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Shah SR, Bhave G. Using Electrolyte Free Water Balance to Rationalize and Treat Dysnatremias. Front Med (Lausanne) 2018; 5:103. [PMID: 29740578 PMCID: PMC5925609 DOI: 10.3389/fmed.2018.00103] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 03/29/2018] [Indexed: 01/07/2023] Open
Abstract
Dysnatremias or abnormalities in plasma [Na+] are often termed disorders of water balance, an unclear physiologic concept often confused with changes in total fluid balance. However, most clinicians clearly recognize that hypertonic or hypotonic gains or losses alter plasma [Na+], while isotonic changes do not modify plasma [Na+]. This concept can be conceptualized as the electrolyte free water balance (EFWB), which defines the non-isotonic components of inputs and outputs to determine their effect on plasma [Na+]. EFWB is mathematically proportional to the rate of change in plasma [Na+] (dPNa/dt) and, therefore, is actively regulated to zero so that plasma [Na+] remains stable at its homeostatic set point. Dysnatremias are, therefore, disorders of EFWB and the relationship between EFWB and dPNa/dt provides a rationale for therapeutic strategies incorporating mass and volume balance. Herein, we leverage dPNa/dt as a desired rate of correction of plasma [Na+] to define a stepwise approach for the treatment of dysnatremias.
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Affiliation(s)
- Sanjeev R. Shah
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Gautam Bhave
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
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Abstract
Pioneering investigations conducted over a half century ago on tonicity, transcapillary fluid exchange, and the distribution of water and solute serve as a foundation for understanding the physiology of body fluid spaces. With passage of time, however, some of these concepts have lost their connectivity to more contemporary information. Here we examine the physical forces determining the compartmentalization of body fluid and its movement across capillary and cell membrane barriers, drawing particular attention to the interstitium operating as a dynamic interface for water and solute distribution rather than as a static reservoir. Newer work now supports an evolving model of body fluid dynamics that integrates exchangeable Na(+) stores and transcapillary dynamics with advances in interstitial matrix biology.
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Affiliation(s)
- Gautam Bhave
- Division of Nephrology and Hypertension, Department of Medicine, S3223 Medical Center North, Vanderbilt University School of Medicine, Nashville, TN 37232-2372, USA.
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Abstract
Both individual cells and organs regulate their volume in response to sustained hypo-osmolality via solute and water losses. Similar processes occur in the whole body to regulate the volumes of extracellular fluid (ECF) and intravascular spaces toward normal levels. Body water losses occur via the phenomena "escape from antidiuresis"; solute losses occur through the secondary natriuresis induced by water retention. As a result of resistance to arginine vasopressin (AVP) signaling, escape from antidiuresis is caused by downregulation of kidney aquaporin-2 expression despite high AVP plasma levels. Recent data have implicated downregulation of vasopressin V2R as a potential mechanism of resistance, and suggest that this may be a result of decreased intrarenal angiotensin II signaling in combination with increased intrarenal nitric oxide and prostaglandin E2 signaling. The natriuresis that results in volume regulation of the ECF and vascular spaces is the result of intrarenal hemodynamic changes produced by volume expansion, but the degree to which these effects are modulated by aldosterone secretion and the activity of distal sodium cotransporters and channels remains to be elucidated. The clinical implication of these volume-regulatory processes is that the chronic hyponatremic state is one of water retention and solute losses from intracellular fluid and ECF compartments. The degree to which solute losses versus water retention contribute to hyponatremia will vary in association with many factors, including the etiology of the hyponatremia, the rapidity of development of the hyponatremia, the chronicity of the hyponatremia, the volume of daily water loading, and individual variability. Understanding these volume-regulatory processes allows a better understanding of many aspects of the conundrum of patients with "clinical euvolemia" and dilutional hyponatremia from AVP-induced water retention.
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Affiliation(s)
- Joseph G Verbalis
- Department of Medicine, Georgetown University School of Medicine, Washington, District of Columbia, USA.
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Noakes TD, Sharwood K, Speedy D, Hew T, Reid S, Dugas J, Almond C, Wharam P, Weschler L. Three independent biological mechanisms cause exercise-associated hyponatremia: evidence from 2,135 weighed competitive athletic performances. Proc Natl Acad Sci U S A 2005; 102:18550-5. [PMID: 16344476 PMCID: PMC1311740 DOI: 10.1073/pnas.0509096102] [Citation(s) in RCA: 236] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2004] [Indexed: 11/18/2022] Open
Abstract
To evaluate the role of fluid and Na+ balance in the development of exercise-associated hyponatremia (EAH), changes in serum Na+ concentrations ([Na+]) and in body weight were analyzed in 2,135 athletes in endurance events. Eighty-nine percent of athletes completed these events either euhydrated (39%) or with weight loss (50%) and with normal (80%) or elevated (13%) serum [Na+]. Of 231 (11%) athletes who gained weight during exercise, 70% were normonatremic or hypernatremic, 19% had a serum [Na+] between 129-135 mmol/liter, and 11% a serum [Na+] of <129 mmol/liter. Serum [Na+] after racing was a linear function with a negative slope of the body weight change during exercise. The final serum [Na+] in a subset of 18 subjects was predicted from the amount of Na+ that remained osmotically inactive at the completion of the trial. Weight gain consequent to excessive fluid consumption was the principal cause of a reduced serum [Na+] after exercise, yet most (70%) subjects who gained weight maintained or increased serum [Na+], requiring the addition of significant amounts of Na+ (>500 mmol) into an expanded volume of total body water. This Na+ likely originated from osmotically inactive, exchangeable stores. Thus, EAH occurs in athletes who (i) drink to excess during exercise, (ii) retain excess fluid because of inadequate suppression of antidiuretic hormone secretion, and (iii) osmotically inactivate circulating Na+ or fail to mobilize osmotically inactive sodium from internal stores. EAH can be prevented by insuring that athletes do not drink to excess during exercise, which has been known since 1985.
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Affiliation(s)
- T D Noakes
- University of Cape Town/Medical Research Council Research Unit for Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town/Sports Science Institute of South Africa, Newlands, 7700, South Africa.
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Campling BG, Sarda IR, Baer KA, Pang SC, Baker HM, Lofters WS, Flynn TG. Secretion of atrial natriuretic peptide and vasopressin by small cell lung cancer. Cancer 1995; 75:2442-51. [PMID: 7736387 DOI: 10.1002/1097-0142(19950515)75:10<2442::aid-cncr2820751009>3.0.co;2-q] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Hyponatremia in patients with small cell lung cancer (SCLC) is a common clinical problem usually attributed to tumor secretion of arginine vasopressin (AVP). It recently was shown that some SCLC cell lines produce atrial natriuretic peptide (ANP). The purpose of this investigation was to determine the frequency and clinical consequences of secretion of ANP by SCLC and the relative contribution of ANP and AVP to the hyponatremia associated with this disease. METHODS Levels of ANP and AVP were measured in 23 SCLC cell lines and 23 other human tumor cell lines. Also, ANP and AVP levels were determined in plasma samples from 69 patients with active small cell carcinomas. RESULTS Of the 23 SCLC lines, 16 (70%) had elevated ANP levels. Only two (8.7%) had elevated AVP levels, and these two also had elevated ANP levels. One of the ANP-producing cell lines was derived from a hyponatremic patient with no other apparent explanation for a low sodium level. However, the four cell lines with the highest levels of ANP were derived from patients who were not hyponatremic. Two other human tumor lines also produced ANP. Of the 69 patients with SCLC, 21 (30.4%) had elevated ANP levels, whereas 4 (6%) had elevated AVP levels. Fifteen of these patients were hyponatremic during their clinical course (21.7%). Of the eight patients who were hyponatremic when samples were collected, two had elevated ANP levels, and only one had elevated AVP levels. Six patients (8.7%) had symptoms of postural hypotension, possibly attributable in some cases of tumor secretion of ANP. CONCLUSIONS The majority of SCLC lines produce ANP, and a minority produce AVP. Secretion of ANP may result in hyponatremia and/or postural hypotension. However, secretion of either or both of these peptides does not account for all cases of hyponatremia in patients with SCLC and does not necessarily cause clinical manifestations.
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Affiliation(s)
- B G Campling
- Department of Oncology, Queen's University, Kingston, Canada
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Southgate HJ, Burke BJ, Walters G. Body space measurements in the hyponatraemia of carcinoma of the bronchus: evidence for the chronic 'sick cell' syndrome? Ann Clin Biochem 1992; 29 ( Pt 1):90-5. [PMID: 1536534 DOI: 10.1177/000456329202900114] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Body space measurements using simultaneous multiple isotope dilution techniques were made in both hyponatraemic and normonatraemic patients with carcinoma of the bronchus and wasting, and compared with those in a group of normal volunteers. Both groups of patients showed osmolal loss from cells. The significance of these findings in relation to the development of hyponatraemia is discussed.
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Affiliation(s)
- H J Southgate
- Department of Chemical Pathology, Worthing Hospital, UK
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Cottrill CM. CORRESPONDENCE. EQUINE VET EDUC 1990. [DOI: 10.1111/j.2042-3292.1990.tb01368.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Case reports and the literature on the treatment of severe hyponatremia were reviewed. It appeared that the conflicting opinions with respect to the rate of correction of severe hyponatremia could be reduced to not differentiating between acute and chronic hyponatremia, to using different criteria for this distinction, and to differences in treatment strategy. After reviewing the available data in the literature, it is suggested that hyponatremia should be classified as acute whenever the rate of decrease of serum sodium exceeds 0.5 mmol/L/hour. If it is unknown at which rate the hyponatremia has developed, it can be assumed to be acute if within a short period of time (two to three days), large quantities of fluid are ingested orally or administered parenterally, especially hypotonic fluids in the presence of impaired water excretion. In other cases, chronic hyponatremia is probable. It is concluded that acute hyponatremia should be treated without delay and rapidly at a rate of at least 1 mmol/L/hour, to prevent severe neurologic damage or death. With respect to chronic hyponatremia, it appeared that severe neurologic complications almost exclusively occurred in patients who were treated with hypertonic or isotonic saline without the addition of furosemide or an osmotic diuretic agent, resulting in a (rapid) correction rate of 0.5 mmol/L/hour or more. In contrast, patients with severe chronic hyponatremia treated with furosemide and isotonic or hypertonic saline almost uniformly did well after rapid correction. Uneventful recovery is also the rule when severe chronic hyponatremia is corrected slowly, at a rate less than 0.5 mmol/L/hour. On pathophysiologic grounds, and bearing in mind that slow correction was used in the majority of reported patients in the literature with severe chronic hyponatremia who recovered without neurologic complications, this treatment modality is preferable. Whenever the available data do not permit a differentiation between acute or chronic hyponatremia, rapid correction has to be pursued by means of administration of hypertonic or isotonic saline together with furosemide.
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Affiliation(s)
- F H Cluitmans
- Department of General Internal Medicine, University Hospital of Leiden, The Netherlands
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Schmidt JA, Krause A, Feddersen CO, Kohl FV, Mariss G, Lütcke A, von Wichert P. [Central pontine myelinolysis following severe hyponatremia]. KLINISCHE WOCHENSCHRIFT 1990; 68:191-8. [PMID: 2314007 DOI: 10.1007/bf01649086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Central pontine myelinolysis is a process of demyelinisation with variable neurological symptoms related to the localization. Predisposing factors are alcoholism and malnutrition. Rapid correction of severe hyponatremia is suspected to be a primary cause for central pontine myelinolysis. We report a 43 year old chronic alcoholic and polytoxicomanic female patient, who was admitted comatose with a serum sodium level of 94 mmol/l, caused by a syndrome of inappropriate ADH secretion. After initial improvement under careful sodium correction, the patients neurologic condition degraded progressively and within 4 weeks she developed a "locked-in"-syndrome. Only then the suspected central pontine myelinolysis could be demonstrated in nuclear magnetic resonance and computer tomography. We presume that, although sodium correction was done relatively slowly in this patient, it probably contributed to her development of central pontine myelinolysis all the same. Due to this case we review the literature on correction of hyponatremia, which shows growing evidence that it should start early but be continued very slowly (rise in serum-Na: max. 0.6 mmol/l/h) and requires frequent laboratory controls.
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Affiliation(s)
- J A Schmidt
- Medizinische Universität Poliklinik, Philipps-Universität, Marburg
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Boer WH, Koomans HA, Dorhout Mees EJ. Lithium clearance during the paradoxical natriuresis of hypotonic expansion in man. Kidney Int 1987; 32:376-81. [PMID: 3669496 DOI: 10.1038/ki.1987.220] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Tubular sodium handling in humans undergoing hypotonic expansion due to the administration of antidiuretic hormone was studied using the clearance of lithium as an index of distal filtrate and sodium delivery. Clearance studies were performed in the morning in eight normal subjects before and on the fourth day of intranasal I-desamino-8-D-arginine vasopressin (dDAVP) administration. Fluid intake was kept constant at 25 ml/kg body weight. After dDAVP body weight increased (2.5 +/- 0.4 kg), plasma sodium fell (from 143 +/- 1 to 128 +/- 5 mmol/liter) and a progressive natriuresis developed. Sodium balance remained negative up to the second clearance study, when the cumulative sodium loss amounted to 148 +/- 96 mmol. Plasma renin activity fell significantly, but plasma aldosterone did not. Inulin clearance rose from 110 +/- 14 to 135 +/- 23 ml/min and lithium clearance from 30.9 +/- 7.6 to 48.9 +/- 15.1 ml/min. Fractional reabsorption of uric acid, phosphate and calcium decreased. Together these changes suggest that the negative sodium balance in hypotonic expansion with dDAVP results from increased filtered sodium load, decreased fractional reabsorption in the proximal tubules, and increased distal delivery. Estimated fractional reabsorption in the distal nephron remained unaltered. The plasma concentration of lithium, of which 10.8 mmol was ingested on the eve of the clearance studies, was not lower during the dDAVP-clearance study. This indicates that the tubular adaptations mentioned are present intermittently, in particular during daytime.
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Affiliation(s)
- W H Boer
- Department of Nephrology and Hypertension, University Hospital, Utrecht, The Netherlands
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Abstract
Malnutrition results in a wide variety of metabolic responses, depending on circumstances, from reactions to pure deprivation of nutrients to include the added stress of injury and sepsis. Important differences of response exist between adults and children. Weight loss with changes in carbohydrate, fat, and protein metabolism are well documented. Disturbances of fluid and electrolyte balance are newer areas of interest as are changes in requirements for micronutrients such as trace metals. Many of these metabolic changes are under hormonal control. The intestinal tract shares in the response to malnutrition, and the consequent changes in mucosal function determine the ability of the intestine to handle enteral feeds. Such a route for nutritional support is important in protecting intestinal function not only in absorption but also in hormone production. Enteral feeding is increasingly having an important role in the interactions between acute diarrhoeal disease and malnutrition.
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Abstract
The treatment of hyponatremia is controversial: some authorities have cautioned that rapid correction causes central pontine myelinolysis, and others warn that severe hyponatremia has a high mortality rate unless it is corrected rapidly. Eight patients treated over a five-year period at our two institutions had a neurologic syndrome with clinical or pathological findings typical of central pontine myelinolysis, which developed after the patients presented with severe hyponatremia. Each patient's condition worsened after relatively rapid correction of hyponatremia (greater than 12 mmol of sodium per liter per day)--a phenomenon that we have called the osmotic demyelination syndrome. Five of the patients were treated at one hospital, and accounted for all the neurologic complications recorded among 60 patients with serum sodium concentrations below 116 mmol per liter; no patient in whom the sodium level was raised by less than 12 mmol per liter per day had any neurologic sequelae. Reviewing published reports on patients with very severe hyponatremia (serum sodium less than 106 mmol per liter) revealed that neurologic sequelae were associated with correction of hyponatremia by more than 12 mmol per liter per day; when correction proceeded more slowly, patients had uneventful recoveries. We suggest that the osmotic demyelination syndrome is a preventable complication of overly rapid correction of chronic hyponatremia.
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Vieweg WV, David JJ, Rowe WT, Peach MJ, Veldhuis JD, Kaiser DL, Spradlin WW. Psychogenic polydipsia and water intoxication--concepts that have failed. Biol Psychiatry 1985; 20:1308-20. [PMID: 4063421 DOI: 10.1016/0006-3223(85)90116-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Ten patients (8 men, 2 women; mean age 38.7 +/- 8.1 years), 7 of whom had schizophrenic disorders and 3 of whom had bipolar disorder (manic-depressive illness), manifested psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome). The relationship between serum sodium and urinary water excretion among the 10 PIP patients is described in detail. The success of lithium in improving serum sodium levels and in decreasing urinary water excretion among the three PIP patients with bipolar disorder and the failure of changes in urinary water excretion to explain changes in serum sodium levels among the 10 PIP patients argue against "psychogenesis" as the explanation for the polydipsia and excessive water intake as the sole explanation for hyponatremia or complications ascribed to water intoxication.
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Rivers RP, Forsling ML, Olver RP. Inappropriate secretion of antidiuretic hormone in infants with respiratory infections. Arch Dis Child 1981; 56:358-63. [PMID: 7259256 PMCID: PMC1627435 DOI: 10.1136/adc.56.5.358] [Citation(s) in RCA: 40] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Four infants in whom excessive secretion of antidiuretic hormone was associated with pulmonary infections are reported. Severe hyponatraemia was noted in 3 of them; in the fourth, fluid restriction may have prevented this complication.
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Padfield PL, Morton JJ. Potassium in the syndrome of inappropriate antidiuretic hormone secretion. Postgrad Med J 1979; 55:721-2. [PMID: 537960 PMCID: PMC2425736 DOI: 10.1136/pgmj.55.648.721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Serum potassium concentration was normal (greater than or equal to 3.6 mmol/l) in 29 of 32 patients with the syndrome of inappropriate antidiuretic hormone excess (SIADH) associated with a bronchogenic carcinoma. In 11 of the patients there was no significant change in serum potassium concentration after correction of the syndrome, by fluid restriction. Hypokalaemia is thus an uncommon finding in SIADH due to bronchogenic carcinomas.
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Abstract
The syndrome of inappropriate secretion of antidiuretic hormone is characterized by production of less than maximally dilute urine in the presence of hypotonic plasma. It may be secondary to malignant disease, central nervous system disorders, or pulmonary disease, among other conditions, or it may be idiopathic. Manifestations are those of water intoxication, eg, confusion, fatigue, nausea, headache, and neurologic signs. The pathogenesis is not completely understood. Restriction of fluid intake to obtain a negative water balance is effective treatment.
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Abstract
SIADH consists of hyponatremia and hyposmolality, continued urinary loss of sodium, excretion of an inappropriately concentrated urine, and absence of dehydration, usually in the presence of normal renal and adrenal function. The retention of excess water caused by the inappropriate secretion of antidiuretic hormone is central to the development of the syndrome. In pediatrics, SIADH is most commonly seen in patients with meningitis or postoperatively. Fluid restriction is vital in such patients to prevent the development of symptomatic SIADH. Fluid restriction alone will also result in the correction of serum electrolyte composition in patients with SIADH. Hypertonic saline should be used only in severely symptomatic patients.
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Abstract
Among the malignant tumors of nonendocrine origin that are capable of producing polypeptide hormones and of manifesting as different endocrine syndromes discussed here are ectopic ACTH syndrome, SIADH, and ectopic gonadotropin-producing tumors.
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Scheiner E. The relationship of antidiuretic hormone to the control of volume and tonicity in the human. Adv Clin Chem 1975; 17:1-52. [PMID: 165659 DOI: 10.1016/s0065-2423(08)60247-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Mir MA, Delamore IW. Hyponatraemia syndrome in acute myeloid leukaemia. BRITISH MEDICAL JOURNAL 1974; 1:52-5. [PMID: 4521414 PMCID: PMC1632902 DOI: 10.1136/bmj.1.5897.52] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Hyponatraemia was observed in 11 out of 14 consecutive patients with acute myeloid leukaemia and its variants. Metabolic studies on these patients revealed an early increase in the urinary sodium excretion, negative free water clearance, and urine osmolality inappropriately higher than that of the serum. It is postulated that this syndrome is caused by a substance released from the primitive cells of the abnormal myeloid series.
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Hayduk K, Kaufmann W. [Ectopic paraneoplastic endocrinopathies associated with water-electrolyte balance disorders]. KLINISCHE WOCHENSCHRIFT 1973; 51:361-76. [PMID: 4354699 DOI: 10.1007/bf01468084] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Stulberger EA, Woodruff LM. Inappropriate antidiuresis in the urologic patient. J Urol 1972; 107:104-8. [PMID: 5058020 DOI: 10.1016/s0022-5347(17)60959-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Nolph KD, Schrier RW. Sodium, potassium and water metabolism in the syndrome of inappropriate antidiuretic hormone secretion. Am J Med 1970; 49:534-45. [PMID: 5477638 DOI: 10.1016/s0002-9343(70)80048-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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MacLennan WJ. Inappropriate antidiuretic hormone secretion associated with bronchial carcinoma, intracranial trauma and hypothyroidism: a diagnostic problem. Postgrad Med J 1970; 46:324-6. [PMID: 5448380 PMCID: PMC2467015 DOI: 10.1136/pgmj.46.535.324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Jones NF, Barraclough MA, Forsling ML, Petch CP. Inappropriate production of vasopressin, potassium deficiency and cerebrovascular disease. Am J Med 1968; 45:474-9. [PMID: 5672743 DOI: 10.1016/0002-9343(68)90081-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Herms W. [The effects of disorders of electrolyte balance on the structure and function of the kidneys]. KLINISCHE WOCHENSCHRIFT 1967; 45:1169-80. [PMID: 4876332 DOI: 10.1007/bf01727630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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