Chest
Volume 103, Issue 2, February 1993, Pages 601-606
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Clinical Commentary
Diuretic-induced Severe Hyponatremia: Review and Analysis of 129 Reported Patients

https://doi.org/10.1378/chest.103.2.601Get rights and content

Thiazides were responsible for severe diuretic-induced hyponatremia (serum sodium level <115 mEq/L) in 94 percent of 129 cases reported in the literature between 1962 and 1990. The hyponatremia developed within 14 days in most of the patients receiving thiazides but in none of the patients who were treated with furosemide. Diuretic-induced hyponatremia was four times more common in women than in men. Advanced age was not associated with a higher tendency for hyponatremia. In the majority of the patients who received thiazides, excess antidiureric hormone activity, hypokalemia, and excess water intake were accompanying findings which, singly or together, appeared to contribute to the development of hyponatremia. In 12 patients, mortality was directly related to hyponatremia. Rapid average correction of hyponatremia and a relatively high total correction (over 20 mEq/L) in the first 24 h were significantly associated with higher mortality or demyelinating syndrome. The presence of neurologic signs is an indication for active sodium replacement. The onset of thiazide-induced hyponatremia may in some cases occur within 1 day and therefore needs to be corrected rapidly, but within a total elevation of 20 mEq/L in the first 24 h. Where the onset is judged to have been slow (over several days), the level should be corrected at a slow rate, up to a total of 12 to 15 mEq/L in 24 h.

Section snippets

MATERIALS AND METHODS

The English-language literature during the years from 1962 to 1990 has been reviewed through a personal search and MEDLINE facilities.1, 2, 8, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57 Included in the study are 14 of our cases which have been reported in other contexts.51, 57 Reports were included in the study if serum sodium levels were equal to or below 115

Personal Series

Table 1 summarizes some of the characteristics of our patients with diuretic-induced severe hyponatremia. The mean age of the patients was 78 years. There were nine women and five men. All of the patients were treated with doses of diuretics within the limits of the pharmacologic recommendations. All of the patients who were receiving thiazides, but one had laboratory findings consistent with excess ADH activity, whereas none of the patients receiving furosemide had these findings. In 10 of the

DISCUSSION

From a review of the literature referring to serumsodium levels of less than 115 mEq/L, the various types of thiazides were found to be the major cause for diuretic-induced hyponatremia. In contrast, only seven cases of severe hyponatremia were reported to be caused by furosemide. Since furosemide is a more powerful natriuretic agent than the commonly used thiazides and since it is used in practice as much as thiazides, why does severe hyponatremia develop more with the latter? One indication

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Manuscript revision accepted June 23.

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