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Veligratli F, Alexandrou D, Shah S, Amin R, Dattani M, Gan HW, Famuboni A, Lopez-Garcia C, Trompeter R, Bockenhauer D. Tolvaptan and urea in paediatric hyponatraemia. Pediatr Nephrol 2024; 39:177-183. [PMID: 37466863 DOI: 10.1007/s00467-023-06091-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/06/2023] [Accepted: 07/06/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND The syndrome of inappropriate antidiuretic hormone (SIADH) is usually treated with fluid restriction. This can be challenging in patients with obligate fluid intake for nutrition or medication. Pharmaceutical treatment with tolvaptan and urea is available but minimal paediatric data are available. We review the efficacy and safety of tolvaptan and urea in paediatric patients with SIADH. METHODS Retrospective review of paediatric inpatients with clinical diagnosis of SIADH. Patients were identified from pharmacy records based on tolvaptan and urea prescriptions. Relevant information was extracted from patient electronic records. The main outcome measures included the number of days to sodium normalisation, the daily change in plasma sodium concentration, and the maximum increase of plasma sodium concentration in 24 h. Reported side effects were captured. RESULTS Thirteen patients received tolvaptan and six urea. Five patients had both agents (tolvaptan converted to urea). Tolvaptan led to plasma sodium normalisation in 10/13 (77%) within 6 days (median 2.5 days, range [1, 6]), with a median change of sodium concentration of 7 mmol/L (- 1, 14) within the first 24 h of treatment. Three patients experienced a change in plasma sodium > 10 mmol/l/day but had no apparent side effects. Urea led to sodium normalisation in 5/6 (83%) patients. The median number of days to normalisation with urea was 2 (1, 10) with a median change of plasma sodium concentration of 2 mmol/L (- 1, 6) within the first 24 h. All patients tolerated tolvaptan and/or urea without unexpected side effects. CONCLUSIONS Tolvaptan and urea appear to be safe and effective when fluid restriction is challenging in paediatric SIADH. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Faidra Veligratli
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Demitra Alexandrou
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Sarit Shah
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Rakesh Amin
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Mehul Dattani
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Hoong-Wei Gan
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Adeola Famuboni
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | | | | | - Detlef Bockenhauer
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.
- UCL Department of Renal Medicine, London, UK.
- Department of Paediatric Nephrology, University Hospital and Catholic University Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Gavryutina I, Bargman R, Shaoba A, Alharash H, Mongia A. Chronic hyponatremia in a 19-month-old child with gross developmental delay: Answers. Pediatr Nephrol 2023; 38:1035-1038. [PMID: 35748946 DOI: 10.1007/s00467-022-05648-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/21/2022] [Accepted: 05/23/2022] [Indexed: 12/01/2022]
Affiliation(s)
| | - Renee Bargman
- SUNY Downstate Medical Center, New York, NY, USA.,Kings County Hospital Center, New York, NY, USA
| | - Asma Shaoba
- SUNY Downstate Medical Center, New York, NY, USA
| | | | - Anil Mongia
- SUNY Downstate Medical Center, New York, NY, USA. .,Kings County Hospital Center, New York, NY, USA.
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3
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Cui J, Halpin K, Paprocki E. Urea as safe treatment for hyponatremia due to syndrome of inappropriate antidiuretic hormone in infant with solitary central incisor and neurofibromatosis-1. J Pediatr Endocrinol Metab 2022; 36:430-434. [PMID: 36420541 DOI: 10.1515/jpem-2022-0294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/28/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Classic treatment for syndrome of inappropriate antidiuretic hormone (SIADH) is fluid restriction. However, this is not ideal for infants who need large fluid volumes to ensure adequate caloric intake for growth. The use of urea has not been thoroughly studied in children. CASE PRESENTATION This infant had SIADH complicated by poor growth, solitary central incisor, and NF1. Following failed attempts to correct hyponatremia with fluid restriction and other therapeutics, urea normalized sodium levels and allowed liberalization of formula volumes, which resulted in improved weight gain. CONCLUSIONS Urea is a safe, cost-effective, long-term treatment for SIADH in infants who are unable to fluid restrict due to caloric goals.
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Affiliation(s)
- Joy Cui
- Kansas City University College of Medicine, Kansas City, MO, USA
| | - Kelsee Halpin
- Division of Endocrinology, Children's Mercy Kansas City, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Emily Paprocki
- Division of Endocrinology, Children's Mercy Kansas City, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
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4
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Bardanzellu F, Marcialis MA, Frassetto R, Melis A, Fanos V. Differential diagnosis between syndrome of inappropriate antidiuretic hormone secretion and cerebral/renal salt wasting syndrome in children over 1 year: proposal for a simple algorithm. Pediatr Nephrol 2022; 37:1469-1478. [PMID: 34468821 PMCID: PMC9192468 DOI: 10.1007/s00467-021-05250-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/28/2021] [Accepted: 07/15/2021] [Indexed: 11/24/2022]
Abstract
Hyponatremia, especially if acute and severe, can be a life-threatening condition. Several conditions can trigger hyponatremia. In this review, we will discuss two conditions that can determine euvolemic hyponatremia: the cerebral/renal salt wasting (CRSW) syndrome and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), including the two subtypes: reset osmostat (RO) and nephrogenic syndrome of inappropriate antidiuresis (NSIAD) and their differential diagnoses. Despite the passage of over 70 years since its first description, to date, the true etiopathogenesis of CRSW syndrome, a rare cause of hypovolemic/euvolemic hyponatremia, is almost unknown. SIADH, including RO and NSIAD, is sometimes difficult to differentiate from CRSW syndrome; in its differential diagnosis, the clinical approach based on the evaluation of the extracellular volume (ECV) was proven insufficient. We therefore suggest a simple diagnostic algorithm based on the assessment of the degree of hyponatremia, urinary osmolality, and the assessment of the fraction of urate excretion (FEUa) in conditions of hyponatremia and after serum sodium correction, to be applied in children over 1 year of life.
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Affiliation(s)
- Flaminia Bardanzellu
- Neonatal Intensive Care Unit, Department of Surgical Sciences, AOU and University of Cagliari, SS 554 km 4, 500, 09042, Monserrato, Italy.
| | - Maria Antonietta Marcialis
- grid.7763.50000 0004 1755 3242Neonatal Intensive Care Unit, Department of Surgical Sciences, AOU and University of Cagliari, SS 554 km 4, 500, 09042 Monserrato, Italy
| | - Roberta Frassetto
- grid.7763.50000 0004 1755 3242Neonatal Intensive Care Unit, Department of Surgical Sciences, AOU and University of Cagliari, SS 554 km 4, 500, 09042 Monserrato, Italy
| | - Alice Melis
- grid.7763.50000 0004 1755 3242Neonatal Intensive Care Unit, Department of Surgical Sciences, AOU and University of Cagliari, SS 554 km 4, 500, 09042 Monserrato, Italy
| | - Vassilios Fanos
- grid.7763.50000 0004 1755 3242Neonatal Intensive Care Unit, Department of Surgical Sciences, AOU and University of Cagliari, SS 554 km 4, 500, 09042 Monserrato, Italy
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5
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Driano JE, Lteif AN, Creo AL. Vasopressin-Dependent Disorders: What Is New in Children? Pediatrics 2021; 147:peds.2020-022848. [PMID: 33795481 DOI: 10.1542/peds.2020-022848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 11/24/2022] Open
Abstract
Arginine vasopressin (AVP)-mediated osmoregulatory disorders, such as diabetes insipidus (DI) and syndrome of inappropriate secretion of antidiuretic hormone (SIADH) are common in the differential diagnosis for children with hypo- and hypernatremia and require timely recognition and treatment. DI is caused by a failure to concentrate urine secondary to impaired production of or response to AVP, resulting in hypernatremia. Newer methods of diagnosing DI include measuring copeptin levels; copeptin is AVP's chaperone protein and serves as a surrogate biomarker of AVP secretion. Intraoperative copeptin levels may also help predict the risk for developing DI after neurosurgical procedures. Copeptin levels hold diagnostic promise in other pediatric conditions, too. Recently, expanded genotype and phenotype correlations in inherited DI disorders have been described and may better predict the clinical course in affected children and infants. Similarly, newer formulations of synthetic AVP may improve pediatric DI treatment. In contrast to DI, SIADH, characterized by inappropriate AVP secretion, commonly leads to severe hyponatremia. Contemporary methods aid clinicians in distinguishing SIADH from other hyponatremic conditions, particularly cerebral salt wasting. Further research on the efficacy of therapies for pediatric SIADH is needed, although some adult treatments hold promise for pediatrics. Lastly, expansion of home point-of-care sodium testing may transform management of SIADH and DI in children. In this article, we review recent developments in the understanding of pathophysiology, diagnostic workup, and treatment of better outcomes and quality of life for children with these challenging disorders.
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Affiliation(s)
- Jane E Driano
- School of Medicine, Creighton University, Omaha, Nebraska; and
| | - Aida N Lteif
- Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, Minnesota
| | - Ana L Creo
- Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, Minnesota
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6
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Hayat A, Florkowski C, Kolla A, Potter H. Nephrogenic syndrome of inappropriate antidiuresis. Intern Med J 2019; 49:680-681. [DOI: 10.1111/imj.14284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 09/09/2018] [Accepted: 11/19/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Ashik Hayat
- Department of Medicine and NephrologyTaranaki Base Hospital Taranaki New Zealand
| | | | - Abhijit Kolla
- Department of Medicine and NephrologyTaranaki Base Hospital Taranaki New Zealand
| | - Howard Potter
- Canterbury Health Laboratories Christchurch New Zealand
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7
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Bardanzellu F, Pintus MC, Masile V, Fanos V, Marcialis MA. Focus on neonatal and infantile onset of nephrogenic syndrome of inappropriate antidiuresis: 12 years later. Pediatr Nephrol 2019; 34:763-775. [PMID: 29546600 DOI: 10.1007/s00467-018-3922-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 02/09/2018] [Accepted: 02/09/2018] [Indexed: 11/25/2022]
Abstract
Nephrogenic syndrome of inappropriate antidiuresis (NSIAD), first described in 2005, is a rare genetic X-linked disease, presenting with hyponatremia, hyposmolarity, euvolemia, inappropriately concentrated urine, increased natriuresis, and undetectable or very low arginine-vasopressine (AVP) circulating levels. It can occur in neonates, infants, or later in life. NSIAD must be early recognized and treated to prevent severe hyponatremia, which can show a dangerous impact on neonatal outcome. In fact, it potentially leads to death or, in case of survival, neurologic sequelae. This review is an update of NSIAD 12 years after the first description, focusing on reported cases of neonatal and infantile onset. The different molecular patterns affecting the AVP receptor 2 (V2R) and determining its gain of function are reported in detail; moreover, we also provide a comparison between the different triggers involved in the development of hyponatremia, the evolution of the symptoms, and modality and efficacy of the different treatments available.
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Affiliation(s)
- Flaminia Bardanzellu
- Neonatal Intensive Care Unit, Neonatal Pathology and Neonatal Section, AOU and University of Cagliari, Cagliari, Italy.
| | - Maria Cristina Pintus
- Neonatal Intensive Care Unit, Neonatal Pathology and Neonatal Section, AOU and University of Cagliari, Cagliari, Italy
| | - Valentina Masile
- Neonatal Intensive Care Unit, Neonatal Pathology and Neonatal Section, AOU and University of Cagliari, Cagliari, Italy
| | - Vassilios Fanos
- Neonatal Intensive Care Unit, Neonatal Pathology and Neonatal Section, AOU and University of Cagliari, Cagliari, Italy
| | - Maria Antonietta Marcialis
- Neonatal Intensive Care Unit, Neonatal Pathology and Neonatal Section, AOU and University of Cagliari, Cagliari, Italy
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Lockett J, Berkman KE, Dimeski G, Russell AW, Inder WJ. Urea treatment in fluid restriction-refractory hyponatraemia. Clin Endocrinol (Oxf) 2019; 90:630-636. [PMID: 30614552 DOI: 10.1111/cen.13930] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/12/2018] [Accepted: 12/31/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Hyponatraemia in hospitalized patients is common and associated with increased mortality. International guidelines give conflicting advice regarding the role of urea in the treatment of SIADH. We hypothesized that urea is a safe, effective treatment for fluid restriction-refractory hyponatraemia. DESIGN Review of urea for the treatment of hyponatraemia in patients admitted to a tertiary hospital during 2016-2017. Primary end-point: proportion of patients achieving a serum sodium ≥130 mmol/L at 72 hours. PATIENTS Urea was used on 78 occasions in 69 patients. The median age was 67 (IQR 52-76), 41% were female. Seventy (89.7%) had hyponatraemia due to SIADH-CNS pathology (64.3%) was the most common cause. The duration was acute in 32 (41%), chronic in 35 (44.9%) and unknown in the rest. RESULTS The median nadir serum sodium was 122 mmol/L (IQR 118-126). Fluid restriction was first-line treatment in 65.4%. Urea was used first line in 21.8% and second line in 78.2%. Fifty treatment episodes (64.1%) resulted in serum sodium ≥130 mmol/L at 72 hours. In 56 patients who received other prior treatment, the mean sodium change at 72 hours (6.9 ± 4.8 mmol/L) was greater than with the preceding treatments (-1.0 ± 4.7 mmol/L; P < 0.001). Seventeen patients (22.7%) had side effects (principally distaste), none were severe. No patients developed hypernatraemia, overcorrection (>10 mmol/L in 24 hours or >18 mmol/L in 48 hours), or died. CONCLUSIONS Urea is safe and effective in fluid restriction-refractory hyponatraemia. We recommend urea with a starting dose of ≥30 g/d, in patients with SIADH and moderate to profound hyponatraemia who are unable to undergo, or have failed fluid restriction.
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Affiliation(s)
- Jack Lockett
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Kathryn E Berkman
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Goce Dimeski
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Chemical Pathology, Pathology Queensland, Brisbane, Queensland, Australia
| | - Anthony W Russell
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Warrick J Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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9
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Affiliation(s)
- Deborah P Jones
- Division of Nephrology and Hypertension, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
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10
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Cailleaux A, Mahieu F, Heinrichs C, Adams B, Ismaili K, Brachet C. [Nephrogenic syndrome of inappropriate antidiuresis: Early diagnosis avoids severe hyponatremia complications]. Arch Pediatr 2017; 24:630-633. [PMID: 28583780 DOI: 10.1016/j.arcped.2017.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 01/10/2017] [Accepted: 04/19/2017] [Indexed: 11/18/2022]
Abstract
AIM Nephrogenic syndrome of inappropriate antidiuresis (NSIAD) is a rare disease characterized by a kidney disability to dilute urine and, as a result, severe recurrent hyponatremia. Due to wide variability in clinical expression, the diagnosis still remains a challenge for clinicians. We report our experience of a case in which NSIAD was diagnosed early. We also stress the importance of early diagnosis and treatment, which protects an infant with NSAID from severe hyponatremia. BACKGROUND A 1-month-old boy was referred to our hospital for persistent hyponatremia and intense vomiting. He was born full term after a normal pregnancy with a normal birth weight. The parents were healthy, nonconsanguineous, of Moroccan origin. They already had healthy twin girls. The physical examination was normal upon admission with no signs of dehydration and normal weight gain since birth. Plasma sodium was very low (125mmol/L) associated with low plasma urea (5mg/dL), osmolality (258 mOsm/kg) and low natriuresis (59mmol/L). These laboratory results suggested inappropriate antidiuretic hormone secretion (SIAD) and the infant was consequently treated with oral urea (he was already receiving sodium supplements that were later stopped). Due to exclusive breastfeeding, water restriction was impossible. Further biological investigation revealed undetectable plasma arginine vasopressin (AVP), suggesting the diagnosis of NSIAD. This was confirmed by genetic sequencing of the AVP receptor (AVPR2), demonstrating the presence of an R137C mutation. CONCLUSIONS We herein report a case of a genetic fluid balance disorder due to an activating mutation of AVPR2. NSIAD is an X-linked disease, first described in 2005 by Feldman et al., which involved severe recurrent hyponatremia. The very early diagnosis (at 7 weeks of life) and appropriate treatment with urea prevented seizures and cerebral damage due to severe recurrent hyponatremia. Clinicians should consider the diagnosis of NSIAD in infants with recurrent hyponatremia with hemodilution and low AVP serum level. Genetic analysis of the AVPR2 sequence on the X chromosome will confirm the diagnosis and, given the wide variability of clinical expression, sequencing of the family members should be done.
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Affiliation(s)
- A Cailleaux
- Pediatric Nephrology unit, hôpital universitaire des Enfants-Reine-Fabiola, n(o) 15, avenue J.J.-Crocq, 1020 Bruxelles, Belgique.
| | - F Mahieu
- Pediatric Department, centre hospitalier universitaire de Tivoli, n(o) 34, avenue Max-Buset, 7100 La Louvière, Belgique
| | - C Heinrichs
- Pediatric Endocrinology unit, hôpital universitaire des Enfants-Reine-Fabiola, n(o) 15, avenue J.J.-Crocq, 1020 Bruxelles, Belgique
| | - B Adams
- Pediatric Nephrology unit, hôpital universitaire des Enfants-Reine-Fabiola, n(o) 15, avenue J.J.-Crocq, 1020 Bruxelles, Belgique
| | - K Ismaili
- Pediatric Nephrology unit, hôpital universitaire des Enfants-Reine-Fabiola, n(o) 15, avenue J.J.-Crocq, 1020 Bruxelles, Belgique
| | - C Brachet
- Pediatric Endocrinology unit, hôpital universitaire des Enfants-Reine-Fabiola, n(o) 15, avenue J.J.-Crocq, 1020 Bruxelles, Belgique
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Dufek S, Booth C, Carroll A, van't Hoff W, Kleta R, Bockenhauer D. Urea is successful in treating inappropriate antidiuretic hormone secretion in an infant. Acta Paediatr 2017; 106:513-515. [PMID: 27935121 DOI: 10.1111/apa.13697] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 11/29/2016] [Accepted: 12/06/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Stephanie Dufek
- Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
- UCL Centre for Nephrology; London UK
| | - Christine Booth
- Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
| | - Adrian Carroll
- Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
| | - William van't Hoff
- Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
| | - Robert Kleta
- Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
- UCL Centre for Nephrology; London UK
| | - Detlef Bockenhauer
- Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
- UCL Centre for Nephrology; London UK
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12
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Powlson AS, Challis BG, Halsall DJ, Schoenmakers E, Gurnell M. Nephrogenic syndrome of inappropriate antidiuresis secondary to an activating mutation in the arginine vasopressin receptor AVPR2. Clin Endocrinol (Oxf) 2016; 85:306-12. [PMID: 26715131 DOI: 10.1111/cen.13011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 11/18/2015] [Accepted: 12/23/2015] [Indexed: 01/15/2023]
Abstract
CONTEXT Nephrogenic syndrome of inappropriate antidiuresis (NSIAD), resulting from activating mutations in the arginine vasopressin receptor type 2 (AVPR2), is a rare cause of hyponatraemia. However, its true prevalence may be underestimated and it should be considered in the investigation of unexplained hyponatraemia, with implications for management and targeted gene testing. OBJECTIVE We describe a structured approach to the investigation of hyponatraemia in a young patient, which allowed a diagnosis of NSIAD to be made. We review current knowledge of NSIAD and use a structural modelling approach to further our understanding of the potential mechanisms by which the causative mutation leads to a constitutively active AVPR2. DESIGN Clinical and biochemical investigation of hyponatraemia; a formal water load test with measurement of arginine vasopressin levels (AVP); sequencing of AVPR2; and computed structural modelling of the wild-type and constitutively activated mutant receptors. RESULTS A 38-year-old man presented with intermittent confusion and nausea associated with hyponatraemia and a biochemical picture consistent with syndrome of inappropriate antidiuretic hormone (SIADH). Adrenocortical and thyroid function and an acute intermittent porphyria screen were normal. Cross-sectional imaging of the head, chest and abdomen did not identify an underlying cause and so we proceeded to a water load test. This demonstrated a marked inability to excrete a free water load (just 15% of a 20 ml/kg oral load by 240 min postingestion), with the onset of hyponatraemia (Na(+) 125 mmol/l, urine osmolality 808 mOsm/kg). However, AVP levels were low throughout the test (0·4-0·9 pmol/l), consistent with a diagnosis of NSIAD. AVPR2 sequencing revealed a previously described hemizygous activating mutation (p.Arg137Cys). Through structural modelling of AVPR2, we suggest that disruption of a hydrogen bond between residues Thr269 and Arg137 may promote stabilization of the receptor in its active conformation. Since diagnosis, the patient has adhered to modest fluid restriction and remained well, with no further episodes of hyponatraemia. CONCLUSION NSIAD should be considered in young patients with unexplained hyponatraemia. A water load test with AVP measurement is a potentially informative investigation, while AVPR2 sequencing provides a definitive molecular genetic diagnosis and a rationale for long-term fluid restriction.
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Affiliation(s)
- Andrew S Powlson
- Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge & National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Benjamin G Challis
- Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge & National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - David J Halsall
- Department of Clinical Biochemistry, Addenbrooke's Hospital, Cambridge, UK
| | - Erik Schoenmakers
- Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge & National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Mark Gurnell
- Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge & National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
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13
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Brachet C, Vandergheynst F, Heinrichs C. Nephrogenic Syndrome of Inappropriate Antidiuresis in a Female Neonate: Review of the Clinical Presentation in Females. Horm Res Paediatr 2016; 84:65-7. [PMID: 25925274 DOI: 10.1159/000381586] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 03/04/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Nephrogenic syndrome of inappropriate antidiuresis (NSIAD) is a rare X-linked disease due to gain-of-function mutations in the AVP V2 receptor gene. Hemizygous males present with recurrent episodes of severe hyponatremia in infancy. Heterozygous females are usually asymptomatic. CASE REPORT We report on a 23-day-old female neonate, born at term with 3,260 g that presented with recurrent hyponatremia (Na between 124 and 134 mmol/l) due to NSIAD. She was a heterozygous carrier of the c.409 C>T mutation in the AVPR2 gene. CONCLUSIONS This is the first report of a female neonate presenting with hyponatremia due to NSIAD. The diagnosis of NSIAD should not be limited to male infants and should also be considered in female infants with the clinical picture of inappropriate antidiuresis.
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Affiliation(s)
- Cécile Brachet
- Endocrinology Unit, Department of Pediatrics, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
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14
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Chen S, Zhao JJ, Tong NW, Guo XH, Qiu MC, Yang GY, Liu ZM, Ma JH, Zhang ZW, Gu F. Randomized, double blinded, placebo-controlled trial to evaluate the efficacy and safety of tolvaptan in Chinese patients with hyponatremia caused by SIADH. J Clin Pharmacol 2015; 54:1362-7. [PMID: 24906029 DOI: 10.1002/jcph.342] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 06/04/2014] [Indexed: 11/08/2022]
Abstract
To study the effect of tolvaptan on non-acute, non-hypovolemic hyponatremia in inappropriate secretion of antidiuretic hormone (SIADH) syndrome in Chinese patients. Hyponatremic SIADH patients received placebo (N = 18) or tolvaptan (N = 19) at an initial dose of 15 mg/day with further titration to 30 mg/day and 60 mg/day based on serum sodium concentrations. Randomized, double-blind, placebo-controlled trial. Primary endpoint was the change of the serum sodium from baseline to days 4 and 7. Analysis of covariance (ANCOVA) was used for statistical analysis. At day 4, average daily changes in serum sodium levels from baseline was 1.9 ± 2.9 mmol/L (1.9 ± 2.9 mEq/L) in the placebo group and 8.1 ± 3.6 mmol/L (8.1 ± 3.6 mEq/L) in the tolvaptan group; at day 7, the values were 2.5 ± 3.9 mmol/L (2.5 ± 3.9 mEq/L) and 8.6 ± 3.9 mmol/L (8.6 ± 3.9 mmEq/L) for the placebo and tolvaptan groups (ANCOVA, P < 0.001). At days 4 and 7, daily urine output and proportions of patients with normalized serum sodium were significantly superior in the tolvaptan group. The most common adverse events occurring in the tolvaptan group were dry mouth and thirst. Tolvaptan demonstrated superiority to placebo in the treatment of Chinese SIADH patients with hyponatremia by elevating serum sodium concentration with acceptable safety profile.
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Affiliation(s)
- Shi Chen
- Department of Endocrinology, Key laboratory of endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academe of Medical Sciences & Peking Union Medical College, Beijing 100730, China
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Greenberg JH, Tufro A, Marsenic O. Approach to the Treatment of the Infant With Hyponatremia. Am J Kidney Dis 2015; 65:513-7. [DOI: 10.1053/j.ajkd.2014.10.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 10/02/2014] [Indexed: 11/11/2022]
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Runkle I, Villabona C, Navarro A, Pose A, Formiga F, Tejedor A, Poch E. [The treament of hyponatremia secundary to the syndrome of inappropriate antidiuretic hormone secretion]. Med Clin (Barc) 2013; 141:507.e1-507.e10. [PMID: 24169317 DOI: 10.1016/j.medcli.2013.09.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 09/02/2013] [Accepted: 09/05/2013] [Indexed: 01/16/2023]
Abstract
The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is the most frequent cause of hyponatremia in a hospital setting. However, detailed protocols and algorithms for its management are lacking. Our objective was to develop 2 consensus algorithms for the therapy of hyponatremia due to SIADH in hospitalized patients. A multidisciplinary group made up of 2 endocrinologists, 2 nephrologists, 2 internists, and one hospital pharmacist held meetings over the period of a year. The group worked under the auspices of the European Hyponatremia Network and the corresponding Spanish medical societies. Therapeutic proposals were based on widely-accepted recommendations, expert opinion and consensus guidelines, as well as on the authors' personal experience. Two algorithms were developed. Algorithm 1 addresses acute correction of hyponatremia posing as a medical emergency, and is applicable to both severe euvolemic and hypovolemic hyponatremia. The mainstay of this algorithm is the iv use of 3% hypertonic saline solution. Specific infusion rates are proposed, as are steps to avoid or reverse overcorrection of serum sodium levels. Algorithm 2 is directed to the therapy of SIADH-induced mild or moderate, non-acute hyponatremia. It addresses when and how to use fluid restriction, solute, furosemide, and tolvaptan to achieve eunatremia in patients with SIADH. Two complementary strategies were elaborated to treat SIADH-induced hyponatremia in an attempt to increase awareness of its importance, simplify its therapy, and improve prognosis.
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Affiliation(s)
- Isabelle Runkle
- Servicio de Endocrinología, Hospital Universitario Clínico San Carlos, Madrid, España.
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Verbalis JG, Goldsmith SR, Greenberg A, Korzelius C, Schrier RW, Sterns RH, Thompson CJ. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. Am J Med 2013; 126:S1-42. [PMID: 24074529 DOI: 10.1016/j.amjmed.2013.07.006] [Citation(s) in RCA: 603] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hyponatremia is a serious, but often overlooked, electrolyte imbalance that has been independently associated with a wide range of deleterious changes involving many different body systems. Untreated acute hyponatremia can cause substantial morbidity and mortality as a result of osmotically induced cerebral edema, and excessively rapid correction of chronic hyponatremia can cause severe neurologic impairment and death as a result of osmotic demyelination. The diverse etiologies and comorbidities associated with hyponatremia pose substantial challenges in managing this disorder. In 2007, a panel of experts in hyponatremia convened to develop the Hyponatremia Treatment Guidelines 2007: Expert Panel Recommendations that defined strategies for clinicians caring for patients with hyponatremia. In the 6 years since the publication of that document, the field has seen several notable developments, including new evidence on morbidities and complications associated with hyponatremia, the importance of treating mild to moderate hyponatremia, and the efficacy and safety of vasopressin receptor antagonist therapy for hyponatremic patients. Therefore, additional guidance was deemed necessary and a panel of hyponatremia experts (which included all of the original panel members) was convened to update the previous recommendations for optimal current management of this disorder. The updated expert panel recommendations in this document represent recommended approaches for multiple etiologies of hyponatremia that are based on both consensus opinions of experts in hyponatremia and the most recent published data in this field.
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Frouget T. [The syndrome of inappropriate antidiuresis]. Rev Med Interne 2012; 33:556-66. [PMID: 22884285 DOI: 10.1016/j.revmed.2012.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 06/11/2012] [Accepted: 07/05/2012] [Indexed: 11/26/2022]
Abstract
The syndrome of inappropriate antidiuresis (SIAD; formerly the syndrome of inappropriate secretion of antidiuretic hormone) is the most frequent cause of hyponatremia. A strong association exists between mortality and hyponatremia, which reflects the severity of the underlying disease. In SIAD, hyponatremia is associated with normovolaemia but the assessment of extracellular volume can be difficult. Clinical features are mainly neurological and can lead to death but mechanisms of adaptation can limit cerebral oedema. The notion of mild asymptomatic hyponatremia was questioned by the observation of subclinical neurocognitive impairment, a greater risk of falls and fractures. Aetiologies are classified into six groups: neurologic disorders, infections mainly cerebral, meningeal and pulmonary, drugs in particular antidepressants, tumors, genetic causes, and idiopathic. Symptomatic acute hyponatremia is a therapeutic emergency that is not specific of SIAD. When hyponatremia is asymptomatic, fluid restriction with salt intake is generally sufficient but urea can be an alternative. In chronic SIAD, there is currently no recommendation. Fluid restriction is not always feasible; urea has proved its efficacy, its good tolerance and its long-term harmlessness. Vaptans have demonstrated their good tolerance and their efficacy on the correction of hyponatremia from SIAD in studies subgroups, for moderate hyponatremia and asymptomatic patients. In the only study having compared vaptans and urea, efficacy and tolerance were similar. Because of the cost difference between vaptans and urea and while waiting for follow-up studies, urea appears at present as the first-line treatment of hyponatremia in SIAD.
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Affiliation(s)
- T Frouget
- Service de Néphrologie, CHU de Pontchaillou, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex 9, France.
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Soupart A, Coffernils M, Couturier B, Gankam-Kengne F, Decaux G. Efficacy and Tolerance of Urea Compared with Vaptans for Long-Term Treatment of Patients with SIADH. Clin J Am Soc Nephrol 2012; 7:742-7. [DOI: 10.2215/cjn.06990711] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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21
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Abstract
Mutations in the vasopressin V2 receptor gene are responsible for two human tubular disorders: X-linked congenital nephrogenic diabetes insipidus, due to a loss of function of the mutant V2 receptor, and the nephrogenic syndrome of inappropriate antidiuresis, due to a constitutive activation of the mutant V2 receptor. This latter recently described disease may be diagnosed from infancy to adulthood, as some carriers remain asymptomatic for many years. Symptomatic children, however, typically present with clinical and biological features suggesting inappropriate antidiuretic hormone secretion with severe hyponatremia and high urine osmolality, but a low plasma arginine vasopressin level. To date, only two missense mutations in the vasopressin V2 receptor gene have been found in the reported patients. The pathophysiology of the disease requires fuller elucidation as the phenotypic variability observed in patients bearing the same mutations remains unexplained. The treatment is mainly preventive with fluid restriction, but urea may also be proposed.
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Cheung CC, Cadnapaphornchai MA, Ranadive SA, Gitelman SE, Rosenthal SM. Persistent elevation of urine aquaporin-2 during water loading in a child with nephrogenic syndrome of inappropriate antidiuresis (NSIAD) caused by a R137L mutation in the V2 vasopressin receptor. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2012; 2012:3. [PMID: 22325688 PMCID: PMC3299583 DOI: 10.1186/1687-9856-2012-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 02/10/2012] [Indexed: 11/28/2022]
Abstract
Nephrogenic Syndrome of Inappropriate Antidiuresis (NSIAD) is a novel disease caused by a gain-of-function mutation in the V2 vasopressin receptor (V2R), which results in water overload and hyponatremia. We report the effect of water loading in a 3-year old boy with NSIAD, diagnosed in infancy, to assess urine aquaporin-2 (AQP2) excretion as a marker for V2R activation, and to evaluate the progression of the disease since diagnosis. The patient is one of the first known NSIAD patients and the only patient with a R137L mutation. Patient underwent a standard water loading test in which serum and urine sodium and osmolality, serum AVP, and urine AQP2 excretion were measured. The patient was also evaluated for ad lib fluid intake before and after the test. This patient demonstrated persistent inability to excrete free water. Only 39% of the water load (20 ml/kg) was excreted during a 4-hour period (normal ≥ 80-90%). Concurrently, the patient developed hyponatremia and serum hypoosmolality. Serum AVP levels were detectable at baseline and decreased one hour after water loading; however, urine AQP2 levels were elevated and did not suppress normally during the water load. The patient remained eunatremic but relatively hypodipsic during ad lib intake. In conclusion, this is the first demonstration in a patient with NSIAD caused by a R137L mutation in the V2R that urine AQP2 excretion is inappropriately elevated and does not suppress normally with water loading. In addition, this is the first longitudinal report of a pediatric patient with NSIAD diagnosed in infancy who demonstrates the ability to maintain eunatremia during ad lib dietary intake.
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Affiliation(s)
- Clement C Cheung
- Department of Pediatrics, Division of Endocrinology, University of California, San Francisco, San Francisco, CA 94143.
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23
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Chehade H, Rosato L, Girardin E, Cachat F. Inappropriate antidiuretic hormone secretion: long-term successful urea treatment. Acta Paediatr 2012; 101:e39-42. [PMID: 21672011 DOI: 10.1111/j.1651-2227.2011.02382.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
UNLABELLED Hyponatremia is the main complication of inappropriate antidiuretic hormone secretion (SIADH), sometimes fatal. Treatment strategy depends on the cause and the severity of the hyponatremia. Recent studies have shown the efficacy of urea in treating acute hyponatremia secondary to SIADH, by inducing an osmotic water drive. We describe an infant with chronic hyponatremia secondary to SIADH in which the long-term oral treatment with urea was successful and well tolerated. The aim of this paper is to highlight the potential benefits of urea treatment in case of chronic hyponatremia secondary to SIADH. CONCLUSION Chronic oral urea treatment in children with SIADH allows an easy and safe water and sodium control and may permit a decrease in fluid restriction in this situation.
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Affiliation(s)
- Hassib Chehade
- Paediatric Department, Paediatric Nephrology Unit, University Hospital, Lausanne, Switzerland.
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24
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Vandergheynst F, Brachet C, Heinrichs C, Decaux G. Long-Term Treatment of Hyponatremic Patients with Nephrogenic Syndrome of Inappropriate Antidiuresis: Personal Experience and Review of Published Case Reports. ACTA ACUST UNITED AC 2012; 120:c168-72. [DOI: 10.1159/000338539] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 03/28/2012] [Indexed: 11/19/2022]
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25
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Abstract
Fluid homeostasis requires adequate water intake, regulated by an intact thirst mechanism and appropriate free water excretion by the kidneys, mediated by appropriate secretion of arginine vasopressin (AVP, also known as antidiuretic hormone). AVP exerts its antidiuretic action by binding to the X chromosome-encoded V2 vasopressin receptor (V2R), a G protein coupled receptor on the basolateral membrane of renal collecting duct epithelial cells. After V2R activation, increased intracellular cyclic adenosine monophosphate mediates shuttling of the water channel aquaporin 2 to the apical membrane of collecting duct cells, resulting in increased water permeability and antidiuresis. Clinical disorders of water balance are common, and abnormalities in many steps involving AVP secretion and responsiveness have been described. This article focuses on the principal disorders of water balance, diabetes insipidus, and the syndrome of inappropriate antidiuretic hormone secretion.
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Affiliation(s)
- Sayali A. Ranadive
- Department of Endocrinology, Children's Hospital and Research Center Oakland, 747 52nd Street, Oakland, CA 94609, USA
| | - Stephen M. Rosenthal
- Department of Pediatrics, Division of Endocrinology, University of California San Francisco, 513 Parnassus Avenue, Room S672, San Francisco, CA 94143, USA,Corresponding author. (S.M. Rosenthal)
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26
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Varsavsky M, Quesada Charneco M, Rozas Moreno P. Urea como opción terapéutica para el tratamiento del síndrome de secreción inadecuada de hormona antidiurética (SIADH). Med Clin (Barc) 2011; 137:237-8. [DOI: 10.1016/j.medcli.2010.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 09/08/2010] [Accepted: 09/09/2010] [Indexed: 10/18/2022]
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27
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Esposito P, Piotti G, Bianzina S, Malul Y, Dal Canton A. The syndrome of inappropriate antidiuresis: pathophysiology, clinical management and new therapeutic options. NEPHRON. CLINICAL PRACTICE 2011; 119:c62-73; discussion c73. [PMID: 21677440 DOI: 10.1159/000324653] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Hyponatremia is a marker of different underlying diseases and it can be a cause of morbidity itself; this implies the importance of a correct approach to the problem. The syndrome of inappropriate antidiuresis (SIAD) is one of the most common causes of hyponatremia: it is a disorder of sodium and water balance characterized by urinary dilution impairment and hypotonic hyponatremia, in the absence of renal disease or any identifiable non-osmotic stimulus able to induce antidiuretic hormone (ADH) release; according to its definition, it is diagnosed through an exclusion algorithm. SIAD is usually observed in hospitalized patients and its prevalence may be as high as 35%. The understanding of the syndrome has notably evolved over the last years, as reflected by the significant change in the name, once the syndrome of inappropriate secretion of ADH (SIADH), today SIAD. This review is up to date and it analyses the newest notions about pathophysiological mechanisms, classification, management and therapy of SIAD, including vaptans.
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Affiliation(s)
- Pasquale Esposito
- Department of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Italy.
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28
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Peruzzo M, Milani GP, Garzoni L, Longoni L, Simonetti GD, Bettinelli A, Fossali EF, Bianchetti MG. Body fluids and salt metabolism - part II. Ital J Pediatr 2010; 36:78. [PMID: 21144005 PMCID: PMC3022615 DOI: 10.1186/1824-7288-36-78] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Accepted: 12/13/2010] [Indexed: 11/30/2022] Open
Abstract
There is a high frequency of diarrhea and vomiting in childhood. As a consequence the focus of the present review is to recognize the different body fluid compartments, to clinically assess the degree of dehydration, to know how the equilibrium between extracellular fluid and intracellular fluid is maintained, to calculate the effective blood osmolality and discuss both parenteral fluid maintenance and replacement.
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Affiliation(s)
- Mattia Peruzzo
- Department of Pediatrics, Bellinzona and Mendrisio, and University of Bern, Switzerland
| | - Gregorio P Milani
- Emergency Unit, Clinica Pediatrica De Marchi, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Luca Garzoni
- Department of Pediatrics, Bellinzona and Mendrisio, and University of Bern, Switzerland
| | - Laura Longoni
- Department of Pediatrics, San Leopoldo Mandic Hospital, Merate-Lecco, Italy
| | | | - Alberto Bettinelli
- Department of Pediatrics, San Leopoldo Mandic Hospital, Merate-Lecco, Italy
| | - Emilio F Fossali
- Emergency Unit, Clinica Pediatrica De Marchi, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Mario G Bianchetti
- Department of Pediatrics, Bellinzona and Mendrisio, and University of Bern, Switzerland
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29
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Levtchenko EN, Monnens LAH. Nephrogenic syndrome of inappropriate antidiuresis. Nephrol Dial Transplant 2010; 25:2839-43. [DOI: 10.1093/ndt/gfq324] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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30
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Long-term outcomes in a family with nephrogenic syndrome of inappropriate antidiuresis. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2009:431527. [PMID: 20148077 PMCID: PMC2817859 DOI: 10.1155/2009/431527] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Accepted: 12/02/2009] [Indexed: 11/18/2022]
Abstract
We report a familial case of the nephrogenic syndrome of inappropriate antidiuresis (NSIAD), including 30-year followup data on two patients. The proband and one maternal uncle presented in their infancy with severe recurrent hyponatremia, and clinical pictures consistent with the syndrome of inappropriate antidiuretic hormone (SIADH) in the absence of an elevated ADH level. They were both confirmed to be hemizygous for the R137C mutation on the V2R gene (AVPR2), the same locus of the gain of function mutation demonstrated in the original reports of this condition. The proband's mother was identified as an asymptomatic carrier of this X-linked condition. Our case describes a favourable long-term outcome for NSIAD, in particular, successful treatment with oral urea during the infancy period, and with self-regulated precautions on fluid intake into adult life.
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Abstract
Fluid homeostasis requires adequate water intake, regulated by an intact thirst mechanism and appropriate free water excretion by the kidneys, mediated by appropriate secretion of arginine vasopressin (AVP, also known as antidiuretic hormone). AVP exerts its antidiuretic action by binding to the X chromosome-encoded V2 vasopressin receptor (V2R), a G protein-coupled receptor on the basolateral membrane of renal collecting duct epithelial cells. After V2R activation, increased intracellular cyclic adenosine monophosphate mediates shuttling of the water channel aquaporin 2 to the apical membrane of collecting duct cells, resulting in increased water permeability and antidiuresis. Clinical disorders of water balance are common, and abnormalities in many steps involving AVP secretion and responsiveness have been described. This article focuses on the principal disorders of water balance, diabetes insipidus, and the syndrome of inappropriate antidiuretic hormone secretion.
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Affiliation(s)
- Sayali A. Ranadive
- Department of Endocrinology, Children's Hospital and Research Center Oakland, 747 52
| | - Stephen M. Rosenthal
- Department of Pediatrics, Division of Endocrinology, University of California San Francisco, San Francisco, California
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Marcialis MA, Dessì A, Contu S, Fanos V. Nephrogenic syndrome of inappropriate antidiuresis: a novel cause of euvolemic hypotonic hyponatremia in newborns. Diagnosis and practical management. J Matern Fetal Neonatal Med 2009; 22 Suppl 3:67-71. [PMID: 19925363 DOI: 10.1080/14767050903196037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Hyponatremia, defined by a serum sodium concentration of less than 135 mmmol/l, is a complex clinical occurrence frequently manifested in newborns admitted to the neonatal intensive care unit. The pathogenetic mechanisms and clinical timing underlying the onset of hyponatremia have not been well established in the newborn. Aim of this review is to present a practical approach and management of hypotonic hyponatremia in newborns, with particular emphasis on nephrogenic syndrome of inappropriate antidiuresis, recently described by us for the first time in the literature in a newborn.
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Affiliation(s)
- Maria Antonietta Marcialis
- Department of Pediatrics and Clinical Medicine-Section of Neonatal Intensive Care Unit, Puericultura Institute and Neonatal Section, Azienda Mista and University of Cagliari, Italy
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Gupta S, Cheetham TD, Lambert HJ, Roberts C, Bourn D, Coulthard MG, Ball SG. Thirst perception and arginine vasopressin production in a kindred with an activating mutation of the type 2 vasopressin receptor: the pathophysiology of nephrogenic syndrome of inappropriate antidiuresis. Eur J Endocrinol 2009; 161:503-8. [PMID: 19542240 DOI: 10.1530/eje-09-0246] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Activating mutations of the vasopressin receptor gene on the X chromosome cause the nephrogenic syndrome of inappropriate antidiuresis (NSIAD). We describe a male child who presented with persistent hyponatraemia and whose mother was also found to be hyponatraemic. She had learnt to avoid excess fluid consumption because of associated malaise. Both individuals had a subnormal ability to excrete a water load with mother also demonstrating a heightened sense of thirst at low serum osmolalities. RESULTS Mother and child were found to have the previously characterised activating mutation (p.Arg137Cys) of the arginine vasopressin receptor type 2 gene (AVPR2), but had measurable levels of AVP when hyponatraemic. CONCLUSIONS We conclude that female carriers of activating mutations of the vasopressin receptor are susceptible to hyponatraemia and therefore need to be provided with advice regarding fluid intake. An altered thirst perception may increase susceptibility to hyponatraemia. We confirm that the presence of measurable amounts of AVP in patients with hyponatraemia does not exclude the diagnosis of NSIAD.
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Affiliation(s)
- S Gupta
- Department of Paediatrics, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, NE1 4LP, UK
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35
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Long-Term Outcomes in a Family with Nephrogenic Syndrome of Inappropriate Antidiuresis. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2009. [DOI: 10.1186/1687-9856-2009-431527] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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36
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Marcialis MA, Faà V, Fanos V, Puddu M, Pintus MC, Cao A, Rosatelli MC. Neonatal onset of nephrogenic syndrome of inappropriate antidiuresis. Pediatr Nephrol 2008; 23:2267-71. [PMID: 18622631 DOI: 10.1007/s00467-008-0913-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Revised: 05/13/2008] [Accepted: 05/14/2008] [Indexed: 11/26/2022]
Abstract
This paper describes the manifestation in a child of a new syndrome characterized by unusual, severe, persistent hyponatremia associated with hyposmolarity, euvolemia, inappropriately concentrated urine and elevated natriuresis. This is the fourth case of this syndrome reported to date, and the first to be reported in a neonate. The clinical features resemble those typically observed in patients with inappropriate antidiuretic hormone secretion, although high arginine vasopressin (AVP) levels are lacking. The findings led the authors to hypothesise a nephrogenic syndrome of inappropriate antidiuresis (NSIAD). The previously described R137C gain-of-function mutation was detected by means of mutation analysis of the V2R gene. Our results indicate that NSIAD is already present during the neonatal period and that molecular analysis of the V2R receptor should therefore be carried out, in all newborns with prolonged euvolemic hyponatremia with hypo-osmolarity, high urinary sodium and normal/low or undetectable AVP levels.
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37
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Verbalis JG, Goldsmith SR, Greenberg A, Schrier RW, Sterns RH. Hyponatremia treatment guidelines 2007: expert panel recommendations. Am J Med 2007; 120:S1-21. [PMID: 17981159 DOI: 10.1016/j.amjmed.2007.09.001] [Citation(s) in RCA: 331] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Although hyponatremia is a common, usually mild, and relatively asymptomatic disorder of electrolytes, acute severe hyponatremia can cause substantial morbidity and mortality, particularly in patients with concomitant disease. In addition, overly rapid correction of chronic hyponatremia can cause severe neurologic deficits and death, and optimal treatment strategies for such cases are not established. An expert panel assessed the potential contributions of aquaretic nonpeptide small-molecule arginine vasopressin receptor (AVPR) antagonists to hyponatremia therapies. This review presents their conclusions, including identification of appropriate treatment populations and possible future indications for aquaretic AVPR antagonists.
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Affiliation(s)
- Joseph G Verbalis
- Division of Endocrinology and Metabolism, Department of Medicine, Georgetown University Medical Center, Washington, District of Columbia 20007, USA.
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Bes DF, Mendilaharzu H, Fenwick RG, Arrizurieta E. Hyponatremia resulting from arginine vasopressin receptor 2 gene mutation. Pediatr Nephrol 2007; 22:463-6. [PMID: 17115194 DOI: 10.1007/s00467-006-0344-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2006] [Revised: 09/23/2006] [Accepted: 09/25/2006] [Indexed: 10/23/2022]
Abstract
Chronic hyponatremia, unless associated with extracellular fluid volume expansion, is an infrequent electrolyte imbalance in pediatrics. We report an infant with chronic hyponatremia suggestive of a syndrome of inappropriate secretion of antidiuretic hormone (SIADH), in the absence of ADH secretion. A mutation was found in the same codon of the gene that results in a loss-of- function of arginine vasopressin receptor 2 (AVPR2) observed in congenital nephrogenic diabetes insipidus. In this case, a gain-of- function of AVPR 2 was found to be responsible for a SIADH-like state.
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Affiliation(s)
- David Francisco Bes
- Department of Pediatrics, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, and Departamento de Riñón Experimental, Instituto de Investigaciones Médicas Dr. Alfredo Lanari, Universidad de Buenos Aires, 1245, Argentina.
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Decaux G, Vandergheynst F, Bouko Y, Parma J, Vassart G, Vilain C. Nephrogenic syndrome of inappropriate antidiuresis in adults: high phenotypic variability in men and women from a large pedigree. J Am Soc Nephrol 2007; 18:606-12. [PMID: 17229917 DOI: 10.1681/asn.2006090987] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Nephrogenic syndrome of inappropriate antidiuresis (NSIAD) is a recently described genetic cause of hyponatremia in male infants. Whether this X-linked condition could be detected in the adult or also could affect women is unknown. A large five-generation family was identified in which the recently described arginine-vasopressin receptor type 2 (AVPR2) mutation that is responsible for NSIAD was segregated. The proband was a 74-yr-old patient who had a syndrome of inappropriate antidiuresis and whose hyponatremia resisted administration of two AVPR2 antagonists. The phenotype of family members who carry the mutation was investigated. Patients with normal serum sodium were subjected to a water-load test. The previously reported activating missense R137C mutation in the AVPR2 gene in three hemizygous male and four heterozygous female individuals was identified. Except in one woman, spontaneous episodes of hyponatremia or abnormal water-load test were identified in all patients with the mutation, whether male or female. Skewed X inactivation was evidenced in the blood of the asymptomatic woman, which is compatible with preferential inactivation of her mutated allele. NSIAD is not limited to male infants. The diagnosis also should be considered in both male and female adults.
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Affiliation(s)
- Guy Decaux
- General Internal Medicine, University Hospital Erasme, Route de Lennik, 808, B-1070 Brussels, Belgium.
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Gitelman SE, Feldman BJ, Rosenthal SM. Nephrogenic syndrome of inappropriate antidiuresis: a novel disorder in water balance in pediatric patients. Am J Med 2006; 119:S54-8. [PMID: 16843086 DOI: 10.1016/j.amjmed.2006.05.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a common cause of hyponatremia. We report findings in 2 unrelated male infants whose clinical presentation and laboratory findings were consistent with SIADH, but who exhibited unmeasurable arginine vasopressin (AVP) levels on repeated occasions. We hypothesized that these infants had a novel gain of function defect in the AVP-signaling pathway. DNA sequencing of each patient's vasopressin V2 receptor (V2R) gene identified mutations (R137C or R137L) in each. R137H mutations have been reported previously to cause nephrogenic diabetes insipidus. To further characterize the effects of these mutations, we re-created each mutation by site-directed mutagenesis in a vasopressin V2R expression vector and cotransfected COS-7 cells with wild-type and mutant vasopressin V2R vectors and a cyclic adenosine monophosphate-responsive luciferase reporter plasmid. The luciferase activity was induced 7.5-fold (R137L mutant; P = 0.0037) and 4-fold (R137C mutant; P = 0.013) more than the wild-type vasopressin V2R, which is the empty vector or the inactivating R137H mutant. This novel gain of function mutation in the vasopressin V2R can cause constitutive activation of the receptor and resultant hyponatremia. These findings represent a previously unrecognized genetic disease, which was designated as nephrogenic syndrome of inappropriate antidiuresis. A number of questions have emerged, including the following: (1) What is the frequency? (2) Are there nonrenal manifestations? (3) Are heterozygotes affected? (4) What is the optimal therapy? and (5) How do these mutations cause constitutive activation of the receptor?
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Affiliation(s)
- Stephen E Gitelman
- Department of Pediatrics, Division of Pediatric Endocrinology, University of California at San Francisco, San Francisco, California 94143, USA.
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