Hyponatremia

Hyponatremia
• Definition
• Epidemiology
• Physiology
• Approach
• Types
• Clinical Manifestations
• Diagnosis
• Treatment
 Definition
• Plasma Na+ concentration <135 mM
• Severe Hyponatremia is serum Sodium < 120 mEq/L
• Life threatening when serum sodium < 110 mEq/L
• Acute hyponatremia is Change of serum sodium< 48
hrs
• Chronic hyponatremia is Change of serum sodium>
48 hrs
 Epidemiology
• Mortality/Morbidity
• 15% of hospitalized patients
• Acute hyponatremia (developing over 48 h or less) are
subject to more severe degrees of cerebral edema
– sodium level is less than 105 mEq/L, the mortality is over 50%
• Chronic hyponatremia (developing over more than 48
h) experience milder degrees of cerebral edema
– Brainstem herniation has not been observed in patients with
chronic hyponatremia
 Physiology
– Serum sodium concentration
regulation:
• stimulation of thirst
• secretion of ADH
• feedback mechanisms of the renin-
angiotensin-aldosterone system
• renal handling of filtered sodium
 Diagnostic Algorithm
Hyponatremia Serum Na <
135 mEq/L Measure serum
Osmolarity

Hyper-osmolar > 290

Hypo-osmolar < 275 mOsm/L Normal 275-290 mOsm/L
mOsm/L

Pseudohyponatremia: Factitious hyponatremia 2˚

Assess volume status - Hyperlipidemia hyperglycemia (1.6 mEq/L
- paraproteinemia dec. Na for every 100 mg/dL
inc. in glucose > 150 mg/dL
- Manitol

Hypovolemia – Measure Isovolemia – Measure Urine Hypervolemia – Measure

Urine Na Na Urine Na
 Diagnostic Algorithm
Hypovolemia – Measure
Urine Na
Urine Na <20 mEq/L
Extrarenal loss:
- GI loss: vomiting, NG
suction, diarrhea
- Skin loss: fever, burns
- 3rd spacing - pancreatitis
Urine Na > 20 mEq/L
Renal Loss:
- Diuretics
- Salt-wasting nephropathy
- Low aldosterone
Isovolemia – Measure Urine Hypervolemia – Measure
Na Urine Na
Urine Na < 20 mEq/L
- Water intoxication Urine Na < 20 mEq/L
- CHF
- Psychogenic polydipsia
- Urine is very dilute (Urine - Nephrotic syndrome
- Cirrhosis
Osm < 100 mEq/L)
Urine Na > 20 mEq/L
- SIADH
- Hypothyroidism
- Adrenal insufficiency Urine Na > 20 mEq/L
- Drugs (NSAIDS, thiazides) - Renal failure
- Renal failure
- Urine is less dilute (Urine
Osm > 100 mEq/L)
 Hyponatremia
• Types
– Hypovolemic hyponatremia
– Euvolemic hyponatremia
– Hypervolemic hyponatremia
– Redistributive hyponatremia
– Pseudohyponatremia
 Hypovolemic hyponatremia
• Nonrenal loss
– GI losses
• Vomiting, Diarrhea, fistulas, pancreatitis
– Excessive sweating
– Third spacing of fluids www.jupiterimages.com

• ascites, peritonitis, pancreatitis, and burns

– Cerebral salt-wasting syndrome
• traumatic brain injury, aneurysmal subarachnoid
hemorrhage, and intracranial surgery
 Hypovolemic hyponatremia
• Renal Loss
– Acute or chronic renal insufficiency
– Diuretics

www.ct-angiogram.com/images/renalCTangiogram2.jpg
 Euvolemic hyponatremia
• Normal sodium stores and a total body excess
of free water
– Psychogenic polydipsia, often in psychiatric
patients
– Administration of hypotonic intravenous or
irrigation fluids in the immediate postoperative
period
 Euvolemic hyponatremia
• SIADH
– Pulmonary Disease
• Small cell, pneumonia, TB, sarcoidosis
– Cerebral Diseases
• CVA, Temporal arteritis, meningitis, encephalitis
– Medications
• SSRI, Antipsychotics, Opiates, Depakote, Tegratol
 Hypervolemic hyponatremia
• Total body sodium increases, and TBW
increases to a greater extent.
– cirrhosis, congestive heart failure, or nephrotic
syndrome
 Redistributive hyponatremia
– Water shifts from the intracellular to the
extracellular compartment, with a resultant
dilution of sodium. The TBW and total body
sodium are unchanged.
• This condition occurs with hyperglycemia
• Administration of mannitol
 Hyponatremia

• Pseudohyponatremia
– The aqueous phase is diluted by excessive
proteins or lipids. The TBW and total body sodium
are unchanged.
• hypertriglyceridemia
• hyperproteinemia
 Hyponatremia
• Clinical Manifestations
– sodium exceeding 125 mEq/L are asymptomatic
– acutely developing hyponatremia are typically
symptomatic at a level of 120 mEq/L
– Most abnormal findings on physical examination
are characteristically neurologic in origin
– patients may exhibit signs of hypovolemia or
hypervolemia
 Hyponatremia
• Clinical Manifestations
– Generalized cellular swelling
– Primarily neurologic(cerebral edema)
• Early symptoms : nausea, headache, and vomiting.
• severe complications : seizure activity, brainstem
herniation, coma, and death. 
 Hyponatremia
• Laboratory tests.
– Serum glucose: falls by 1.6  for every 100-mg/dL
increase in glucose 
– Electrolyte: hyperkalemia may suggest adrenal
insufficiency or hypoaldosteronism
– BUN,Cr: renal dysfunction
– Plasma osmolality : exclude pseudohyponatremia
– Urine osmolality
– Urine sodium concentration
– Uric acid level
– FeNa
 Hyponatremia
• Laboratory tests Cont.
– Plasma osmolality[Serum Osmolality = (2 x Na )+
(BUN / 2.8) + (glucose / 18)]
• normally ranges from 275 to 290 mosmol/kg
• If >290 mosmol/kg :
– Hyperglycemia or administration of mannitol
• If 275 – 290 mosmol/kg :
– hyperlipidemia or hyperproteinemia
• If <275 mosmol/kg :
– Eval volume status
 Hyponatremia
• Laboratory tests Cont.
– Plasma osmolality < 275 mosmol/kg
• Increased volume:
– CHF, cirrhosis, nephrotic syndrome
• Euvolemic
– SIADH, hypothyroidism, psychogenic polydipsia, beer
potomania, postoperative states
• Decreased volume
– GI loss, skin, 3rd spacing, diuretics
 Hyponatremia
• Laboratory tests Cont.
– Urine osmolality
 Hyponatremia
• Laboratory tests Cont.
– Urine Sodium
• >20 mEq/L
– SIADH, diuretics
• <20 mEq/L
– cirrhosis, nephrosis, congestive heart failure, GI loss, skin, 3rd
spacing, psychogenic polydipsya
– Uric Acid Level
• < 4 mg/dl consider SIADH
 Hyponatremia
Laboratory tests Cont.
–FENa
• Help to determine pre-renal from renal causes
–<1% = pre-renal
–>1%= renal eg. Acute renal failure, ATN

•Radiologic imaging : pulmonary or CNS cause for

hyponatremia.
 TREATMENT
1. Presence and/or severity of symptoms
2. Corrected by 10–12 mM /24 h and to <18
mmol/L in 48 hours.(1 to 2 mmol/L per hr)
3. Volume status
Acute symptomatic hyponatremia:
– hypertonic 3% saline (513 mM)
– increase plasma Na+concentration by 1–2 mM/h
–  Na+ deficit = 0.6 xbody weight x (target plasma
Na+ concentration – starting plasma
Na+ concentration)
– monitor Na+ every 2–4 h
 Treatment is based on symptoms
• Patients with serum sodium above 120 are
generally asymptomatic
• Symptoms tend to occur at serum sodium
levels lower than 120 or when a rapid decline
in sodium levels occur
• Patients can have mild symptoms at sodium
concentrations of 110-115 mEq/L when this
level is reached gradually
 Severe symptoms present
• As stated earlier, symptoms dictate treatment
• If severe symptoms are present: 3%
hypertonic saline
• Goals for correction:
– 1 to 2 mEq/L per hour for first 3-4 hours until
symptoms resolve
– Increase by no more than 10 mEq/L in first 24 hrs
– Increase by no more than 18 mEq/L in first 48 hrs
 Example:
• Sodium deficit = TBW x (desired Na–actual Na)
• TBW =BW x 0.5 for women or 0.6 for men
Eg.
• 60 kg woman with sodium level of 116
• How much sodium will bring him up to 124 in
the next 24 hours?
• Sodium needed = 0.5 x 60 x (124-116) = 240
 Example (continued)
• The patient needs 240 mEq in next 24 hours
• That averages to 10 mEq per hour or 20 mL of
3%NaCl per hour
– 3%NaCl 1000 ml=513meq
– 240 meq= 468ml in 24 hrs = 20ml/hr
 Example (continued)
• However, this will only raise the serum
sodium by 0.33 per hour which is very slow.
• To produce desired rate of serum sodium
increase of 1.0 to 1.5 mEq per hour
– Sodium needed = 0.5 x 60 x1=30meq=60ml/hr
 Osmotic demyelination syndrome
• clinical manifestations
– tremor
– incontinence
– hyperreflexia,
– quadriparesis, quadriplegia
– dysarthria, dysphagia
– cranial nerve palsies
Hypovolemic
hyponatremia
Hypervolemic
hyponatremia
 Euvolemic hyponatremia
• Symptomatic Asymptomatic : find
cause
 Hyponatremia
– SIADH
• Water restriction
– 0.5-1 liter/day
• Salt tablets
• Demeclocycline
– Inhibits the effects of ADH
– Onset of action may require up to one week
 Summary of Hyponatremia
• Hyponatremia has variety of causes
• Treatment is based on symptoms
– Severe symptoms = Hypertonic Saline
– Mild or no symptoms = Fluid restriction
• Overcorrection, more than 12 mEq increase in
24 hours must be avoided with monitoring
• Serum Osmolality, Urine Osmolality and Urine
sodium concentration are initial tests to order
 References:
• Harrison’s internal medicine 19th edition
• NEJM: Primary care hyponatremia by Horacio
and Nicolas
• American Family Physician: Management of
Hyponatremia