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Syndromeof inappropriate secretion of the antidiuretic hormone (SIADH), was first described by Schwartz et al (1) in patients with bronchogenic carcinoma whowere hyponatremic, but clinically euvolemic with normal renal and adrenal function in 1957. Long lists of disorders which can be associated with SIADHwere proposed by many investigators (2-4), but all excluded adrenal insufficiency. Numerouscriteria or guides for the diagnosis of SIADH(3, 4) emphasize normal adrenal function as an important diagnostic category. Clinical practitioners readily believe and follow these criteria and give the diagnosis of SIADHto their hyponatremic patients simply after confirming their patient's adrenal corticosteroid level to be normal. To begin with, hyponatremia is the most commondisorder of body fluid and electrolyte balance encountered in clinical practice of medicine; the incidence ranges from 1 to 2.5% in chronically hospitalized patients (5). The problem is that hyponatremia is the most common laboratory finding in patients with acute and chronic adrenocortical insuffiency, either primary or secondary due to adrenocorticotropic hormone (ACTH)deficiency or tertially due to corticotropin-releasing hormone (CRH) deficiency. The clinico-pathological findings of hyponatremia in some of the patients with adrenal insufficiency are similar to SIADHcharacterized by sodium loss without edema or dehydration, partly because of impaired water diuresis. Diuretic effects of glucocorticoids are well knownfor water dysuresis in adrenal insufficiency as has been demonstrated in the Oleesky test (6). In the absence of adrenal steroids, the kidneys are unable to excrete a water load and the defect is restored by glucocorticoids. The effect of glucocorticoid can be explained by improved renal hemodynamics and the effect on permeability of the renal tubule epithelium to water. In addition, a participation of antidiuretic hormone (ADH)must be taken into consideration as Shibata et al (7) described in this issue of Internal Medicine.

internal medicine

The Role of Antidiuretic Hormone in Hyponatremia in Adrenal Insufficiency-Is the Guideline for the Diagnosis of Syndrome of Inappropriate Secretion of the Antidiuretic Hormone Appropriate?-