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Cerebral salt wasting and siadh

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by prof dr samie alanasary prof of icu ain shams university

Published in: Health & Medicine
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Cerebral salt wasting and siadh

  1. 1. SAMIR EL ANSARY ICU PROFESSOR AIN SHAMS CAIRO
  2. 2. SIADH • Syndrome of Inappropriate ADH Secretion • Definition: levels of ADH are inappropriately elevated compared to body’s low osmolality, and ADH levels are not suppressed by further decreases in blood osmolality.
  3. 3. SIADH Causes • Irritation of CNS meningitis, encephalitis, brain tumors, brain hemorrhage, hypoxic insult, trauma, brain abscess, Guillain Barre, hydrocephalus • Pulmonary disorders pneumonia, asthma, positive end expiratory pressure ventilation, CF, TB, pneumothorax
  4. 4. SIADH causes • Drugs: vincristine, vinblastine, opiates, carbamazepime, cyclophosphamide • Unregulated tumor production of ADH-like peptides: oat cell lung carcinoma for example, Ewings sarcoma, carcinoma of duodenum, pancreas, thymus
  5. 5. SIADH function of ADH • Antidiuretic hormone = vasopressin • ADH is made in the supra-optic nuclei in the hypothalamus, stored in the posterior pituitary • Normally released into the bloodstream when osmo-receptors detect high plasma osmolality
  6. 6. SIADH function of ADH • At the kidney, attaches to receptors in the collecting ducts, opens up water channels • Water is passively reabsorbed along the kidney’s medullary concentration gradient
  7. 7. SIADH signs and symptoms • Decreased / low urine output • Signs of hyponatremia: lethargy, apathy, disorientation, muscle cramps, anorexia, agitation • Signs of water toxicity: nausea, vomiting, personality changes, confused, combative • If Na < 110 mEq/L, seizures, bulbar palsies, hypothermia, stupor, coma
  8. 8. SIADH lab values • Serum Na < 135 (Na is diluted by excessive free water re-absorption) • Serum osmolality low, normal is ~ 270 • Urine Na is inappropriately high, >20 mmol/L, actually losing Na in urine instead of retaining it
  9. 9. SIADH lab values • Urine osmolality is inappropriately high, can range b/t 300-1400 mosm/L • CVP is high from free water retention
  10. 10. SIADH Treatment • Fluid restriction, ¾ maintenance • If symptomatic, may actually need to replace NaCl, can use hypertonic saline for example: 300cc/m2 of 1 ½ % NS • Diuretics such as lasix • Treat underlying disorder, for example usually resolves after removal of lung carcinomas
  11. 11. SIADH treatment cont… • Demeclochlorotetracycline, blocks ADH receptors in the renal collecting ducts • In severe cases, hemodialysis • Warning, if increase Na too fast, at risk for pontine myelinolysis • Max correction of 15mEq in 24 hours
  12. 12. DI = Diabetes Insipidus • Definition: inability to effectively conserve urinary water • Central: ADH not made or not released in the hypothalamic-pituitary axis • Nephrogenic: ADH is released but not detected by the receptors in the kidney collecting ducts, often a sex- linked recessive condition, also due to renal pathology, electrolyte disorders, drugs
  13. 13. Central DI causes • Head trauma • Brain neoplasms • Congenital CNS defects • CNS infections • CNS hypoxia • ADH secretion also decreased by certain drugs: EtOh, demerol, MSO4, dilantin, barbiturates, glucocorticoids
  14. 14. DI • Make sure distinguish DI from conditions in which the presence of non-absorbable, osmotically active solutes in the renal tubules prevent water re- absorption. • Example: glucose loss in the urine of diabetics will decrease the tubule- medullary concentration gradient and even though ADH is there, water won’t get passively reabsorbed
  15. 15. Central DI Signs/symptoms • Polyuria • Dehydration, may not be readily apparent b/c of hyper-osmolarity, fluid shifts from cells to intravascular spaces and maintains blood pressure, CVP • Weight loss is a better measure of fluid status
  16. 16. Central DI Lab values • Hypernatremia, Na >150-160 • High serum osmolality (normal 270) • Urine Na < 20 mmol/L • Low urine osmolality (very dilute urine)
  17. 17. Central DI Treatment • Increase po or IV free H20 consumption, use hypotonic saline • Volume replacement cc for cc • Vasopressin/ ADH administration (bolus or drip 1.5-2.5 mU/kg/hr) • Of course, treat underlying cause
  18. 18. Cerebral Salt Wasting Causes: • CNS damage • Closed head injury • CNS surgery • CNS tumors • CNS infections, meningitis
  19. 19. Cerebral Salt Wasting • Signs/symptoms: –Polyuria –Wt loss –Dehydration/hypovolemia –Hypotension –Low CVP
  20. 20. Cerebral Salt Wasting • Lab values: – Hyponatremia due to excessive renal Na loss – High urine Na, > 20 mmol/L – Increased plasma ANP, atrial natriuretic peptide, b/c of low volume status – Inappropriately normal or low aldosterone and ADH levels despite high ANP
  21. 21. Cerebral Salt Wasting • Treatment: –Volume for volume replacement of urine Na losses –When dc’d from hospital, most will still need oral Na supplementation for a period of time
  22. 22. DI SIADH CSW Urine Output polyuric decreased polyuric Serum Na high low low Urine Na low high high Serum osm high low Can be low or normal Urine osm low high Can be low or normal CVP Can be normal or low high low
  23. 23. GOOD LUCK SAMIR EL ANSARY ICU PROFESSOR AIN SHAMS CAIRO elansarysamir@yahoo.com

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