Mechanism

Plasma Osmolality 275-295 (Nl)

Plasma [Na+] <136 <136 mEq/L

Urine [Na+] mEq/L < 10

Urine Osm mOsm/Kg H2 O >400

BUN/Creatinine

Isotonic Hyponatremia

Lab Artifact due to increased lipids and proteins

15:1

Hypertonic Hyponatremia

[Glucose] in plasma draws water out from cells; giving a falsely low [Na+]

>295

2 mEq/L for each glucose by 100 above 100

< 10

>400

15:1

Hypotonic Hyponatremia - Plasma tonicity decreases with plasma [Na+]

-Hypovolemic intravasc. Vol. (orthostatic hypoTN, tachycardia, low JVP) (1) more Na+ is lost than H2 O or (2) losses in Na+ and H2O are replaced by pure H2O Renal losses: impaired Na+ reabsorption in distal tubules and cortical collecting ducts Aldo deficiency Thiazide-type diuretics Tx: Isotonic Saline

<275

<136 mEq/L

> 20 >400 (Though RAAS is (intravasc. stimulated, vol stimulates Na+ reabsorption ADH) is impaired) >100 (Not as high, since Na+ losses and polyuria prevent formation of a hypertonic medullary interstitium; however ADH is still active)

20:1 (decreased intravasc. volume)

polyuria

Cerebral Salt Wasting (CSW) BNP-mediated increase in GFR

<275

<136 mEq/L

>20 (BNP-mediated GFR => RAAS => Na+ reabsorption)

20:1 (decreased intravasc. volume)

Non-renal losses: vomiting, secretory diarrhea, or excessive sweat -Hypervolemic intravasc. Vol. (Edema, JVP) Pt. retain more H2O than Na+

<275

<136 mEq/L

<10 (RAAS is active, and unopposed)

>400 (ADH is active)

20:1 (decreased intravasc. volume)

DRUG OF CHOICE: Tolvaptan (for non-renal only) Tx: Na+ and H2O restriction ~300 (failing kidneys unable to dilute or concentrate urine, isotonic to plasma) >400 (intravasc. vol turned on ADH)

intravasc. Vol. Renal retention: ATN and (effective) chronic kidney failure

<275

<136 mEq/L

>20 (cant reabsorb Na+)

15:1 (Na+/H2O/BUN) reabsorption is impaired

Non-renal retention: CHF, intravasc. Vol. Cirrhosis, and nephritic (effective) syndrome -Isovolemic intravasc. Vol. (no edema, JVP Nl; look Nl on exam)
DDx w/ SIADH: (1) Glucocorticoid deficiency: ACTH disinhibits ADH release (2) Hypothyroidism: CO => GFR => nonosmotic release of ADH (3) Carbamazepine: ADH release (4) NSAIDs, chlorpropamide: ADH action (5) Exercise: IL-6mediated inflammation polyuria (3 L/day)

<275

<136 mEq/L

<10 (RAAS is activated by intravasc. vol (effective)

20:1 (effective intravasc. vol)

Retention of electrolyte free H2O

DRUG OF CHOICE: Conivaptan (V1a/V2 receptor antagonist); blocks ADH!! TX: Water restriction

SIADH H2O retention and Na+ excretion Inappropriate inflammation-mediated release of ADH (IL-6) <275 <136 mEq/L

>20 (RAAS is inhibited by retention of H2O => GFR)

>100 (may or may not be higher than plasma)

15:1 (<10) (w/out RAAS)

(6) Primary psychogenic polydypsia

<275

<136 mEq/L

>20 (RAAS is inhibited by drinking 20L of

<100 (drinking so much water, that dilutes

15:1

pure H2O) -Hypovolemic loss of more H2O than Na+ renal medulla has Renal losses: interstitial tonicity => -loop diuretics => intravasc. less driving force to suck up water from vol. depletion
lumen
orthostatic hypoTN tackycardia

the urine)

Hypernatremia: inadequate H2O intake => hypertonicity of the ECF compartment

>295 >145 mEq/L Tx: Hypotonic Saline >20 <600 (large amts. of (intravascular Na+ being volume secreted in urine) depletion) >300-350 >20 (kidneys are (large amts. of unable to + Na being reabsorb Na+ secreted in urine) and urea) <10 >600 (RAAS is (ADH is stimulated by stimulated by IVD) IVD) Tx: Water replacement <100 (ADH doesnt work at all) 20:1 (intravascular volume depletion) 15:1 (No IVD) 20:1 (IVD) 15:1 (w/o absorbing Na+/H2O, BUN wont go)

-osmotic diuresis -chronic kidney dz

>295

>145 mEq/L

UO < 500 mls/day

Non-renal losses: -excessive sweat -osmotic diarrhea electrolyte-free H2O loss Total body Na+ is normal Central DI: ADH secretion -head trauma, -craniopharyngioma

>295

>145 mEq/L

20:1

-Isovolemic

Nephrogenic DI: ADH activity in kidney - lithium -demeclocycline more Na+ than H2O -Hypervolemic addition administration of NaCl and NaHCO3 solutions:

polyuria (18-20L/day)

>295

>145 mEq/L

edema, JVP

>295

>145 mEq/L

>100 (ADH partially works) DOC: Thiazide Diuretics Tx: Water replacement >600 (since >40 hypertonicity (RAAS is being inhibited) => ADH secretion)

<10 (RAAS is okay)

15:1 (no intravasc. vol depletion)