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Nephrogenic diabetes insipidus is a disorder in which a defect in the small tubes (tubules) in the kidneys causes a person to pass a large amount of urine. Hyponatremia is a state of excess water compared with the amount of solute in the extracellular fluid. Another challenge lies in the interpretation of UNa, which frequently is used as a surrogate for extra-arterial blood volume (EABV) status.10 Unfortunately, in the setting of diuretic use, UNa becomes inaccurate. How to Manage Pain in Patients with Renal Insufficiency or End-Stage Renal Disease on Dialysis?
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The Hospitalist, is the winner of two 2015 APEX Awards for Publication Excellence for Health and Medical Writing. A Hyponatremia and Hypernatremia in the ElderlyA  A more recent article on this topic is available. The aging process is frequently accompanied by various maladaptations to stress in different organ systems and physiologic functions. SIADH– Syndrome of Inappropriate Antidiuretic Hormone Hypersecretion is a condition caused due to excessive secretion of the Antidiuretic Hormone (ADH) also known as vasopressin.
The main function of ADH is to control the amount of water reabsorbed by kidneys thus diluting the blood and decreasing the concentration of sodium in the blood. It may be caused due to lowered secretion of thyroid hormone, a condition called hypothyroidism. Therapeutic agents such as Nonsteroidal anti-inflammatory drugs(NSAIDs) inhibit prostaglandin E2, which impedes vasopressin’s action. It may be caused due to post operative effects on patients hospitalized for injuries to the central nervous system. Drugs that majorly cause this condition are : Clorpropamide, Clofibrate, Phenothiazine, Cyclophosphamide, Carbamazepine,  Selective Serotonin reuptake inhibitors (SSRI’s), Methylenedioxymethamphetamine(MDMA). It is used to treat low blood sodium levels associated with SIADH as well as congestive heart failure and cirrhosis. If timely treatment not taken it can lead to two more conditions known as Hypokalaemia and Hypomagnesemia. The pituitary is a small gland located at the base of the brain, roughly in the space between your eyes.It is responsible for the regulation and secretion of a number of different hormones both in adults and in children. Read What Your Physician is Reading on Medscape Hypopituitarism »Hypopituitarism is a partial or complete insufficiency of pituitary hormone secretion, which may derive from pituitary or hypothalamic disease.
The original diagnostic criteria for SIADH, with minor modifications, are presented in Table 2, page 18).6,7,8 However, applying these criteria in clinical settings presents several difficulties, most notably a determination of ECV.
Our lab does not do any urine testing beyond a UA in house so the urine osmol and urine Na+ tests would be send outs which take several days to come back. The Hospitalist reaches more than 25,000 hospitalists, physician assistants, nurse practitioners, residents, and medical administrators interested in the practice and business of hospital medicine.
Because age-related changes and chronic diseases are often associated with impairment of water metabolism in elderly patients, it is absolutely essential for clinicians to be aware of the pathophysiology of hyponatremia and hypernatremia in the elderly. The complex mechanisms associated with water metabolism are particularly vulnerable to age-related maladaptations and to the various disease processes and medical interventions that frequently occur in the elderly.Hyponatremia and hypernatremia are common in the elderly, particularly among those who are hospitalized or living in long-term care facilities. Sodium is the dominant cation in extracellular fluid and the primary determinant of serum osmolality. Hypernatremia may be broadly viewed in four major etiologic categories, as follows13:Primary Hypodipsia. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. PolzinRenal failure (kidney failure) occurs when kidney function has deteriorated to such a degree that the kidneys can no longer perform their normal functions of excreting wastes, maintaining water and electrolyte balance, and producing hormones. This hormone is secreted by supraoptic and paraventricular nuclei in the hypothalamus and finally secreted via the posterior pituitary gland. When administered into patients alongwith regular diuretics it increases the excretion of excess fluids and improve blood sodium levels in patients with heart failure without giving rise to side effects like hypotension. ADH normally tells the kidneys to make the urine more concentrated. As a result of the defect, the kidneys release an excessive amount of water into the urine, producing a large quantity of very dilute urine.
The sensation of thirst, renal function, concentrating abilities and hormonal modulators of salt and water balance are often impaired in the elderly, which makes such patients highly susceptible to morbid and iatrogenic events involving salt and water. Hyponatremia is defined as a serum sodium concentration of less than 137 mEq per L (137 mmol per L). If a change in the total-body water concentration occurs without an accompanying change in total-body solute, osmolality changes along with the serum sodium concentration. The elderly patient has a diminished reserve of water balance and an impaired regulatory mechanism. It is caused by extreme hyperlipidemia or hyperproteinemia13,14 and now rarely occurs as a result of improved laboratory techniques for measuring serum sodium.
Primarily a defect of thirst, hypodipsia is usually associated with destruction of the hypothalamic thirst center secondary to primary or metastatic tumors, granulomatous disease, vascular disease or trauma.Diabetes Insipidus. The more impaired the patient, the greater the likelihood that water homeostasis will be overcome by medical events. Determination of body composition by multiisotope method and the elimination kinetics of these isotopes in healthy elderly subjects. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.
The main function of the ADH is to regulate the water reabsorption and as a result influences urine concentration. Another hormone called Secretin which is also secreted from the posterior pituitary gland is a neurosecretory hormone that shows abnormal functions during this condition. Hypopituitarism can occur at any age.Picture of the Pituitary GlandThe pituitary gland sends signals to other glands to produce hormones (for example, it makes thyroid stimulating hormone (TSH - which regulates production of thyroid hormone by the thyroid gland).

I find it complicated and when the urine tests are not readily available its difficult to use the algorithm. Clinicians should use a systematic approach in evaluating water and sodium problems, utilizing a comprehensive history and physical examination, and a few directed laboratory tests to make the clinical diagnosis. Simply put, hypernatremia and hyponatremia are primary disturbances of free water and reflect pathologic alterations in water homeostasis.At steady state, water intake and water losses are matched. Diabetes insipidus is primarily a defect in the secretion or action of ADH, which may be hypothalamic (central) or nephrogenic (Tables 4 and 5). As a consequence, hyponatremia is caused that in turn leads to fluctuation in the sodium concentration in the blood.
Once this dilution which is also known as plasma osmolality is detected by osmoreceptors in the hypothalamus, ADH secretion is signaled to stop. This condition is referred to by the names of reporters of this diseases namely,  Schwats and Bartter and is occasionally known as Schwats-Bartter syndrome. The hormones released by the pituitary and other glands have a significant impact on important bodily functions, such as growth, reproduction, blood pressure, and metabolism (the physical and chemical processes of the body). Congenital diabetes insipidus is present at birth as a result of an inherited defect that usually affects men, although women can pass the gene on to their children. Most commonly, nephrogenic diabetes insipidus develops because of other reasons. Furthermore, clinicians should have a clear appreciation of the roles that iatrogenic interventions and lapses in nutrition and nursing care frequently play in upsetting the homeostatic balance in elderly patients, particularly those who are in long-term institutional and inpatient settings. Hypotonic hyponatremia can be divided into two categories based on the extracellular fluid volume: hypovolemic and euvolemic hypotonic hyponatremia. It is essential for physicians to work with other members of the health care team, including nursing staff, dietary staff and family members, to prevent or at least minimize the degree of disruption to water balance in susceptible patients. In contrast, chronic renal failure has been present for months to years at the time of diagnosis and is irreversible.
The inhibition of ADH reduces reabsorption of water by kidneys thereby increasing the urine output. If our hospital does not have the right urine tests readily available should I be sending these pts to the larger hospital from the ER if sodium is <125 instead of admitting them? Thirst is stimulated when the serum osmolality rises above 290 to 295 mOsm per kg (290 to 295 mmol per kg).
Hypovolemic hyponatremia is caused by true volume depletion or by volume depletion of the effective arterial volume.Euvolemic hyponatremia is usually the result of an increase in free water with little change in body sodium. Dogs and cats with chronic renal failure cannot be cured, but their clinical signs can often be managed successfully.Kidneys are composed of many small functional units called nephrons (approximately 190,000 in cats and approxi-mately 400,000 in dogs).
In SIADH (Dilutional Hyponatremia) when the blood water concentration increases ADH secretion is not stopped as a result the sodium in the blood dissolves and sodium concentration is considerably decreased.
ACTH triggers these adrenal glands to release hormones, including adrenaline (epinephrine) and cortisol, which regulate many aspects of metabolism, immune function, and blood pressure.Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are hormones that control sexual development and function in males and females. Dogs, cats, and humans are nor-mally born with such an abundance of nephrons that signs of kidney failure do not become apparent until more than two thirds of the nephrons have been damaged. You will produce large amounts of urine, usually more than 3 - 15 liters per day. If you do not drink enough fluids, dehydration can result. Renal water conservation is the first-line defense against water depletion, but this mechanism is insufficient in settings of significant dehydration and hypertonicity.
Causes of euvolemic hyponatremia include certain drugs (such as hydrochlorothiazides), glucocorticoid deficiency, hypothyroidism, the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and reset osmostat syndrome.13SIADH is characterized by the continued release of ADH in the face of dilution of body fluids and increased extracellular volume.
Because of this redundant kidney tissue, it is possible to donate a kidney for transplantation and survive.
On the other hand, surplus nephrons make it difficult to detect chronic kidney diseases until they are well advanced.
The lack of hormone results in a loss of function of the gland or organ that it controls.The most common pituitary hormone deficiency is growth hormone deficiency.
In conditions of volume depletion or hypertonicity, secretion of antidiuretic hormone (ADH) is stimulated, water is reabsorbed, and a concentrated urine is excreted.
As a consequence, chronic kidney failure is often an insidious condition that remains unrecognized until it is severe.
In the United States, growth hormone deficiency occurs rarely with a frequency of less than 1 in 3,480 children.
The amount of fluids given should be about equal to the amount of urine produced. If the condition is due to a certain medication, stopping the medicine may improve symptoms. Because kidney disease is often quite advanced at the time of initial diagnosis, the initiating cause of chronic renal failure can rarely be estab-lished.
Never stop taking any medication without first talking to your doctor. A medicine called hydrochlorothiazide may improve symptoms.
Although chronic renal failure occurs most often in older dogs and cats, renal failure is not simply a result of aging.The earliest signs of renal failure are typically thirst (poly-dipsia) and increased urine volume (polyuria). Other common early signs include weight loss, poor haircoat, and an increasingly selective appetite. It is the consequence of accidental or intentional ingestion of hypertonic solutions, such as hypertonic saline or bicarbonate-containing solutions.Inadequate Fluid Intake in the Setting of Increased Free-Water Loss. Further decline in kidney function results in progressive inability to excrete waste products, leading to retention of toxic wastes in blood and tissues in the body. Hypernatremia in the elderly is most commonly due to the combination of inadequate fluid intake and increased fluid losses. Age-related impairment in the thirst mechanism and barriers to accessible fluids are often contributing factors. Other important effects of renal failure include anemia (caused by inability of failing kidneys to produce erythropoietin, the hormone responsible for making red blood cells) and high blood pressure. Pure water loss is frequently associated with fever, hyperventilation or diabetes insipidus.
Anemia worsens the weakness, lethargy, and loss of appetite of dogs and cats with chronic renal failure, and high blood pressure may cause sudden blindness, strokelike signs (such as mental dullness, sudden behavioral changes, coma, or seizures), or injury to the kidneys and heart.Diagnosis of chronic renal failure is confirmed by laboratory evaluation of your pet's blood and urine.

Symptoms often do not occur until the serum sodium concentration drops below 125 mEq per L (125 mmol per L). More commonly, hypotonic loss is seen related to gastrointestinal sources, burns, diuretic therapy or osmotic diuresis.
A urine test can help determine whether the kidneys can form concen-trated urine and provide evidence of other urinary tract problems such as urinary tract infections. The most common manifestations of hyponatremia are neurologic, the result of swelling of brain cells secondary to intracellular movement of water.
Recognition of free-water loss in elderly patients is frequently delayed, and the frail elderly patient can quickly slip into a clinically significant hypernatremic state.EVALUATIONThe clinical manifestations of hypernatremia are nonspecific and often subtle in the elderly. Blood tests used to evaluate kidney function include blood urea nitrogen (BUN) and serum creatinine concentrations. Patients with severe hyponatremia may present with nausea, headache, lethargy, confusion, coma or respiratory arrest. They are primarily central nervous system (CNS) manifestations, such as irritability, restlessness, lethargy, muscular twitching, spasticity and hyperreflexia, all of which are secondary to decreased water content in the brain cells.13 Water exits the intra-cellular compartment, and cells shrink. Because the kidneys excrete urea and creatinine, increases in urine and creatinine concentrations in blood indicate decreased kidney function.
If hyponatremia develops rapidly, muscular twitches, irritability and convulsions can occur. In the brain, this action can lead to traction on vessels, which may result in hemorrhage.The first step in the clinical assessment of the patient with hypernatremia is a detailed analysis of the clinical circumstance.
This includes a careful review of the patient's weight, intake and output, and a critical analysis of fluid nutrition and nursing care. The serum creatinine concen-tration is the more specific test for kidney function, and treatment and other factors may influence the BUN.
If the urine osmolality is less than 100 mOsm per kg (100 mmol per kg), evaluation for psychogenic polydipsia should be conducted. The urgency of the clinical state should be evaluated by carefully assessing the volume status and by performing a neurologic examination.
In addition to evaluating kidney function, other tests may be used to evaluate your pet for anemia, electrolyte and acid- base abnormalities, nutrition, and hypertension. Such an analysis provides the answer in most hospitalized patients who acquire hypernatremia during their hospital stay. Ultrasound examination and x-rays may also be used to evaluate kid-ney disease.Fortunately, most dogs and cats can be treated, providing a good quality of life for months or years. Evidence of renal failure (elevated blood urea nitrogen [BUN] and creatinine levels) points to primary renal disease as the likely cause of hyponatremia. If BUN and creatinine levels are normal, assessment of the extracellular fluid volume should be conducted. Consumption of excess protein may make some pets ill because the waste products of protein metabolism are excreted by the kidneys and are retained in renal failure. The urine sodium determination should be used as a guide in noneuvolemic states to determine whether further evaluation for renal failure or pathophysiologic renal sodium loss is required.
Finally, a urine osmolality that is quite low (less than 150 mOsm per kg [150 mmol per kg]) is diagnostic of diabetes insipidus in the setting of hypernatremia and polyuria. Dehydration (abnormal depletion of body fluids) is a special threat to pets with renal failure, and they may deteriorate if episodes of vomiting, diarrhea, or inadequate water intake are not dealt with promptly.
Water should never be withheld from dogs and cats with renal failure.In humans, renal failure is most often managed by dialysis (hemodialysis or peritoneal dialysis) or renal transplantation.
Chronic hemodialysis and peritoneal dialysis have thus far not proved to be satisfactory options for dogs and cats with chronic renal failure because they are expensive and fail to provide an acceptable quality of life. Renal transplantation is an expensive but potentially useful option for selected cats but has not met with similar success in dogs.
Urine Therapy Introduction - information from HPS Online on the medicinal use of one's own urine. Urine Homepage  - general information, world conference data, books on urine therapy, and consultation services. A general guideline is to correct 50 percent of the calculated water deficit in the first 12 to 24 hours, with the remainder corrected over the next one to two days.2 Initially, ongoing water losses should be identified and quantified, and continuing water losses should be replaced continually. Volume depletion should be corrected before initiating replacement therapy to correct the deficit. If the hypernatremia is secondary to solute excess, a diuretic along with water replacement may be needed.
In some circumstances of volume overload, dialysis may be indicated.A standing prescription for free-water intake that matches losses should be written in the medical record of patients with primary hypodipsia. A too-rapid increase in the serum sodium concentration, with the rapid transfer of free water out of the brain cells, can cause diffuse cerebral demyelination, specifically in the pons (central pontine myelinolysis).
Nephrogenic diabetes insipidus is often treated with a low-salt diet and thiazide diuretics. Hyponatremia in a euvolemic patient can be managed with fluid restriction and discontinuation of any medications that affect free-water excretion, along with initiation of treatment of the underlying cause. Fluid restriction must be less than free-water losses, and total fluid intake should typically be less than 500 to 800 mL per day in the elderly patient with euvolemic hyponatremia.2If hyponatremia is secondary to a low extra-cellular volume (volume contraction), the fluid deficit should be corrected by administration of normal saline solution. For example, hyponatremia related to heart failure should resolve if treatment to decrease the afterload, increase the preload or increase the contractility of the heart corrects the clinical situation.SIADH is treated with free-water restriction until the underlying cause of the disorder is corrected.
Administration of normal saline is not an appropriate therapy because the sodium may be rapidly excreted while the water is retained, exacerbating hyponatremia.13 An adjunct to free-water restriction, in some circumstances, is the addition of therapy with demeclocycline (Declomycin) in a dosage of 600 to 1,200 mg per day.

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