Disorders of Sodium balance

Sodium balance
• An electrolyte and a mineral
• Most often found in the plasma outside the cell
• Transmit electrical impulses in heart and nervous system
• Regulates water distribution and fluid balance through
entire body
• Help regulate acid/base balance

Normal Levels
• Extracellular level: 135-145 mEq/L
• Intracellular level: 10-12 mEq/L
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 Sodium balance

Sodium imbalances normally

related to changes in total body
water, not changes in sodium.

Sodium imbalances can lead to

hypovolemia or hypervolemia.
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 Foods High in Sodium
1. Cheese 8. Preserved meats
2. Celery 9. Sauerkraut
3. Dried fruits 10.Soy sauce
4. Ketchup 11.All prepared foods
5. Mustard (canned and
6. Olives packaged) and fast
foods are very high
7. Pickles
in sodium

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Hyponatremia
 Normal Serum [Na] (135-145 mEq/L) Closely Guarded

ADH
(pM)

↓ ECFv Thirst

0
130 135 140 145
PNa (mEq/L)
 What is Appropriate Urine Concentration?

1) Complete DI
2) Defective osmoreceptor, normal AVP release to ECFv contraction
3) High-set osmoreceptor: AVP release is sluggish/delayed
4) AVP release at normal Posm but subnormal in amount
 Osmolality

• Plasma Osmolality:
Posm = 2 (Na+K) + glucose + urea
Normal = 2 (140+5) + 5 + 5 = 300 (280-300 mM)
• Urine Osmolality:
• Normal: 400-500 mM
» Maximal dilution 50-100 mM (USG 1.002-1.003)
» Maximal concentration 900-1200 mM (USG 1.030-1.040)
• Concentrated Urine: > 500 mM (at least!), USG > 1.017
i.e. UOSM > POSM is not enough to R/O Diabetes Insipidus
 Urine Specific Gravity USG
• Estimates solute concentration of urine on basis of weight as
compared with an equal volume of distilled water
• Normal Posm is 0.8-1.0% heavier than water so PSG = 1.008-1.010
• Each ↑ in UOSM 30-35 mM ↑ USG by 0.1% (0.001)
• Therefore, USG of 1.010 ~ UOSM 300-350 mM
• Larger MW urinary OSM (glucose, radiocontrast, carbenicillin) if
present will falsely elevate USG
• Nothing falsely lowers USG
 Three Main Types Hyponatremia
Hypovolemic Euvolemic Hypervolemic

Total body water decreases Total body water increases Total body sodium
increases
Total body sodium Total body sodium remains
decreases normal Total body water increases

Extracellular fluid volume Extracellular fluid increases Extracellular fluid increases

decreases minimally (no edema) markedly (with edema)

*Most Common*

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 Hyponatremia
Serum OSM

Low Normal High

Marked hyperlipidemia Hyperglycemia
(lipemia, TG >35mM) Mannitol
Hypotonic Hyperproteinemia
Hyponatremia (Multiple myeloma)
*Note: all have ↑ADH
•SIADH: inappropriate
ECFv * •Rest: appropriate

Low High
Normal
•CHF
•Hypothyroidism
•Cirrhosis
Renal loss (UNa > 20) Extra-renal loss (UNa <10) •AI
•Nephrosis
• Diuretics • Bleeding •SIADH
• Thiazide • Burns •Reset Osmostat
• K-sparing • GI (N/V, diarrhea) •Water Intoxication
• ACE-I, ARB • Pancreatitis 1° Polydipsia
• IV RTA, Hypoaldo TURP post-op
• Cerebral salt wasting
 Signs/Symptoms hyponatremia

• Headache, lethargy, confusion

• Mild anorexia, nausea, abdominal discomfort
• Muscle cramps, weakness
• Mental status changes, decreased level of
consciousness
• Seizures, tremors
• Orthostatic vital signs
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 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
– Symptomatic Hyponatremia (Seizures, coma, etc.)
• Alleviate symptoms
• “Quickly”: 3% NS, 1-2 mEq/L/h until:
• Symptoms stop
• 3-4h elapsed and/or Serum Na has reached 120 mEq/L
• 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

• Rx slowly (correct < 0.5 mEq/L/h, 10-12 mEq/L/d)

– Symptomatic/Acute: rapid Rx has resolved symptoms and brought
serum Na up to 120 mEq/L
– Asymptomatic, mild, chronic hyponatremia
– Want to prevent myelinolysis
• Increased risk: Women, alcoholics, malnourished
• ECFv contracted
• Bolus NS until BP, HR, JVP stable
• Then correct slowly with 0.9% NS or po salt
• ECFv Normal or ECFv Overloaded
• Fluid Restriction alone (exception: SAH, HI, post-neurosurgery)
• i.e. they do NOT need any IV or po salt!
 SIADH Ddx
• Intracranial disease
• Pulmonary disease
• Chest wall disorder (surgery, VZV)
• Severe pain or emotional distress
• Severe N/V
• Ectopic ADH: Small cell lung cancer
• Drugs: opiods, carbamazepine, chlorpropamide,
cyclophosphamide, cisplatin, vincristine, vinblastine,
amitriptylline, SSRI, neuroleptics, bromocriptine, ecstasy
(MDMA)
 SIADH
Diagnosis
• Normal ECFv (or slightly increased)
• Hypothyroidism & AI ruled out
• ↓ serum Na/OSM
• UOSM > 100 mM, UNa > 40 mEq/L
• Low plasma uric acid (< 238 umol/L)
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)
• Solution given must be of greater OSM than UOSM or in long run will just make
hyponatremia worse (often IV NS not sufficient)
 Cerebral Salt Wasting
• Cerebral disease (particularly SAH)
• Mimics SIADH with hyponatremia except primary defect is
salt wasting not water retention.
• Circulating factor which impairs renal tubular fn.
• Atrial natriuretic peptide?
• Brain natriuretic peptide?
• Endogenous ouabain?
• Plasma urate variable (normal or even lower than SIADH)
• Treatment is NS to correct ECFv contraction
 SIADH v.s. Cerebral Salt Wasting
SIADH CSW
Serum Na ↓ ↓
ECFv Normal ↓
UNa ↑ ↑↑
UOSM ↑ ↑
Urine volume N or ↓ ↑
Serum urate ↓ N or ↓
Urine urate ↑ N or ↑
Hypernatremia
 Signs/Symptoms Hypernatremia
• Restlessness, change in mental status,
irritability, seizure activity
• Nausea, vomiting, increased thirst
• Ataxia, tremors, hyper-reflexia
• Flushed skin, increased capillary refill time
• Decreased cardiac output related to
decreased myocardial contractility

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 Diabetes Insipidus Ddx
Central (CDI)
• Idiopathic
– autoimmune
• Neurosurgery, head trauma
• Cerebral hypoperfusion
• Tumor
– Craniopharyngioma, pituitary
adenoma, suprasellar
meningioma, pineal gland,
metastasis
• Infiltration
– Fe, Sarcoid, Histiocytosis X
Nephrogenic (NDI)
• X-linked recessive
• Hypokalemia
• Hypercalcemia (2° to HPT in
particular)
• Renal disease: after ATN,
postobstructive uropathy, RAS,
renal transplant, amyloid,
Sickle cell anemia
• Sjogren’s
• Drugs:
– Lithium, 20% of chronic users
– Demeclocycline, amphotericin,
colchicine
 Treatment of DI
• Rx Dehydration
• NS initially if ECFv contraction
• Then IV D5W or enteral free water to lower serum [Na]
» 1-2 mEq/h if Na > 160, symptomatic (coma, SZ), acute
» Otherwise 0.5-1.0 mEq/h
• Insensible losses? (0.5 L/d)
• Do NOT replace U/O if giving DDAVP
• DDAVP (Desmopressin)
• Reduces U/O and therefore simplifies fluid therapy
• Long t½: duration 8-12h, up to 24h
• Therefore use judiciously
» DDAVP 1ug IV/SC x 1
» Only repeat if breaks-thru again (i.e. becomes
hypernatremic with dilute polyuria)
» Once nasal mucosa stable can switch to intranasal
» Also oral form DDAVP now available

DDAVP: 1ug IV/SC = 10 ug IN = 0.1 mg PO

 Treatment of DI
• AVP, Aqueous vasopressin (Pitressin)
• Only parenteral form, 5-10 U SC q2-4h
• Lasts 2-6h
• Can cause HTN, coronary vasospasm
• Chlorpropamide (OHA which stimulates AVP secretion)
• 100-500 mg po OD-bid
• Only useful for partial DI, can cause hypoglycemia
• HTCZ (induces volume contraction which diminishes free water excretion)
• 50-100 mg OD-bid
• Mainstay of Rx for chronic NDI
• Amiloride (blunts Lithium uptake in distal tubules & collecting ducts)
• 5-20 mg po OD-bid
• Drug of choice for Lithium induced DI
• Indomethacin 100-150 mg po bid-tid (PGs antagonize AVP action)
• Clofibrate 500 mg po qid (augments AVP release in partial CDI)
• Tegretol 200-600 mg po od (augments AVP release in partial CDI)