Hyponatremia

Hyponatremia
Tad Kim UF Surgery

Hyponatremia

Overview
Fluid compartments and solutes Define hypoNa Normal physiology preventing hypoNa Pathophysiology of hypoNa Manifestations Work-up & Differential Diagnosis Treatment

Hyponatremia

Fluid Compartments/Solutes
Distribution of water- due to osmotic forces Na is mainly extracellular, K is intracellular Serum osmol = 2(Na)+ BUN/2.8 + Gluc/18
Sodium is the primary determinant

Serum osmol tightly regulated (275 290) Mechanisms for regulation

If osmol 1. thirst mechanism, 2. ADH Effective circulating volume also ADH

Hyponatremia

Defining Hyponatremia
Abnormal ratio of Na to water Na < 135 Most often due to retention of free water
2ndary to impaired excretion of free water

Occ. due to Na loss exceeding water loss

i.e. thiazide-induced hypoNa (elderly women)

Hyponatremia

Normal Physiology
Excretion of free water requires:
1. generation of free water (aka dilute urine) by reabsorption of NaCl w/o water in ascending Loop of Henle 2. excretion of this water by maintenance of impermeability to water in collecting duct (No ADH)
Remember that ADH leads to retention of water via pores

Hyponatremia

Pathophysiology
Simply, hyponatremia is due to inability to match water excretion with water ingestion 1. Defect in water excretion
SIADH (inappropriate ADH release) Hypovolemic state(appropriate ADH release) Hyperglycemia (draws water into plasma) Advanced renal failure

2. System overwhelmed (water ingestion)

i.e. primary polydipsia

Hyponatremia

Manifestations
In acute hyponatremia, osmotic forces cause water movement into brain cells leading to cerebral edema Mild Sx: anorexia, nausea, lethargy Mod Sx: disoriented, agitated, neuro deficit Sev Sx: seizures, coma, death

Hyponatremia

Differential Diagnosis/Work-Up
First test to obtain: serum osmolality Helps exclude two easier to remember causes of hyponatremia 1. Hyperosmolar hypoNa (osmo > 290)
Hyperglycemia, mannitol

2. Iso-osmolar hypoNa (nl serum osmo)

Severe hyperlipidemia or hyperproteinemia pseudohyponatremia not a true hypoNa

DDx / Work-up
Hypo-osmolar hypoNa (most common) Three types (based on volume status)
Hypervolemic (congested states)
CHF, cirrhosis, nephrotic syndrome, ARF / CRI

Hyponatremia

Hypovolemic (appropriate ADH secretion)

renal loss (diuretics, nephropathy, hypoAldosteron) GI loss (vomiting, diarrhea, NGT) Skin loss (sweating, burns, cystic fibrosis) Peritonitis or sepsis

Hyponatremia

DDX / Work-up
Euvolemic (normal volume state)
SIADH Pain and nausea can cause non-osmotic ADH release Post-op state, especially TURP Hypocortisolism or hypothyroidism Psychogenic polydipsia (water intoxication) Reset osmostat(pregnancy, psych disorders)
In this case, body thinks normal is lower -> no Tx

DDX / Work-Up
Next lab value: Urine osmolality Is free water excretion, or ability to dilute the urine, intact in the face of hypoNa? Remember: problem is too much water
Normal physiologic response = excrete water

Hyponatremia

If Uosm < 100, means appropriate excretion of dilute urine

Psychogenic polydipsia or reset osmostat

If Uosm > 200, reflected impaired water excretion (usu due to inability to stop ADH)

Hyponatremia

DDx / Work-Up
Final lab value: Urine sodium UNa < 30 implies hypovolemic or reduced effective circ volume (CHF, nephrotic, cirrhosis)
Kidneys reabsorb solutes to retain water and volume

UNa > 30 seen in the euvolemic types

Hyponatremia

Treatment Urgent
If symptomatic & urgent, give hypertonic saline
Do not correct more than 8mEq / day Risk of central pontine myelinolysis(CPM)

Hyponatremia

Treatment in asymptomatics
Correct the underlying cause in the DDx Hypovolemic give volume Hypervolemic Na & water restriction
Loop diuretics if CHF or nephrotic syndrome

Euvolemic water restriction (because excretion cant match it)

Specifics: if its hypothyroid give thyroxine Also use loops or, rarely, demeclocycline causes opposite problem (diabetes insipidus)

Take Home Points

If asked to work-up hypoNa, first: H&P
History of fluid loss (vomit/diarrh) or diuretics. On exam: mucous membranes, skin turgor, peripheral edema/ascites (CHF or cirrhosis)

Hyponatremia

Labs: ask for serum osmolality FIRST

Rule out the hyper & iso-osmolar forms

#2: assess volume status if hypo-osmolar

Determine if its Hyper- / Eu- / Hypovolemic form

Ask for urine osmolality & urine sodium

Identify the cause of hypoNa, then treat