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• W1545804586 abstract "An 80-year-old man presented to the emergency department with a complaint of dizziness, lower abdominal pain, and difficulty with urination for 1 day. He described frequent urinary dribbling but no dysuria or hematuria. He reported one episode of emesis but no fever or chills. The patient had a prior history of hypertension, gastroesophageal reflux, and benign prostatic hyperplasia (BPH). He also had undergone transurethral resection of transitional cell carcinoma of the bladder 1 year before, with no evidence of recurrence at cystoscopy 6 months ago. The patient stated that he was being treated for “hard to control” hypertension, and the medical record suggested medication nonadherence. Outpatient medications included finasteride 5 mg and metoprolol 25 mg. Lisinopril 20 mg had been added 3 weeks before this presentation for uncontrolled hypertension. Two weeks before, hydrochlorothiazide 25 mg had also been added, and the patient reported he was instructed to decrease his salt intake and increase water intake, which prompted him to eat “nothing with salt” and to drink “2 to 3 gallons of water a day” since that time. The patient's blood pressure upon arrival at the emergency department was 203/93, with blood work notable for a serum sodium of 120 mEq/L. On examination, he appeared fatigued but was described as alert and oriented with suprapubic fullness. There were no other neurological findings. An indwelling urinary catheter was placed after an attempt to urinate, with 1,500 mL bladder residual volume. Because of concerns of hypovolemia, 500 mL of normal saline was administered over 2 hours, and the patient was admitted to the hospital. In the hospital, hydrochlorothiazide was discontinued, and he was placed on free water restriction. Urine and serum studies were consistent with syndrome of inappropriate antidiuretic hormone secretion (SIADH), and after a further decrease in his serum sodium (to a low of 116 mEq/L) (Figure 1), demeclocycline was begun with continued water restriction. No evidence of infection or malignancy was identified. He was also started on an alpha blocker for BPH. As his serum sodium slowly increased (to 133 mEq/L on the day of discharge), he reported less fatigue, and subtle improvements in his cognition were noted. Repeat cystoscopy as an outpatient did not show evidence of bladder tumor recurrence, and the patient's serum sodium level remained in the normal range. Serum sodium concentration. Hyponatremia, commonly defined as a serum sodium concentration of less than 136 mEq/L, is among the most common electrolyte abnormalities encountered in clinical practice.1 Older age is independently associated with hyponatremia at presentation and hospital-acquired hyponatremia.2 Hyponatremia may arise from different etiologies depending on whether presentation is during the postoperative period, in the intensive care unit, in the emergency department, or at other times.3 There has been prior report of urinary retention itself potentially causing hyponatremia.4 The proposed mechanism for this is SIADH triggered by the bladder distention itself or related pain. Urinary catheterization may be the key to treatment in these cases. Cases have also been reported of hyponatremic encephalopathy in patients with compulsive water drinking while taking a thiazide diuretic. Several mechanisms have been postulated for thiazide-induced hyponatremia, including natriuresis, reduced free water clearance, and SIADH.5 Aging is also associated with lower physiological reserve, such as low cardiac and renal reserve and poor ability to compensate for fluctuations in environmental conditions.6 These properties make elderly people more vulnerable to changes in water and electrolyte gain or loss, with resulting morbidity and mortality.6 It is important to remember that changes in plasma sodium concentration usually reflect an excess or deficit of water rather than a change in sodium balance. Older people may be particularly vulnerable to adverse effects of zealous salt restriction and excessive water intake. Hyponatremia in this patient probably resulted from multiple etiologies, including diuretic use, low solute intake, excessive water intake, and perhaps urinary retention. Caution is warranted in the use of thiazides combined with instructions for excessive water intake in older people. Urinary retention may also be a factor contributing to hyponatremia in older patients. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. Author Contributions: Navid Ezra and Cathy Alessi: study concept and design, acquisition of data, analysis and interpretation of data, and preparation of manuscript. Sponsor's Role: None." @default.
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• W1545804586 date "2009-12-01" @default.
• W1545804586 modified "2023-10-14" @default.
• W1545804586 title "CLINICAL OBSERVATION: HYPONATREMIA ASSOCIATED WITH DIURETIC USE AND URINARY RETENTION IN AN OLDER MAN" @default.
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• W1545804586 doi "https://doi.org/10.1111/j.1532-5415.2009.02604.x" @default.
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