Hyponatremia

Hyponatremia
• Most common electrolyte imbalance occuring in 22% of hospitalized

patients.
• Defined as a serum [Na] below 135 mmol/L.
Important clinically because:

1) acute severe hyponatremia can cause substantial
morbidity and mortality;
2) adverse outcomes are higher in hyponatremic
patients with a wide range of underlying diseases;
3) overly rapid correction of chronic hyponatremia can
cause severe neurological deficits and death.
ETIOLOGY AND PATHOPHYSIOLOGY
OF HYPOTONIC HYPONATREMIA
• Hypotonic hyponatremia
It is defined as sodium ion concentratin <125 meq/l(severe hyponatremia)
and plasma osmolality <275 milliosmoles.
total body water(TBW) decreases and also Total body salt decreases(TBS)
seen in:
1. GI CAUSES:Diarrhoea/Vomitting
2. CNS CAUSES: CSWS(Cerebral Salt wasting syndrome)/Diuretics/Addisons
disease
Treatment:
ORS(Oral rehydration solution)
RL(Ringer Lactate solution)
• CSWS(Cerebral salt wasting syndrome)
As sodium directly contribute to the plasma osmolality ;
change in the plasma concentration leads to a
fluid shift in brain(if the fluid shift occurs in <48 hours)
causing CNS manifestations like cerebral edema,seizures,nausea
,delirium ,lethargy and coma
• Addisons disease
Occurs due to the decrease in Aldosterone secretion and
characterized by hyponatremia with ECF volume contraction
• Euvolaemic hyponatremia
Characterised by (↑H2O, ←→Na+)
seen in:
1. SIADH(Syndrome of inappropiate ADH release)
2. Primary polydipsia or Psychogenic polydipsia
3. Beer potomania
4. Hypothyroidism
5. Post operative patients
6. Endurance sports
Treatment:
Fluid restriction + Vaptans(V2 receptor antagonists)
• SIADH
A defect in osmoregulation causes vasopressin to be
inappropriately stimulated, leading to urinary concentration.
Excess vasopressin: CNS disturbances such as hemorrhage,
tumors, infections, and trauma.
Elevated urinary sodium excretion (>20 mmol/L) while on
normal salt and water intake.
Inappropriate urinary concentration (Uosm >100 mOsmol/kg
H2O) with normal renal function) at some level of plasma
hyposmolality.
PSYCHOGENIC
POSTERIOR PITUARTY HYPOTHYROIDISM
POLYDIPSIA
• Hypervolaemic hyponatremia
Characterised by (↑↑H2O, ↑Na+)
Seen most commonly in patients of ascites and its associated features:
1. CHF
2. Cirrhosis
3. Nephrotic syndrome
4. Chronic Kidney disease
Treatment:
Diuretics
5. if ascites due to chroic cause, then we give SPIRONOLACTONE (Potassium
sparing diuretics)
6. if ascites due to acute cause, then we give FUROSEMIDE (Loop diuretics)
• Massive Ascites
leads to severe decrease in circulating fluid volume( due to collection of
fluid in the abdomen) which leads to GFR↓ leading to RAAS stimulation
and release of ALDOSTERONE and activation of ENaC channels causing
more absorption of Na+/H20 and excretion of K+/H+.
• Acute Hyponatremia – <48 hours
• chronic hyponatremia - > 48
hours
STEP1-Serum Osmolality :
Serum Osmolality: lab value or calculation in mosm/kg
=(2 x Na+) + (glucose/18) + (BUN/2.8).
Hypertonic - >295 milliosmoles/kg

Examples:hyperglycemia, mannitol
Isotonic - 280-295 milliosmoles/kg

Also known as pseudo hyponatremia
it is a Laboratory error
Examples: HYPERLIPIDEMIA , HYPERPROTEINIMIA
Hypotonic - <280 milliosmoles/kg

excess fluid intake, low solute intake, renal disease, SIADH,
hypothyroidism, adrenal insufficiency, CHF, cirrhosis, etc.
• STEP 2 –Volume Status
assess volume status (extracellular fluid volume)
Hypotonic hyponatremia has 3 main etiologies:
1.Hypovolemic – both water and Na decreased (H20 < Na)
Consider obvious losses from diarrhea, vomiting,
dehydration,malnutrition, etc
2.Euvolemic – water increased and Na stable

Consider SIADH, thyroid disease, primary polydipsia
3.Hypervolemic – water increased and Na increased (H2O > Na)

Consider obvious CHF, cirrhosis, renal failure
• STEP 3 – Urine Studies
For euvolemic hyponatremia, check urine osmolality
Urine osmolality <100 - excess water intake
Primary polydipsia, tap water enemas, post-TURP
Urine osmolality >100 - impaired renal concentration
SIADH, hypothyroidism, cortisol deficiency
Check urine sodium & calculate FeNa %

Low urine sodium (<20) and low FeNa (<1%) implies the
kidneys are appropriately reabsorbing sodium
High urine sodium (>20) and high FeNa (>1%) implies the
kidneys are not functioning properly
Treatment:
When considering the treatment of patients with hyponatremia, five issues must be addressed:
• Risk of osmotic demyelination syndrome.
• Appropriate rate of correction to minimize this risk
• Optimal method of raising the plasma sodium concentration
• Estimation of the sodium deficit if sodium is to be given
• Management of the patient in whom overly rapid correction has occurred

Methods of Sodium Correction
• Water restriction
• primary therapy for hyponatremia in edematous states,
SIADH, primary polydipsia, and advanced renal failure.
• Sodium chloride administration
• usually as isotonic saline or increased dietary salt
given to patients with true volume depletion, adrenal
insufficiency, and in some cases of SIADH.
• contraindicated in edematous patients (eg, heart
failure, cirrhosis, renal failure) since it will lead to exacerbation of the edema
• Hypertonic saline is generally recommended only for

patients with symptomatic or severe hyponatremia.
• The increase in plasma Na+ concentration can be highly unpredictable during treatment with hypertonic saline due to rapid changes in the underlying physiology.
• Patient should be monitored carefully for changes in neurologic and pulmonary status, and serum electrolytes should be checked frequently, every 2 - 4 hours.
Treatment of symptomatic acute hyponatremia
Goal:
Urgent correction by 1-2 mmol/hr upto 4-6 mmol/L, to prevent brain
herniation and neurological damage from cerebral ischemia.
Upper limit for correction,10-12 mmol/L in any 24hour period; 18
mmol/L in any 48-hour period.
How much fluids to give?

Total body water = weight x 0.6 for men / 0.5 for woman
• One liter of NS contains: 154 mmol/L of Na+ Cl−
• One liter of 3% saline contains:514 mmol/L of Na+ Cl−
Treatment of chronic hyponatremia(Avoiding ODS)
Goal:
Minimum correction of serum [Na] by 4-8 mmol/L per day, with a lower
goal of 4-6 mmol/L per day if the risk of ODS is high.
Limits not to exceed:
• 8-10 mmol/L in any 24-hour period.
OSMOTIC DEMYLEINATION SYNDROME
also known as central pontine myleinosis
ODS occurs if chronic hyponatremia is corrected too

rapidly.
Present in a stereotypical biphasic pattern (initially improve neurologically with correction of hyponatremia, but then, one to several days later, new, progressive, and sometimes permanent neurological deficits emerge).
Patients can present para- or quadraparesis, dysphagia, dysarthria, diplopia, a "locked-in syndrome," and/or loss of consciousness.
Most commonly affected area is pons.
Other regions of the brain affected in ODS: (in order of frequency) cerebellum, lateral geniculate body, thalamus, putamen, and cerebral cortex or subcortex.

Hyponatremia

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Hyponatremia

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Hyponatremia

• Most common electrolyte imbalance occuring in 22% of hospitalized

Important clinically because:

Hypertonic - >295 milliosmoles/kg

Isotonic - 280-295 milliosmoles/kg

Hypotonic - <280 milliosmoles/kg

2.Euvolemic – water increased and Na stable

3.Hypervolemic – water increased and Na increased (H2O > Na)

Check urine sodium & calculate FeNa %

• Appropriate rate of correction to minimize this risk

• Optimal method of raising the plasma sodium concentration

• Estimation of the sodium deficit if sodium is to be given

• Management of the patient in whom overly rapid correction has occurred

• Hypertonic saline is generally recommended only for

How much fluids to give?

ODS occurs if chronic hyponatremia is corrected too

Most commonly affected area is pons.

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