Osmotic Demyelination Unrelated to Hyponatremia

Am J Kidney Dis. 2018 Mar;71(3):436-440. doi: 10.1053/j.ajkd.2017.10.010. Epub 2017 Dec 23.


Osmotic demyelination unrelated to hyponatremia is rarely reported. We present a case of osmotic demyelination in a patient with hypernatremia in the absence of preceding hyponatremia and review previously reported cases of osmotic demyelination in nonhyponatremic patients. We conclude that a rapid increase in serum sodium concentration and plasma tonicity even in the absence of preceding hyponatremia may surpass the brain's capacity for adaptation to hypertonicity and lead to osmotic demyelination in predisposed individuals. Risk factors for osmotic demyelination in patients with chronic hyponatremia and without hyponatremia are probably similar and are usually associated with states of limited brain osmolyte response, such as alcoholism, liver disease (including those undergoing orthotopic liver transplantation), malnutrition, malignancy, pregnancy/postpartum state, severe illness/sepsis, adrenal insufficiency, and metabolic derangements. Clinicians should be vigilant in identifying individuals who may, even in the absence of hyponatremia, have increased susceptibility to osmotic demyelination and avoid rapid fluctuations in serum sodium concentrations in such patients.

Keywords: Osmotic demyelination; case report; central pontine myelinolysis; chronic kidney disease (CKD); electrolyte shifts; extrapontine myelinolysis; hypernatremia; hyponatremia; literature review; osmolality; osmolytes; serum sodium concentration.

Publication types

  • Case Reports
  • Review

MeSH terms

  • Blood Chemical Analysis
  • Diabetes Mellitus, Type 2 / complications
  • Diabetes Mellitus, Type 2 / diagnosis
  • Diabetes Mellitus, Type 2 / drug therapy
  • Disease Progression
  • Hepatic Encephalopathy / diagnostic imaging
  • Hepatic Encephalopathy / etiology*
  • Hepatic Encephalopathy / therapy
  • Hospice Care
  • Humans
  • Hypernatremia / complications
  • Hypernatremia / diagnosis*
  • Liver Cirrhosis, Alcoholic / complications
  • Liver Cirrhosis, Alcoholic / diagnosis
  • Liver Cirrhosis, Alcoholic / therapy
  • Magnetic Resonance Imaging / methods*
  • Male
  • Middle Aged
  • Multimorbidity*
  • Myelinolysis, Central Pontine / diagnostic imaging
  • Myelinolysis, Central Pontine / etiology*
  • Prognosis
  • Renal Insufficiency, Chronic / complications
  • Renal Insufficiency, Chronic / diagnosis
  • Renal Insufficiency, Chronic / therapy
  • Risk Assessment