The term cerebral salt wasting (CSW) was introduced before the syndrome of inappropriate Four years later, Schwartz et al. published their landmark paper on SIADH. . Damaraju SC, Rajshekhar V, Chandy MJ: Validation study of a central. Cerebral salt wasting (CSW) is another potential cause of hyponatremia in those with The causes and diagnosis of hyponatremia, causes and treatment of SIADH, and the general Sivakumar V, Rajshekhar V, Chandy MJ. While fluid restriction is the treatment of choice in SIADH, the treatment .. Differential diagnosis of cerebral salt wasting (CSW) vs syndrome of.

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In order to avoid worsening hyponatraemia in this setting the osmolality of the fluid given must exceed the osmolality of the urine.

In this review, we briefly discuss the pathophysiology of SIADH and renal salt wasting RSWand the difficulty in differentiating SIADH from RSW, and review the origin of the perceived rarity of RSW, as well as the value of determining fractional excretion of urate FEurate in differentiating both syndromes, the high prevalence of RSW which highlights the inadequacy of the volume approach to hyponatremia, the importance of changing wasfing salt wasting to RSW, and the proposal to eliminate reset osmostat as a subtype of SIADH, and finally propose a new algorithm to replace the outmoded volume approach by highlighting FEurate.

There was a slight decline in plasma volume, although it was not statistically significant.

SIADH versus Cerebral Salt Wasting

On hospital day 10 the patient cerehral noted to be confused and hypotensive. The determination of UNa has not been useful in the evaluation of patients with hyponatremia.

Once patients are capable of taking oral medications, salt tablets can be utilized. Raven Press, New York: ANP and BNP have also been shown capable of directly decreasing autonomic outflow through effects at the level of the brain stem [ 1718 ]. These peptides are also capable of increasing urinary sodium excretion without causing hypokalaemia.


FEurate in percentage excretion of the filtered load of urate can be determined by dividing the ratio of urine to plasma urate by the ratio of urine to plasma creatinine and multiplying by In SIADH expansion of ECF volume is not typically accompanied by overt signs of hypervolaemia such as oedema or distended neck veins since only one-third of retained water is distributed in the ECF space.

Role of the central nervous system in metabolism of electrolytes and water. Normotensive ischemic acute renal failure. Open in a separate window. Abnormal renal urate transport in patients with intracranial disease.

Another unusual condition in which more modest amounts of fluid intake can lead to hyponatraemia in association with a maximally dilute urine is when solute intake is extremely limited. Psychogenic polydipsia can be readily diagnosed wwasting the history of ingesting large volumes of water, having polyuria and excretion of dilute urines, and beer potomania by the history of ingesting sqlt amounts of beer with low solute intake [ 4243 ].

NaK 20, Cl In addition to decreased neural input to the kidney, release of one or more natriuretic factors may also play a role in the renal salt wasting observed in CSW. Determining Siadn after correcting hyponatremia by judicious use of hypertonic saline might be an effective way of differentiating SIADH from RSW Figure 1being mindful of avoiding too rapid correction of hyponatremia to reduce the risk of ssalt osmotic demyelination, monitor the patient for any evidence of fluid overload such bs induction of heart failure easting that saline has a meager effect on FEurate.

The cerebrla urinary sodium concentration and decreased serum uric acid suggest a volume-expanded state such as SIADH.

Only in recent years has cerebral salt wasting again come into favour as a distinct entity. A water loading test was normal after volume repletion and correction of his hyponatremia, suggesting that like the patient with a hip fracture, there was an appropriate hypovolemia-induced increase in ADH.

Please review our privacy policy. Substances such as uric acid and urea nitrogen, that are reabsorbed in concert with sodium proximally, also tend to be reduced because of diminished proximal reabsorption. Plasma renin concentration was the same in both groups but plasma aldosterone concentrations were suppressed and varied in an opposite direction cdrebral that of BNP in the subarachnoid haemorrhage group.


The administration of pitressin to a normal human subject results in an abrupt increase in urine osmolality U osm. In patients with SIADH, serum urate is not elevated but is actually depressed as these patients are volume expanded, although it is clinically difficult to detect the degree of volume expansion.

Cerebral salt wasting versus SIADH: what difference?

The ability of these compounds to increase xiadh filtration rate accounts for some of the natriuresis, however, even in the absence of a change in GFR urinary sodium excretion increases due to a direct inhibitory effect on sodium transport in the inner medullary collecting duct [ 17 ]. None, Conflict of Interest: While correction of the serum sodium concentration in SIADH leads to a normalization of uric acid diadh by the kidney [ 25 ], hypouricaemia and increased renal uric acid excretion remains a persistent finding following the correction of the serum sodium concentration in CSW [ 21 ].

After several days of pitressin administration, a large increase in urine sodium and chloride excretion was noted. He was treated with librium for his tremulousness, dilantin for seizure prophylaxis, and thiamine, folate and multivitamins. He was lethargic, disoriented to person, place, and time, and had increased tremulousness.

The recommendation to sidh virtually all hyponatremics exposes the aiadh to resolve the diagnostic and therapeutic dilemma of deciding whether to water restrict a patient with the syndrome of inappropriate antidiuretic hormone secretion SIADH or administer salt and water to a renal salt waster.

View large Download slide. Physical findings that support a diagnosis of CSW include orthostatic changes in blood pressure and pulse, dry mucous membranes, and flat neck veins.

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