Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"

Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Important Notice

Original article / research
Year : 2009 | Month : April | Volume : 3 | Issue : 2 | Page : 1419 - 1425

Clinical Profile Of Hyponatraemia In Adult Patients Admitted To Hamad General Hospital, Qatar: Experience With 53 Cases


*(MD)Attending physician,** (MD)Attending physician, *** (MD) Deptt of medicine, Hamad General Hospital/Doha-(Qatar)

Correspondence Address :
Dr. Ali Ibrahim Rahil, (MD) Attending physician,
Dept. of medicine, Hamad general hospital, Doha, Qatar.
Tel: 0974 4392489, 0974 5600465 Fax: 0974 4392745
P.O.Box- 3050, Doha-(Qatar)


Background: There is limited information about the clinical profile of hyponatraemia in Qatar.
Objectives: The aim of this study was to describe the clinical presentation and aetiology of moderate and severe hyponatraemia in patients admitted to Hamad general hospital.
Patients And Methods: This descriptive observational hospital-based study was conducted at Hamad general hospital from June 2007 to July 2008; it involved all adult patients who were admitted to Hamad general hospital with moderate and severe hyponatraemia.
Results: During the 12-month study period, 53 consecutive patients with moderate and severe hyponatraemia were admitted to Hamad general hospital. 33 (62.3%) were males and 20 (37.7%) were females). The mean age of the patients was 56± 20 years (range of 17-93 years). Females had a significantly higher mean age than males (63.9±16.9 versus 51.6±21.2, p = 0.02). Hyponatraemia due to extra-renal sodium loss was the most frequent cause of hyponatraemia, it was found in 18 (33.9%) patients; whereas the aetiology of hyponatraemia remained unknown in four patients. Of all, 31 (58.4%) patients had moderate hyponatraemia, whereas 22 (41.6%) patients had severe hyponatraemia. Impairment of consciousness was found in 13 (24.5%), it ranged from confusion to coma in 13 patients with impairment of consciousness, 10 (76.9%) had severe hyponatraemia and 3 (9.6%) had moderate hyponatraemia.
Conclusions: Hyponatraemia due to extra-renal loss was the most frequent cause of hyponatraemia in our study; it was more prevalent among elderly patients than in younger patients. No significant gender related difference differences were found in the relative frequency rates. Moreover, no significant differences were found between moderate and severe hyponatraemia with respect to consciousness impairment.


Hyponatraemia; Diuretics; SIADH; renal failure

Hyponatraemia is the most common disorder of electrolytes encountered in clinical practice, occurring in up to 15% to 30% of both acutely and chronically hospitalized patients (1). Significant hyponatraemia also can be found in healthy individuals who participate in high-endurance exercises such as marathon and iron man triathlons (2).
Although most cases are mild and relatively asymptomatic, hyponatraemia is important clinically because: (1) acute severe hyponatraemia can cause substantial morbidity and mortality; (2) mortality is higher in patients with hyponatraemia who have a wide range of underlying diseases; and (3) overly rapid correction of chronic hyponatraemia can cause severe neurological deficit and death (3).

Despite the awareness on hyponatraemia since the mid-20th century, this common disorder remains incompletely understood in many basic areas because of its association with a plethora of underlying disease states, and its multiple aetiologies with differing pathophysiological mechanisms (4). Data on the characteristics of patients with hyponatraemia among all patients admitted to the Hamad General Hospital (HGH) is lacking; the aim of this study was to describe the prevalence, clinical presentation, aetiological factors and outcome of hyponatraemia among the hospitalized patients at HGH, and to compare the results with previously reported studies.

Material and Methods

This prospective observational hospital-based study was conducted at Hamad General Hospital from June 2007 to July 2008.

Inclusion Criteria
1. patients aged ≥ 15 years
2. patients with true hyponatraemia ( low plasma osmolality <260 mOsm/kg)
3. patients with moderate and severe hyponatraemia:

a) Moderate hyponatraemia is defined as plasma [Na+] of 115-124 meq/l, while severe hyponatraemia is defined as plasma [Na+] of less than 115 meq/l
b) Syndrome of inappropriate ADH secretion (SIADH): Euvolaemic hyponatraemia with plasma osmolality of less than 280 mOsm./kg; urine osmolality of more than 100 mOsm./kg; urine sodium of more 20 meq/l; and exclusion of renal, adrenal, thyroid, and pituitary dysfunction.
c) Hyponatraemia due to renal loss is characterized by renal sodium excretion of >20 mmol/L, whereas hyponatraemia due to extra-renal loss is characterized by renal sodium excretion of <10 mmol/L.
d) The diagnosis of heart failure- induced hyponatraemia required the following criteria: evidence of heart failure (clinically as well as by echocardiography), urine sodium of less than 10 meq/l in the absence of liver cirrhosis, renal failure and other causes of hyponatraemia.
e) Liver cirrhosis hyponatraemia was defined as hyponatraemia that occurred in the setting of liver cirrhosis with ascites, with hypervolaemic status and shows urine sodium of less 10 meq/l.
f) Diuretics are considered to be a cause of hyponatraemia when urine sodium is more than 20 meq/l in hypovolaemic or apparently euvolaemic patients excluding other causes of hyponatraemia.
g) Extra-renal fluid loss including vomiting, diarrhoea, and diaphoresis is considered as a cause of hyponatraemia when urine sodium is less than 10 meq/l, in the presence of hypovolaemic status.

Data Collection
Data was collected by one of the authors into a special form which included demographic data, clinical data, treatment, and outcome.

Data Analysis
Statistical analysis was carried out using the software EpiInfo2000. Quantitative variables are expressed as mean ± standard deviation. Student t- test was used for continuous variables and the Mann-Whitney U test was used if variables were not normally distributed. Fisher exact test or Chi Square test were used when appropriate, to compare the data in young vs. older patients. Results were considered significant if P-values were less than 0.05.

Research Committee Approval
The study was approved by the Research Committee and Medical Research Centre at the Hamad Medical Corporation (HMC). Informed consent was obtained from each participant before any interview or physical examination was conducted.


During the 12-month study period, 53 consecutive patients with moderate and severe hyponatraemia were admitted to Hamad General Hospital. There were 33 (62.3%) males and 20 (37.7%) females) with no significant gender- related differences in the relative frequency rates. The mean age was 56± 20 years (range of 17-93 years). Females had a significantly higher mean age than males (63.9±16.9 versus 51.6±21.2, p = 0.02).

Twenty one (39.6%) patients were Qatari. Non-Qatari patients were 32 (60.4%) of whom 8 (15.1%) were Nepalese, 5 (9.4%) were Indians, 3 (5.7%) were Saudis, 3 (5.7%) were Pakistani, 3 (5.7%) were Sudanese, 2 (3.8%) were Palestinians and there was one (1.9%) each from Bangladeshi, British, Chinese, Jordanian, Philippino, Somali, South African and Turkish ethnicities.

Hyponatraemia due to extra-renal loss was the most frequent cause of hyponatraemia, which was found in 18 (33.9%) patients. Other most frequent causes were SIADH in 11 (20.8%), diuretics in 10 patients (18.9%), heart failure in 3 patients (5.7%) and renal failure in 3 patients (5.7%). In four patients, the aetiology of hyponatraemia remained unknown. Other causes of hyponatraemia are shown in (Table/Fig 1).

Of all, 31 (58.4%) patients had moderate hyponatraemia, whereas 22 (41.6%) patients had severe hyponatraemia. Impairment of consciousness (ranged from confusion to coma) was found in 13 (24.5%), 10 patients (76.9%) had severe hyponatraemia and 3 (9.6%) had moderate hyponatraemia. A comparison between young and older patients was made and no significant differences were found in relation to aetiology and outcome, except for the number of patients in each group; the number of older patients with hyponatraemia was greater than that in young patients (37 vs. 16; p=0.01). Moreover, CNS manifestations were more prevalent among older patients than in young patients (Table/Fig 2).
Total in hospital mortality was 11.3% (6 out of 53 patients); 3 patients (5.7%) presented with moderate hyponatraemia while the other three had severe hyponatraemia.


We found that hyponatraemia accounted for approximately (0.8%) of admissions to the medical ward of Hamad General Hospital in Qatar during the period of the study, which is less than that found in many reports. (1),(4),(5) The reason for this is not clear; it could have resulted from the exclusion of mild hyponatraemia in this study, which represented the majority of admitted cases in other reports. We have studied moderate to severe hyponatraemia in our study because of the fact that this is the level usually associated with symptoms and requires a prompt but cautious approach towards treatment in order to avoid cerebral oedema on one side and iatrogenic central myelinolysis on the other side.

In similarity to other reports (6),(7),(8) hyponatraemia in this study was more prevalent among elderly patients than in younger patients (37 vs. 16; p=0.01).

Because there are many causes of hyponatraemia and the treatment differs according to the cause, a thorough understanding of the pathophysiological process of hyponatraemia and its associated risk factors is of great importance for prevention and prompt and effective intervention in this potentially life-threatening disturbance.

Hyponatraemia is ascribed to either water retention or (less often) loss of effective solute (sodium plus potassium) in excess of water. Because the capacity for water excretion normally is so great, the retention of water resulting in hyponatraemia takes place only in the presence of conditions that impair renal excretion of water. An exception to this rule is primary polydipsia, in which the excessive water intake can overwhelm even normal excretory capacity. Given that suppression of arginine vasopressin (antidiuretic hormone [ADH]) secretion is essential for the excretion of any water load, the presence of high serum ADH concentrations is the sine qua non for the development and maintenance of hyponatraemia.

Virtually, all causes of hyponatraemia (except renal failure and primary polydipsia) are characterized by an excess of ADH (despite the presence of hypotonicity), which is most frequently caused by the syndrome of inappropriate ADH secretion (SIADH) or effective circulating volume depletion (which is a normal stimulus to ADH secretion) (9),(10).

Distinguishing the cause(s) of hyponatraemia may be challenging in clinical practice. In a prospective study conducted in a general medical-surgical setting, (9) 66 patients (34%) had euvolaemic hyponatraemia, 38 (19%) had hypervolaemic hyponatraemia associated with oedematous disorders, and 33 (17%) had hypovolaemic conditions, chiefly related to G.I fluid loss or diuretic use. Extra-renal fluid loss including vomiting, diarrhoea, or diaphoresis was the most frequent cause of hyponatraemia in our study and it was found in 18/53 (33.9%) patients.

In spite of being the most usual aetiological factor for hyponatraemia in hospitalized elderly patients (11) as well as the most common cause of normovolaemic hyponatraemia, the syndrome of inappropriate ADH secretion (SIADH) is normally diagnosed by exclusion of other causes including diuretics and renal, liver, thyroid, adrenal, and pituitary diseases. (12) SIADH was considered to be the cause in 11/53 (20.7%) patients included in our study.

Diuretics (mainly thiazide) were found to be the cause of hyponatraemia in 10/53 (18.9%) of our patients; all of them were over the age of 45 years, in consistence with several studies that showed thiazide to be the major diuretic causing hyponatraemia (13),(14),15],(16),(17),(18). They also demonstrated that older patients, particularly women, were more vulnerable to thiazide-induced hyponatraemia because they generally have a decreased ability to excrete water load due to reduced intra-renal generation of prostaglandins (19),(20),(21).
The clinical presentations of severe hyponatraemia can range from mild non specific symptoms such as nausea, headache, and lethargy, to severe symptoms causing seizure and coma (22). Thirteen of our patients (24.5%) presented with impaired level of consciousness that ranged from confusion to coma and most of them had serum sodium of less than 115meq/l. There was no significant age or gender difference, despite the evidence from animal studies that showed females to have greater sensitivity to vasopressin than males and less ability to extrude sodium from brain than males (23). Furthermore, oestrogen has been shown to stimulate the release of vasopressin, which potentially increases water retention, while testosterone reduces ADH levels (24).

Not only is hyponatraemia associated with severe manifestations, but it also predicts mortality and this has been demonstrated in patients with heart failure in whom sodium levels less than 125 meq/l represents near end stage disease (25). This is an adverse predictor of short term outcomes(26),(27) mainly in patients with liver cirrhosis and ascites in whom there is a correlation between severity of hyponatraemia and the degree of ascites, impaired renal function, degree of hepatic encephalopathy, spontaneous bacterial peritonitis, and hepatorenal syndrome (28). Hyponatraemia has also been shown to be a strong predictor of death in cirrhosis (29),(30),(31).

In our study, two out of three patients with heart failure, and two patients with liver cirrhosis died during hospitalization, emphasizing the prognostic value of hyponatraemia.

The endocrine causes of hyponatraemia are not infrequently missed and as they can be easily treated with hormone replacement, they should be looked for; these include hypothyroidism, primary adrenal insufficiency, and hypopituitarism. Hypothyroidism was documented in one patient, and hypopituitarism in another patient in our study.

As noted, the total in hospital mortality was 11.3% (6 out of 53 patients); whereas no case of clinically evident central myelinosis was documented, following the treatment of hyponatraemia.

A limitation of this study was the small number of patients. Moreover, the study was hospital based rather than population based, which necessitates further prospective population based studies.


Hyponatraemia was found to be more prevalent among elderly patients than in younger patients. Extra-renal loss and SIADH were the most frequent causes of hyponatraemia in our study. No significant gender -related differences were found in the relative frequency rates; moreover, no significant differences were found between moderate and severe hyponatraemia with respect to consciousness impairment.


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. Verbalis JG, Goldsmith SR, Greenberg A, Schrier RW, Sterns RH. Hyponatremia treatment guidelines 2007: Expert Panel Recommendations. Am J Med 2007;120 (11A), S1–S21
. Verbalis JG. The syndrome of inappropriate antidiuretic hormone secretion and other hypoosmolar disorders. In: Schrier RW, ed. Diseases of the Kidney and Urinary Tract. Philadelphia, Pa: Lippincott Williams and Wilkins; 2007:2214 –48.
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