Prevalence of adrenal insufficiency among patients with euvolemic hyponatremia

Abstract

Background: The diagnosis of SIAD requires the exclusion of secondary adrenal insufficiency (AI) among patients with euvolemic hyponatremia (EuVHNa). Studies have suggested about 2.7% to 3.8% of unselected patients presenting to the emergency room with EuVHNa have undiagnosed AI and it is as high as 15% among patients admitted to specialized units for evaluation of hyponatremia. Objective: To study the prevalence of AI among inpatients with EuVHNa in a general medical ward setting Methods: This was a prospective, single centre observational study conducted among general medical inpatients with EuVHNa, defined as patients with a serum Na <135 mmol/L, clinical euvolemia and urine spot sodium >30mmol/L. Additionally patients with recent vomiting, current renal failure, diuretic use and those with uncontrolled hyperglycemia were excluded. Adrenal functions were assessed by a modified ACTH stimulation test called Acton Prolongatum™ stimulation test (APST). A cut off cortisol value of <18mg/dl after 60 minutes of ACTH injection was used to diagnose AI. Results: One hundred and forty-one (141) patients were included and underwent an APST. APST suggested 20/141 (14.2%) had undiagnosed AI. The most common cause of AI (9/20) was secondary AI because of the use of steroids including inhaled steroids and indigenous medicines contaminated with steroids. In 5 (3.5%) patients hypopituitarism was newly diagnosed. Despite primary adrenal insufficiency not commonly presenting as EuVHNa, 2/20 patients had primary adrenal insufficiency. Conclusions: AI is much commoner in our country among inpatients with EuVHNa primarily driven by exogenous steroid use and undiagnosed hypopituitarism.

A Conspectus of Euvolemic Hyponatremia, Its Various Etiologies, and Treatment Modalities: A Comprehensive Review of the Literature

“…Conditions including bronchial carcinoma, acute respiratory failure, psychosis, meningitis, hydrocephaly, encephalitis, and spinal cord lesions may also be characterized by euvolemic hyponatremia secondary to SIADH [ 18 - 20 ]. Hyponatremia resulting from SIADH can also be a frequent complication during pulmonary infections (pneumonia) and central nervous system (CNS) infections, whereby the critical mechanisms involved in SIADH development are attributed to hypoxia and intravascular volume depletion [ 21 , 22 ]. Given that SIADH is more frequently observed in patients with greater disease severity as well as inflammation, it is plausible that nonosmotic stimulation of ADH secretion may result from nonosmotic stimulation of ADH secretion triggered by excessive amounts of pro-inflammatory cytokines released, especially interleukin 6 (IL-6) [ 21 ].…”

Glucocorticoid Use Audits

“…A recent paper from North India suggested that 3.5% (5/141) of patients presenting to the medical ward with euvolemic hyponatremia had adrenal insufficiency secondary to undocumented steroid use including contamination of indigenous medications with steroids. [ 1 ]…”