Hyponatremia

Hyponatremia
• Hyponatremia is defined as a plasma sodium less than
135 mEq/L
• A true hyponatremia is characterized by hypo-
osmolality
True Hyponatremia (Hypo-osmolar hyponatremia)
• Hyponatremia with normal ECF volume
• SIADH, Hypothyroidism, Glucocorticoid deficiency
• Post operative pain
• Psychogenic polydipsia
• Hyponatremia with increased ECF(Hypervolemia)–Dilutional
hyponatreamia
• Cardiac Failure
• Cirrhosis
• Nephrotic Syndrome
• Renal Failure
• Hyponatremia with low ECF (Hypovolemia)
• Renal loss – Diuretics, osmotic diuresis, salt wasting nephropathy
• Extra renal cause – vomiting, diarrhoea, peritonitis
Psudo hyponatremia and SIADH
• Pseudo Hyponatremia
• Normal osmolality – Hyperlipidemia, hyperproteinemia
• High osmolality – Hyperglycaemia ( Plasma Na+
concentration falls by 1.4 mmol/L for every 100 mg/dL
rise in the plasma glucose concentration)
• Syndrome of inappropriate ADH secretion (SIADH) —
• Persistent ADH release and water retention can be seen in
SIADH.
• Major causes of SIADH include CNS disease, malignancy /
mainly lung, certain drugs, and post-surgery.
SIADH diagnostic criteria
• Patients are typically normovolemic
• Low plasma sodium concentration (typically < 130 mmol/l)
• Low plasma osmolality (< 270 mmol/kg)
• Inappropriately concentrated urine - Urine osmolality elevated(> 100
mmol/kg)
• Urine sodium concentration elevated (>40 mEq/L)
• By definition, they also should have normal renal, adrenal, and thyroid
function and usually have normal K+ and acid-base balance.
• SIADH may be associated with hypouricemia due to the uricosuric state
induced by volume expansion.
• Exclusion of other causes of hyponatremia
Clinical features
Mild hyponatremia Moderate Severe

Anorexia Personality change Drowsiness

Headache Muscle cramps Diminished reflexes
Nausea Muscle weakness Convulsions
Vomiting Confusion Coma
Lethargy Ataxia Death

Acute hyponatremia produce more symptoms than chronicSymptoms are more

prominent in elderly patients than in youngIn hyponatremia there will be
increase in volume of ICF especially in brain cells. This will lead to cerebral
oedema. Therefore clinical findings will be mainly neurological
Plasma Osmolality

• Low – True hyponatremia

• Normal or elevated – Pseudohyponatremia /hyperglycaemia
Urine osmolality
• Urine osmolality ( The appropriate renal response to
hypo-osmolality is to excrete a maximally dilute urine
- urine osmolality <100 mOsm/L )
• < 100 mOsm / Kg – Primary polydipsia with normal water
excretion
• > 100 mOsm / Kg – Hyponatremia with impaired water
excretion
Urine sodium
• Urine Sodium Concentration ( It is used to
discriminate between extrarenal and renal losses of
Na+ )
• > 20 mEq/L – SIADH, Salt wasting nephropathy,
diuretic therapy, hypoaldosteronism
• < 20 mEq/L – Extra renal sodium loss – Diarrhoea,
Vomiting
Steps of management
• There are two steps in management of
hyponatremia
• Correction of water imbalance
• Correction of salt imbalance
Correction of water excess

•Correction of water / fluid imbalance

• Water restriction is treatment of choice in
SIADH, Renal, Cardiac, Liver failures and
Polydipsia
Corrrection of sodium
• Calculation of requirement of sodium
• (Desired Na+ -- Serum Na+) x (0.6 x Body weight in Kg)
• Try oral salt first if not symptomatic
• IV fluids then
Solution Na+ mEq / L
7.5% NaHCO3 900
3% NaCl 513
0.9% NaCl(NS),DNS 154
0.45% NaCl 70
Ringer’s Lactate 130
Isolyte G 63
Isolyte M 40
Isolyte P 25
5% Dextrose 0
Normal saline in water with salt depletion
• 0.9% NaCl (NS), is given to patients with true volume depletion.
• The administered sodium and water initially corrects the
hyponatremia (by approximately 1 meq/L for every liter of isotonic
saline infused) and then, once volume repletion is attained, by
removing the stimulus to ADH release and allowing the excess water
to be excreted.
3% saline
• Knowing that each 1L of 3% saline will provide 513meq (100 ml = 51.3
mEq), the total volume of 3% saline needed for correction can be
calculated:
• Infuse the calculated volume of 3% saline over 24 hrs
• Eg : 50 year old male patient, 70 kg ,with serum sodium 110 mEq/L
• Desired sodium level after 24 hours = 122 m Eq/L
• Sodium deficit to be corrected in 24 hours = (122 – 110 ) x (0.6 x70 ) = 12 x 42 = 504
mEq
• 100 ml 3 % saline(one bottle) = 51.3 mEq sodium
• 504 / 51.3 = 9.8 bottles of 100 ml 3% saline in 24 hours
• Per hour infusion = 980 ml /24 = 40.8 ml /hour
• Caution : Check sodium level every 4 – 6 hours
• If Serum sodium >122 mEq/L stop infusion for that 24 hours ( if not symptomatic)
• Restart infusion next day with new target sodium level
CPM or ODS
• Correct sodium slowly otherwise patient may develop
central pontine myelinolysis - CPM or osmotic
demyelination syndrome- ODS (Dysarthria,
Dysphagia, Flaccid quadriplegia, pseudobulbar palsy
and coma are features of CPM.
• The pathology consists of demyelination without
inflammation in the base of the pons, with relative
sparing of axons and nerve cells.)
Hyponatremia with seizures
• 100 mL of 3 % saline IV bolus, which should
raise the serum sodium by 1.5 meq/L in men
and 2 meq/L in women, thereby reducing
cerebral edema.
• If neurologic symptoms persist or worsen, a 100
mL bolus of 3 % saline can be repeated one or
two more times at ten minute intervals.
Vaptans in SIADH
• The vasopressin receptor antagonists (Vaptans, aquaretics) produce
a selective water diuresis (aquaresis) without affecting sodium and
potassium excretion.
• Tolvaptan
• Oral: Initial: 15 mg OD; after at least 24 hours, may increase to 30 mg once
daily to a maximum of 60 mg once daily titrating at 24-hour intervals to
desired serum sodium concentration.
• Avoid use in patients with underlying liver disease, including cirrhosis.
• Conivaptan
• Loading Dose: 20 mg IV administered over 30 minutes, followed by
• Continuous infusion: 20 mg/day over 24 hours for 2 to maximum 4 days.
• Following initial day of treatment, dosage may be increased to
• 40 mg/day continuous infusion as needed to raise serum sodium.