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      Call for Papers: Green Renal Replacement Therapy: Caring for the Environment

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      Unexplained Hyponatremia: Seek and You Will Find

      case-report

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          Abstract

          Background: Hyponatremia is a common diagnostic challenge. Methods: An index case is presented to discuss the diagnostic approach to chronic and unexplained hyponatremia. Results: The index case concerns a 60-year-old man with chronic hepatitis C and previous alcohol use who was referred because of weight loss, poor dietary intake, dizzy spells, and unexplained hyponatremia (serum sodium 124–129 mmol/l). A low urine sodium concentration (20 mmol/l) and a lowfractional sodium excretion (0.07%) were observed repeatedly, while urine osmolality washigh (>400 mosm/kg). The central questions in this case are: what is the differential diagnosis, which tests are needed to confirm or exclude a diagnosis, and how would you proceed if no obvious cause is found? Conclusions: The diagnosis of this case of unexplained hyponatremia was unexpected, but important because it was treatable. The challenges and caveats of the diagnostic approach to hyponatremia are discussed. A diagnostic algorithm to guide clinicians who are confronted with similar cases is presented.

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          Mild chronic hyponatremia is associated with falls, unsteadiness, and attention deficits.

          Benoit Renneboog, Wim Musch, Xavier Vandemergel … (2006)
          The study objective was to determine the eventual consequences (falls, unsteadiness, and cognitive impairment) of mild chronic hyponatremia, which is generally considered as asymptomatic. In a case-control study, we focused on the incidence of falls among 122 patients (mean age 72+/-13 years) with asymptomatic chronic hyponatremia (mean serum sodium concentration [SNa] 126+/-5 mEq/L), who were admitted to the medical emergency department, compared with 244 matched controls. To explore the mechanisms of the excess of falls, we prospectively asked 16 comparable patients (mean age 63+/-15 years; SNa+/-2 mEq/L) to perform 8 attention tests and a gait test consisting of 3 steps "in tandem," in which we measured the "total traveled way" by the center of pressure or total traveled way. Thereafter, the patients were treated and tested again (50% of the patients were tested first with normal SNa to avoid learning biases). Epidemiology of falls: Twenty-six patients (21.3%) of 122 were admitted for falls, compared with only 5.3% of the control patients (adjusted odds ratio: 67; 95% confidence: 7.5-607; P <.001). The frequency of falls was the same regardless of the level of hyponatremia. Gait: The total traveled way by the center of pressure significantly increased in hyponatremia (1336+/-320 mm vs 1047+/-172 mm with normal SNa; P=.003). Attention tests: The mean response time was 673+/-182 milliseconds in hyponatremia and 615+/-184 milliseconds in patients with normal SNa (difference: 58 milliseconds, P <.001). The total error number in hyponatremia increased 1.2-fold (P=.001). These modifications were comparable to those observed after alcohol intake in 10 volunteers. Mild chronic hyponatremia induces a high incidence of falls possibly as the result of marked gait and attention impairments. Treating these patients might prevent a considerable number of hospitalizations.
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            A syndrome of renal sodium loss and hyponatremia probably resulting from inappropriate secretion of antidiuretic hormone.

            Michael W. Schwartz, F C Bartter, S CURELOP … (1957)
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              Nephrogenic syndrome of inappropriate antidiuresis.

              Brian J. Feldman, Stephen M Rosenthal, Gabriel Vargas … (2005)
              The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a common cause of hyponatremia. We describe two infants whose clinical and laboratory evaluations were consistent with the presence of SIADH, yet who had undetectable arginine vasopressin (AVP) levels. We hypothesized that they had gain-of-function mutations in the V2 vasopressin receptor (V2R). DNA sequencing of each patient's V2R gene (AVPR2) identified missense mutations in both, with resultant changes in codon 137 from arginine to cysteine or leucine. These novel mutations cause constitutive activation of the receptor and are the likely cause of the patients' SIADH-like clinical picture, which we have termed "nephrogenic syndrome of inappropriate antidiuresis." Copyright 2005 Massachusetts Medical Society.
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                Author and article information

                Journal
                Journal ID (publisher-id): NEP
                Journal ID (nlm-ta): Nephron Physiol
                Journal ID (doi): 10.1159/issn.1660-2137
                Title: Nephron Physiology
                Publisher: S. Karger AG
                ISSN (Electronic): 1660-2137
                Publication date Subscription-year: 2011
                Publication date (Print): June 2011
                Publication date (Electronic): 07 January 2011
                Volume: 118
                Issue: 3
                Pages: p66-p71
                Affiliations
                Departments of aInternal Medicine and bGastroenterology &amp; Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
                Author notes
                *Ewout J. Hoorn, MD, PhD, PO Box 2040, Room D-405, NL–3000 CA Rotterdam (The Netherlands), Tel. +31 10 704 0704, Fax +31 10 436 6372, E-Mail ejhoorn@gmail.com
                Article
                Publisher ID: 322240 Other ID: Nephron Physiol 2011;118:p66–p71
                DOI: 10.1159/000322240
                PubMed ID: 21212700
                SO-VID: 85359222-b8ef-4d09-8ece-83f3dc3f2be9
                Copyright © © 2011 S. Karger AG, Basel
                License:

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                Date received : 30 June 2010
                Date accepted : 13 October 2010
                Page count
                Figures: 4, Tables: 2, Pages: 6
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Cardiovascular Medicine,Nephrology
                Keywords: Hyponatremia,Chronic hyponatremia,Syndrome of inappropriate antidiuretic hormone secretion,Unexplained hyponatremia,Syndrome of inappropriate antidiuresis
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine, Nephrology
                Keywords: Hyponatremia, Chronic hyponatremia, Syndrome of inappropriate antidiuretic hormone secretion, Unexplained hyponatremia, Syndrome of inappropriate antidiuresis

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