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14-September-2008 18:02:48 - Syndrome of inappropriate antidiuretic hormone Syndrome of inappropriate antidiuretic hormone Classification and external resources ICD-10 E22.2 ICD-9 253.6 DiseasesDB 12050 MedlinePlus 003702 eMedicine emerg/784 med/3541 ped/2190 MeSH D007177 The syndrome of inappropriate antidiuretic hormone SIADH is a condition commonly found in the hospital population, especially in patients being hospitalized for central nervous system CNS injury. This is a syndrome characterized by excessive release of antidiuretic hormone ADH or vasopressin from the posterior pituitary gland or another source. The result is hyponatremia, and sometimes fluid overload. It should be noted that vasopressin has other important functions, addressed in the appropriate articles. Contents 1 Pathophysiology 2 Clinical Findings 3 Diagnosis 4 Causes 5 Management 6 Differential diagnosis 7 History 8 References Pathophysiology The normal function of ADH on the kidneys is to control the amount of water reabsorbed by kidney nephrons. ADH acts in the distal portion of the renal tubule Distal Convoluted Tubule as well as on the collecting duct and causes the retention of water, but not solute. Hence, ADH activity effectively dilutes the blood decreasing the concentrations of solutes such as sodium. ADH is secreted to prevent water loss in the kidneys. When water is ingested, it is taken up into the circulation and results in a dilution of the plasma. This dilution, otherwise described as a reduction in plasma osmolality is detected by osmoreceptors in the hypothalamus of the brain and these then switch off the release of ADH. The decreasing concentration of ADH effectively inhibits the aquaporins in the collecting ducts and distal convoluted tubules in the nephrons of the kidney. Hence, less water is reabsorbed, thereby increasing urine output, decreasing urine osmolality, and increasing normalization of blood osmolality. In SIADH the release of ADH is not inhibited by a reduction in plasma osmolality when the individual ingests water and the osmolality of the plasma drops. As the main solute of plasma is sodium, this hypoosmolar state is usually detected as a low sodium level on laboratory testing. SIADH is therefore primarily a condition that results in the abnormal handling of water loading and not a problem with excessive solute loss. This is why it is usually treated with fluid in particular water restriction. Diuretics may also be given to decrease reabsorption of water, but care must be taken not to correct water imbalances too rapidly. This causes dilutional hyponatremia and all the consequences associated with that condition: headache, nausea, vomiting, and confusion may ensue. Severe hyponatremia may cause convulsions or coma. Clinical Findings In general, increased ADH causes water retention and extracellular fluid volume expansion without edema or hypertension, owing to natriuresis retention of water and passing of sodium in urine. The water retention and sodium loss both cause hyponatremia, which is a key feature in SIADH. Hyponatremia and concentrated urine UOsm 300 mOsm are seen, as well as no signs of edema or dehydration. When hyponatremia is severe sodium 120 mOsm, or acute in onset, symptoms of cerebral edema become prominent irritability, confusion, seizures, and coma. Diagnosis Laboratory findings in diagnosis of SIADH include- Hyponatremia 130 mEq/L, and POsm 270 mOsm/kg. Other findings include- Urine sodium concentration 20 mEqlL inappropriate natriuresis Maintained hypervolemia Suppression of renin-angiotensin system No equal concentration of atrial natriuretic peptide Low blood urea nitrogen BUN Low creatinine Low uric acid Low albumin Causes Some common causes of SIADH include: Head injury Subarachnoid hemorrhage Cancers Lung cancer especially small cell lung cancer, as well as other small-cell malignancies of other organs Infections Brain abscess Pneumonia Lung abscess Drugs Chlorpropamide Clofibrate Phenothiazine Cyclophosphamide Carbamazepine Selective serotonin reuptake inhibitors SSRIs, a class of antidepressants Methylenedioxymethamphetamine MDMA, commonly called Ecstasy. SIADH due to taking ecstasy was cited as a factor in the death of Leah Betts Management Management of SIADH includes: Treating underlying causes when possible. Fluid restriction to 800-1,000 ml/d should be obtained to increase serum sodium. Intravenous saline - For very symptomatic patients severe confusion, convulsions, or coma hypertonic saline 5% 200-300 ml IV in 3-4 h should be given. Drugs Demeclocycline can be used in chronic situations when fluid restrictions are difficult to maintain; demeclocycline is the most potent inhibitor of AVP action. Conivaptan - an approved antagonist of both V1A and V2 vasopressin receptors. Its indications are treatment of euvolemic hyponatremia e.g. the syndrome of inappropriate secretion of antidiuretic hormone, or in the setting of hypothyroidism, adrenal insufficiency, pulmonary disorders, etc. in hospitalized patients.1 Tolvaptan - an unapproved oral antagonist of the V2 vasopressin receptor. A randomized controlled trial showed conivaptan that can raise the serum sodium by 5 mmol/L. 2 Care must be taken when correcting hyponatremia. A rapid rise in the sodium level may cause central pontine myelinolysis.3 Differential diagnosis Cerebral salt wasting syndrome also presents with hyponatremia, but is treated differently. History The condition was first described by researchers from Boston, Massachusetts and Bethesda, Maryland including Dr Frederic Bartter in two patients with lung cancer.4 Criteria were developed by Schwartz and Bartter in 1967,5 and have remained essentially unchanged since then.6 The condition is occasionally referred to by the names of the authors of the first report - Schwatz-Bartter syndrome.7 References ^ Vaprisol conivaptan hydrochloride Liquid Astellas Pharma US, Inc.. Retrieved on 2007-06-08. ^ Schrier RW, Gross P, Gheorghiade M, et al 2006. Tolvaptan, a selective oral vasopressin V2-receptor antagonist, for hyponatremia. N. Engl. J. Med. 355 20: 2099-112. doi:10.1056/NEJMoa065181. PMID 17105757. ^ Ashrafian H, Davey P 2001. A review of the causes of central pontine myelinosis: yet another apoptotic illness?. Eur. J. Neurol. 8 2: 103-9. doi:10.1046/j.1468-1331.2001.00176.x. PMID 11430268. ^ Schwarts WB, Bennett W, Curelop S, Bartter FC 1957. A syndrome of renal sodium loss and hyponatremia probably resulting from inappropriate secretion of antidiuretic hormone. Am. J. Med. 23 4: 529-42. PMID 13469824. reproduced in Schwartz WB, Bennett W, Curelop S, Bartter FC 2001. A syndrome of renal sodium loss and hyponatremia probably resulting from inappropriate secretion of antidiuretic hormone. 1957. J. Am. Soc. Nephrol. 12 12: 2860-70. PMID 11729259. ^ Bartter FC, Schwartz WB 1967. The syndrome of inappropriate secretion of antidiuretic hormone. Am. J. Med. 42 5: 790-806. doi:10.1016/0002-93436790096-4. PMID 5337379. ^ Verbalis JG, Goldsmith SR, Greenberg A, Schrier RW, Sterns RH 2007. Hyponatremia treatment guidelines 2007: expert panel recommendations. Am. J. Med. 120 11 Suppl 1: S1-21. doi:10.1016/j.amjmed.2007.09.001. PMID 17981159. ^ Schwartz-Bartter syndrome at Who Named It v d e Endocrine pathology: endocrine diseases E00-35, 240-259 Pancreas/ glucose metabolism Diabetes mellitus types: type 1, type 2, MODY, complications: coma, angiopathy, ketoacidosis, nephropathy, neuropathy, retinopathy Hypoglycemia - Hyperinsulinism - Zollinger-Ellison syndrome - insulin receptor Rabson-Mendenhall syndrome - Insulin resistance Hypothalamic/ pituitary axes Pituitary Hyperpituitarism Acromegaly, Hyperprolactinaemia, SIADH Hypopituitarism Sheehan's syndrome, Kallmann syndrome, Growth hormone deficiency, Diabetes insipidus Adiposogenital dystrophy - Empty sella syndrome - Pituitary apoplexy - ACTH deficiency Thyroid Hypothyroidism Iodine deficiency, Cretinism, Congenital hypothyroidism, Goitre, Myxedema Hyperthyroidism Graves disease, Toxic multinodular goitre, Teratoma with thyroid tissue or Struma ovarii Thyroiditis De Quervain's thyroiditis, Hashimoto's thyroiditis, Riedel's thyroiditis Euthyroid sick syndrome - Thyroid hormone resistance - Thyroid nodule Parathyroid Hypoparathyroidism Pseudohypoparathyroidism - Hyperparathyroidism Primary, Secondary, Tertiary Adrenal Adrenocortical hyperfunction: Cushing's syndrome Nelson's syndrome, Pseudo-Cushing's syndrome - Hyperaldosteronism Conn syndrome, Bartter syndrome CAH Lipoid, 3β, 11β, 17α, 21α Adrenal insufficiency Addison's disease, Waterhouse-Friderichsen syndrome - Hypoaldosteronism Gonads ovarian Polycystic ovary syndrome, Premature ovarian failure testicular 5-alpha-reductase deficiency, 17-beta-hydroxysteroid dehydrogenase deficiency general Hypogonadism, Delayed puberty, Precocious puberty Other Androgen insensitivity syndrome - Autoimmune polyendocrine syndrome - Carcinoid syndrome - Gigantism - Short stature Laron syndrome, Psychogenic dwarfism - Multiple endocrine neoplasia 1, 2 - Progeria - Woodhouse-Sakati syndrome - thymus Abscess of thymus, Thymus hyperplasia see also congenital, neoplasia Retrieved from http://en..org/wiki/Syndrome_of_inappropriate_antidiuretic_hormone Categories: Endocrinology | Neurosurgery | Syndromes Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages Deutsch Español Français Italiano Nederlands 日本語 Polski Svenska This page was last modified on 22 June 2008, at 11:48
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