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Schwarz C, Lindner G, Windpessl M, Knechtelsdorfer M, Saemann MD. [Consensus recommendations on the diagnosis and treatment of hyponatremia from the Austrian Society for Nephrology 2024]. Wien Klin Wochenschr 2024; 136:1-33. [PMID: 38421476 PMCID: PMC10904443 DOI: 10.1007/s00508-024-02325-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 03/02/2024]
Abstract
Hyponatremia is a disorder of water homeostasis. Water balance is maintained by the collaboration of renal function and cerebral structures, which regulate thirst mechanisms and secretion of the antidiuretic hormone. Measurement of serum-osmolality, urine osmolality and urine-sodium concentration help to diagnose the different reasons for hyponatremia. Hyponatremia induces cerebral edema and might lead to severe neurological symptoms, which need acute therapy. Also, mild forms of hyponatremia should be treated causally, or at least symptomatically. An inadequate fast increase of the serum sodium level should be avoided, because it raises the risk of cerebral osmotic demyelination. Basic pathophysiological knowledge is necessary to identify the different reasons for hyponatremia which need different therapeutic procedures.
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Affiliation(s)
- Christoph Schwarz
- Innere Medizin 1, Pyhrn-Eisenwurzenklinikum, Sierningerstr. 170, 4400, Steyr, Österreich.
| | - Gregor Lindner
- Zentrale Notaufnahme, Kepler Universitätsklinikum GmbH, Johannes-Kepler-Universität, Linz, Österreich
| | | | | | - Marcus D Saemann
- 6.Medizinische Abteilung mit Nephrologie und Dialyse, Klinik Ottakring, Wien, Österreich
- Medizinische Fakultät, Sigmund-Freud Universität, Wien, Österreich
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Warren AM, Grossmann M, Christ-Crain M, Russell N. Syndrome of Inappropriate Antidiuresis: From Pathophysiology to Management. Endocr Rev 2023; 44:819-861. [PMID: 36974717 PMCID: PMC10502587 DOI: 10.1210/endrev/bnad010] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 02/19/2023] [Accepted: 03/27/2023] [Indexed: 03/29/2023]
Abstract
Hyponatremia is the most common electrolyte disorder, affecting more than 15% of patients in the hospital. Syndrome of inappropriate antidiuresis (SIAD) is the most frequent cause of hypotonic hyponatremia, mediated by nonosmotic release of arginine vasopressin (AVP, previously known as antidiuretic hormone), which acts on the renal V2 receptors to promote water retention. There are a variety of underlying causes of SIAD, including malignancy, pulmonary pathology, and central nervous system pathology. In clinical practice, the etiology of hyponatremia is frequently multifactorial and the management approach may need to evolve during treatment of a single episode. It is therefore important to regularly reassess clinical status and biochemistry, while remaining alert to potential underlying etiological factors that may become more apparent during the course of treatment. In the absence of severe symptoms requiring urgent intervention, fluid restriction (FR) is widely endorsed as the first-line treatment for SIAD in current guidelines, but there is considerable controversy regarding second-line therapy in instances where FR is unsuccessful, which occurs in around half of cases. We review the epidemiology, pathophysiology, and differential diagnosis of SIAD, and summarize recent evidence for therapeutic options beyond FR, with a focus on tolvaptan, urea, and sodium-glucose cotransporter 2 inhibitors.
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Affiliation(s)
- Annabelle M Warren
- Department of Medicine, University of Melbourne, Victoria 3010, Australia
- Department of Endocrinology, The Austin Hospital, Victoria 3084, Australia
| | - Mathis Grossmann
- Department of Medicine, University of Melbourne, Victoria 3010, Australia
- Department of Endocrinology, The Austin Hospital, Victoria 3084, Australia
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel 4031, Switzerland
- Department of Clinical Research, University of Basel and University Hospital Basel, Basel 4031, Switzerland
| | - Nicholas Russell
- Department of Medicine, University of Melbourne, Victoria 3010, Australia
- Department of Endocrinology, The Austin Hospital, Victoria 3084, Australia
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Osher E, Zohar NE, Yacobi-Bach M, Cantrell D, Serebro M, Sofer Y, Greenman Y, Tordjman K, Stern N. Endocrinology specialty service for inpatients: an unmet growing need. BMC Health Serv Res 2023; 23:142. [PMID: 36759836 PMCID: PMC9911334 DOI: 10.1186/s12913-023-09134-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/01/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND There is recent concern regarding the documented mismatch between demand and supply, vis-à-vis the growing need for trained endocrinologists unmet by parallel rise in the world workforce of endocrinologist. Due to the increasing complexity of disease in inpatients, in recent years we have experienced a growing demand for inpatient endocrine consults. Surprisingly, the need for the endocrinology subspecialty in the overall care of inpatients in the current setting of general hospitals has received little attention. METHODS A retrospective analysis of endocrine consult service based on solicited consults carried out during 3 consecutive months. RESULTS During 3 months, there were 767 consults, comprised of 156 diabetes referrals and 611 endocrine/metabolic consult requests. The 611 "non-glucocentric" consult requests were related to 295 inpatients (2.1 ± 2.7 consults/patient). Mean patient age was 58.9 ± .18 years (range 21-92), with some F/M preponderance (58/42%). Requests for endocrine consults were evenly distributed (49.8%, 50.2%) between internal medicine and surgery wards. Case distribution was as follows: thyroid 45.4%, calcium & bone 11.5%, pituitary 12%, adrenal 10% and all others 8.1-0.7%. The mean response time was 4.4 ± 2.7 h. The consults had a discernible effect on the patients' disease management in 60% of the patients. Of these, the consults modified the hospital treatment in 74%, the discharge treatment recommendations in 19% and the diagnosis in 7%. CONCLUSION At a large medical center, endocrine consults were requested for ~ 3.3% of all admitted inpatients. The endocrine consults modified pre-consult diagnosis or treatment in ~ 60% of the cases. Contrary to its common image as an exclusively outpatient-based subspecialty, endocrinology practiced by specialists and endocrine trainees has a notable role in the daily care of inpatients admitted to a referral general hospital.
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Affiliation(s)
- Esther Osher
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, 6423906, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Naomi Even Zohar
- grid.413449.f0000 0001 0518 6922Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, 6423906 Israel
| | - Michal Yacobi-Bach
- grid.413449.f0000 0001 0518 6922Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, 6423906 Israel
| | - Dror Cantrell
- Department of Internal Medicine C, Shamir Medical Center, Zerifin, Israel
| | - Merav Serebro
- grid.413449.f0000 0001 0518 6922Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, 6423906 Israel
| | - Yael Sofer
- grid.413449.f0000 0001 0518 6922Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, 6423906 Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yona Greenman
- grid.413449.f0000 0001 0518 6922Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, 6423906 Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Karen Tordjman
- grid.413449.f0000 0001 0518 6922Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, 6423906 Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naftali Stern
- grid.413449.f0000 0001 0518 6922Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, 6423906 Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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The management and outcome of hyponatraemia following transsphenoidal surgery: a retrospective observational study. Acta Neurochir (Wien) 2022; 164:1135-1144. [PMID: 35079890 PMCID: PMC8967808 DOI: 10.1007/s00701-022-05134-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/13/2022] [Indexed: 01/11/2023]
Abstract
Purpose Hyponatraemia is a common complication following transsphenoidal surgery. However, there is sparse data on its optimal management and impact on clinical outcomes. The aim of this study was to evaluate the management and outcome of hyponatraemia following transsphenoidal surgery. Methods A prospectively maintained database was searched over a 4-year period between January 2016 and December 2019, to identify all patients undergoing transsphenoidal surgery. A retrospective case-note review was performed to extract data on hyponatraemia management and outcome. Results Hyponatraemia occurred in 162 patients (162/670; 24.2%) with a median age of 56 years. Female gender and younger age were associated with hyponatraemia, with mean nadir sodium being 128.6 mmol/L on postoperative day 7. Hyponatraemic patients had longer hospital stay than normonatraemic group with nadir sodium being inversely associated with length of stay (p < 0.001). In patients with serum sodium ≤ 132 mmol/L, syndrome of inappropriate antidiuretic hormone secretion (SIADH) was the commonest cause (80/111; 72%). Among 76 patients treated with fluid restriction as a monotherapy, 25 patients (25/76; 32.9%) did not achieve a rise in sodium after 3 days of treatment. Readmission with hyponatraemia occurred in 11 cases (11/162; 6.8%) at a median interval of 9 days after operation. Conclusion Hyponatraemia is a relatively common occurrence following transsphenoidal surgery, is associated with longer hospital stay and risk of readmission and the effectiveness of fluid restriction is limited. These findings highlight the need for further studies to better identify and treat high-risk patients, including the use of arginine vasopressin receptor antagonists. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-022-05134-9.
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Gürbüz F, Taştan M, Turan İ, Yüksel B. Efficiency of Single Dose of Tolvaptan Treatment During the Triphasic Episode After Surgery for Craniopharyngioma. J Clin Res Pediatr Endocrinol 2019; 11:202-206. [PMID: 30257818 PMCID: PMC6571528 DOI: 10.4274/jcrpe.galenos.2018.2018.0182] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Inappropriate antidiuretic hormone syndrome (SIADH) may develop after intracranial surgery. SIADH in the pediatric age group is usually encountered in patients with an intracranial mass both before and after surgery. Fluid restriction is the standard therapy in SIADH. However, a resistant, hyponatremic pattern may be encountered in some cases. Vaptans have been recently introduced for treatment of hyponatremia due to SIADH. There is inadequate data concerning tolvaptan treatment in pediatric patients. We present a 13 year-old female with SIADH of triphasic episode who was transferred to our clinic after surgery for craniopharyngioma. Resistant hyponatremia did not resolve despite fluid restriction and hypertonic saline support. The patient responded rapidly to a single dose of tolvaptan, with no adverse effect, which resulted in successful control of her SIADH.
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Affiliation(s)
- Fatih Gürbüz
- Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey,* Address for Correspondence: Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey Phone: +90 322 338 60 60 E-mail:
| | - Mehmet Taştan
- Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey
| | - İhsan Turan
- Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey
| | - Bilgin Yüksel
- Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey
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Cuesta M, Garrahy A, Slattery D, Gupta S, Hannon AM, McGurren K, Sherlock M, Tormey W, Thompson CJ. Mortality rates are lower in SIAD, than in hypervolaemic or hypovolaemic hyponatraemia: Results of a prospective observational study. Clin Endocrinol (Oxf) 2017; 87:400-406. [PMID: 28574597 DOI: 10.1111/cen.13388] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 05/09/2017] [Accepted: 05/29/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Hyponatraemia is associated with increased mortality, but the mortality associated specifically with SIAD is not known. We hypothesized that mortality in SIAD was elevated, but that it was less than in hypervolaemic (HEN) or hypovolaemic (HON) hyponatraemia. DESIGN Mortality rates are presented as risk ratios (RR),with 95% confidence intervals (CI), and compared to normonatraemic controls (NN). METHODS Prospective, single centre, noninterventional study of all patients with hyponatraemia (≤130 mmol/L) admitted to hospital. RESULTS A total of 1323 admissions with hyponatraemia were prospectively evaluated and 1136 contemporaneous NN controls. 431(32.6%) hyponatraemic patients had HON, 573(43.3%) had SIAD and 275(20.8%) patients had HEN. In patient mortality was higher in hyponatraemia than NN (9.1% vs 3.3%, P<.0001). The RRs for in-hospital mortality compared to NN were: SIAD, 1.76 (95% CI 1.08-2.8, P=.02), HON 2.77 (95% CI 1.8-4.3, P<.0001) and HEN, 4.9 (95% CI 3.2-7.4, P<.0001). The mortality rate was higher in HEN (RR 2.85; 95% CI 1.86-4.37, P<.0001) and in HON, (RR 1.6; 95% CI 1.04-2.52; P=.03), when compared to SIAD. The Charlson Comorbidity Index was lower in SIAD than in eunatraemic patients (P<.0001). 9/121(7.4%) patients died with plasma sodium <125 mmol/L and 4(3.3%) with plasma sodium <120 mmol/L. However, 69/121(57%) patients died with a plasma sodium above 133 mmol/L. CONCLUSIONS We confirmed higher all-cause mortality in hyponatraemia than in NN. Mortality was higher in SIAD than in normonatraemia and was not explained on the basis of co-morbidities. Mortality was higher in HON and HEN than in SIAD. Mortality rates reported for all-cause hyponatraemia in the medical literature are not applicable to SIAD.
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Affiliation(s)
- Martín Cuesta
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - Aoife Garrahy
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - David Slattery
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - Saket Gupta
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - Anne Marie Hannon
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - Karen McGurren
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - Mark Sherlock
- Department of Endocrinology, The Adelaide and Meath Hospital, Dublin/Trinity College, Dublin, Ireland
| | - William Tormey
- Department of Chemical Pathology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
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Garrahy A, Thompson CJ. Syndrome of inappropriate antidiuresis should it be managed by specialised endocrinologists? Endocrine 2017; 57:193-195. [PMID: 28451925 DOI: 10.1007/s12020-017-1304-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 04/10/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Aoife Garrahy
- Academic Dept of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - Chris J Thompson
- Academic Dept of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland.
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