Dr.Methaq A.M.

Hussein
MRCP(UK),
Endocrine ,D.M
(LONDON) ,
Professor of
Medicine

Hyponatremia

Hyponatrem ia defines as serum sodium concentration ž

<135m eq/L.

Most frequent electrolyte abnorm ality in the hospitalized ž

pt.

Essentially com m on in critical care units. In addition to ž

being a potentially life-threatening condition,
hyponatrem ia is an independent predictor of death
am ong intensive care unit and geriatric patients and those
with heart failure, and cirrhosis.
Hyponatremia
Changes in serum sodium concentration results from ž
derangements in water balance.

Low serum sodium concentration denotes a relative ž

deficit of sodium and /or a relative excess of water.

Serum sodium = total body sodium

total body water

As seen in the formula, hyponatremia may result from ž

either a decrease in the numerator or an increase in
the denominator.

Approach to the pt with hyponatremia

Decreased serum osmolality --check volume status. ¨

It could be:

Hypovolumeic,
Hypervolumeic or
Euvolumeic.
Approach to the patient with Hyponatremia

Hypovolumeic Hyponatremia (Dehydartion) ž

Decrease Sodium
Decrease water

Causes ž

Diarrhea
Diuretic use
Mineralcorticoid defeciency
Osmotic diuresis like mannitol

Approach to the patient with Hyponatremia

Hypervolumeic Hyponatremia ž

Sodium content unchanged

Increase water

Causes ž

Heart Failure
Cirrhosis
Nephrotic syndrome
 Approach to the patient with Hyponatremia

Euvolumeic Hyponatremia ¨

Sodium content unchanged

Relative increase in water

Cause ¨
Syndrome of inappropriate diuretic hormone
(SIADH)

Approach to the patient with Hyponatrem ia

Hyponatremia with decreases serum osmolality

ECF volume ECF volume ECF volume

decreased normal (euvolumic) increased (edema)

TB Na TB Na TB Na
TB water TB water TB water

Renal Extrarenal SIADH CHF

Diuretics GI losses Cirrhosis
Nephrotic syndrome

Urine Na Urine Na Urine Na Urine

Na
 SIADH

Inappropriate release of ADH causes siadh. ¨

It is diagnosed by checking : ¨
Serum sodium <135
Serum osm olality <280
Urine osm olality >100
Urine sodium >30
also low serum uric acid <4.0

Causes of SIADH
Cen tral n ervous system ; ž
m eningitis, brain abcess,
stroke, acute psycosis

Pulm on ary ž
pneum onia, lung abcess,
tuberculosis

En docrin e ž
Addison's disease, hypothyroidisim ,
hypopituitarism

Neoplastic ž
pancreatic or lung cancers.
Drugs induced SIADH

Increased ADH ADH potentiation

Anti-depressant carbamazepine
anti-psycotics chlopropamide
carbamazepine cyclophosphamide
platinum alkaloids Nsaids
alkylating agents ADH like activity
interferon vasopressin
levimasole ddavp
oxytocin

Clinical manifestation of siadh

Acute: (<48 hours)

Stupor/coma ž
Convulsions Treatment with ž

Respiratory arrest 3% NaCl ž

Chronic; (>48 hours)

Headache ž
Irritability Treat with medicines ž

Nausea & vomiting like Vaptans ž

Confusion & Disorientation ž

Gait disturbance ž
SIADH

Treatment
Fluid Restriction ¨
Oral Salt, Hi-protein diet or Urea (30 g/d): promote solute diuresis ¨

Lasix 20 mg po od-bid: Loop direct diminishes medullary gradient ¨

Demeclocycline 300-600 mg bid (can be nephrotoxic) ¨

Lithium (induces NDI) ¨
IV salt solution: ¨
Rarely if ever needed (i.e. only if symptomatic with SZ/coma) n
)

Rx Hyponatremia
Na deficit = 0.6 x wt(kg) x (desired [Na] - actual [Na]) ¨

(mmol)

When do you need to Rx quickly? ¨

Acute (<24h) severe (< 120 mEq/L) Hyponatremia ¤
Prevent brain swelling or Rx brain swelling n
Symptomatic Hyponatremia (Seizures, coma, etc.) ¤
Alleviate symptoms n

“Quickly”: 3% NS, 1-2 mEq/L/h until: ¨

Symptoms stop n
3-4h elapsed and/or Serum Na has reached 120 mEq/L n

Then SLOW down correction to 0.5 mEq/L/h with 0.9% NS ¨

or simply fluid restriction. Aim for overall 24h correction to
be < 10-12 mEq/L/d to prevent myelinolysis
Rx Hyponatremia (Example)

Na deficit (mmol) = 0.6 x wt(kg) x (desired [Na] - actual [Na]) ¨

60 kg women, serum Na 107, seizure recalcitrant to benzodiazepines. ¨

Na defecit = 0.6 x (60) x (120 – 107) = 468 mEq ¨
Want to correct at rate 1.5 mEq/L/h: 13/1.5 = 8.7h ¨
468 mEq / 8.7h = 54 mEq/h ¨
3% NaCl has 513 mEq/L of Na ¨
54 mEq/h = x ¨
513 mEq 1L
x = rate of 3% NaCl = 105 cc/h over 8.7h to correct serum Na to 120 mEq/h ¨

Note: Calculations are always at best estimates, and anyone getting ¨

hyponatremia corrected by IV saline (0.9% or 3%) needs frequent
serum electrolyte monitoring (q1h if on 3% NS).

Correcting hyponatremia

traditional approach; ¨

add to the
numerator

Serum sodium = Total body sodium

Total body water
 Correcting hyponatremia

Current approach; ¨

Serum sodium = Total body sodium

Total body water

Subtract from the

the denominator

Treatment strategies for Acute

hyponatremic emergencies

3% NaCl: 100ml bolus for severe symptoms. ¨

3% NaCl@1 to 2ml/kg/hr for 2 to 4 hours plus ¨

furosemide.
Goal: correction by 4 to 6 mEq/L in first few ¨
hours.
Monitor closely to avoid excessive correction. ¨
Treatment strategies for chronic hyponatremia

Treatment Mechanism Advantages Limitations

Fluid restriction Water intake Effective, Poor compliance
(0.5- 1 liter/day) inexpensive
Demeclocycline Inhibits action of Easily available 3-4 days for
(600-1200mg/d) adh onset,
nephrotoxicity

Urea Osmotic diuresis Decreased risk Poor palatability,

(30mg/d) Avoid in ckd

Lithium Inhibits action of Easily available Slow onset,

(up to 900mg/d) adh toxicity

Rate of correction
Acute symptomatic : ž
4 to 6 mEq/L in first 4 hours
Target <12 mEq/L in first 24 hours.

Chronic: ž
Target correction at <8 mEq/L in first 24 hours

Goal not to exceed; ž

12 mEq/L in first 24 hr
18 mEq/L in first 48 hr
Importance of appropriate serum sodium
correction
Too-rapid correction of hyponatrem ia (e.g., >12 m Eq/L/24 ž
hours) can cause osm otic dem yelination syndrom e (ODS)
resulting in:

dysarthria, dysphagia,
seizures, com a and death
spastic quadriparesis.

Risk factors for ODS: ž

severe m alnutrition,
alcoholism ,
advanced liver disease

Non-peptide AVP receptor antagonist

(Vaptans)

Aquaretic nonpeptide arginine vasopressin receptor ž

(AVPR) antagonists are safe and effective
hyponatrem ia therapies.
Vaptans lead to aquaresis, an electrolyte-sparing ž
excretion of free water, that results in the correction of
serum sodium concentration.