Clinical Overview > Condition/ Syndrome > Hyponatraemia

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Michael Dick Faculty of Medical and Health Sciences, The University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand

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Sarah R Catford Department of Endocrinology and Diabetes, The Alfred Hospital, Commercial Road, Melbourne, Victoria, 3004, Australia

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Kavita Kumareswaran Department of Endocrinology and Diabetes, The Alfred Hospital, Commercial Road, Melbourne, Victoria, 3004, Australia
Department of Medicine, Faculty of Medicine, Nursing and Health Sciences, Alfred Hospital, Monash University, Clayton, Victoria, 3168, Australia

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Peter Shane Hamblin Department of Endocrinology and Diabetes, The Alfred Hospital, Commercial Road, Melbourne, Victoria, 3004, Australia
Department of Medicine, Faculty of Medicine, Nursing and Health Sciences, Alfred Hospital, Monash University, Clayton, Victoria, 3168, Australia

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Duncan J Topliss Department of Endocrinology and Diabetes, The Alfred Hospital, Commercial Road, Melbourne, Victoria, 3004, Australia
Department of Medicine, Faculty of Medicine, Nursing and Health Sciences, Alfred Hospital, Monash University, Clayton, Victoria, 3168, Australia

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Summary

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) can occur following traumatic brain injury (TBI), but is usually transient. There are very few case reports describing chronic SIADH and all resolved within 12 months, except for one case complicated by meningo-encephalitis. Persistent symptomatic hyponatremia due to chronic SIADH was present for 4 years following a TBI in a previously well 32-year-old man. Hyponatremia consistent with SIADH initially occurred in the immediate period following a high-speed motorbike accident in 2010. There were associated complications of post-traumatic amnesia and mild cognitive deficits. Normalization of serum sodium was achieved initially with fluid restriction. However, this was not sustained and he subsequently required a permanent 1.2 l restriction to maintain near normal sodium levels. Multiple episodes of acute symptomatic hyponatremia requiring hospitalization occurred over the following years when he repeatedly stopped the fluid restriction. Given the ongoing nature of his hyponatremia and difficulties complying with strict fluid restriction, demeclocycline was commenced in 2014. Normal sodium levels without fluid restriction have been maintained for 6 months since starting demeclocycline. This case illustrates an important long-term effect of TBI, the challenges of complying with permanent fluid restrictions and the potential role of demeclocycline in patients with chronic hyponatremia due to SIADH.

Learning points

  • Hyponatraemia due to SIADH commonly occurs after TBI, but is usually mild and transient.

  • Chronic hyponatraemia due to SIADH following TBI is a rare but important complication.

  • It likely results from damage to the pituitary stalk or posterior pituitary causing inappropriate non-osmotic hypersecretion of ADH.

  • First line management of SIADH is generally fluid restriction, but hypertonic saline may be required in severe cases. Adherence to long-term fluid restriction is challenging. Other options include oral urea, vasopressin receptor antagonists and demeclocycline.

  • While effective, oral urea is poorly tolerated and vasopressin receptor antagonists are currently not licensed for use in Australia or the USA beyond 30 days due to insufficient long-term safety data and specific concerns of hepatotoxicity.

  • Demeclocycline is an effective, well-tolerated and safe option for management of chronic hyponatraemia due to SIADH.

Open access
Sudeep K Rajpoot College of Medicine, American University of Antigua, Antigua

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Carlos Maggi Pediatric Intensive Care, Miller Children's Hospital, Long Beach, California, USA

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Amrit Bhangoo Pediatric Intensive Care, Miller Children's Hospital, Long Beach, California, USA

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Summary

Neonatal hyperkalemia and hyponatremia are medical conditions that require an emergent diagnosis and treatment to avoid morbidity and mortality. Here, we describe the case of a 10-day-old female baby presenting with life-threatening hyperkalemia, hyponatremia, and metabolic acidosis diagnosed as autosomal dominant pseudohypoaldosteronism type 1 (PHA1). This report aims to recognize that PHA1 may present with a life-threatening arrhythmia due to severe hyperkalemia and describes the management of such cases in neonates.

Learning points

  • PHA1 may present with a life-threatening arrhythmia.

  • Presentation of PHA can be confused with congenital adrenal hyperplasia.

  • Timing and appropriate medical management in the critical care unit prevented fatality from severe neonatal PHA.

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Ramesh Srinivasan Department of Paediatric Endocrinology, Royal Victoria Infirmary, Newcastle-upon-Tyne Hospitals NHS Trust, Newcastle-upon-Tyne NE1 4LP, UK

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Stephen Ball Department of Endocrinology, Royal Victoria Infirmary, Newcastle-upon-Tyne NE1 4LP, UK
The Medical School, Newcastle University, Newcastle NE24HH, UK

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Martin Ward-Platt Ward 35, Royal Victoria Infirmary, Newcastle-upon-Tyne NE1 4LP, UK

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David Bourn The Institute of Genetic Medicine, Newcastle University, International Centre for Life, Central Parkway, Newcastle-upon-Tyne NE1 3BZ, UK

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Ciaron McAnulty The Institute of Genetic Medicine, Newcastle University, International Centre for Life, Central Parkway, Newcastle-upon-Tyne NE1 3BZ, UK

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Tim Cheetham Department of Paediatric Endocrinology, Royal Victoria Infirmary, Newcastle-upon-Tyne Hospitals NHS Trust, Newcastle-upon-Tyne NE1 4LP, UK
The Institute of Genetic Medicine, Newcastle University, International Centre for Life, Central Parkway, Newcastle-upon-Tyne NE1 3BZ, UK

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Summary

Aim: Differentiating familial cranial diabetes insipidus (CDI) from primary polydipsia can be difficult. We report the diagnostic utility of genetic testing as a means of confirming or excluding this diagnosis.

Patient and methods: The index case presented at 3 months with polydipsia. He was diagnosed with familial CDI based on a positive family history combined with what was considered to be suspicious symptomatology and biochemistry. He was treated with desmopressin (DDAVP) but re-presented at 5 months of age with hyponatraemia and the DDAVP was stopped. Gene sequencing of the vasopressin gene in father and his offspring was undertaken to establish the underlying molecular defect.

Results: Both father and daughter were found to have the pathogenic mutation c.242T>C (p.Leu81Pro) in exon 2 of the AVP gene consistent with a diagnosis of familial diabetes insipidus. The index case did not have the pathogenic mutation and the family could be reassured that he would not require intervention with DDAVP.

Conclusions: Gene sequencing of AVP gene can have a valuable role in predicting whether or not a child is at risk of developing CDI in future. This can help to prevent family uncertainty and unnecessary treatment with its associated risks.

Learning points

  • Differentiating patients with familial cranial diabetes insipidus from those with primary polydipsia is not always straightforward.

  • Molecular genetic analysis of the vasopressin gene is a valuable way of confirming or refuting a diagnosis of familial CDI in difficult cases and is a valuable way of identifying individuals who will develop CDI in later childhood. This information can be of great value to families.

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