Hyponatremia due to hypothyroidism: a pure renal mechanism

doi:10.1016/S0300-2977(01)00081-X

The Netherlands Journal of Medicine

Volume 58, Issue 3, March 2001, Pages 143-149

The Netherlands Jour...

https://doi.org/10.1016/S0300-2977(01)00081-X Get rights and content

Abstract

Hyponatremia is a common disorder. When hyponatremia is the result of hypothyroidism it can be successfully treated with thyroid hormone substitution. We followed cumulative sodium- and fluid balances of a patient with hyponatremia, resulting from hypothyroidism. We concluded that hyponatremia in hypothyroidism is due to a pure renal mechanism, and cannot be ascribed to inappropriate secretion of antidiuretic hormone.

Introduction

Hyponatremia is an important clinical problem. The prevalence of hyponatremia (Na<131 mmol/l) in patients admitted to the Department of Internal Medicine is 1.25% [1]. The prevalence of hyponatremia in all the hospital departments is 0.97% and in the department of Surgery the prevalence is even higher: 4.4% [2], [3]. In the hospital laboratory hyponatremia (Na<137 mmol/l) occurs in 23.4% of all serum sodium assays (Na 130–137 mmol/l in 20.4%; Na 120–129 mmol/l in 2.7%) [4].

Hyponatremia may cause life-threatening clinical symptoms like seizures, coma, respiratory arrest and brain-stem herniation that need to be treated according to its pathophysiology and taking into account the rate of development [5]. It can be a symptom of an important underlying, but not yet identified, disease. In every case of hyponatremia a careful diagnostic analysis must be performed. Only after understanding its pathophysiology treatment can be installed appropriately. We describe a patient in whom initially several possible causes of hyponatremia were considered. Eventually an uncommon, but — in this particular patient — not unexpected, diagnosis could be made.

Section snippets

Case report

An 88-year-old man was admitted to the otorhinolaryngology department of our hospital because of leakage of a speaking valve. The patient’s medical history included a pT4N0M0 hypopharynxcarcinoma 3 years earlier that was treated by laryngectomy, partial hypopharyngectomy, hemithyroidectomy, right-sided cervical lymph node dissection and radiotherapy. One month before admission he was treated with paroxetine by his general practitioner because of a depression. He did not use any other drugs. On

Discussion

Hyponatremia is defined as a decrease in the serum sodium concentration below 135 mmol/l. The serum sodium concentration is the main determinant of the plasmaosmolality.

As a result hyponatremia usually reflects hypoosmolality. Hypotonic hyponatremia represents an excess of water in relation to existing sodium stores, which can be decreased, normal or increased. The primary response to a fall in plasmaosmolality, as occurs in normal subjects after the ingestion of a water load, is to diminish

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Cited by (26)

Vasopressin, Diabetes Insipidus, and the Syndrome of Inappropriate Antidiuresis
2015, Endocrinology: Adult and Pediatric
Evaluation of thyroid and adrenal functions in patients with hyponatremia
2013, Medical Journal Armed Forces India
Citation Excerpt :
This can directly diminish free water excretion by diminishing water delivery to the diluting segments. Decreased delivery may be particularly important in those cases in which hyponatremia develop despite appropriate suppression of ADH release.11 The incidence detected in our study is comparable to various other studies.
Hyponatremia is frequently detected as a cause in patients admitted to command Hospital Kolkata with altered sensorium. We evaluated these patients to rule out two common endocrine causes as etiological factors i.e. hypothyroidism and hypoadrenalism.
We studied 100 patients over a period of two years in all seasons who were admitted to hospital with altered sensorium and found to have hyponatremia as a cause, after ruling out other causes of altered sensorium as per inclusion and exclusion criteria. They were subjected to thyroid and adrenal evaluation in addition to detailed history, clinical examination and lab evaluation as per study protocol.
Total 100 patients were enrolled in the study. The age of patients varied from 31 years to more than 70 years. Majority of patients were between the age group of 41–60 years (49 patients. Males were predominant in the study. Only 8 patients were detected to have hypothyroidism requiring replacement therapy and only 2 patients had adrenal insufficiency. 48 patients had drug induced hyponatremia and 42 idiopathic hyponatremia. No seasonal variation was noted.
Thiazide diuretic intake as antihypertensive drug was found to be a major cause of hyponatremia. Most of the patients in this group were using thiazide diuretics. In idiopathic group the cause of hyponatremia can be hypothesized as multifactorial. The hot and humid climate of Kolkata and other coastal regions made them more vulnerable to develop hyponatremia. Hypothyroidism and hypoadrenalism were not found to be major causes of unexplained hyponatremia.
Vasopressin, Diabetes Insipidus, and the Syndrome of Inappropriate Antidiuretic Hormone Secretion
2010, Endocrinology: Adult and Pediatric, Sixth Edition
Chronic Thyroiditis
2009, Clinical Management of Thyroid Disease
Disorders of Body Water Homeostasis in Critical Illness
2006, Endocrinology and Metabolism Clinics of North America
Citation Excerpt :
Moreover, once thyroid hormone replacement was given and thyroid function normalized, creatinine values returned to their baseline euthyroid levels before the iatrogenically induced hypothyroid state [47]. Based on this combined evidence, the major cause of impaired water excretion in hypothyroidism appears to be an alteration in renal perfusion and GFR secondary to systemic effects of thyroid hormone deficiency on cardiac output and peripheral vascular resistance [48–50]. In hypervolemic hyponatremia, there is an excess in total body water and total body sodium, resulting in clinically evident edema or ascites; however, in many cases, the increase in total body water is out of proportion to that of total body sodium, causing hyponatremia.
A case of lymphocytic hypophysitis with masked diabetes insipidus unveiled by glucocorticoid replacement
2005, American Journal of Kidney Diseases
Lymphocytic hypophysitis may involve the pituitary gland and various hormonal abnormalities. A 72-year-old man presented with euvolemic hyponatremia caused by glucocorticoid deficiency. After glucocorticoid replacement, hypernatremia in the presence of dilute urine was found. Central diabetes insipidus (DI) was confirmed later by a significant increase in urine osmolality after vasopressin administration. Brain magnetic resonance imaging showed a pituitary mass and loss of hyperintense signal in the posterior pituitary gland on T1-weighted imaging. The patient underwent a transsphenoidal adenectomy, and pathological examination of dissected tissues showed a typical finding of lymphocytic hypophysitis. Two months after surgery, the patient’s central DI had resolved sufficiently that 1-desamino-8-d-arginine vasopressin therapy was discontinued without polyuria. However, he was kept on glucocorticoid and levothyroxine therapy. In conclusion, lymphocytic hypophysitis may feature a concealed central DI caused by glucocorticoid deficiency–associated hyponatremia.

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Brief reportHyponatremia due to hypothyroidism: a pure renal mechanism

Abstract

Introduction

Section snippets

Case report

Discussion

Pathogenesis of clinical hyponatremia: observations of vasopressin and fluid intake in 100 hyponatremic medical patients

Eur J Clin Invest

Hyponatremia: a prospective analysis of its epidemiology and the pathogenetic role of vasopressin

Ann Intern Med

Postoperative hyponatremia: a prospective study

Arch Intern Med

Hyponatraemia

Br Med J

Management of severe hyponatremia: rapid or slow correction?

Am J Med

Synergistic action of liquorice and cortisone in Addison’s and Simmonds’s disease

Lancet

Clinical physiology of acid–base and electrolyte disorders

Primary care: hyponatremia

New Engl J Med

Brief report
Hyponatremia due to hypothyroidism: a pure renal mechanism