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Syndrome Of inapropriate

Antidiuretic hormone
(SIADH)
MOHD ASRUL
MEDICAL DEPARTMENT

Syndrome Of inapropriate
Antidiuretic hormone (SIADH)
Hyponatremia and hypo-osmolality
(plasma) resulting from
inappropriate, continued secretion or
action of the hormone despite normal
or increased plasma volume, which
results in impaired water excretion

Anatomy
Vasopressin or antidiuretic hormone
produces at Posterior Pituitary gland
Act on the renal tubules to induce
water retention leading to
concentration of urine
Excessive or inapropriate production
of ADH predispose to hyponatreamia
reflecting water retention.

Physiology

Sign and symptoms


Typically, the condition is asymptomatic
during the initial stages, especially if the
fall in the serum sodium level is slow.
Rapid onset of hyponatraemia is associated
with confusion, drowsiness, convulsions,
coma, and death.
Symptoms are uncommon until the serum
sodium falls to 120 mmol/l or less, or the
plasma osmolality drops below 268
mOsmol/kg.

Diagnosis
Concentrated urine (Na > 20 mmol/L
and osmolality >500 mosmol/kg) in
the presence of hyponatreamia
(plasma Na < 125 mmol/L or low
plasma osmolality (<260 mosmol/kg)
and the absence of hypovolemia
oedema or diuretics.

Since there are many causes of


hyponatraemia the diagnosis of SIADH
should only be entertained in the
absence of
oedema-forming states,
hypovolaemia, or hypotension,
and when renal and adrenal function
are normal

Hyponatraemia

Is patient dehydrated

yes

Is urinary Na >20 mm
ol/L

yes

Na & h2o lost via


Kidneys

No

Is the patient is
edematous

No

Na & H2O lost other


than kidney

Is the urine osmolarity


is > 500 mosmol/kg

yes
Addisons dis
Diuretic excess
Osmolar diuresis
High urea and high
glucose

Diarrhoea
Vomiting
Burn
Heat exposure
Small bowel
obstruction

No

yes

Nephrotic syndrome
Cardiac failure
Liver cirrhosis
Renal failure

No
SIADH

Water overload
Severe
hypothyroidism
Glucocorticoid
insuficiency

Investigation
Renal profile
Urine osmolality
Plasma osmolality

Treatment
Restrict fluid intake less than the
sum of insensible water loss and
urinary output.
Consider salt+loop diuretics if severe
Vasopressin receptor antagonist
Vaptans
Eg. Conivaptan,
ADH antagonist Demeclocycline.

Fluid restriction to between 500 and 750


ml/24h usually reverses any adverse clinical
features and restores the circulating sodium
level and osmolality to normal
The use of hypertonic saline infusions is
very rarely required and only if severe
drowsiness or convulsions are experienced,
which are unresponsive to fluid restriction
and if the serum sodium is around 100
mmol/l.

Hypertonic saline should only be


administered under close supervision to
avoid rapid increases in the plasma sodium
concentration and the risk of central pontine
myelinolysis
The plasma sodium concentration should rise
by no more than 0.5 mmol/l per hour
Drugs such as demeclocycline, which induce
nephrogenic diabetes insipidus, may be
helpful but the effects are often short lasting.

Reference
Oxford textbook of Medicine
Harrison Internal medicine
Oxford handbook of medicine