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Higinbotham A, Nayate AP. Unusual progression of osmotic demyelination after liver transplantation on MRI brain. Radiol Case Rep 2022; 17:604-609. [PMID: 34987689 PMCID: PMC8703185 DOI: 10.1016/j.radcr.2021.11.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 11/28/2021] [Accepted: 11/28/2021] [Indexed: 12/02/2022] Open
Abstract
Osmotic demyelination syndrome, comprised of central pontine and extrapontine myelinolysis, is an important and potentially fatal complication primarily related to rapid overcorrection of serum sodium leading to devastating neurological symptoms. While traditionally presenting in the pons, we report the case of a 43-year-old female patient who recently underwent a liver transplant and developed extrapontine myelinolysis and subsequently central pontine myelinolysis resulting in irreversible spastic quadriparesis. This rare case highlights the variability of presentation of osmotic demyelination syndrome on imaging.
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Sindhu DM, Holla VV, Prasad S, Kamble N, Netravathi M, Yadav R, Pal PK. The Spectrum of Movement Disorders in Cases with Osmotic Demyelination Syndrome. Mov Disord Clin Pract 2021; 8:875-884. [PMID: 34405095 DOI: 10.1002/mdc3.13250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/12/2021] [Accepted: 05/04/2021] [Indexed: 11/11/2022] Open
Abstract
Background Osmotic demyelination syndrome (ODS) can be a central pontine myelinolysis (CPM) and extrapontine myelinolysis (EPM) based on the regions involved even though they share the same disease process, aetiopathogenesis and time course. Objectives Present study aims to characterize the clinical, radiological features and the outcome of patients with ODS with movement disorders as the forthcoming manifestation. Methods Chart review of patients with ODS with movement disorders. Demographic, clinical and radiological details of the patients were reviewed. Results Eleven patients (six females; mean age: 48.3 ± 17.6 years) were included in the study. Parkinsonism alone and parkinsonism with dystonia was noted in four patients each (36.4%) while dystonia alone was noted in the other 3 (27.3%). Five patients (45.5%) had postural tremors. While 5 patients had dystonia early in the course of illness (3-7 days), it was delayed (6-9 months) in the other 2. A triphasic course was noted in two patients. The first phase of hyponatremia induced neurological impairment was followed by a second phase of worsening due to the immediate effect of ODS and a third delayed phase of worsening due to delayed effect of ODS. MRI showed both EPM and CPM in eight patients, EPM alone in two patients and CPM alone in 1 patient. Nine patients had a good outcome with mRS < 3. Conclusion Parkinsonism and dystonia are important manifestations of ODS. Triphasic course with a delayed phase of worsening of movement disorders is probably due to the maladaptive neuronal repair. The concept of triphasic ODS is first being described in our series.
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Affiliation(s)
| | - Vikram V Holla
- Department of Neurology National Institute of Mental health and Neurosciences Bengaluru India
| | - Shweta Prasad
- Department of Neurology National Institute of Mental health and Neurosciences Bengaluru India.,Department of Clinical Neurosciences National Institute of Mental health and Neurosciences Bengaluru India
| | - Nitish Kamble
- Department of Neurology National Institute of Mental health and Neurosciences Bengaluru India
| | - Manjunath Netravathi
- Department of Neurology National Institute of Mental health and Neurosciences Bengaluru India
| | - Ravi Yadav
- Department of Neurology National Institute of Mental health and Neurosciences Bengaluru India
| | - Pramod K Pal
- Department of Neurology National Institute of Mental health and Neurosciences Bengaluru India
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3
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Bose P. Central pontine myelinolysis and the osmotic demyelination syndromes: an open and shut case? Acta Neurol Belg 2021; 121:849-858. [PMID: 33713026 DOI: 10.1007/s13760-021-01634-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 02/16/2021] [Indexed: 12/01/2022]
Abstract
Central pontine myelinolysis and extrapontine myelinolysis are collectively called the osmotic demyelination syndromes. Despite being described in 1959, there are several aspects of the disorder that remain an enigma. Animal models and neuroimaging techniques have allowed us to understand the condition better. From being a universally fatal disorder that was diagnosed post mortem, increased awareness, neuroimaging techniques and supportive care have enabled us to make the diagnosis ante-mortem. This has also led to a significant drop in associated mortality. The aim of this review is to highlight the clinical spectrum, neuroimaging findings, and recent developments.
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Affiliation(s)
- Pyari Bose
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand.
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4
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Lambeck J, Hieber M, Dreßing A, Niesen WD. Central Pontine Myelinosis and Osmotic Demyelination Syndrome. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:600-606. [PMID: 31587708 DOI: 10.3238/arztebl.2019.0600] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 07/30/2018] [Accepted: 05/29/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Osmotic demyelination syndrome (ODS), which embraces central pontine myelinolysis (CPM) and extrapontine myelinosis (EPM), is often underdiagnosed in clinical practice, but can be fatal. In this article, we review the etiology, patho- physiology, clinical features, diagnosis, treatment, and prognosis of ODS. METHODS Pertinent publications from the years 1959 to 2018 were retrieved by a selective search in PubMed. RESULTS The most common cause of ODS is hyponatremia; particular groups of patients, e.g., liver transplant recipients, are also at risk of developing ODS. The pathophysiology of ODS consists of cerebral apoptosis and loss of myelin due to osmotic stress. Accordingly, brain areas that are rich in oligodendrocytes and myelin tend to be the most frequently affected. Patients with ODS often have a biphasic course, the first phase reflecting the underlying predisposing illness and the second phase reflecting ODS itself, with pontine dysfunction, impaired vigilance, and movement disorders, among other neurological abnormalities. The diagnostic modality of choice is magnetic resonance imaging (MRI) of the brain, which can also be used to detect oligosymptomatic ODS. The current mainstay of management is prevention; treatment strategies for manifest ODS are still experimental. The prognosis has improved as a result of MRI-based diagnosis, but ODS can still be fatal (33% to 55% of patients either die or remain permanently dependent on nursing care). CONCLUSION ODS is a secondary neurological illness resulting from a foregoing primary disease. Though rare overall, it occurs with greater frequency in certain groups of patients. Clinicians of all specialties should therefore be familiar with the risk constellations, clinical presentation, and prevention of ODS. The treatment of ODS is still experimental at present, as no evidence-based treatment is yet available.
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Affiliation(s)
- Johann Lambeck
- Department of Neurology and Neurophysiology, University Medical Center Freiburg, Germany
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5
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Decaux G, Gankam Kengne F. Hypertonic saline, isotonic saline, water restriction, long loops diuretics, urea or vaptans to treat hyponatremia. Expert Rev Endocrinol Metab 2020; 15:195-214. [PMID: 32401559 DOI: 10.1080/17446651.2020.1755259] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/09/2020] [Indexed: 01/08/2023]
Abstract
Introduction: Hyponatremia is the most common fluid and electrolyte abnormality. It is associated with much higher morbidity and mortality rates than found in non hyponatremic patients.Areas covered: When the physician is faced to a hyponatremic patient he first has to confirm that hyponatremia is associated with hypoosmolality. Then he must answer to a series of questions: What is its origin? Is it acute or chronic? Which treatment is the most appropriate? We will discuss the various options for the treatment of hypotonic hyponatremia. For a better comprehensive approach of the treatment we will also discuss some pathophysiological data. The use of urea in euvolemic and hypervolemic hyponatremia will be particularly discussed. Literature was reviewed from Jan 1970 to Dec 2019.Expert opinion: Prospective studies showing the benefit in decreasing morbidity by increasing SNa in patients with chronic hyponatremia should be done. These studies should also compare the efficacy and side effects of urea therapy compare to vaptans.
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Affiliation(s)
- Guy Decaux
- Department of Internal Medicine, Erasmus University Hospital, ULB, Brussels, Belgium
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6
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Reijnders TDY, Janssen WMT, Niamut SML, Kramer AB. Role of Risk Factors in Developing Osmotic Demyelination Syndrome During Correction of Hyponatremia: A Case Study. Cureus 2020; 12:e6547. [PMID: 32042522 PMCID: PMC6996461 DOI: 10.7759/cureus.6547] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
This case report describes a 57-year-old man who presented first with lethargy and dysarthria due to hyponatremia resulting from poor intake and diuretics. One week after discharge, he returned with confusion, ataxia and dysphagia, and he ultimately turned out to have developed an osmotic demyelination syndrome (ODS). In his first hospital admission, his serum sodium was corrected without new neurological symptoms occurring. In retrospect, he had several risk factors for the development of ODS during the correction of hyponatremia. The serum sodium correction rate only briefly exceeded the recommended limits. This case underlines that (1) extra awareness of the serum sodium correction rate is warranted in patients with risk factors, (2) factors other than sodium can play an important role in the development of ODS and (3) that the manifestations of ODS can be delayed substantially after an incident of osmotic stress.
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Affiliation(s)
- Tom D Y Reijnders
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, NLD
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7
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Bansal LR, Zinkus T. Osmotic Demyelination Syndrome in Children. Pediatr Neurol 2019; 97:12-17. [PMID: 31128892 DOI: 10.1016/j.pediatrneurol.2019.03.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 03/09/2019] [Accepted: 03/20/2019] [Indexed: 11/28/2022]
Abstract
Osmotic demyelination syndrome is an acute demyelination process that usually occurs several days following an osmotic stress. This syndrome is rare in adults (0.4% to 0.56%) and even more uncommon in children. We performed a review of all reported pediatric osmotic demyelination syndrome patients from 1960 to 2018. Among all 106 cases, 49 presented with isolated central pontine myelinolysis, 30 with isolated extrapontine myelinolysis, and 27 with combined central pontine myelinolysis and extrapontine myelinolysis. There was no gender preponderance, and the highest prevalence was noted between the ages one and five years. Magnetic resonance imaging remains the diagnostic modality of choice, and diffusion tensor imaging is now increasingly used for prognostication in osmotic demyelination syndrome. Sixty percent of the children had a complete neurological recovery. Current management of osmotic demyelination syndrome in children consists of supportive medical care, steroids, and intravenous immunoglobulin. Our review of the literature supports the hypothesis that steroids and immunoglobulins are potentially helpful, although additional controlled studies are needed.
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Affiliation(s)
- Lalit R Bansal
- Division of Neurology, Children's Mercy Hospital, Kansas City, Missouri.
| | - Timothy Zinkus
- Department of Radiology, Children's Mercy Hospital, Kansas City, Missouri
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8
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Clinical Resolution of Osmotic Demyelination Syndrome following Overcorrection of Severe Hyponatremia. Case Rep Nephrol 2019; 2019:1757656. [PMID: 31016055 PMCID: PMC6446114 DOI: 10.1155/2019/1757656] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/07/2019] [Indexed: 01/06/2023] Open
Abstract
Osmotic Demyelination Syndrome (ODS) occurs after rapid overcorrection of severe chronic hyponatremia usually in those with a predisposition such as chronic alcoholism, malnutrition, or liver disease. Rarely, do patients make a full recovery. We report a case of ODS secondary to overcorrection of severe hyponatremia with pathognomonic clinical and radiologic signs making a complete neurological recovery. A detailed course of events, review of literature, and optimal and aggressive management strategies are discussed. There is some controversy in the literature regarding the prognosis of these patients. Our aim here is to show that, with aggressive therapy and long-term care, recovery is possible in these patients.
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Nicaise C, Marneffe C, Bouchat J, Gilloteaux J. Osmotic Demyelination: From an Oligodendrocyte to an Astrocyte Perspective. Int J Mol Sci 2019; 20:E1124. [PMID: 30841618 PMCID: PMC6429405 DOI: 10.3390/ijms20051124] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 12/15/2022] Open
Abstract
Osmotic demyelination syndrome (ODS) is a disorder of the central myelin that is often associated with a precipitous rise of serum sodium. Remarkably, while the myelin and oligodendrocytes of specific brain areas degenerate during the disease, neighboring neurons and axons appear unspoiled, and neuroinflammation appears only once demyelination is well established. In addition to blood‒brain barrier breakdown and microglia activation, astrocyte death is among one of the earliest events during ODS pathology. This review will focus on various aspects of biochemical, molecular and cellular aspects of oligodendrocyte and astrocyte changes in ODS-susceptible brain regions, with an emphasis on the crosstalk between those two glial cells. Emerging evidence pointing to the initiating role of astrocytes in region-specific degeneration are discussed.
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Affiliation(s)
| | - Catherine Marneffe
- Laboratory of Glia Biology (VIB-KU Leuven Center for Brain & Disease Research), Department of Neuroscience, KU Leuven, 3000 Leuven, Belgium.
| | - Joanna Bouchat
- URPhyM-NARILIS, Université de Namur, 5000 Namur, Belgium.
| | - Jacques Gilloteaux
- URPhyM-NARILIS, Université de Namur, 5000 Namur, Belgium.
- Department of Anatomical Sciences, St George's University School of Medicine, Newcastle upon Tyne NE1 8ST, UK.
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Dreyfuss D, Gaudry S. Quelle étrange idée : utiliser un analogue de l’hormone antidiurétique au cours du traitement d’une hyponatrémie ? MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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11
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Abdul Halim S, Mohd Amin NA. Treatment response in osmotic demyelination syndrome presenting as severe parkinsonism, ptosis and gaze palsy. BMJ Case Rep 2018; 2018:bcr-2018-225751. [PMID: 30344146 DOI: 10.1136/bcr-2018-225751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Osmotic demyelination syndrome commonly affects the pons and infrequently involves the extrapontine region. We report a patient with severe hyponatraemia who developed osmotic demyelination syndrome as a consequence of rapid sodium correction. The condition manifested as acute severe parkinsonism, bilateral ptosis and gaze impairment. MRI revealed typical features of central pontine and extrapontine myelinolysis. The patient improved gradually after treatment with a combination of levodopa, intravenous immunoglobulin and dexamethasone. However, it is important to emphasise that the improvement of neurological symptoms is not necessarily causal with these experimental therapies.
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Affiliation(s)
- Sanihah Abdul Halim
- Department of Medicine (Neurology), School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Nur Aida Mohd Amin
- Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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12
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Boehm E, Kumar S, Nankervis A, Colman P. Managing hyponatraemia secondary to primary polydipsia: beware too rapid correction of hyponatraemia. Intern Med J 2018; 47:956-959. [PMID: 28782208 DOI: 10.1111/imj.13507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 01/26/2017] [Accepted: 01/26/2017] [Indexed: 11/29/2022]
Abstract
We describe three cases of severe hyponatraemia in the setting of primary polydipsia that were managed in our centre in 2016. Despite receiving different solute loads, large volume diuresis and rapid correction of serum sodium occurred in all cases. Given the potentially catastrophic consequence of osmotic demyelination, we highlight the judicious use of desmopressin and hypotonic fluid infusion to mitigate sodium overcorrection in this setting.
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Affiliation(s)
- Emma Boehm
- Diabetes and Endocrinology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Shanal Kumar
- Diabetes and Endocrinology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alison Nankervis
- Diabetes and Endocrinology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Peter Colman
- Diabetes and Endocrinology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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13
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Crismale JF, Meliambro KA, DeMaria S, Bronster DB, Florman S, Schiano TD. Prevention of the Osmotic Demyelination Syndrome After Liver Transplantation: A Multidisciplinary Perspective. Am J Transplant 2017; 17:2537-2545. [PMID: 28422408 DOI: 10.1111/ajt.14317] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/23/2017] [Accepted: 04/08/2017] [Indexed: 01/25/2023]
Abstract
The osmotic demyelination syndrome (ODS) is a serious neurologic condition that occurs in the setting of rapid correction of hyponatremia. It presents with protean manifestations, from encephalopathy to the "locked-in" syndrome. ODS can complicate liver transplantation (LT), and its incidence may increase with the inclusion of serum sodium as a factor in the Mayo End-Stage Liver Disease score. A comprehensive understanding of risk factors for the development of ODS in the setting of LT, along with recommendations to mitigate the risk of ODS, are necessary. The literature to date on ODS in the setting of LT was reviewed. Major risk factors for the development of ODS include severe pretransplant hyponatremia (serum sodium [SNa] < 125 mEq/L), the magnitude of change in SNa pre- versus posttransplant, higher positive intraoperative fluid balance, and the presence of postoperative hemorrhagic complications. Strategies to reduce the risk of ODS include correcting hyponatremia pretransplant via fluid restriction and/or ensuring an appropriate rate of increase from the preoperative SNa via close attention to fluid and electrolyte management both during and after surgery. Multidisciplinary management involving transplant hepatology, nephrology, neurology, surgery, and anesthesiology/critical care is key to performing LT safely in patients with hyponatremia.
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Affiliation(s)
- J F Crismale
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - K A Meliambro
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - S DeMaria
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - D B Bronster
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - S Florman
- Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - T D Schiano
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.,Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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14
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Feltracco P, Cagnin A, Carollo C, Barbieri S, Ori C. Neurological disorders in liver transplant candidates: Pathophysiology and clinical assessment. Transplant Rev (Orlando) 2017; 31:193-206. [DOI: 10.1016/j.trre.2017.02.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 12/29/2016] [Accepted: 02/20/2017] [Indexed: 12/14/2022]
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Abstract
The brain operates in an extraordinarily intricate environment which demands precise regulation of electrolytes. Tight control over their concentrations and gradients across cellular compartments is essential and when these relationships are disturbed neurologic manifestations may develop. Perturbations of sodium are the electrolyte disturbances that most often lead to neurologic manifestations. Alterations in extracellular fluid sodium concentrations produce water shifts that lead to brain swelling or shrinkage. If marked or rapid they can result in profound changes in brain function which are proportional to the degree of cerebral edema or contraction. Adaptive mechanisms quickly respond to changes in cell size by either increasing or decreasing intracellular osmoles in order to restore size to normal. Unless cerebral edema has been severe or prolonged, correction of sodium disturbances usually restores function to normal. If the rate of correction is too rapid or overcorrection occurs, however, new neurologic manifestations may appear as a result of osmotic demyelination syndrome. Disturbances of magnesium, phosphate and calcium all may contribute to alterations in sensorium. Hypomagnesemia and hypocalcemia can lead to weakness, muscle spasms, and tetany; the weakness from hypophosphatemia and hypomagnesemia can impair respiratory function. Seizures can be seen in cases with very low concentrations of sodium, magnesium, calcium, and phosphate.
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Affiliation(s)
- M Diringer
- Department of Neurology, Washington University, St. Louis, MO, USA.
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Sánchez-Ferrer ML, Prieto-Sánchez MT, Orozco-Fernández R, Machado-Linde F, Nieto-Diaz A. Central pontine myelinolysis during pregnancy: Pathogenesis, diagnosis and management. J OBSTET GYNAECOL 2016; 37:273-279. [DOI: 10.1080/01443615.2016.1244808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- María Luisa Sánchez-Ferrer
- Obstetrics and Gynaecology Department, Virgen de la Arrixaca Clinical Hospital, University of Murcia, Murcia, Spain
| | - María Teresa Prieto-Sánchez
- Obstetrics and Gynaecology Department, Virgen de la Arrixaca Clinical Hospital, University of Murcia, Murcia, Spain
| | - Rodrigo Orozco-Fernández
- Obstetrics and Gynaecology Department, Virgen de la Arrixaca Clinical Hospital, University of Murcia, Murcia, Spain
| | - Francisco Machado-Linde
- Obstetrics and Gynaecology Department, Virgen de la Arrixaca Clinical Hospital, University of Murcia, Murcia, Spain
| | - Anibal Nieto-Diaz
- Obstetrics and Gynaecology Department, Virgen de la Arrixaca Clinical Hospital, University of Murcia, Murcia, Spain
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Shah B, Tobias JD. Osmotic Demyelination and Hypertonic Dehydration in a 9-Year-Old Girl: Changes in Cerebrospinal Fluid Myelin Basic Protein. J Intensive Care Med 2016; 21:372-6. [PMID: 17095502 DOI: 10.1177/0885066606293358] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
A 9-year-old girl was admitted for the treatment of hyper-natremic dehydration. Her history was significant for psychogenic polydipsia, hyponatremia, and a renal concentrating defect. She presented with a 2-day history of altered mental status, ataxia, lethargy, fever, nausea, vomiting, and diarrhea. Meningitis was ruled out. Over the course of her illness, slow rehydration was maintained with a gradual decrease (10 mEq per 24 hours) of the serum sodium. Despite this care, she developed quadriparesis, and magnetic resonance imaging performed on day 6 of her illness was consistent with osmotic demyelination (central pontine myelinolysis). To rule out an excessively rapid correction of hypernatremia as the etiology of the problem, a myelin basic protein was measured in the cerebrospinal fluid that had been obtained on hospital day 1. The myelin basic protein was 649.50 ng/mL (normal, 0.07-4.10 ng/mL). The current literature is presented regarding the postulated pathogenesis of central pontine myelinolysis and suggested therapies, previous reports of central pontine myelinolysis in children are reviewed, and the potential role of myelin basic protein in its diagnosis is discussed.
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Affiliation(s)
- Bobby Shah
- University of Missouri School of Medicine, Columbia, MO 65212, USA
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18
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Zhou Y, Zhu Y, Wang W, Xing B. Preoperative Extrapontine Myelinolysis with Good Outcome in a Patient with Pituitary Adenoma. J Korean Neurosurg Soc 2016; 59:161-4. [PMID: 26962424 PMCID: PMC4783484 DOI: 10.3340/jkns.2016.59.2.161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 01/31/2015] [Accepted: 02/23/2015] [Indexed: 12/19/2022] Open
Abstract
Few preoperative extrapontine myelinolysis (EPM) cases with pituitary adenoma have been reported. No such case had long follow-up to see the outcome of EPM. We reported a 38-year-old man complaining of nausea, malaise and transient loss of consciousness who was found to have severe hyponatremia. Neurologic deficits including altered mental status, behavioral disturbances, dysarthria and dysphagia developed despite slow correction of hyponatremia. Endocrine and imaging studies revealed hypopituitarism, nonfunctional pituitary macroadenoma and extrapontine myelinolysis. Transsphenoidal surgery was performed after three weeks of supportive therapy, when neurological symptoms improved significantly. The patient recovered function completely 3 months after surgery. Our case indicates that outcome of EPM can be good even with prolonged periods of severe neurologic impairment.
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Affiliation(s)
- Ying Zhou
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, P.R. China
| | - Yicheng Zhu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, P.R. China
| | - Wenze Wang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, P.R. China
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, P.R. China
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MacMillan TE, Tang T, Cavalcanti RB. Desmopressin to Prevent Rapid Sodium Correction in Severe Hyponatremia: A Systematic Review. Am J Med 2015; 128:1362.e15-24. [PMID: 26031887 DOI: 10.1016/j.amjmed.2015.04.040] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 04/10/2015] [Accepted: 04/28/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hyponatremia is common among inpatients and is associated with severe adverse outcomes such as osmotic demyelination syndrome. Current guidelines recommend serum sodium concentration correction targets of no more than 8 mEq/L per day in patients at high risk of osmotic demyelination syndrome. Desmopressin is recommended to control high rates of serum sodium concentration correction in severe hyponatremia. However, recommendations are based on limited data. The objective of this study is to review current strategies for DDAVP use in severe hyponatremia. METHODS Systematic literature search of 4 databases of peer-reviewed studies was performed and study quality was appraised. RESULTS The literature search identified 17 observational studies with 80 patients. We found 3 strategies for desmopressin administration in hyponatremia: 1) proactive, where desmopressin is administered early based on initial serum sodium concentration; 2) reactive, where desmopressin is administered based on changes in serum sodium concentration or urine output; 3) rescue, where desmopressin is administered after serum sodium correction targets are exceeded or when osmotic demyelination appears imminent. A proactive strategy of desmopressin administration with hypertonic saline was associated with lower incidence of exceeding serum sodium concentration correction targets, although this evidence is derived from a small case series. CONCLUSIONS Three distinct strategies for desmopressin administration are described in the literature. Limitations in study design and sample size prevent definitive conclusions about the optimal strategy for desmopressin administration to correct hyponatremia. There is a pressing need for better quality research to guide clinicians in managing severe hyponatremia.
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Affiliation(s)
- Thomas E MacMillan
- Division of General Internal Medicine, and HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, ON, Canada.
| | - Terence Tang
- Division of General Internal Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Trillium Health Partners, Mississauga, ON, Canada
| | - Rodrigo B Cavalcanti
- Division of General Internal Medicine, and HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, ON, Canada; Division of General Internal Medicine, University of Toronto, Toronto, ON, Canada
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Rafat C, Flamant M, Gaudry S, Vidal-Petiot E, Ricard JD, Dreyfuss D. Hyponatremia in the intensive care unit: How to avoid a Zugzwang situation? Ann Intensive Care 2015; 5:39. [PMID: 26553121 PMCID: PMC4639545 DOI: 10.1186/s13613-015-0066-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 09/02/2015] [Indexed: 12/11/2022] Open
Abstract
Hyponatremia is a common
electrolyte derangement in the setting of the intensive care unit. Life-threatening neurological complications may arise not only in case of a severe (<120 mmol/L) and acute fall of plasma sodium levels, but may also stem from overly rapid correction of hyponatremia. Additionally, even mild hyponatremia carries a poor short-term and long-term prognosis across a wide range of conditions. Its multifaceted and intricate physiopathology may seem deterring at first glance, yet a careful multi-step diagnostic approach may easily unravel the underlying mechanisms and enable physicians to adopt the adequate measures at the patient’s bedside. Unless hyponatremia is associated with obvious extracellular fluid volume increase such as in heart failure or cirrhosis, hypertonic saline therapy is the cornerstone of the therapeutic of profound or severely symptomatic hyponatremia. When overcorrection of hyponatremia occurs, recent data indicate that re-lowering of plasma sodium levels through the infusion of hypotonic fluids and the cautious use of desmopressin acetate represent a reasonable strategy. New therapeutic options have recently emerged, foremost among these being vaptans, but their use in the setting of the intensive care unit remains to be clarified.
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Affiliation(s)
- Cédric Rafat
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,AP-HP, Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Paris, France.
| | - Martin Flamant
- AP-HP, Service de Physiologie Rénale, Hôpital Bichat, Paris, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,INSERM, U1149, Centre de Recherche sur l'Inflammation, Paris, France.
| | - Stéphane Gaudry
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,ECEVE UMR 1123, ECEVE, Paris, France.
| | - Emmanuelle Vidal-Petiot
- AP-HP, Service de Physiologie Rénale, Hôpital Bichat, Paris, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,INSERM, U1149, Centre de Recherche sur l'Inflammation, Paris, France.
| | - Jean-Damien Ricard
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,INSERM UMR 1137, IAME, Paris, France.
| | - Didier Dreyfuss
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,INSERM UMR 1137, IAME, Paris, France.
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Babanrao SA, Prahladan A, Kalidos K, Ramachandran K. Osmotic myelinolysis: Does extrapontine myelinolysis precede central pontine myelinolysis? Report of two cases and review of literature. Indian J Radiol Imaging 2015; 25:177-83. [PMID: 25969642 PMCID: PMC4419428 DOI: 10.4103/0971-3026.155870] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Osmotic myelinolysis is an acute, rare, demyelinating process. After the initial description of the condition by Adam and colleagues in 1959, many case series have been published describing the central and extrapontine myelinolysis. Imaging has a definitive role in establishing the diagnosis of osmotic myelinolysis in vivo and diffusion-weighted imaging reveals earliest changes in affected brain parenchyma. We report two cases of patients with proven malignancy who developed extrapontine myelinolysis after treatment for hyponatremia and progressed to central pontine myelinolysis within a week. This was confirmed with magnetic resonance (MR) imaging and clinical assessment. This temporal progression of MR features, especially on diffusion-weighted imaging, from extrapontine to central pontine myelinolysis in osmotic injury has not been described in literature to the best of our knowledge. An early MRI of the brain in suspected/high-risk cases of osmotic myelinolysis may show features of extrapontine myelinolysis in the form of restricted diffusion in bilateral basal ganglia and may serve as a guide for predicting progression, prognosticating and deciding further treatment of pontine myelinolysis. We propose that in a significant number of cases, central pontine myelinolysis may be predicted by doing an early MRI of the brain with diffusion-weighted imaging, when extrapontine symptoms start to develop. This can potentially increase the window period and possibilities for therapeutic intervention and may even help in prevention.
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Affiliation(s)
| | - Anil Prahladan
- Department of Imageology, Regional Cancer Centre, Trivandrum, Kerala, India
| | - Kalirajan Kalidos
- Department of Imageology, Regional Cancer Centre, Trivandrum, Kerala, India
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22
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Risk factors, complication and measures to prevent or reverse catastrophic sodium overcorrection in chronic hyponatremia. Am J Med Sci 2015; 349:170-5. [PMID: 25163018 DOI: 10.1097/maj.0000000000000324] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Hyponatremia is the most common electrolyte disorder encountered in clinical practice. Patients who develop this condition for more than 48 hours are at risk for severe neurological sequelae if correction of the serum sodium occurs too rapidly. Certain medical disorders are known to place patients at an increased risk for rapid correction of serum sodium concentration. Large-volume polyuria in this setting is an ominous sign. For these patients, early identification of risk factors, close monitoring of serum sodium correction and the use of 5% dextrose with or without desmopressin to prevent or reverse overcorrection are important components of treatment.
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23
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Buffington MA, Abreo K. Hyponatremia: A Review. J Intensive Care Med 2015; 31:223-36. [PMID: 25592330 DOI: 10.1177/0885066614566794] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 10/24/2014] [Indexed: 01/03/2023]
Abstract
Hyponatremia is the most frequently occurring electrolyte abnormality and can lead to life-threatening complications. This disorder may be present on admission to the intensive care setting or develop during hospitalization as a result of treatment or multiple comorbidities. Patients with acute hyponatremia or symptomatic chronic hyponatremia will likely require treatment in the intensive care unit (ICU). Immediate treatment with hypertonic saline is needed to reduce the risk of permanent neurologic injury. Chronic hyponatremia should be corrected at a rate sufficient to reduce symptoms but not at an excessive rate that would create a risk of osmotic injury. Determination of the etiology of chronic hyponatremia requires analysis of serum osmolality, volume status, and urine osmolality and sodium level. Correct diagnosis points to the appropriate treatment and helps identify risk factors for accelerated correction of the serum sodium level. Management in the ICU facilitates frequent laboratory draws and allows close monitoring of the patient's mentation as well as quantification of urine output. Overly aggressive correction of serum sodium levels can result in neurological injury caused by osmotic demyelination. Therapeutic measures to lower the serum sodium level should be undertaken if the rate increases too rapidly.
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Affiliation(s)
- Mary Ansley Buffington
- LSU Health Shreveport School of Medicine, Nephrology Section of Department of Internal Medicine, Shreveport, LA, USA.
| | - Kenneth Abreo
- LSU Health Shreveport School of Medicine, Nephrology Section of Department of Internal Medicine, Shreveport, LA, USA
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24
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Straube A, Klein M, Erbguth F, Maschke M, Klawe C, Sander D, Hilz MJ, Ziemssen T, Klucken J, Kohl Z, Winkler J, Bettendorf M, Staykov D, Berrouschot J, Dörfler A. Metabolische Störungen. NEUROINTENSIV 2015. [PMCID: PMC7175475 DOI: 10.1007/978-3-662-46500-4_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Im folgenden Kapitel werden die verschiedenen metabolischen Störungen betrachtet. Zunächst wird auf die allgemeinen und spezifischen neurologischen Komplikationen bei Organtransplantation eingegangen. Dann geht es um die metabolischen Enzephalopathien: Störungen der Gehirntätigkeit bei angeborenen und erworbenen Stoffwechselerkrankungen im engeren Sinn, Elektrolytstörungen, Hypovitaminosen, zerebrale Folgen einzelner Organdysfunktionen, zerebrale Hypoxien, Endotheliopathien und Mitochondropathien. Anschließend werden das Alkoholdelir und die Wernicke-Enzephalopathie erörtert. Bei zahlreichen akuten Erkrankungen von Gehirn, Rückenmark und peripherem Nervensystem treten typische Störungen vegetativer Systeme auf, deren Erkennung und Therapie insbesondere bei Intensivpatienten eine vitale Bedeutung haben kann: die autonomen Störungen. Bei der zentralen pontinen Myelinolyse kommt es zu einer akuten, vorwiegend fokal-symmetrischen Demyelinisierung im Hirnparenchym. Auch Basalganglienerkrankungen können intensivmedizinisch relevant werden. Und schließlich wird die akute Stressreaktion betrachtet, die aufgrund der vielfältigen metabolischen und endokrinen Veränderungen bei kritischen Erkrankungen entsteht. Gerade das RCVS als neuere Krankheitsentität und wichtige Differenzialdiagnose zur Vaskulitis des ZNS verdient einen eigenen Platz, in diesem Unterkapitel werden ebenfalls verwandte Syndrome wie die hypertensive Enzephalopathie und das PRES abgehandelt.
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25
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Srisung W, Mankongpaisarnrung C, Anaele C, Dumrongmongcolgul N, Ahmed V. A rare case of low-solute hyponatremia in a nonalcoholic person. Case Rep Nephrol Dial 2014; 5:49-53. [PMID: 25849675 PMCID: PMC4360732 DOI: 10.1159/000370236] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Low-solute hyponatremia is a relatively uncommon entity of euvolemic hyponatremia. Classic cases were described in alcoholics as beer potomania, which is characterized by hyponatremia in the setting of low-solute intake due to heavy beer drinking. We report a case of low-solute hyponatremia in a nonalcoholic person who was given a solute load, and, subsequently, had excessive diuresis with the resultant rapid increase in serum sodium concentration.
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Affiliation(s)
- Weeraporn Srisung
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Tex., USA
| | | | - Cyriacus Anaele
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Tex., USA
| | - Nat Dumrongmongcolgul
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Tex., USA
| | - Vaqar Ahmed
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Tex., USA
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26
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Giuliani C, Peri A. Effects of Hyponatremia on the Brain. J Clin Med 2014; 3:1163-77. [PMID: 26237597 PMCID: PMC4470176 DOI: 10.3390/jcm3041163] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 09/18/2014] [Accepted: 10/10/2014] [Indexed: 12/31/2022] Open
Abstract
Hyponatremia is a very common electrolyte disorder, especially in the elderly, and is associated with significant morbidity, mortality and disability. In particular, the consequences of acute hyponatremia on the brain may be severe, including permanent disability and death. Also chronic hyponatremia can affect the health status, causing attention deficit, gait instability, increased risk of falls and fractures, and osteoporosis. Furthermore, an overly rapid correction of hyponatremia can be associated with irreversible brain damage, which may be the result of the osmotic demyelination syndrome. This review analyzes the detrimental consequences of acute and chronic hyponatremia and its inappropriate correction on the brain and the underlying physiopathological mechanisms, with a particular attention to the less known in vivo and in vitro effects of chronic hyponatremia.
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Affiliation(s)
- Corinna Giuliani
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence 50139, Italy.
| | - Alessandro Peri
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence 50139, Italy.
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27
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John TM, Jacob CN, Xavier J, Kondanath S, Ittycheria CC, Jayaprakash R. A case of acute onset parkinsonism. Qatar Med J 2014; 2013:29-32. [PMID: 25003061 PMCID: PMC4080490 DOI: 10.5339/qmj.2013.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 09/12/2013] [Indexed: 11/10/2022] Open
Abstract
Extra pontine myelinolysis (EPM) is a form of osmotic demyelination syndrome, characterized by the presence of signal alterations in varied sites in the brain other than the pons. When caudate and putamen are involved, it results in a constellation of extra pyramidal signs and symptoms resembling parkinsonism. Here we report a case of this unique syndrome presenting with features of parkinsonism which was successfully treated with dopaminergic drugs.
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Affiliation(s)
- Teny Mathew John
- 1Department of Medicine, Government Medical College, Kottayam, Kerala, India
- 2Department of Medicine, Hamad General Hospital, Doha, Qatar
| | - Ceena Neena Jacob
- 1Department of Medicine, Government Medical College, Kottayam, Kerala, India
| | - Jerry Xavier
- 1Department of Medicine, Government Medical College, Kottayam, Kerala, India
| | - Saifudeen Kondanath
- 1Department of Medicine, Government Medical College, Kottayam, Kerala, India
| | | | - R. Jayaprakash
- 1Department of Medicine, Government Medical College, Kottayam, Kerala, India
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28
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Abstract
Dysnatremias occur simultaneously with disorders in water balance. The first priority is to correct dehydration; once the patient is euvolemic, the sodium level can be reassessed. In unstable patients with hyponatremia, the clinician should rapidly administer hypertonic saline. In unstable patients with hypernatremia, the clinician should administer isotonic intravenous fluid. In stable patients with either hyponatremia or hypernatremia, the clinician should aim for correction over 24 to 48 hours, with the maximal change in serum sodium between 8 to 12 mEq/L over the first 24 hours. This rate of correction decreases the chances of cerebral edema or osmotic demyelination syndrome.
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Affiliation(s)
- Theresa R Harring
- Section of Emergency Medicine, Ben Taub General Hospital, Baylor College of Medicine, Emergency Center, 1504 Taub Loop, Room EC 61, Houston, TX 77030, USA.
| | - Nathan S Deal
- Section of Emergency Medicine, Ben Taub General Hospital, Baylor College of Medicine, Emergency Center, 1504 Taub Loop, Room EC 61, Houston, TX 77030, USA
| | - Dick C Kuo
- Section of Emergency Medicine, Ben Taub General Hospital, Baylor College of Medicine, Emergency Center, 1504 Taub Loop, Room EC 61, Houston, TX 77030, USA.
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29
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Unpredictable nature of tolvaptan in treatment of hypervolemic hyponatremia: case review on role of vaptans. Case Rep Endocrinol 2014; 2014:807054. [PMID: 24511399 PMCID: PMC3912886 DOI: 10.1155/2014/807054] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 12/03/2013] [Indexed: 11/30/2022] Open
Abstract
Hyponatremia is one of the most commonly encountered electrolyte abnormalities occurring in up to 22% of hospitalized patients. Hyponatremia usually reflects excess water retention relative to sodium rather than sodium deficiency. Volume status and serum osmolality are essential to determine etiology. Treatment depends on several factors, including the cause, overall volume status of the patient, severity of hyponatremic symptoms, and duration of hyponatremia at presentation. Vasopressin antagonists like tolvaptan seem promising for the treatment of euvolemic and hypervolemic hyponatremia in heart failure. Low sodium concentrations cause cerebral edema, but the overly rapid sodium correction can also lead to iatrogenic cerebral osmotic demyelination syndrome. Demyelination may occur days after sodium correction or initial neurologic recovery from hyponatremia. The following case report analyzes the role of vasopressin antagonists in the treatment of hyponatremia and the need for daily dosing of tolvaptan and the monitoring of serum sodium levels to avoid rapid overcorrection which can result in osmotic demyelination syndrome (ODS).
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31
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Rafat C, Schortgen F, Gaudry S, Bertrand F, Miguel-Montanes R, Labbé V, Ricard JD, Hajage D, Dreyfuss D. Use of desmopressin acetate in severe hyponatremia in the intensive care unit. Clin J Am Soc Nephrol 2013; 9:229-37. [PMID: 24262506 DOI: 10.2215/cjn.00950113] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND OBJECTIVES Excessive correction of chronic and profound hyponatremia may result in central pontine myelinolysis and cause permanent brain damage. In the case of foreseeable or established hyponatremia overcorrection, slowing down the correction rate of sodium plasma levels (PNa) or reinducing mild hyponatremia may prevent this neurologic complication. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This retrospective and observational study was performed with 20 consecutive patients admitted to two intensive care units for severe hyponatremia, defined by PNa <120 mmol/L and/or neurologic complications ascribable to hyponatremia and subsequently treated by desmopressin acetate (DDAVP) during correction of hyponatremia when the rate of correction was overtly or predictably excessive. The primary endpoint was the effectiveness of DDAVP on PNa control. RESULTS DDAVP dramatically decreased the rate of PNa correction (median 0.81 mmol/L per hour [interquartile range, 0.46, 1.48] versus -0.02 mmol/L per hour [-0.16, 0.22] before and after DDAVP, respectively; P<0.001) along with a concurrent decrease in urine output (650 ml/h [214, 1200] versus 93.5 ml/h [43, 143]; P=0.003), and a rise in urine osmolarity (86 mmol/L [66, 180] versus 209 mmol/L [149, 318]; P=0.002). The maximal magnitude of PNa variations was also markedly reduced after DDAVP administration (11.5 mmol/L [8.25, 14.5] versus 5 mmol/L [4, 6.75]; P<0.001). No patient developed seizures after DDAVP or after subsequent relowering of PNa that occurred in 11 patients. CONCLUSIONS Desmopressin acetate is effective in curbing the rise of PNa in patients admitted in the intensive care unit for severe hyponatremia, when the initial rate of correction is excessive.
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Affiliation(s)
- Cédric Rafat
- Medical-Surgical Intensive Care Unit, Louis Mourier Hospital, Assistance Publique-Hôpitaux de Paris, Colombes, France;, †Diderot University of Paris, Sorbonne Paris Cité, Paris, France;, ‡Medical Intensive Care Unit, Henri Mondor Hospital, Public Assistance Hospitals of Paris, Créteil, France;, §Institut National de la Santé et de la Recherche Médicale U722, Paris, France, ‖Department of Public Health, Epidemiology, and Clinical Research, Bichat hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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32
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Souza AD, Desai PK. More often striatal myelinolysis than pontine? A consecutive series of patients with osmotic demyelination syndrome. Neurol Res 2013; 34:262-71. [DOI: 10.1179/1743132812y.0000000009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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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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AlZahrani A, Sinnert R, Gernsheimer J. Acute kidney injury, sodium disorders, and hypercalcemia in the aging kidney: diagnostic and therapeutic management strategies in emergency medicine. Clin Geriatr Med 2013. [PMID: 23177611 DOI: 10.1016/j.cger.2012.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This article summarizes the current literature regarding the structural and functional changes of the aging kidney and describes how these changes make the older patient more susceptible to acute kidney injury and fluid and electrolyte disorders. It discusses the clinical manifestations, evaluation, and management of hyponatremia and shows how the management of hypernatremia in geriatric patients involves addressing the underlying cause and safely correcting the hypernatremia. The current literature regarding evaluation and management of hypercalcemia in older patients is summarized. The management of severe hypercalcemia is discussed in detail. The evaluation and management of acute kidney injury is described.
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Affiliation(s)
- Abdullah AlZahrani
- Department of Emergency Medicine, SUNY Downstate College of Medicine, Brooklyn, NY 11203, USA
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35
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Jovanovich AJ, Berl T. Where vaptans do and do not fit in the treatment of hyponatremia. Kidney Int 2012; 83:563-7. [PMID: 23254896 DOI: 10.1038/ki.2012.402] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The treatment of hyponatremia, an exceedingly common electrolyte disorder, has been a subject of controversy for many years. The advent of vasopressin antagonists (vaptans) has added to the treatment arsenal. This review focuses on why hyponatremia should be treated and the role of these antagonists in the treatment. Upon analysis of the available literature, we conclude that there is presently no role for vaptans in acute symptomatic hyponatremia. Although numerous therapeutic approaches are available for chronic symptomatic hyponatremia, vasopressin antagonists provide a simpler treatment option. Vaptans are efficacious in raising serum sodium in long-standing 'asymptomatic' hyponatremia. However, the cost of the only Food and Drug Administration-approved oral agent (tolvaptan) makes its use prohibitive for most patients in this setting.
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Affiliation(s)
- Anna J Jovanovich
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado 80045, USA
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Hornik A, Rodriguez Porcel FJ, Agha C, Flaster M, Morales Vidal S, Schneck MJ, Lee J, Biller J. Central and extrapontine myelinolysis affecting the brain and spinal cord. An unusual presentation of pancreatic encephalopathy. Front Neurol 2012; 3:135. [PMID: 23060853 PMCID: PMC3461402 DOI: 10.3389/fneur.2012.00135] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 09/06/2012] [Indexed: 11/13/2022] Open
Abstract
Pancreatic encephalopathy refers to a gamut of neuropsychiatric symptoms complicating acute pancreatitis. Osmotic myelinolysis is a known complication of pancreatic encephalopathy. We evaluated a 58-year-old woman with pancreatic encephalopathy associated to pontine and extrapontine myelinolysis involving the brain and spinal cord. To our knowledge, this is the first clinic pathological case report of pancreatic encephalopathy involving the spinal cord.
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Affiliation(s)
| | | | | | | | | | | | - John Lee
- Loyola University Medical CenterChicago, IL, USA
| | - José Biller
- Loyola University Medical CenterChicago, IL, USA
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Myélinolyse centro- et extrapontine. Données actuelles et spécificités en réanimation. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0504-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Relowering of serum na for osmotic demyelinating syndrome. Case Rep Neurol Med 2012; 2012:704639. [PMID: 22937357 PMCID: PMC3420698 DOI: 10.1155/2012/704639] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 05/27/2012] [Indexed: 11/30/2022] Open
Abstract
We report a case in whom slow correction of hyponatremia (5 mmol/day for 3 days) induced central pontine myelinolysis (CPM). After the diagnosis was confirmed by imaging, we started to relower serum Na that completely recovered the sign and symptoms of CPM. Rapid correction of serum sodium is known to be associated with CPM. However, it may occur even after slow correction of hyponatremia. Currently, there is no standard therapy for CPM other than supportive therapy. Other therapy includes sterioid, plasmaphresis and IVIG, but these therapies have not been shown to be particularly effective. The pathophysiology of CPM is related to a relative dehydration of the brain during the correction of hyponatremia, resulting in cell death and demyelination, therefore gentle rehydration with lowering serum sodium may not be an unreasonable therapy. The present case provides supportive evidence that reinduction of hyponatremia is effective in treating CPM if started immediately after the diagnosis is suggested. The present case tells us that severe chronic hyponatremia must be managed with extreme care especially in patients with chronic debilitating illness and that relowering serum Na is a treatment of choice when CPM is suggested.
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Kamel KS, Halperin ML. Managing Overly Rapid Correction of Chronic Hyponatremia: An Ounce of Prevention or a Pound of Cure? J Am Soc Nephrol 2010; 21:2015-6. [DOI: 10.1681/asn.2010101062] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Sterns RH, Hix JK, Silver S. Treating profound hyponatremia: a strategy for controlled correction. Am J Kidney Dis 2010; 56:774-9. [PMID: 20709440 DOI: 10.1053/j.ajkd.2010.04.020] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 04/20/2010] [Indexed: 01/18/2023]
Abstract
An alcoholic patient presented with profound hyponatremia (serum sodium concentration, 96 mEq/L) caused by the combined effects of a thiazide diuretic, serotonin reuptake inhibitor, beer potomania, and hypovolemia. A computed tomographic scan of the brain was indistinguishable from one obtained 3 weeks earlier when he was normonatremic. Concurrent administration of 3% saline solution and desmopressin controlled the rate of correction to an average of 6 mEq/L daily and resulted in full neurologic recovery without evidence of osmotic demyelination. This case illustrates the value of controlled correction of profound hyponatremia.
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Affiliation(s)
- Richard H Sterns
- Rochester General Hospital, Nephrology Division, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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Abstract
The osmotic demyelination syndrome (ODS) has been a recognized complication of the rapid correction of hyponatremia for decades. However, in recent years, a variety of other medical conditions have been associated with the development of ODS, independent of changes in serum sodium. This finding suggests that the pathogenesis of ODS may be more complex and involve the inability of brain cells to respond to rapid changes in osmolality of the interstitial (extracellular) compartment of the brain, leading to dehydration of energy-depleted cells with subsequent axonal damage that occurs in characteristic areas. Features of the syndrome include quadriparesis and neurocognitive changes in the presence of characteristic lesions found on magnetic resonance imaging of the brain. Although slow correction of hyponatremia seems to be the best way to prevent development of the syndrome, there are new data that suggest reintroduction of hyponatremia in those patients who have undergone inadvertent rapid correction of the serum sodium and corticosteroids may play a role in prevention of ODS.
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Berl T, Rastegar A. A patient with severe hyponatremia and hypokalemia: osmotic demyelination following potassium repletion. Am J Kidney Dis 2010; 55:742-8. [PMID: 20338465 DOI: 10.1053/j.ajkd.2009.12.024] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 12/23/2009] [Indexed: 12/12/2022]
Affiliation(s)
- Tomas Berl
- University of Colorado Denver, Division of Renal Diseases and Hypertension, Aurora, CO 80045, USA.
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Passeron A, Dupeux S, Blanchard A. Hyponatrémie : de la physiopathologie à la pratique. Rev Med Interne 2010; 31:277-86. [DOI: 10.1016/j.revmed.2009.03.369] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Revised: 02/06/2009] [Accepted: 03/11/2009] [Indexed: 11/30/2022]
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Rahman M, Friedman WA. Hyponatremia in neurosurgical patients: clinical guidelines development. Neurosurgery 2009; 65:925-35; discussion 935-6. [PMID: 19834406 DOI: 10.1227/01.neu.0000358954.62182.b3] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Neurosurgical patients have a high risk of hyponatremia and associated complications. We critically evaluated the existing literature to identify the determinants for the development of hyponatremia and which management strategies provided the best outcomes. METHODS A multidisciplinary panel in the areas of neurosurgery, nephrology, critical care medicine, endocrinology, pharmacy, and nursing summarized and classified hyponatremia literature scientific studies published in English from 1950 through 2008. The panel's recommendations were used to create an evaluation and treatment protocol for hyponatremia in neurosurgical patients at the University of Florida. RESULTS Hyponatremia should be further investigated and treated when the serum sodium level is less than 131 mmol/L (class II). Evaluation of hyponatremia should include a combination of physical examination findings, basic laboratory studies, and invasive monitoring when available (class III). Obtaining levels of hormones such as antidiuretic hormone and natriuretic peptides is not supported by the literature (class III). Treatment of hyponatremia should be based on severity of symptoms (class III). The serum sodium level should not be corrected by more than 10 mmol/L/d (class III). Cerebral salt wasting should be treated with replacement of serum sodium and intravenous fluids (class III). Fludrocortisone may be considered in the treatment of hyponatremia in subarachnoid hemorrhage patients at risk of vasospasm (class I). Hydrocortisone may be used to prevent natriuresis in subarachnoid hemorrhage patients (class I). Hyponatremia in subarachnoid hemorrhage patients at risk of vasospasm should not be treated with fluid restriction (class II). Syndrome of inappropriate antidiuretic hormone may be treated with urea, diuretics, lithium, demeclocycline, and/or fluid restriction (class III). CONCLUSION The summarized literature on the evaluation and treatment of hyponatremia was used to develop practice management recommendations for hyponatremia in the neurosurgical population. However, the practice management recommendations relied heavily on expert opinion because of a paucity of class I evidence literature on hyponatremia.
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Affiliation(s)
- Maryam Rahman
- Department of Neurosurgery, University of Florida, Gainesville, Florida 32610-0265, USA.
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Vu T, Wong R, Hamblin PS, Zajac J, Grossmann M. Patients presenting with severe hypotonic hyponatremia: etiological factors, assessment, and outcomes. Hosp Pract (1995) 2009; 37:128-136. [PMID: 20877181 DOI: 10.3810/hp.2009.12.266] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Although hospital-acquired hyponatremia is well described, severe community-acquired hyponatremia has been studied less extensively. AIM To assess characteristics and outcomes of patients admitted with severe hypotonic hyponatremia (SHH) (defined as serum sodium ≤ 120 mmol/L). METHODS All patients with serum sodium of ≤ 120 mmol/L who were admitted to 2 large teaching hospitals from January 2000 to August 2007 were identified, and data were obtained from medical records. Main outcome measures were incidence of osmotic demyelination and mortality. RESULTS Two hundred fifty-five patients were admitted who had SHH (female to male ratio 2:1), and the mean age was 72 ± 14 years. The most common etiological factors were thiazide/indapamide diuretics (41%), syndrome of inappropriate antidiuretic hormone secretion (38%), and hypovolemia (24%). Inappropriately rapid correction of serum sodium (> 12 mmol/L over the first 24 hours) occurred in 37 patients (15%), with 4 patients (11%) developing osmotic demyelination. Patients who developed osmotic demyelination were more likely to be younger, abuse alcohol (3 of 4 patients), and have lower serum potassium levels. One patient had a hypoxic-anoxic episode at presentation. The patients also had a mean serum sodium increase in the first 24 and 48 hours of 21 ± 5 mmol/L and 28 ± 8 mmol/L, respectively. None of the patients with osmotic demyelination received hypertonic saline. None of the patients in whom the serum sodium increment was limited to ≤ 12 mmol/L developed osmotic demyelination. Overall, mortality was 10% and was not related to sodium level at presentation. CONCLUSIONS Patients treated with thiazide or indapamide (particularly elderly women) may benefit from monitoring of serum sodium levels. Inappropriately rapid serum sodium correction is associated with osmotic demyelination, particularly in patients with risk factors for this condition. In contrast to what has been reported for hyponatremia in hospitalized patients, severity of hyponatremia on admission did not predict increased mortality in our patient population.
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Affiliation(s)
- Thuy Vu
- Department of Medicine, University of Melbourne Austin Health, Heidelberg, Victoria 3081, Australia.
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Abstract
Hyponatraemia is a commonly encountered electrolyte abnormality in hospitalised patients and is associated with significant morbidity and mortality. The fact that most cases of hyponatraemia are the result of water imbalance rather than sodium imbalance underscores the role of antidiuretic hormone (ADH) in the pathophysiology. Hyponatraemia can be classified according to the measured plasma osmolality as isotonic, hypertonic or hypotonic. Hyponatraemia with a normal plasma osmolality usually indicates pseudohyponatraemia, while hyponatraemia because of a high plasma osmolality is typically caused by hyperglycaemia. After excluding isotonic and hypertonic causes, hypotonic hyponatraemia is further classified according to the volume status of the patient as hypovolaemic, hypervolaemic or euvolaemic. Hypovolaemic hyponatraemia is accompanied by extracellular fluid (ECF) volume deficit, while hypervolaemic hyponatraemia manifests with ECF volume expansion. The syndrome of inappropriate ADH (SIADH) should be suspected in any patient with euvolaemic hyponatraemia with a urine osmolality above 100 mOsm/kg and urine sodium concentration above 40 mEq/l. In the management of any hyponatraemia regardless of the patient's volume status, it is advised to restrict free water and hypotonic fluid intake. Hypertonic saline and vasopressin antagonists can be used to correct symptomatic hyponatraemia. The rate of correction is dependent upon the duration, degree of hyponatraemia and the presence or absence of symptoms. Symptomatic acute hyponatraemia (< 48 h) is a medical emergency requiring rapid correction to prevent the worsening of brain oedema. In asymptomatic patients with chronic hyponatraemia (> 48 h or unknown duration), fluid restriction and close monitoring alone are sufficient, while a slow correction by 0.5 mEq/l/h may be attempted in symptomatic patients. Excessive rapid correction should be avoided in both acute and chronic hyponatraemia, because it can lead to irreversible neurological complications including central osmotic demyelination.
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Affiliation(s)
- P Reddy
- Department of Medicine, University of Florida College of Medicine, Jacksonville, FL 32209, USA
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Re-induction of hyponatremia after rapid overcorrection of hyponatremia reduces mortality in rats. Kidney Int 2009; 76:614-21. [DOI: 10.1038/ki.2009.254] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
The diagnosis and management of hyponatremia can be intimidating, for both trainees and clinicians alike. We present five clinical scenarios of patients with hyponatremia. These discussions reinforce concepts reviewed elsewhere in this issue of Seminars in Nephrology and/or emphasize specific causes and management issues.
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Affiliation(s)
- David B Mount
- Renal Division, Brigham and Women's Hospital and VA Boston Healthcare System, Harvard Medical School, Boston, MA 02215, USA.
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