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Hema T, Mohanthi S, Umamaheswari S, Ramesh M, Ren Z, Poopal RK. A study to assess the health effects of an anticancer drug (cyclophosphamide) in zebrafish ( Danio rerio): eco-toxicity of emerging contaminants. ENVIRONMENTAL SCIENCE. PROCESSES & IMPACTS 2023; 25:870-884. [PMID: 37010127 DOI: 10.1039/d2em00527a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Cyclophosphamide (CP) is widely used for treating various kinds of cancer. Because of its high intake, metabolism and excretion, these anticancer medications have been detected in the aquatic environment. There is very limited data on the toxicity and effects of CP on aquatic organisms. The present study aims to assess the toxic effect of CP on certain oxidative stress biomarkers (superoxide dismutase-SOD, catalase-CAT, glutathione peroxidase-GPx, glutathione-GSH, glutathione S-transferases-GST and lipid peroxidation-LPO), protein, glucose, metabolising enzymes (aspartate aminotransferase-AST, alanine aminotransferase-ALT), and ion-regulatory markers (sodium ions-Na+, potassium ions-K+, and chloride ions-Cl-), and histology in the gills and liver of Danio rerio at environmentally relevant concentrations (10, 100 and 1000 ng L-1). Exposure to CP for 42 days led to a significant decrease in SOD, CAT, GST, GPx and GSH levels in the gills and liver tissues of zebrafish. The level of lipid peroxidation in the gills and liver tissues of zebrafish was significantly increased compared to the control group. Chronic exposure significantly changes protein, glucose, AST, ALT, Na+, K+ and Cl- biomarkers. Fish exposed to different levels of CP showed necrosis, inflammation, degeneration and hemorrhage in the gills and hepatic tissues. The observed changes in the studied tissue biomarkers were proportional to both dose and time. In conclusion, CP at environmentally relevant concentrations causes oxidative stress, energy demand, homeostasis disturbances, and enzyme and histological alterations in the vital tissues of zebrafish. These alterations were similar to the toxic effects reported in mammalian models.
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Affiliation(s)
- Tamilselvan Hema
- Unit of Toxicology, Department of Zoology, Bharathiar University, Coimbatore, 641 046, TamilNadu, India.
| | - Sundaram Mohanthi
- Unit of Toxicology, Department of Zoology, Bharathiar University, Coimbatore, 641 046, TamilNadu, India.
| | - Sathisaran Umamaheswari
- Unit of Toxicology, Department of Zoology, Bharathiar University, Coimbatore, 641 046, TamilNadu, India.
| | - Mathan Ramesh
- Unit of Toxicology, Department of Zoology, Bharathiar University, Coimbatore, 641 046, TamilNadu, India.
| | - Zongming Ren
- Institute of Environment and Ecology, Shandong Normal University, Jinan 250358, People's Republic of China.
| | - Rama-Krishnan Poopal
- Institute of Environment and Ecology, Shandong Normal University, Jinan 250358, People's Republic of China.
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Gómez-Hernando M, Quintana LF, Suárez-Lledo M, Martínez-Cibrian N, Rivero A, Ruiz-Boy S, Carcelero E, Mate P, Riu G, Monge I, Serrahima A, Solano MT, Rosiñol L, Esteve J, Urbano-Ispizua A, Carreras E, Fernández-Avilés F, Martínez C, Rovira M, Salas MQ. Hyponatremia induced by post-transplant cyclophosphamide in allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2023; 58:212-214. [PMID: 36335256 DOI: 10.1038/s41409-022-01864-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 10/21/2022] [Accepted: 10/26/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Marta Gómez-Hernando
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain
| | - Luis F Quintana
- Clinical Nephrology Section, Nephrology and Renal Transplantation Department, Hospital Clínic de Barcelona, ICNU, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - María Suárez-Lledo
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Nuria Martínez-Cibrian
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Andrea Rivero
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Sonia Ruiz-Boy
- Pharmacy Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Ester Carcelero
- Pharmacy Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Paula Mate
- Pharmacy Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Gisela Riu
- Pharmacy Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Inés Monge
- Pharmacy Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Anna Serrahima
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain
| | - Maria Teresa Solano
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain
| | - Laura Rosiñol
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Jordi Esteve
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Alvaro Urbano-Ispizua
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Enric Carreras
- Fundació i Institut de Recerca Josep Carreras contra la leucèmia (Campus Clínic), Barcelona, Spain
| | - Francesc Fernández-Avilés
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Carmen Martínez
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Montserrat Rovira
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Maria Queralt Salas
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain. .,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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3
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Chen J, Jin Y, Li C, Li Z. Symptomatic hyponatremia induced by low-dose cyclophosphamide in patient with systemic lupus erythematosus: A case report. Medicine (Baltimore) 2020; 99:e22498. [PMID: 33235058 PMCID: PMC7710175 DOI: 10.1097/md.0000000000022498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
RATIONALE Cyclophosphamide (CY) is an alkylating agent used widely to treat cancer and autoimmune diseases. Hyponatremia is a common adverse effect of high-dose and moderate-dose of intravenous CY, but is rare in patients treated with low-dose (<15 mg/kg). PATIENT CONCERNS A 52-year-old woman with new-onset systemic lupus erythematosus (SLE) was treated with low-dose cyclophosphamide (8 mg/kg, CY), but showed sudden headaches, disorientation and weakness. Laboratory examinations revealed severe isovolumic hyponatremia along with low-serum osmolality and high urine osmolality. DIAGNOSIS The acute hyponatremia was consistent with the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and was an adverse event of low-dose CY, with no evidence of endocrine, cancer, pulmonary, or cerebral abnormalities relevant to the SIADH. INTERVENTION The hyponatremia was resolved after the supplementation of NaCl solution. OUTCOMES The hyponatremia was resolved without any complications. LESSONS Hyponatremia induced by low-dose CY should be recognized as an underlying life-threatening complication in clinical practice.
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Krishnamurthy A, Bhattacharya S, Lathia T, Kantroo V, Kalra S, Dutta D. Anticancer Medications and Sodium Dysmetabolism. EUROPEAN ENDOCRINOLOGY 2020; 16:122-130. [PMID: 33117443 DOI: 10.17925/ee.2020.16.2.122] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/04/2020] [Indexed: 12/15/2022]
Abstract
Therapeutic advances have revolutionised cancer treatment over the last two decades, but despite improved survival and outcomes, adverse effects to anticancer therapy such as dyselectrolytaemias do occur and need to be managed appropriately. This review explores essential aspects of sodium homeostasis in cancer with a focus on alterations arising from anticancer medications. Sodium and water balance are tightly regulated by close interplay of stimuli arising from hypothalamic osmoreceptors, arterial and atrial baroreceptors and the renal juxtaglomerular apparatus. This delicate balance can be disrupted by cancer itself, as well as the medications used to treat it. Some of the conventional chemotherapeutics, such as alkylating agents and platinum-based drugs, can cause hyponatraemia and, on rare occasions, hypernatraemia. Other conventional agents such as vinca alkaloids, as well as newer targeted cancer therapies including small molecule inhibitors and monoclonal antibodies, can cause hyponatraemia, usually as a result of inappropriate antidiuretic hormone secretion. Hyponatraemia can also sometimes occur secondarily to drug-induced hypocortisolism or salt-wasting syndromes. Another atypical but distinct mechanism for hyponatraemia is via pituitary dysfunction induced by immune checkpoint inhibitors. Hypernatraemia is uncommon and occasionally ensues as a result of drug-induced nephrogenic diabetes insipidus. Identification of the aetiology and appropriate management of these conditions, in addition to averting treatment-related problems, can be lifesaving in critical situations.
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Affiliation(s)
- Aishwarya Krishnamurthy
- Endocrinology Department, Max Super Speciality Hospital, Patparganj, New Delhi, Delhi, India
| | - Saptarshi Bhattacharya
- Endocrinology Department, Max Super Speciality Hospital, Patparganj, New Delhi, Delhi, India
| | - Tejal Lathia
- Endocrinology Department, Fortis Hospital, Vashi, Navi Mumbai, Maharashtra, India
| | - Viny Kantroo
- Respiratory Department, Critical Care and Sleep Medicine, Apollo Hospitals, Sarita Vihar, New Delhi, Delhi, India
| | - Sanjay Kalra
- Endocrinology Department, Bharti Hospital, Karnal, Haryana, India
| | - Deep Dutta
- CEDAR Superspeciality Clinics, Dwarka, New Delhi, Delhi, India
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5
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Verzicco I, Regolisti G, Quaini F, Bocchi P, Brusasco I, Ferrari M, Passeri G, Cannone V, Coghi P, Fiaccadori E, Vignali A, Volpi R, Cabassi A. Electrolyte Disorders Induced by Antineoplastic Drugs. Front Oncol 2020; 10:779. [PMID: 32509580 PMCID: PMC7248368 DOI: 10.3389/fonc.2020.00779] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 04/22/2020] [Indexed: 12/23/2022] Open
Abstract
The use of antineoplastic drugs has a central role in treatment of patients affected by cancer but is often associated with numerous electrolyte derangements which, in many cases, could represent life-threatening conditions. In fact, while several anti-cancer agents can interfere with kidney function leading to acute kidney injury, proteinuria, and hypertension, in many cases alterations of electrolyte tubular handling and water balance occur. This review summarizes the mechanisms underlying the disturbances of sodium, potassium, magnesium, calcium, and phosphate metabolism during anti-cancer treatment. Platinum compounds are associated with sodium, potassium, and magnesium derangements while alkylating agents and Vinca alkaloids with hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion (SIADH). Novel anti-neoplastic agents, such as targeted therapies (monoclonal antibodies, tyrosine kinase inhibitors, immunomodulators, mammalian target of rapamycin), can induce SIADH-related hyponatremia and, less frequently, urinary sodium loss. The blockade of epidermal growth factor receptor (EGFR) by anti-EGFR antibodies can result in clinically significant magnesium and potassium losses. Finally, the tumor lysis syndrome is associated with hyperphosphatemia, hypocalcemia and hyperkalemia, all of which represent serious complications of chemotherapy. Thus, clinicians should be aware of these side effects of antineoplastic drugs, in order to set out preventive measures and start appropriate treatments.
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Affiliation(s)
- Ignazio Verzicco
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Giuseppe Regolisti
- Unità di Ricerca sulla Insufficienza Renale Acuta e Cronica, Unità di Nefrologia, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Federico Quaini
- Ematologia e Oncologia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Pietro Bocchi
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Irene Brusasco
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Massimiliano Ferrari
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Giovanni Passeri
- Unità di Endocrinologia e Malattie Osteometaboliche, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Valentina Cannone
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Pietro Coghi
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Enrico Fiaccadori
- Unità di Ricerca sulla Insufficienza Renale Acuta e Cronica, Unità di Nefrologia, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Alessandro Vignali
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Riccardo Volpi
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
- Unità di Endocrinologia e Malattie Osteometaboliche, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Aderville Cabassi
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
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Esposito P, Domenech MV, Serpieri N, Calatroni M, Massa I, Avella A, La Porta E, Estienne L, Caramella E, Rampino T. Severe cyclophosphamide-related hyponatremia in a patient with acute glomerulonephritis. World J Nephrol 2017; 6:217-220. [PMID: 28729970 PMCID: PMC5500459 DOI: 10.5527/wjn.v6.i4.217] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/12/2017] [Accepted: 06/08/2017] [Indexed: 02/06/2023] Open
Abstract
Cyclophosphamide is frequently used to treat cancer, autoimmune and renal diseases, such as rapidly progressive glomerulonephritis. Its side effects are well-known, including bone marrow depression, infections, alopecia, sterility, bladder malignancy and hemorrhagic cystitis. Moreover, in some cases cyclophosphamide use has been related to the onset of hyponatremia, by development of a syndrome of inappropriate antidiuresis. Indeed, severe hyponatremia has been previously reported in patients treated with high-dose or moderate-dose of intravenous cyclophosphamide, while only few cases have been reported in patients treated with low dose. Here, we discuss a case of a syndrome of inappropriate antidiuresis followed to a single low-dose of intravenous cyclophosphamide in a patient with a histological diagnosis of acute glomerulonephritis, presenting as acute kidney injury. After cyclophosphamide administration (500 mg IV), while renal function gradually improved, the patient developed confusion and headache. Laboratory examinations showed serum sodium concentration dropped to 122 mmol per liter associated with an elevated urinary osmolality of 199 mOsm/kg, while common causes of acute hyponatremia were excluded. He was successfully treated with water restriction and hypertonic saline solution infusion with the resolution of the electrolyte disorder. This case, together with the previous ones already reported, highlights that electrolyte profile should be strictly monitored in patients undergoing cyclophosphamide therapy in order to early recognize the potentially life-threatening complications of acute water retention.
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Liamis G, Filippatos TD, Elisaf MS. Electrolyte disorders associated with the use of anticancer drugs. Eur J Pharmacol 2016; 777:78-87. [PMID: 26939882 DOI: 10.1016/j.ejphar.2016.02.064] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 02/23/2016] [Accepted: 02/26/2016] [Indexed: 12/23/2022]
Abstract
The use of anticancer drugs is beneficial for patients with malignancies but is frequently associated with the occurrence of electrolyte disorders, which can be hazardous and in many cases fatal. The review presents the electrolyte abnormalities that can occur with the use of anticancer drugs and provides the related mechanisms. Platinum-containing anticancer drugs induce hypomagnesemia, hypokalemia and hypocalcemia. Moreover, platinum-containing drugs are associated with hyponatremia, especially when combined with large volumes of hypotonic fluids aiming to prevent nephrotoxicity. Alkylating agents have been linked with the occurrence of hyponatremia [due to syndrome of inappropriate antidiuretic hormone secretion (SIADH)] and Fanconi's syndrome (hypophosphatemia, aminoaciduria, hypouricemia and/or glucosuria). Vinca alkaloids are associated with hyponatremia due to SIADH. Epidermal growth factor receptor monoclonal antibody inhibitors induce hypomagnesemia, hypokalemia and hypocalcemia. Other, monoclonal antibodies, such as cixutumumab, cause hyponatremia due to SIADH. Tyrosine kinase inhibitors are linked to hyponatremia and hypophosphatemia. Mammalian target of rapamycin inhibitors induce hyponatremia (due to aldosterone resistance), hypokalemia and hypophosphatemia. Other drugs such as immunomodulators or methotrexate have been also associated with hyponatremia. The administration of estrogens at high doses, streptozocin, azacitidine and suramin may induce hypophosphatemia. Finally, the drug-related tumor lysis syndrome is associated with hyperphosphatemia, hyperkalemia and hypocalcemia. The prevention of electrolyte derangements may lead to reduction of adverse events during the administration of anticancer drugs.
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Affiliation(s)
- George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Theodosios D Filippatos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Moses S Elisaf
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece.
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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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