Juan Carlos Q. Velez, MD
Dr. Velez is Associate Professor at Ochsner Clinical School/University of Queensland and Interim Chair in the Department of Nephrology at Ochsner Clinic Foundation. Follow him @VelezNephHepato.
Competitors for the Hyponatremia Region
There is a reason why hyponatremia is the most common term searched on UpToDate. It is the diagnosis that invariably puzzles the medical resident and provokes anxiety in the young hospitalist and even concerns the experienced internist. Hyponatremia is always a great topic to teach in hospital rounds and one that drives the intern to compulsively search for that manual that shows the infamous trichotomized diagnostic algorithm.
On the other hand, the nephrology consultant and her/his team welcome those new hyponatremia consults (or really any that is going to break the monotony of those many unfollowed recommendations throughout the day). For this new consult, the nephrologist knows very well that everybody will await their recommendations, and yes, this time, those recommendations will be followed to the minimum detail.
The joy of a hyponatremia consultation comes with a great responsibility: to apply knowledge, expertise and clinical judgment to manage a difficult case. And there is no better scenario for it than a case of SIADH, the momentous occasion for the nephrologist, the opportunity to showcase years of training and bring calm to the stormy medical ward. They likely already know that the diagnosis is not volume depletion, heart failure, or cirrhosis. They may suspect SIADH, but they need our blessing and a pat on their shoulder to carry them along during treatment.
I am of the opinion that while recipes, guidelines, and algorithms provide a useful tool for and enhance consistency in clinical grounds, they can interfere with critical thinking and the true art of medicine. I am not going to waste a lot of lines debunking the urea-minded European Guidelines led by the “urea guy” Guy Decaux or the vaptan-friendly US Guidelines led by the “tolvaptan guy” Joseph Verbalis. I respect wholeheartedly both outstanding scientists and their contributions to the field, as well as the panel of experts that constructed those important documents.
However, when it comes to managing hyponatremia, I am not going to digest an 18-page document to decide my approach. Nephrologists are kidney physiologists and we have gained the right to enjoy the moment in our practice in a more romantic and traditional way. We are poised to make educated decisions and provide optimal care to our patients. SIADH is the electrolyte disorder that solidifies our passion for the beans. When we face it, everything makes sense again. The elusive case of renal Salt Wasting by cisplatin or a brain mass can certainly make a mark on us, but many nephrologists spend their careers without convincingly encountering it.
At the end, SIADH is our baby, a moment to shine, a disorder to fix, an opportunity to learn, and many times, a very grateful patient and an exhilarating medicine team that will not hesitate to call us again when the next dysnatremia arrives.
– Post by Juan Carlos Q. Velez. Follow him @VelezNephHepato.
As with all content on the AJKD Blog, the opinions expressed are those of the author of each post, and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.