Hyponatremia differential diagnosis: Difference between revisions
Iqra Qamar (talk | contribs) |
|||
| Line 93: | Line 93: | ||
|↑ | |↑ | ||
|- | |- | ||
| | |SIADH<ref name="pmid19666518">{{cite journal |vauthors=Tian W, Fu Y, Garcia-Elias A, Fernández-Fernández JM, Vicente R, Kramer PL, Klein RF, Hitzemann R, Orwoll ES, Wilmot B, McWeeney S, Valverde MA, Cohen DM |title=A loss-of-function nonsynonymous polymorphism in the osmoregulatory TRPV4 gene is associated with human hyponatremia |journal=Proc. Natl. Acad. Sci. U.S.A. |volume=106 |issue=33 |pages=14034–9 |date=August 2009 |pmid=19666518 |pmc=2729015 |doi=10.1073/pnas.0904084106 |url=}}</ref><ref name="pmid16843086">{{cite journal |vauthors=Gitelman SE, Feldman BJ, Rosenthal SM |title=Nephrogenic syndrome of inappropriate antidiuresis: a novel disorder in water balance in pediatric patients |journal=Am. J. Med. |volume=119 |issue=7 Suppl 1 |pages=S54–8 |date=July 2006 |pmid=16843086 |doi=10.1016/j.amjmed.2006.05.008 |url=}}</ref> | ||
|<nowiki>+/-</nowiki> | |<nowiki>+/-</nowiki> | ||
| +/- | | +/- | ||
Revision as of 18:39, 21 May 2018
|
Hyponatremia Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Hyponatremia differential diagnosis On the Web |
|
American Roentgen Ray Society Images of Hyponatremia differential diagnosis |
|
Risk calculators and risk factors for Hyponatremia differential diagnosis |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2] Saeedeh Kowsarnia M.D.[3]
Overview
Hyponatremia must be differentiated from other diseases that cause muscle weakness or cramps, oliguria, vomiting or diarrhea and seizures.
Differentiating Hyponatremia from other Diseases
| Disease | Clinical manifestations | Paraclinical Findings | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Symptoms and Signs | Lab Findings | ||||||||||||||||
| Muscle weakness/ Cramps | Seizures | Oliguria | Vomiting/ Diarrhea | Volume status | JVP | Edema | Crackles | Ascites | Tachycardia | Hypotension | Dry mucous membranes | Urine Analysis | Serum Osmolality | ADH levels | |||
| Urine Na | Urine Osm | FeNa | |||||||||||||||
| Renal failure[1] | +/- | +/- | +/- | - | Hypervolemic | + | + | + | + | - | - | - | >20 | - | >1% | ↓ | Normal or ↑ |
| Congestive heart failure[2] | +/- | +/- | - | - | Hypervolemic | + | + | + | + | - | - | - | <10 | - | <1% | ↓ | ↑ |
| Cirrhosis[2] | +/- | +/- | - | - | Hypervolemic | + | + | + | + | - | - | - | <10 | - | <1% | ↓ | ↑ |
| SIADH[3][4] | +/- | +/- | - | - | Euvolemic | - | - | - | - | - | - | - | - | >100 | - | ↓ | ↑ |
| Hypothyroidism | +/- | +/- | - | - | Euvolemic | - | - | - | - | - | - | - | - | >100 | - | ↓ | ↑ |
| Adrenal insufficiency | +/- | +/- | - | - | Euvolemic | - | - | - | - | - | - | - | - | >100 | - | ↓ | ↑ |
| Psychogenic polydipsia | +/- | +/- | - | - | Euvolemic | - | - | - | - | - | - | - | - | <100 | - | ↓ | ↑ |
| Beer drinker's potomania | +/- | +/- | - | - | Euvolemic | - | - | - | - | - | - | - | - | <100 | - | ↓ | ↓ |
| Pregnancy | +/- | +/- | - | - | Euvolemic | - | - | - | - | - | - | - | - | Variable | - | ↓ | ↓ |
| Anorexia (Chronic malnutrition) | +/- | +/- | - | - | Euvolemic | - | - | - | - | - | - | - | - | Variable | - | ↓ | - |
| Diuretic induced hyponatremia | +/- | +/- | + | - | Hypovolemic | - | - | - | - | + | + | + | >20 | - | >1% | ↓ | - |
| Non oliguric ATN | +/- | +/- | - | - | Hypovolemic | - | - | - | - | + | + | + | >20 | - | >1% | ↓ | - |
| Diseases causing 3rd spacing (Pancreatitis, SBO) | +/- | +/- | + | +/- | Hypovolemic | - | - | - | - | + | + | + | <10 | - | <1% | ↓ | - |
| Gastroenteritis | +/- | +/- | + | + | Hypovolemic | - | - | - | - | + | + | + | <10 | - | <1% | ↓ | - |
| Sweating | +/- | +/- | + | - | Hypovolemic | - | - | - | - | - | +/- | +/- | <10 | - | <1% | ↓ | - |
| Cerebral salt-losing syndrome | +/- | +/- | - | +/- | Euvolemic | - | - | - | - | - | +/- | - | >20 | >100 | > 1% | ↓ | - |
Approach to differential diagnosis
| Serum Na ≤ 135 meq/L | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
| Hypotonicity <275 mOsm/kg | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| UOsm < 100mOsm/kg | UOsm > 200mOsm/kg | UOsm 100–200mOsm/kg | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Hypovolemia Based on history & physical exam | Hypervolemia | Euvolemia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| UNa < 30 mEq/L | Variable UNa | UNa > 30 mEq/L | UNa < 30 mEq/L | UNa > 30 mEq/L | Variable UNa | UNa < 20 mEq/L | > 20 UNa < 40 mEq/L | UNa > 40 mEq/L | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Extrarenal losses |
|---|
| •Vomiting (Ucl ↓) •Diarrhea •Pancreatitis •Sweating •Small bowel obstruction |
| A04=
| Renal losses |
|---|
| •Osmotic diuresis (glucose, urea,bicarbonaturia) •Salt-Iosing nephropathy •Addison disease •CSW |
|A03=Variable UNa
•Diuretic use
Discontinue diuretics if UNa is still abnormal| B03=
| Conditions |
|---|
| •Heart failure •Liver disease •Nephrotic syndrome |
| B04=
| Conditions |
|---|
| •Chronic kidney disease •Diuretic use in: Heart failure Liver disease [[Nephrotic syndrome |
|C08=Probable hypovolemia| C10=Hypovolemia or euvolemia| C09=•Probable euvolemia
•SIAD
•Cortisol deficiency
•Hypothyroidism | C07=Discontinue diuretics if PNa normalize it's not SIAD if it's not normalized}}
Administer 0.9% saline
Normalize PNa
Administer 1–2 L 0.9% saline
Failure to normalize PNa
Hypovolemia
PNa decreases or no change
PNa increases
Decreasing UOsm
No change in UOsm but UNa increases
No change in UOsm but UNa increases
Decreased UNa
Hypovolemia
Salt-depleted SIAD
Hypovolemia
Decreasing Uosm
Administer additional saline
No change in UOsm
but UNa increases
Salt-depleted SIAD
References
- ↑ Tannen RL, Regal EM, Dunn MJ, Schrier RW (May 1969). "Vasopressin-resistant hyposthenuria in advanced chronic renal disease". N. Engl. J. Med. 280 (21): 1135–41. doi:10.1056/NEJM196905222802101. PMID 5782121.
- ↑ 2.0 2.1 Schrier RW (May 1992). "An odyssey into the milieu intérieur: pondering the enigmas". J. Am. Soc. Nephrol. 2 (11): 1549–59. PMID 1610976.
- ↑ Tian W, Fu Y, Garcia-Elias A, Fernández-Fernández JM, Vicente R, Kramer PL, Klein RF, Hitzemann R, Orwoll ES, Wilmot B, McWeeney S, Valverde MA, Cohen DM (August 2009). "A loss-of-function nonsynonymous polymorphism in the osmoregulatory TRPV4 gene is associated with human hyponatremia". Proc. Natl. Acad. Sci. U.S.A. 106 (33): 14034–9. doi:10.1073/pnas.0904084106. PMC 2729015. PMID 19666518.
- ↑ Gitelman SE, Feldman BJ, Rosenthal SM (July 2006). "Nephrogenic syndrome of inappropriate antidiuresis: a novel disorder in water balance in pediatric patients". Am. J. Med. 119 (7 Suppl 1): S54–8. doi:10.1016/j.amjmed.2006.05.008. PMID 16843086.