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Hyponatremia Pocket Guide
Hyponatremia Pocket Guide
Recognition
Evaluation
Consequences
Management
Fundamentals of
VI SI T
2 3
Table of contents
Chapter 1: Recognition 4
Definition .................................................4
Prevalence ................................................5
Etiologies ..................................................6
Signs, symptoms, and complications ......7
Chapter 2: Evaluation 10
Classification ..........................................10
Prognostic markers ................................11
Acute vs chronic .....................................12
Levels of severity ...................................12
Misdiagnosis ...........................................13
Chapter 3: Consequences 14
Potential effect on the brain ...............14
Impact on selected outcomes ...............15
In-hospital mortality ..............................16
Risk of mortality ....................................17
Impact on hospital costs .......................18
Chapter 4: Management 20
Considerations .......................................20
Rate of correction..................................20
Management strategy
for correction .........................................21
Introduction
Hyponatremia is the most common electrolyte disorder in
hospitalized patients.
1
Hyponatremia can be a serious threat.
1
One study found that mild, or even asymptomatic, hyponatremia
may be associated with increased morbidity and the risk of
mortality.
1,2
While the symptoms of hyponatremia are not
always severe, the danger may be real.
1
Hyponatremia can produce a range of symptoms involving
almost all of the body systems.
2
The effects on the central
nervous system (CNS) can be significant and potentially lethal.
2
Hyponatremia also impacts hospital economics as it has been
shown to induce longer, more costly hospital stays.
3
Although there are many scientific articles on hyponatremia,
this pocket guide is designed to bring you the broad
fundamentals. From the definition of hyponatremia to
its relationship with mortality to its estimated burden on
the national healthcare system, you will find important
information in one concise resource.
VI SI T
4 5
0
10
20
30
40
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Hyponatremia during the hospital stay
1
Hospital-acquired hyponatremia
0
10
20
30
40
Hyponatremia upon admission
6
Acute care hospital patients
Serum sodium level
upon admission
was <136 mEq/L
Serum sodium level
upon admission
was <126 mEq/L
P
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%
Prevalence in the hospital
Approximately 25% of acute care patients had
hyponatremia ([Na
+
] <136 mEq/L) upon admission
to the hospital
6
Analyzed in a large study of more than 100,000 patients
conducted at an Asian hospital
6
A more severe level of hyponatremia (defined in this study
as [Na
+
] <126 mEq/L) was seen in 2.6% of hospitalized patients
6
In a separate study, it was shown that 38.2% of patients
acquired hyponatremia during their hospital stay
1
Determined in a retrospective analysis of 53,236
hospitalizations represented by 7 years of discharge records
1
Hospital-acquired hyponatremia developed in 10,662 of
27,897 hospitalizations for which the initial serum sodium
level was within 138-142 mEq/L and length of stay was
longer than 1 day
1
Chapter 1: Recognition
Defining hyponatremia
Hyponatremia, defined as a serum sodium level of <135 mEq/L,
indicates a relative excess of total body water to sodium
4
Most common electrolyte disorder in the hospital
1
Types of hyponatremia
2,5
Dilutional
Hypervolemic
Total body sodium
increased
Total body water
increased
Edema
Euvolemic
Total body sodium
unchanged
Total body water
increased
No edema
Depletional
Hypovolemic
Total body sodium
and water reduced
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6 7
Etiologies of hyponatremia
Hypervolemic
5,7
Congestive heart failure
Cirrhosis
Nephrotic syndrome
Acute/chronic renal failure
Euvolemic
5,7-9
Adrenal insufficiency
Hypothyroidism
Syndrome of Inappropriate
Antidiuretic Hormone (SIADH)
Drugs (antidepressants, antipsychotics,
barbiturates, nicotine, NSAIDs,
morphine, vincristine)
Physical/emotional stress
Malignancies
Pulmonary disease
CNS disorders
Idiopathic
Hypovolemic
5
Diuretic excess
Mineralocorticoid deficiency
Salt-losing nephritis
Osmotic diuresis
Ketonuria
Bicarbonaturia
Vomiting or diarrhea (extrarenal origin)
Third-spacing (ie, burns, pancreatitis)
Seizures
Coma
Permanent
brain damage
Respiratory
arrest
Brain-stem
herniation
Death
Headache
Nausea
Vomiting
Muscle cramps
Lethargy
Restlessness
Disorientation
Depressed
reflexes
Signs and
symptoms of
hyponatremia
14,15
Complications of
severe and rapidly
evolving hyponatremia
14,15
Signs, symptoms,
and complications
The symptoms of hyponatremia
may not always be clear
10
The symptoms of hyponatremia may overlap with the
symptoms of other disorders or diseases
11-13
While hyponatremia can affect a wide range of body
systems, the most severe consequences involve the CNS
2
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8 9
21.3
%
5.3
%
0
5
10
15
20
25
Patients admitted for falls
16
Hyponatremic patients
126 5 mEq/L
(n=122)
Adjusted OR 67.4,
95% CI 7.5-607.4,
P<0.001
Mean serum [Na
+
]:
No. of patients:
Control patients
139 2 mEq/L
(n=244)
P
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s
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m
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f
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s
,
%
Incidence of falls among 122 patients (mean age 72 13 years) with asymptomatic
chronic hyponatremia (mean serum sodium concentration [SNa] 126 5 mEq/L)
compared with 244 matched controls (mean age 71 12 years). Adapted from
Renneboog B et al. Am J Med. 2006;119(1):71.e1-71.e8.
16
Mild hyponatremia is
not always asymptomatic
16
Irregular gait
16
Unsteadiness of gait was shown to be significantly greater
in patients with hyponatremia (n=12) as compared with
patients who were normonatremic
16
Assessed in a study (N=122, approximate mean serum
Na 126 mEq/L) of mild, chronic hyponatremia conducted
in a Brussels, Belgium, hospital over the course of 3 years
16
High incidence of falls
16
In this same study, falls were demonstrated to be a common
symptom in mild chronic hyponatremia
16
Patients with chronic asymptomatic hyponatremia were
admitted for falls significantly more frequently than patients
with normal sodium levels
16
140
120
100
80
60
40
20
0
-20
-40
-60
-80
-100
-120
-500 -400 -300 -200 -100 100 200
[Na
+
]=124 mEq/L
Irregular gait with mild
asymptomatic hyponatremia
16
Evolution of the total traveled way (TTW) by the center of pressure in the dynamic test
to walk on the platform 3 stereotyped steps in tandem, eyes open, in patient C with
mild asymptomatic hyponatremia. Patient is walking from right to left. Irregular path
of the center of pressure observed in the hyponatremia condition (arrow).
Adapted with permission from Renneboog B et al. Am J Med. 2006;119(1):71.e1-71.e8.
16
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10 11
Classifying hyponatremia
Plasma osmolality
Hypotonic
hyponatremia
Euvolemic
hyponatremia
SIADH Endocrinopathies
Hypothyroidism
Glucocorticoid
deficiency
Excess water intake Impaired renal concentrating ability
Serum sodium <135 mEq/L
Hypovolemic
hyponatremia
Hypervolemic
hyponatremia
>295 mOsm/kg <280 mOsm/kg 280-295 mOsm/kg
>100 mOsm/kg <100 mOsm/kg
Isotonic
hyponatremia
Hypertonic
hyponatremia
Urine osmolality
Extracellular fluid
Urine sodium
>20 mEq/L
Renal
failure
>20 mEq/L <10 mEq/L
Urine sodium
Renal
solute loss
Extrarenal
solute loss
>20 mEq/L <10 mEq/L
Urine sodium
Edematous
disorders
Heart failure
Cirrhosis
Nephrotic
syndrome
Hyponatremia classification algorithm
5
Adapted from Douglas I. Clev Clin J Med. 2006;73(3):S4-S12.
5
Chapter 2: Evaluation
Prognostic markers
Laboratory measurements can be used in the differentiation
of hyponatremia
17
* Compared with serum osmolality.
Adapted from Hoorn EJ et al. Nephron Physiol. 2008;108(3):46-59.
17
Diagnostic indicators
17
Laboratory Disease/
measurement disorder
Serum osmolality: high Hyperglycemia, glycine
solutions
Serum osmolality: normal Pseudohyponatremia
Serum osmolality: low Hypotonic hyponatremia
Urine osmolality: high* Vasopressin-dependent
cause of hyponatremia
Urine osmolality: low* Vasopressin-independent
cause of hyponatremia
Urine sodium: low Heart/liver failure,
polydipsia, nonrenal
sodium loss, volume
depletion
Urine sodium: high Diuretics, cerebral
and renal salt wasting,
SIADH, primary
adrenal insufficiency,
hypopituitarism
Serum potassium: low Diuretic use, vomiting,
diarrhea
Serum potassium: high Primary adrenal
insufficiency, renal failure
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12 13
Acute vs chronic
Hyponatremia can be further classified as acute or chronic,
defined as duration of onset of <48 hours or 48 hours
2,5
Serum sodium falls
rapidly over a period of
<48 hours
Serum sodium falls
slowly over a period of
48 hours
Acute Chronic
Hyponatremia
Classification by rate
of declining serum sodium
2
The distinction of acute vs chronic significantly influences the
severity of CNS manifestations and potential complications
2
Patients with acute hyponatremia (serum sodium
<120 mEq/L) are at risk of irreversible neurologic damage
when the rate of serum sodium decrease exceeds
0.5 mEq/L/h
18
Levels of severity
Mild to severe hyponatremia
18,19
*
Mild
Moderate
Severe
130-135 mEq/L
120-130 mEq/L
<120 mEq/L
Mild hyponatremia can often be asymptomatic
19
While lower serum sodium levels can lead to more severe
consequences of hyponatremia, mounting evidence has
found that even mild hyponatremia can be associated with
increased morbidity and mortality
1,14,16
Misdiagnosis
As the cause of hyponatremia is often
unclear, the differential diagnosis of
hyponatremia may be complex
20
Assessed in a study analyzing a diagnostic algorithm for
hyponatremia in 121 patients presenting with serum
sodium <130 mEq/L
20
In this study common causes of misdiagnosis:
Effect of diuretics on clinical presentation and laboratory
measurements
20
Use of extracellular volume status as the determining
diagnostic factor
20
Hyponatremia and inadequate therapy may substantially
raise morbidity, mortality, and healthcare expenditure;
therefore, a careful diagnostic approach to patients with
hyponatremia is considered essential
20
Rate of misdiagnosis
20
:
Patients on diuretics
20
0 5 10 15 20 25
Percentage of patients misdiagnosed
Rate of misdiagnosis
20
:
Extracellular fluid volume
5
0 5 10 15 20 25
Percentage of patients misdiagnosed
* Serum Na values defining hyponatremia and its severity may vary across institutional laboratories
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14 15
In-hospital
mortality
19,030
1151
621
65
Admission [Na
+
]
<138 mEq/L and
further drop
Admission [Na
+
]
<138 mEq/L and
no further drop
Disposition
Adjusted
odds ratio
Adjustments for age, sex, race, admission service, and Deyo-Charlson Comorbidity Index score.
Hospitalizations resulting in death were excluded from analyses of disposition and length of stay.
2 3
Admissions
(n)
Impact of hyponatremia* on
selected outcomes
1
In-hospital
deaths (n)
18,409
1086
6744
569
Admission [Na
+
]
<138 mEq/L and
further drop
Admission [Na
+
]
<138 mEq/L and
no further drop
Admissions
(n)
18,409
1086
Admission [Na
+
]
<138 mEq/L and
further drop
Admission [Na
+
]
<138 mEq/L and
no further drop
Admissions
(n)
Discharged to
facilities (n)
Increased
length of stay