HYPERNATREMIA

Ryan James L. Miguel

First year IM Resident
Objectives
• Present the case of patient FE who presented with
Hypernatremia
• Discuss the etiologies of Hypernatremia
• Discuss the management of Hypernatremia
General Data

• EE
• 64 y/o
• Female
• Jones, Isabela
Chief Complaint

GENERALIZED BODY WEAKNESS

History of Present Illness
• 1 year prior to consult with noted intermittent episodes of cough,
occasionally productive, no dyspnea, no fever  no weight loss noted.
No consult was done.

• Interim: Persistence of cough noted

• 2 months prior, patient now is noted with progression of cough, more

productive and with episodes of dyspnea, still no fever, no weight loss
noted, sought consult at private clinic where she was advised chest
xray, however due to lack of funds, it was not facilitated. Patient was
then managed as a case of pneumonia, and was given unrecalled dose
of Co-amoxiclax for 7 days and ambroxol
History of Present Illness
• 3 days prior to consult, persistence of above condition was noted, now
with body weakness, which prompted patient to do chest xray which
revealed left massive pleural effusion. Patient was advised for
admission but refused.
• Due to the xray result, patient opted to minimize fluid intake,
amounting to just 2 glasses/day, due to fear of further increasing the
fluid level seen in her lungs.
• On day of consult, patient now is noted to have progressive
generalized body weakness, hence ER consult, and admission.
 Past Medical History
(-) Hypertension
(-) Diabetes Mellitus
(-) Previous Ptb Treatment
Family History
• No Hypertension
• No Diabetes Mellitus
• No Bronchial Asthma
• No PTB
Personal social history
• Non smoker
• Non alcoholic drinker
• Denies illicit drug use

• Housewife
 Review of system
•Constitutional symptoms: (-) Fever
•Skin: (-) itchiness, (-)dryness, (-)cyanosis, (-) jaundice
•Head: (-) headache, (-) dizziness, (-) vertigo
•Eyes: (-) pain, (-) blurring of vision, (-)double vision, (-) excessive lacrimation,
(-)photophobia
•Ears: (-) earache, (-) deafness, (-) tinnitus, (-) ear discharge
•Nose and sinuses: (-) changes in smell, (-) nose bleeding, (-) nasal obstruction, (-)nasal
discharge, (-) pain over paranasal sinuses
•Mouth and throat: (-) toothache, (-)gum bleeding, (-) disturbance in taste, (-) sore
throat, (-) hoarseness
•Neck: (-) pain, (-) limitation of movement, (-) mass
•Breast: (-) pain, (-) lumps, (-) nipple discharge
•Respiratory: (+) pleuritic chest pain, (-) audible wheezing
 Review of system
•Cardiovascular: (-) palpitations, (-) syncope, (-) Chest pain
•Gastrointestinal:, (-) dysphagia, (-) diarrhea, (-) constipation, (-)
hematemesis, (-) hepatic tenderness, (-)melena, (-) hematochezia, (-)
regurgitation, (-) epigastric fullness, (-) dyspepsia
•Genitourinary: (-) dysuria, (-)urinary frequency, (-) urgency, (-) hematuria, (-)
incontinence
•Extremities: (-) palmar erythema, (-) swelling of joints, (-)stiffness, (-)
numbness, (-) intermittent claudication, (-) limitation of movement
•Nervous: (-) loss of consciousness, (-) focal weakness, (-) parethesia, (-)
speech disorder, (-) loss of memory, (-) confusion,
•Hematologic: (, (-) easy bruising
•Endocrine: (-) intolerance to heat and cold, (-) polydipsia (-) Polyuria
 Physical Examination
• General Survey: Alert, weak looking, in mild respiratory distress
• VS: BP: 110/80 RR: 24 cpm CR: 92 bpm T: 36.3˚C O2 sat 97% on O2 via
NC at 1lpm
• Wt: 45kg Height: 1.5cm BMI: 20 (N)
• Skin: (-) pallor (-) jaundice, poor skin turgor
• HEENNT: Normocephalic, Anicteric sclera, pink palpebral conjunctiva,
No nasoaural discharge, dry lips and oral mucosa, no lesions noted;
no Cervicolympadenopathies
 Physical Examination
• Thorax and Lungs: (-) lesions, (-) mass, and (-) dilated vessels ,no
retractions
• No tenderness on palpation, Asymmetrically decreased tactile
fremitus, left;
• Decreased breath sounds, Left
 Physical Examination

• Cardiac: Adynamic precordium, normal rate regular

rhythm, no murmur
• Abdomen: Flat Abdomen, normoactive bowel sounds,
tympanitic, no tenderness or palpable masses
• (-) edema, full and equal pulses
Neuro exam
• GCS 15 (E4V5M6)
• Frontal:
• Fluency: able to complete sentences
• Comprehension: follows commands
• Repetition: able to repeat phrases
• Parietal: knows her left hand and right feet, able to write, able to
name fingers (thumb, ring finger), able to answer simple addition
• Occipital: able to identify person (daughter)
• Temporal: able to recall recent events
• Cranial Nerves
• I NA
• II PERLA
• III IV VI intact EOMs
• V intact corneal reflex
• VII (-) facial asymmetry
• VIII intact gross hearing
• IX X intact gag reflex
• XII no tongue deviation
• (-) nuchal rigidity
• (-) meningeal signs
• (-) motor deficit
• (-) sensory deficit
Salient Features
• 64/ F
• 1 year history of cough, body weakness, decrease in appetite, and
opted to decrease oral fluid intake
• Diagnosed with Pleural Effusion, Left
• PE: Weak looking, poor skin turgor, dry lips and oral mucosa,decrease
Breath sounds, left; decreased tactile fremitus, left;
Working impression
• Electrolyte imbalance: Hypernatremia secondary to moderate
dehydration secondary to poor oral fluid intake
• Pleural Effusion, Left prob sec to 1. PTB 2. R/O malignancy
Laboratory BUN 11
CBC PC Crea 34.7
WBC 12.1 AST 30
HGB 10.7
ALT 30
HCT 33.1
Indices N, N
Na 165
Platelet 371 Water Deficit 4.8Liters/ 48hrs
{(165-140) /140}x 45kg x0.60
Neutrophils 82.5
K 3.8
Lymphocyte 17.9
Monocyte 7.9
RBS 89
Eosinophil 0.9
Basophil 0.8
HYPERNATREMIA
• >145mmol/L
• Mortality rates of 40–60%
• Result of a combined water and electrolyte deficit
• Ingestion or iatrogenic administration of excess Sodium
(sodium chloride or sodium bicarbonate)
ETIOLOGIES
• AGE (ELDERLY)
• reduced thirst and/or poor intake
• WATER LOSSES
RENAL EXTRARENAL
OSMOTIC DIURESIS (MANNITOL) INSENSIBLE LOSSES
DIURETICS (FUROSEMIDE) DIARRHEA
DIABETES INSIPIDUS FLUID ACCUMULATION (ASCITES)
ETIOLOGIES

• DIABETIC INSIPIDUS
• ADIPSIC
• CENTRAL OR NEPHROGENIC
• GESTATIONAL
ADIPSIC DIABETES INSIPIDUS
• Central defect in hypothalamic osmoreceptor
function
• decreased thirst and reduced Arginine Vasopressin
hormone secretion
• Brain tumors, occlusion or ligation of the
anterior communicating artery, trauma,
hydrocephalus, and inflammation
NEPHROGENIC DIABETES INSIPIDUS
• GENETIC
• MUTATIONS IN AVP-REPONSIVE AQUAPORIN 1 AND 2
• METABOLIC
• HYPERCALCEMIA
• Calcium signals directly through the calcium-sensing receptor to
downregulate sodium, potassium, and Chloride– transport by the Thick
Ascending Loop of Henle and water transport in principal cells, thus
reducing renal concentrating ability
• HYPOKALEMIA
• inhibits the renal response to AVP and downregulates aquaporin-2
expression
NEPHROGENIC DIABETES INSIPIDUS
• DRUGS
• LITHIUM
• inhibition of renal glycogen synthase kinase-3 (GSK3)
• IFOSFAMIDE
• ANTIVIRAL AGENTS (FOSCARNET, CIDOFOVIR)
GESTATIONAL DIABETES INSIPIDUS
• In late-term pregnancy, there is increased activity of a
circulating placental protease with “vasopressinase”
activity leading to reduced AVP resulting to polyuria
and hypernatremia
• Treatment:
• DDAVP (Desmopressin)
CLINICAL FEATURES
• Neurologic
• Altered mental status (mild confusion to lethargy to coma)
• Parenchymal or subarachnoid hemorrhages
• Rhabdomyolysis
DIAGNOSTIC APPROACH
• History and PE
• Presence or absence of thirst, polyuria, water losses
(vomiting, diarrhea, diuresis)
• Detailed neurologic exam
• Assessment of fluid status
• Orthostatic tachycardia (increase in 15-20bpm upon
standing)
• Orthostatic hypotension (drop of 10-20mmHg SBP upon
standing)
DIAGNOSTIC APPROACH
DIAGNOSTIC APPROACH
• Serum osmolality

• Urine osmolality
DIAGNOSTIC APPROACH
TREATMENT
 Laboratory
Urine 1100
output
(24hrs)
Urine Na 125
Urine K 18
Serum Na 165
Weight 45kg
• Water deficit
• 4860mL
• On going water loss
• 143mL
• Insensible losses
• 45 X 10= 450mL
• Total
• 5453 mL/48hrs
• D5W

• Change in serum Na
• 3.14
• Drip rate
• 105cc/hr
• Insensible losses
• 20cc/hr
• Total: 125cc/hr x 24 hrs

• Shift IVF to D5W 1L x 125CC/hr x

24hrs
• Na monitoring q4-6
TREATMENT
• It is imperative to correct hypernatremia slowly to avoid cerebral
edema (<10mmol/L/day) typically replacing the calculated free water
deficit over 48h
• Water should ideally be administered by mouth or by nasogastric
tube, as the most direct way to provide free water
• Alternatively, patients can receive free water in dextrose-containing IV
solutions, such as 5% dextrose (D5W)
TREATMENT
• Central Diabetes Insipidus
• DDAVP (Desmopressin)
• Nephrogenic Diabetes Insipidus
• Thiazide
• inducing hypovolemia and increasing proximal tubular water
reabsorption
• NSAID
• Reduce effect of intrarenal prostaglandins
TREATMENT
• Lithium-associated NDI
• Amiloride (2.5–10 mg/d), which decreases entry of lithium into
principal cells by inhibiting Epithelial Sodium Channels
(ENaC), thus reducing polyuria
THANK YOU!