Hyponatremia can be associated with low, normal or high intravascular volume status. In this case, the serum was clearly hypotonic (commensurate with a reduced serum sodium concentration) and the physical examination revealed clinical euvolemia suggesting “euvolemic hyponatremia.” Euvolemic hyponatremia signifies a disorder of renal diluting capacity that results from diverse pathologies. In patients with hypotonic hyponatremia, urine osmolality estimates ADH activity, and together with the history and volume assessment, directs the differential diagnosis (Fig. 2).
Our patient’s history was striking for both acute (in hospital) and chronic polydipsia of several months’ duration. However, his admission urine osmolality was 155 mEq/L (that is, not < 100 mOsm/L and therefore not maximally dilute). We hypothesized that the failure to achieve maximal urinary dilution was partly due to several days of poor dietary solute intake. This phenomenon has been reported in patients with the classic “tea-and-toast diet” and results in submaximal urinary dilution due to an inadequate solute intake that limits water excretion [4]. Our patient’s reduced dietary intake for several days prior to admission and a relatively low blood urea nitrogen (BUN) level both suggested that limited protein and solute intake contributed to his reduced ability to secrete water. However, his obese habitus [body mass index (BMI) 32], and normal serum albumin suggested a more robust, long-term nutritional status that would be adequate to support normal water excretion. Clinical history, vital signs, physical examination, and laboratory testing excluded potential contributions of abnormal thyroid and adrenal dysfunction to his hyponatremia. The combination of a normal uric acid level and relatively low urine osmolality were also atypical for the syndrome of inappropriate ADH (SIADH) secretion. Further, the family history was unremarkable for hyponatremia and therefore did not suggest nephrogenic syndrome of inappropriate antidiuresis [5].
A review of the patient’s electronic medical record revealed mild, chronic hyponatremia with baseline serum sodium values ranging between 123 and 133 mEq/L for at least 3 years prior to presentation. Upon further questioning, he endorsed chronic polydipsia that episodically worsened with either dyspepsia or anxiety. He also noted that increasing his water intake consistently stimulated recurrent hiccups and prompted additional water intake. The patient’s ability to both dilute and concentrate his urine and chronic hyponatremia suggested that a reset osmostat resulted in an abnormal threshold for ADH release as well as ADH suppression.
The patient was discharged on hospital day 6 with a stable serum sodium concentration of 133 mEq/L and was maintained on a daily fluid intake restricted to 1.8 L/day without salt tablets. At the time of discharge, he remained euvolemic, normotensive, and asymptomatic. Seven months later, he returned to the hospital with confusion, intractable hiccups, and a serum sodium of 117 mEq/L. Immediately prior to the second admission, he admitted to ingesting more than 6 L of water daily. Symptomatic hyponatremia again responded to 3% saline infusion and water restriction. Interestingly, ethanol itself is known cause of hiccups, most likely via stimulation of GABA receptors that increase efferent innervation of motor fibers of phrenic nerve that contract the diaphragm and accessory nerves that mediate intercostal muscles contraction [7]. Although it is unusual for hyponatremia itself to induce persistent hiccups [6], our patient later admitted that intermittent alcohol intoxication caused his hiccups and also stimulated his desire to “drink more water.” His discharge serum sodium concentration was again low at 131 mEq/L, suggesting that his osmostat remained reset at a lower than normal serum osmolality.
In the syndrome of inappropriate ADH (SIADH) caused by medications or other nonosmotic stimuli, patients exhibit persistent ADH secretion despite hypo-osmolality. In contrast, our patient discontinued his home medications prior to admission and showed wide fluctuations in urine osmolality (from < 100 to > 400 mOsm/kg) that would not be expected in the presence of an elevated ADH level. Poor dietary intake for several days prior to admission and a relatively low BUN level both supported limited protein and solute intake. However, his clinical history, obese habitus (BMI 32), and normal serum albumin suggested a normal level of nutrition. Clinical history, vital signs, physical examination, and laboratory testing excluded potential contributions of abnormal thyroid and adrenal dysfunction to his hyponatremia. The combination of a normal uric acid level and relatively low urine osmolality were also atypical for SIADH. Although not likely to be causal in our patient, osmoreceptors were recently detected in human gastrointestinal cells, suggesting that the brain is not the exclusive site for regulating thirst [8]. Curiously, these gastric receptors suppress thirst even before serum osmolality is altered by an oral water load, illustrating the exquisite regulation of water balance in the human body at multiple anatomic sites [9].
Although initially thought to be rare [10], a reset osmostat with sustained hyponatremia has been reported from a myriad of physiologic and pathologic processes. This condition is defined by in patients with persistent hyponatremia with hypo-osmolality but intact urinary concentrating and diluting capacity. Specifically, chronic hyponatremia due to a reset osmostat has been reported in patients with gastric carcinoma [11], tuberculosis [12], neurological disease [13, 14], and head trauma [10]. Interestingly, chronic exogenous desmopressin abuse also resets the osmostat and this abnormality can persist for several months or more [15]. A subset of patients with primary polydipsia (as detected in our patient), increase their urine concentration (that is, release ADH) during fluid deprivation, albeit at a lower than normal serum osmolality [16]. A reset osmostat also occurs in normal pregnancy but returns to normal postpartum [17], showing that the osmostat setpoint is remarkably flexible and can be reset when physiologic circumstances alter circulating blood volume.
As observed in our case, substantial evidence suggests that psychiatric patients with polydipsia reset their osmostat. In a series of 20 patients with psychogenic polydipsia and hyponatremia, moderate-to-severe hyponatremia (98–124 mEq/L), and an astonishing range of daily free water clearance between 12 and 36 L was observed after water intake of 7–43 L daily [16]. Remarkably, seven patients subjected to fluid restriction experienced a “reset osmostat” characterized by urinary osmolality that exceeded serum osmolality when serum osmolality rose only to 242–272 mOsm/kg, a level significantly below the normal range. Based on existing literature [16] and our patient’s ability to concentrate or dilute his urine at a lower serum sodium setpoint than expected, we speculate that chronic hyponatremia itself resets the osmostat by altering the feedback loop located in the hypothalamic-pituitary axis that controls thirst [18]. Taken together, these reports suggest that hypothalamic–pituitary axis may be amenable to pharmacologic intervention that resets the osmotic setpoint.
Unfortunately, no clear recommendations exist for treating patients with a reset osmostat, including those with concomitant psychogenic polydipsia with a predisposition to severe or symptomatic hyponatremia [19]. Although a reset osmostat might seem innocuous, substantial evidence suggests that mild hyponatremia (< 135 mEq/L) impairs balance and gait [20], increases fall risk [21], short-term memory loss [22], and also promotes progressive osteoporosis [23] as well as fractures, especially in the elderly [24]. A number of interventions have been proposed to address this clinical challenge. Independent of an antipsychotic effect, clozapine suppresses thirst in patients with primary polydipsia [19, 25, 26]. However, it is unclear whether suppressing primary polydipsia actually resets an abnormal osmostat [19, 25, 26]. Due to their potent ADH effects, it is tempting to suggest that ADH antagonists that pharmacologically increase Na might reset the osmostat to a normal setpoint [27]. If so, then resetting the osmostat in patients with chronic hyponatremia might be a novel indication for these agents. On the other hand, the salt tablets, a maneuver that increases the serum sodium concentration by only 2–3 mEq/L [28], can also increase thirst in patients predisposed to polydipsia and therefore risks inadvertent worsening of hyponatremia.
