HYPOTONIC DISORDERS

DEFINITION.
In a hypotonic disorder, the ratio of solutes to water in body fluids is reduced, and the serum osmolality
and serum sodium are both reduced in parallel.
True hypotonicity must be distinguished from disorders in which the measured serum sodium is low while
the measured serum osmolality is either normal or increased.
The measured serum sodium concentration can be reduced either because there is an increased
concentration of small, non-sodium solutes restricted to the ECF or because of a laboratory artifact.
In hyperglycemia or excessive mannitol administration, these solutes, which are restricted to the ECF,
draw water from the cellular compartment.
The serum sodium level is therefore reduced, even though the serum osmolality may be increased.
When a small, non-sodium solute is distributed in total body water, as in ethanol intoxication or in
azotemia, the serum osmolality rises but the serum sodium concentration remains normal, resulting in an
"osmolar gap."
Instances of spurious hyponatremia due to hyperlipemia or hyperproteinemia are becoming less common
as more laboratories use ion-selective electrodes to measure the serum sodium concentration.
ETIOLOGY AND PATHOGENESIS.
Hyponatremia and simultaneous body water hypotonicity develop whenever water intake exceeds the sum
of renal plus extrarenal water losses; in chronic hyponatremia, the net water intake and net water output
may be equal.
Thus, hyponatremia and body fluid hypotonicity occur when there is a
o primary increase in water ingestion,
o when the ability of the kidney to dilute urine maximally is limited
o when a combination of these factors is operative.
The kidney regulates serum sodium concentration by increasing or decreasing free water excretion.
Free water is generated by the kidney across the diluting segments by absorbing salt without water.
Failure to generate free water occurs in those clinical circumstances in which less salt is delivered to the
diluting segments.
Free water is absorbed in the collecting duct.
o The rate of free water reabsorption is regulated in large part by ADH.
o Thus, the higher the ADH concentration, the greater is the rate of free water reabsorption,
assuming that other driving forces for water reabsorption remain constant.
Conditions with increased ADH concentrations are generally associated with hyponatremia.
The collecting duct can maintain large osmotic gradients; however, this capacity is limited, and the
minimal osmolality of the urine is approximately 50 mOsm/kg H2 O.
If more dilute fluid is delivered to the collecting duct, this water will be reabsorbed even in the absence of
ADH, as occurs in psychogenic polydipsia and in beer potomania.