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By Sheena Howson, MD

2/18/2011

SIADH
Inappropriate secretion of ADH
Water excretion is impaired
Suppression of ADH is impaired
Functions of ADH
Increases permeability of water in the cells of the distal

tubules by upregulating Aquaporin-2 channels (V2


receptors)
Increases the permeability of collecting ducts to urea
Increases SVR via IP3/Ca++ 2 nd messengers on
endothelium
CNS effects like memory formation and circadian rhythm

SIADH - causes
Intracranial infection, stroke, hemorrhage, tumor, very

common in SAH population (69%)


Intrathoracic malignancy, abscess, PNA, effusion, PTX,
chest wall deformity
Drugs vasopressin, DDAVP, oxytocin, analgesics,
antidepressants, amiodarone, antipsychotics,
sulfonylureas, carbamazepine, cyclophosphamide
Extracranial tumors small-cell lung CA, pancreatic CA
HIV/AIDS
Hereditary gain-of-function V2 receptor mutation
Miscellaneous Guillan-Barre, nausea, stress, pain,
acute psychosis
Major surgery ****
Idiopathic

SIADH
Hypothalamus
receives feedback
from:
Osmoreceptors
Aortic arch
baroreceptors
Carotid
baroreceptors
Atrial stretch
receptors
Any increase in
osmolality or
decrease in blood
volume will stimulate
ADH secretion from

SIADH - pathophysiology
ADH-induced water retention
Dilutional hyponatremia
Volume expansion -> secondary natriuresis
Sodium and water loss
Potassium loss
Result: Euvolemic hyponatremia
Reduced serum osmolality
Increased urine osmolality
Increased urine sodium

SIADH - diagnosis
Laboratory Findings
Na < 135 mEq/L
Posm < 270 mOsm/kg
Uosm > 300 mOsm/kg
UNa > 25 mEq/L
Low BUN
Normal Cr
Low uric acid
Low albumin

SIADH - treatment
Treat the underlying cause, if known
Fluid Restriction commonly 800-1000mL/d
Correct Na+ deficit no more than 10mEq/L

in 24 hours, 18mEq/L in 48 hours


0.9% NaCl
3% NaCl
NaCl enteral tablets 2-3g TID
Add a loop diuretic

SIADH treatment
Vasopressin receptor antagonists
Promote aquaresis
Tolvaptan, conivaptan

Vaprisol (Conivaptan)
Indicated in euvolemic or hypervolemic
hyponatremia
Contraindicated in hypovolemic hyponatremia
V1a and V2 receptors
Causes aquaresis or excretion of free water

Demeclocycline or Lithium (diminished

collecting tubule response to ADH)

Cerebral Salt Wasting


Hyponatremia caused by impaired renal

tubular function -> inability of kidneys to


conserve salt
Salt wasting leads to volume depletion
Two theories:
Impaired sympathetic neural input -> failure of

aldosterone release -> no sodium resorption


BNP release decreases sodium resorption,
inhibits renin/aldosterone release, decreases
autonomic outflow at level of brainstem

Cerebral Salt Wasting


Commonly occurs in subarachnoid

hemorrhage population (7%)


Carcinomatous, infectious meningitis
Encephalitis
Poliomyelitis
CNS tumors
CNS surgery usually within the first 10 days

Cerebral Salt Wasting


Diagnosis:
Evidence of volume depletion
Increased urine output
Laboratory Findings
Na < 135 mEq/L
Low Posm
Uosm > 300 mOsm/kg
UNa > 40 mEq/L
High BUN
Increased Cr
Low uric acid
Increased albumin

Cerebral Salt Wasting


Treat with volume repletion
0.9% NaCl
3% NaCl is sometimes warranted
Fludrocortisone

Diabetes Insipidus
The most common cause of hypernatremia in

neurological population
Deficient ADH
Central DI occurs with hypothalamic-pituitary

axis dysfunction or injury


Nephrogenic DI diminished renal sensitivity to
ADH

Usually considered a euvolemic to

hypovolemic state, depending on the patients


thirst mechanism

Diabetes Insipidus

Diabetes Insipidus
Typical Clinical picture:
Polyuria
Polydipsia
Laboratory Findings
Na >145 mEq/L
Nocturia
Posm > 285 mOsm/kg
Uosm < 300 mOsm/kg
UNa low
Urine Spec. Grav. < 1.005
UOP > 3ml/kg/h

Diabetes Insipidus
Goal is to restore plasma volume and serum

Na+ levels
Patient with intact thirst mechanism

Pitcher at bedside. Drink to thirst only!

Severe forms

Replace UOP 1:1 with 1/2NS


DDAVP 5u SQ Q4-6h, commonly given orally/nasally
DDAVP will be ineffective if nephrogenic (HCTZ can
be used)

Review
SIADH

CSW

DI

Serum Na+

< 135 mEq/L

< 135 mEq/L

> 145 mEq/L

Urine Na+

> 25 mEq/L

> 40 mEq/L

< 25 mEq/L

Serum Osm

< 270 mOsm/kg < 270 mOsm/kg > 285 mOsm/kg

Urine Osm

> 300 mOsm/kg > 300 mOsm/kg < 300 mOsm/kg

Urine O/P

oliguria

polyuria

polyuria

CVP

normal/high

low

normal/low

Plasma ADH

high

normal

low

Rx

Fluid restrict,
give Na+,
vaprisol,
demeclocycline

Give volume,
give Na+,
fludrocortisone

Drink to thirst,
DDAVP
(central), HCTZ
(nephrogenic)