Abstract
Hypotonic hyponatremia, a serious and recognized complication of any intracranial disorder, results from extra-cellular fluid volume depletion, inappropriate anti-diuresis or renal salt-wasting. The putative mechanisms by which intracranial disorders might lead to renal salt-wasting are either a disrupted neural input to the kidney or the elaboration of a circulating natriuretic factor. The key to diagnosis of renal salt-wasting lies in the assessment of extra-cellular volume status: the central venous pressure is currently considered the yardstick for measuring fluid volume status in subjects with intracranial disorders and hyponatremia. Approximately 110 cases have been reported so far in subjects ≤18 years of age (male: 63%; female: 37%): intracranial surgery, meningo-encephalitis (most frequently tuberculous) or head injury were the most common underlying disorders. Volume and sodium repletion are the goals of treatment, and this can be performed using some combination of isotonic saline, hypertonic saline, and mineralocorticoids (fludrocortisone). It is worthy of a mention, however, that some authorities contend that cerebral salt wasting syndrome does not exist, since this diagnosis requires evidence of a reduced arterial blood volume, a concept but not a measurable variable.
Similar content being viewed by others
References
Bianchetti MG, Simonetti GD, Bettinelli A (2009) Body fluids and salt metabolism. Part I. Ital J Pediatr 35:36
Peruzzo M, Milani GP, Garzoni L, Longoni L, Simonetti GD, Bettinelli A, Fossali EF, Bianchetti MG (2010) Body fluids and salt metabolism. Part II. Ital J Pediatr 36:78
Moritz ML, Ayus JC (2010) New aspects in the pathogenesis, prevention, and treatment of hyponatremic encephalopathy in children. Pediatr Nephrol 25:1225–1238
Albanese A, Hindmarsh P, Stanhope R (2001) Management of hyponatraemia in patients with acute cerebral insults. Arch Dis Child 85:246–251
Brimioulle S, Orellana-Jimenez C, Aminian A, Vincent JL (2008) Hyponatremia in neurological patients: cerebral salt wasting versus inappropriate antidiuretic hormone secretion. Intensive Care Med 34:125–131
Yee AH, Burns JD, Wijdicks EF (2011) Cerebral salt wasting: pathophysiology, diagnosis, and treatment. Neurosurg Clin N Am 21:339–352
Palmer BF (2003) Hyponatremia in patients with central nervous system disease: SIADH versus CSW. Trends Endocrinol Metab 14:182–187
Rivkees SA (2008) Differentiating appropriate antidiuretic hormone secretion, inappropriate antidiuretic hormone secretion and cerebral salt wasting: the common, uncommon, and misnamed. Curr Opin Pediatr 20:448–452
Sterns RH, Silver SM (2008) Cerebral salt wasting versus SIADH: what difference? J Am Soc Nephrol 19:194–196
Schwartz WB, Bennett W, Curelop S, Bartter FC (1957) A syndrome of renal sodium loss and hyponatremia probably resulting from inappropriate secretion of antidiuretic hormone. Am J Med 23:529–542
Powell KR, Sugarman LI, Eskenazi AE, Woodin AE, Kays MA, McCormick KL, Miller ME, Sladek CD (1990) Normalization of plasma arginine vasopressin concentrations when children with meningitis are given maintenance plus replacement fluid therapy. J Pediatr 117:515–522
Bianchetti MG, Cattaneo FA (1991) Secretion of antidiuretic hormone in children with meningitis: requiem for the so called SIADH? J Pediatr 118:997
Bianchetti MG, Thyssen HR, Laux-End R, Schaad UB (1996) Evidence for fluid volume depletion in hyponatremic patients with bacterial meningitis. Acta Paediatr 85:1163–1166
Von Vigier RO, Colombo SM, Stoffel PB, Meregalli P, Truttmann AC, Bianchetti MG (2001) Circulating sodium in acute meningitis. Am J Nephrol 21:87–90
Maconochie IK, Baumer JH, Stewart M (2009) Summary of “Fluid therapy for acute bacterial meningitis”, including tables of key findings and quality of included trials. Evid Based Child Health 4:58–60
Peters JP, Welt LG, Sims EA, Orloff J, Needham J (1950) A salt-wasting syndrome associated with cerebral disease. Trans Assoc Am Physicians 63:57–64
Maesaka JK, Imbriano LJ, Ali NM, Ilamathi E (2009) Is it cerebral or renal salt wasting? Kidney Int 76:934–938
Damaraju SC, Rajshekhar V, Chandy MJ (1997) Validation study of a central venous pressure-based protocol for the management of neurosurgical patients with hyponatremia and natriuresis. Neurosurgery 40:312–316
Brouh Y, Paut O, Tsimaratos M, Camboulives J (2004) Les hyponatrémies postopératoires de l’enfant: physiopathologie, diagnostic et traitement. Ann Fr Anesth Réanim 23:39–49
Singh S, Bohn D, Carlotti AP, Cusimano M, Rutka JT, Halperin ML (2002) Cerebral salt wasting: truths, fallacies, theories, and challenges. Crit Care Med 30:2575–2579
Askar A, Tarif N (2007) Cerebral salt wasting in a patient with head trauma: management with saline hydration and fludrocortisone. Saudi J Kidney Dis Transpl 18:95–99
Berger TM, Kistler W, Berendes E, Raufhake C, Walter M (2002) Hyponatremia in a pediatric stroke patient: syndrome of inappropriate antidiuretic hormone secretion or cerebral salt wasting? Crit Care Med 30:792–795
Berkenbosch JW, Lentz CW, Jimenez DF, Tobias JD (2002) Cerebral salt wasting syndrome following brain injury in three pediatric patients: suggestions for rapid diagnosis and therapy. Pediatr Neurosurg 36:75–79
Bussmann C, Bast T, Rating D (2001) Hyponatraemia in children with acute CNS disease: SIADH or cerebral salt wasting? Childs Nerv Syst 17:58–62
Byeon JH, Yoo G (2005) Cerebral salt wasting syndrome after calvarial remodeling in craniosynostosis. J Korean Med Sci 20:866–869
Carbajal Rodríguez L, Reynés Manzur JN, Zarco RJ, Luna Figueroa MA, Reyes Gómez U (2000) Síndrome cerebral perdedor de sal como diagnóstico diferencial del síndrome de secreción inadecuada de hormona antidiurética. Informe de un caso. Rev Mex Pediatr 67:128–132
Carrascosa AJ, Salcedo E, Gallego ME, Bermúdez JL, Yuste JA, Lledó G (1999) Hiponatremia en el postoperatorio de la patología tumoral neuroquirúrgica. Rev Esp Anestesiol Reanim 46:40–44
Celik US, Alabaz D, Yildizdas D, Alhan E, Kocabas E, Ulutan S (2005) Cerebral salt wasting in tuberculous meningitis: treatment with fludrocortisone. Ann Trop Paediatr 25:297–302
Dass R, Nagaraj R, Murlidharan J, Singhi S (2003) Hyponatraemia and hypovolemic shock with tuberculous meningitis. Indian J Pediatr 70:995–997
Dedeoglu IO, Matanguihan ET, Springate JE (1995) Clinical quiz. Cerebral salt wasting syndrome. Pediatr Nephrol 9:395–396
Donati-Genet PC, Dubuis JM, Girardin E, Rimensberger PC (2001) Acute symptomatic hyponatremia and cerebral salt wasting after head injury: an important clinical entity. J Pediatr Surg 36:1094–1097
Emet M, Caner I, Cakir M, Aslan S, Cakir Z (2010) Lightning injury may cause abrupt cerebral salt wasting syndrome. Am J Emerg Med 28:640.e1–640.e3
Ganong CA, Kappy MS (1993) Cerebral salt wasting in children. The need for recognition and treatment. Am J Dis Child 147:167–169
Hiranrat P, Katavetin P, Supornsilchai V, Wacharasindhu S, Srivuthana S (2003) Water and sodium disorders in children undergoing surgical treatment of brain tumors. J Med Assoc Thai 86 [Suppl 2]:S152–S159
Huang SM, Chen CC, Chiu PC, Cheng MF, Chiu CL, Hsieh KS (2004) Tuberculous meningitis complicated with hydrocephalus and cerebral salt wasting syndrome in a three-year-old boy. Pediatr Infect Dis J 23:884–886
Inatomi J, Yokoyama Y, Sekine T, Igarashi T (2008) A case of cerebral salt-wasting syndrome associated with aseptic meningitis in an 8-year-old boy. Pediatr Nephrol 23:659–662
Jiménez R, Casado-Flores J, Nieto M, García-Teresa MA (2006) Cerebral salt wasting syndrome in children with acute central nervous system injury. Pediatr Neurol 35:261–263
Kappy MS, Ganong CA (1996) Cerebral salt wasting in children: the role of atrial natriuretic hormone. Adv Pediatr 43:271–308
Karadag A, Tabel Y, Dogan DG, Aktas M, Aslan M, Dogan M (2010) Fludrocortisone therapy in a newborn with cerebral salt wasting due to hypernatremia and severe hyperbilirubinemia. Med Hypotheses 75:677–679
Kinik ST, Kandemir N, Baykan A, Akalan N, Yordam N (2001) Fludrocortisone treatment in a child with severe cerebral salt wasting. Pediatr Neurosurg 35:216–219
Kurtoğlu S, Atabek ME, Keskin M, Patiroglu T, Kumandas S, Topaloglu N (2006) Rhabdomyosarcoma with coexistent diabetes insipidus and cerebral salt wasting as postoperative complication. Pediatr Int 48:79–81
Lee SJ, Huh EJ, Byeon JH (2004) Two cases of cerebral salt wasting syndrome developing after cranial vault remodeling in craniosynostosis children. J Korean Med Sci 19:627–630
Levine JP, Stelnicki E, Weiner HL, Bradley JP, McCarthy JG (2001) Hyponatremia in the postoperative craniofacial pediatric patient population: a connection to cerebral salt wasting syndrome and management of the disorder. Plast Reconstr Surg 108:1501–1508
Lin JJ, Lin KL, Hsia SH, Wu CT, Wang HS (2009) Combined central diabetes insipidus and cerebral salt wasting syndrome in children. Pediatr Neurol 40:84–87
Madden JR, Dobyns E, Handler M, Foreman NK (2010) Experience with electrolyte levels after craniotomy for pediatric brain tumors. J Pediatr Oncol Nurs 27:21–23
Mocan H, Erduran E, Aslan Y, Gedik Y, Ökten A, Değer O, Gör A (1995) Two disturbances of water and electrolyte metabolism in patients with tuberculous meningitis: cerebral salt wasting (CSW) and the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Paediatr Today 3:8–13
Murthy SN, Cohen ME (2002) Pseudomigraine with prolonged aphasia in a child with cranial irradiation for medulloblastoma. J Child Neurol 17:134–138
Nagotkar L, Shanbag P, Dasarwar N (2008) Cerebral salt wasting syndrome following neurosurgical intervention in tuberculous meningitis. Indian Pediatr 45:598–601
Orbak Z, Kara IS (2010) Unusual complication in a child with lightning strike: cerebral salt wasting. Childs Nerv Syst 26:1125–1127
Oruckaptan HH, Ozisik P, Akalan N (2000) Prolonged cerebral salt wasting syndrome associated with the intraventricular dissemination of brain tumors. Report of two cases and review of the literature. Pediatr Neurosurg 33:16–20
Ozdemir H, Aycan Z, Degerliyurt A, Metin A (2010) The treatment of cerebral salt wasting with fludrocortisone in a child with lissencephaly. Turk Neurosurg 20:100–102
Papadimitriou DT, Spiteri A, Pagnier A, Bayle M, Mischalowski MB, Bourdat G, Passagia JG, Plantaz D, Bost M, Garnier PE (2007) Mineralocorticoid deficiency in post-operative cerebral salt wasting. J Pediatr Endocrinol Metab 20:1145–1150
Paul JJ, Tani LY, Shaddy RE, Minich LL (2003) Spectrum of left ventricular dysfunction in potential pediatric heart transplant donors. J Heart Lung Transplant 22:548–552
Sakarcan A, Bocchini J Jr (1998) The role of fludrocortisone in a child with cerebral salt wasting. Pediatr Nephrol 12:769–771
Segura Matute S, Balaguer Gargallo M, Cambra Lasaosa FJ, Zambudio Sert S, Martín Rodrigo JM, Palomeque Rico A (2007) Trastornos hidroelectrolíticos en postoperados de tumores cerebrales. An Pediatr (Barc) 67:225–230
Sengupta K, Ali U, Andankar P (2002) Cerebral salt wasting. Indian Pediatr 39:488–491
Simsek E, Dilli D, Yasitli U, Ozlem N, Bostanci I, Dallar Y (2008) Cerebral salt wasting in a child with cervicothoracic hematoma. J Pediatr Endocrinol Metab 21:695–700
Steelman R, Corbitt B, Pate MF (2006) Early onset of cerebral salt wasting in a patient with head and facial injuries. J Oral Maxillofac Surg 64:746–747
Taplin CE, Cowell CT, Silink M, Ambler GR (2006) Fludrocortisone therapy in cerebral salt wasting. Pediatrics 118:e1904–e1908
Urina H (2005) Síndrome cerebral de pérdida de sal. Arch Venez Pueric Pediatr 68:25–29
Vingerhoets F, de Tribolet N (1988) Hyponatremia hypo-osmolarity in neurosurgical patients. “Appropriate secretion of ADH” and “cerebral salt wasting syndrome”. Acta Neurochir (Wien) 91:50–54
Von Bismarck P, Ankermann T, Eggert P, Claviez A, Fritsch MJ, Krause MF (2006) Diagnosis and management of cerebral salt wasting (CSW) in children: the role of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP). Childs Nerv Syst 22:1275–1281
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Bettinelli, A., Longoni, L., Tammaro, F. et al. Renal salt-wasting syndrome in children with intracranial disorders. Pediatr Nephrol 27, 733–739 (2012). https://doi.org/10.1007/s00467-011-2093-5
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00467-011-2093-5