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Warren AM, Grossmann M, Christ-Crain M, Russell N. Syndrome of Inappropriate Antidiuresis: From Pathophysiology to Management. Endocr Rev 2023; 44:819-861. [PMID: 36974717 PMCID: PMC10502587 DOI: 10.1210/endrev/bnad010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 02/19/2023] [Accepted: 03/27/2023] [Indexed: 03/29/2023]
Abstract
Hyponatremia is the most common electrolyte disorder, affecting more than 15% of patients in the hospital. Syndrome of inappropriate antidiuresis (SIAD) is the most frequent cause of hypotonic hyponatremia, mediated by nonosmotic release of arginine vasopressin (AVP, previously known as antidiuretic hormone), which acts on the renal V2 receptors to promote water retention. There are a variety of underlying causes of SIAD, including malignancy, pulmonary pathology, and central nervous system pathology. In clinical practice, the etiology of hyponatremia is frequently multifactorial and the management approach may need to evolve during treatment of a single episode. It is therefore important to regularly reassess clinical status and biochemistry, while remaining alert to potential underlying etiological factors that may become more apparent during the course of treatment. In the absence of severe symptoms requiring urgent intervention, fluid restriction (FR) is widely endorsed as the first-line treatment for SIAD in current guidelines, but there is considerable controversy regarding second-line therapy in instances where FR is unsuccessful, which occurs in around half of cases. We review the epidemiology, pathophysiology, and differential diagnosis of SIAD, and summarize recent evidence for therapeutic options beyond FR, with a focus on tolvaptan, urea, and sodium-glucose cotransporter 2 inhibitors.
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Affiliation(s)
- Annabelle M Warren
- Department of Medicine, University of Melbourne, Victoria 3010, Australia
- Department of Endocrinology, The Austin Hospital, Victoria 3084, Australia
| | - Mathis Grossmann
- Department of Medicine, University of Melbourne, Victoria 3010, Australia
- Department of Endocrinology, The Austin Hospital, Victoria 3084, Australia
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel 4031, Switzerland
- Department of Clinical Research, University of Basel and University Hospital Basel, Basel 4031, Switzerland
| | - Nicholas Russell
- Department of Medicine, University of Melbourne, Victoria 3010, Australia
- Department of Endocrinology, The Austin Hospital, Victoria 3084, Australia
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Tandukar S, Sterns RH, Rondon-Berrios H. Osmotic Demyelination Syndrome following Correction of Hyponatremia by ≤10 mEq/L per Day. KIDNEY360 2021; 2:1415-1423. [PMID: 35373113 PMCID: PMC8786124 DOI: 10.34067/kid.0004402021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 02/04/2023]
Abstract
Background Overly rapid correction of chronic hyponatremia may lead to osmotic demyelination syndrome. European guidelines recommend a correction to ≤10 mEq/L in 24 hours to prevent this complication. However, osmotic demyelination syndrome may occur despite adherence to these guidelines. Methods We searched the literature for reports of osmotic demyelination syndrome with rates of correction of hyponatremia ≤10 mEq/L in 24 hours. The reports were reviewed to identify specific risk factors for this complication. Results We identified 19 publications with a total of 21 patients that were included in our analysis. The mean age was 52 years, of which 67% were male. All of the patients had community-acquired chronic hyponatremia. Twelve patients had an initial serum sodium <115 mEq/L, of which seven had an initial serum sodium ≤105 mEq/L. Other risk factors identified included alcohol use disorder (n=11), hypokalemia (n=5), liver disease (n=6), and malnutrition (n=11). The maximum rate of correction in patients with serum sodium <115 mEq/L was at least 8 mEq/L in all but one patient. In contrast, correction was <8 mEq/L in all but two patients with serum sodium ≥115 mEq/L. Among the latter group, osmotic demyelination syndrome developed before hospital admission or was unrelated to hyponatremia overcorrection. Four patients died (19%), five had full recovery (24%), and nine (42%) had varying degrees of residual neurologic deficits. Conclusion Osmotic demyelination syndrome can occur in patients with chronic hyponatremia with a serum sodium <115 mEq/L, despite rates of serum sodium correction ≤10 mEq/L in 24 hours. In patients with severe hyponatremia and high-risk features, especially those with serum sodium <115 mEq/L, we recommend limiting serum sodium correction to <8 mEq/L. Thiamine supplementation is advisable for any patient with hyponatremia whose dietary intake has been poor.
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Affiliation(s)
| | - Richard H. Sterns
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Helbert Rondon-Berrios
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Unpredictable nature of tolvaptan in treatment of hypervolemic hyponatremia: case review on role of vaptans. Case Rep Endocrinol 2014; 2014:807054. [PMID: 24511399 PMCID: PMC3912886 DOI: 10.1155/2014/807054] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 12/03/2013] [Indexed: 11/30/2022] Open
Abstract
Hyponatremia is one of the most commonly encountered electrolyte abnormalities occurring in up to 22% of hospitalized patients. Hyponatremia usually reflects excess water retention relative to sodium rather than sodium deficiency. Volume status and serum osmolality are essential to determine etiology. Treatment depends on several factors, including the cause, overall volume status of the patient, severity of hyponatremic symptoms, and duration of hyponatremia at presentation. Vasopressin antagonists like tolvaptan seem promising for the treatment of euvolemic and hypervolemic hyponatremia in heart failure. Low sodium concentrations cause cerebral edema, but the overly rapid sodium correction can also lead to iatrogenic cerebral osmotic demyelination syndrome. Demyelination may occur days after sodium correction or initial neurologic recovery from hyponatremia. The following case report analyzes the role of vasopressin antagonists in the treatment of hyponatremia and the need for daily dosing of tolvaptan and the monitoring of serum sodium levels to avoid rapid overcorrection which can result in osmotic demyelination syndrome (ODS).
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Baek TH, Yang SH, Sung JH, Lee SW. Central Pontine and Extrapontine Myelinolysis in a Patient with Traumatic Brain Injury Following Not Rapid Correction of Hyponatremia: A Case Report. Korean J Neurotrauma 2014; 10:31-4. [PMID: 27169030 PMCID: PMC4852590 DOI: 10.13004/kjnt.2014.10.1.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 04/13/2014] [Accepted: 04/15/2014] [Indexed: 11/28/2022] Open
Abstract
Central pontine myelinolysis occurs inconsistently as a complication of severe and prolonged hyponatremia, particularly when corrected too rapidly. This condition is a concentrated, frequently symmetric, noninflammatory demyelination within the central basis pontis. We describe a head injury patient who developed central pontine and extrapontine myelinolysis following a gradual correction of hyponatremia. More attention should be paid to correcting hyponatremia combined with hypokalemia in patients who have a history of alcoholism.
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Affiliation(s)
- Tae Hyun Baek
- Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Seung-Ho Yang
- Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Jae Hoon Sung
- Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Sang Won Lee
- Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
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de Souza A. Movement disorders and the osmotic demyelination syndrome. Parkinsonism Relat Disord 2013; 19:709-16. [PMID: 23660544 DOI: 10.1016/j.parkreldis.2013.04.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Revised: 04/11/2013] [Accepted: 04/13/2013] [Indexed: 10/26/2022]
Abstract
With the advent of MRI, osmotic demyelination syndromes (ODS) are increasingly recognised to affect varied sites in the brain in addition to the classical central pontine lesion. Striatal involvement is seen in a large proportion of cases and results in a wide variety of movement disorders. Movement disorders and cognitive problems resulting from ODS affecting the basal ganglia may occur early in the course of the illness, or may present as delayed manifestations after the patient survives the acute phase. Such delayed symptoms may evolve over time, and may even progress despite treatment. Improved survival of patients in the last few decades due to better intensive care has led to an increase in the incidence of such delayed manifestations of ODS. While the outcome of ODS is not as dismal as hitherto believed - with the acute akinetic-rigid syndrome associated with striatal myelinolysis often responding to dopaminergic therapy - the delayed symptoms often prove refractory to medical therapy. This article presents a review of the epidemiology, pathophysiology, clinical features, imaging, and therapy of movement disorders associated with involvement of the basal ganglia in ODS. A comprehensive review of 54 previously published cases of movement disorders due to ODS, and a video recording depicting the spectrum of delayed movement disorders seen after recovery from ODS are also presented.
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Affiliation(s)
- Aaron de Souza
- Department of Neurology, Goa Medical College, Bambolim, Goa 403 202, India.
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Atypical forms of the osmotic demyelination syndrome. Acta Neurol Belg 2013; 113:19-23. [PMID: 22815090 DOI: 10.1007/s13760-012-0110-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 06/22/2012] [Indexed: 10/28/2022]
Abstract
Osmotic demyelination syndrome (ODS) is the damage over the central nervous system caused by several electrolytes, metabolic and toxic disorders. We aimed to describe cases of unusual forms of ODS. In a 9-year period, 25 consecutive patients with ODS (15 men; mean age 42 years) were registered in our referral institution, among them, four (16 %) with atypical neuroimaging findings were abstracted for this communication. None of them presented cardiorespiratory arrest, head trauma, seizures, neuromyelitis optica spectrum or contact with toxic chemicals. Case 1 was a 33-year-old alcoholic man without hypertension or electrolyte imbalance, who presented a classic central pontine myelinolysis (CPM) and a hemorrhage within the pons. Case 2 was a 34-year-old alcoholic man with hypoglycemia and hyponatremia who presented CPM and diffuse bihemispheric extrapontine myelinolysis (EPM) after correction of serum sodium. Case 3 was a 52-year-old woman with mild hypokalemia and hyponatremia (inadequately corrected), who presented a peduncular and cerebellar EPM. Case 4 was a 67-year-old woman who had a suicidal attempt with antidepressants and carbamazepine without impaired consciousness, who complicated with mild hyponatremia associated with a classical CPM and a spinal cord EPM. Case 2 died and the rest remained with variable neurological impairments at last follow-up visit. With modern neuroimaging, the so-called atypical forms of ODS may not be as rare as previously thought; however, they could have a more adverse outcome than the classical ODS.
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Relowering of serum na for osmotic demyelinating syndrome. Case Rep Neurol Med 2012; 2012:704639. [PMID: 22937357 PMCID: PMC3420698 DOI: 10.1155/2012/704639] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 05/27/2012] [Indexed: 11/30/2022] Open
Abstract
We report a case in whom slow correction of hyponatremia (5 mmol/day for 3 days) induced central pontine myelinolysis (CPM). After the diagnosis was confirmed by imaging, we started to relower serum Na that completely recovered the sign and symptoms of CPM. Rapid correction of serum sodium is known to be associated with CPM. However, it may occur even after slow correction of hyponatremia. Currently, there is no standard therapy for CPM other than supportive therapy. Other therapy includes sterioid, plasmaphresis and IVIG, but these therapies have not been shown to be particularly effective. The pathophysiology of CPM is related to a relative dehydration of the brain during the correction of hyponatremia, resulting in cell death and demyelination, therefore gentle rehydration with lowering serum sodium may not be an unreasonable therapy. The present case provides supportive evidence that reinduction of hyponatremia is effective in treating CPM if started immediately after the diagnosis is suggested. The present case tells us that severe chronic hyponatremia must be managed with extreme care especially in patients with chronic debilitating illness and that relowering serum Na is a treatment of choice when CPM is suggested.
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Akinetic-rigid syndrome due to extrapontine and pontine myelinolysis following appropriate correction of hyponatraemia. J Clin Neurosci 2011; 18:587-9. [DOI: 10.1016/j.jocn.2010.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2010] [Revised: 05/16/2010] [Accepted: 08/02/2010] [Indexed: 11/19/2022]
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New aspects in the pathogenesis, prevention, and treatment of hyponatremic encephalopathy in children. Pediatr Nephrol 2010; 25:1225-38. [PMID: 19894066 PMCID: PMC2874061 DOI: 10.1007/s00467-009-1323-6] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 08/17/2009] [Accepted: 08/27/2009] [Indexed: 12/28/2022]
Abstract
Hyponatremia is the most common electrolyte abnormality encountered in children. In the past decade, new advances have been made in understanding the pathogenesis of hyponatremic encephalopathy and in its prevention and treatment. Recent data have determined that hyponatremia is a more serious condition than previously believed. It is a major comorbidity factor for a variety of illnesses, and subtle neurological findings are common. It has now become apparent that the majority of hospital-acquired hyponatremia in children is iatrogenic and due in large part to the administration of hypotonic fluids to patients with elevated arginine vasopressin levels. Recent prospective studies have demonstrated that administration of 0.9% sodium chloride in maintenance fluids can prevent the development of hyponatremia. Risk factors, such as hypoxia and central nervous system (CNS) involvement, have been identified for the development of hyponatremic encephalopathy, which can lead to neurologic injury at mildly hyponatremic values. It has also become apparent that both children and adult patients are dying from symptomatic hyponatremia due to inadequate therapy. We have proposed the use of intermittent intravenous bolus therapy with 3% sodium chloride, 2 cc/kg with a maximum of 100 cc, to rapidly reverse CNS symptoms and at the same time avoid the possibility of overcorrection of hyponatremia. In this review, we discuss how to recognize patients at risk for inadvertent overcorrection of hyponatremia and what measures should taken to prevent this, including the judicious use of 1-desamino-8d-arginine vasopressin (dDAVP).
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Bhattarai N, Kafle P, Panda M. Beer potomania: a case report. BMJ Case Rep 2010; 2010:2010/apr29_1/bcr1020092414. [PMID: 22736559 DOI: 10.1136/bcr.10.2009.2414] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A syndrome of hyponatraemia associated with excessive beer drinking was first recognised in 1971. This syndrome has been referred to as beer potomania. Dilutional hyponatraemia occurs due to excessive consumption of an exclusive beer diet which is poor in salt and protein. We report a case of beer potomania who improved dramatically with introduction of solute load, with no subsequent neurological sequelae.
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Affiliation(s)
- Nimesh Bhattarai
- University of Tennessee, College of Medicine, Internal Medicine, Chattanooga, TN 37403, USA.
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Moritz ML, Ayus JC. 100 cc 3% sodium chloride bolus: a novel treatment for hyponatremic encephalopathy. Metab Brain Dis 2010; 25:91-6. [PMID: 20221678 DOI: 10.1007/s11011-010-9173-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Accepted: 01/28/2010] [Indexed: 12/21/2022]
Abstract
Hyponatremic encephalopathy is a potentially lethal condition with numerous reports of death or permanent neurological injury. The optimal treatment for hyponatremic encephalopathy remains controversial. We have introduced a unified approach to the treatment of hyponatremic encephalopathy which uses 3% NaCl (513 mEq/L) bolus therapy. Any patient with suspected hyponatremic encephalopathy should receive a 2 cc/kg bolus of 3% NaCl with a maximum of 100 cc, which could be repeated 1-2 times if symptoms persist. The approach results in a controlled and immediate rise in serum sodium with little risk of inadvertent overcorrection.
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Affiliation(s)
- Michael L Moritz
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, The University of Pittsburgh School of Medicine, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA.
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Oztoprak I, Engin A, Gümüs C, Egilmez H, Oztoprak B. Transient splenial lesions of the corpus callosum in different stages of evolution. Clin Radiol 2007; 62:907-13. [PMID: 17662742 DOI: 10.1016/j.crad.2007.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2007] [Revised: 04/02/2007] [Accepted: 04/19/2007] [Indexed: 11/23/2022]
Affiliation(s)
- I Oztoprak
- Department of Radiology, Cumhuriyet University, Faculty of Medicine, Sivas, Turkey.
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Hong JM, Joo IS. A case of isolated and transient splenial lesion of the corpus callosum associated with disseminated Staphylococcus aureus infection. J Neurol Sci 2006; 250:156-8. [PMID: 16876825 DOI: 10.1016/j.jns.2006.06.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2006] [Accepted: 06/21/2006] [Indexed: 11/24/2022]
Abstract
We report a 20-year-old man who presented with temporary encephalopathy. Serial brain MRI revealed an isolated and transient splenial lesion of the corpus callosum (SCC). He was subsequently diagnosed with septic metastasis of Staphylococcus aureus (S. aureus) involving both lungs and multiple joints; however, there was no indication of S. aureus involvement of the meninges or brain parenchyma in CSF and MRI studies. Within 24 h of presentation, the serum sodium concentration and effective osmolality changed by approximately 10 mmol/L and 25 mOsm/kg H(2)O, respectively. On the basis of the MRI findings, the changes in electrolyte concentration, and a review of relevant literature, an isolated and transient SCC in this case might be related to osmotic demyelination caused by fluid imbalance rather than direct invasion of S. aureus.
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MESH Headings
- Adult
- Anti-Bacterial Agents/therapeutic use
- Arthritis, Infectious/complications
- Arthritis, Infectious/diagnostic imaging
- Arthritis, Infectious/microbiology
- Brain Diseases, Metabolic/microbiology
- Brain Diseases, Metabolic/physiopathology
- Corpus Callosum/metabolism
- Corpus Callosum/pathology
- Corpus Callosum/physiopathology
- Humans
- Joints/microbiology
- Joints/pathology
- Lung/diagnostic imaging
- Lung/microbiology
- Lung/pathology
- Magnetic Resonance Imaging
- Male
- Nerve Fibers, Myelinated/metabolism
- Nerve Fibers, Myelinated/pathology
- Osmolar Concentration
- Pneumonia, Bacterial/complications
- Pneumonia, Bacterial/diagnostic imaging
- Pneumonia, Bacterial/microbiology
- Sepsis/complications
- Sepsis/physiopathology
- Staphylococcal Infections/complications
- Staphylococcal Infections/drug therapy
- Staphylococcal Infections/physiopathology
- Staphylococcus aureus/physiology
- Tomography, X-Ray Computed
- Treatment Outcome
- Water-Electrolyte Balance/physiology
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Affiliation(s)
- Ji Man Hong
- Ajou University School of Medicine, Suwon 442-721, South Korea
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Brouns R, De Deyn PP. Neurological complications in renal failure: a review. Clin Neurol Neurosurg 2005; 107:1-16. [PMID: 15567546 DOI: 10.1016/j.clineuro.2004.07.012] [Citation(s) in RCA: 237] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2004] [Revised: 07/27/2004] [Accepted: 07/27/2004] [Indexed: 02/08/2023]
Abstract
Neurological complications whether due to the uremic state or its treatment, contribute largely to the morbidity and mortality in patients with renal failure. Despite continuous therapeutic advances, many neurological complications of uremia, like uremic encephalopathy, atherosclerosis, neuropathy and myopathy fail to fully respond to dialysis. Moreover, dialytic therapy or kidney transplantation may even induce neurological complications. Dialysis can directly or indirectly be associated with dialysis dementia, dysequilibrium syndrome, aggravation of atherosclerosis, cerebrovascular accidents due to ultrafiltration-related arterial hypotension, hypertensive encephalopathy, Wernicke's encephalopathy, hemorrhagic stroke, subdural hematoma, osmotic myelinolysis, opportunistic infections, intracranial hypertension and mononeuropathy. Renal transplantation itself can give rise to acute femoral neuropathy, rejection encephalopathy and neuropathy in graft versus host disease. The use of immunosuppressive drugs after renal transplantation can cause encephalopathy, movement disorders, opportunistic infections, neoplasms, myopathy and progression of atherosclerosis. We address the clinical, pathophysiological and therapeutical aspects of both central and peripheral nervous system complications in uremia.
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Affiliation(s)
- R Brouns
- Department of Neurology and Memory Clinic, Middelheim General Hospital, Antwerp, Belgium
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Chu K, Kang DW, Ko SB, Kim M. Diffusion-weighted MR findings of central pontine and extrapontine myelinolysis. Acta Neurol Scand 2001; 104:385-8. [PMID: 11903095 DOI: 10.1034/j.1600-0404.2001.00096.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Diffusion-weighted MR (DWI) can detect changes in water diffusion associated with cellular dysfunction, which enables the differentiation of cytotoxic edema from vasogenic edema. In this study on DWI findings in central pontine (CPM) and extrapontine myelinolysis (EPM), DWI showed high signal intensities in the bilateral pons, midbrain, and genu of the corpus callosum. The corresponding apparent diffusion coefficient values were rather low. This suggests that cytotoxic edema does in fact exist in CPM and EPM and that DWI can be useful in the rapid diagnosis and prediction of the various types of edema occurring in active demyelinating diseases.
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Affiliation(s)
- K Chu
- Department of Neurology, Seoul National University Hospital, Neuroscience Research Institute, SNUMRC, South Korea
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Bracco D, Favre JB, Ravussin P. [Hyponatremia in neurologic intensive care: cerebral salt wasting syndrome and inappropriate antidiuretic hormone secretion]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2001; 20:203-12. [PMID: 11270242 DOI: 10.1016/s0750-7658(00)00286-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hyponatraemia is a frequent complication in neurologically injured patients; it is a secondary cerebral injury. Hyponatraemia leads to consciousness problems, convulsions, worsening of the neurological status and thus the neurological evaluation. Hyponatraemia is secondary to free water retention (inappropriate ADH secretion) or to renal salt loss. The cerebral salt wasting syndrome (CSWS) has been described with head injury, subarachnoid haemorrhage and after several sorts of brain insults. It is characterised by an increased natriuresis and diuresis. Diagnosis is based on hyponatraemia, hypernatriuresis, increased diuresis and hypovolaemia. However, inappropriate ADH secretion and CSWS share several diagnostic criteria. The atrial natriuretic factor and the C-type natriuretic factors play a role in the development of the CSWS. The diagnostic approach and monitoring are based on the assessment of sodium and water losses. Therapy is based on correction of the circulating volume and natraemia. Speed of correction is a matter of debate: slow correction presents the risk of further neurological injury whereas rapid correction presents the risk of central pontine myelinosis.
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Affiliation(s)
- D Bracco
- Département d'anesthésiologie et de réanimation, hôpital de Sion, 1950 Sion, Suisse
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Prough DS. Physiologic acid-base and electrolyte changes in acute and chronic renal failure patients. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2000; 18:809-33, ix. [PMID: 11094692 DOI: 10.1016/s0889-8537(05)70196-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Patients with acute and chronic renal failure are vulnerable to a wide variety of acid-base and electrolyte disturbances. The variety is related not only to predictable disturbances that arise as a consequence of impaired urinary excretion, but also to associated factors, such as intercurrent disease processes, chronic medications, and renal replacement therapy. This article emphasizes the pathogenesis, diagnosis, and treatment of common problems, including metabolic acidosis, hyponatremia, hypernatremia, hyperkalemia, hyperphosphatemia, and hypocalcemia.
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Affiliation(s)
- D S Prough
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, USA.
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Abstract
Focal symmetric demyelination in the central nervous system may be precipitated by aggressive correction of a hyper- or hypo-osmolar state and until recently has been associated with a high rate of morbidity and mortality. Specific anatomical locations are more susceptible to demyelination than others, although the mechanism of injury is unknown. Classic clinical and anatomical descriptions associated with a central pontine location have been supplemented by descriptions of patients with unusual symptoms associated with demyelinating lesions in extrapontine locations. The separation of patients with myelinolysis in central pontine and extrapontine locations is possible on the basis of clinical symptoms, and may direct specific pharmacological treatment. Patients at risk of central myelinolysis who are subjected to aggressive osmolar correction may be rescued with appropriate fluid management before brain injury has occurred; once injury is suspected on the basis of neurological symptoms, additional forms of intervention may still improve the outcome. Recent investigation of the molecular basis of the demyelinating process and the adaptive responses of the brain to dysosmolar challenge has allowed for the refinement of standard treatments and has made the osmotic demyelination syndrome a treatable condition with a better than expected prognosis.
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Affiliation(s)
- W D Brown
- Department of Pediatrics and Neurology, Brown University, Providence, Rhode Island 02912, USA.
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