Loop diuretics hyponatremia with

Diuretics are used widely for the treatment of hypertension see Chapter 32), and loop diuretics appear to lower blood pressure as effectively as Na+-CL symporter inhibitors e.g., thiazides and thiazide-hke diuretics) while causing smaller perturbations in the Upid profile. However, the short elimination half-lives of loop diuretics render them less useful for hypertension than thiazide-type diuretics. The edema of nephrotic syndrome often is refractory to other classes of diuretics, and loop diuretics often are the only drugs capable of reducing the massive edema associated with this disease. Loop diuretics also are employed in the treatment of edema and ascites of hepatic cirrhosis however, care must be taken not to induce encephalopathy or hepatorenal syndrome. In patients with a drug overdose, loop diuretics can be used to induce a forced diuresis to facilitate more rapid renal elimination of the offending drug. Loop diuretics, combined with isotonic saline administration to prevent volume depletion, are used to treat hypercalcemia. Loop diuretics interfere with the kidney s capacity to produce a concentrated urine. Consequently, loop diuretics combined with hypertonic saline are useful for the treatment of hfe-threatening hyponatremia. Loop diuretics also are used to treat edema associated with chronic renal insufficiency. Most patients with ARE receive... 

Hypotonic hyponatremia with an increase in ECF is also known as dilutional hyponatremia. In this scenario, patients have an excess of total body sodium and TBW however, the excess in TBW is greater than the excess in total body sodium. Common causes include CHF, hepatic cirrhosis, and nephrotic syndrome. Treatment includes sodium and fluid restriction in conjunction with treatment of the underlying disorder—for example, salt and water restrictions are used in the setting of CHF along with loop diuretics, angiotensin-converting enzyme inhibitors, and spironolactone.15... 

Patients with hypervolemic hypotonic hyponatremia should be treated with 3% saline and prompt initiation of fluid restriction. Loop diuretic therapy will also likely be required to facilitate urinary excretion of free water. 

Because Henle s loop is indirectly responsible for water reabsorption by the downstream collecting duct, loop diuretics can cause severe dehydration. Hyponatremia is less common than with the thiazides (see below), but patients who increase water intake in response to hypovolemia-induced thirst can become severely hyponatremic with loop agents. Loop agents are sometimes used for their calciuric effect, but hypercalcemia can occur in volume-depleted patients who have another—previously occult—cause for... 

The most serious side effects of diuretics are fluid depletion and electrolyte imbalance.13,88 By the very nature of their action, diuretics decrease extracellular fluid volume as well as produce sodium depletion (hyponatremia) and potassium depletion (hypokalemia). Hypokalemia is a particular problem with the thiazide and loop diuretics, but occurs less frequently when the potassium-sparing agents are used. Hypokalemia and other disturbances in fluid and electrolyte balance can produce serious metabolic and cardiac problems and may even prove fatal in some individuals. Consequently, patients must be monitored closely, and the drug dosage should be maintained at the lowest effective dose. Also, potassium supplements are used in some patients to prevent hypokalemia. 

Loop diuretics Sertraline, paroxetine, and fluvoxamine may cause hyponatremia additive hyponatremic effects may be seen with combined use. 

In patients with the syndrome of inappropriate secretion of antidiuretic hormone and symptomatic hypotonic hyponatremia, the most efficient means of correcting the hyponatremia involves the administration of 3% saline in conjunction with a loop diuretic. 

Diuretic-induced hyponatremia occurs more frequently in patients treated with thiazide diuretics than in patients who are receiving loop diuretics. In addition to causing extracellular volume depletion and nonosmotic stimulation of ADH, thiazides interfere with urinary dilution and water excretion by blocking tubular sodium and potassium reabsorption in the distal tubule. Water is then retained in excess of sodium by virtue of nonosmotic release of ADH and excretion of urine with a concentration of sodium and potassium that exceeds that of the plasma. 

Hyponatremia occurs less commonly with loop diuretics for several reasons. Eirst, most loop diuretics have a shorter half-life than that of thiazides, and patients can therefore replete the urinary sodium and water losses prior to taking the next dose, thereby minimizing the degree of nonosmotic ADH stimulation. Loop diuretics also interfere with both urinary dilution and concentration. The latter is disrupted through inhibition of solute transport into the medulla, which interferes with creation of the medullary osmotic gradient. Thus relatively less water is retained in the presence of ADH. 

In hypercalcemia, excessive volume depletion, hyponatremia, and hypotension are major risks associated with the use of loop diuretics, and the side effects of hypokalemia, hyperuricemia, and hyperglycemia are always present. Loop diuretics should not be used concurrently with ototoxic aminoglycoside antibiotics (i.e., streptomycin, gentamicin, kanamycin, tobramycin). 

The use of diuretics which promote heavy potassium loss (e.g., loop diuretics and thiazide diuretics) with carbamazepine therapy may precipitate a marked hyponatremia. 

B. Effects In full doses, thiazides produce moderate but sustained sodium and chloride diuresis. Hypokalemic metabolic alkalosis may occur (Table 15-2). Reduction in the transport of sodium into the tubular cell reduces intracellular sodium and promotes sodium-calcium exchange. As a result, reabsorption of calcium from the urine is increased and urine calcium content is decreased— the opposite of the effect of loop diuretics. Because they act in a diluting segment of the nephron, thiazides may interfere with excretion of water and cause dHutional hyponatremia. 

Furosemide (Lasix) Inhibits chloride reabsorption in thick ascending loop of Henie. High loss of K+ in urine. Preferred diuretic in patients with low GFR and in hypertensive emergencies. Also, edema, pulmonary edema, and to mobilize large volumes of fluid. Sometimes used to reduce serum potassium levels. Hyponatremia, hypokalemia, dehydration, hypotension, hyperglycemia, hyperuricemia, hypocalcemia, ototoxicity, sulfonamide allergy, hypomagnesemia, hypochloremic alkalosis, hypovolemia. 

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