Approach to

Hyponatremia



Core Topic
UCI Internal Medicine Residency, 2012

Clinical Scenario
74-year-old man p/w recent gastroenteritis characterized by
n/v/d x 5 days, in addition to fatigue and headache.
CT head (-) in ED. No focal neurologic deficits found. He
looks dry on physical exam, with no evidence of fluid
overload.
BMP significant for Na+ of 118, baseline unknown. Serum
osmolality is 266. Urine osmolality is 377. Urine sodium is 8.
How would you approach this patients hyponatremia?
How would your approach be different if this patient
presented with new-onset seizures?
Lecture Objectives
Hyponatremia

Clinical manifestations
Diagnostic approach
Clinical Scenario discussed
Hyponatremia Defined
Definition: Serum Na+ <135 meq/L
Generally associated with decreased osmolality to <275
Most common electrolyte abnormality in the US
Caused by retention of water
Usually a drop in osmolality will suppress ADH to allow
excretion of the excess water via dilute urine
Most forms of hyponatremia are associated with elevated
ADH (whether appropriate or inappropriate), which
concentrates urine


Signs & Symptoms
More profound when the decrease in sodium is very large or
occurs rapidly (i.e. over hours)
Generally asymptomatic if Na+ level >125
Symptoms include:
Headache
Nausea, vomiting
Muscle cramps
Disorientation, depressed reflexes, lethargy, restlessness
Seizure, coma, permanent brain damage, respiratory arrest,
brainstem herniation & death
Serious complications are more commonly seen in primary
polydipsia, after surgery, and in menstruating women

Approach to Hyponatremia
1
st
assess volume status
Is the patient volume overloaded, depleted, or euvolemic?
2
nd
assess osmolality (hyper, iso, or hypo)
Is the blood concentrated? For hypotonic hyponatremia,
continue to 3
rd
step:
3
rd
assess urinary sodium excretion and FeNa %
Is the urine concentrated?

*Remember VOU volume status, osmolality, and urine studies
STEP 1 (V) Volume Status
1
st
assess volume status (extracellular fluid volume)
Hypotonic hyponatremia has 3 main etiologies:
Hypovolemic both H2O and Na decreased (H20 < Na)
Consider obvious losses from diarrhea, vomiting,
dehydration, malnutrition, etc
Euvolemic H20 increased and Na stable
Consider siADH, thyroid disease, primary polydipsia
Hypervolemic H20 increased and Na increased (H2O > Na)
Consider obvious CHF, cirrhosis, renal failure



STEP 2 - (O) Osmolality
2
nd
assess osmolality hyper, iso, or hypo
Hypotonic hyponatremia = warrants further workup, especially when
there is no obvious fluid overload or depletion
Serum Osmolality: lab value or calculation in mosm/kg
=(2 x Na+) + (glucose/18) + (BUN/2.8) + (ethanol)/4.6

Hypertonic - >295
hyperglycemia, mannitol, glycerol
Isotonic - 280-295
pseudo-hyponatremia from elevated lipids or protein
Hypotonic - <280
excess fluid intake, low solute intake, renal disease, siADH,
hypothyroidism, adrenal insufficiency, CHF, cirrhosis, etc.

STEP 3 (U) 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 %
A low urine sodium (<10) and low FeNa (<1%) implies the
kidneys are appropriately reabsorbing sodium
A high urine sodium (>20) and high FeNa (>1%) implies the
kidneys are not functioning properly
Hyponatremia Flow Sheet
Hypotonic
Hyponatremia
Hypovolemic
Urine Na >20
FeNa >1%
Renal losses,
mineralocorticoid
deficiency, Addisons
disease
Urine Na <10
FeNa <1%
Extrarenal losses
(diarrhea, emesis,
burns)
Euvolemic use
patient history
Uosm >100
SiADH (urine osm
usually much higher)
Hypothyroidism
Cortisol deficiency
Uosm <100
Primary polydipsia or
low solute intake
Uosm variable
Reset osmostat (ie
malnutrition,
pregnancy)
Hypervolemic
Urine Na <10
FeNa <1%
CHF
Cirrhosis
Nephrosis

Urine Na >20
FeNa >1%
Renal failure
Treatment of Hyponatremia

Be CAUTIOUS with correction:
0.5 meq/L increase per every hour initially
Do not increase Na more than 10 meq/L in 24 hrs or 18
meq/L in 48 hrs
Treatment varies greatly by etiology of hyponatremia,
and it is important to look-up via online or other
resources.

Clinical Scenario - Conclusion
74-year-old man p/w recent gastroenteritis characterized by n/v/d x 5 days, in addition
to fatigue and headache.
BMP significant for Na+ of 118, baseline unknown. Serum osmolality is 266. Urine
osmolality is 377.
How would you approach this patients hyponatremia? The steps:
1) Serum osmolality 266, decreased (hypotonic)
2) Urine osmolality 377, increased (>100)
3) Volume status - hypovolemic
4) Urine Na, FeNa urine Na 8, appropriately reabsorbing, likely volume depleted 2/2 N/V
5) Treatment: Mild symptoms, correct slowly w/ isotonic saline
How would your approach be different if this patient presented with new-onset
seizures?
For symptomatic, severe hyponatremia, more rapid correction using 3% normal saline

TAKE HOME POINTS
Symptoms: Usually Na <125 or rapid decline
N/V, headache, lethargy, AMS, seizures, coma
WORK-UP in 3 important steps (V-O-U):
1) Assess volume status
2) Assess serum osmolality
3) Check urine sodium, osmolarity, & calculate FeNa

Treatment varies by etiology, but cautious correction of
sodium important to prevent demyelination as fluid leaves
the brain