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NBME 22 Answers

nbme22/Block 1/Question#1
A 66-year-old man develops worsening ...
Dilution of serum sodium due to ADH (vasopressin) secretion🔍

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 +12  upvote downvote
submitted by imgdoc(100),

I think alot of people might have over emphasized how important ANP and BNP really are, yes it is important to know these peptides get secreted by the atrial/ventricular myocardium during heart failure. However their overall effectiveness in treating heart failure is zilch, a preceptor told me that if ANP and BNP were so useful in natriuresis then why do we give diuretics? It's because RAAS overpowers this system hence causing negative effects and the endless loop of heart failure. AKA why we give ACE inhibitors.

Knowing that ANP gets neutralized by the RAAS system, we can shift our focus back to heart failure in this patient, where cardiac output is decreased, leading to ADH secretion and finally dilutional hyponatremia.

almondbreeze  a concept continuously emphasized by uw, but I get always wrong :'( +  
almondbreeze  good work done! +  
raffff  why does the body make anp at all since its so useless +2  
makinallkindzofgainz  @raffff - at least BNP gives us a good marker for heart failure exacerbations :) thanks body! +  
mdrahimi7  Also read my answer mdrahimi7. I think it seems logical... +  
mannan  Yeah it's important clinically because it has a high sensitivity (if negative, rule out) for Heart failure. +  



 +10  upvote downvote
submitted by meningitis(307),

I also thought the same as @bubbles, but now trying to "justify" this tricky NBME question: I think this revolves on the fact that the patient has a HIGH blood pressure meaning we should focus on an answer that explains both increased BP and Hypovolemia (i.e: increased ADH which vasoconstricts and also absorbs free-water, both of which increase BP and cause hypovolemia).

Maybe if this patient were decompensated with LOW BP, one could think more about ANP.

I still think this question is TOO tricky.

meningitis  Sorry, hyponatremia* right? +  
mantarayray  I think that it's not ANP because ANP will cause a loss of Na but water will follow (they usually go together), whereas ADH will cause absorption of only water and will cause hyponatremia except only thought this post getting the question wrong :") +2  
mantarayray  Oops sorry the formatting is confusing: I think that it's not ANP because ANP will cause a loss of Na but water will follow (they usually go together), whereas ADH will cause absorption of only water and will cause hyponatremia. +2  
pg32  @mantaray pretty sure you are right and that is the only way to get this question correct. Remembering that Na concentration really is a measure of water balance is key. If the pt is hyponatremic, that just means they have too much water in the blood, which is caused by ADH. If the patient was hypoVOLEMIC, that might mean they are losing too much Na. This is illustrated by pts with SIADH. They are hyponatremic, but euvolemic, meaning that they have too much water (hyponatremia from the ADH) but their Na balance is ok (due to excretion of Na via ANP/BNP) +  
mdrahimi7  Also read my answser mdrahimi7. I think it seems logical... +  



 +3  upvote downvote
submitted by nwinkelmann(218),

From UpToDate: PATHOGENESIS

Like most other causes of hyponatremia, heart failure impairs the ability to excrete ingested water by increasing antidiuretic hormone levels. When cardiac output and systemic blood pressure are reduced, "hypovolemic" hormones, such as renin (with a subsequent increase in angiotensin II formation), antidiuretic hormone (ADH), and norepinephrine, respond [1-3]. Although edematous patients with heart failure have increased plasma and extracellular fluid volumes, the body perceives volume depletion (reduced effective arterial blood volume) since the low cardiac output decreases the pressure perfusing the baroreceptors in the carotid sinus and the renal afferent arteriole. The degree of neurohumoral activation is generally related to the severity of cardiac dysfunction, as assessed by left ventricular ejection fraction or functional class [2]. The neurohumoral changes limit both sodium and water excretion in an attempt to return perfusion pressure to normal. ADH release directly enhances water reabsorption in the collecting tubules, whereas angiotensin II and norepinephrine limit distal water delivery (and thereby water excretion) by lowering the glomerular filtration rate (due to a marked reduction in renal perfusion) and by increasing proximal sodium and water reabsorption [4]. In addition, both the low cardiac output and high angiotensin II levels are potent stimuli to thirst, leading to enhanced water intake.

https://www.uptodate.com/contents/hyponatremia-in-patients-with-heart-failure#H2




 +2  upvote downvote
submitted by bubbles(50),

This question confused me a lot because so many questions have drilled me on the importance of the ANP escape mechanism in times of fluid overload (as in CHF).

I thought ANP was a huge player in the loss of Na in circumstances of volume overload as in this patient (which is why you see euvolemic hypOnatremia in patients with SIADH or overactivity of the RAAS as in CHF).

Why is ADH now being named as the responsible agent?

jooceman739  My thinking is that ANP causes natriuresis, so you're losing salt and water at the same time (isoosmotic fluid?). Meanwhile, ADH absorbs only free water, so it would dilute the serum. Correct me if i'm wrong. +8  
bubbles  Ohhh you are right. Thank you for the explanation! I got so fixated on that one mechanism haha. +2  



 +1  upvote downvote
submitted by moloko270(52),

https://www.ncbi.nlm.nih.gov/pubmed/7058822

"syndrome of "dilutional hypo-osmolality" in severe congestive heart failure may be caused by an inappropriately high ADH secretion in which the osmoreceptor system is dominated by nonosmolar stimuli"

hayayah  Apparently, in chronic CHF you see hyponatremia. Because CHF causes a decrease in cardiac output and circulating blood volume, which in turn triggers a compensatory response aimed at preserving blood pressure. This stimulates the body to retain both water and sodium. +4  
seagull  i agree with Hayayah... the RAAS system is activated due to poor perfusion to the kidney due to decomp heart failure. +4  



 +1  upvote downvote
submitted by dr.xx(101),

CHF patients often display signs and symptoms of increased vasopressin secretion.

hyperfukus  if all else fails i hope i just drill this one statement in my brain and it comes out in the right way on test day thank u!!! +  



i kinda of feel "odd" asking this question : but the patient had an MI 6 months ago, so why would it be unlikely that he was told to "restrict salt, restrict fluids (water) " ??

Guess what i'm asking is : what makes choice E such an unlikely choice (JVD, bi-basilar crackles, peripheral edema) ?

& @meningitis : his bp is 135/82 mmHg ... why is that "HIGH" ??




Here we go:

  • decreased LV contractility (bilateral crackles)
  • decreased cardiac output
  • activate RAAS → ADH
  • increase sympathetic activity → more RAAS → more ADH



 +0  upvote downvote
submitted by nicsar(1),

Hyponatremia from Heartfailure pt.

It should be approached from Heart faiure.

HF-> RAAs -> excessive Aldosterone, ADH; ANP escape faiure, like secondary hyperaldosteronism; Hyponatremia

https://www.wjgnet.com/1949-8462/full/v5/i9/WJC-5-317-g001.htm




 +0  upvote downvote
submitted by dubywow(8),

Decompensated HF. Lack of blood flow due to failing heart -> lower BP -> increased ADH to increase blood pressure back to stable level. In DHF, ADH outpaces homeostasis of counteracting ANP & BNP. Thus, the term "decompensated". Associated with shortness of breath, edema (often of lungs).

This vicious cycle continues as body prioritizes adequate BP for survival, but it comes at the expense of overworked heart that must work harder and harder, ultimately exacerbating the heart failure condition.




 +0  upvote downvote
submitted by asharm10(7),

Always know this Hypo or hypernatremia is because of change in the volume, this patient is going through heart failure, renal perfusion has gone down that leads to release of ADH cos of osmoreceptors stimulation. Now high ADH will reabsorb more free water that will lead to hyponatremia. So hyponatremia is almost always related to high ADH. I know few of you will think but RAAS system is activated too but that abosrb Na along with water but ADH just free water.




 +0  upvote downvote
submitted by hello(180),

There has to be a better explanation for why ANP is wrong?

waterloo  If this pt's ANP/BNP were causing him to become hyponatremic, why does he have fluid overload symptoms (bilateral crackles, JVD, high BP)? There has to be something else overcoming the ANP system. +  



 -2  upvote downvote
submitted by mdrahimi7(-1),

Answer 👇 Actually when you study the history of patient that patient had myocardial infarction six months ago right + now some complications related to heart failure has been developed. It is true that anp leading to not secretion of adh +raas so from one way it prevents the h2o reabsorbtion through adh and on other hand aldestrone because of inhibition of raas will not be activated so in lack of aldestrone we loss na +h2o( because na drag water with it) so if you think the concentration of na it hasn't been diluted .it is not diluted !why? Because when we say normal level of na is is 135 to 145 milliequivalents per liter (mEq/L) Actually when say normal level of na according blood amount so anp it didnt lead you decrease concentration of na . So now you know when anp work its function so amount of blood volume decrease again adh and raas will be activated by action of raas again na+ h2o will be reabsorb so no hyponatremia but you know adh also release so leads to attraction of h2o and make the blood volume diluted so concentration of na decrease as compared to h2o so hyponatremia develops. Always remember : When we are talking about hyponatremia always consider the amount of plasma with na level and na if any mechanism decreases just na so hyponatremia can be develop and also when extra pure h2o is reabsorbed still hyponatremia will be there bevause it has been diluted but when we say something is drag na+h2o from blood so we lose plasma with na so na will not be diluted!




 -2  upvote downvote
submitted by lauri(-2),

I CANNOT VIEW THE ENTIRE QUESTION. IS THIS NORMAL?

trichotillomaniac  Hi Lauri, this is normal. We can't post the whole question due to copy right laws but you can almost always find the question you are looking for and the answer to by going to the form and then Ctrl + find -ing the age of the patient and other key words or the answer! +1  
drdoom  HI LAURI. THANK YOU FOR DEMONSTRATING YOUR PROFICIENCY WITH ALL-CAP COMPOSITION! +3  









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