Symptomatic Hyponatremia Research Articles

Treatment of symptomatic hyponatremia with hypertonic saline: a real-life observational study.

ObjectiveTreatment of symptomatic hyponatremia is not well established. The European guidelines recommend bolus-wise administration of 150 mL of 3% hypertonic saline. This recommendation is, however, based on low level of evidence.DesignObservational study.MethodsSixty-two consecutive hyponatremic patients admitted to the emergency department or intensive care unit of the University Hospital Wuerzburg were divided in subgroups according to treatment (150 mL bolus of 3% hypertonic saline or conventional treatment) and symptom severity. Treatment target was defined as an increase in serum sodium by 5–10 mEq/L within first 24 h and maximum 8 mEq/L during subsequent 24 h.ResultsThirty-three out of sixty-two patients (53%) were presented with moderate symptoms and 29/62 (47%) with severe symptoms. Thirty-six were treated with hypertonic saline and 26 conventionally. In the hypertonic saline group, serum sodium increased from 116 ± 7 to 123 ± 6 (24 h) and 127 ± 6 mEq/L (48 h) and from 121 ± 6 to 126 ± 5 and 129 ± 4 mEq/L in the conventional group, respectively. Overcorrection at 24 h occurred more frequent in patients with severe symptoms than with moderate symptoms (38% vs 6%, P < 0.05). Diuresis correlated positively with the degree of sodium overcorrection at 24 h (r = 0.6, P < 0.01). Conventional therapies exposed patients to higher degrees of sodium fluctuations and an increased risk for insufficient sodium correction at 24 h compared to hypertonic saline (RR: 2.8, 95% CI: 1.4–5.5).ConclusionSodium increase was more constant with hypertonic saline, but overcorrection rate was high, especially in severely symptomatic patients. Reducing bolus-volume and reevaluation before repeating bolus infusion might prevent overcorrection. Symptoms caused by hypovolemia can be misinterpreted as severely symptomatic hyponatremia and diuresis should be monitored.

Avoid Always and Never

Avoid <i>Always</i> and <i>Never</i>

A very uncommon clinical entity: Lansoprazole-induced symptomatic hyponatremia in a young woman

A very uncommon clinical entity: Lansoprazole-induced symptomatic hyponatremia in a young woman

Hyponatremic Unconsciousness as a Presenting Symptom of COVID-19: A Case Series

The novel Coronavirus Disease-2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection can present with a multitude of clinical symptoms. The virus, disease symptomatology, pathogenesis and complications are being studied and new concepts are evolving rapidly. The current worldwide situation caused by the disease makes it exceedingly important to recognise varied presentations of the disease. Three cases are being discussed hereby, wherein the patients presented with altered sensorium secondary to hyponatremia as the initial and only presentation of SARS-CoV-2 infection, in the absence of fever or any respiratory involvement. Acute symptomatic hyponatremia is an under-recognised presentation with only a few cases reported till date and needs further awareness and understanding.

Challenges of Diagnosing Hyponatremic Syndromes in Pulmonary and Extra Pulmonary Tuberculosis

Abstract Introduction Pulmonary tuberculosis (PTB) is one of the rare pulmonary infections causing hyponatremia (serum sodium ˂135 mmol/L) and severe hyponatremia (serum sodium ˂125 mmol/L). Although the major cause of hyponatremia in TB patients is syndrome of inappropriate antidiuretic hormone (SIADH) secretion, cerebral salt wasting syndrome (CSWS) can occur and requires evidence of inappropriate urinary salt losses and reduced arterial blood volume. Adrenal insufficiency (AI) is rare in TB with scanty literature describing it. The two reported cases highlight three possible causes of severe symptomatic hyponatremia in TB pleural effusion and disseminated TB, their treatment modalities, and the need to increase the index of suspicion to diagnose TB hyponatremia in children. Case Report Case 1: a 10-year-old girl with TB pleural effusion who developed recurrent hyponatremia in the first few weeks of anti-TB treatment which was responsive to sodium correction. Case 2: an 8-year-old girl presenting to our facility with presumptive TB. She deteriorated over several months and progressed to disseminated TB with AI. Discussion Early diagnosis and prompt and correct treatment of TB hyponatremia cannot be overemphasized, as AI, SIADH secretion, and CSWS, each require different therapeutic regimens, most especially AI on its own poses a huge clinical challenge. Conclusion A high index of suspicion, with intensified case finding at all levels of care, is necessary to identify and manage children with TB hyponatremia because early diagnosis and prompt treatment is lifesaving.

An unusual case report of COVID-19 presenting with syndrome of inappropriate ADH secretion

Coronavirus disease-2019 (COVID-19) caused by novel coronavirus continues to produce enormous health effects and deaths since it started in 2019. Research till now has shown that COVID-19 manifests with unusual presentations causing various challenges in its management. Hyponatremia is a common condition found in critical care units and syndrome of inappropriate ADH (SIADH) accounts for one-third of those cases. Several infections associated with COVID-19 have been reported, but there are only few case reports of association with SIADH. We report the case of a 30-year-old male admitted with seizure due to acute symptomatic hyponatremia and SIADH attributed to COVID-19.

Stroke vs. SIADH: A case of symptomatic hyponatremia secondary to SIADH in association with COVID-19 infection

A 66-year-old male with no known past medical history presented with history of two days of throbbing frontal headache associated with nausea, vomiting and left-sided facial droop. The patient also reported dizziness, subjective chills without cough, shortness of breath, or sputum production. Laboratory findings revealed elevated inflammatory markers but normal thyroid, kidney, and liver function tests. Initial sodium level was 126 mEq/L. Urine studies showed elevated urine osmolality of 647 mOsm/Kg and urine sodium level of 175 mEq/L, both suggestive of syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The TSH and ACTH stimulation tests both came back as normal. CT scan of the chest showed no evidence of lung infiltrates. Diffusion weighted MRI of the brain showed no evidence of acute or subacute CVA. SARS-CoV-2 nasal swab test was resulted positive. With these findings we diagnosed our patient with SIADH. Patient was initially started on 3% saline infusion for symptomatic hyponatremia. A fluid restricted diet was enforced. Patient was also started on salt tablets in order to increase solute intake. Sodium slowly corrected throughout the hospitalization. Of note, our patient never became hypoxic, neither did he show evidence of clinical pneumonia. A CT imaging of the chest showed no lung infiltrates, and an MRI of the brain was negative for any acute intracranial abnormalities. This case highlights the role of early recognition of SIADH in the setting of SARS-CoV-2 infection even in the absence of hypoxemia or lung pathology.

Optimal treatment with hypertonic saline in patients with symptomatic hyponatremia: a perspective from a randomized clinical trial (SALSA trial).

Optimal treatment with hypertonic saline in patients with symptomatic hyponatremia: a perspective from a randomized clinical trial (SALSA trial).

Rapid Bolus vs. Continuous Infusion of Hypertonic Saline for Hyponatremia

Correction of symptomatic hyponatremia is a delicate balance: It must occur quickly enough to prevent cerebral edema but slowly enough to prevent

Risk of Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion Therapies of Hypertonic Saline for Patients With Symptomatic Hyponatremia

Few high-quality studies have clarified whether hypertonic saline is best administered as slow continuous infusion (SCI) therapy or rapid intermittent bolus (RIB) therapy for symptomatic severe hyponatremia. To compare the risk of overcorrection in RIB and SCI with hypertonic saline in patients with symptomatic hyponatremia. This prospective, investigator-initiated, multicenter, open-label, randomized clinical trial enrolled 178 patients older than 18 years with moderately severe to severe hyponatremia and glucose-corrected serum sodium (sNa) levels of 125 mmol/L or less. Recruitment took place from August 24, 2016, until August 21, 2019, across emergency departments and wards of 3 general hospitals in the Republic of Korea. Either RIB or SCI of hypertonic saline, 3%, for 24 to 48 hours stratified by the severity of clinical symptoms. The primary outcome was overcorrection at any given period, defined as increase in the sNa level by greater than 12 or 18 mmol/L within 24 or 48 hours, respectively. Secondary and post hoc outcomes included efficacy and safety of the treatment approaches. The sNa concentrations were measured every 6 hours for 2 days. The 178 patients (mean [SD] age, 73.1 [12.2] years; 80 (44.9%) male; mean [SD] sNa concentrations, 118.2 [5.0] mmol/L) were randomly assigned to the RIB group (n = 87) or the SCI group (n = 91). Overcorrection occurred in 15 of 87 (17.2%) and 22 of 91 (24.2%) patients in the RIB and SCI groups, respectively (absolute risk difference, -6.9% [95% CI, -18.8% to 4.9%]; P = .26). The RIB group showed lower incidence of relowering treatment than the SCI group (36 of 87 [41.4%] vs 52 of 91 [57.1%] patients, respectively; absolute risk difference, -15.8% [95% CI, -30.3% to -1.3%]; P = .04; number needed to treat, 6.3). Groups did not differ in terms of efficacy in increasing sNa concentrations nor improving symptoms, but RIB, when compared with SCI, showed better efficacy in achieving target correction rate within 1 hour (intention-to-treat analysis: 28 of 87 (32.2%) vs 16 of 91 (17.6%) patients, respectively; absolute risk difference, 14.6% [95% CI, 2%-27.2%]; P = .02; number needed to treat, 6.8; per-protocol analysis: 21 of 72 (29.2%) vs 12 of 73 (16.4%) patients, respectively; absolute risk difference, 12.7% [95% CI, -0.8% to 26.2%]; P = .07). The statistical significance of the intention-to-treat and per-protocol analyses were similar for all outcomes except for achieving the target correction rate within 1 hour. This randomized clinical trial found that both RIB and SIC therapies of hypertonic saline for treating hyponatremia were effective and safe, with no difference in the overcorrection risk. However, RIB had a lower incidence of therapeutic relowering treatment and tended to have a better efficacy in achieving sNa within 1 hour than SCI. RIB could be suggested as the preferred treatment of symptomatic hyponatremia, which is consistent with the current consensus guidelines. ClinicalTrials.org Identifier: NCT02887469.

Efficacy and Safety of Rapid Intermittent Correction vs. Slow Continuous Correction with Hypertonic Saline in Patients with Symptomatic Hyponatremia: A Randomized Clinical Trial (SALSA Trial)

Efficacy and Safety of Rapid Intermittent Correction vs. Slow Continuous Correction with Hypertonic Saline in Patients with Symptomatic Hyponatremia: A Randomized Clinical Trial (SALSA Trial)

Awareness of the use of hyponatraemia-inducing medications in older adults with hyponatraemia: a study of their prevalent use and association with recurrent symptomatic or severe hyponatraemia.

Cautious use or avoidance of hyponatraemia-inducing medications (HIMs) is recommended in older patients with hyponatraemia. To evaluate the use of HIMs after treatment for symptomatic or severe hyponatraemia and to investigate the impact of HIMs on the recurrence of symptomatic or severe hyponatraemia in older patients. A cross-sectional and nested case-control study using data obtained from national insurance claims databases. The rate of prescribing HIMs during the 3 months before and after the established index date was analysed in a cross-sectional analysis. Multivariable logistic regression was performed to investigate the association between HIM use and recurrence of symptomatic or severe hyponatraemia after adjusting for covariates in a case-control study. The cross-sectional study included 1,072 patients treated for symptomatic or severe hyponatraemia. The proportion of patients prescribed any HIMs after hyponatraemia treatment decreased from 76.9 to 70.1%. The prescription rates significantly decreased for thiazide diuretics (from 41.9 to 20.8%) and desmopressin (from 8.6 to 4.0%), but the proportion of patients prescribed antipsychotics increased from 9.2 to 17.1%. Of 32,717 patients diagnosed with hyponatraemia, 913 (2.8%) showed recurrent hyponatraemia. After adjusting for comorbid conditions, the use of any HIMs including proton pump inhibitors [adjusted odds ratio (aOR) 1.34, 95% confidence interval (CI) 1.15-1.57] and two or more HIMs (aOR 1.48, 95% CI 1.22-1.78) especially in combination with thiazide diuretics increased the likelihood of severe hyponatraemia recurrence. Prevalent use of HIMs after treatment for symptomatic or severe hyponatraemia and multiple HIM use increase the risk of recurrent hyponatraemia in geriatric patients.

Osmotic demyelination syndrome in a patient with Noonan syndrome and anterior hypopituitarism.

SummarySevere hyponatremia and osmotic demyelination syndrome (ODS) are opposite ends of a spectrum of emergency disorders related to sodium concentrations. Management of severe hyponatremia is challenging because of the difficulty in balancing the risk of overcorrection leading to ODS as well as under-correction causing cerebral oedema, particularly in a patient with chronic hypocortisolism and hypothyroidism. We report a case of a patient with Noonan syndrome and untreated anterior hypopituitarism who presented with symptomatic hyponatremia and developed transient ODS.Learning points:Patients with severe anterior hypopituitarism with severe hyponatremia are susceptible to the rapid rise of sodium level with a small amount of fluid and hydrocortisone.These patients with chronic anterior hypopituitarism are at high risk of developing ODS and therefore, care should be taken to avoid a rise of more than 4–6 mmol/L per day.Early recognition and rescue desmopressin and i.v. dextrose 5% fluids to reduce serum sodium concentration may be helpful in treating acute ODS.

Fluid Replacement Versus Fluid Restriction in COVID-19 Associated Hyponatremia

Hyponatremia is one of the most frequently observed electrolyte abnormalities in coronavirus disease 2019 (COVID-19). Literature describes syndrome of inappropriate anti diuretic hormone (SIADH) as the mechanism of hyponatremia in COVID-19 requiring fluid restriction for management. However, it is important to rule out other etiologies of hyponatremia in such cases keeping in mind the effect of an alternate etiology on patient management and outcome. We present a case of hypovolemic hyponatremia in a patient with COVID-19, which unlike SIADH, required fluid replacement early in the disease course for its correction. A 52-year-old Filipino gentleman presented with a three-week history of diarrhea and symptomatic hyponatremia. There was no history of fever or respiratory symptoms. Physical examination revealed a dehydrated and confused middle-aged gentleman. Labs revealed lymphopenia, thrombocytopenia, and severe hyponatremia (108 mmol/L). Blood cultures and stool workup were negative. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nasopharyngeal swab was positive. Hyponatremia workup excluded SIADH. The patient had hypovolemic hyponatremia due to gastrointestinal (GI) losses and was managed with saline infusion for correction of hyponatremia with improvement in his clinical status. Hyponatremia in COVID-19 is not only secondary to SIADH but can also be due to other etiologies. Hypovolemic hyponatremia should be distinguished from SIADH as these conditions employ different management strategies, and early diagnosis and management of hypovolemic hyponatremia affects morbidity and mortality.

ENDOCRINOLOGY IN THE TIME OF COVID-19: Management of diabetes insipidus and hyponatraemia.

COVID-19 has changed the nature of medical consultations, emphasizing virtual patient counseling, with relevance for patients with diabetes insipidus (DI) or hyponatraemia. The main complication of desmopressin treatment in DI is dilutional hyponatraemia. Since plasma sodium monitoring is not always possible in times of COVID-19, we recommend to delay the desmopressin dose once a week until aquaresis occurs allowing excess retained water to be excreted. Patients should measure their body weight daily. Patients with DI admitted to the hospital with COVID-19 have a high risk for mortality due to volume depletion. Specialists must supervise fluid replacement and dosing of desmopressin. Patients after pituitary surgery should drink to thirst and measure their body weight daily to early recognize the development of the postoperative syndrome of inappropriate antidiuresis (SIAD). They should know hyponatraemia symptoms. The prevalence of hyponatraemia in patients with pneumonia due to COVID-19 is not yet known, but seems to be low. In contrast, hypernatraemia may develop in COVID-19 patients in ICU, from different multifactorial reasons, for example, due to insensible water losses from pyrexia, increased respiration rate and use of diuretics. Hypernatraemic dehydration may contribute to the high risk of acute kidney injury in COVID-19. IV fluid replacement should be administered with caution in severe cases of COVID-19 because of the risk of pulmonary oedema.

Excessive juice drinking causing symptomatic hyponatraemia in a patient with gastrointestinal pseudo – obstruction and congenital short bowel

Excessive juice drinking causing symptomatic hyponatraemia in a patient with gastrointestinal pseudo – obstruction and congenital short bowel

Etiologies, Clinical Manifestations, and Factors Associated with Severe Symptomatic Hyponatremia among Hospitalized Hyponatremia Patients

Background: Hyponatremia is associated with unfavorable outcomes in many cases. The mainstay of hyponatremia treatment depends on its symptoms and etiology. However, etiologies, clinical manifestations, and factors associated with severe symptomatic hyponatremia have been rarely reported. Objective: To analyze and report etiologies, clinical manifestations, and factors associated with severe symptomatic hyponatremia. Materials and Methods: In the present cross-sectional study, the authors enrolled hospitalized patients with hyponatremia who had consulted a nephrologist between October 1, 2017, and October 31, 2018. Their baseline characteristics and clinical manifestations were recorded. Etiologies were confirmed by the attending nephrology staff. Factors associated with severe symptomatic hyponatremia were evaluated using logistic regression analysis. Results: One hundred patients were included in this study. The syndrome of inappropriate antidiuresis (SIAD), hypovolemia, and hydrochlorothiazide use were the leading hyponatremia etiologies. Hyponatremia etiologies differed between patients with community-acquired hyponatremia (n=50) and those with hospital-associated hyponatremia (n=50). Patients with communityacquired hyponatremia were older, presented with a higher frequency of severe symptomatic hyponatremia, and showed lower SNa-levels. Low SNa-levels were significantly associated with severe symptomatic hyponatremia (p=0.014). Conclusion: Hyponatremia remains an important health problem. SIAD, hypovolemia, and hydrochlorothiazide use are among the leading etiologies of hyponatremia. Low SNa-levels are associated with severe symptomatic hyponatremia; thus, physicians should pay close attention to low SNa-levels in hospitalized patients. Keywords: Hyponatremia, Symptomatic Hyponatremia, Community-acquired hyponatremia, Hospital-associated hyponatremia

MON-248 Tachycardia and Myocardial Injury Induced Natriuresis - a Rare Clinical Encounter

Introduction:Hyponatremia in the context of cerebral salt wasting secondary to intracranial events has well been described due to increased release of natriuretic peptides. We describe a case of natriuresis leading to acute symptomatic hyponatremia associated with tachyarrhythmia and myocardial infarction.Case:A 72-year-old lady was admitted with atrial fibrillation with rapid ventricular rate between 130-150 beats per minute, troponin positive chest pain, with high sensitivity troponin T of 1307 ng/L (<14 ng/L) and managed as type II myocardial infarction. 12 hours after admission she became acutely confused, agitated, associated with visual hallucinations and myoclonic jerks. On Examination she was dehydrated and there were no focal neurological features. Investigations showed acute hyponatremia with serum sodium (Na+) of 117 mmol/L (135 - 145 mmol/L) which 12 hours earlier, on admission, was 137 mmol/L, serum osmolarity 249 mosm/kg (275 - 295 mosm/kg), urine osmolarity 486 mosm/kg, urinary sodium of 160 mmol/L, pro-NTBNP 6575pg/ml (<450 pg/ml), 9am serum cortisol 575 nmol/L (140 - 690 nmol/L), TSH 4.72 mu/L (0.2 - 5.0 mu/L), FT4: 18.6pmol/L (10.0 - 24.0 pmol/L) and normal chest x-ray. She was treated with hypertonic saline (2.7%) 200ml followed by 0.9% saline infusion that corrected her serum sodium levels to 136 mmol/L over next 48-72 hours along with clinical symptoms gradually went back to normal. Repeat pro-NTBNP after recovery was 3153 pg/ml. Echocardiography showed normal left ventricular systolic function with normal atrial size and moderate mitral regurgitation with pulmonary artery pressure of 30mmHg. Based on acute onset hyponatremia and raised urinary sodium, we proposed diagnosis of hyponatremia secondary to salt wasting and we believe that in absence of acute intracranial pathology and raised pro-NTBNP, renal salt wasting was induced by acute rise in natriuretic peptides of cardiac origin either secondary to myocardial infarction or tachyarrhythmia. Paroxysmal SVT is a known cause of transient polyuria after termination but is not known to cause hyponatremia. Although well described in context of intracranial events, this is the first case of myocardial injury or tachyarrhythmia induced natriuresis leading to acute hyponatremia.Conclusion:Salt wasting due to natriuretic peptides is not exclusive to intracranial events. Any cardiac event leading to sudden increase in natriuretic peptides can lead to natriuresis which if prolonged enough can lead to acute symptomatic hyponatremia.Reference:1. Yee AH, Burns JD, Wijdicks EF. Cerebral Salt Wasting: Pathophysiology, Diagnosis, and Treatment. Neurosurgery Clinics of North America, 21(2), pp.339-352.2. Tan SY, Nolan J, Craig K, Swainson CP. Supraventricular tachycardia, right atrial pressure, atrial natriuretic peptide and polyuria—a necessary sequence? J Int Med 1993; 233: 415-17.

Severe symptomatic hyponatremia with SIADH picture due to influenza A

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Additional risk factors associated with symptomatic hydrochlorothiazide-induced hyponatremia in hypertensive patients

Background. Hydrochlorothiazide is a cheap and effective antihypertensive agent but may cause hyponatremia. Even though several risk factors for hydrochlorothiazide-induced hyponatremia have been reported, this study aimed to evaluate additional risk factors for hydrochlorothiazide-induced hyponatremia in hypertensive patients. Material and methods. The inclusion criteria were: adult patients, diagnosed with hypertension and receiving hydrochlorothiazide treatment. Eligible patients were divided into two groups: with and without hyponatremia. Those with hyponatremia were identified by using the ICD-10 code E871, while those without hyponatremia were patients who did not have any reported hyponatremia until the last visit. The ratio between hyponatremia and non-hyponatremia group was 1:2. Predictors for hyponatremia were analyzed by using logistic regression analysis. Results. During the study period, there were 68 patients admitted due to symptomatic hyponatremia from hydrochlorothiazide. There were four independent factors in the model predictive of occurrence of symptomatic hydrochlorothiazide-induced hyponatremia in hypertensive patients: sex, body mass index, plasma glucose, and serum albumin. Male sex, body mass index, and serum albumin were negatively associated with occurrence of symptomatic hydrochlorothiazide-induced hyponatremia in hypertensive patients with adjusted OR of 0.099, 0.683, and 0.122, respectively. The plasma glucose had adjusted OR of 1.030 [95% CI of (1.009, 1.051)]. Conclusions. Factors associated with hydrochlorothiazide-induced symptomatic hyponatremia in hypertensive patients were sex, body mass index, plasma glucose level, and serum albumin level. The latter two risk factors have never been reported as risk factors for hydrochlorothiazide-induced symptomatic hyponatremia in hypertensive patients.