Summary
Because hyponatremia is frequently associated with preceding diuretic treatment and unrestricted fluid indake — conditions which have not been addressed sufficiently in published literature — we studied the pathophysiology and the clinical setting of such hyponatremia in a large group of internal medicine patients. We observed:
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a)
Of an initial 310 patients with chemical hyponatremia only 204 (64%) had an associated plasma hypoosmolality. Sience a normal plasma osmolality excludes a disturbance of water metabolism only the 204 patients with hypoosmolar hyponatremia were included in the study. This data shows that plasma osmolality is an essential measurement in any evaluation of hyponatremia.
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b)
In 204 consecutive patients with hypoosmolar hyponatremia the electrolyte disturbance was related to advanced congestive cardiac failure in 25%, decompensated liver cirrhosis in 18%, volume contraction in 28%, syndrome of inappropriate antidiuretic hormone secretion in 19% and renal insufficiency in 4%.
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c)
Plasma vasopressin was measurable in 90% of the 204 patients. It is known that radioimmunoassays to measure vasopressin fail to reliably detect low concentrations of circulating vasopressin (<0.5 pg/ml). It may therefore be stated that hypoosmolar hyponatremia was generally characterized by a failure of antidiuretic hormone suppression.
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d)
Mean daily fluid intake of hyponatremic patients was 2.35±0.15 l. In the presence of stimulated vasiopressin this large a fluid intake is bound to worsen the severity of hyponatremia.
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e)
Of 204 patients 126 were treated with diuretics at the time of study. In these patients hyponatremia worsened during such treatments and was associated with evidence of prerenal azotemia. However there were no significant differences between diuretic-treated and -untreated patients with respect to plasma vasopressin stimulation and amount of fluid intake.
In conclusion, stimulated vasopressin and high fluid intake explain the hyponatremia observed in the present study. This applied similary to diuretictreated and -untreated patients.
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Abbreviations
- ADH:
-
antidiuretic hormone
- AVP:
-
arginine vasopressin
- ECF:
-
extracellular fluid
- PRA:
-
plasma renin activity
- P Na :
-
plasma sodium concentration
- SIADH:
-
syndrome of inappropriate antidiuretic hormone secretion
References
Anderson RJ, Cronin RE, McDonald KM, Schrier RW (1976) Mechanism of portal hypertension-induced alterations in renal hemodynamics, renal water excretion and renin secretion. J Clin Invest 58:964–970
Anderson RJ, Chung HM, Kluge R, Schrier RW (1985) Hyponatremia: a prospective analysis of its epidemiology and the pathogenetic role of vasopressin. Ann Int Med 102:164–168
Beck LH (1979) Hypouricemia in the syndrome of inappropriate secretion of antidiuretic hormone. N Engl J Med 301:528–530
Bichet DG, Groves BM, Schrier RW (1983) Mechanism of improvement of water and sodium excretion by immersion in decompensated cirrhotic patients. Kidney Int 24:788–794
Da Prada M, Zürcher G (1976) Simultaneous radioenzymatic determination of plasma and tissue adrenaline, noradrenaline and dopamine within the femtomol range. Life Sci 19:1161–1174
Dürr JA, Schrier RW (1987) Cardiovascular and hemodynamic effects of arginine vasopressin. In: Brenner BM, Stein JH (eds) Contemporary issues in nephrology. Churchill Livingstone, vol 16, pp 131–162
Dzau VJ, Hollenberg NK (1984) Renal response to captopril in severe heart failure: role of furosemide in natriuresis and reversal of hyponatremia. Ann Int Med 100:777–782
Epstein FH (1982) Underfilling versus overflow in hepatic ascites. N Engl J Med 307:1577–1578
Forrest JN, Cox M, Hong C, Morrison G, Bia M, Singer I (1978) Superiority of demeclocycline over lithium in the treatment of chronic syndrome of inappropriate secretion of antidiuretic hormone. N Engl J Med 298:173–177
Francis GS, Goldsmith SR, Levine TB, Olivary MT, Cohn JN (1984) The neurohumoral axis in congestive heart failure. Ann Int Med 101:370–377
Gross PA, Ketteler M, Hausmann C, Ritz E (1987) The charted and the uncharted waters of hyponatremia. Kidney Int 32:S67-S75
Haber E, Koerner T, Page LB, Kleman B, Purnode A (1969) Application of a RIA for angiotensin I to the physiologic measurement of PRA in normal subjects. J Clin Endocrinol Metab 29:1349–1355
Pruszczynsky W, Vahanian A, Ardaillou R, Acar J (1984) Role of antidiuretic hormone in impaired water excretion of patients with congestive heart failure. J Clin Endocrinol Metab 58:599–605
Rascher W, Lang RE, Unger T, Ganten D, Gross F (1982) Vasopressin in brain of spontaneously hypertensive rats. Am J Physiol 242:H496-H499
Sawyer WH, Manning M (1985) The use of antagonists of vasopressin in studies of its physiological functions. Fed Proc 44:78–80
Schrier RW, Berl T (1980) Disorders of water metabolism. In: Schrier RW (ed) Renal and electrolyte disorders. Little, Brown, Boston, pp 1–64
Schrier RW, Berl T, Anderson RJ (1979) Osmotic and non-osmotic control of vasopressin release. Am J Physiol 236:F321-F332
Shapiro MD, Nicholls KM, Groves BM, Kluge R, Chung HM, Bichet DG, Schrier RW (1985) Interrelationship between cardiac output and vascular resistence as determinants of effective arterial blood volume in cirrhotic patients. Kidney Int 28:206–211
Szatalowicz VL, Arnold PE, Chaimovitz C, Bichet D, Berl T, Schrier RW (1981) Radioimmunoassay of plasma arginine vasopressin in hyponatremic patients with congestive heart failure. N Engl J Med 305:263–266
Szczepanska-Sadowska E, Sobocinsky J, Sadowski B (1982) Central dipsogenic effect of vasopressin. Am J Physiol 243:R372-R379
Thibonnier M, Roberts JM (1985) Characterisation of human platelet vasopressin receptors. J Clin Invest 76:1857–1864
Thrasher TN, Moore Gillon M, Wade CE, Keil LC, Ramsay DJ (1983) Inappropriate drinking and secretion of vasopressin after caval constriction in dogs. Am J Physiol 244:R850-R856
Uretsky BF, Verbalis JG, Generalovich T, Valdes A, Reddy PS (1985) Plasma vasopressin response to osmotic and hemodynamic stimuli in heart failure. Am J Physiol 248:H396-H402
Vecsei P, Gless KH (1975) Aldosterone radioimmunoassay. In: Vecsei P (ed) Aldosterone radioimmunoassay. Enke Verlag, Stuttgart
Yaron M, Bennet CM (1978) Mechanism of impaired water excretion in acute right ventricular failure in conscious dogs. Circ Res 42:801–805
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Supported by grants from the Deutsche Forschungsgemeinschaft, Gr 605/3-2, Gr 605/6-1 and Ra 326/1-2
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Gross, P., Ketteler, M., Hausmann, C. et al. Role of diuretics, hormonal derangements, and clinical setting of hyponatremia in medical patients. Klin Wochenschr 66, 662–669 (1988). https://doi.org/10.1007/BF01726923
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DOI: https://doi.org/10.1007/BF01726923