyponat”“sodium”“fluid restrict”“Low na”We regarded the following conditions as risk factors for hyponatraemia:cardiacmalignancyrespiratoryhypothyroidrenalhepaticstrokeWe regarded following medications as risk factors:opioidsdiureticscarbamazepinetheophyllineantipsychoticsNSAIDsPPIsACE-IARBsamiodaronedomperidonesulphonylureasResult14 of the 20 patients were taking antidepressants. Of those: 13 were eligible for regular sodium monitoring due to risk factors 11 of these had 3-monthly sodium levels during admission For only 2 of these did we make a plan for the GP to continue to monitor the sodium level in community 3 had an episode of hyponatraemia implicated antidepressants: sertraline plus mirtazapine mirtazapine (very serious episode which caused seizure) sertraline for 2 of them an appropriate plan was made 1 without a plan - a mild hyponatraemia with nothing documented in the notesConclusionDuring their admission to Meridian Ward, 85% of patients taking antidepressants who had risk factors for hyponatraemia had three-monthly sodium levels in line with the trust guidance. However, only two patients (15%) had a plan for further sodium levels in the discharge summary sent to the GP. This highlights a need for improved awareness of risk factors for hyponatraemia and, in particular, improved communication with general practitioners who are going to take over prescribing of antidepressant medications.Recommendations3 monthly Na levels for all patients with risk factorsi.e. on any antidepressant prescribed PLUS any one of:&gt;80 yearsHistory of low sodiumAKI during admissionRelevant comorbidities (see above)&gt;1 antidepressantOther meds that can cause hyponatraemiaMore frequent monitoring for all those with with multiple risk factors AND who are starting/increasing antidepressant:baseline sodium plus repeat after 2 and 4 weeksCommunicate to GP the need for 3-monthly sodium monitoring for those with above risk factorsRe-audit in 6-12 months’ time

Acute hyponatremia after aneurysmal subarachnoid hemorrhage: Frequency, treatment, and outcome

We retrospectively examined the course of serum sodium levels in 180 patients with acute aneurysmal subarachnoid hemorrhage (SAH) who had been admitted to the anesthesiologic-neurosurgical intensive care unit of the University Medical Center Regensburg, Germany, between January 2014 and December 2018. Each patient file was analyzed regarding the frequency and intensity of hyponatremic episodes and the administered medication. At admission to the intensive care unit (ICU), 18patients had shown initial hyponatremia (<135 mmol/L) and 4 patients hypernatremia (greater than145 mmol/L). 88(48.9%) of the 158 patients with normal serum sodium levels developed at least one hyponatremic episode during ICU treatment. The number of hyponatremic episodes was similar between patients with higher-grade and lower-grade aneurysmal SAH (P = 0.848). At the end of ICU treatment, outcome did not differ between patients with and without hyponatremia (40/88, 45.5% vs. 38/70, 54.3%, P = 0.270). At 6 months after SAH, however, good outcome (Glasgow outcome scale, GOS 4–5) was more frequently observed in patients with hyponatremia (26/88, 29.5% vs. 32/70, 45.7%, P = 0.036). Medication with sodium chloride, fludrocortisone, or tolvaptan was initiated in 75.4% patients with mild hyponatremia (130–134 mmol/L) and in 92.9% with moderate hyponatremia (125–129 mmol/L). At 6 months after SAH, patients treated with tolvaptan had a lower rate of poor outcome than patients who had not received tolvaptan (1/14, 7.1% vs. 25/74, 33.8%, P = 0.045). In patients with acute aneurysmal SAH and hyponatremic episodes, consequent treatment of hyponatremia prevented impaired outcome. Because administration of tolvaptan rapidly normalized serum sodium levels, this therapy seems to be a promising treatment approach.

Symptomatology of carbamazepine- and oxcarbazepine-induced hyponatremia in people with epilepsy.

ObjectiveTo ascertain whether adverse effects experienced by people taking carbamazepine or oxcarbazepine could be attributed to carbamazepine‐ or oxcarbazepine‐induced hyponatremia (COIH).MethodsWe performed an observational study, collecting data between 2017 and 2019 on serum sodium levels and adverse effects retrospectively in people with epilepsy while receiving treatment with either carbamazepine (CBZ) or oxcarbazepine (OXC). We defined hyponatremia as sodium level ≤134 mEq/L and severe hyponatremia as sodium level ≤128 mEq/L. Adverse effects experienced were compared between groups of individuals with and without hyponatremia.ResultsA total of 1370 people using CBZ or OXC were identified, of whom 410 had at least one episode of hyponatremia. We checked for symptoms related to the use of CBZ and OXC in 710 people (410 with and 300 without hyponatremia) and found relevant information in 688. Adverse effects occurred in 65% of people with hyponatremia compared to 21% with normal sodium levels (odds ratio [OR] 7.5, P ≤ .001) and in 83% of people with severe hyponatremia compared to 55% in those with mild hyponatremia (P ≤ .001). Significant predictors of adverse effects were the drug (OXC vs CBZ), and the number of concomitant anti‐seizure medications. Dizziness (28% vs 6%), tiredness (22% vs 7%), instability (19% vs 3%), and diplopia (16% vs 4%) were reported more often in the hyponatremia group than in patients with normal levels.SignificancePeople with COIH had a 7‐fold increased risk of developing adverse effects during treatment. Clinicians should consider ascertainment of sodium levels in patients taking CBZ and OXC and act upon findings.

Active management of hyponatraemia and mortality in older hospitalised patients compared with younger patients: results of a prospective cohort study.

Hyponatraemia is associated with increased morbidity and mortality; the aetiology and outcomes of hyponatraemia in older patients have not been defined in prospective studies. A single-centre 9-month prospective observational study in which clinical outcomes in hospitalised patients≥ 65years (older patients with hyponatraemia (OP-HN)) and those <65years (young patients with hyponatraemia (YP-HN)) with hyponatraemia were analysed, and compared with eunatraemic controls (older patients with normonatraemia (OP-NN) and young patients with normonatraemia (YP-NN)). In total, 1,321 episodes of hyponatraemia in 1,086 patients were included; 437 YP-HN, median age 54years (IQR 44,60) and 884 OP-HN, median age 77years (IQR 71,82). A total of 1,120 consecutive eunatraemic control patients were simultaneously recruited; 690 OP-NN, median age 77years (IQR 71,83) and 430 YP-NN, median age 52years (IQR 41,58). Euvolaemic hyponatraemia was the commonest cause of hyponatraemia in both age groups (48% in YP-HN and 46% in OP-HN). Sixty-two percent of OP-HN received hyponatraemia-directed treatment within the initial 48h, compared with 55% of YP-HN, P = 0.01. Despite the greater treatment rates in OP-HN, younger patients were 24% more likely to be discharged with normal plasma sodium concentration (pNa) compared with older patients, relative risk (RR) 1.24 (95% confidence interval (CI) 1.12-1.37), P < 0.001.Using OP-NN as the reference group, the RR of in-hospital death in OP-HN was 2.15 (95% CI 1.3-3.56), P = 0.002. Using YP-NN as the reference group, the RR of in-hospital death in YP-HN was 4.34 (95% CI 1.98-9.56), P < 0.001. Despite greater rates of HN-targeted treatment, the risk of in-hospital death is increased in older hyponatraemic patients compared with older eunatraemic controls. The impact of hyponatraemia on mortality is even greater in younger patients.

A Case Report on Hyponatremia: Leading Sign of Hypopituitarism [Secondary to Adrenal Insufficiency

Severe hyponatremia due to hypopituitarism and adrenal insufficiency can be life threatening and treatment with glucocorticoids is very effective once the diagnosis of the underlying disorder has been made. In our experience, the diagnosis of hypopituitarism in hyponatremic patients is often overlooked. We report the case of a 54 year old female admitted to our hospital in an obtunded state with altered sensorium. We found that a severe hyponatremia was the cause of patient condition . Previously she was diagnosed with recurrent episodes of hyponatremia leading to encephalopathy. The diagnosis of hypopituitarism is often overlooked in hyponatremic patients. Hyponatremia should always be ruled out for endocrinological cause Our study concludes that hyponatremia is due to hypopituitarism that is secondary to adrenal insufficiency leading to encephalopathy.

P1067CONDUCTIVITY BASED ONLINE MONITORING OF PREDIALYTIC HYPONATREAMIA AS DIAGNOSTIC TOOL IN HEMODIALYIS

Abstract Background and Aims Hyponatremia in dialysis patients is a strong indicator of poor outcome in dialysis patients that requires early detection to facilitate clinical workup and management. However, plasma sodium concentration as determined by lab methods (Na-Lab) is measured at the best monthly in clinical practice. Recently, online monitoring of predialytic plasma Na (pPlNa) as estimated from dialysate conductivity using an electrolyte model has become available at every hemodialysis session, thus providing an unprecedented close and almost continuous monitoring of this crucial indicator. This could be used as diagnostic tool to identify changes in patient status and alert earlier the physician. Method In a monocentric retrospective clinical study in 114 patients on maintenance hemodialysis (&amp;gt;90% online postdilution HDF) for whom online pPlNa was available for a period of at least 12 months at least once a week, kinetics of pPlNa were analyzed. For 10 patients with hyponatremic episodes as manifested in pPlNa, the agreement between time course of pPlNa and Na-Lab and the correlation to the manifestation of clinical findings was explored. Results Time course of pPlNa and Na-Lab showed very good agreement. Hyponatremia onset was clinically related to diagnoses such as fluid overload and congestive heart failure, diarrhea secondary to inflammatory bowel disease, sepsis, liver cirrhosis, cancer and use of loop diuretics. Conclusion The clinical examples show that due to the good agreement of the time course of online monitoring of pPlNa and Na-Lab, pPlNa can be used as adjuvant diagnostic tool for the early detection of onset and progression of morbid events. Due to its routine availability variations in pPlNa could be used to timely trigger clinical workup and investigations.

Hypophysitis: A Rare Cause of Impaired Consciousness in a Middle-Aged Woman

Hypophysitis occurs predominantly in women, usually during pregnancy or postpartum period. Hypophysitis involving the anterior pituitary often presents with adrenal insufficiency. We describe a 43-year-old woman who presented with recurrent episodes of alteration of sensorium due to hyponatremia. She had a 3-month history of amenorrhea and on evaluation had evidence of pan-hypopituitarism. The magnetic resonance images of the brain showed mild pituitary enlargement and thickened pituitary stalk with homogenous contrast enhancement indicating hypophysitis. She was treated with oral steroids and thyroxine supplements. She remained asymptomatic at 15-month follow-up on low-dose oral steroids and thyroxine supplements. Hypopituitarism due to hypophysitis resulted in recurrent episodes of hyponatremia in our patient. Our case highlights the importance of a systematic search for the etiology for hyponatremic encephalopathy.