di, siadh, csw

8/9/2019 Di, Siadh, Csw

1/17

By Sheena Howson, MD

2/18/2011


2/17

SIADHInappropriate secretion of ADH

Water excretion is impaire

S!ppression of ADH is impaire

"!nctions of ADH

Increases permea#i$ity of water in the ce$$s of the ista$t!#!$es #y !pre%!$atin% A&!aporin'2 channe$s ()2receptors*

Increases the permea#i$ity of co$$ectin% !cts to !reaIncreases S)+ ia I-./a 2n messen%ers on

enothe$i!m

S eects $i3e memory formation an circaian rhythm


3/17

SIADH ' ca!sesIntracranial 4 infection, stro3e, hemorrha%e, t!mor, ery

common in SAH pop!$ation (567*Intrathoracic 4 ma$i%nancy, a#scess, -A, e!sion, -9,

chest wa$$ eformityDrugs 4 asopressin, DDA)-, oxytocin, ana$%esics,

antiepressants, amioarone, antipsychotics,s!$fony$!reas, car#ama:epine, cyc$ophosphamie

Extracranial tumors 4 sma$$'ce$$ $!n% A, pancreatic AHIV/AIDS

Hereditary 4 ;%ain'of'f!nction< )2 receptor m!tationMiscellaneous 4 =!i$$an'Barre, na!sea, stress, pain,

ac!te psychosisMajor surgery >>>>Idiopathic


4/17

SIADHHypothalamusreceives feedac!from"

• #smoreceptors• Aortic archaroreceptors• $arotidaroreceptors• Atrial stretchreceptors

Any increase inosmolality ordecrease in lood

volume %ill stimulateADH secretion from


5/17

SIADH ' pathophysio$o%yADH'in!ce water retention

Di$!tiona$ hyponatremia

)o$!me expansion '? seconary natri!resisSoi!m an water $oss

-otassi!m $oss

+es!$t@ !o$emic hyponatremia

+e!ce ser!m osmo$a$ity

Increase !rine osmo$a$ity

Increase !rine soi!m


6/17


7/17

SIADH ' treatment reat the !ner$yin% ca!se, if 3nown

"$!i +estriction 4 common$y 800'1000m/

orrect a ecit 4 no more than 10m&/in 2 ho!rs, 18m&/ in 8 ho!rs

0J67 a$

.7 a$

a$ entera$ ta#$ets 4 2'.% IDA a $oop i!retic


8/17

SIADH 4 treatment)asopressin receptor anta%onists

-romote a&!aresis

o$aptan, coniaptan )apriso$ (oniaptan* Inicate in e!o$emic or hypero$emic

hyponatremia

ontrainicate in hypoo$emic hyponatremia

)1a an )2 receptors

a!ses a&!aresis or excretion of free water

Demec$ocyc$ine or ithi!m (iminisheco$$ectin% t!#!$e response to ADH*


9/17

ere#ra$ Sa$t Wastin%Hyponatremia ca!se #y impaire rena$

t!#!$ar f!nction '? ina#i$ity of 3ineys toconsere sa$t

Sa$t wastin% $eas to o$!me ep$etion

wo theories@

Impaire sympathetic ne!ra$ inp!t '? fai$!re of

a$osterone re$ease '? no soi!m resorptionB- re$ease ecreases soi!m resorption,

inhi#its renin/a$osterone re$ease, ecreasesa!tonomic o!tKow at $ee$ of #rainstem


10/17

ere#ra$ Sa$t Wastin%ommon$y occ!rs in s!#arachnoi

hemorrha%e pop!$ation (E7*

arcinomato!s, infectio!s menin%itisncepha$itis

-o$iomye$itis

S t!mors

S s!r%ery 4 !s!a$$y within the rst 10 ays


11/17

ere#ra$ Sa$t Wastin%Dia%nosis@ience of o$!me ep$etion

Increase !rine o!tp!t'aoratory (indings

a 1.C m&/

ow -osm

Gosm ? .00 mFsm/3%

Ga ? 0 m&/

Hi%h BG

Increase r

ow !ric aci

Increase a$#!min


12/17

ere#ra$ Sa$t Wastin% reat with o$!me rep$etion

0J67 a$

.7 a$ is sometimes warrante"$!rocortisone


13/17

Dia#etes Insipi!s he most common ca!se of hypernatremia in

ne!ro$o%ica$ pop!$ation

Decient ADHentra$ DI 4 occ!rs with hypotha$amic'pit!itary

axis ysf!nction or inL!ry

ephro%enic DI 4 iminishe rena$ sensitiity to

ADHGs!a$$y consiere a e!o$emic to

hypoo$emic state, epenin% on the patientsthirst mechanism


14/17

Dia#etes Insipi!s


15/17

Dia#etes Insipi!s ypica$ $inica$ pict!re@

-o$y!ria

-o$yipsiaoct!ria

'aoratory (indingsa ?1C m&/

-osm ? 28C mFsm/3%

Gosm .00 mFsm/3%

Ga $ow

Grine SpecJ =raJ 1J00C

GF- ? .m$/3%/h


16/17

Dia#etes Insipi!s=oa$ is to restore p$asma o$!me an ser!m

a $ee$s

-atient with intact thirst mechanism -itcher at #esieJ Drin3 to thirst on$yN

Seere forms +ep$ace GF- 1@1 with 1/2S

DDA)- C! SO O'5h, common$y %ien ora$$y/nasa$$y

DDA)- wi$$ #e ineectie if nephro%enic (HP can#e !se*


17/17

SIADH $S) DI

Ser!m a 1.C m&/ 1.C m&/ ? 1C m&/

Grine a ? 2C m&/ ? 0 m&/ 2C m&/

Ser!m Fsm 2E0 mFsm/3% 2E0 mFsm/3% ? 28C mFsm/3%

Grine Fsm ? .00 mFsm/3% ? .00 mFsm/3% .00 mFsm/3%

Grine F/- o$i%!ria po$y!ria po$y!ria

)- norma$/hi%h $ow norma$/$ow

-$asma ADH hi%h norma$ $ow

+x "$!i restrict,%ie a,apriso$,

emec$ocyc$ine

=ie o$!me,%ie a,

K!rocortisone

Drin3 to thirst,DDA)-

(centra$*, HP(nephro%enic*

+eiew

di, siadh, csw

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