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Tumor-Related Hyponatremia
Adedayo A. Onitilo, MD, MSCR, FACP; Ebenezer Kio, MD; and Suhail A. R. Doi, MBBS, FRCP, PhD
Hyponatremia is an important and common electrolyte disorder in tumor patients and one that
has been reported in association with a number of different primary diagnoses. The correct
diagnosis of the pathophysiological basis for each patient is important because it significantly
alters the treatment approach. In this article, we review the epidemiology and presentation of
patients with hyponatremia, the pathophysiologic groups for the disorder with respect to
sodium and water balance and the diagnostic measures for determining the correct
pathophysiologic groups. We then present the various treatment options based on the
pathophysiologic groups including a mathematical approach to the use of hypertonic saline in
management. In cancer patients, hyponatremia is a serious co-morbidity that requires particular
attention as its treatment varies by pathophysiologic groups, and its consequences can have a
deleterious effect on the patient’s health.
Keywords: Antidiuretic hormone; Arginine vasopressin; Cancer; Hypertonic saline; Hyponatremia;
Malignancy; SIADH; Sodium
228
posterior pituitary and then released from the pituitary in though they may have a clinically apparent excess of
response to increased serum osmolarity sensed by extracellular fluid volume (i.e., edema or ascites). This occurs
osmoreceptors in the paraventricular nucleus. AVP release because, in an attempt to restore the perfusion pressure to the
can also be triggered by a decrease in circulating volume tissues of the body, these baroreceptors signal the posterior
(arterial pressure) mediated via baroreceptors. The latter pituitary to release antidiuretic hormone (ADH) resulting in
mechanism plays a lesser role in AVP release, as a relatively free water reabsorption and hyponatremia, even if the plasma
higher degree of hypovolemia is required to simulate AVP is already dilute. The volume of extracellular fluid needed to
release. AVP induces aquaphores in the cells of the distal maintain such perfusion pressure and avoid stimulation of
collecting duct, allowing movement of water into the ADH release has been called the effective circulating blood
hypertonic medullary interstitium. In this way, volume. It may be noted here that although there also is
hyperosmolality is prevented by dilution of sodium ions. A usually a positive sodium balance, its incremental effect is
malfunction in any of these mechanisms may result in less than the depressive effect of the positive water balance on
hyponatremia and, if severe enough, associated symptoms. the serum sodium concentration.8
Disturbed Sodium Balance The same thing happens when sodium loss directly leads to
In some diseases, both sodium and water homeostasis go hypovolemia and decreases in the true circulating blood
awry, leading the kidney to reabsorb water even though the volume. This lowers the osmotic threshold at which ADH is
patient also appears fluid-overloaded or depleted. In both secreted.9 Thus, ADH secretion will persist even if plasma
situations, as a result of water retention, the plasma osmolality is <275 mOsm/kg H2O. This is sometimes seen in
osmolality decreases and hyponatremia ensues. In patients with gastrointestinal solute loss (e.g., from diarrhea
hypervolemic patients, such as with heart failure or hepatic or emesis), third-spacing (e.g., from ileus or pancreatitis),
cirrhosis, retention of sodium and water may continue even diuretic use and salt-wasting renal disorders. Again, water
IIb Renal solute loss Adrenocortical insufficiency Volume depleted with decreased
Excess ANP or BNP extracellular fluid volume due to
Ectopic ANP disturbed renal handling of Na.
Cerebral salt wasting
Renal salt wasting
Anticancer drugs
Cisplatin
Carboplatin
ADH, antidiuretic hormone; ANP, atrial natriuretic peptide; BNP, brain natriuretic peptide; SIADH, syndrome of inappropriate secretion of antidiuretic hormone.
If there is inadvertent over-correction of hyponatremia, (((50 * 0.6) – 0.8) * 500) / (120 * 0.8) = 152 cc/h
osmotic demyelination can be avoided by rapid re-induction
of the hyponatremia via administration of hypotonic fluids Obviously he would have to have volume restriction and his
(via oral and intravenous routes) combined with DDAVP. This normal dose of DDAVP withheld until the sodium returns to
will induce a prompt decline in the serum sodium normal. This infusion should be followed by close monitoring
concentration with an acceptable final gradient of correction. of serum sodium every 2 hours to ensure that the predicted
This maneuver is reported to be well-tolerated without rate of correction ensues. Although the main use of 3% saline
untoward effects60 and can potentially avoid the adverse is in syndromes of excess ADH, as in this patient, it may also
outcome reported for inadvertent overcorrection.61 be used in acute hyponatremia precipitated by use of
hypotonic solutions in patients with true circulating volume
USE OF SALINE INFUSIONS IN SEVERE depletion,35 but it must be closely monitored as repletion of
HYPONATREMIA the circulating volume may lead to free water diuresis from
In severe cases with encephalopathy, 3% hypertonic saline can removal of the non-osmotic stimulus to ADH secretion and a
also be used to increase free water excretion by the kidneys. It dangerous jump in serum sodium levels.
has been suggested that the appropriate infusion rate for
hypertonic saline in euvolemic hyponatremia be based on a Hyponatremia with Disturbed Sodium Balance (IIb)
calculated sodium deficit being infused (mmol/hour) and TRUE CIRCULATING VOLUME DEPLETION
calculated by the total body water multiplied by the desired In states of true volume depletion, administered sodium and
correction rate (mmol/L/hour).59,62 Thus if 3% saline were water will initially be retained. In this setting, isotonic saline
used, this would then require a volume/hour equal to about corrects the hyponatremia and thus asymptomatic
twice the calculated sodium infusion rate to achieve this as it hyponatremia due to cerebral salt wasting or extracellular
contains 513 mmol Na/L. This nevertheless is counterintuitive fluid volume depletion should be treated with infusion of
because euvolemic hyponatremia is a state of water excess and saline. Recognition and withdrawal of inciting agents is an
the principal determinant of plasma sodium concentration is important accompaniment. In the case of cisplatin-induced
total body water. Patients do not have a problem with sodium renal salt wasting, it may take several weeks for recovery of
handling and if 1 liter of infusate were given, assuming the renal function.
patient is sodium replete, all the sodium will be excreted in a
volume that is dependent on urine osmolality. We therefore Management of cerebral salt wasting includes treatment of
suggest a different equation for the infusion rate that will raise the underlying cerebral disorder, volume resuscitation and
the serum sodium concentration by 0.5 mmol/L/hour as sodium replacement.64 Generally, volume and sodium
follows (derivation is provided in Appendix 1): repletion is accomplished with intravenous isotonic saline
Author Affiliation where 1 represents the volume of the infusate, and iOsm and
Adedayo A. Onitilo, MD, MSCR, FACP uOsm are infusate and urine osmolality, respectively. It
Department of Hematology/Oncology should be noted here that in the initial derivation by Doi63 the
Marshfield Clinic Weston Center subtraction of 1 liter (infusate) was inadvertently omitted.
3501 Cranberry Boulevard This then reduces to two practical and corrected equations for
Weston, Wisconsin clinical use: