Professional Documents
Culture Documents
patients.
Important clinically because:
diseases;
Vasopressin
due to volume
contraction
Hypovolemic
hyponatremia
Diuretic therapy
Thiazide
Loop diuretics
diuretics
In TALH
DCT Blocks sodium
reabsorption
vasopressin release.
Uncommon.
Mineralocorticoid (Aldosterone) Deficiency
vasopressin release).
excretion >55%
Failure to improve or worsening of hyponatremia after
↑vasopressin
Drugs Causing Hyponatremia
Desmopressin Cyclophosphamid
Oxytocin e NSAIDs
Acetaminophen
Clofibrate Haloperidol
Carbamazepine Amitryptyline
Vincristine Fluoxetine
Nicotine Fluphenazine
Narcotics IVIG
SSRI Methylmetha
ifosfamide mphetamine
(MDMA)
Hypervolemic Hyponatremia (↑↑H O,
2
↑Na+)
Failure
↓MAP, ↓CO
Reduced effective
intravascular volume
↑Thirst ↓GFR
Cirrhosis
In pts of advanced cirrhosis
↑plasma renin,
↑ norepinephrine,
↑ vasopressin
Dilutional hyponatremia
Advanced Chronic kidney disease
hyponatremia.
Hypertonic - >295
hyperglycemia, mannitol, glycerol
Isotonic - 280-295
pseudo-hyponatremia from elevated
lipids or protein
Hypotonic - <280
excess fluid intake, low solute intake,
renal disease, SIADH, hypothyroidism,
STEP 2 –Volume
Status
2 n d assess volume status (extracellular fluid
volume)
Hypotonic hyponatremia has 3 main
etiologies:
Hypovolemic – both water and Na decreased
(H20 < Na)
Consider obvious losses from
diarrhea, vomiting, dehydration,
malnutrition, etc
Euvolemic – water increased and Na
stable
Consider SIADH, thyroid disease,
STEP 3 – Urine
Studies
Fo r
euvolemic hyponatremia, check urine
osmolality
Urine osmolality <100 - excess water
intake
Primary polydipsia, tap water enemas, post-TURP
Urine osmolality >100 - impaired renal
concentration
SIADH, hypothyroidism, cortisol deficiency
Goal:
mineralocorticoid replacement.
Treatment of euvolemic hyponatremia
- Vaptans
loop
diuretics.
If the serum [Na] does not correct to the desired level, lift the
Cirrhosis-Severe daily
fluid restriction,
Vaptans an alternative choice if fluid restriction has failed to maintain
liver transplantation.
CKD-Restricting fluid intake. Aquaretics (vaptans)
mg/dL)}.
Role of VAPTANS
Vaptans have long been anticipated as a more effective
Urine ↓ ↓ ↓
osmolality
Sodium ↔ ↔ ↔ at low dose,
excretion/d ↑at high dose
Status FDA approved FDA & EMA approved Phase 3
completed
Dosage 20mg over 30min f/b cont 15mg on D1, then titrate to -
inf 20-40mg/d 30-60mg/d
rapidly.
intravenously: 3 mL/kg/h;
Hypotonic
hyponatremia/t
rue
hyponatremia
Access Impaired renal Primary renal
renal function disease
status
Edema – CHF, cirrhosis, nephrotic
Norma
Accessl syndrome
volume
Ur, Na + <20
vomiting, =
burns,
status Volume diarrhoea,
pancreatitis
depletion Ur, Na + >20 =
Normal diuretics, salt
volume losing
nephropathy
Adrenal & Adrenal & thyroid
thyroid insufficiency
function
Normal
YES Dilute Psychogenic
Access Urine urine polydipsia
osmolality(A
ble to dilute NO
>100 mOsmol/kg SIAD
urine)
THANK YOU