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in the hospital setting

• Recognition
• Evaluation
• Consequences
• Management
Fundamentals of
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Table of contents
Chapter 1: Recognition 4
• Definition .................................................4
• Prevalence ................................................5
• Etiologies ..................................................6
• Signs, symptoms, and complications ......7
Chapter 2: Evaluation 10
• Classification ..........................................10
• Prognostic markers ................................11
• Acute vs chronic .....................................12
• Levels of severity ...................................12
• Misdiagnosis ...........................................13
Chapter 3: Consequences 14
• Potential effect on the brain ...............14
• Impact on selected outcomes ...............15
• In-hospital mortality ..............................16
• Risk of mortality ....................................17
• Impact on hospital costs .......................18
Chapter 4: Management 20
• Considerations .......................................20
• Rate of correction..................................20
• Management strategy
for correction .........................................21
Introduction
Hyponatremia is the most common electrolyte disorder in
hospitalized patients.
1
Hyponatremia can be a serious threat.
1

One study found that mild, or even asymptomatic, hyponatremia
may be associated with increased morbidity and the risk of
mortality.
1,2
While the symptoms of hyponatremia are not
always severe, the danger may be real.
1
Hyponatremia can produce a range of symptoms involving
almost all of the body systems.
2
The effects on the central
nervous system (CNS) can be significant and potentially lethal.
2
Hyponatremia also impacts hospital economics as it has been
shown to induce longer, more costly hospital stays.
3
Although there are many scientific articles on hyponatremia,
this pocket guide is designed to bring you the broad
fundamentals. From the definition of hyponatremia to
its relationship with mortality to its estimated burden on
the national healthcare system, you will find important
information in one concise resource.
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0
10
20
30
40
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Hyponatremia during the hospital stay
1
Hospital-acquired hyponatremia
0
10
20
30
40
Hyponatremia upon admission
6
Acute care hospital patients
Serum sodium level
upon admission
was <136 mEq/L
Serum sodium level
upon admission
was <126 mEq/L
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%
Prevalence in the hospital
Approximately 25% of acute care patients had
hyponatremia ([Na
+
] <136 mEq/L) upon admission
to the hospital
6
• Analyzed in a large study of more than 100,000 patients
conducted at an Asian hospital
6
• A more severe level of hyponatremia (defined in this study
as [Na
+
] <126 mEq/L) was seen in 2.6% of hospitalized patients
6
In a separate study, it was shown that 38.2% of patients
acquired hyponatremia during their hospital stay
1
• Determined in a retrospective analysis of 53,236
hospitalizations represented by 7 years of discharge records
1
— Hospital-acquired hyponatremia developed in 10,662 of
27,897 hospitalizations for which the initial serum sodium
level was within 138-142 mEq/L and length of stay was
longer than 1 day
1
Chapter 1: Recognition
Defining hyponatremia
• Hyponatremia, defined as a serum sodium level of <135 mEq/L,
indicates a relative excess of total body water to sodium
4
• Most common electrolyte disorder in the hospital
1
Types of hyponatremia
2,5
Dilutional
• Hypervolemic
— Total body sodium
increased
— Total body water
increased
— Edema
• Euvolemic
— Total body sodium
unchanged
— Total body water
increased
— No edema
Depletional
• Hypovolemic
— Total body sodium
and water reduced
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Etiologies of hyponatremia
Hypervolemic
5,7
• Congestive heart failure
• Cirrhosis
• Nephrotic syndrome
• Acute/chronic renal failure
Euvolemic
5,7-9
• Adrenal insufficiency
• Hypothyroidism
• Syndrome of Inappropriate
Antidiuretic Hormone (SIADH)
— Drugs (antidepressants, antipsychotics,
barbiturates, nicotine, NSAIDs,
morphine, vincristine)
— Physical/emotional stress
— Malignancies
— Pulmonary disease
— CNS disorders
— Idiopathic
Hypovolemic
5
• Diuretic excess
• Mineralocorticoid deficiency
• Salt-losing nephritis
• Osmotic diuresis
• Ketonuria
• Bicarbonaturia
• Vomiting or diarrhea (extrarenal origin)
• Third-spacing (ie, burns, pancreatitis)
• Seizures
• Coma
• Permanent
brain damage
• Respiratory
arrest
• Brain-stem
herniation
• Death
• Headache
• Nausea
• Vomiting
• Muscle cramps
• Lethargy
• Restlessness
• Disorientation
• Depressed
reflexes
Signs and
symptoms of
hyponatremia
14,15
Complications of
severe and rapidly
evolving hyponatremia
14,15
Signs, symptoms,
and complications
The symptoms of hyponatremia
may not always be clear
10
• The symptoms of hyponatremia may overlap with the
symptoms of other disorders or diseases
11-13
— While hyponatremia can affect a wide range of body
systems, the most severe consequences involve the CNS
2
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21.3
%
5.3
%
0
5
10
15
20
25
Patients admitted for falls
16
Hyponatremic patients
126 ± 5 mEq/L
(n=122)
Adjusted OR 67.4,
95% CI 7.5-607.4,
P<0.001
Mean serum [Na
+
]:
No. of patients:
Control patients
139 ± 2 mEq/L
(n=244)
P
a
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,

%
Incidence of falls among 122 patients (mean age 72 ± 13 years) with asymptomatic
chronic hyponatremia (mean serum sodium concentration [SNa] 126 ± 5 mEq/L)
compared with 244 matched controls (mean age 71 ± 12 years). Adapted from
Renneboog B et al. Am J Med. 2006;119(1):71.e1-71.e8.
16
Mild hyponatremia is
not always “asymptomatic”
16
Irregular gait
16
• Unsteadiness of gait was shown to be significantly greater
in patients with hyponatremia (n=12) as compared with
patients who were normonatremic
16
• Assessed in a study (N=122, approximate mean serum
Na 126 mEq/L) of mild, chronic hyponatremia conducted
in a Brussels, Belgium, hospital over the course of 3 years
16
High incidence of falls
16
• In this same study, falls were demonstrated to be a common
symptom in mild chronic hyponatremia
16
• Patients with chronic “asymptomatic” hyponatremia were
admitted for falls significantly more frequently than patients
with normal sodium levels
16
140
120
100
80
60
40
20
0
-20
-40
-60
-80
-100
-120
-500 -400 -300 -200 -100 100 200
[Na
+
]=124 mEq/L
Irregular gait with mild
asymptomatic hyponatremia
16
Evolution of the “total traveled way” (TTW) by the center of pressure in the dynamic test
to walk on the platform 3 stereotyped steps “in tandem,” eyes open, in patient C with
mild asymptomatic hyponatremia. Patient is walking from right to left. Irregular path
of the center of pressure observed in the hyponatremia condition (arrow).
Adapted with permission from Renneboog B et al. Am J Med. 2006;119(1):71.e1-71.e8.
16
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Classifying hyponatremia
Plasma osmolality
Hypotonic
hyponatremia
Euvolemic
hyponatremia
SIADH Endocrinopathies
• Hypothyroidism
• Glucocorticoid
deficiency
Excess water intake Impaired renal concentrating ability
Serum sodium <135 mEq/L
Hypovolemic
hyponatremia
Hypervolemic
hyponatremia
>295 mOsm/kg <280 mOsm/kg 280-295 mOsm/kg
>100 mOsm/kg <100 mOsm/kg
Isotonic
hyponatremia
Hypertonic
hyponatremia
Urine osmolality
Extracellular fluid
Urine sodium
>20 mEq/L
Renal
failure
>20 mEq/L <10 mEq/L
Urine sodium
Renal
solute loss
Extrarenal
solute loss
>20 mEq/L <10 mEq/L
Urine sodium
Edematous
disorders
• Heart failure
• Cirrhosis
• Nephrotic
syndrome
Hyponatremia classification algorithm
5
Adapted from Douglas I. Clev Clin J Med. 2006;73(3):S4-S12.
5
Chapter 2: Evaluation
Prognostic markers
• Laboratory measurements can be used in the differentiation
of hyponatremia
17
* Compared with serum osmolality.
Adapted from Hoorn EJ et al. Nephron Physiol. 2008;108(3):46-59.
17
Diagnostic indicators
17
Laboratory Disease/
measurement disorder
Serum osmolality: high Hyperglycemia, glycine
solutions
Serum osmolality: normal Pseudohyponatremia
Serum osmolality: low Hypotonic hyponatremia
Urine osmolality: high* Vasopressin-dependent
cause of hyponatremia
Urine osmolality: low* Vasopressin-independent
cause of hyponatremia
Urine sodium: low Heart/liver failure,
polydipsia, nonrenal
sodium loss, volume
depletion
Urine sodium: high Diuretics, cerebral
and renal salt wasting,
SIADH, primary
adrenal insufficiency,
hypopituitarism
Serum potassium: low Diuretic use, vomiting,
diarrhea
Serum potassium: high Primary adrenal
insufficiency, renal failure
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Acute vs chronic
• Hyponatremia can be further classified as acute or chronic,
defined as duration of onset of <48 hours or ≥48 hours
2,5
Serum sodium falls
rapidly over a period of
<48 hours
Serum sodium falls
slowly over a period of
≥48 hours
Acute Chronic
Hyponatremia
Classification by rate
of declining serum sodium
2
• The distinction of acute vs chronic significantly influences the
severity of CNS manifestations and potential complications
2
• Patients with acute hyponatremia (serum sodium
<120 mEq/L) are at risk of irreversible neurologic damage
when the rate of serum sodium decrease exceeds
0.5 mEq/L/h
18
Levels of severity
Mild to severe hyponatremia
18,19
*
Mild
Moderate
Severe
130-135 mEq/L
120-130 mEq/L
<120 mEq/L
• Mild hyponatremia can often be asymptomatic
19
• While lower serum sodium levels can lead to more severe
consequences of hyponatremia, mounting evidence has
found that even mild hyponatremia can be associated with
increased morbidity and mortality
1,14,16
Misdiagnosis
As the cause of hyponatremia is often
unclear, the differential diagnosis of
hyponatremia may be complex
20
• Assessed in a study analyzing a diagnostic algorithm for
hyponatremia in 121 patients presenting with serum
sodium <130 mEq/L
20
• In this study common causes of misdiagnosis:
— Effect of diuretics on clinical presentation and laboratory
measurements
20

— Use of extracellular volume status as the determining
diagnostic factor
20
• Hyponatremia and inadequate therapy may substantially
raise morbidity, mortality, and healthcare expenditure;
therefore, a careful diagnostic approach to patients with
hyponatremia is considered essential
20
Rate of misdiagnosis
20
:
Patients on diuretics
20
0 5 10 15 20 25
Percentage of patients misdiagnosed
Rate of misdiagnosis
20
:
Extracellular fluid volume
5
0 5 10 15 20 25
Percentage of patients misdiagnosed
* Serum Na values defining hyponatremia and its severity may vary across institutional laboratories
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In-hospital
mortality
19,030
1151
621
65
Admission [Na
+
]
<138 mEq/L and
further drop
Admission [Na
+
]
<138 mEq/L and
no further drop
Disposition

Adjusted
odds ratio

Adjusted relative prolongation
Disposition = discharge to short- or long-term care facility.

Adjustments for age, sex, race, admission service, and Deyo-Charlson Comorbidity Index score.

Hospitalizations resulting in death were excluded from analyses of disposition and length of stay.
§
Adjusted relative prolongation (95% CI).
0 1
§
§
2 3
Admissions
(n)
Impact of hyponatremia* on
selected outcomes
1
In-hospital
deaths (n)
18,409
1086
6744
569
Admission [Na
+
]
<138 mEq/L and
further drop
Admission [Na
+
]
<138 mEq/L and
no further drop
Admissions
(n)
18,409
1086
Admission [Na
+
]
<138 mEq/L and
further drop
Admission [Na
+
]
<138 mEq/L and
no further drop
Admissions
(n)
Discharged to
facilities (n)
Increased
length of stay

* Community-acquired hyponatremia or hospital-aggravated hyponatremia.
Adapted from Wald R et al. Arch Intern Med. 2010;170(3):294-302.
1
Impact of hyponatremia on
selected outcomes
One study showed that hospital-acquired
hyponatremia (n=10,662 hospitalizations)
was associated with twice the incidence
of in-hospital mortality (2.9% vs 1.4%)
compared with a group without hospital-
acquired hyponatremia
1
• Analyzed in a retrospective analysis of 53,236 hospitalizations*
represented by 7 years of discharge records
1
Chapter 3: Consequences
Potential effect on the brain
The brain reveals most of the clinical
effects associated with hyponatremia
21
• Patients exhibiting symptoms of hyponatremia usually
have cerebral edema
22
• If the brain has not adapted sufficiently to the swelling,
the resulting pressure on the skull can cause a decrease
in cerebral blood flow and pressure necrosis
22
• Unrestrained brain swelling will often lead to death
or permanent brain damage
23
Adapted from Gross P. Kidney Int. 2001;60(6):2417-2427.
24
Cerebral edema in acute,
severe hyponatremia
24
AXIAL
COMPUTER
TOMOGRAPHIC
(CT) SCAN OF
THE BRAIN
SHOWING
CEREBRAL
EDEMA
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Risk of mortality may continue
4
In a separate study, postdischarge mortality
was nearly double in hyponatremic patients
vs normonatremic patients at 1 year
4
• Determined by a 3-year cohort analysis of 98,411 admissions
4
*
• The study demonstrated that even mild hyponatremia carried
a significantly increased risk of death in-hospital, at 1 year,
and at 5 years following discharge
4
• Resolution of hyponatremia during hospitalization attenuated
an increased mortality risk conferred by hyponatremia
10
Patients with hyponatremia had
higher mortality rates than patients with
normal serum sodium concentrations
4
Normonatremic
patients
Hyponatremic
patients
Serum sodium level
(mEq/L)
135-144 <135
Mean age (years) 63.1 67.0
Crude in-hospital
mortality (%)
2.4 5.4
Crude 1-year
mortality (%)
11.7 21.4
Crude 5-year
mortality (%)
42.3 54.8
*Patients’ serum sodium was <135 mEq/L. The study assessed the risk of mortality
at 2 academic teaching hospitals in Boston, Massachusetts.
Adapted from Waikar SS et al. Am J Med. 2009;122(9):857-865.
4
In-hospital mortality
One study showed that the risk for
mortality began to rise at serum sodium
<138 mEq/L
25

• Assessed by the OPTIMIZE-HF registry, which evaluated the
risk of mortality in heart failure patients (N=48,612) with
hyponatremia at the time of admission
25
— Risk of mortality was more than double in the serum
sodium range of 132-135 mEq/L compared to the normal
serum sodium range
25
— The overall mortality rate was 3.8% in the study
25
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m
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r
a
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e
Admission serum sodium, mEq/L
0.08
0.07
0.06
0.05
0.04
0.03
0.02
0.01
125126127 129 128 130131132133134135136137138139140141142143144145146147
Restrictive cubic spline transformation plot with 95% confidence intervals is shown.
Adapted from Gheorghiade M et al. Eur Heart J. 2007;28(8):980-988.
Relationship between admission
serum sodium levels and
in-hospital mortality
25
• Any level of hyponatremia can be associated with potentially
adverse outcomes
1
Adapted from Gheorghiade M et al. Eur Heart J. 2007;28(8):980-988.
25
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One study estimated the potential
burden of hyponatremia on the national
healthcare system
3
• On a national level, the estimated economic burden of
hyponatremia

for hospitals included
3
— 1.4 million additional bed days
— $1.1 billion in additional costs
• Hospitals will likely bear the responsibility for these costs,
which under most reimbursement programs are unable to
bill patients or payers for these extended hospital stays
3
• Higher treatment costs are associated with patients requiring
ICU care, especially among those with moderate to severe
hyponatremia
3
In a separate study, the presence of various
levels of hyponatremia was associated
with longer lengths of stay compared with
the absence of hyponatremia
3
• This data analysis of more than 50,000 hospitalizations over a
7-year period further implicated the potential financial impact
of hyponatremia
1
Impact on hospital costs
In one study, patients with hyponatremia
incurred ~$1400 to nearly $3000 more
per hospital visit
3
• Analyzed in a retrospective cohort study, patients (N=9620)
with moderate to severe (n=547) or mild to moderate (n=1500)
hyponatremia had longer hospital stays vs patients in the
normal range (n=7573)
3
• Increased median LOS by 2 to 3 days
3
• Incurred extra costs per visit by severity of hyponatremia:
— Approximately $1400 for mild to moderate
hyponatremic patients
3
— Nearly $3000 for moderate to severe
hyponatremic patients
3
• Based on an annual admission of approximately 55,000
patients in this study, it was estimated that because of
hyponatremia the hospital accrued an additional
3
— $2.15 million in hospital costs
3
— Over 3400 additional bed days
3
Hyponatremia
n
Hospital LOS, Percent admitted Total cost,
status median days* to ICU* USD*
Moderate
to severe
(≤129 mEq/L)
547 8 32 $19,519
Mild to
moderate
(130-134 mEq/L)
1500 8 26 $18,054
Normal
serum sodium
(135-145 mEq/L)
7573 6 22 $17,085
Average in-hospital hyponatremia
levels and associated cost in
the hospital setting
3
Hospital LOS, ICU admission rate, and total cost
per admission by hyponatremia status adjusted
for clinical and demographic variables
*P<0.001 for Cuzick’s test for trend.
Abbreviations: ICU, intensive care unit; LOS, length of stay.
Adapted from Callahan MA et al. Postgrad Med. 2009;121(2):186-191.
3
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The risk of overly rapid correction
5,28
• Too rapid correction of serum sodium levels may lead to
osmotic demyelination, which can result in adverse neurologic
outcomes or death
5,28
Understanding the physiology
for correcting hyponatremia
Plasma sodium is the balance of
exchangeable sodium and potassium
divided by total body water.
29,30
This
simplified equation illustrates two
approaches to potentially correct
hyponatremia:
• Increase the numerator by adding sodium
29,30
• Decrease the denominator by subtracting water
29,30
Key:
[Na
+
]: plasma sodium concentration
Nae: total exchangeable sodium
Ke: total exchangeable potassium
TBW: total body water
[Na
+
] =
TBW
Na
e
+ K
e
Considerations in
treating hyponatremia
The rate of decline in serum sodium
concentration
5
• The rapidity of onset of hyponatremia determines whether
the imbalance is chronic or acute
5
• As there are risks associated with all forms of hyponatremia,
once identified, patient monitoring and careful management
are critical
1
Dilutional hyponatremia
5
• Mild hyponatremia may require less aggressive therapies
(e.g., fluid restriction)
26
• Moderate hyponatremia may require specific therapy
(e.g., aquaretic drugs)
• Severe symptomatic hyponatremia, with apparent
neurologic signs, will require more immediate attention
(e.g., hypertonic saline)
5,26
Depletional hyponatremia
5
• Isotonic saline is typically the mainstay of treatment
17
• If appropriate, discontinuation of diuretic can be considered
17
Rates of serum
sodium correction
Increasing serum sodium levels
It has been shown that osmotic demyelination syndrome (ODS)
can occur when hyponatremia is overcorrected, e.g., serum
sodium levels are increased 10 – 12 mEq/L in 24 hours and/or
18 mEq/L in 48 hours.
5,27
The treatment goal for improving serum sodium levels should
be sufficient to keep patients safe from hyponatremia-associated
complications while avoiding injury due to overcorrection.
5,27
Chapter 4: Management
Adapted from Rose BD. Am J Med. 1986;81(6):1033-1040 and Edelman IS et al. J Clin Invest.
1958;37(9):1236-1256.
29,30
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Notes: Notes:
©2012 Otsuka America Pharmaceutical, Inc. December 2012 0712W-5845I
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on selected outcomes. Arch Intern Med. 2010;170(3):294-302. 2. Adrogué HJ. Consequences of inadequate
management of hyponatremia. Am J Nephrol. 2005;25(3):240-249. 3. Callahan MA, Do HT, Caplan DW, Yoon-Flannery K.
Economic impact of hyponatremia in hospitalized patients: a retrospective cohort study. Postgrad Med.
2009;121(2):186-191. 4. Waikar SS, Mount DB, Curhan GC. Mortality after hospitalization with mild, moderate,
and severe hyponatremia. Am J Med. 2009;122(9):857-865. 5. Douglas I. Hyponatremia: why it matters, how it
presents, how we can manage it. Cleve Clin J Med. 2006;73(suppl 3):S4-S12. 6. Hawkins RC. Age and gender as
risk factors for hyponatremia and hypernatremia. Clin Chim Acta. 2003;337(1-2):169-172. 7. Widdess-Walsh P,
Sabharwal V, Demirjian S, DeGeorgia M. Neurologic effects of hyponatremia and its treatment. Cleve Clin J Med.
2007;74(5):377-383. 8. Kumar S, Berl T. Sodium. Lancet. 1998;352(9123):220-228. 9. Verbalis JG, Goldsmith SR,
Greenberg A, et al. Hyponatremia treatment guidelines 2007: expert panel recommendations. Am J Med.
2007;120(suppl 11A):S1-S21. 10. Hoorn EJ, van der Lubbe N, Zietse R. SIADH and hyponatraemia: why does it
matter? NDT Plus. 2009;2(suppl 3):iii5-iii11. 11. National Digestive Diseases Information Clearinghouse (NDDIC)
Web site. What I need to know about cirrhosis of the liver. http://digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis_
ez/index.htm. Accessed August 3, 2010. 12. National Heart, Lung, and Blood Institute, National Institutes of
Health Web site. What are the signs and symptoms of heart failure? http://www.nhlbi.nih.gov/health/dci/Diseases/
Hf/HF_SignsAndSymptoms.html. Accessed August 3, 2010. 13. Robertson GL. Regulation of arginine vasopressin in
the syndrome of inappropriate antidiuresis. Am J Med. 2006;119(7A)(suppl 1):S36-S42. 14. Adrogué HJ, Madias NE.
Hyponatremia. N Engl J Med. 2000;342(21):1581-1589. 15. Mayo Clinic Web site. Hyponatremia: symptoms.
http://www.mayoclinic.com/health/hyponatremia/DS00974/DSECTION=symptoms. Accessed December 21, 2010.
16. Renneboog B, Musch W, Vandemergel X, Manto MU, Decaux G. Mild chronic hyponatremia is associated
with falls, unsteadiness, and attention deficits. Am J Med. 2006;119:71.e1-71.e8. doi:10.1016/j.amjmed.2005.09.026.
17. Hoorn EJ, Zietse R. Hyponatremia revisited: translating physiology to practice. Nephron Physiol. 2008;108(3):46-59.
18. Ghali JK. Mechanisms, risks, and new treatment options for hyponatremia. Cardiology. 2008;111(3):147-157.
19. Bagshaw SM, Townsend DR, McDermid RC. Disorders of sodium and water balance in hospitalized patients.
Can J Anesth. 2009;56(2):151-167. 20. Fenske W, Maier SK, Blechschmidt A, Allolio B, Störk S. Utility and limitations
of the traditional diagnostic approach to hyponatremia: a diagnostic study. Am J Med. 2010;123(7):652-657.
21. Sterns RH, Silver SM. Brain volume regulation in response to hypo-osmolality and its correction. Am J Med.
2006;119(7A)(suppl 1):S12-S16. 22. Arieff AI. Management of hyponatraemia. BMJ. 1993;307(6899):305-308.
23. Ayus JC, Achinger SG, Arieff A. Brain cell volume regulation in hyponatremia: role of sex, age, vasopressin,
and hypoxia. Am J Physiol Renal Physiol. 2008;295(3):F619-F624. 24. Gross P. Treatment of severe hyponatremia.
Kidney Int. 2001;60(6):2417-2427. 25. Gheorghiade M, Abraham WT, Albert NM, et al; OPTIMIZE-HF Investigators
and Coordinators. Relationship between admission serum sodium concentration and clinical outcomes in patients
hospitalized for heart failure: an analysis from the OPTIMIZE-HF registry. Eur Heart J. 2007;28(8):980-988.
26. Fraser CL, Arieff AI. Epidemiology, pathophysiology, and management of hyponatremic encephalopathy.
Am J Med. 1997;102(1):67-77. 27. Sterns H, Nigwekar SU, Hix JK. The treatment of hyponatremia. Semin Nephrol.
2009;29(3):282-299. 28. Sterns RH, Riggs JE, Schochet SS. Osmotic demyelination syndrome following correction
of hyponatremia. N Engl J Med. 1986;314(24):1535-1542. 29. Rose BD. New approach to disturbances in the
plasma sodium concentration. Am J Med. 1986;81(6):1033-1040. 30. Edelman IS, Leibman J, O’Meara MP,
et al. Interrelations between serum sodium concentration, serum osmolality and total exchangeable sodium, total
exchangeable potassium and total body water. J Clin Invest. 1958;37(9):1236-1256.
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Connect with important updates about:
Hyponatremia: The most common electrolyte disorder
in hospitalized patients
1
Effects on the brain: The brain reveals most of the clinical
effects associated with hyponatremia
21
Risk of mortality: Mortality is significantly higher among
hospitalized patients with hyponatremia
25
Impact on the hospital: Hyponatremia can induce longer, more
costly hospital stays
3