Hyponatraemia

Aiman Dilnawaz
4th year medical student
 Introduction
• sodium is an extracellular electrolyte
• Normal sodium level = 135-145mmol/L
• Hyponatremia severity:
Mild – 125 – 134 mol/L
Moderate – 120-124 mmol/L
Severe – <120 mol/L
• Types
1) Hypertonic hyponatremia (↑ serum osmolality)
2) Isotonic hyponatremia (↔ serum osmolality)
3) Hypotonic hyponatremia (↓ serum osmolality)
- Hypovolemic
- Euvolemic
- Hypervolemic
What is serum “How much water is
in the blood
compared to how
osmolality? many solutes are in
the blood”
 Hypertonic hyponatremia
(↑ serum osmolality)

• Hyperglycemia = Due to a water shift from intracellular to

extracellular
• Use of mannitol
 Isotonic hyponatremia
(↔ serum osmolality)

• Pseudohyponatremia = Elevated
concentrations of serum proteins or
lipids lead to a dilution of plasma
sodium.
e.g. Hyperlipidemia
 Hypotonic hyponatremia
(↓ serum osmolality)
Hypovolemic Hyponatremia
Volume of extracellular fluid is decreased. Typically caused by loss of
both salt and water
• Renal causes
1) diuretics (particularly loop diuretics and thiazide)
2) aldosterone deficiency (Addison's disease)
3) Nephrotic syndrome
• Extrarenal causes
1) Vomiting
2) Diarrhoea
3) Burn
4) Bleeding
Hypotonic hyponatremia
(↓ serum osmolality)
Hypervolemic hyponatremia
A subtype of hypotonic hyponatremia associated with
signs of fluid overload
Causes
1) Congestive HF
2) Liver cirrhosis
3) CKD
Hypotonic hyponatremia
(↓ serum osmolality)
Euvolemic hyponatremia
A subtype of hypotonic hyponatremia that is not associated
with clinical signs of hypovolemia
Causes
1) Syndrome of inappropriate ADH syndrome (SIADH)
2) Psychogenic polydipsia
3) Hypothyroidism - leads to an increase in ADH
secretion
 • Mild – nausea, vomiting, headache,
anorexia, lethargy
• Moderate – muscle cramps, weakness,
Symptoms confusion, ataxia
• Severe – drowsiness, seizures, coma
 Signs

• Decreased level of consciousness

• Cognitive impairment – short-
term memory loss, disorientation,
confusion
• Focal or generalised seizures
(Neurological symptoms due to
cerebral oedema!)
• Hypervolaemia – pulmonary
oedema, peripheral oedema,
raised jugular venous pressure,
ascites
 Diagnosis

• Bloods
- Serum Na+
- Serum K+ = if high in presence of hyponatremia –
consider ADDISON’S
-TFTs = Hypothyroidism - potential cause of SIADH
- Serum cortisol = low cortisol suggest Addison’s
• Urine
- High osmolality = SIADH water retention but not
solute (SIADH is diagnosis of exclusion!)
• CXR
- useful in detecting the source of SIADH
 • Treat underlying cause
• Careful correction of sodium
levels: maximum correction within 24
hours is 10 mmol/L
Rapid increase in sodium levels → risk of central
pontine myelinolysis
• Hypovolemic hyponatremia
– Mild to moderate symptoms: normal
saline (0.9%)
– Severe symptoms: hypertonic saline (3%)
• Euvolemic hyponatremia
– Mild to moderate symptoms: fluid
Management restriction (500mls to 1L)
– Severe symptoms: hypertonic saline
• Hypervolemic hyponatremia:
– Mild to moderate symptoms:
fluid restriction ± loop diuretic
– Severe symptoms: hypertonic saline

• ADH blockers such as Talvaptan

(endocrinologists will initiate)
• Tetracycline antibiotics (blocks ADH)
Central
Pontine
Myelinolysis
 MCQ
1) When considering a diagnosis of SIADH,
which condition must be excluded?
A. Decreased kidney function
B. Glucocorticoid deficiency
C. Hypothyroidism
D. Addison
E. All of the above
 MCQ
• A 1 month old patient with RSV bronchiolitis and
dehydration develops vomiting and altered mental
status leading to generalized a tonic-clonic seizure. Her
serum sodium is 118 mEq/L. The most likely
mechanism for her clinical deterioration is:
A) Demyelination
B) Cerebral edema
C) Brainstem herniation
D) Intracranial haemorrhage
E) Dehydration
 MCQ
• An 87 year old man is post op after a total hip replacement following a
fractured neck of femur. He is found to have hyponatraemia that is stable
around 120 mmol/l.
This is causing postural hypotension, muscle cramps and occasional mild
confusion.
He is euvolaemic, has a urinary sodium concentration of 75 mmol/l, and has
normal thyroid function, chest xray and short synacthen tests.
Fluid restriction achieves a slight rise in serum sodium to 125 mmol/l.
What is the next most appropriate option for treating the cause of his
hyponatraemia.

A) Tolvaptan
B) IV Hypertonic saline
C) Normal saline
D) Desmopressin
E) All of the above
 Feedback
https://docs.google.com/forms/d/e/1FAIpQLSc
ML-B5JSuzun68OpzDbJ_eS3IxH1m-
QWCZ_NVNX9u3vJB9Jg/viewform?usp=pp_url