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Differentiating SIADH from Cerebral/Renal Salt Wasting: Failure of the Volume Approach and Need for a New Approach to Hyponatremia

Department of Medicine, Winthrop-University Hospital, Mineola, NY 11501, USA
Department of Medicine, Columbia University, New York, NY 10027, USA
Author to whom correspondence should be addressed.
These authors contributed equally to this work.
J. Clin. Med. 2014, 3(4), 1373-1385;
Received: 7 July 2014 / Revised: 26 August 2014 / Accepted: 9 September 2014 / Published: 8 December 2014
(This article belongs to the Special Issue Hyponatremia: Advances in Diagnosis and Management)
PDF [122 KB, uploaded 8 December 2014]


Hyponatremia is the most common electrolyte abnormality. Its diagnostic and therapeutic approaches are in a state of flux. It is evident that hyponatremic patients are symptomatic with a potential for serious consequences at sodium levels that were once considered trivial. The recommendation to treat virtually all hyponatremics exposes the need to resolve the diagnostic and therapeutic dilemma of deciding whether to water restrict a patient with the syndrome of inappropriate antidiuretic hormone secretion (SIADH) or administer salt and water to a renal salt waster. In this review, we briefly discuss the pathophysiology of SIADH and renal salt wasting (RSW), and the difficulty in differentiating SIADH from RSW, and review the origin of the perceived rarity of RSW, as well as the value of determining fractional excretion of urate (FEurate) in differentiating both syndromes, the high prevalence of RSW which highlights the inadequacy of the volume approach to hyponatremia, the importance of changing cerebral salt wasting to RSW, and the proposal to eliminate reset osmostat as a subtype of SIADH, and finally propose a new algorithm to replace the outmoded volume approach by highlighting FEurate. This algorithm eliminates the need to assess the volume status with less reliance on determining urine sodium concentration, plasma renin, aldosterone and atrial/brain natriuretic peptide or the BUN to creatinine ratio. View Full-Text
Keywords: hyponatremia; renal salt wasting; fractional excretion urate (FEurate); algorithm hyponatremia; renal salt wasting; fractional excretion urate (FEurate); algorithm

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Maesaka, J.K.; Imbriano, L.; Mattana, J.; Gallagher, D.; Bade, N.; Sharif, S. Differentiating SIADH from Cerebral/Renal Salt Wasting: Failure of the Volume Approach and Need for a New Approach to Hyponatremia. J. Clin. Med. 2014, 3, 1373-1385.

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