ARTICULO MEDICO:Pathophysiology and etiology of the syndrome of inappropriate antidiuretic hormone.SIADH

Pathophysiology and etiology of the syndrome of inappropriate antidiuretic hormone
secretion (SIADH)
Author
Richard H Sterns, MD
Section Editor
Michael Emmett, MD
Deputy Editor
John P Forman, MD, MSc
Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jan 2013. | This topic last updated: nov 20, 2012.
INTRODUCTION — The syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
is a disorder of impaired water excretion caused by the inability to suppress the secretion of
antidiuretic hormone (ADH) [1]. If water intake exceeds the reduced urine output, the ensuing
water retention leads to the development of hyponatremia.
The SIADH should be suspected in any patient with hyponatremia, hypoosmolality, and a urine
osmolality above 100 mosmol/kg. In SIADH, the urine sodium concentration is usually above 40
meq/L, the serum potassium concentration is normal, there is no acid-base disturbance, and the
serum uric acid concentration is frequently low [1]. (See "Evaluation of the patient with
hyponatremia".)
The pathophysiology and etiology of SIADH will be reviewed here. The treatment of this
disorder is discussed separately. (See "Treatment of hyponatremia: Syndrome of inappropriate
antidiuretic hormone secretion (SIADH) and reset osmostat".)
PATHOPHYSIOLOGY
Pathogenesis of hyponatremia — The plasma sodium concentration (PNa) is a function of the
ratio of the body's content of exchangeable sodium and potassium (NaE and KE) and total body
water (TBW) as described by Edelman's classic equation:
PNa ≈ NaE + KE/Total body water
Antidiuretic hormone (ADH, arginine vasopressin) secretion results in a concentrated urine and
therefore a reduced urine volume. The higher the plasma ADH, the more concentrated the
urine. In most patients with the syndrome of inappropriate secretion of antidiuretic hormone
(SIADH), ingestion of water does not adequately suppress ADH, and the urine remains
concentrated. This leads to water retention, which increases TBW. This increase in TBW lowers
the plasma sodium concentration by dilution (see above equation) [1]. In addition, the increase
in TBW transiently expands the extracellular fluid volume and thereby triggers increased urinary
sodium excretion, which both returns the extracellular fluid volume toward normal and further
lowers the plasma sodium concentration.
Hyponatremia can occur in SIADH even if the only fluid given is isotonic saline [2]. The
mechanism by which this occurs and why isotonic saline administration can lower the plasma
sodium concentration in patients with SIADH and a highly concentrated urine is discussed
separately. (See "Treatment of hyponatremia: Syndrome of inappropriate antidiuretic hormone
secretion (SIADH) and reset osmostat", section on 'Intravenous saline'.)
Patterns of ADH secretion — In normal individuals, plasma ADH levels are very low when the
plasma osmolality is below 280 mosmol /kg, thereby permitting the excretion of ingested water,
and ADH levels increase progressively as the plasma osmolality rises above 280 mosmol/kg
(figure 1).
ADH regulation is impaired in SIADH; four different patterns have been described [3,4]:
 Type A is characterized by erratic, unregulated release of ADH that varies widely
with no relation to the plasma osmolality. Plasma ADH levels are often above that
required for maximum antidiuresis, so the urine osmolality is typically very high.
 Type B is characterized by a modest and constant leak of ADH.
 Type C, characterized by downward resetting of the osmostat, is a variant of
SIADH in which the plasma sodium concentration is normally regulated (and is
therefore stable) at a lower level, typically between 125 and 135 meq/L.
Establishing the presence of this condition is important because, unlike other
forms of SIADH, there is no need to be concerned that the plasma sodium will
continue to fall without therapy. This disorder is discussed in detail elsewhere.
(See "Treatment of hyponatremia: Syndrome of inappropriate antidiuretic hormone
secretion (SIADH) and reset osmostat", section on 'Reset osmostat'.)
 Type D, the least common, is characterized by normal osmoregulation (ie, ADH
secretion varies appropriately with the plasma osmolality), but the urine is
concentrated even if ADH release is suppressed. At least one mechanism by
which this occurs is a germ cell mutation in which the V2 vasopressin receptor is
constituently activated [3]. Other potential mechanisms include production of an
antidiuretic compound other than immunoreactive arginine vasopressin and a
postreceptor defect in trafficking of aquaporin-2 water channels, which mediate
ADH-induced antidiuresis. (See 'Hereditary SIADH' below.)
Determinants of urine output — In addition to the persistent secretion of ADH, there are two
other potentially important determinants of the urine output in patients with SIADH: the rate of
solute excretion and partial escape from the effect of ADH.
Solute excretion — In normal subjects, the urine output is primarily determined by water
intake. Changes in water intake lead to alterations in the plasma osmolality that are sensed by
the osmoreceptors in the hypothalamus that regulate both ADH release and thirst. As an
example, an increase in water intake sequentially lowers the plasma osmolality, decreases ADH
secretion, and reduces collecting tubule permeability to water; the net effect is the rapid
excretion of the excess water in a dilute urine.
In SIADH, however, an increase in water intake does not produce an increase in water
excretion because ADH release is relatively fixed. Suppose that a patient has moderately
severe SIADH with a urine osmolality that cannot be reduced below 750 mosmol/kg (the normal
minimum urine osmolality is 40 to 100 mosmol/kg). In this patient, the urine output is determined
by the rate of excretion of solutes (primarily sodium and potassium salts and urea). Now
suppose this patient consumes a typical Western diet containing approximately 750 mosmol of
solute, all of which are excreted in the urine each day. With a fixed urine osmolarity of 750
mosmol/kg, the daily urine output will be only one liter (750 ÷ 750 = 1), and it will not increase in
response to increased water intake.
One way to increase water excretion in this hypothetical patient with SIADH is to prescribe a
high salt and protein diet without a increase in water ingestion. If, for example, the solute intake
and therefore solute excretion rose to 1200 mosmol/day, the urine output would increase to 1.6
L/day (1200 ÷ 750 = 1.6). The increase in water excretion would then tend to raise the plasma
sodium concentration toward normal.
Similar considerations concerning the role of solute intake apply when ADH effect is relatively
fixed at a low level in central or nephrogenic diabetes insipidus. (See "Urine output in diabetes
insipidus".)
Escape from the effect of ADH — Studies in experimental animals given ADH and water have
shown an initial phase of water retention and hyponatremia followed by partial escape from the
antidiuresis so that, despite persistently high levels of ADH, urine osmolality decreases. When
the urine osmolality falls, water excretion increases, matching water intake, and the plasma
sodium concentration tends to stabilize [5,6]. A similar response appears to occur in humans
[7,8].
This escape from ADH-induced antidiuresis appears to be mediated by decreased expression
of aquaporin-2, the ADH-sensitive water channel in the collecting tubules [9]. The regulation of
aquaporin-2 in this setting appears to be unrelated to plasma or tissue osmolality [10,11].
ETIOLOGY — One of the following causes of persistent antidiuretic hormone (ADH) release is
likely to be present in patients who fulfill the clinical criteria for the syndrome of inappropriate
secretion of antidiuretic hormone (SIADH) [1,12]:
CNS disturbances — Any CNS disorder, including stroke, hemorrhage, infection, trauma, and
psychosis, can enhance ADH release. A discussion of the disturbances in water balance that
may occur in patients with mental illness and a brief review of the antidiuretic action of
carbamazepine, a drug that can cause an SIADH picture, are found elsewhere. (See "Polydipsia
and hyponatremia in patients with mental illness".)
As in other causes of SIADH, hyponatremia associated with intracranial bleeding, as well as
other severe neurologic events, is due to ADH-mediated water retention and to urinary sodium
losses. However, with these severe neurological conditions, there is uncertainty as to whether
the sodium losses are a result of SIADH-induced expansion of the extracellular volume or
whether they are caused by salt wasting (ie, cerebral salt wasting), with release of ADH that is
secondary to a reduction in extracellular fluid volume. (See 'Cerebral salt wasting' below.)
Because of this uncertainty, therapy of hyponatremia in patients with CNS disorders usually
requires the administration of hypertonic saline, rather than fluid restriction or isotonic saline
(see 'Cerebral salt wasting' below).
Malignancies — Ectopic production of ADH by a tumor is most often due to a small cell
carcinoma of the lung and is rarely seen with other lung tumors [1,13]. Less common causes of
malignancy-associated SIADH include head and neck cancer, olfactory neuroblastoma
(esthesioneuroblastoma), and extrapulmonary small cell carcinomas [14-16].
Ectopic ADH secretion by tumor cells has been documented in vitro. In addition, some small cell
lung cancer cells increase ADH secretion in response to high osmolality, suggesting a degree of
regulation of the ectopic secretion [17]. This in vitro finding is compatible with the clinical
observation that some patients with tumor-induced SIADH show evidence of osmoregulation of
ADH release [4]. (See "Pathobiology and staging of small cell carcinoma of the lung".)
Drugs — Certain drugs can enhance ADH release or effect, including chlorpropamide,
carbamazepine, oxcarbazepine (a derivative of carbamazepine), high-dose intravenous
cyclophosphamide, and selective serotonin reuptake inhibitors [1,18-26]. Experimental studies
suggest that chlorpropamide may increase concentrating ability both by increasing sodium
chloride reabsorption in the loop of Henle (thereby enhancing the efficiency of countercurrent
exchange) and by augmenting collecting tubule permeability to water [19]. The latter effect may
be mediated by an increased number of ADH receptors in the collecting tubule cells.
Carbamazepine and oxcarbazepine also act at least in part by increasing the sensitivity to ADH
[20,21,24].
SIADH due to high-dose intravenous cyclophosphamide may be a particular problem since
patients receiving this regimen are often fluid loaded to prevent hemorrhagic cystitis [25,26]. As
a result, marked water retention and potentially fatal hyponatremia may ensue in selected cases
[25]. This complication has been primarily described with doses in the range of 30 to 50 mg/kg
used to treat malignancy, or 6 g/m2 as given in the STAMP protocol in preparation for bone
marrow rescue [26]. Although less common, hyponatremia can also occur with the lower doses
(10 to 15 mg/kg) that are given as pulse therapy in autoimmune diseases such as lupus
nephritis. Chemotherapy-induced nausea may play a contributory role since nausea is a potent
stimulus to ADH release. (See "Chapter 6B: Antidiuretic hormone and water balance", section
on 'Other factors affecting ADH secretion'.) The fall in the plasma sodium concentration in this
setting can be minimized by using isotonic saline rather than free water to maintain a high urine
output.
SIADH is also associated with the selective serotonin reuptake inhibitors (eg, fluoxetine,
sertraline) [27-31]. The exact prevalence is unknown; patients above age 65 years may be more
susceptible to the complication [31].
Many other drugs have been associated with the SIADH. These include vincristine, vinblastine,
vinorelbine, cisplatin, thiothixene, thioridazine, haloperidol, amitriptyline, monoamine oxidase
inhibitors, melphalan, ifosfamide, methotrexate, opiates, nonsteroidal antiinflammatory agents,
interferon-alpha, interferon-gamma, sodium valproate, bromocriptine, lorcainide, amiodarone,
ciprofloxacin, high-dose imatinib, and "ecstasy" (methylenedioxymethamphetamine), a drug of
abuse that may also be associated with excessive water intake [1,27,32-36].
Surgery — Surgical procedures are often associated with hypersecretion of ADH, a response
that is probably mediated by pain afferents [37-39]. In addition, hyponatremia may develop after
other types of interventional procedures, such as cardiac catheterization [40].
Hyponatremia is also a common late complication of transsphenoidal pituitary surgery,
occurring in 21 to 35 percent of cases [41,42]. Although relative cortisol deficiency may
contribute, the major cause is inappropriate ADH release from the injured posterior pituitary
gland. The fall in the plasma sodium concentration is most severe on the sixth to seventh
postoperative day. This form of isolated hyponatremia (or isolated second phase) appears to be
a subset of the classic triphasic cycle in which initial polyuria is followed by transient SIADH
and then either recovery or, in severe cases, a third phase of permanent central diabetes
insipidus. (See "Clinical manifestations and causes of central diabetes insipidus", section on
'Neurosurgery or trauma'.)
Rarely, hyponatremia after pituitary surgery is due to cerebral salt wasting (see 'Cerebral salt
wasting' below).
Pulmonary disease — Pulmonary diseases, particularly pneumonia (viral, bacterial,
tuberculous), can lead to the SIADH, although the mechanism by which this occurs is not clear
[38]. A similar response may infrequently be seen with asthma, atelectasis, acute respiratory
failure, and pneumothorax [1,38].
Hormone deficiency — Both hypopituitarism and hypothyroidism may be associated with
hyponatremia and an SIADH picture that can be corrected by hormone replacement. (See
"Hyponatremia and hyperkalemia in adrenal insufficiency" and "Causes of hyponatremia",
section on 'Hypothyroidism'.)
Hormone administration — The SIADH can by induced by exogenous hormone
administration, as with vasopressin (to control gastrointestinal bleeding),
desmopressin (dDAVP, to treat von Willebrand disease or hemophilia or platelet dysfunction), or
oxytocin (to induce labor) [43-46]. As with vasopressin and desmopressin, oxytocin acts by
increasing the activity of the V2 (antidiuretic) vasopressin receptor [47].
HIV infection — A common cause of hyponatremia is symptomatic HIV infection, either the
acquired immune deficiency syndrome (AIDS) or early symptomatic HIV infection [48]. Although
volume depletion (due, for example, to gastrointestinal losses) or adrenal insufficiency may be
responsible, many patients have the SIADH. Pneumonia, due to Pneumocystis carinii or other
organisms, central nervous system infections, and malignant disease, are most often
responsible in this setting [48]. (See "Electrolyte disturbances with HIV infection".)
Hereditary SIADH — The clinical picture of SIADH may result from genetic disorders that result
in antidiuresis. At least two genetic abnormalities have been identified, one affecting the gene
for the renal vasopressin-2 (V2) receptor, which some investigators have named nephrogenic
syndrome of inappropriate antidiuresis, and one affecting osmolality sensing in the
hypothalamus.
In the initial description of the nephrogenic syndrome, two male infants were described who
presented with hyponatremia, hypoosmolality, increased urine osmolality, and a high urine
sodium concentration consistent with SIADH, but with no detectable circulating ADH [49,50].
Gain-of-function mutations were found in the gene encoding the V2 receptor that mediates the
antidiuretic response to ADH; persistent activation of the receptor was responsible for the
persistent antidiuretic state [51]. The gene for the V2 receptor is located on the X chromosome,
and loss-of-function mutations of the gene are responsible for X-linked nephrogenic diabetes
insipidus. (See "Clinical manifestations and causes of nephrogenic diabetes insipidus", section
on 'Hereditary nephrogenic DI'.)
The nephrogenic syndrome of inappropriate antidiuresis has also been found in adult men and
women. In one study, a 74-year-old man with an initial diagnosis of SIADH was unresponsive to
oral inhibitors of the V2 receptor; he was subsequently discovered to have a gain-of-function
mutation of the gene for this receptor [52]. After screening of family members, two additional
hemizygous males and four heterozygous females were identified. Spontaneous episodes of
hyponatremia and/or an abnormal water-load test were observed in all but one woman with the
genetic defect, who had preferential inactivation of the X chromosome harboring the mutated
allele.
The hereditary hypothalamic syndrome is due to a mutation in the transient receptor potential
vanilloid type 4 (TRPV4) gene, which encodes a component of the central osmolality-sensing
mechanism in the hypothalamus [53]. A loss-of-function polymorphism in this gene interferes
with sensing of hypoosmolality and therefore interferes with appropriate suppression of ADH
release in the presence of hypoosmolality. Thus, affected individuals behave as if they have a
reset osmostat, as the serum sodium is modestly reduced (mean 136 meq/L in this family) and
regulated normally around that value. Thus, in the absence of a superimposed disease, there is
no risk of progressive hyponatremia. (See "Treatment of hyponatremia: Syndrome of
inappropriate antidiuretic hormone secretion (SIADH) and reset osmostat", section on 'Reset
osmostat'.)
Idiopathic — Idiopathic SIADH has been described primarily in elderly patients [54-57].
However, some cases of apparently idiopathic disease were later found to be caused by an
occult tumor (most often small cell carcinoma or olfactory neuroblastoma) and, in older patients,
giant cell (temporal) arteritis [1,55,58,59].
CEREBRAL SALT WASTING — A rare syndrome has been described in patients with cerebral
disease (particularly subarachnoid hemorrhage) that mimics all of the findings in the syndrome
of inappropriate secretion of antidiuretic hormone (SIADH) except that salt wasting is thought to
be the primary defect, with the ensuing volume depletion causing a secondary rise in
antidiuretic hormone (ADH) release. This distinction is not always easy to make since the true
volume status of the patient is sometimes difficult to ascertain. The pathogenesis,
manifestations, and treatment of cerebral salt wasting are discussed separately. (See "Cerebral
salt-wasting".)
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 Basics topic (see "Patient information: Syndrome of inappropriate antidiuretic
hormone secretion (SIADH) (The Basics)")
SUMMARY
 The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a
disorder of impaired water excretion caused by the inability to suppress the
secretion of antidiuretic hormone (ADH). (See 'Introduction' above.)
 SIADH should be suspected in any patient with hyponatremia, hypoosmolality, and
a urine osmolality above 100 mosmol/kg. In SIADH, the urine sodium
concentration is usually above 40 meq/L, the serum potassium concentration is
normal, there is no acid-base disturbance, and the serum uric acid concentration is
frequently low. (See 'Introduction' above.)
 ADH secretion results in a concentrated urine and therefore a reduced urine
volume. In most patients with SIADH, ingestion of water does not adequately
suppress ADH, and the urine remains concentrated. This leads to water retention,
which increases total body water (TBW). This increase in TBW lowers the plasma
sodium concentration by dilution. In addition, the increase in TBW transiently
expands the extracellular fluid volume and thereby triggers increased urinary
sodium excretion, which both returns the extracellular fluid volume toward normal
and further lowers the plasma sodium concentration. (See
'Pathophysiology' above.)
 One of the following causes of persistent ADH release is likely to be present in
patients who fulfill the clinical criteria for the SIADH (see 'Etiology' above):
 Any CNS disorder, including stroke, hemorrhage, infection, trauma, and
psychosis can enhance ADH release. There is uncertainty as to whether
hyponatremia in patients with severe neurologic disorders (such as
hemorrhage or trauma) is due to SIADH or salt wasting (ie, cerebral salt
wasting). (See 'CNS disturbances' above and 'Cerebral salt wasting' above.)
 Ectopic production of ADH by a tumor is most often due to a small cell
carcinoma of the lung and is rarely seen with other lung tumors. Less common
causes of malignancy-associated SIADH include head and neck cancer,
olfactory neuroblastoma (esthesioneuroblastoma), and extrapulmonary small
cell carcinomas. (See 'Malignancies' above.)
 Certain drugs can enhance ADH release or effect, including chlorpropamide,
carbamazepine, oxcarbazepine (a derivative of carbamazepine), high-dose
intravenous cyclophosphamide, and selective serotonin reuptake inhibitors.
Many other drugs have been associated with the SIADH. These include
vincristine, vinblastine, vinorelbine, cisplatin, thiothixene, thioridazine,
haloperidol, amitriptyline, monoamine oxidase inhibitors, melphalan,
ifosfamide, methotrexate, opiates, nonsteroidal antiinflammatory agents,
interferon-alpha, interferon-gamma, sodium valproate, bromocriptine,
lorcainide, amiodarone, ciprofloxacin, and high-dose imatinib. "Ecstasy"
(methylenedioxymethamphetamine) is a drug of abuse that may also be
associated with both SIADH and excessive water intake. (See 'Drugs' above.)
 Surgical procedures are often associated with hypersecretion of ADH, a
response that is probably mediated by pain afferents. In addition,
hyponatremia may develop after other interventional medical procedures, such
as cardiac catheterization. (See 'Surgery' above.)
 Pulmonary diseases, particularly pneumonia (viral, bacterial, tuberculous), can
lead to the SIADH, although the mechanism by which this occurs is not clear.
A similar response may infrequently be seen with asthma, atelectasis, acute
respiratory failure, and pneumothorax. (See 'Pulmonary disease' above.)
 Both hypopituitarism and hypothyroidism may be associated with
hyponatremia and clinical findings identical to SIADH, but these abnormalities
are corrected by hormone replacement. (See 'Hormone deficiency' above.)
 SIADH can by induced by exogenous administration of hormones: vasopressin
(to control gastrointestinal bleeding); ADH analogs, such as
desmopressin (dDAVP, to treat von Willebrand disease, hemophilia, other
forms of platelet dysfunction, or enuresis); or other hormones with antidiuretic
effects, such as oxytocin (to induce labor). (See 'Hormone
administration' above.)
 Symptomatic HIV infection is associated with SIADH. (See 'HIV
infection' above.)
 The clinical picture of SIADH may result from genetic disorders that result in
antidiuresis. (See 'Hereditary SIADH' above.)