SIADH

Inappropriate secretion of ADH

Water excretion is impaired
Suppression of ADH is impaired
Functions of ADH
Increases permeability of water in the cells of the distal
tubules by upregulating Aquaporin-2 channels (V2
receptors)
Increases the permeability of collecting ducts to urea
Increases SVR via IP3/Ca++ 2nd messengers on endothelium
CNS effects like memory formation and circadian rhythm
SIADH - causes
Intracranial infection, stroke, hemorrhage, tumor, very common in
SAH population (69%)
Intrathoracic malignancy, abscess, PNA, effusion, PTX, chest wall
deformity
Drugs vasopressin, DDAVP, oxytocin, analgesics, antidepressants,
amiodarone, antipsychotics, sulfonylureas, carbamazepine,
cyclophosphamide
Extracranial tumors small-cell lung CA, pancreatic CA
HIV/AIDS
Hereditary gain-of-function V2 receptor mutation
Miscellaneous Guillan-Barre, nausea, stress, pain, acute psychosis
Major surgery ****
Idiopathic
SIADH
Hypothalamus receives
feedback from:

Osmoreceptors
Aortic arch baroreceptors
Carotid baroreceptors
Atrial stretch receptors

Any increase in osmolality or

decrease in blood volume will
stimulate ADH secretion from
posterior pituitary.
SIADH - pathophysiology
ADH-induced water retention
Dilutional hyponatremia
Volume expansion -> secondary natriuresis
Sodium and water loss
Potassium loss
Result: Euvolemic hyponatremia
Reduced serum osmolality
Increased urine osmolality
Increased urine sodium
SIADH - diagnosis
Laboratory Findings
Na < 135 mEq/L
Posm < 270 mOsm/kg
Uosm > 300 mOsm/kg
UNa > 25 mEq/L
Low BUN
Normal Cr
Low uric acid
Low albumin
SIADH - treatment
Treat the underlying cause, if known
Fluid Restriction commonly 800-1000mL/d
Correct Na+ deficit no more than 10mEq/L in 24 hours,
18mEq/L in 48 hours
0.9% NaCl
3% NaCl
NaCl enteral tablets 2-3g TID
Add a loop diuretic
SIADH treatment
Vasopressin receptor antagonists
Promote aquaresis
Tolvaptan, conivaptan
Vaprisol (Conivaptan)
Indicated in euvolemic or hypervolemic hyponatremia

Contraindicated in hypovolemic hyponatremia

V1a and V2 receptors

Causes aquaresis or excretion of free water

Demeclocycline or Lithium (diminished collecting

tubule response to ADH)
Cerebral Salt Wasting
Hyponatremia caused by impaired renal tubular function
-> inability of kidneys to conserve salt
Salt wasting leads to volume depletion
Two theories:
Impaired sympathetic neural input -> failure of aldosterone
release -> no sodium resorption
BNP release decreases sodium resorption, inhibits
renin/aldosterone release, decreases autonomic outflow at
level of brainstem
Cerebral Salt Wasting
Commonly occurs in subarachnoid hemorrhage
population (7%)
Carcinomatous, infectious meningitis
Encephalitis
Poliomyelitis
CNS tumors
CNS surgery usually within the first 10 days
Cerebral Salt Wasting
Diagnosis:
Evidence of volume depletion
Increased urine output
Laboratory Findings
Na < 135 mEq/L
Low Posm
Uosm > 300 mOsm/kg
UNa > 40 mEq/L
High BUN
Increased Cr
Low uric acid
Increased albumin
Cerebral Salt Wasting
Treat with volume repletion
0.9% NaCl
3% NaCl is sometimes warranted
Fludrocortisone
Diabetes Insipidus
The most common cause of hypernatremia in
neurological population
Deficient ADH
Central DI occurs with hypothalamic-pituitary axis
dysfunction or injury
Nephrogenic DI diminished renal sensitivity to ADH
Usually considered a euvolemic to hypovolemic state,
depending on the patients thirst mechanism
Diabetes Insipidus
Diabetes Insipidus
Typical Clinical picture:
Polyuria
Polydipsia Laboratory Findings
Nocturia Na >145 mEq/L
Posm > 285 mOsm/kg
Uosm < 300 mOsm/kg
UNa low
Urine Spec. Grav. < 1.005
UOP > 3ml/kg/h
Diabetes Insipidus
Goal is to restore plasma volume and serum Na+ levels
Patient with intact thirst mechanism
Pitcher at bedside. Drink to thirst only!
Severe forms
Replace UOP 1:1 with 1/2NS
DDAVP 5u SQ Q4-6h, commonly given orally/nasally

DDAVP will be ineffective if nephrogenic (HCTZ can be used)

Review
SIADH CSW DI
Serum Na+ < 135 mEq/L < 135 mEq/L > 145 mEq/L
Urine Na+ > 25 mEq/L > 40 mEq/L < 25 mEq/L
Serum Osm < 270 mOsm/kg < 270 mOsm/kg > 285 mOsm/kg
Urine Osm > 300 mOsm/kg > 300 mOsm/kg < 300 mOsm/kg
Urine O/P oliguria polyuria polyuria
CVP normal/high low normal/low
Plasma ADH high normal low
Rx Fluid restrict, give Give volume, give Drink to thirst,
Na+, vaprisol, Na+, DDAVP (central),
demeclocycline fludrocortisone HCTZ (nephrogenic)