Diagnosis and Management of

Hyponatraemia in Cancer Patients

Fahad A Saadi
MB.BCh.BAO, MSc, BSc
F1 Medical Oncology, Belfast City Hospital
fsaadi01@qub.ac.uk
 Outline

• Why should we care

• Classification

• True vs False Hyponatraemia

• Hypo-, Hyper- and Euvolaemic hyponatraemia

• SIADH in Cancer Patients

• Treatment Algorithms
 Why we should care

• Most common electrolyte disorder

• Multiple aetiologies in cancer patients

• Potential for substantial morbidity and mortality

• Economic burden
 Classification

• Acute (< 48 hours) Vs Chronic (> 48 hours)

• Mild Moderate Severe

 Hyponatraemia

• Na < 130 mmol/L

• True Vs False Hyponatraemia

 False Hyponatraemia

• Low Serum Na conc. associated with:

• —> Normal or High Osmolality

• Does NOT causes the water to move into the cells

1. Water does not move at all = Pseudohyponatraemia (lab error, protein/lipids)

2. Water moves out of the cells = Factitious Hyponatraemia (hyperglycaemia)

 True Hyponatraemia

• Low Serum Na conc. associated with:

• —> Low Osmolality

• In other wards Hypoosmolar hyponatraemia

• Causes the water to move into the cells - Osmosis

 True Hyponatraemia

• True Hyponatraemia can be:

1. Hypovolumic

2. Euvolumic

3. Hypervolumic

• All of the above are ADH dependent

• Requires volume status assessment
 Physiologic stimuli for ADH

1. Increased serum osmolality - not revenant here

2. Decreased perfusion

1. Volume depletion

2. Hypotension
Hypovolaemic Hyponatraemia

VOLUME DEPLETION

• GI loss - diarrhoea/vomiting

• Renal loss - diuretics

Hypervolaemic Hyponatraemia

HYPOTENSION

• heart failure

• cirrhosis

• nephrotic syndrome
 Euvolaemic Hyponatraemia

• Fixed ADH release: Not due to hypotension or volume

depletion
 Differentiation
• How do you differentiate Euvolaemic
hyponatraemia

• from

• Hyper- and Hypovolaemic hyponatraemia

Overview
 Overview

• SIADH: most common aetiology in Cancer

 SIADH diagnostic criteria

R. Berardi et al. / Critical Reviews in

Oncology/Hematology 102 (2016) 15–25

• Diagnosis of exclusion, rule out other causes of

hypoosmolar euvolemic hyponatraemia:

• Hypothyroidism (severe)

• Hypocortisolism (glucocorticoid insufficiency)

• Also absence of diuretic use and normal renal function

 Causes of SIADH in Cancer

R. Berardi et al. / Critical Reviews in Oncology/Hematology

102 (2016) 15–25
 Treatment of Hyponatraemia

• Acute symptomatic: A medical emergency

• Chronic asymptomatic: Depends on fluid status

• 

Acute Symptomatic Hyponatraemia

• 3% Hypertonic saline
• Goal: Na+ level does not rise by
more than 6 mmol/L in the first
six hours or 10 mmol/L in the
first 24 hours.
• Rapid overcorrection: osmotic
demyelination syndrome.


• Low risk once the serum [Na] has

reached 125 mmol/L 


Copyright © 2015 The Authors European Journal of Clinical Investigation published by John Wiley & Sons Ltd on
behalf of Stichting European Society for Clinical Investigation Journal Foundation.
 Asymptomatic Hyponatraemia

Copyright © 2015 The Authors European Journal of Clinical Investigation published by John Wiley & Sons Ltd on behalf of Stichting European Society for
Clinical Investigation Journal Foundation.
 Asymptomatic Hyponatraemia

i-e SIADH:


Fluid restrict (500-1000 ml/day for adults).

If fluid restriction ineffective:

Demeclocycline: licensed to treat SIADH due to
malignant disease

Vaptans (vasopressin receptor antagonists - eg,

tolvaptan) may be useful;
• expensive
• potentially may increase sodium levels too rapidly

Copyright © 2015 The Authors European Journal of Clinical Investigation published by John Wiley & Sons Ltd on behalf of Stichting European Society for
Clinical Investigation Journal Foundation.
 Conslusion

1. Hyponatraemia Na < 130 mmol/L

2. Determine serum osmolality

• True hyponatraemia is: Hypoosmolar Hypovolaemic

3. Determine Volume status (Hypo-, Hyper-, Euvolaemic)

4. Determine urine sodium to differentiate Hypo-, Hyper-,

Euvolaemic hyponatraemia

5. Treat based on aetiology and acuteness of development

 References

Verbalis, Joseph G., Steven R. Goldsmith, Arthur Greenberg, Cynthia Korzelius,

Robert W. Schrier, Richard H. Sterns, and Christopher J. Thompson. "Diagnosis,
Evaluation, and Treatment of Hyponatremia: Expert Panel Recommendations." The
American Journal of Medicine 126.10 (2013): n. pag.

Berardi, Rossana, Silvia Rinaldi, Miriam Caramanti, Christian Grohè, Matteo

Santoni, Francesca Morgese, Mariangela Torniai, Agnese Savini, Ilaria Fiordoliva, and
Stefano Cascinu. "Hyponatremia in Cancer Patients: Time for a New Approach."
Critical Reviews in Oncology/Hematology 102 (2016): 15-25.

Newson, Dr Louise. "Hyponatraemia. Abnormally Low Sodium Levels Information."

Patient. Patient.info, n.d. Web. 19 May 2017

Grant P, Ayuk J, Bouloux PM, et al; The diagnosis and management of inpatient
hyponatraemia and SIADH. Eur J Clin Invest. 2015 Aug 45(8):888-94. doi: 10.1111/
eci.12465. Epub 2015 Jun 28.

Hyponatraemia; NICE CKS, March 2015 (UK access only)

 Questions

Thank you!