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malnutrition During pregnancy, the physiologic reset osmostat may suppress osmolality by about 10 mmol/kg of water The third pattern leakage of ADH refers to when low levels of ADH are leaked into the circulation despite hypo-osmolality in conditions such as basilar skull fractures If serum osmolality rises to normal, ADH secretion increases appropriately and then continues to respond normally if osmolality further increases 2 Hyponatremia after a surgery or procedure Severe postoperative hyponatremia can develop in 2 days or less after elective surgery in healthy patients, especially premenopausal women Most have received excessive postoperative hypotonic fluid in the setting of elevated ADH levels related to pain of surgery with continuing excretion of hypertonic urine Patients awake normally from general anesthesia, but within 2 days nausea, headache, seizures, and even respiratory arrest develop Similar mechanisms have been suspected for hyponatremia after colonoscopy This is not a direct effect of the large volume of liquid-cleansing agents such as polyethylene glycol solution but is due to the diarrhea, nausea, vomiting, and potential volume depletion sometimes produced by these agents Increased oral water intake or hypotonic fluid administration after colonoscopy (in the presence of elevated ADH) may then result in hyponatremia; occasionally, if thirst is impaired, hypernatremia results 3 Hypothyroidism Hyponatremia is not commonly caused by hypothyroidism, but it can occur on occasion with serum sodium levels as low as 110 mEq/L Water retention is the cause, probably both from inappropriately elevated ADH levels and from alterations in the handling of water by the kidneys 4 Psychogenic polydipsia and beer potomania Marked excess free water intake (generally > 10 L/d) may produce hyponatremia Euvolemia is maintained through the renal excretion of sodium Urine sodium is therefore generally elevated (> 20 mEq/L), but unlike SIADH, levels of ADH are suppressed Urine osmolality is appropriately low (< 300 mosm/kg) as the increased free water is excreted Hyponatremia from bursts of ADH occurs in manic-depressive patients with excess free water intake Psychogenic polydipsia is observed in patients with psychological problems, and these patients frequently take drugs interfering with water excretion Similarly, excessive intake of beer, which contains very small amounts of sodium (< 5 mEq/L), can cause severe hyponatremia in cirrhotic patients, who have elevated ADH and often a decreased GFR 5 Idiosyncratic diuretic reaction In addition to hyponatremia developing from volume contraction due to diuretic therapy (see above), a less common diureticinduced hyponatremia can occur in euvolemic patients, typically from thiazides This syndrome is most often seen in healthy older women (over 70 years of age) often after a few days of therapy The mechanism for the hyponatremia appears to be a combination of excessive renal sodium loss and water retention
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Table 21 3 Causes of syndrome of inappropriate secretion of ADH (SIADH)
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Central nervous system disorders Head trauma Stroke Subarachnoid hemorrhage Hydrocephalus Brain tumor Encephalitis Guillain-Barr syndrome Meningitis Acute psychosis Acute intermittent porphyria Pulmonary lesions Tuberculosis Bacterial pneumonia Aspergillosis Bronchiectasis Neoplasms Positive pressure ventilation Malignancies Bronchogenic carcinoma Pancreatic carcinoma Prostatic carcinoma Renal cell carcinoma Adenocarcinoma of colon Thymoma Osteosarcoma Malignant lymphoma Leukemia Drugs Increased ADH production Antidepressants: tricyclics, monoamine oxidase inhibitors, SSRIs Antineoplastics: cyclophosphamide, vincristine Carbamazepine Methylenedioxymethylamphetamine (MDMA; Ecstasy) Clofibrate Neuroleptics: thiothixene, thioridazine, fluphenazine, haloperidol, trifluoperazine Potentiated ADH action Carbamazepine Chlorpropamide, tolbutamide Cyclophosphamide NSAIDs Somatostatin and analogs Amiodarone Others Postoperative Pain Stress AIDS Pregnancy (physiologic) Hypokalemia ADH, antidiuretic hormone; SSRIs, selective serotonin reuptake inhibitors; NSAIDs, nonsteroidal anti-inflammatory drugs
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nervous system diseases Reset osmostat is characterized by ADH secretion appropriately suppressed at very low serum osmolalities but with ADH osmoregulation downset to a lower level of normal Therefore, ADH is secreted at a subnormal serum osmolality threshold (< 280 mosm/ kg) Appropriate urinary dilution can be attained but at low serum osmolalities This pattern is seen in the elderly, and in patients with pulmonary processes, tuberculosis, or
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