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Wei X, Pan W, Lun S, Wu Y, Chen Y, Feng T, Liu M, Chen X. Worldwide productivity and research trend of publications concerning SIAD: a bibliometric study. Front Endocrinol (Lausanne) 2024; 15:1297164. [PMID: 38505746 PMCID: PMC10948503 DOI: 10.3389/fendo.2024.1297164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/19/2024] [Indexed: 03/21/2024] Open
Abstract
Background Syndrome of inappropriate antidiuretic(SIAD) occurs secondary to various diseases, which is characterised by hypotonic hyponatremia and impaired urinary diluting capacity. Research on SIAD in both domestic and international contexts has a long history. This study objectively and comprehensively analyses the research trends, hotspots and development of SIAD research of the past 20 years using the method of bibliometric analysis. Methods The 2003-2022 data in the Web of Science Core Collection database were searched. The Bibliometrix software package, VOSviewer and CiteSpace were used to mine, extract and visualise the retrieved literature, and the generated maps were used in analysing the main topics and trends in the field of SIAD research. Results A total of 1215 articles published in 623 journals were included in the analysis, with a total of 18,886 citations. Results showed that the research output on SIAD has continuously increased in the past 20 years, and the United States had the highest number of publications and citations. Keywords with the highest burst strength in recent years were the most mentioned keywords, in addition to the search terms 'hyponatremia', 'covid-19', and 'mortality'. Thus, the relationship among SIAD, covid-19 and mortality may become research frontiers and trends. Fifteen milestone articles were identified through co-citation analysis, which mainly focused on the pathophysiology and treatment of SIAD. Conclusion Based on bibliometric analysis and knowledge mapping, this study summarises development trends in the field of SIAD research, providing references for current and future research into SIAD.
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Affiliation(s)
- Xiaodan Wei
- Department of Hospice, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Weiyuan Pan
- First College of Clinical Medicine, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Shaocong Lun
- First College of Clinical Medicine, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Yuexuan Wu
- First College of Clinical Medicine, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Yushi Chen
- First College of Clinical Medicine, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Taoshan Feng
- First College of Clinical Medicine, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Meilian Liu
- Department of Pulmonary Oncology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Xiaoming Chen
- Department of Endocrinology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
- Faculty of Chinese Medicine, Macau University of Science and Technology, Avenida Wai Long, Taipa, Macau, China
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2
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Dang S, Zhang S, Zhao J, Li X, Li W. The syndrome of inappropriate antidiuretic hormone associated with nasal and paranasal malignant tumors. Eur Arch Otorhinolaryngol 2024; 281:1443-1448. [PMID: 38163817 PMCID: PMC10858107 DOI: 10.1007/s00405-023-08347-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/08/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE To investigate the clinical characteristics of the syndrome of inappropriate antidiuretic hormone (SIADH) associated with nasal and paranasal malignant tumors. METHODS Patients with locally advanced or recurrence/metastatic malignant tumors of the nasal and paranasal sinuses were included. The SIADH was diagnosed according to the diagnostic criteria. The clinical characteristics of SIADH patients were retrospectively analyzed. RESULTS Six patients (6/188, 3.2%) met the diagnostic criteria of SIADH, including four olfactory neuroblastoma (4/26, 15.4%), one neuroendocrine carcinoma (1/9, 11.1%), and one squamous cell carcinoma (1/63, 1.6%). Five patients (83.3%) had severe hyponatremia; however, the hyponatremia could be improved by fluid restriction or tolvaptan. Three patients' SIADH were recovered during the chemotherapy and the other three were recovered after the surgery. CONCLUSION The incidence of SIADH associated with nasal and paranasal malignant tumors is relatively more common in olfactory neuroblastoma and neuroendocrine carcinoma. The hyponatremia caused by SIADH may be corrected by fluid restriction or tolvaptan, and the SIADH may be recovered through anti-tumor therapy.
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Affiliation(s)
- Shoutao Dang
- Cancer Center, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Shurong Zhang
- Cancer Center, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Jingyang Zhao
- Cancer Center, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Xinyu Li
- Cancer Center, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Wei Li
- Cancer Center, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China.
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Schwarz C, Lindner G, Windpessl M, Knechtelsdorfer M, Saemann MD. [Consensus recommendations on the diagnosis and treatment of hyponatremia from the Austrian Society for Nephrology 2024]. Wien Klin Wochenschr 2024; 136:1-33. [PMID: 38421476 PMCID: PMC10904443 DOI: 10.1007/s00508-024-02325-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 03/02/2024]
Abstract
Hyponatremia is a disorder of water homeostasis. Water balance is maintained by the collaboration of renal function and cerebral structures, which regulate thirst mechanisms and secretion of the antidiuretic hormone. Measurement of serum-osmolality, urine osmolality and urine-sodium concentration help to diagnose the different reasons for hyponatremia. Hyponatremia induces cerebral edema and might lead to severe neurological symptoms, which need acute therapy. Also, mild forms of hyponatremia should be treated causally, or at least symptomatically. An inadequate fast increase of the serum sodium level should be avoided, because it raises the risk of cerebral osmotic demyelination. Basic pathophysiological knowledge is necessary to identify the different reasons for hyponatremia which need different therapeutic procedures.
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Affiliation(s)
- Christoph Schwarz
- Innere Medizin 1, Pyhrn-Eisenwurzenklinikum, Sierningerstr. 170, 4400, Steyr, Österreich.
| | - Gregor Lindner
- Zentrale Notaufnahme, Kepler Universitätsklinikum GmbH, Johannes-Kepler-Universität, Linz, Österreich
| | | | | | - Marcus D Saemann
- 6.Medizinische Abteilung mit Nephrologie und Dialyse, Klinik Ottakring, Wien, Österreich
- Medizinische Fakultät, Sigmund-Freud Universität, Wien, Österreich
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Martínez González Á, Rodeiro Escobar P, Llópiz Castedo J, Díaz Vázquez M, Sánchez Juanas FDL, Villar Carballo M, López Ribera MJ, González Nunes M, Rodríguez Zorrilla S, Rodríguez González A. [Effectiveness of urea administration for the treatment of hyponatremia in heart failure]. Med Clin (Barc) 2024; 162:56-59. [PMID: 37798246 DOI: 10.1016/j.medcli.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVES To assess the efficacy and safety of urea in patients with hyponatremia and heart failure (HF). METHODS AND RESULTS This is a retrospective observational analytical study of patients with HF and hyponatremia (Na+ <135mmol/L). Forty-nine patients treated with urea and 47 patients who did not receive urea, all under standard treatment (according to usual clinical practice) for HF, were included and followed up at Álvaro Cunqueiro Hospital in Vigo (Spain) between January 2013 and May 2022. The study evaluated the normalization of sodium levels (Na >135mmol/L). The initial natremia at the start of oral urea treatment was 127±5.22 mmol/L, at 24h the sodium level was 128±2.47 (P<.009), and the mean on the day of normalization was 135.19±4.23mmol/L (P<.005). The average number of days to achieve sodium normalization was 5.03±2.37 days. The initial uremia at the start of urea treatment was 73±46.93mg/dL, and the mean on the day of Na+ normalization was 116.05±63.64mg/dL (P<.002). The average oral urea dose was 22.5g/day. No relevant adverse effects were observed, nor were there significant changes in creatinine levels. CONCLUSIONS Oral urea treatment, when added to standard treatment for short periods of time, is safe and effective in correcting natremia in patients with hypervolemic HF with hyponatremia.
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Affiliation(s)
| | - Pedro Rodeiro Escobar
- Servició de Medicina Familiar y Comunitaria, Área Sanitaria de Vigo, Vigo, Pontevedra, España
| | - José Llópiz Castedo
- Servició de Medicina Familiar y Comunitaria, Área Sanitaria de Vigo, Vigo, Pontevedra, España
| | - María Díaz Vázquez
- Servició de Medicina Familiar y Comunitaria, Área Sanitaria de Vigo, Vigo, Pontevedra, España
| | | | - María Villar Carballo
- Servició de Medicina Familiar y Comunitaria, Área Sanitaria de Vigo, Vigo, Pontevedra, España
| | | | | | - Samuel Rodríguez Zorrilla
- Departamento de Medicina Oral, Cirugía Oral e Implantología, Universidad de Santiago de Compostela, Santiago de Compostela, A Coruña, España
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Arecco A, Demontis D, Della Sala L, Musso N, Gay S, Boschetti M, Ferone D, Gatto F. Case report: Twice-daily tolvaptan dosing regimen in a challenging case of hyponatremia due to SIAD. Front Endocrinol (Lausanne) 2024; 14:1309657. [PMID: 38288467 PMCID: PMC10822982 DOI: 10.3389/fendo.2023.1309657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/27/2023] [Indexed: 02/01/2024] Open
Abstract
Background Syndrome of inappropriate antidiuresis (SIAD) is one of the most frequent causes of euvolemic hyponatremia (serum sodium levels < 135 mEq/L) and it represents more than 35% of hyponatremia cases in hospitalized patients. It is characterized by an inappropriate vasopressin (AVP)/antidiuretic hormone (ADH) secretion, which occurs independently from effective serum osmolality or circulating volume, leading to water retention via its action on type 2 vasopressin receptor in the distal renal tubules. Corpus callosum agenesis (CCA) is one of the most common congenital brain defects, which can be associated to alterations in serum sodium levels. This report presents a rare case of chronic hyponatremia associated with SIAD in a woman with CCA, whose correction of serum sodium levels only occurred following twice-daily tolvaptan administration. Case presentation A 30-year-old female was admitted to our hospital for non-acute hyponatremia with dizziness, headache, distal tremors, and concentration deficits. She had profound hyponatremia (Na 121 mmol/L) with measured plasma hypo-osmolality (259 mOsm/Kg) and urinary osmolality greater than 100 mOsm/Kg (517 mOsm/Kg). She presented clinically as normovolemic. After the exclusion of other causes of normovolemic hyponatremia, such as hypothyroidism and adrenal insufficiency, a diagnosis of SIAD was established. We have ruled out paraneoplastic, inflammatory, and infectious causes, as well as ischemic events. Her medical history showed a CCA and frontal teratoma. We administered tolvaptan initially at a low dosage (15 mg once a day) with persistence of hyponatremia. Therefore, the dosage was first doubled (30 mg once a day) and then increased to 45 mg once a day with an initial improvement in serum sodium levels, although not long-lasting. We therefore tried dividing the 45 mg tolvaptan administration into two doses of 30 mg and 15 mg respectively, using an off-label treatment schedule, thus achieving long-lasting serum sodium levels in the low-normal range associated with a general clinical improvement. Conclusions This report underlines the importance of the correct diagnosis, management and treatment of SIAD, as well as the need for further studies about the pharmacokinetics and pharmacodynamics of vasopressin receptor antagonists.
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Affiliation(s)
- Anna Arecco
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
| | - Davide Demontis
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
| | - Leonardo Della Sala
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
| | - Natale Musso
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Stefano Gay
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Mara Boschetti
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Diego Ferone
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Federico Gatto
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Bondanelli M, Aliberti L, Gagliardi I, Ambrosio MR, Zatelli MC. Long-term low-dose tolvaptan efficacy and safety in SIADH. Endocrine 2023; 82:390-398. [PMID: 37507553 PMCID: PMC10543144 DOI: 10.1007/s12020-023-03457-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023]
Abstract
PURPOSE Tolvaptan, a selective vasopressin V2-receptor antagonist, is approved for the treatment of SIADH-related hyponatremia, but its use is limited. The starting dose is usually 15 mg/day, but recent clinical experience suggests a lower starting dose (<15 mg/day) to reduce the risk of sodium overcorrection. However, long-term low-dose efficacy and safety has not been explored, so far. Aim of our study is to characterize safety and efficacy of long-term SIADH treatment with low-dose Tolvaptan. METHODS We retrospectively evaluated 11 patients receiving low-dose Tolvaptan (<15 mg/day) for chronic SIADH due to neurological, idiopathic and neoplastic causes. Plasma sodium levels were measured before and 1, 3, 5, 15 and 30 days after starting Tolvaptan and then at 3-month intervals. Anamnestic and clinical data were collected. RESULTS Mean time spanned 27.3 ± 29.8 months (range 6 months-7 years). Mean plasma sodium levels were within normal range 1, 3 and 6 months after starting Tolvaptan as well as after 1, 2, 3, 5 and 7 years of therapy. Neither osmotic demyelination syndrome nor overcorrection were observed. Plasma sodium levels normalization was associated with beneficial clinical effects. Neurological patients obtained seizures disappearance, improvement in neurological picture and good recovery from rehabilitation. Neoplastic patients were able to start chemotherapy and improved their general condition. Patients did not show hypernatremia during long-term follow-up and reported mild thirst and pollakiuria. CONCLUSIONS The present study shows that long-term low-dose Tolvaptan is safe and effective in SIADH treatment. No cases of overcorrection were documented and mild side effects were reported.
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Affiliation(s)
- Marta Bondanelli
- Section of Endocrinology, Geriatrics and Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy.
| | - Ludovica Aliberti
- Section of Endocrinology, Geriatrics and Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Irene Gagliardi
- Section of Endocrinology, Geriatrics and Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Maria Rosaria Ambrosio
- Section of Endocrinology, Geriatrics and Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Maria Chiara Zatelli
- Section of Endocrinology, Geriatrics and Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
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Affiliation(s)
- Horacio J Adrogué
- From the Department of Medicine, Section of Nephrology, Baylor College of Medicine, and the Department of Medicine, Division of Nephrology, Houston Methodist Hospital - both in Houston (H.J.A.); and the Department of Medicine, Tufts University School of Medicine, and the Department of Medicine, Division of Nephrology, St. Elizabeth's Medical Center - both in Boston (N.E.M.)
| | - Nicolaos E Madias
- From the Department of Medicine, Section of Nephrology, Baylor College of Medicine, and the Department of Medicine, Division of Nephrology, Houston Methodist Hospital - both in Houston (H.J.A.); and the Department of Medicine, Tufts University School of Medicine, and the Department of Medicine, Division of Nephrology, St. Elizabeth's Medical Center - both in Boston (N.E.M.)
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8
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Mori M, Takeshita S, Nakamura N, Mizuno Y, Tomita A, Aoyama M, Kakita H, Yamada Y. Efficacy of tolvaptan in an infant with syndrome of inappropriate antidiuretic hormone secretion associated with holoprosencephaly: A case report. World J Clin Cases 2023; 11:6262-6267. [PMID: 37731562 PMCID: PMC10507562 DOI: 10.12998/wjcc.v11.i26.6262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/31/2023] [Accepted: 08/15/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Holoprosencephaly (HPE) is a congenital malformation with various degrees of incomplete separation of the cerebral hemispheres due to differentiation disorders of the forebrain. Although HPE with diabetes insipidus due to associated pituitary dysfunction has been reported, HPE with the syndrome of inappropriate antidiuretic hormone secretion (SIADH) is very rare. Tolvaptan, a vasopressin V2 receptor antagonist, is effective in adults with SIADH. However, there is no report of its efficacy in infants with SIADH. The purpose of this report is to demonstrate that tolvaptan is effective for SIADH in infants and that administration of tolvaptan eliminates the need for restriction of water intake and sodium administration. CASE SUMMARY A 2414-g female infant was born at 38 wk by normal vaginal delivery. Facial anomalies and head magnetic resonance imaging indicated semilobar HPE. After birth, she had hyponatremia due to SIADH and was treated using water and sodium restriction. However, she developed an exaggerated response to the fluid restrictions, resulting in large fluctuations in serum sodium levels. Subsequent administration of tolvaptan improved the fluctuations in serum sodium levels without the need for adjustment of water or sodium administration. Serum sodium was maintained within the normal range after discontinuation of tolvaptan at 80 d of life. There were no side effects, such as hypernatremia or liver dysfunction, during the administration of tolvaptan. CONCLUSION This is the first report on the safety and efficacy of tolvaptan in an infant with SIADH associated with HPE.
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Affiliation(s)
- Mari Mori
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, Nagakute 480-1195, Japan
| | - Satoru Takeshita
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, Nagakute 480-1195, Japan
- Department of Pathobiology, Nagoya City University Graduate School of Pharmaceutical Sciences, Nagoya 467-8603, Japan
| | - Nami Nakamura
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, Nagakute 480-1195, Japan
- Department of Pediatrics, Aichi Medical University, Nagakute 480-1195, Japan
| | - Yuki Mizuno
- Department of Pharmacy, Aichi Medical University, Nagakute 480-1195, Japan
| | - Akiko Tomita
- Department of Pharmacy, Aichi Medical University, Nagakute 480-1195, Japan
| | - Mineyoshi Aoyama
- Department of Pathobiology, Nagoya City University Graduate School of Pharmaceutical Sciences, Nagoya 467-8603, Japan
| | - Hiroki Kakita
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, Nagakute 480-1195, Japan
- Department of Pathobiology, Nagoya City University Graduate School of Pharmaceutical Sciences, Nagoya 467-8603, Japan
| | - Yasumasa Yamada
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, Nagakute 480-1195, Japan
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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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Krisanapan P, Tangpanithandee S, Thongprayoon C, Pattharanitima P, Kleindienst A, Miao J, Craici IM, Mao MA, Cheungpasitporn W. Safety and Efficacy of Vaptans in the Treatment of Hyponatremia from Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH): A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:5483. [PMID: 37685548 PMCID: PMC10488023 DOI: 10.3390/jcm12175483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
The utilization of vasopressin receptor antagonists, known as vaptans, in the management of hyponatremia among patients afflicted with the syndrome of inappropriate antidiuretic hormone (SIADH) remains a contentious subject. This meta-analysis aimed to evaluate the safety and efficacy of vaptans for treating chronic hyponatremia in adult SIADH patients. Clinical trials and observational studies were identified by a systematic search using MEDLINE, EMBASE, and Cochrane Database from inception through September 2022. The inclusion criteria were the studies that reported vaptans' safety or efficacy outcomes compared to placebo or standard therapies. The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD 42022357307). Five studies were identified, comprising three RCTs and two cohort studies, enrolling a total of 1840 participants. Regarding short-term efficacy on days 4-5, vaptans exhibited a significant increase in serum sodium concentration from the baseline in comparison to the control group, with a weighted mean difference of 4.77 mmol/L (95% CI, 3.57, 5.96; I2 = 34%). In terms of safety outcomes, the pooled incidence rates of overcorrection were 13.1% (95% CI 4.3, 33.6; I2 = 92%) in the vaptans group and 3.3% (95% CI 1.6, 6.6; I2 = 27%) in the control group. Despite the higher correction rate linked to vaptans, with an OR of 5.72 (95% CI 3.38, 9.70; I2 = 0%), no cases of osmotic demyelination syndrome were observed. Our meta-analysis comprehensively summarizes the efficacy and effect size of vaptans in managing SIADH. While vaptans effectively raise the serum sodium concentration compared to placebo/fluid restriction, clinicians should exercise caution regarding the potential for overcorrection.
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Affiliation(s)
- Pajaree Krisanapan
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (C.T.); (J.M.); (I.M.C.)
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand;
- Division of Nephrology, Department of Internal Medicine, Thammasat University Hospital, Pathum Thani 12120, Thailand
| | - Supawit Tangpanithandee
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (C.T.); (J.M.); (I.M.C.)
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10540, Thailand
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (C.T.); (J.M.); (I.M.C.)
| | - Pattharawin Pattharanitima
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand;
| | - Andrea Kleindienst
- Department of Neurosurgery, Friedrich-Alexander-University Nürnberg-Erlangen, 91054 Erlangen, Germany;
| | - Jing Miao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (C.T.); (J.M.); (I.M.C.)
| | - Iasmina M. Craici
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (C.T.); (J.M.); (I.M.C.)
| | - Michael A. Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (C.T.); (J.M.); (I.M.C.)
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Monnerat S, Atila C, Baur F, Santos de Jesus J, Refardt J, Dickenmann M, Christ-Crain M. Effect of protein supplementation on plasma sodium levels in the syndrome of inappropriate antidiuresis: a monocentric, open-label, proof-of-concept study-the TREASURE study. Eur J Endocrinol 2023; 189:252-261. [PMID: 37540987 DOI: 10.1093/ejendo/lvad108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/07/2023] [Accepted: 07/12/2023] [Indexed: 08/06/2023]
Abstract
IMPORTANCE The syndrome of inappropriate antidiuresis (SIAD) can be treated with oral urea; however, compliance is impaired by its poor palatability. OBJECTIVE To investigate whether dietary proteins could increase plasma sodium levels through urea-induced osmotic diuresis. DESIGN An open-label, proof-of-concept trial. SETTING University Hospital of Basel, Switzerland, between October 2021 and February 2023. PARTICIPANTS Outpatients with chronic SIAD. INTERVENTIONS OR EXPOSURES Ninety grams of protein daily for 7 days in the form of protein powder, followed by 30 g of oral urea daily for 7 days after a wash-out period of ≥1 week. MAIN OUTCOMES AND MEASURES The increase in sodium levels from baseline to the end of the 7-day protein supplementation. RESULTS Seventeen patients were included. After 7 days of 90 g daily protein supplementation (n = 17), plasma sodium levels increased from 131 (129-133) to 133 (132-137), that is, by a median of 3 mmol L-1 (0-5) (P = .01). Plasma urea levels increased by 3 mmol L-1 (1.7-4.9) (P < .01), and urine urea to creatinine ratio increased by 21.2 mmol mmol-1 (6.2-29.1) (P < .01). After 7 days of 30 g oral urea (n = 10), plasma sodium levels increased from 132 (130-133) to 134 (131-136), that is, by a median of 2 mmol L-1 (1-3) (P = .06). Plasma urea levels increased by 5.8 mmol L-1 (2.7-9.2) (P < .01), and urine urea to creatinine ratio increased by 31.0 mmol mmol-1 (18.7-45.1) (P < .01). CONCLUSIONS AND RELEVANCE Our findings suggest that protein powder increases plasma sodium levels in patients with chronic SIAD through protein-induced ureagenesis and osmotic diuresis. The effects are comparable with oral urea.
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Affiliation(s)
- Sophie Monnerat
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Cihan Atila
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Fabienne Baur
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Joyce Santos de Jesus
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
| | - Julie Refardt
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
| | - Michael Dickenmann
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
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12
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Ghosal A, Qadeer HA, Nekkanti SK, Pradhan P, Okoye C, Waqar D. A Conspectus of Euvolemic Hyponatremia, Its Various Etiologies, and Treatment Modalities: A Comprehensive Review of the Literature. Cureus 2023; 15:e43390. [PMID: 37700952 PMCID: PMC10495223 DOI: 10.7759/cureus.43390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2023] [Indexed: 09/14/2023] Open
Abstract
Hyponatremia is the most prevalent electrolyte imbalance encountered among hospitalized patients, athletes, the elderly, patients with chronic ailments, postoperative patients, and a few asymptomatic individuals. Clinical manifestations of hyponatremia can be diverse, with characteristic neurological symptoms. Depending on in-depth medical history, physical examination (including volume status assessment), laboratory investigation, and drug history, patients can be classified broadly as undergoing hypervolemic, euvolemic, or hypovolemic hyponatremia. However, patients with hypervolemic hyponatremia often present with distinctive signs such as edema or ascites, and the clinical presentation of hypovolemic and euvolemic hyponatremia poses significant challenges for clinicians. The convolution in clinical manifestations of patients is due to the varied etiologies of euvolemic hyponatremia, such as syndrome of inappropriate antidiuretic hormone secretion (SIADH), adrenocortical insufficiency, hypothyroidism, psychogenic polydipsia, different classes of drugs (chemotherapeutics, antipsychotics, antidepressants), endurance exercise events, and reset osmostat syndrome (ROS). The management of hyponatremia depends on the rate of hyponatremia onset, duration, severity of symptoms, levels of serum sodium, and underlying comorbidities. Over the last decade, the clinical understanding of hyponatremia has been scattered due to the introduction of innovative laboratory markers and new drugs. This article will be a conspectus of all the recent advancements in the field of diagnosis, investigations, management, and associations of hyponatremia, along with traditional clinical practices. Subsequently, a holistic overview has been laid out for the clinicians to better understand and identify knowledge deficiencies on this topic.
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Affiliation(s)
- Anit Ghosal
- Internal Medicine, Kolkata Medical College and Hospital, Kolkata, IND
| | - Hafiza Amna Qadeer
- Internal Medicine, Foundation University Medical College, Islamabad, PAK
| | | | | | - Chiugo Okoye
- Internal Medicine, Igbinedion University, Okada, NGA
| | - Danish Waqar
- Internal Medicine/Nephrology, Loyola University Medical Center, Chicago, USA
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13
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Tzoulis P, Kaltsas G, Baldeweg SE, Bouloux PM, Grossman AB. Tolvaptan for the treatment of the syndrome of inappropriate antidiuresis (SIAD). Ther Adv Endocrinol Metab 2023; 14:20420188231173327. [PMID: 37214762 PMCID: PMC10192810 DOI: 10.1177/20420188231173327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/15/2023] [Indexed: 05/24/2023] Open
Abstract
The syndrome of inappropriate antidiuresis (SIAD), the commonest cause of hyponatraemia, is associated with significant morbidity and mortality. Tolvaptan, an oral vasopressin V2-receptor antagonist, leads through aquaresis to an increase in serum sodium concentration and is the only medication licenced in Europe for the treatment of euvolaemic hyponatraemia. Randomised controlled trials have shown that tolvaptan is highly efficacious in correcting SIAD-related hyponatraemia. Real-world data have confirmed the marked efficacy of tolvaptan, but they have also reported a high risk of overly rapid sodium increase in patients with a very low baseline serum sodium. The lower the baseline serum sodium, the higher the tolvaptan-induced correction rate occurs. Therefore, a lower starting tolvaptan dose of 7.5 mg has been evaluated in small cohort studies, demonstrating its efficacy, but it still remains unclear as to whether it can reduce the risk of overcorrection. Most international guidelines, except for the European ones, recommend tolvaptan as second-line treatment for SIAD after fluid restriction. However, the risk of unduly rapid sodium correction in combination with its high cost have limited its routine use. Prospective controlled studies are warranted to evaluate whether tolvaptan-related sodium increase can improve patient-related clinical outcomes, such as mortality and length of hospital stay in the acute setting or neurocognitive symptoms and quality of life in the chronic setting. In addition, the potential role of a low tolvaptan starting dose needs to be further explored. Until then, tolvaptan should mainly be used as second-line treatment for SIAD, especially when there is a clinical need for prompt restoration of normonatraemia. Tolvaptan should be used with specialist input according to a structured clinical pathway, including rigorous monitoring of electrolyte and fluid balance and, if needed, implementation of appropriate measures to prevent, or when necessary reverse, overly rapid hyponatraemia correction.
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Affiliation(s)
| | - Gregory Kaltsas
- First Department of Propaedeutic and Internal
Medicine, Laiko University Hospital, National and Kapodistrian University of
Athens, Athens, Greece
| | - Stephanie E. Baldeweg
- Department of Diabetes & Endocrinology,
University College London Hospitals NHS Foundation Trust, London, UK
- Division of Medicine, University College
London, London, UK
| | | | - Ashley B. Grossman
- Green Templeton College, University of Oxford,
Oxford, UK
- Neuroendocrine Tumour Unit, Royal Free
Hospital, London, UK
- Centre for Endocrinology, Barts and the London
School of Medicine, Queen Mary University of London, London, UK
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14
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Brooks EK, Inder WJ. Disorders of Salt and Water Balance After Pituitary Surgery. J Clin Endocrinol Metab 2022; 108:198-208. [PMID: 36300330 PMCID: PMC9759173 DOI: 10.1210/clinem/dgac622] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 10/17/2022] [Indexed: 02/03/2023]
Abstract
Transsphenoidal surgery is the first-line treatment for many clinically significant pituitary tumors and sellar lesions. Although complication rates are low when performed at high-volume centers, disorders of salt and water balance are relatively common postoperatively. Both, or either, central diabetes insipidus (recently renamed arginine vasopressin deficiency - AVP-D), caused by a deficiency in production and/or secretion of arginine vasopressin, and hyponatremia, most commonly secondary to the syndrome of inappropriate antidiuresis, may occur. These conditions can extend hospital stay and increase the risk of readmission. This article discusses common presentations of salt and water balance disorders following pituitary surgery, the pathophysiology of these conditions, and their diagnosis and management.
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Affiliation(s)
- Emily K Brooks
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane 4072, Australia
| | - Warrick J Inder
- Correspondence: Warrick Inder MD, FRACP, Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba, QLD 4102, Australia. E-mail:
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15
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Abstract
IMPORTANCE Hyponatremia is the most common electrolyte disorder and it affects approximately 5% of adults and 35% of hospitalized patients. Hyponatremia is defined by a serum sodium level of less than 135 mEq/L and most commonly results from water retention. Even mild hyponatremia is associated with increased hospital stay and mortality. OBSERVATIONS Symptoms and signs of hyponatremia range from mild and nonspecific (such as weakness or nausea) to severe and life-threatening (such as seizures or coma). Symptom severity depends on the rapidity of development, duration, and severity of hyponatremia. Mild chronic hyponatremia is associated with cognitive impairment, gait disturbances, and increased rates of falls and fractures. In a prospective study, patients with hyponatremia more frequently reported a history of falling compared with people with normal serum sodium levels (23.8% vs 16.4%, respectively; P < .01) and had a higher rate of new fractures over a mean follow-up of 7.4 years (23.3% vs 17.3%; P < .004). Hyponatremia is a secondary cause of osteoporosis. When evaluating patients, clinicians should categorize them according to their fluid volume status (hypovolemic hyponatremia, euvolemic hyponatremia, or hypervolemic hyponatremia). For most patients, the approach to managing hyponatremia should consist of treating the underlying cause. Urea and vaptans can be effective treatments for the syndrome of inappropriate antidiuresis and hyponatremia in patients with heart failure, but have adverse effects (eg, poor palatability and gastric intolerance with urea; and overly rapid correction of hyponatremia and increased thirst with vaptans). Severely symptomatic hyponatremia (with signs of somnolence, obtundation, coma, seizures, or cardiorespiratory distress) is a medical emergency. US and European guidelines recommend treating severely symptomatic hyponatremia with bolus hypertonic saline to reverse hyponatremic encephalopathy by increasing the serum sodium level by 4 mEq/L to 6 mEq/L within 1 to 2 hours but by no more than 10 mEq/L (correction limit) within the first 24 hours. This treatment approach exceeds the correction limit in about 4.5% to 28% of people. Overly rapid correction of chronic hyponatremia may cause osmotic demyelination, a rare but severe neurological condition, which can result in parkinsonism, quadriparesis, or even death. CONCLUSIONS AND RELEVANCE Hyponatremia affects approximately 5% of adults and 35% of patients who are hospitalized. Most patients should be managed by treating their underlying disease and according to whether they have hypovolemic, euvolemic, or hypervolemic hyponatremia. Urea and vaptans can be effective in managing the syndrome of inappropriate antidiuresis and hyponatremia in patients with heart failure; hypertonic saline is reserved for patients with severely symptomatic hyponatremia.
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Affiliation(s)
- Horacio J Adrogué
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Division of Nephrology, Department of Medicine, Houston Methodist Hospital, Houston, Texas
| | - Bryan M Tucker
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Division of Nephrology, Department of Medicine, Houston Methodist Hospital, Houston, Texas
| | - Nicolaos E Madias
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
- Division of Nephrology, Department of Medicine, St Elizabeth's Medical Center, Boston, Massachusetts
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16
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Poch E, Molina A, Piñeiro G. Syndrome of inappropriate antidiuretic hormone secretion. Med Clin (Barc) 2022; 159:139-146. [PMID: 35659417 DOI: 10.1016/j.medcli.2022.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 10/18/2022]
Abstract
Hyponatremia is the most frequent electrolytic disorder in hospitalized patients, and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), the most frequent cause of hiponatremia with clinically normal extracellular volume. It consists of a disorder of the regulation of body water that obeys to different causes, mainly cancer, pulmonary illnesses, disorders of the central nervous system and diverse drugs. As in any hiponatremia it a physiological knowledge of the regulation of body water and sodium is essential as well as the application of precise diagnostic criteria in order to manage the problem with an effective treatment. The available data until the moment show that the clinical diagnosis of SIADH made by professionals is mainly not supported on the established criteria drawn by experts and this lack of accuracy probably hits in the therapeutic result. The basis of the treatment of the SIADH is to correct its cause, water restriction, solutes (sodium chloride) and the use of vaptans in case of failure of the previous measures.
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Affiliation(s)
- Esteban Poch
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, España; IDIBAPS; Departamento de Medicina, Universidad de Barcelona, Barcelona, España.
| | - Alicia Molina
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, España
| | - Gastón Piñeiro
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, España
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17
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The management and outcome of hyponatraemia following transsphenoidal surgery: a retrospective observational study. Acta Neurochir (Wien) 2022; 164:1135-1144. [PMID: 35079890 PMCID: PMC8967808 DOI: 10.1007/s00701-022-05134-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/13/2022] [Indexed: 01/11/2023]
Abstract
Purpose Hyponatraemia is a common complication following transsphenoidal surgery. However, there is sparse data on its optimal management and impact on clinical outcomes. The aim of this study was to evaluate the management and outcome of hyponatraemia following transsphenoidal surgery. Methods A prospectively maintained database was searched over a 4-year period between January 2016 and December 2019, to identify all patients undergoing transsphenoidal surgery. A retrospective case-note review was performed to extract data on hyponatraemia management and outcome. Results Hyponatraemia occurred in 162 patients (162/670; 24.2%) with a median age of 56 years. Female gender and younger age were associated with hyponatraemia, with mean nadir sodium being 128.6 mmol/L on postoperative day 7. Hyponatraemic patients had longer hospital stay than normonatraemic group with nadir sodium being inversely associated with length of stay (p < 0.001). In patients with serum sodium ≤ 132 mmol/L, syndrome of inappropriate antidiuretic hormone secretion (SIADH) was the commonest cause (80/111; 72%). Among 76 patients treated with fluid restriction as a monotherapy, 25 patients (25/76; 32.9%) did not achieve a rise in sodium after 3 days of treatment. Readmission with hyponatraemia occurred in 11 cases (11/162; 6.8%) at a median interval of 9 days after operation. Conclusion Hyponatraemia is a relatively common occurrence following transsphenoidal surgery, is associated with longer hospital stay and risk of readmission and the effectiveness of fluid restriction is limited. These findings highlight the need for further studies to better identify and treat high-risk patients, including the use of arginine vasopressin receptor antagonists. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-022-05134-9.
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18
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Lawless SJ, Thompson C, Garrahy A. The management of acute and chronic hyponatraemia. Ther Adv Endocrinol Metab 2022; 13:20420188221097343. [PMID: 35586730 PMCID: PMC9109487 DOI: 10.1177/20420188221097343] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/11/2022] [Indexed: 11/15/2022] Open
Abstract
Hyponatraemia is the most common electrolyte abnormality encountered in clinical practice; despite this, the work-up and management of hyponatraemia remain suboptimal and varies among different specialist groups. The majority of data comparing hyponatraemia treatments have been observational, up until recently. The past two years have seen the publication of several randomised control trials investigating hyponatraemia treatments, both for chronic and acute hyponatraemia. In this article, we aim to provide a background to the physiology, cause and impact of hyponatraemia and summarise the most recent data on treatments for acute and chronic hyponatraemia, highlighting their efficacy, tolerability and adverse effects.
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Affiliation(s)
- Sarah Jean Lawless
- Academic Department of Endocrinology, Beaumont
Hospital/RCSI Medical School, Dublin, Ireland
| | - Chris Thompson
- Academic Department of Endocrinology, Beaumont
Hospital/RCSI Medical School, Dublin, Ireland
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19
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Donald DM, Sherlock M, Thompson CJ. Hyponatraemia and the syndrome of inappropriate antidiuresis (SIAD) in cancer. ENDOCRINE ONCOLOGY (BRISTOL, ENGLAND) 2022; 2:R78-R89. [PMID: 37435459 PMCID: PMC10259335 DOI: 10.1530/eo-22-0056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/10/2022] [Indexed: 07/13/2023]
Abstract
Hyponatraemia is a common electrolyte abnormality seen in a wide range of oncological and haematological malignancies and confers poor performance status, prolonged hospital admission and reduced overall survival, in patients with cancer. Syndrome of inappropriate antidiuresis (SIAD) is the commonest cause of hyponatraemia in malignancy and is characterised by clinical euvolaemia, low plasma osmolality and concentrated urine, with normal renal, adrenal and thyroid function. Causes of SIAD include ectopic production of vasopressin (AVP) from an underlying tumour, cancer treatments, nausea and pain. Cortisol deficiency is an important differential in the assessment of hyponatraemia, as it has an identical biochemical pattern to SIAD and is easily treatable. This is particularly relevant with the increasing use of immune checkpoint inhibitors, which can cause hypophysitis and adrenalitis, leading to cortisol deficiency. Guidelines on the management of acute, symptomatic hyponatraemia recommend 100 mL bolus of 3% saline with careful monitoring of the serum sodium to prevent overcorrection. In cases of chronic hyponatraemia, fluid restriction is recommended as first-line treatment; however, this is frequently not feasible in patients with cancer and has been shown to have limited efficacy. Vasopressin-2 receptor antagonists (vaptans) may be preferable, as they effectively increase sodium levels in SIAD and do not require fluid restriction. Active management of hyponatraemia is increasingly recognised as an important component of oncological management; correction of hyponatraemia is associated with shorter hospital stay and prolonged survival. The awareness of the impact of hyponatraemia and the positive benefits of active restoration of normonatraemia remain challenging in oncology.
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Affiliation(s)
- D Mc Donald
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - M Sherlock
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - C J Thompson
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
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20
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Natrium- und Kalziumstoffwechselstörungen in der Notaufnahme. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00899-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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21
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Skov J, Falhammar H, Calissendorff J, Lindh JD, Mannheimer B. Association between lipid-lowering agents and severe hyponatremia: a population-based case-control study. Eur J Clin Pharmacol 2021; 77:747-755. [PMID: 33215235 PMCID: PMC8032630 DOI: 10.1007/s00228-020-03006-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 09/18/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE Drug-induced hyponatremia is common, with medications from many drug-classes implicated. Lipid-lowering agents are among the most prescribed drugs. Limited evidence suggests an inverse association between statins and hyponatremia, while data on other lipid-lowering agents is absent. The objective of this investigation was to study the association between lipid-lowering drugs and hospitalization due to hyponatremia. METHODS This was a register-based case-control study of the general Swedish population. Those hospitalized with a main diagnosis of hyponatremia (n = 11,213) were compared with matched controls (n = 44,801). Multivariable logistic regression adjusting for co-medication, diseases, previous hospitalizations, and socioeconomic factors was used to explore the association between severe hyponatremia and the use of lipid-lowering drugs. RESULTS Unadjusted ORs (95% CI) for hospitalization due to hyponatremia were 1.28 (1.22-1.35) for statins, 1.09 (0.79-1.47) for ezetimibe, 1.38 (0.88-2.12) for fibrates, and 2.12 (1.31-3.35) for resins. After adjustment for confounding factors the adjusted odds ratios (95% CI) compared with controls were 0.69 (0.64-0.74) for statins, 0.60 (0.41-0.86) for ezetimibe, 0.87 (0.51-1.42) for fibrates, and 1.21 (0.69-2.06) for resins. CONCLUSIONS Use of statins and ezetimibe was inversely correlated with severe hyponatremia. Consequently, these drugs are unlikely culprits in patients with hyponatremia, and they appear safe to initiate in hyponatremic patients. A potential protective effect warrants further studies on how statins and other lipid-lowering drugs are linked to dysnatremias.
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Affiliation(s)
- Jakob Skov
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Karlstad Central Hospital, Karlstad, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Calissendorff
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Jonatan D Lindh
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Buster Mannheimer
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
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22
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Pose-Reino A, Runkle de la Vega I, de Jong-Laird A, Kabra M, Lindner U. Real-World, Non-Interventional, Retrospective Study (SAMPLE) of Tolvaptan in Patients with Hyponatraemia Secondary to the Syndrome of Inappropriate Antidiuretic Hormone Secretion. Adv Ther 2021; 38:1055-1067. [PMID: 33306187 DOI: 10.1007/s12325-020-01560-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/04/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is the most common cause of hyponatraemia in hospital inpatients. We present data on treatment setting, patient characteristics, and outcomes for patients treated with tolvaptan for SIADH across a range of real-world settings in Germany and Spain. METHODS This was a non-interventional, observational, retrospective chart review study. Management was at the discretion of the treating physician, with tolvaptan prescribed according to local clinical practice. Hospital notes and/or medical charts were reviewed from treatment initiation for 6 weeks. Follow-up data were collected when patients were discharged early. Patients were eligible for inclusion if they were ≥ 18 years of age and had been treated with ≥ 2 doses of tolvaptan for one episode of hyponatraemia secondary to SIADH in 2014. RESULTS The Full Analysis Set comprised 100 patients from 8 centres. The mean age of patients was 73.9 years. The primary endpoint of the mean increase in serum sodium level from baseline to hospital discharge, or to final available measurement, was 10.3 mmol/L (SD 6.4; 95% CI 9.0, 11.6), from 123.0 mmol/L (SD 6.0) to 133.3 mmol/L (SD 4.9). Seventy-seven patients (77.0%) achieved sodium normalisation within 6 weeks of tolvaptan initiation. Mean daily dose of tolvaptan was 12.7 mg (SD 9.2), and mean treatment duration 28.0 days (SD 16.5). Tolvaptan at off-label doses (< 15 mg/day) was prescribed to 72 patients at some point. A favourable safety and tolerability profile was reported. CONCLUSIONS Tolvaptan was well tolerated and effectively corrected sodium levels in hospitalised adults with hyponatraemia secondary to SIADH in real-world settings. CLINICALTRIALS. GOV IDENTIFIER NCT02545101.
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Affiliation(s)
- Antonio Pose-Reino
- Department of Internal Medicine, Facultad de Medicina, Universidad de Santiago de Compostela, A Coruña, Spain
| | - Isabelle Runkle de la Vega
- Endocrinology and Nutrition Department, Hospital Clínico San Carlos- IdISSC, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Anne de Jong-Laird
- Otsuka Pharmaceutical Companies Europe, Wexham Springs, Framewood Road, Wexham, Slough, UK
| | - Madhu Kabra
- Otsuka Pharmaceutical Companies Europe, Wexham Springs, Framewood Road, Wexham, Slough, UK
| | - Uwe Lindner
- Department of Endocrinology and Diabetology, Klinikum Chemnitz gGmbH, Klinikum Chemnitz gGmbH, Chemnitz, Germany.
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23
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Arima H, Goto K, Motozawa T, Mouri M, Watanabe R, Hirano T, Ishikawa SE. Open-label, multicenter, dose-titration study to determine the efficacy and safety of tolvaptan in Japanese patients with hyponatremia secondary to syndrome of inappropriate secretion of antidiuretic hormone. Endocr J 2021; 68:17-29. [PMID: 32863282 DOI: 10.1507/endocrj.ej20-0216] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study was to determine the efficacy and safety of tolvaptan in Japanese patients with hyponatremia secondary to syndrome of inappropriate secretion of antidiuretic hormone (SIADH). This multicenter, open-label, dose-escalation, phase III study enrolled Japanese patients (20-85 years old) with hyponatremia secondary to SIADH who were unresponsive to fluid restriction. Oral tolvaptan was administered for up to 30 days, initially at 7.5 mg/day, but escalated daily as necessary, based on the serum sodium concentration and safety, over the first 10 days until the optimal maintenance dose was determined for each patient (maximum 60 mg/day). The primary endpoint was the proportion of patients with normalized serum sodium concentration on the day after the final tolvaptan dose. Secondary endpoints included the mean change in serum sodium concentration from baseline on the day after the final dose. Sixteen patients (male, 81.3%; mean ± standard deviation age 71.9 ± 6.1 years) received tolvaptan treatment and 11 patients completed the study with one patient re-administered tolvaptan in the treatment period. Serum sodium concentrations normalized in 13 of 16 (81.3%) patients on the day after the final tolvaptan dose. The mean change in serum sodium concentration from baseline on the day after the final dose was 11.0 ± 4.3 mEq/L. Adverse events considered related to tolvaptan (10 [62.5%] patients) were generally of mild to moderate severity. Oral tolvaptan corrects hyponatremia in Japanese patients with SIADH with a similar efficacy and safety profile as that noted in non-Japanese patients.
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Affiliation(s)
- Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Koichi Goto
- Department of Thoracic Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Tomohisa Motozawa
- Clinical Development Headquarters, Otsuka Pharmaceutical Co., Ltd, Osaka, Japan
| | - Makoto Mouri
- Clinical Development Headquarters, Otsuka Pharmaceutical Co., Ltd, Osaka, Japan
| | - Ryo Watanabe
- Clinical Development Headquarters, Otsuka Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Takahiro Hirano
- Medical Affairs, Otsuka Pharmaceutical Co., Ltd., Tokyo, Japan
| | - San-E Ishikawa
- Department of Endocrinology and Metabolism, International University of Health and Welfare Hospital, Tochigi, Japan
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Flahault A, Girault-Sotias PE, Keck M, Alvear-Perez R, De Mota N, Estéoulle L, Ramanoudjame SM, Iturrioz X, Bonnet D, Llorens-Cortes C. A metabolically stable apelin-17 analog decreases AVP-induced antidiuresis and improves hyponatremia. Nat Commun 2021; 12:305. [PMID: 33436646 PMCID: PMC7804859 DOI: 10.1038/s41467-020-20560-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 12/09/2020] [Indexed: 01/29/2023] Open
Abstract
Apelin and arginine-vasopressin (AVP) are conversely regulated by osmotic stimuli. We therefore hypothesized that activating the apelin receptor (apelin-R) with LIT01-196, a metabolically stable apelin-17 analog, may be beneficial for treating the Syndrome of Inappropriate Antidiuresis, in which AVP hypersecretion leads to hyponatremia. We show that LIT01-196, which behaves as a potent full agonist for the apelin-R, has an in vivo half-life of 156 minutes in the bloodstream after subcutaneous administration in control rats. In collecting ducts, LIT01-196 decreases dDAVP-induced cAMP production and apical cell surface expression of phosphorylated aquaporin 2 via AVP type 2 receptors, leading to an increase in aqueous diuresis. In a rat experimental model of AVP-induced hyponatremia, LIT01-196 subcutaneously administered blocks the antidiuretic effect of AVP and the AVP-induced increase in urinary osmolality and induces a progressive improvement of hyponatremia. Our data suggest that apelin-R activation constitutes an original approach for hyponatremia treatment.
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Grants
- Fondation pour la Recherche Médicale (Foundation for Medical Research in France)
- Fondation Pour la Recherche en Chimie (Frontier Research in Chemistry Foundation)
- This work was supported by the Institut National de la Santé et de la Recherche Médicale (INSERM) including financial support for Proof of Concept, CoPoc Apelinatremia 2015-2017 by INSERM Transfert, the Centre National de la Recherche Scientifique, the Université de Strasbourg, the LabEx MEDALIS, the Collège de France, the Agence Nationale de la Recherche "Vie, santé et bien-être 2016" (ANR-16-CE18-0030, FluoroPEP), the Fédération Française de Cardiologie and the FRC (Frontier Research in Chemistry). AF was supported by a fellowship from INSERM (Poste d’Accueil pour Hospitaliers). PEGS was supported by a fellowship from the Fondation pour la Recherche Médicale, grant number “PBR201810007643”. LE and SMR were supported by a fellowship from the Ministère de l’Education Nationale, de l’Enseignement Supérieur et de la Recherche and the Agence Nationale pour la Recherche, respectively.
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Affiliation(s)
- Adrien Flahault
- Laboratory of Central Neuropeptides in the Regulation of Body Fluid Homeostasis and Cardiovascular Functions, Center for Interdisciplinary Research in Biology, INSERM, Unit U1050, Centre National de la Recherche Scientifique, Unite Mixte de Recherche 7241, Collège de France, Paris, France
| | - Pierre-Emmanuel Girault-Sotias
- Laboratory of Central Neuropeptides in the Regulation of Body Fluid Homeostasis and Cardiovascular Functions, Center for Interdisciplinary Research in Biology, INSERM, Unit U1050, Centre National de la Recherche Scientifique, Unite Mixte de Recherche 7241, Collège de France, Paris, France
| | - Mathilde Keck
- Laboratory of Central Neuropeptides in the Regulation of Body Fluid Homeostasis and Cardiovascular Functions, Center for Interdisciplinary Research in Biology, INSERM, Unit U1050, Centre National de la Recherche Scientifique, Unite Mixte de Recherche 7241, Collège de France, Paris, France
| | - Rodrigo Alvear-Perez
- Laboratory of Central Neuropeptides in the Regulation of Body Fluid Homeostasis and Cardiovascular Functions, Center for Interdisciplinary Research in Biology, INSERM, Unit U1050, Centre National de la Recherche Scientifique, Unite Mixte de Recherche 7241, Collège de France, Paris, France
| | - Nadia De Mota
- Laboratory of Central Neuropeptides in the Regulation of Body Fluid Homeostasis and Cardiovascular Functions, Center for Interdisciplinary Research in Biology, INSERM, Unit U1050, Centre National de la Recherche Scientifique, Unite Mixte de Recherche 7241, Collège de France, Paris, France
| | - Lucie Estéoulle
- Laboratory of Therapeutic Innovation, Unité Mixte de Recherche 7200, Centre National de la Recherche Scientifique, Faculty of Pharmacy, University of Strasbourg, Illkirch, France
| | - Sridévi M Ramanoudjame
- Laboratory of Therapeutic Innovation, Unité Mixte de Recherche 7200, Centre National de la Recherche Scientifique, Faculty of Pharmacy, University of Strasbourg, Illkirch, France
| | - Xavier Iturrioz
- Laboratory of Central Neuropeptides in the Regulation of Body Fluid Homeostasis and Cardiovascular Functions, Center for Interdisciplinary Research in Biology, INSERM, Unit U1050, Centre National de la Recherche Scientifique, Unite Mixte de Recherche 7241, Collège de France, Paris, France
| | - Dominique Bonnet
- Laboratory of Therapeutic Innovation, Unité Mixte de Recherche 7200, Centre National de la Recherche Scientifique, Faculty of Pharmacy, University of Strasbourg, Illkirch, France.
| | - Catherine Llorens-Cortes
- Laboratory of Central Neuropeptides in the Regulation of Body Fluid Homeostasis and Cardiovascular Functions, Center for Interdisciplinary Research in Biology, INSERM, Unit U1050, Centre National de la Recherche Scientifique, Unite Mixte de Recherche 7241, Collège de France, Paris, France.
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Indirli R, Ferreira de Carvalho J, Cremaschi A, Mantovani B, Sala E, Serban AL, Locatelli M, Bertani G, Carosi G, Fiore G, Tariciotti L, Arosio M, Mantovani G, Ferrante E. Tolvaptan in the Management of Acute Euvolemic Hyponatremia After Transsphenoidal Surgery: A Retrospective Single-Center Analysis. Front Endocrinol (Lausanne) 2021; 12:689887. [PMID: 34108941 PMCID: PMC8181462 DOI: 10.3389/fendo.2021.689887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/10/2021] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Syndrome of inappropriate antidiuresis (SIAD) can be a complication of hypothalamus-pituitary surgery. The use of tolvaptan in this setting is not well established, hence the primary aim of this study was to assess the sodium correction rates attained with tolvaptan compared with standard treatments (fluid restriction and/or hypertonic saline). Furthermore, we compared the length of hospital stay in the two treatment groups and investigated the occurrence of overcorrection and side effects including osmotic demyelination syndrome. METHODS We retrospectively reviewed 308 transsphenoidal surgical procedures performed between 2011 and 2019 at our hospital. We selected adult patients who developed post-operative SIAD and recorded sodium monitoring, treatment modalities and outcomes. Correction rates were adjusted based on pre-treatment sodium levels. RESULTS Twenty-nine patients (9.4%) developed post-operative SIAD. Tolvaptan was administered to 14 patients (median dose 15 mg). Standard treatments were employed in 14 subjects (fluid restriction n=11, hypertonic saline n=1, fluid restriction and hypertonic saline n=2). Tolvaptan yielded higher adjusted sodium correction rates (12.0 mmolL-1/24h and 13.4 mmolL-1/48h) than standard treatments (1.8 mmolL-1/24h, p<0.001, and 4.5 mmolL-1/48h, p=0.004, vs. tolvaptan). The correction rate exceeded 10 mmolL-1/24h or 18 mmolL-1/48h in 9/14 and 2/14 patients treated with tolvaptan, respectively, and in no patient who received standard treatments. No side effects including osmotic demyelination occurred. Tolvaptan was associated with a shorter hospital stay (11vs.15 days, p=0.01). CONCLUSIONS Tolvaptan is more effective than fluid restriction (with or without hypertonic saline) and allows for a shortened hospital stay in patients with SIAD after transsphenoidal surgery. However, its dose and duration should be carefully tailored, and close monitoring is recommended to allow prompt detection of overcorrection.
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Affiliation(s)
- Rita Indirli
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Arianna Cremaschi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Beatrice Mantovani
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa Sala
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andreea Liliana Serban
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Locatelli
- Department of Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giulio Bertani
- Department of Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Carosi
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Giorgio Fiore
- Department of Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Leonardo Tariciotti
- Department of Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Maura Arosio
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanna Mantovani
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- *Correspondence: Giovanna Mantovani,
| | - Emanuele Ferrante
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Girault-Sotias PE, Gerbier R, Flahault A, de Mota N, Llorens-Cortes C. Apelin and Vasopressin: The Yin and Yang of Water Balance. Front Endocrinol (Lausanne) 2021; 12:735515. [PMID: 34880830 PMCID: PMC8645901 DOI: 10.3389/fendo.2021.735515] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/19/2021] [Indexed: 12/21/2022] Open
Abstract
Apelin, a (neuro)vasoactive peptide, plays a prominent role in controlling body fluid homeostasis and cardiovascular functions. Experimental data performed in rodents have shown that apelin has an aquaretic effect via its central and renal actions. In the brain, apelin inhibits the phasic electrical activity of vasopressinergic neurons and the release of vasopressin from the posterior pituitary into the bloodstream and in the kidney, apelin regulates renal microcirculation and counteracts in the collecting duct, the antidiuretic effect of vasopressin occurring via the vasopressin receptor type 2. In humans and rodents, if plasma osmolality is increased by hypertonic saline infusion/water deprivation or decreased by water loading, plasma vasopressin and apelin are conversely regulated to maintain body fluid homeostasis. In patients with the syndrome of inappropriate antidiuresis, in which vasopressin hypersecretion leads to hyponatremia, the balance between apelin and vasopressin is significantly altered. In order to re-establish the correct balance, a metabolically stable apelin-17 analog, LIT01-196, was developed, to overcome the problem of the very short half-life (in the minute range) of apelin in vivo. In a rat experimental model of vasopressin-induced hyponatremia, subcutaneously (s.c.) administered LIT01-196 blocks the antidiuretic effect of vasopressin and the vasopressin-induced increase in urinary osmolality, and induces a progressive improvement in hyponatremia, suggesting that apelin receptor activation constitutes an original approach for hyponatremia treatment.
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Garrahy A, Galloway I, Hannon AM, Dineen R, O'Kelly P, Tormey WP, O'Reilly MW, Williams DJ, Sherlock M, Thompson CJ. Fluid Restriction Therapy for Chronic SIAD; Results of a Prospective Randomized Controlled Trial. J Clin Endocrinol Metab 2020; 105:5900862. [PMID: 32879954 DOI: 10.1210/clinem/dgaa619] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/31/2020] [Indexed: 01/23/2023]
Abstract
CONTEXT Fluid restriction (FR) is the recommended first-line treatment for syndrome of inappropriate antidiuresis (SIAD), despite the lack of prospective data to support its efficacy. DESIGN A prospective nonblinded randomized controlled trial of FR versus no treatment in chronic SIAD. INTERVENTIONS AND OUTCOME A total of 46 patients with chronic asymptomatic SIAD were randomized to either FR (1 liter/day) or no specific hyponatremia treatment (NoTx) for 1 month. The primary endpoints were change in plasma sodium concentration (pNa) at days 4 and 30. RESULTS Median baseline pNa was similar in the 2 groups [127 mmol/L (interquartile range [IQR] 126-129) FR and 128 mmol/L (IQR 126-129) NoTx, P = 0.36]. PNa rose by 3 mmol/L (IQR 2-4) after 3 days FR, compared with 1 mmol/L (IQR 0-3) NoTx, P = 0.005. There was minimal additional rise in pNa by day 30; median pNa increased from baseline by 4 mmol/L (IQR 2-6) in FR, compared with 1 mmol/L (IQR 0-1) NoTx, P = 0.04. After 3 days, 17% of FR had a rise in pNa of ≥5 mmol/L, compared with 4% NoTx, RR 4.0 (95% CI 0.66-25.69), P = 0.35. After 3 days, 61% of FR corrected pNa to ≥130 mmol/L, compared with 39% of NoTx, RR 1.56 (95% CI 0.87-2.94), P = 0.24. CONCLUSION FR induces a modest early rise in pNa in patients with chronic SIAD, with minimal additional rise thereafter, and it is well-tolerated. More than one-third of patients fail to reach a pNa ≥130 mmol/L after 3 days of FR, emphasizing the clinical need for additional therapies for SIAD in some patients.
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Affiliation(s)
- Aoife Garrahy
- Academic Department of Endocrinology, RCSI Medical School and Beaumont Hospital, Dublin, Ireland
| | - Iona Galloway
- Academic Department of Endocrinology, RCSI Medical School and Beaumont Hospital, Dublin, Ireland
| | - Anne Marie Hannon
- Academic Department of Endocrinology, RCSI Medical School and Beaumont Hospital, Dublin, Ireland
| | - Rosemary Dineen
- Academic Department of Endocrinology, RCSI Medical School and Beaumont Hospital, Dublin, Ireland
| | - Patrick O'Kelly
- Department of Medical Statistics, Beaumont Hospital, Dublin, Ireland
| | - William P Tormey
- Department of Chemical Pathology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Academic Department of Endocrinology, RCSI Medical School and Beaumont Hospital, Dublin, Ireland
| | - David J Williams
- Department of Geriatric and Stroke Medicine, RCSI Medical School and Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Academic Department of Endocrinology, RCSI Medical School and Beaumont Hospital, Dublin, Ireland
| | - Chris J Thompson
- Academic Department of Endocrinology, RCSI Medical School and Beaumont Hospital, Dublin, Ireland
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Sencanski M, Perovic V, Pajovic SB, Adzic M, Paessler S, Glisic S. Drug Repurposing for Candidate SARS-CoV-2 Main Protease Inhibitors by a Novel In Silico Method. Molecules 2020; 25:E3830. [PMID: 32842509 PMCID: PMC7503980 DOI: 10.3390/molecules25173830] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/05/2020] [Accepted: 08/21/2020] [Indexed: 01/01/2023] Open
Abstract
The SARS-CoV-2 outbreak caused an unprecedented global public health threat, having a high transmission rate with currently no drugs or vaccines approved. An alternative powerful additional approach to counteract COVID-19 is in silico drug repurposing. The SARS-CoV-2 main protease is essential for viral replication and an attractive drug target. In this study, we used the virtual screening protocol with both long-range and short-range interactions to select candidate SARS-CoV-2 main protease inhibitors. First, the Informational spectrum method applied for small molecules was used for searching the Drugbank database and further followed by molecular docking. After in silico screening of drug space, we identified 57 drugs as potential SARS-CoV-2 main protease inhibitors that we propose for further experimental testing.
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Affiliation(s)
- Milan Sencanski
- Laboratory of Bioinformatics and Computational Chemistry, Institute of Nuclear Sciences Vinca, National Institute of the Republic of Serbia, University of Belgrade, 11001 Belgrade, Serbia; (M.S.); (V.P.)
| | - Vladimir Perovic
- Laboratory of Bioinformatics and Computational Chemistry, Institute of Nuclear Sciences Vinca, National Institute of the Republic of Serbia, University of Belgrade, 11001 Belgrade, Serbia; (M.S.); (V.P.)
| | - Snezana B. Pajovic
- Department of Molecular Biology and Endocrinology, VINCA Institute of Nuclear Sciences, National Institute of the Republic of Serbia, University of Belgrade, 11001 Belgrade, Serbia; (S.B.P.); (M.A.)
| | - Miroslav Adzic
- Department of Molecular Biology and Endocrinology, VINCA Institute of Nuclear Sciences, National Institute of the Republic of Serbia, University of Belgrade, 11001 Belgrade, Serbia; (S.B.P.); (M.A.)
| | - Slobodan Paessler
- Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA;
- Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Sanja Glisic
- Laboratory of Bioinformatics and Computational Chemistry, Institute of Nuclear Sciences Vinca, National Institute of the Republic of Serbia, University of Belgrade, 11001 Belgrade, Serbia; (M.S.); (V.P.)
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Mentrasti G, Scortichini L, Torniai M, Giampieri R, Morgese F, Rinaldi S, Berardi R. Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH): Optimal Management. Ther Clin Risk Manag 2020; 16:663-672. [PMID: 32801723 PMCID: PMC7386802 DOI: 10.2147/tcrm.s206066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 04/20/2020] [Indexed: 12/20/2022] Open
Abstract
Hyponatremia, defined as serum sodium concentration <135 mEq/l, is the most common electrolyte balance disorder in clinical practice. Many causes are listed, but syndrome of inappropriate antidiuretic hormone secretion (SIADH) is certainly the most relevant, mainly in oncological and hospitalized patients. In this review, the pathophysiological and clinical aspects are described in detail. Patients’ extensive medical history and structured physical and biochemical tests are considered the milestones marking the way of the SIADH management as to provide early detection and proper correction. We focused our attention on the poor prognostic role and negative effect on patient’s quality of life of SIADH-induced hyponatremia in both malignant and non-malignant settings, stressing how optimal management of this electrolyte imbalance can result in improved outcomes and lower health costs.
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Affiliation(s)
- Giulia Mentrasti
- Clinica Oncologica, Università Politecnica delle Marche, AOU Ospedali Riuniti Di Ancona, Ancona, Italy
| | - Laura Scortichini
- Clinica Oncologica, Università Politecnica delle Marche, AOU Ospedali Riuniti Di Ancona, Ancona, Italy
| | - Mariangela Torniai
- Clinica Oncologica, Università Politecnica delle Marche, AOU Ospedali Riuniti Di Ancona, Ancona, Italy
| | - Riccardo Giampieri
- Clinica Oncologica, Università Politecnica delle Marche, AOU Ospedali Riuniti Di Ancona, Ancona, Italy
| | - Francesca Morgese
- Clinica Oncologica, Università Politecnica delle Marche, AOU Ospedali Riuniti Di Ancona, Ancona, Italy
| | - Silvia Rinaldi
- Clinica Oncologica, Università Politecnica delle Marche, AOU Ospedali Riuniti Di Ancona, Ancona, Italy
| | - Rossana Berardi
- Clinica Oncologica, Università Politecnica delle Marche, AOU Ospedali Riuniti Di Ancona, Ancona, Italy
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Kleindienst A, Georgiev S, Schlaffer SM, Buchfelder M. Tolvaptan Versus Fluid Restriction in the Treatment of Hyponatremia Resulting from SIADH Following Pituitary Surgery. J Endocr Soc 2020; 4:bvaa068. [PMID: 32666012 PMCID: PMC7326480 DOI: 10.1210/jendso/bvaa068] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/08/2020] [Indexed: 12/21/2022] Open
Abstract
Context The relevance of hyponatremia has been acknowledged by guidelines from the United States (2013) and Europe (2014). However, treatment recommendations differ due to limited evidence. Objective In hyponatremia following pituitary surgery-caused by the syndrome of inappropriate antidiuretic hormone (SIADH) secretion-we compared fluid restriction with the pharmacological increase of water excretion by blocking the vasopressin 2 receptors with tolvaptan at a low and a moderate dose. Design Prospective observational study. Setting Neurosurgical Department of a University hospital with more than 200 surgical pituitary procedures per year. Patients Patients undergoing pituitary surgery and developing serum sodium below 136 mmol/L. The diagnosis of SIADH was established by euvolemia (daily measurement of body weight and fluid balance), inappropriately concentrated urine (specific gravity), and exclusion of adrenocorticotropic and thyroid-stimulating hormone deficiency. Intervention Patients were treated with fluid restriction (n = 40) or tolvaptan at 3.75 (n = 38) or 7.5 mg (n = 48). Main Outcome Measures Treatment efficacy was assessed by the duration of hyponatremia, sodium nadir, and length of hospitalization. Safety was established by a sodium increment below 10 mmol/L per day and exclusion of side effects. Results Treatment with 7.5 mg of tolvaptan resulted in a significant attenuation of hyponatremia and in a significant overcorrection of serum sodium in 30% of patients. The duration of hospitalization did not differ between treatment groups. Conclusions Tolvaptan at a moderate dose is more effective than fluid restriction in the treatment of SIADH. Overcorrection of serum sodium may be a side effect of tolvaptan even at low doses.
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Affiliation(s)
- Andrea Kleindienst
- Department of Neurosurgery, Friedrich-Alexander-University Nürnberg-Erlangen, Erlangen, Germany
| | - Simeon Georgiev
- Department of Neurosurgery, Friedrich-Alexander-University Nürnberg-Erlangen, Erlangen, Germany
| | - Sven Martin Schlaffer
- Department of Neurosurgery, Friedrich-Alexander-University Nürnberg-Erlangen, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander-University Nürnberg-Erlangen, Erlangen, Germany
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ISIKTAS SAYILAR E, ERSOY A, AYAR Y, AYDIN M, YAVUZ M. Effectiveness of Tolvaptan Treatment in Hyponatremic Patients. TURKISH JOURNAL OF INTERNAL MEDICINE 2020. [DOI: 10.46310/tjim.706226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Abstract
PURPOSE OF REVIEW Hyponatremia is seen commonly in patients with cancer and is associated with increased mortality and morbidity. Understanding the proper diagnosis and therapy of cancer-associated hyponatremia is critical to ensure improved outcomes. RECENT FINDINGS The most common cancers associated with hyponatremia are the various forms of lung cancer with incidences approaching 25-45%. The most common causes of hyponatremia in cancer patients are the syndrome of inappropriate antidiuretic hormone secretion [syndrome of inappropriate antidiuretic hormone (ADH)] and volume depletion. Proper diagnosis rests on clinical information supplemented by laboratory studies and is critical to ensure appropriate therapy. In recent years, the development of drugs that specifically antagonize the vasopressin type 2 receptor in the distal tubule have offered targeted and highly effective therapies for syndrome of inappropriate ADH. SUMMARY Hyponatremia in cancer patients generally indicates advanced or severe disease but proper therapy that targets the underlying process can improve outcomes.
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Barajas-Galindo DE, Vidal-Casariego A, Gómez-Hoyos E, Fernández-Martínez P, Guerra González M, Hernández-Moreno A, Alejo-Ramos M, Villar-Taibo R, Cano-Rodríguez I, Ballesteros-Pomar MD. Experiencia clínica con distintas dosis iniciales de tolvaptán en SIADH. Nefrologia 2019; 39:672-674. [DOI: 10.1016/j.nefro.2019.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 03/12/2019] [Accepted: 03/19/2019] [Indexed: 10/27/2022] Open
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Yuan X, Pan H, Zhu H, Li J, Miao H, Ke X, Chen S. A new method of intermittent lower dose of tolvaptan combined with fluid restriction to treat the syndrome of inappropriate antidiuresis: A case report. Medicine (Baltimore) 2019; 98:e17586. [PMID: 31651865 PMCID: PMC6824761 DOI: 10.1097/md.0000000000017586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Tolvaptan, an oral vasopressin V2 receptor antagonist, is a new approach for the treatment of adult patients with the syndrome of inappropriate antidiuresis (SIADH). However, dose-dependent side effect including rapid increase in serum sodium levels and liver injury, and the expensive price limit the long-term use of tolvaptan. We report a case of SIADH patient treated with intermittent lower dose of tolvaptan combined with fluid restriction. PATIENT CONCERNS A 60-year-old woman presented of nausea and vomiting, dizzy and amaurosis, and transient disturbance, after a week of persistent diarrhea. DIAGNOSIS Diagnosis of SIADH was based on severe persistent hyponatremia, decreased plasma osmolality, raised urinary sodium excretion, and the absence of other causes. INTERVENTIONS She was given the treatment of tolvaptan 15 mg once daily, and experienced tolvaptan-related side effects including thirst and dry mouth, polyuria, and dizziness. Then, single dose of tolvaptan was reduced from 15 to 7.5 mg, and the interval between medication was gradually prolonged from 24 to 72 hours. Meanwhile, serum sodium was negatively correlated with the amount of daily water intake in interval days, so daily water intake of the patient was restricted to 1500 mL in interval days. OUTCOMES Serum sodium was maintained within the normal range, 137 to 141 mmol/L without liver damage. LESSONS For patients with chronic SIADH, the tolvaptan dose should be individualized, and the regimen of intermittent lower dose of tolvaptan combined with fluid restriction maybe an effective choice.
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Sensory primary cilium is a responsive cAMP microdomain in renal epithelia. Sci Rep 2019; 9:6523. [PMID: 31024067 PMCID: PMC6484033 DOI: 10.1038/s41598-019-43002-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/12/2019] [Indexed: 02/07/2023] Open
Abstract
Primary cilia are hair-like cellular extensions that sense microenvironmental signals surrounding cells. The role of adenylyl cyclases in ciliary function has been of interest because the product of adenylyl cyclase activity, cAMP, is relevant to cilia-related diseases. In the present study, we show that vasopressin receptor type-2 (V2R) is localized to cilia in kidney epithelial cells. Pharmacologic inhibition of V2R with tolvaptan increases ciliary length and mechanosensory function. Genetic knockdown of V2R, however, does not have any effect on ciliary length, although the effect of tolvaptan on ciliary length is dampened. Our study reveals that tolvaptan may have a cilia-specific effect independent of V2R or verapamil-sensitive calcium channels. Live-imaging of single cilia shows that V2R activation increases cilioplasmic and cytoplasmic cAMP levels, whereas tolvaptan mediates cAMP changes only in a cilia-specific manner. Furthermore, fluid-shear stress decreases cilioplasmic, but not cytoplasmic cAMP levels. Our data indicate that cilioplasmic and cytoplasmic cAMP levels are differentially modulated. We propose that the cilium is a critical sensor acting as a responsive cAMP microcompartment during physiologically relevant stimuli.
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Liu QB, Zheng R. Natural killer/T-cell lymphoma with concomitant syndrome of inappropriate antidiuretic hormone secretion: A case report and review of literature. World J Clin Cases 2018; 6:694-702. [PMID: 30430128 PMCID: PMC6232570 DOI: 10.12998/wjcc.v6.i13.694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/03/2018] [Accepted: 10/11/2018] [Indexed: 02/05/2023] Open
Abstract
We report a case of natural killer (NK)/T-cell lymphoma with concomitant syndrome of inappropriate antidiuretic hormone secretion (SIADH). The patient was a 64-year-old woman with a history of nasopharyngeal carcinoma of over 30 years. She was admitted with a chief complaint of intermittent fever for 2 mo. Palpation after admission indicated a swollen lymph node below the left jaw. Multiple imaging examinations on admission indicated multiple enlarged lymph nodes throughout the body. We performed a left submandibular lymph node biopsy, and the results revealed NK/T-cell lymphoma. A biochemical examination indicated Epstein-Barr virus positivity. At the same time, the patient developed hyponatremia. Based on her laboratory examination and clinical manifestation, decreased plasma osmolality, urine osmolality greater than plasma osmolality, lack of skin swelling, normal blood pressure, normal renal function, no adrenal function detected on serology, and no abnormalities in imaging examination of the adrenal glands, the likelihood of SIADH in the patient was high. After fluid restriction and administration of sodium chloride, the patient’s blood sodium level gradually increased. Subsequently, the immune function of the patient declined, there were severe symptoms of infection, and she died of respiratory failure. NK/T-cell lymphoma associated with SIADH has not, to our knowledge, been previously reported in PubMed. This case emphasizes the importance of monitoring serum ion levels, especially serum sodium, in patients with NK/T-cell lymphoma.
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Affiliation(s)
- Quan-Bo Liu
- Department of Respiratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Rui Zheng
- Department of Respiratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
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Ramirez de Noriega F, Manley GT, Moscovici S, Itshayek E, Tamir I, Fellig Y, Shkara RA, Rosenthal G. A swine model of intracellular cerebral edema - Cerebral physiology and intracranial compliance. J Clin Neurosci 2018; 58:192-199. [PMID: 30454689 DOI: 10.1016/j.jocn.2018.10.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 10/07/2018] [Indexed: 10/28/2022]
Abstract
Cerebral edema leading to elevated intracranial pressure (ICP) is a fundamental concern after severe traumatic brain injury (TBI), stroke, and severe acute hyponatremia. We describe a swine model of water intoxication and its cerebral histological and physiological sequela. We studied female swine weighing 35-45 kg. Four serum sodium intervals were designated: baseline, mild, moderate, and severe hyponatremia attained by infusing hypotonic saline. Intracranial fluid injections were performed to assess intracranial compliance. At baseline and following water intoxication wedge biopsy was obtained for pathological examination and electron microscopy. We studied 8 swine and found an increase in ICP that was strongly related to the decrease in serum sodium level. Mean ICP rose from a baseline of 6 ± 2 to 28 ± 6 mm Hg during severe hyponatremia, while cerebral perfusion pressure (CPP) decreased from 72 ± 10 to 46 ± 11 mm Hg. Brain tissue oxygen tension (PbtO2) decreased from 18.4 ± 8.9 to 5.3 ± 3.0 mm Hg. Electron microscopy demonstrated intracellular edema and astrocytic foot process swelling following water intoxication. With severe hyponatremia, 2 cc intracranial fluid injection resulted in progressively greater ICP dose, indicating a worsening intracranial compliance. Our model leads to graded and sustained elevation of ICP, lower CPP, and decreased PbtO2, all of which cross clinically relevant thresholds. Intracranial compliance worsens with increased cerebral swelling. This model may serve as a platform to study which therapeutic interventions best improve the cerebral physiological profile in the face of severe brain edema.
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Affiliation(s)
| | - Geoffrey T Manley
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Samuel Moscovici
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Eyal Itshayek
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Idit Tamir
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yakov Fellig
- Department of Pathology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ramiz Abu Shkara
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Guy Rosenthal
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA.
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Woodward M, Gonski P, Grossmann M, Obeid J, Scholes R, Topliss DJ. Diagnosis and management of hyponatraemia in the older patient. Intern Med J 2018; 48 Suppl 1:5-12. [PMID: 29318728 DOI: 10.1111/imj.13682] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Hyponatraemia (serum sodium concentration below 135 mmol/L) is the most common electrolyte disturbance and occurs commonly in older people. The causes can be complex to diagnose and treat and many published guidelines do not focus on the issues in an older patient group. Here, we are principally concerned with diagnosis and management of euvolaemic and hypervolaemic hyponatraemia in hospitalised patients over 70 years old. We also aim to increase awareness of hyponatraemia in residential aged care facilities and the community. Hyponatraemia can have many causes; in older people, chronic hyponatraemia can often be the result of medications used to treat chronic disease, particularly thiazide or thiazide-like drugs (such as indapamide) or drugs acting on the central nervous system. Where a reversible trigger (such as drug-induced hyponatraemia) can be identified, hyponatraemia may be treated relatively simply. Chronic hyponatraemia due to an irreversible cause will require ongoing treatment. Fluid restriction can be an effective therapy in dilutional hyponatraemia, although poor compliance and the burdensome nature of the restrictions are important considerations. Tolvaptan is an oral vasopressin receptor antagonist that can increase serum sodium concentrations by increasing electrolyte-free water excretion. Tolvaptan use is supported by clinical trial evidence in patients with hypervolaemic or euvolaemic hyponatraemia below 125 mmol/L. Clinical trial evidence also supports its use after a trial of fluid restriction in patients with symptomatic hyponatraemia above 125 mmol/L. The use of tolvaptan is affected by regulatory restriction of chronic therapy due to safety concern and the non-subsidised cost of treatment.
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Affiliation(s)
- Michael Woodward
- Aged Care Services, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Austin Health, Melbourne, Victoria, Australia
| | - Peter Gonski
- Southcare (Aged and Extended Care) Sutherland Hospital, Sydney, New South Wales, Australia
| | - Mathis Grossmann
- Department of Medicine, The University of Melbourne, Austin Health, Melbourne, Victoria, Australia
| | - John Obeid
- Specialist Services Medical Group, Sydney, New South Wales, Australia
| | - Ron Scholes
- Epworth Healthcare, Melbourne, Victoria, Australia
| | - Duncan J Topliss
- Department of Endocrinology and Diabetes, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
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Herrera-Gómez F, Monge-Donaire D, Ochoa-Sangrador C, Bustamante-Munguira J, Alamartine E, Álvarez FJ. Correction of Hyponatremia May Be a Treatment Stratification Biomarker: A Two-Stage Systematic Review and Meta-Analysis. J Clin Med 2018; 7:jcm7090262. [PMID: 30205538 PMCID: PMC6162844 DOI: 10.3390/jcm7090262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 08/29/2018] [Accepted: 09/06/2018] [Indexed: 12/21/2022] Open
Abstract
Changes in serum sodium concentration ([Na+]serum) can permit evaluation of the treatment effect of vasopressin antagonists (vaptans) in patients with worsening heart failure (HF) or cirrhotic ascites; that is, they may act as a treatment stratification biomarker. A two-stage systematic review and meta-analysis were carried out and contextualized by experts in fluid resuscitation and translational pharmacology (registration ID in the International Prospective Register of Systematic Reviews (PROSPERO): CRD42017051440). Meta-analysis of aggregated dichotomous outcomes was performed. Pooled estimates for correction of hyponatremia (normalization or an increase in [Na+]serum of at least 3–5 mEq/L) under treatment with vaptans (Stage 1) and for clinical outcomes in both worsening HF (rehospitalization and/or death) and cirrhotic ascites (ascites worsening) when correction of hyponatremia is achieved (Stage 2) were calculated. The body of evidence was assessed. Correction of hyponatremia was achieved under vaptans (odds ratio (OR)/95% confidence interval (95% CI)/I2/number of studies (n): 7.48/4.95–11.30/58%/15). Clinical outcomes in both worsening HF and cirrhotic ascites improved when correction of hyponatremia was achieved (OR/95% CI/I2/n: 0.51/0.26–0.99/52%/3). Despite the appropriateness of the study design, however, there are too few trials to consider that correction of hyponatremia is a treatment stratification biomarker. Patients with worsening HF or with cirrhotic ascites needing treatment with vaptans, have better clinical outcomes when correction of hyponatremia is achieved. However, the evidence base needs to be enlarged to propose formally correction of hyponatremia as a new treatment stratification biomarker. Markers for use with drugs are needed to improve outcomes related to the use of medicines.
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Affiliation(s)
- Francisco Herrera-Gómez
- Pharmacology and Therapeutics, Faculty of Medicine, University of Valladolid, Avenida Ramón y Cajal, 7, 47005 Valladolid, Spain.
- Nephrology, Hospital Virgen de la Concha-Sanidad de Castilla y León, 49022 Zamora, Spain.
| | - Diana Monge-Donaire
- Intensive Care Medicine, Hospital Virgen de la Concha-Sanidad de Castilla y León, 49022 Zamora, Spain.
| | - Carlos Ochoa-Sangrador
- Research Unit, Hospital Virgen de la Concha-Sanidad de Castilla y León, 49022 Zamora, Spain.
| | - Juan Bustamante-Munguira
- Cardiac Surgery, Hospital Clínico Universitario de Valladolid-Sanidad de Castilla y León, 47003 Valladolid, Spain.
| | - Eric Alamartine
- Nephrology, Dialysis and Transplantation, Centre Hospitalier Universitaire de Saint-Etienne, 42270 Saint-Priest-en-Jarez, France.
| | - F Javier Álvarez
- Pharmacology and Therapeutics, Faculty of Medicine, University of Valladolid, Avenida Ramón y Cajal, 7, 47005 Valladolid, Spain.
- CEIm Área de Salud Valladolid Este, Hospital Clínico Universitario de Valladolid-Sanidad de Castilla y León, 47003 Valladolid, Spain.
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Nagler EV, Haller MC, Van Biesen W, Vanholder R, Craig JC, Webster AC. Interventions for chronic non-hypovolaemic hypotonic hyponatraemia. Cochrane Database Syst Rev 2018; 6:CD010965. [PMID: 29953167 PMCID: PMC6513194 DOI: 10.1002/14651858.cd010965.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Chronic (present > 48 hours) non-hypovolaemic hyponatraemia occurs frequently, can be caused by various conditions, and is associated with shorter survival and longer hospital stays. Many treatments, such as fluid restriction or vasopressin receptor antagonists can be used to improve the hyponatraemia, but whether that translates into improved patient-important outcomes is less certain. OBJECTIVES This review aimed to 1) look at the benefits and harms of interventions for chronic non-hypovolaemic hypotonic hyponatraemia when compared with placebo, no treatment or head-to-head; and 2) determine if benefits and harms vary in absolute or relative terms dependent on the specific compound within a drug class, on the dosage used, or the underlying disorder causing the hyponatraemia. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 1 December 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also screened the reference lists of potentially relevant studies, contacted authors, and screened the websites of regulatory agencies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of any intervention with placebo, no treatment, standard care, or any other intervention in patients with chronic non-hypovolaemic hypotonic hyponatraemia. We also included subgroups with hyponatraemia from studies with broader inclusion criteria (e.g. people with chronic heart failure or people with cirrhosis with or without hyponatraemia), provided we could obtain outcomes for participants with hyponatraemia from the report or the study authors. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed risk of bias. We expressed treatment effects as mean difference (MD) for continuous outcomes (health-related quality of life, length of hospital stay, change from baseline in serum sodium concentration, cognitive function), and risk ratio (RR) for dichotomous outcomes (death, response and rapid increase in serum sodium concentration, hypernatraemia, polyuria, hypotension, acute kidney injury, liver function abnormalities) together with 95% confidence intervals (CI). MAIN RESULTS We identified 35 studies, enrolling 3429 participants. Twenty-eight studies (3189 participants) compared a vasopressin receptor antagonist versus placebo, usual care, no treatment, or fluid restriction. In adults with chronic, non-hypovolaemic hypotonic hyponatraemia, vasopressin receptor antagonists have uncertain effects on death at six months (15 studies, 2330 participants: RR 1.11, 95% CI 0.92 to 1.33) due to risk of selective reporting and serious imprecision; and on health-related quality of life because results are at serious risk of performance, selective reporting and attrition bias, and suffer from indirectness related to the validity of the Short Form Health Survey (SF-12) in the setting of hyponatraemia. Vasopressin receptor antagonists may reduce hospital stay (low certainty evidence due to risk of performance bias and imprecision) (3 studies, 610 participants: MD -1.63 days, 95% CI -2.96 to -0.30), and may make little or no difference to cognitive function (low certainty evidence due to indirectness and imprecision). Vasopressin receptor antagonists probably increase the intermediate outcome of serum sodium concentration (21 studies, 2641 participants: MD 4.17 mmol/L, 95% CI 3.18 to 5.16), corresponding to two and a half as many people having a 5 to 6 mmol/L increase in sodium concentration compared with placebo at 4 to 180 days (moderate certainty evidence due to risk of attrition bias) (18 studies, 2014 participants: RR 2.49, 95% CI 1.95 to 3.18). But they probably also increase the risk of rapid serum sodium correction - most commonly defined as > 12 mmol/L/d (moderate certainty evidence due to indirectness) (14 studies, 2058 participants: RR 1.67, 95% CI 1.16 to 2.40) and commonly cause side-effects such as thirst (13 studies, 1666 participants: OR 2.77, 95% CI 1.80 to 4.27) and polyuria (6 studies, 1272 participants): RR 4.69, 95% CI 1.59 to 13.85) (high certainty evidence). The potential for liver toxicity remains uncertain due to large imprecision. Effects were generally consistent across the different agents, suggesting class effect.Data for other interventions such as fluid restriction, urea, mannitol, loop diuretics, corticosteroids, demeclocycline, lithium and phenytoin were largely absent. AUTHORS' CONCLUSIONS In people with chronic hyponatraemia, vasopressin receptor antagonists modestly raise serum sodium concentration at the cost of a 3% increased risk of it being rapid. To date there is very low certainty evidence for patient-important outcomes; the effects on mortality and health-related quality of life are unclear and do not rule out appreciable benefit or harm; there does not appear to be an important effect on cognitive function, but hospital stay may be slightly shorter, although available data are limited. Treatment decisions must weigh the value of an increase in serum sodium concentration against its short-term risks and unknown effects on patient-important outcomes. Evidence for other treatments is largely absent.Further studies assessing standard treatments such as fluid restriction or urea against placebo and one-another would inform practice and are warranted. Given the limited available evidence for patient-important outcomes, any study should include these outcomes in a standardised manner.
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Affiliation(s)
- Evi V Nagler
- Ghent University HospitalRenal Division, Sector Metabolic and Cardiovascular ConditionsDe Pintelaan 185GhentBelgium9000
- Guidance Body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA)European Renal Best Practice (ERBP)LondonUK
| | - Maria C Haller
- Guidance Body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA)European Renal Best Practice (ERBP)LondonUK
- Medical University ViennaSection for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent SystemsSpitalgasse 23ViennaAustriaA‐1090
- Ordensklinikum Linz ElisabethinenDepartment of NephrologyFadingerstraße 1LinzAustria4020
| | - Wim Van Biesen
- Ghent University HospitalRenal Division, Sector Metabolic and Cardiovascular ConditionsDe Pintelaan 185GhentBelgium9000
- Guidance Body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA)European Renal Best Practice (ERBP)LondonUK
| | - Raymond Vanholder
- Ghent University HospitalRenal Division, Sector Metabolic and Cardiovascular ConditionsDe Pintelaan 185GhentBelgium9000
- Guidance Body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA)European Renal Best Practice (ERBP)LondonUK
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | - Angela C Webster
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
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Sterns RH. Tolvaptan for the Syndrome of Inappropriate Secretion of Antidiuretic Hormone: Is the Dose Too High? Am J Kidney Dis 2018; 71:763-765. [PMID: 29801549 DOI: 10.1053/j.ajkd.2018.02.355] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 02/20/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Richard H Sterns
- University of Rochester School of Medicine and Dentistry and Rochester General Hospital, Rochester, NY.
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Park GH, Lee CM, Song JW, Jung MC, Kim JK, Song YR, Kim HJ, Kim SG. Comparison of tolvaptan treatment between patients with the SIADH and congestive heart failure: a single-center experience. Korean J Intern Med 2018; 33:561-567. [PMID: 28286940 PMCID: PMC5943653 DOI: 10.3904/kjim.2016.155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/07/2016] [Accepted: 07/08/2016] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND/AIMS Tolvaptan is a very effective treatment for hypervolemic or euvolemic hyponatremia. We compared the clinical efficacy of and response to tolvaptan in patients with the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and congestive heart failure (CHF). METHODS We retrospectively reviewed the medical records of 50 patients (SIADH, n = 30; CHF, n = 20) who were prescribed tolvaptan between July 2013 and October 2015. Tolvaptan was prescribed when the serum sodium level was < 125 mmol/L and the standard treatment failed. Normonatremia was defined as a serum sodium level of > 135 mmol/L. RESULTS After the initiation of tolvaptan therapy, there was an immediate response in the urine volume and serum sodium level in all patients. The improvements in the urine volume and serum sodium concentration were highest within the first 24 hours of treatment. In addition, the mean change in the serum sodium level during the first 24 hours was significantly higher in patients with SIADH than in those with CHF (∆Na, 9.9 ± 4.5 mmol/L vs. 6.9 ± 4.4 mmol/L, respectively; p = 0.025). Also, the mean maintenance dose was lower, and the total duration of tolvaptan use was slightly shorter in the SIADH group than CHF group (21.5 ± 14.9 days vs. 28.0 ± 20.1 days, p = 0.070). CONCLUSIONS The early response to tolvaptan treatment was better in patients with SIADH than in those with CHF. Thus, the tolvaptan treatment strategy should be differed between patients with SIADH and those with CHF.
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Affiliation(s)
- Gun Ha Park
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
- Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Chang Min Lee
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
- Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jae Won Song
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
- Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Moon Chan Jung
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
- Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jwa Kyung Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
- Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
- Department of Clinical Immunology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Young Rim Song
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
- Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Hyung Jik Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
- Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sung Gyun Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
- Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
- Department of Clinical Immunology, Hallym University Sacred Heart Hospital, Anyang, Korea
- Correspondence to Sung Gyun Kim, M.D. Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang 14068, Korea Tel: +82-31-380-3720 Fax: +82-31-380-3726 E-mail:
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Han SW, Yi JH, Kang KP, Kim HY, Kim SW, Choi HY, Ha SK, Kim GH, Kim YW, Jeong KH, Shin SK, Kim HJ. Safety and Efficacy of Tolvaptan in Korean Patients with Hyponatremia Caused by the Syndrome of Inappropriate Antidiuretic Hormone. J Korean Med Sci 2018; 33:e112. [PMID: 29629516 PMCID: PMC5890082 DOI: 10.3346/jkms.2018.33.e112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 02/26/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The aim of this multicenter study was to evaluate the safety and efficacy of tolvaptan (TLV) in Korean patients with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). METHODS Of 51 enrolled patients with SIADH, 39 patients (16 female patients, aged 70.8 ± 11.3 years) were included in an intention to treat analysis. All patients received 15 mg/day as the initial dose, and the dose was then increased up to 60 mg/day (as needed) until day 4. RESULTS Serum sodium increased significantly from baseline during the first 24 hours (126.8 ± 4.3 vs. 133.7 ± 3.8 mmol/L, P < 0.001), rose gradually between days 1 and 4 (133.7 ± 3.8 vs. 135.6 ± 3.6 mmol/L, P < 0.05), and then plateaued until day 11 (136.7 ± 4.5 mmol/L). The correlation between the change in serum sodium for the first 24 hours and initial serum sodium concentration was significant (r = -0.602, P < 0.001). In severe hyponatremia (< 125 mmol/L), the change was significantly higher (11.1 ± 4.8 mmol/L) than in moderate (6.4 ± 2.5 mmol/L, P < 0.05) or mild hyponatremia (4.3 ± 3.3 mmol/L, P < 0.01). In addition, logistic regression analysis showed that body weight (odds ratio [OR], 0.858; 95% confidence interval [CI], 0.775-0.976; P = 0.020) and body mass index (BMI) (OR, 0.692; 95% CI, 0.500-0.956; P = 0.026) were associated with rapid correction. No serious adverse events were reported, but in 13% of patients hyponatremia was overcorrected. CONCLUSION TLV is effective in correcting hyponatremia and well-tolerated in Korean patients with SIADH. However, those with low body weight, low BMI or severe hyponatremia, could be vulnerable to overcorrection with the initial dose of 15 mg TLV.
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Affiliation(s)
- Sang Woong Han
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Joo Hark Yi
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea.
| | - Kyung Pyo Kang
- Department of Internal Medicine, Chonbuk National University School of Medicine, Jeonju, Korea
| | - Ha Yeon Kim
- Department of Internal Medicine, Chonnam National University School of Medicine, Gwangju, Korea
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University School of Medicine, Gwangju, Korea
| | - Hoon Young Choi
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kyu Ha
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Gheun Ho Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Yang Wook Kim
- Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Kyung Hwan Jeong
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sug Kyun Shin
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Ho Jung Kim
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
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Morris JH, Bohm NM, Nemecek BD, Crawford R, Kelley D, Bhasin B, Nietert PJ, Velez JCQ. Rapidity of Correction of Hyponatremia Due to Syndrome of Inappropriate Secretion of Antidiuretic Hormone Following Tolvaptan. Am J Kidney Dis 2018; 71:772-782. [PMID: 29478867 DOI: 10.1053/j.ajkd.2017.12.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 12/18/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Tolvaptan effectively corrects hyponatremia due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), but undesired overcorrection can occur. We hypothesized that pretherapy parameters can predict the rapidity of response to tolvaptan in SIADH. STUDY DESIGN Multicenter historical cohort study. SETTING & PARTICIPANTS Adults with SIADH or congestive heart failure (CHF) treated with tolvaptan for a serum sodium concentration ≤ 130 mEq/L at 5 US hospitals. PREDICTORS Demographic and laboratory parameters. OUTCOMES Rate of change in serum sodium concentration. MEASUREMENTS Spearman correlations, analysis of variance, and multivariable linear mixed-effects models. RESULTS 28 patients with SIADH and 39 patients with CHF treated with tolvaptan (mean baseline serum sodium, 120.6 and 122.4 mEq/L, respectively) were studied. Correction of serum sodium concentration > 12 mEq/L/d occurred in 25% of patients with SIADH compared to 3% of those with CHF (P<0.001). Among patients with SIADH, the increase in serum sodium over 24 hours was correlated with baseline serum sodium concentration (r=-0.78; P<0.001), serum urea nitrogen concentration (SUN; r=-0.76; P<0.001), and estimated glomerular filtration rate (r=0.58; P=0.01). Baseline serum sodium and SUN concentrations were identified as independent predictors of change in serum sodium concentration in multivariable analyses. When patients were grouped into 4 categories according to baseline serum sodium and SUN median values, those with both low baseline serum sodium (≤121 mEq/L) and low baseline SUN concentrations (≤10mg/dL) exhibited a significantly greater rate of increase in serum sodium concentration (mean 24-hour increase of 15.4 mEq/L) than the other 3 categories (P<0.05). Among patients with CHF, only baseline SUN concentration was identified as an independent predictor of change in serum sodium concentration over time. LIMITATIONS Lack of uniformity in serial serum sodium concentration determinations and documentation of water intake. CONCLUSIONS Baseline serum sodium and SUN values are predictive of the rapidity of hyponatremia correction following tolvaptan use in SIADH. We advise caution when dosing tolvaptan in patients with both low serum sodium and SUN concentrations.
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Affiliation(s)
- Jesse H Morris
- Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Nicole M Bohm
- Department of Clinical Pharmacy, Medical University of South Carolina, Charleston, SC
| | - Branden D Nemecek
- Department of Pharmacy Practice, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA
| | - Rachel Crawford
- Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Denise Kelley
- Department of Pharmacy, University of Florida Health at Jacksonville, Jacksonville, FL
| | - Bhavna Bhasin
- Division of Nephrology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Paul J Nietert
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
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Martín Guerra JM, Martín Asenjo M, Sánchez Muñoz LÁ, Dueñas Gutiérrez CJ. Hyponatremia in COPD: a Little Known Complication. Arch Bronconeumol 2018; 54:S0300-2896(17)30423-4. [PMID: 29338899 DOI: 10.1016/j.arbres.2017.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/17/2017] [Accepted: 11/21/2017] [Indexed: 11/25/2022]
Affiliation(s)
| | - Miguel Martín Asenjo
- Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, España
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46
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Sbardella E, Isidori AM, Arnaldi G, Arosio M, Barone C, Benso A, Berardi R, Capasso G, Caprio M, Ceccato F, Corona G, Della Casa S, De Nicola L, Faustini-Fustini M, Fiaccadori E, Gesualdo L, Gori S, Lania A, Mantovani G, Menè P, Parenti G, Pinto C, Pivonello R, Razzore P, Regolisti G, Scaroni C, Trepiccione F, Lenzi A, Peri A. Approach to hyponatremia according to the clinical setting: Consensus statement from the Italian Society of Endocrinology (SIE), Italian Society of Nephrology (SIN), and Italian Association of Medical Oncology (AIOM). J Endocrinol Invest 2018; 41:3-19. [PMID: 29152673 DOI: 10.1007/s40618-017-0776-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 10/13/2017] [Indexed: 12/17/2022]
Affiliation(s)
- E Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - G Arnaldi
- Clinica di Endocrinologia e Malattie del Metabolismo, Università Politecnica delle Marche Azienda Ospedaliero-Universitaria, Ospedali Riuniti Umberto I-GM Lancisi-G Salesi, Ancona, Italy
| | - M Arosio
- Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - C Barone
- UOC di Oncologia Medica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - A Benso
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - R Berardi
- Clinica Oncologica, Università Politecnica delle Marche Azienda Ospedaliero-Universitaria; Ospedali Riuniti Umberto I-GM Lancisi-G Salesi, Ancona, Italy
| | - G Capasso
- Dipartimento di Scienze Cardio-Toraciche e Respiratorie, Università della Campania "Luigi Vanvitelli", Caserta, Italy
| | - M Caprio
- Laboratory of Cardiovascular Endocrinology, IRCCS San Raffaele Pisana, Rome, Italy
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Rome, Italy
| | - F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padua, Italy
| | - G Corona
- Endocrinology Unit, Medical Department, Azienda Usl Bologna Maggiore-Bellaria Hospital, Bologna, Italy
| | - S Della Casa
- Endocrinology and Metabolic Diseases Unit, Catholic University of the Sacred Heart, Rome, Italy
| | - L De Nicola
- Nephrology, Medical School, University of Campania Luigi Vanvitelli, Naples, Italy
| | - M Faustini-Fustini
- Pituitary Unit, IRCCS Institute of Neurological Sciences, Bellaria Hospital, Bologna, Italy
| | - E Fiaccadori
- Renal Unit, Parma University Medical School, Parma, Italy
| | - L Gesualdo
- Nephrology Dialysis and Transplantation, Bari University Medical School, Bari, Italy
| | - S Gori
- UOC Oncologia Medica, Ospedale Sacro Cuore Don Calabria, Negrar, Verona, Italy
| | - A Lania
- Endocrine Unit, Department of Biomedical Sciences, Humanitas Research Hospital, Humanitas University, Rozzano (MI), Italy
| | - G Mantovani
- Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - P Menè
- Nephrology, Sapienza University of Rome, Rome, Italy
| | - G Parenti
- Endocrine Unit, Careggi Hospital, Florence, Italy
| | - C Pinto
- Oncologia Medica IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Naples, Italy
| | - P Razzore
- Endocrine Unit, AO Ordine Mauriziano, Turin, Italy
| | - G Regolisti
- Renal Unit, Parma University Medical School, Parma, Italy
| | - C Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padua, Italy
| | - F Trepiccione
- Dipartimento di Scienze Cardio-Toraciche e Respiratorie, Università della Campania "Luigi Vanvitelli", Caserta, Italy
| | - A Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A Peri
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", AOU Careggi, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy.
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47
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Alzarka B, Usala R, Whitehead MT, Ahn SY. Hyponatremia: An Unusual Presentation in a Neonate With Chromosome 1q21.1 Deletion Syndrome. Front Pediatr 2018; 6:273. [PMID: 30364227 PMCID: PMC6193093 DOI: 10.3389/fped.2018.00273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 09/11/2018] [Indexed: 11/13/2022] Open
Abstract
Chromosome 1q21.1 deletion syndrome is associated with a wide variety of clinical features including mild to moderate mental retardation, microcephaly, cardiac abnormalities, and cataracts. We report an unusual case of a premature neonate with persistent hyponatremia, markedly elevated plasma arginine vasopressin level (32.7 pg/mL), and clinical findings consistent with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The patient, who also had microcephaly and dextrocardia, was subsequently diagnosed with chromosome 1q21.1 deletion syndrome. Further evaluation revealed hypothalamic abnormalities, features not previously described with this syndrome. To our knowledge, this is the first report of SIADH associated with congenital hypothalamic anomalies in a neonate with chromosome 1q21.1 deletion syndrome. We also report our experience using tolvaptan, a vasopressin receptor antagonist, in this patient to effectively maintain eunatremia.
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Affiliation(s)
- Bakri Alzarka
- Department of Nephrology, Children's National Health System, Washington, DC, United States.,The George Washington University School of Medicine, Washington, DC, United States
| | - Rachel Usala
- Departments of Medicine and Pediatrics, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Matthew T Whitehead
- The George Washington University School of Medicine, Washington, DC, United States.,Department of Radiology, Children's National Health System, Washington, DC, United States
| | - Sun-Young Ahn
- Department of Nephrology, Children's National Health System, Washington, DC, United States.,The George Washington University School of Medicine, Washington, DC, United States
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48
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Humayun MA, Cranston IC. In-patient Tolvaptan use in SIADH: care audit, therapy observation and outcome analysis. BMC Endocr Disord 2017; 17:69. [PMID: 29110656 PMCID: PMC5674865 DOI: 10.1186/s12902-017-0214-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 10/09/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Indications for use of tolvaptan in SIADH-associated hyponatraemia remain controversial. We audited our local guidelines for Tolvaptan use in this situation to review treatment implications including drug safety, hospital admission episode analysis (episodes of liver toxicity, CNS myelinolysis, sodium-related re-admission rates), morbidity; mortality and underlying aetiologies. METHODS We report a retrospective case series analysis of on-going treatment outcomes (case-note review) for 31 patients (age 73.3 ± 10.5 years, 55% females) consecutively treated with Tolvaptan as in-patient for confirmed SIADH with persistent S/Na+ < 125 mmol/L despite removal of reversible causes and 24-48 h fluid restriction, and include longer-term outcome data (re-treatment/readmissions/mortality) for up to 4 years of follow-up. A minimum of 6 months follow-up data were reviewed unless the patient died before that period. RESULTS Short-term outcomes were favourable; 94%-achieved treatment targets after a mean of 3.48 ± 2.46 days. There was statistically significant rise in S/Na+ level after Tolvaptan treatment (before treatment: mean sodium 117.8 ± 3.73, 108-121 mmol/L and after treatment: mean sodium 128.7 ± 3.67, 125-135.2 mmol/L, P < .001). Although the target S/Na+ level was >125 mmol/L in fact one third (35%) of the patients achieved a S/Na+ level of >130 mmol/L by the time of hospital discharge. No patient experienced S/Na+ rise >12 mmol/L/24 h, drug-associated liver injury or CNS-myelinolysis. The average length of hospital stay following start of Tolvaptan treatment was 3.2 days. Relapse of hyponatraemia occurred in 26% of the patients, requiring retreatment with Tolvaptan. In all patients where either relapse of hyponatraemia occurred or readmission was necessary, SIADH was associated with malignancy, which was present overall in 60% of the group studied. CONCLUSIONS This study confirms the safety and efficacy of Tolvaptan in the treatment of SIADH-related significant, symptomatic hyponatraemia when used under specialist guidance and strict monitoring. A sodium level relapsing below the treatment threshold by 1 week after discontinuation is a good indicator of a patient group with re-treatment/longer-term therapy needs, all of whom had underlying malignancy. The criteria set locally in our trust to initiate Tolvaptan use also identifies a group where further investigation for underlying malignancy should be considered.
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Affiliation(s)
- Malik Asif Humayun
- Department of Endocrinology & Diabetes, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, MK6 5LD, UK.
| | - Iain C Cranston
- Department of Endocrinology & Diabetes, Queen Alexandra Hospital Portsmouth, Portsmouth, PO6 3LY, UK
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49
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Abstract
Hyponatremia is the most common electrolyte disorder in clinical practice and associated with increased morbidity and mortality, independent of underlying disease. Untreated acute hyponatremia can cause substantial morbidity and mortality as a result of osmotically induced cerebral edema whilst over rapid correction of chronic hyponatremia can cause serious neurologic impairment and death resulting from osmotic demyelination. Still hyponatremia is often neglected and insufficiently addressed, most likely due to limited understanding of its pathophysiological mechanisms. Being familiar with only few basic principles of body fluid regulation may be a worthwhile investment into the clinical career and save patients' lives.
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50
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Shoaf SE, Bricmont P, Dandurand A. Low-dose tolvaptan PK/PD: comparison of patients with hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion to healthy adults. Eur J Clin Pharmacol 2017; 73:1399-1408. [PMID: 28803333 PMCID: PMC5662662 DOI: 10.1007/s00228-017-2302-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 07/03/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE Tolvaptan (TLV) is indicated to treat hyponatremia due to syndrome of inappropriate diuretic hormone (SIADH) in Europe. Treatment is to be initiated at 15 mg QD but post-approval reporting indicates increasing use of 7.5 mg as the starting dose. Physicians believe 7.5 mg is effective and has a lower incidence of overly rapid correction of serum sodium. METHODS Single TLV doses of 3.75, 7.5, and 15 mg were administered to 14 healthy adults in a crossover design and to 29 subjects ≥18 years with SIADH and serum sodium between 120 and 133 mmol/L in a parallel-group design. Pharmacodynamics and TLV plasma concentrations were assessed for 24 h post-dose. RESULTS In SIADH subjects, corrections of serum sodium (Δ of ≥8 mmol/L in the first 8 h or ≥12 mmol/L in the first 24 h) were observed in one, one, and two subjects in the 3.75-, 7.5-, and 15-mg dose groups. Fluid balance (FB) for 0-6 h post-dose was correlated (r 2 = 0.37) with maximum increases in serum sodium; subjects with large corrections had large (~1 L) negative FB. Compared to healthy adults, subjects with SIADH did not drink in response to their negative FB and had larger increases in serum sodium at 24 h. Median time of maximum increase in healthy adults was 6 h, with no rapid corrections, and FB was near 0 mL by 24 h. CONCLUSION Starting titration with 7.5 mg TLV will not eliminate the risk of rapid corrections in serum sodium. Monitoring FB may indicate that a subject is at risk for over correction.
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Affiliation(s)
- Susan E Shoaf
- Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, NJ, USA. .,, 2440 Research Blvd, Rockville, MD, 20850, USA.
| | - Patricia Bricmont
- Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, NJ, USA.,, 2440 Research Blvd, Rockville, MD, 20850, USA
| | - Ann Dandurand
- Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, NJ, USA
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