HYPERNATREMIA

DONA P S

Roll no: 76
CAUSES : increased Na+ concentration(loss of H20)

NON RENAL LOSS

1. Insensible loss: fever,burns,exercise, heat exposure or when patient is mechanically ventilated
2. Diarrhoea:most common GI cause of hypernatremia
● Osmotic diarrhoea and viral gastroenteritis generate stools with Na+ and K+<100mM Leading to water loss and hypernatremia
RENAL LOSS

1. OSMOTIC DIURESIS
Hyperglycaemia, urea, postobstructive diuresis, mannitol
2. DIABETES INSIPIDUS
● CENTRAL: has a defect in ADH synthesis or release
● NEPHROGENIC: renal resistance to AVP
○ Genetic causes
○ Hypercalcaemia
○ Hypokalaemia
○ Drugs-Li,ifosfamide,antiviral drugs
● GESTATIONAL DI: late term pregnancy
CLINICAL FEATURES

● Increased osmolality of ECF : efflux of intra cellular water, leading to cellular

shrinkage
● Neurological symptoms
○ Mild confusion, lethargy, deep coma
● Haemorrhages
○ Parenchymal, SAH, SDH (primarily encountered in paediatrics and
neonatal patients)
● Hypernatremic Rhabdomyolysis: due to osmotic damage to muscle membrane
● Chronic hypernatraemia(<48hr)
○ Intra cellular accumulation of organic osmolytes (glutamate creatinine
betaine myoinositol taurine)
○ Rapid over correction is avoided to prevent cerebral edema , seizure (10mM
per day)
DIAGNOSTIC APPROACH
● History
○ Presence or absence of thirst
○ Polyuria present or absent
○ Any extra renal cause of water loss? -diarrhoea.
● Physical examination
○ Detailed neurological examination
○ Assessment of extra cellular fluid volume
○ Daily fluid intake
○ Daily urine output
● Laboratory investigation
○ Measurement of serum osmolality
○ Urine osmolality and electrolytes measurement
● AVP assays : done in pregnant woman
 Renal
Extra renal cause
cause

Polyuria

Dilute
urine
Concentrated urine
( diabetes
insipidus)
Desmopressin administered
TREATMENT
● Treat the underlying cause -drugs, hyperglycaemia ,hypercalcaemia, hypokalaemia,
diarrhoea
● Correct slowly to avoid cerebral edema (except acute hypernatraemia)
○ Replace over 48 hours
○ Less than 10mM per day
○ Acute hypernatraemia can be corrected at the rate of 1 mM/hr
● Water administration
○ Ideally through mouth via nasogastric tube
○ Dextrose 5% can be used to maintain blood sugar levels
○ Hypotonic saline(1/2N or 1/4N) is also used in hypovolemic hypernatraemia
● DDAVP(desmopressin acetate) in the case of diabetes insipidus
● Amiloride-2.5-10mg/day (blocks epithelial sodium channels and decrease entry of lithium
into principal cells)
● Thiazides-used in nephrogenic diabetes, insipidus to decrease polyuria
● NSAIDS - inhibit prostaglandins
○ PGs inhibit counter current mechanism
THANK YOU