Fancony syndrome bartter syndrome renal concentrating defect renal structure and function normal nephrogenic. The lowsodium syndrome or, less specifically, the low salt syndrome are terms used synonomously. 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. However, less is known about the significance of hyponatremia in pulmonary hypertension, particularly in the absence of left ventricular dysfunction.
The hyponatremic hypertensive syndrome in renal artery stenosis. Smith neurocritical care society 2012 abstract sustained intracranial hypertension and acute brain herniation are brain codes, signifying. E evaluate a assess t teach addisons down, down down up down cushings up up up down up addisons hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia. Hyponatremia is one of the most common electrolyte. The syndrome is characterized by hypertension and profound natriuresis, leading to body sodium and water depletion. In the preterm or term neonate, volume contraction with hypotonic hyponatremia may occur secondary to excessive renal losses. Hyponatremic hypertensive syndrome hhs is characterized by. Initial treatment with captopril resulted in severe hypotension and hemodynamic instability. An eighteen monthold male presented with drowsiness, sudden onset status epilepticus and blood pressure of 210160. The serum sodium concentration is the primary determinant of serum tonicity also known as effective serum osmolality see diagnostic evaluation of adults with hyponatremia. Serum osmolality is reduced in hypotonic hyponatremia hyponatremia with volume contraction, there is a disproportionally greater loss of sodium than of water.
Hyponatremia is an important and common clinical problem. The body has independent regulatory mechanisms for both these processes. Hyponatremic hypertensive syndrome secondary to renal. Hyponatremic hypertensive syndrome is an important complication of severe arterial hypertension with the potential for significant morbidity and mortality. Nov 15, 2012 hyponatremic hypertensive syndrome hhs is an uncommon disorder, in which hypertension is associated with profound hyponatremia. Association of hyponatremia and outcomes in pulmonary. The rate of change in serum sodium levels must be monitored every 2 to 3 hours, and the infusion adjusted as needed.
Common finding of mild hyponatremia in children evaluated at the emergency department and its correlation with plasma creactive protein values. Reversible encephalopathy, hypertensive crisis, hypertensive emergency, eclampsia, immunosuppressants introduction posterior reversible encephalopathy syndrome pres is a clinicalneuroradiological entity, 1 initially described in 1996 by hinchey and coworkers, as reversible posterior leukoencephalopathy syndrome. Malignant hypertension as a presentation has been reported in adults with hhs but is rare in children. Sodium homeostasis is of importance in the pediatric population. May 08, 2018 hyponatremia occurs when the concentration of sodium in your blood is abnormally low. See overview of the treatment of hyponatremia in adults and diagnostic evaluation of adults with hyponatremia. Hyponatremic hypertensive syndrome in an obese man with. Hyponatremic hypertensive syndrome hhs is characterized by hyponatremia, severe hypertension, polyuria and polydipsia in association with unilateral renal artery stenosis 24. Certain drugs eg, diuretics, antidepressants, and antiepileptics. Learn why it happens, how to spot the symptoms, and how to get the right treatment. Hyponatremia in patients with heart failure uptodate.
Hyponatremic hypertensive syndrome, pediatric nephrology. Over the years, multiple organizations have developed recommendations to assist clinicians in the management of hyponatremia. Renal artery stenosis is one of the secondary causes of pediatric hypertension. After removal of the leiomyosarcoma, plasma concentration of active renin, but not of prorenin, normalized and the. Hyponatremic hypertensive syndrome hhs in an 18month. The high incidence of hyponatremia 30% reported in hypertensive neonates, suggests that hhs is probably more common than we think.
Amiodaroneinduced syndrome of inappropriate antidiuretic. Lab work revealed significant hyponatremia, elevated peripheral renin activity, and. Renovascular hypertension associated with hyponatremia is known as hyponatremichypertensive syndrome hhs. Severe polyuria and polydipsia in hyponatremichypertensive. Hyponatremic hypertensive syndrome hhs in an 18month old. Hypertensive urgencies are associated with severe bp elevation in otherwise stable patients without acute or impending change in target organ damage or dysfunction. Hyponatremic hypertensive syndrome hhs is an uncommon disorder, in which hypertension is associated with profound hyponatremia.
In this case, both sodium and water content increase. Clinical practice guidelines and consensus statements provide recommendations to help evidencebased practice by suggesting the most appropriate diagnostic tests and the most appropriate treatments. Pdf severe polyuria and polydipsia in hyponatremic. Metabolic disturbances in children can present as emergencies. Serotonin syndrome and acute hyponatremia can both overlap in the clinical presentation which was the diag nostic dilemma in our patient. Hypertensive emergencies are severe elevations in bp associated with evidence of new or worsening target organ damage. We report on such a case in which a patient was found to be hyponatremic after evaluation. Resistant hyponatremia and hypokalemia treated successfully with. The cornerstone of management is the treatment of underlying hypertensive disease, but the correction of hyponatremic dehydration and safe decrease of blood pressure are essential in the emergency phase of hyponatremic hypertensive syndrome. By contrast, primary hyperaldosteronism typically induces mild hypernatremia, because of the lowered antidiuretic hormone release related to hypervolemia 3. The syndrome of inappropriate antidiuretic hormone adh secretion siadh is defined by the hyponatremia and hypoosmolality resulting from inappropriate, continued secretion or action of the hormone despite normal or increased plasma volume, which results in impaired water excretion. Both conditions are associated with an increased risk of death. An infrequent cause of hyponatremia browne wl, nair b department of geriatric abstract medicine, john hunter.
Defining hyponatremia abnormally low sodium level electrolyte regulates water in and out of cells normal serum sodium 5145 meql hyponatremia is typically defined as a serum sodium concentration below 5 meql. We report on a 4yearold girl with hyponatremichypertensive syndrome hhs, a rare entity in childhood. Hyponatremia is more common in patients with neurologic dis. 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. Hyponatremia owing to inadequate salt intake, in the absence of diuretic treatment, is an unusual but probably overlooked cause.
Pdf hyponatremichypertensive syndrome associated with. Hiponatremikhipertansif sendrom hyponatremic hypertensive 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. If your blood sodium levels get too low, you might develop a condition called hyponatremia. Unilateral renal artery stenosis presented with hyponatremic. Hyponatremia and hepatorenal syndrome are severe complications in patients with cirrhosis and ascites resulting from circulatory abnormalities splanchnic and systemic vasodilata tion that develop with portal hypertension. Treatment varies with the nature of onset acute or chronic, severity and symptoms. In hyponatremia, one or more factors ranging from an underlying medical condition to drinking too much water cause the sodium in your body to become.
Accelerated hypertension with hyponatremia and hypokalaemia. Hyponatremichypertensive syndrome in an 18monthold male. 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. The optimal antihypertensive therapy depends on the underlying condition. Clinical endocrinologists worldwide rely on endocrine practice, the official journal of the american association of clinical endocrinologists aace, to keep them on the leading edge of treatment of patients with endocrine diseases. Unilateral renal artery stenosis presenting as hypertensive hyponatremic syndrome hhs has been infrequently reported in pediatrics, with only. 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. Hyponatremic hypertensive syndrome with renal ischemia.
Hyponatremic hypertensive syndrome a retrospective. Hyponatremic hypertensive syndrome in an obese man with renal. 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. Overviews of the evaluation and treatment of hyponatremia are presented separately. The lower the sodium and the faster the fall, the more symptomatic a patient will become. Hyponatremia nejm 2000 pdf natremia always denotes hypertonicity, hyponatremia downloaded from. All presented with polyuria and polydipsia, electrolyte disturbances, metabolic alkalosis, variable tubular dysfunction. The hyponatremic hypertensive syndrome hhs was firstly described in pediatric patients. The girl was referred to us from a local hospital with a history of recurrent fever, vomiting, and seizures. Proper interpretation of the various laboratory tests helps to differentiate the various types of hyponatremia.
Elevated plasma levels of renin in most cases suggest that the stimulation of renin release from the ischemic kidney plays an important pathophysiologic role. Internationally respected endocrine practice is the journal for clinical endocrinologists. Hyponatremic hypertensive syndrome is a manifestation of severe hypertension related to renal ischemia. We describe a 4yearold boy who presented with severe hypertension, profound hyponatremia. The hyponatremic hypertensive syndrome and proteinuria promptly responded to treatment with angiotensinconverting enzyme inhibitors, suggesting an angiotensin ii dependency of these disorders. Distinctly, the diagnosis of hyponatremic hypertensive syndrome secondary to. 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. The key to understanding the pathophysiology, signs, symp. Pdf hyponatremic hypertensive syndrome hhs in an 18month. Backgroundhyponatremic hypertensive syndrome hhs is an uncommon. Renovascular hypertension renal artery stenosis hyponatremic hypertensive syndrome abnormal.
This paper presents the case of 73 yearold woman, suffering from arterial hypertension and depression treated with aceinhibitor and fluoxetine, who developed symptomatic hyponatremia due to syndrome of inappropriate diuretic hormone secretion. The hyponatremic hypertensive syndrome hhs was firstly described in. Renovascular hypertension is the most common type of secondary hypertension with a variety of symptoms caused by activation of reninangiotensin system by ischemic kidneys. We aimed to increase awareness of early diagnosis of hhs among polyuric, hypertensive and hyponatremic children in order to prevent renal damage and lifethreatening complications. Many medical illnesses, such as congestive heart failure, liver failure, renal failure, or pneumonia, may be associated with hyponatremia. However, hyponatremia in association with hypertension and hypokalaemia is highly suggestive of secondary hyperaldosteronism due to renal ischemia 2. Rarity of hyponatremic hypertensive syndrome in children may project its underrecognition. Hyponatremia can develop in patients with severe myocardial dysfunction. In fact, overly rapid correction of hyponatremia is the most common cause of that potentially devastating disorder. Constellation of renovascular hypertension with severe polydipsia, hyponatremia and hypokalemia led to the probable diagnosis of hyponatremic hypertensive syndrome hhs. Detailed summary from the 2017 guideline for the prevention. Hyponatremia is known to be an important marker and prognosticator in leftsided heart failure.
Hyponatremic hypertensive syndrome secondary to renal ischemia. The hyponatremic hypertensive syndrome in renal artery. In view of history of angioedema secondary to lisinopril, angiotensin ii receptor blockers or. This is a case of hyponatremic hypertensive syndrome related to renovascular hypertension and occurring as an additional abnormality. It is mostly encountered in adults with unilateral renal artery stenosis. 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. The hyponatremic hypertensive syndrome is a rare but serious complication of renovascular disease. Although renovascular hypertension is one of the commonest causes for severe hypertension in children, hhs is rarely reported in childhood. Hyponatremia may be euvolemic, hypovolemic or hypervolemic. 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 in a preterm infant. Increase in the amount of sodium leads to hypervolemia and water content to hyponatremia.
The combination of hyponatremia and renovascular hypertension is called hyponatremic hypertensive syndrome hhs. This pdf is available for free download from a site hosted by medknow publications. Pdf the hyponatremic hypertensive syndrome in a preterm. Hyponatremia not so fun facts not as asymptomatic as you might think gait instability, falls and fractures for na 124 mmoll renneboog b. The fall in serum tonicity in patients with hypotonic hyponatremia promotes water movement into the brain and, if the hyponatremia is acute and severe, can lead to cerebral edema and neurologic symptoms. Diagnosis and treatment of hyponatremia american journal of.
Symptomatic hyponatremia in nephrotic syndrome jama. The treatment of hyponatremia saint lukes health system. These findings initially evoked primary hyperaldosteronism to the authors, until the plasma reninaldosterone profile proved them wrong. Serotonin syndrome and acute hyponatremia, complex.
Without appropriate treatment, hypertensive encephalopathy. Renovascular hypertension can occur secondary to renal artery stenosis which can sometime present as hyponatremic hypertensive syndrome hhs. Angiotensinconverting enzyme inhibition ameliorates the. Continuation of aii blockade for treatment of htn would have led to loss of gfr mostly on the affected side.
The causes of hyponatremia may vary depending on its type. Hyponatremichypertensive syndrome in an 18monthold. Silver rochester general hospital, rochester, university of rochester school of medicine and dentistry, rochester, new york last year, a visitor from addis ababa, ethiopia, was admitted to our hospital withtuberculousmeningitis,hyponatre. Initial investigations revealed severe hyponatremia serum na 120 mmoll, hypochloremia serum cl 68 mmoll, and mild hypokalemia. Hyponatremic hypertensive syndrome in pediatric patients. Renal artery stenosis precipitates hyponatremic hypertensive. Hyponatremia is a common finding in hospitalized patients with a prevalence ranging from 1530%. In children, 525% of the cases with secondary hypertension are. Pdf the combination of hyponatremia and renovascular hypertension is called hyponatremic hypertensive syndrome hhs. Hyponatremic syndrome jama internal medicine jama network. 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.
Sodium is an electrolyte, and it helps regulate the amount of water thats in and around your cells. Pediatric critical care protocol for the use of hypertonic. Our case also reaffirms the role of the antiphospholipid syndrome in renovascular hypertension as has been described previously. Hyponatremichypertensive syndrome with renal ischemia. Jun 17, 2019 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. Severe polyuria and polydipsia in hyponatremic hypertensive syndrome associated with wilms tumor. The hyponatremichypertensive syndrome in patients with renal ischemia is not. Pdf renovascular hypertension occasionally manifests clinically as electrolyte disorders and albuminuria in addition to elevated blood. Pediatric critical care protocol for the use of hypertonic saline revision 08232010 introduction. Stephen huff josh duckworth alexander papangelou scott d. A case of severe hyponatremia induced by duloxetine and ziprasidone. Hyponatremic hypertensive syndrome hhs is characterized by unilateral renal artery stenosis with secondary hypertension and glomerular and tubular dysfunction due to hyperfiltration and activation of the reninangiotensin system ras.
An elevation of the total creatine kinase and leukocyte count and elevated transaminase. Symptoms are often vague and nonspecific presenting as headache, irritability, lethargy, confusion, agitation or unstable gait leading to a fall. Journal of pediatric and neonatal individualized medicine jpnim. Hypotonic hyponatremia an overview sciencedirect topics.
Syndrome of inappropriate antidiuretic hormone secretion. Hyponatremic hypertensive syndrome hhs is characterized by hypertensive crisis, and hyponatremia secondary to unilateral renal damage with glomerular and tubular dysfunction. Hyponatremic hypertensive syndrome a retrospective cohort study. Lab work revealed hyponatremia, hypokalemia, and elevated. It also reaffirms the notsowellrecognized hyponatremic hypertensive syndrome 1 6 and its similar resolution. Virtually all investigators now agree that selfinduced water intoxication, symp tomatic hospitalacquired hyponatremia, and hyponatremia associated with intracranial pa. 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. Mar 27, 2014 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. A case of severe hyponatremia with neurological sequels. Nejm the syndrome of inappropriate antidiuresis therapeutic relowering of the serum sodium in a patient after excessive correction of hyponatremia. An 88yearold male who presented to the emergency depart ment was found to be hyponatremic secondary to amiodarone. Hyponatremia and the syndrome of inappropriate secretion of. Hyponatremia, the most common electrolyte disorder encountered, is associated with increased morbidity and mortality even in its milder forms.
Hyponatremia in emergency medicine differential diagnoses. In siadh, hyponatremia results from a pure disorder of water handling by the kidney, whereas. 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. It is a rare, but serious complication of unilateral renal stenosis characterized by resistant hypertension and profound natriuresis. Apr 27, 2004 the combination of hyponatremia and renovascular hypertension is called hyponatremic hypertensive syndrome hhs.
54 1197 1196 1472 550 1366 544 1388 104 966 207 530 1330 1401 18 826 802 1483 788 87 1306 1209 935 520 1538 456 401 722 384 1313 1044 744 639 555 1032 218 1447 704 580 527 733 993 758 971 461 1391 952