Diagnostic Utility of Fractional Excretion of Urate, Urinary Phosphate and Brain Natriuretic Peptide in Distinguishing Cerebral/Renal Salt Wasting From SIADH in Neurologically Ill Children: A Systematic Review.
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BACKGROUND: Hyponatremia remains a common and life-threatening complication in children with traumatic brain injury, subarachnoid haemorrhage, brain tumours and post neurosurgical states, yet distinguishing its two primary neurogenic etiologies-syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral/renal salt wasting (C/RSW)-remains difficult. Misdiagnosis may result in inappropriate treatment strategies with a significant risk of morbidity. While adult studies suggest diagnostic roles for fractional excretion of uric acid (FEurate), fractional excretion of phosphate (PEphosphate) and NT-proBNP level, no paediatric-specific guidelines or reference thresholds currently exist. OBJECTIVE: To evaluate the diagnostic accuracy of FEurate, FEphosphate and NT-proBNP in distinguishing C/RSW from SIADH in hyponatremic children with neurologic conditions. DATA SOURCES: A comprehensive literature search was performed across PubMed, Embase, Web of Science, Scopus and the Cochrane Library. STUDY SELECTION AND DATA EXTRACTION: Eligible studies included RCTs, systematic reviews, meta-analysis and prospective/retrospective studies involving paediatric patients diagnosed with SIADH or C/RSW using any of the three biomarkers. Systematic reviews were appraised using AMSTAR 2. Two reviewers independently assessed eligibility and extracted data. RESULTS: Out of 69 identified studies, there were only two prospective paediatric cohort studies reported on the use of biomarkers in C/RSW versus SIADH syndromes. LIMITATION: Findings are limited by the absence of paediatric-specific cut-off values. CONCLUSIONS: Current evidence suggests that FEurate, FEphosphate and NT-proBNP may provide diagnostic clues, but each biomarker has limitations related to assay variability, age-dependent reference ranges, comorbidities and confounding medications. FEurate response to sodium correction appears most useful, though serial measurements are often required.