Background and Aims
Hyponatremia is the most common electrolyte disturbance in clinical care. Even mild presentations are associated with poor prognosis and increased mortality, in spite of which there is a trend to minimize the importance of small variations in natremia, that have historically been dismissed as not having negative consequences despite growing evidence against it. In this regard, it has not been studied to date whether an intermittent but recurrent hyponatremia is relevant. There are clinical scenarios where this condition could occur and be overlooked, such as cirrhosis or heart failure.
Method
Different rat models have been used to study the effects of different hypotonic situations on the electrolyte balance and central nervous system: intermittent recurrent hyponatremia (intraperitoneal (i.p.) daily dose of desmopressin acetate (ddAVP) and a water dose equivalent to 2.5% of the animal's body weight in hyposodic diet fed animals), acute on intermittent recurrent hyponatremia (i.p. water overload equivalent to 10% of the animal's body weight in animals subjected to intermittent recurrent hyponatremia) and acute hyponatremia (i.p. administration of a 10% of the animal's body weight water overload in chow fed animals). Apparent diffusion coefficient (ADC) obtained from diffusion weighted images (DWI) acquired through magnetic resonance (7T Bruker Biospec) was used to study content and distribution of brain water, and immunohistochemistry was used to examine glial fibrillary acidic-protein (GFAP), astrocyte marker, and myelin basic protein (MBP), oligodendrocyte and myelin marker.
Results
In the intermittent recurrent hyponatremia model, mild and transient hyponatremia was induced (baseline Nap 136.50±1.73mEq/L vs 4h post-medication 129.44±1.20mEq/L, p<0.001), which was recovered 24h after treatment (141.25±0.96mEq/L, NS compared to baseline). However, this situation was repeated over a 7 day period. This translated into a lower ADC value in the whole brain (WB) compared to chow fed animals (25.07±1.71 vs 26.71±2.40*10−3mm2/s, p = 0.05) after this 7 day period, suggesting an increase in total brain water in this situation. There was also an increase in GFAP expression in the gray matter (GM) compared to chow fed animals (33.22±5.25 vs 25.07±2.31au, p = 0.031), although no significant changes in MBP’s expression were seen. Acute on intermittent recurrent hyponatremia induced hypotonic hyponatremia (116.00±1.16mEq/L, p<0.001 compared to baseline). In this situation, a progressive decrease in ADC values in the WB was seen, and it was less pronounced compared to chow fed animals (slope -0.11±0.02 vs -0.26±0.006, p = 0.014). When GM and white matter (WM) were analysed separately, they both showed a progressive increase in ADC values, more evident in the WM (slope WM 0.19±0.04, p<0.05; slope GM 0.05±0.02, p = 0.002). The water overload increased GFAP and MBP’s expression in the WM (GFAP 23.17±6.37 vs 16.83±5.17au, p = 0.001; MBP 45.20±8.32 vs 28.76±7.03au, p<0.001), but no changes were seen in the GM, similarly to what had been observed in the acute hyponatremia model.
Conclusion
Intermittent recurrent hyponatremia is a novel animal model that suggests there can be significant water retention after only a few hours of hyponatremia a day, provided this situation is repeated over time. Such water retention translates into greater brain water accumulation and astroglial activation in the GM. These animals's response to an additional water overload does not show big variations compared to what is observed in acute hyponatremia. This study highlights the importance of slight fluctuations in natremia, which, if maintained over time, can translate underlying water retention with consequences at the central nervous system level.
