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New aspects in the pathogenesis, prevention, and treatment of hyponatremic encephalopathy in children

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Abstract

Hyponatremia is the most common electrolyte abnormality encountered in children. In the past decade, new advances have been made in understanding the pathogenesis of hyponatremic encephalopathy and in its prevention and treatment. Recent data have determined that hyponatremia is a more serious condition than previously believed. It is a major comorbidity factor for a variety of illnesses, and subtle neurological findings are common. It has now become apparent that the majority of hospital-acquired hyponatremia in children is iatrogenic and due in large part to the administration of hypotonic fluids to patients with elevated arginine vasopressin levels. Recent prospective studies have demonstrated that administration of 0.9% sodium chloride in maintenance fluids can prevent the development of hyponatremia. Risk factors, such as hypoxia and central nervous system (CNS) involvement, have been identified for the development of hyponatremic encephalopathy, which can lead to neurologic injury at mildly hyponatremic values. It has also become apparent that both children and adult patients are dying from symptomatic hyponatremia due to inadequate therapy. We have proposed the use of intermittent intravenous bolus therapy with 3% sodium chloride, 2 cc/kg with a maximum of 100 cc, to rapidly reverse CNS symptoms and at the same time avoid the possibility of overcorrection of hyponatremia. In this review, we discuss how to recognize patients at risk for inadvertent overcorrection of hyponatremia and what measures should taken to prevent this, including the judicious use of 1-desamino-8d-arginine vasopressin (dDAVP).

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Authors and Affiliations

  1. Division of Nephrology, Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Michael L. Moritz

  2. Renal Consultants of Houston, Houston, TX, USA

    Juan Carlos Ayus

  3. Division of Nephrology, Children’s Hospital of Pittsburgh of UPMC, One Children’s Hospital Drive, 4401 Penn Ave, Pittsburgh, PA, 15224, USA

    Michael L. Moritz

Authors
  1. Michael L. Moritz
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  2. Juan Carlos Ayus
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Corresponding author

Correspondence to Michael L. Moritz.

Additional information

Answers

1. a

2. c

3. d

4. e

5. b

Appendices

Questions

(Answers appear following the reference list)

  1. 1.

    What is the main risk factor for developing hyponatremia?

    1. a.

      AVP excess

    2. b.

      Intravenous fluid therapy

    3. c.

      Prematurity

    4. d.

      Prolonged hospitalization

    5. e.

      Mechanical ventilation

  2. 2.

    Which of the following is NOT a feature of hyponatremic encephalopathy?

    1. a.

      Headache

    2. b.

      Noncardiogenic pulmonary edema

    3. c.

      Hyperpyrexia

    4. d.

      Seizures

    5. e.

      Orthopedic injuries

  3. 3.

    Why are children at increased risk for developing hyponatremic encephalopathy?

    1. a.

      Increased expression of aquaporin 4

    2. b.

      Increased sensitivity of AVP

    3. c.

      Increased basal metabolic rate

    4. d.

      Increased brain- to skull-size ratio

    5. e.

      Increased brain idiogenic osmole production

  4. 4.

    What is the most effective therapy of hyponatremic encephalopathy?

    1. a.

      Vasopressin 2 antagonists

    2. b.

      Mannitol

    3. c.

      0.9% NaCl plus Lasix

    4. d.

      Craniotomy

    5. e.

      3% NaCl

  5. 5.

    Which of the following is NOT a risk factor for developing cerebral demyelination?

    1. a.

      Liver disease

    2. b.

      Acute hyponatremic encephalopathy

    3. c.

      Hypoxia

    4. d.

      Correction in SNa of >25 mEq/L in 48 h

    5. e.

      Thiazide diuretics

Note added in proof

Following the submission of this manuscript, Neville et al. [134] reported on a prospective randomized trial of 124 postoperative children who received either 0.9% NaCl or 0.45% NaCl at either 100% or 50% of standard maintenance. The incidence of hyponatremia (Na < 135) within the first 24 hours of surgery was 30% in the 0.45% NaCl group compared to 10% in the 0.9% NaCl (p=0.02), with 15% of patients in the 0.45% NaCl group having a fall in SNa of ≥5 mEq/L compared to none in the 0.9% NaCl. Fluid restriction at 50% maintenance did not decrease the incidence of hyponatremia, but resulted in a 23% incidence of dehydration. Administration of 0.9% NaCl did not result in clinically significant hypernatremia.

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Moritz, M.L., Ayus, J.C. New aspects in the pathogenesis, prevention, and treatment of hyponatremic encephalopathy in children. Pediatr Nephrol 25, 1225–1238 (2010). https://doi.org/10.1007/s00467-009-1323-6

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  • DOI: https://doi.org/10.1007/s00467-009-1323-6

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