This study was designed to determine the association of hyponatremia in hypertensive patients on diuretic therapy. The combination of hyponatremia and renovascular hypertension is called hyponatremic hypertensive syndrome hhs. Hyponatremia may be euvolemic, hypovolemic or hypervolemic. Among hypertensive patients with hypokalemia and metabolic alkalosis, cushing syndrome or excess mineralocorticoids from primary or secondary hyperaldosteronism may cause hypokalemia.
Hyponatremia is an important and common clinical problem. However, hyponatremia in association with hypertension and hypokalaemia is highly suggestive of secondary hyperaldosteronism due to renal ischemia 2. Initial investigations revealed severe hyponatremia serum na 120 mmoll, hypochloremia serum cl 68 mmoll, and mild hypokalemia. An eighteen monthold male presented with drowsiness, sudden onset status epilepticus and blood pressure of 210160. The syndrome of inappropriate adh secretion siadh, also recently referred to as the syndrome of inappropriate antidiuresis, is an often underdiagnosed cause of hypotonic hyponatremia, resulting for instance from ectopic release of adh in lung cancer or as a sideeffect of various drugs. This patient, however, had low aldosterone and did not have physical findings consistent with cushing syndrome. The syndrome has been described more often in preterm than in term infants 811 and sometimes showed a lethal course 12. The hyponatremic hypertensive syndrome hhs was firstly described in pediatric patients. Hyponatremic hypertensive syndrome in an obese man with renal. Overviews of the evaluation and treatment of hyponatremia are presented separately. Diuretic induced hyponatremia in hypertensive patients. Hyponatremic hypertensive syndrome a retrospective. A minimum of 20 cirrhotic control subjects and 40 cirrhotic patients with hyponatremia 20 with hyponatremia preceded by precipitating factors and 20 with spontaneously developed hyponatremia were therefore needed. Serum sodium concentration and serum osmolarity normally are maintained under precise control by homeostatic mechanisms involving stimulation of thirst, secretion of antidiuretic hormone adh, and renal handling of filtered sodium.
Retention of water as a primary event can explain why many patients with thiazideinduced hyponatremia behave. The high incidence of hyponatremia 30% reported in hypertensive neonates, suggests that hhs is probably more common than we think. The cornerstone of management is the treatment of underlying hypertensive disease, but the correction of hyponatremic dehydration and safe decrease of blood. Hyponatremic syndrome jama internal medicine jama network.
We aimed to explore the scope, content, and consistency of these documents. Severe hyponatremia as a result of thiazide diuretic. Follow up with your healthcare provider as directed. The combination of hyponatremia and renovascular hypertension is known as hyponatremichypertensive syndrome hhs and so rarely described in children but associated with various kinds of. Hyponatremic hypertensive syndrome hhs in an 18month old.
Unsuppressed adh causes an unrelenting increase in solutefree water being returned by the tubules of the kidney to the venous circulation. Hyponatremic hypertensive syndrome hhs is characterized by hypertensive crisis, and hyponatremia secondary to unilateral renal damage with glomerular and tubular dysfunction. We report an 82yearold patient with this syndrome and describe the results of an audit of the clinical records of. This pdf is available for free download from a site hosted by medknow publications. We hypothesized that pretherapy parameters can predict the rapidity of response to tolvaptan in siadh.
Hyponatremic hypertensive syndrome secondary to renal ischemia. Hyponatremic hypertensive syndrome associated with. It is mostly encountered in adults with unilateral renal artery stenosis. Pdf hyponatremichypertensive syndrome associated with. Hyponatremia and hepatorenal syndrome arpan mohanty, md, and guadalupe garciatsao, md keywords hyponatremia, hepatorenal syndrome, cirrhosis, ascites dr mohanty is a clinical fellow in the section of digestive diseases at yale university school of medicine in new haven, connecticut and is affiliated with the section of digestive diseases at the. This potentially deleterious response is the result of siadh being a disorder in which renal water handling is impaired but renal sodium handling is normal. Hyponatremia and hepatorenal syndrome are severe complications in patients with cirrhosis and ascites resulting from circulatory abnormalities splanchnic and systemic vasodilatation that develop with portal hypertension. Many medical illnesses, such as congestive heart failure, liver failure, renal failure, or pneumonia, may be associated with hyponatremia. The hyponatremic syndrome is a prevalent phenomenon, according to recent reports, perhaps largely owing to the facility with which sodium determinations have been able to be performed by the flame photometer in the last decade. Although the use of reninangiotensin system inhibitors is the treatment of. This is a case of hyponatremichypertensive syndrome related to renovascular hypertension and occurring as an additional abnormality.
Cases with critical unilateral renal artery stenosis manifesting with the hyponatremic hypertensive syndrome are rare and a comprehensive description of this disorder in the pediatric population is lacking in the literature. These symptoms developed progressively during the last weeks, since she has received a fixed combination of amlodipine, valsartan, and hydrochlorothiazide for a poorly controlled hypertension. Symptoms are often vague and nonspecific presenting as headache, irritability, lethargy, confusion, agitation or unstable gait leading to a fall. Hyponatremic hypertensive syndrome in an obese man with. The lower the sodium and the faster the fall, the more symptomatic a patient will become. Although renovascular hypertension is one of the commonest causes for severe hypertension in children, hhs is rarely reported in childhood. Renovascular hypertension associated with hyponatremia is known as hyponatremic hypertensive syndrome hhs. Diagnosis and treatment of hyponatremia american journal. Cerebral salt wasting vs siadh pdf the term cerebral salt wasting csw was introduced before the syndrome of inappropriate four years later, schwartz et. Hyponatremia in patients with neurologic disorders hyponatremia defined as serum sodium level less than 5 meql is known to occur in up to 20% of hospitalized patients14 and is associated with 1. Hyponatremic hypertensive syndrome, pediatric nephrology.
Hyponatremic hypertensive syndrome, a rare condition, consists of severe hypertension associated with renal artery stenosis, hyponatremia, hypokalemia. Hyponatremia in patients with heart failure uptodate. Dilutional hyponatremia in patients with cirrhosis and ascites. Proper interpretation of the various laboratory tests helps to differentiate the various types of hyponatremia.
Hyponatremic hypertensive syndrome in an 87year old woman. The hyponatremic hypertensive syndrome hhs was firstly described in. The girl was referred to us from a local hospital with a history of recurrent fever, vomiting, and seizures. It is mostly encountered in adults with unilateral renal artery. We searched medline, embase, and websites of guideline organizations and professional societies to september 2014 without language restriction for. The hyponatremic hypertensive syndrome in a preterm infant. Treatment varies with the nature of onset acute or chronic, severity and symptoms. Diuretic induced hyponatremia in hypertensive patients aysha almas1, nayla ahmed 2, fareed khawaja and aamir hameed khan1 abstract diuretics are the recommended antihypertensive by several international guidelines. Hyponatremic hypertensive syndrome hhs is characterized by. Hyponatremic hypertensive syndrome secondary to renal. The hyponatremic hypertensive syndrome hhs is a rare but serious complication of. We describe a 4yearold boy who presented with severe hypertension, profound hyponatremia.
Hyponatremia can develop in patients with severe myocardial dysfunction. The hyponatremic hypertensive syndrome is a rare but serious complication of renovascular disease. Hyponatremia, the most common electrolyte disorder encountered, is associated with increased morbidity and mortality even in its milder forms. Though deemed a rare disease we identified within a span of 18 mo, 3 children with hhs presentation characterized by hypertension, hyponatremia, hypokalemia and metabolic alkalosis. Clinically significant hyponatremia is relatively uncommon and is nonspecific in its presentation. The hyponatremic hypertensive syndrome in renal artery. Syndrome of inappropriate antidiuretic hormone secretion siadh is characterized by excessive unsuppressible release of antidiuretic hormone adh either from the posterior pituitary gland, or an abnormal nonpituitary source. Description sodium is an atom, or ion, that carries a single positive charge. Hyponatremichypertensive syndrome in an 18monthold.
Hyponatremia is defined as a serum sodium level of less than 5 meql and is considered severe when the serum level is below 125 meql. Study population during a 6month period, 155 patients were hospitalized. Bone fracture risk with hyponatremia is not only due to fall risk, but also due to an increase in bone fragility as a result of the hyponatremia 9,10. We report on a 4yearold girl with hyponatremichypertensive syndrome hhs, a rare entity in childhood. Hyponatremic hypertensive syndrome is a manifestation of severe hypertension related to renal ischemia.
Renovascular hypertension occasionally manifests clinically as electrolyte disorders and albuminuria in addition to elevated blood pressure. See overview of the treatment of hyponatremia in adults and diagnostic evaluation of adults with hyponatremia. It is recognized by the association of the clinical signs and symptoms of hyponatremia and hypertension. Criteria for diagnosis of the hyponatremichypertensive syndrome caused. Hyponatremia and hypernatremia are common findings in the inpatient and outpatient settings. The hyponatremichypertensive syndrome in patients with renal ischemia is. Rapidity of correction of hyponatremia due to syndrome of. Hiponatremikhipertansif sendrom hyponatremichypertensive syndrome 2 introduction hyponatremic hypertensive syndrome hhs is a condition characterized by severe hypertension, hyponatremia or hypochloremia caused by unilateral renal artery stenosis or occlusion 1. It is a rare, but serious complication of unilateral renal stenosis characterized by resistant hypertension and profound natriuresis. Elevated plasma levels of renin in most cases suggest that the stimulation of renin release from the ischemic kidney plays an important pathophysiologic role. Hyponatremia is one of the major side effects of diuretic treatment in hypertensive patients.
Plasma sodium levels of 125 mm or less are dangerous and can result in seizures and coma. In children, 525% of the cases with secondary hypertension are. Renovascular hypertension is the most common type of secondary hypertension with a variety of symptoms caused by activation of reninangiotensin system by ischemic kidneys. Hyponatremia and the syndrome of inappropriate secretion. Renovascular hypertension can occur secondary to renal artery stenosis which can sometime present as hyponatremic hypertensive syndrome hhs. Hyponatremia in emergency medicine differential diagnoses. Hyponatremia definition the normal concentration of sodium in the blood plasma is 6145 mm. After few days of therapy, the serum sodium concentration was still low between. Hyponatremia is more common in patients with neurologic dis. A 75 years old female was admitted for muscle weakness, confusion, nausea and dizziness. The most common underlying cause of hyponatremic hypertensive syndrome in adults is severe atherosclerotic renovascular disorder while in children the most common cause of. Tolvaptan effectively corrects hyponatremia due to the syndrome of inappropriate secretion of antidiuretic hormone siadh, but undesired overcorrection can occur.
We present here a case of a patient who presented with a constellation of hypertension with severe polydipsia, subnephrotic proteinuria, with resistant hyponatremia and hypokalemia. Hyponatremia definition of hyponatremia by medical. Hyponatremic hypertensive syndrome hhs is an uncommon disorder, in which hypertension is associated with profound hyponatremia. Sodium disorders are associated with an increased risk of morbidity and mortality. Continuation of aii blockade for treatment of htn would have led to loss of gfr mostly on the. In fact, overly rapid correction of hyponatremia is the most common.
Hyponatremia occurs when the amount of sodium salt in your blood is lower than normal. Sodium is an electrolyte mineral that helps your muscles, heart, and digestive system work properly. England health, syndrome is characterized by hypertension and profound natriuresis, leading to body sodium and water depletion. Treatment of ht and hyponatremia as two independent identities without. Hyponatremia must be corrected slowly in order to lessen the chance of the development of osmotic demyelination syndrome or central pontine myelinolysis cpm, a severe neurological disease. The combination of hyponatremia and nor mal plasma osmolality 280 to 300 mosm per kg 280 to 300 mmol per kg of water can be caused by pseudohyponatremia or by the post transurethral prostatic resection syndrome. Malignant hypertension as a presentation has been reported in adults with hhs but is rare in children. Syndrome of inappropriate antidiuretic hormone secretion. Multiple organizations have published guidance documents to assist clinicians in managing hyponatremia. The most common underlying cause of hyponatremic hypertensive syndrome in adults is severe atherosclerotic renovascular disorder while in children the most common cause of hyponatremic hypertensive syndrome is unilateral congenital renal artery stenosis due to some form of arterial dysplasia.
The hyponatremic hypertensive syndrome in renal artery stenosis. The lowsodium syndrome or, less specifically, the low salt syndrome are terms used synonomously. Renal artery stenosis is one of the secondary causes of pediatric hypertension. These findings initially evoked primary hyperaldosteronism to the authors, until the plasma reninaldosterone profile proved them wrong.
Persistent hyponatremia and hypokalemia in the setting of hypertension may be a manifestation of an underlying hyperreninemic state. Hyponatremia in the elderly has been associated with increased falls and fractures. The combination of hyponatremia and renovascular hypertension is known as hyponatremichypertensive syndrome. An infrequent cause of hyponatremia browne wl, nair b department of geriatric abstract medicine, john hunter. Hyponatremic hypertensive syndrome hhs in an 18month. A syndrome of renal sodium loss and hyponatremia probably resulting from inappropriate secretion of antidiuretic hormone. A 49yearold man who had renovascular hypertension also had severe hypokalemia, hyponatremia, polyuria and polydipsia that were treated by an angiotensinconverting enzyme inhibitor and resection of an atrophic kidney with a compromised blood supply.
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