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Hyponatremia

By

James Yost, MD, MS, MBA

Emory Family Medicine


Hyponatremia
• Definition
• Epidemiology
• Physiology
• Pathophysiology
• Types
• Clinical Manifestations
• Diagnosis
• Treatment
Hyponatremia
• Definition:
– Commonly defined as a serum sodium concentration
135 meq/L
– Hyponatremia represents a relative excess of water in
relation to sodium.
Hyponatremia
• Epidemiology:
– Frequency ocw.jhsph.edu

• Hyponatremia is the most common electrolyte disorder


• incidence of approximately 1%
• prevalence of approximately 2.5%
• surgical ward, approximately 4.4%
• 30% of patients treated in the intensive care unit
Hyponatremia
• Epidemiology Cont.
– Mortality/Morbidity
• Acute hyponatremia (developing over 48 h or less) are
subject to more severe degrees of cerebral edema
– sodium level is less than 105 mEq/L, the mortality is over 50%
• Chronic hyponatremia (developing over more than 48
h) experience milder degrees of cerebral edema
– Brainstem herniation has not been observed in patients with
chronic hyponatremia
Hyponatremia
• Epidemiology Cont.
– Age
• Infants
– fed tap water in an effort to treat symptoms of gastroenteritis
– Infants fed dilute formula in attempt to ration
• Elderly patients with diminished sense of thirst,
especially when physical infirmity limits independent
access to food and drink
Hyponatremia
• Physiology
– Serum sodium concentration
regulation:
• stimulation of thirst
• secretion of ADH
• feedback mechanisms of the renin-
angiotensin-aldosterone system
www.daviddarling.info
• renal handling of filtered sodium
Hyponatremia
• Physiology Cont.
– Stimulation of thirst
• Osmolality increases
– Main driving force
– Only requires an increase of 2% - 3%
• Blood volume or pressure is reduced
– Requires a decrease of 10% - 15%
• Thirst center is located in the anteriolateral center of
the hypothalamus
– Respond to NaCL and angiotensin II
Hyponatremia
• Physiology Cont.
– Secretion of ADH
• Synthesized by the neuroendocrine cells in the
supraoptic and paraventricular nuclei of the
hypothalamus
• Triggeres:
– Osmolality of body fluids
» A change of about 1%
– Volume and pressure of the vascular system
• Increases the permeability of the collecting duct to
water and urea
Hyponatremia
• Physiology Cont
– renin-angiotensin-aldosterone
• Renin
– Stemuli are perfusion pressure, sympathetic activity, and NaCl
delivery to the macula densa
– Increase in NaCl delivery to the macula decreases the GFR by
decrease in the renin secretion
• Aldosterone
– Reduces NaCl excretion by stimulating it’s resorption
» Ascending loop of Henle
» Distal tubule
» Collecting duct
Hyponatremia

www.merricks.com/tech_electrolyte_new.htm
Hyponatremia
• Physiology Cont.
– extracellular-fluid and intracellular-fluid
compartments make up 40 percent and 60
percent of total body water
– renal handling of water is sufficient to excrete as
much as 15-20 L of free water per day
– sodium is the predominant osmole in the
extracellular fluid (ECF) compartment and serum
Hyponatremia
• Pathophysiology
– hyponatremia can only occur when some
condition impairs normal free water excretion
– acute drop in the serum osmolality:
• neuronal cell swelling occurs due to the water shift
from the extracellular space to the intracellular space
• Swelling of the brain cells elicits 2 responses for
osmoregulation, as follows:
– It inhibits ADH secretion and hypothalamic thirst center
– immediate cellular adaptation
Hyponatremia
• Types
– Hypovolemic hyponatremia
– Euvolemic hyponatremia
– Hypervolemic hyponatremia
– Redistributive hyponatremia
– Pseudohyponatremia
Hypovolemic hyponatremia
• develops as sodium and free
water are lost and/or replaced
by inappropriately hypotonic
fluids
• Sodium can be lost through
renal or non-renal routes

www.grouptrails.com/.../0-Beat-Dehydration.jpg
Hypovolemic hyponatremia
• Nonrenal loss
– GI losses
• Vomiting, Diarrhea, fistulas, pancreatitis
– Excessive sweating
– Third spacing of fluids www.jupiterimages.com

• ascites, peritonitis, pancreatitis, and burns


– Cerebral salt-wasting syndrome
• traumatic brain injury, aneurysmal subarachnoid
hemorrhage, and intracranial surgery
• Must distinguish from SIADH
Hypovolemic hyponatremia
• Renal Loss
– Acute or chronic renal insufficiency
– Diuretics

www.ct-angiogram.com/images/renalCTangiogram2.jpg
Euvolemic hyponatremia
• Normal sodium stores and a total body excess
of free water
– Psychogenic polydipsia, often in psychiatric
patients
– Administration of hypotonic intravenous or
irrigation fluids in the immediate postoperative
period
Euvolemic hyponatremia
– administration of hypotonic maintenance
intravenous fluids
– Infants who may have been given inappropriate
amounts of free water
– bowel preparation before colonoscopy or
colorectal surgery
Euvolemic hyponatremia
• SIADH
– downward resetting of the osmostat
– Pulmonary Disease
• Small cell, pneumonia, TB, sarcoidosis
– Cerebral Diseases
• CVA, Temporal arteritis, meningitis, encephalitis
– Medications
• SSRI, Antipsychotics, Opiates, Depakote, Tegratol
Hypervolemic hyponatremia
• Total body sodium increases, and TBW
increases to a greater extent.
• Can be renal or non-renal
– acute or chronic renal failure
• dysfunctional kidneys are unable to excrete the
ingested sodium load
– cirrhosis, congestive heart failure, or nephrotic
syndrome
Redistributive hyponatremia
– Water shifts from the intracellular to the
extracellular compartment, with a resultant
dilution of sodium. The TBW and total body
sodium are unchanged.
• This condition occurs with hyperglycemia
• Administration of mannitol
Hyponatremia

• Pseudohyponatremia
– The aqueous phase is diluted by excessive
proteins or lipids. The TBW and total body sodium
are unchanged.
• hypertriglyceridemia
• multiple myeloma
Hyponatremia
• Clinical Manifestations
– most patients with a serum sodium concentration
exceeding 125 mEq/L are asymptomatic
– Patients with acutely developing hyponatremia
are typically symptomatic at a level of
approximately 120 mEq/L
– Most abnormal findings on physical examination
are characteristically neurologic in origin
– patients may exhibit signs of hypovolemia or
hypervolemia
Hyponatremia
• Diagnosis
– CT head, EKG, CXR if symptomatic
– Repeat Na level
– Correct for hyperglycemia
– Laboratory tests provide important initial
information in the differential diagnosis of
hyponatremia
• Plasma osmolality
• Urine osmolality
• Urine sodium concentration
• Uric acid level
• FeNa
Hyponatremia
• Laboratory tests Cont.
– Plasma osmolality
• normally ranges from 275 to 290 mosmol/kg
• If >290 mosmol/kg :
– Hyperglycemia or administration of mannitol
• If 275 – 290 mosmol/kg :
– hyperlipidemia or hyperproteinemia
• If <275 mosmol/kg :
– Eval volume status
Hyponatremia
• Laboratory tests Cont.
– Plasma osmolality < 275 mosmol/kg
• Increased volume:
– CHF, cirrhosis, nephrotic syndrome
• Euvolemic
– SIADH, hypothyroidism, psychogenic polydipsia, beer
potomania, postoperative states
• Decreased volume
– GI loss, skin, 3rd spacing, diuretics
Hyponatremia
• Laboratory tests Cont.
– Urine osmolality
• Normal value is > 100 mosmol/kg
• Normal to high:
– Hyperlipidemia, hyperproteinemia, hyperglycemia, SIADH
• < 100 mosmol/kg
– hypoosmolar hyponatremia
» Excessive sweating
» Burns
» Vomiting
» Diarrhea
» Urinary loss
Hyponatremia
• Laboratory tests Cont.
– Urine Sodium
• >20 mEq/L
– SIADH, diuretics
• <20 mEq/L
– cirrhosis, nephrosis, congestive heart failure, GI loss, skin, 3rd
spacing, psychogenic polydipsya
– Uric Acid Level
• < 4 mg/dl consider SIADH
– FeNa
• Help to determine pre-renal from renal causes
Hyponatremia
• Treatment
– four issues must be addressed
• Asyptomatic vs. symptomatic
• acute (within 48 hours)
• chronic (>48 hours)
• Volume status
– 1st step is to calculate the total body water
• total body water (TBW) = 0.6 × body weight
Hyponatremia
• Treatment Cont.
– next decide what our desired correction rate
should be
– Symptomatic
• immediate increase in serum Na level by 8 to 10 meq/L
in 4 to 6 hours with hypertonic saline is recommended
– acute hyponatremia
• more rapid correction may be possible
– 8 to 10 meq/L in 4 to 8 hours
– chronic hyponatremia
• slower rates of correction
– 12 meq/L in 24 hours
Hyponatremia
• Symptomatic or Acute
– Treatment Cont. - Here comes the Math!!!
• estimate SNa change on the basis of the amount of Na
in the infusate
• ΔSNa = {[Na + K]inf − SNa} ÷ (TBW + 1)
– ΔSNa is a change in SNa
– [Na + K]inf is infusate Na and K concentration in 1 liter of
solution
– OH MY GOD, what did he just say!!!!!!!!!!!!!!!!!!
Hyponatremia
• IV Fluids
– One liter of Lactated Ringer's Solution contains:
• 130 mEq of sodium ion = 130 mmol/L
• 109 mEq of chloride ion = 109 mmol/L
• 28 mEq of lactate = 28 mmol/L
• 4 mEq of potassium ion = 4 mmol/L
• 3 mEq of calcium ion = 1.5 mmol/L
– One liter of Normal Saline contains:
• 154 mEq/L of Na+ and Cl−
– One liter of 3% saline contains:
• 514 mEq/L of Na+ and Cl−
Hyponatremia
• Example:
– a 60 kg women with a plasma sodium of 110
meq/L
– Formula:
• ΔSNa = {[Na + K]inf − SNa} ÷ (TBW + 1)
– What is the TBW?
– How high will 1 liter of normal saline raise the
plasma sodium?
• Answer:
– TBW is 30 L
– Serum sodium will increase by approximately 1.4
meq/L for a total SNa of 111.4 meq/L
Hyponatremia
• Example:
– a 90 kg man with a plasma sodium of 110 meq/L
– Formula:
• ΔSNa = {[Na + K]inf − SNa} ÷ (TBW + 1)
– What is the TBW?
– How high will 1 liter of 3% saline raise the plasma
sodium?
• Answer:
– TBW is 54 L
– Serum sodium will increase by approximately 7.3
meq/L for a total SNa of 117.3 meq/L
Hyponatremia
• Asymptomatic or Chronic
– SIADH
• response to isotonic saline is different in the SIADH
• In hypovolemia both the sodium and water are
retained
• sodium handling is intact in SIADH
• administered sodium will be excreted in the urine,
while some of the water may be retained
– possible worsening the hyponatremia
Hyponatremia
• Asypmtomatic or Chronic
– SIADH
• Water restriction
– 0.5-1 liter/day
• Salt tablets
• Demeclocycline
– Inhibits the effects of ADH
– Onset of action may require up to one week
Hyponatremia
• Example:
– 85 y/o male with weakness and head ache
– SNa is 118 mEq/L
– Plasma osmolality is 254 mosmol/kg
– Urine osmolality is 130 mosmol/kg
– Urine sodium >20 mEq/L
– Uric acid is 3mg/dl
• What type of hyponatremia does this patient
have?
• What additional labs/studies would you
want?
Ouch!!!!!

Hyponatremia
• Example Cont.:
– Noncontrast CT Head:
• Tx
– Call Neurology and
neurosurgery
– Free water restriction
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Hyponatremia
• Example:
– 63 y/o female at 75 Kg with N/V/D for 4 days
– SNa is 108 mEq/L
– She has had one seizure in the ambulance
• Plasma osmolality is 251 mosmol/kg
• Urine osmolality is 47 mosmol/kg
• Uric acid is 6mg/dl hollywoodphony.files.wordpress.com

• What type of hyponatremia does this patient


have?
• What additional labs/studies would you want?
Hyponatremia
• How will you Tx her?
– Calculate the total body water
• 0.5 x weight = 37.5 L
– What rate of correction do you want?
• 8 to 10 mEq/L in 6 to 8 hours
– What fluid will you use?
• 3% Saline
– How will you calculate the amount of sodium to
give her?
• ΔSNa = {[Na + K]inf − SNa} ÷ (TBW + 1)
– How will her sodium increase after 1 liter of 3%
saline?
• By 10.8 mEq/L to 118.8 mEq/L
Hyponatremia
• What other medication will she need?
– Lasix and a foley
• Her sodium increases to 118.8 mEq/L over the
next 8-10 hours. How will you continue to
correct her hyponatremia?
– ΔSNa = {[Na + K]inf − SNa} ÷ (TBW + 1)
– ΔSNa = 154mEq/L – 118.8mEq/L ÷ 38.5L = 0.9 mEq/L
• So 2 liters of normal saline over the next 14
hours
Hyponatremia
• Congrats!!!!!!!! You saved her!

• Questions????