Hyponatremia causes

	Hyponatremia Microchapters
Home
Patient information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Hyponatremia from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X-ray
Echocardiogram or Ultarsound
CT scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Hyponatremia causes On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Hyponatremia causes All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Hyponatremia causes
CDC on Hyponatremia causes
Hyponatremia causes in the news
Blogs on Hyponatremia causes
Directions to Hospitals Treating hyponatremia
Risk calculators and risk factors for Hyponatremia causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Saeedeh Kowsarnia M.D.[2]

Overview

Disease name] may be caused by [cause1], [cause2], or [cause3].

OR

Common causes of [disease] incl ude [cause1], [cause2], and [cause3].

OR

The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].

OR

The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click here.

Causes

Hyponatremia results from:

Decreased renal excretion of water is the most cases of hyponatremia, secondary to persistent action of ADH.

Blood sampling from a vein that is being infused with hypotonic medications.
Older techniques (e.g., flame photometry) for sodium measurement, high levels of protein or triglyceride can cause false hyponatremia (Pseudohyponatremia).
Hyperglycemia can also cause hyponatremia, osmotic water movement from cells into the blood, resulting in a relative decrease in serum sodium concentration in the absence of hypo-osmolality.

(for each 100-mg/dL increase in glucose concentration above 100 mg/dL The sodium concentration should be increased by approximately 1.6 to 2 mmol/L)

Excess water intake is a rare cause of hyponatremia.In psychogenic polydipsia, ingesting large volumes (>15-20 L/day) of water results in hyponatremia, in spite of preserved renal function and diluting ability.
Medications which interfere with urinary dilution (thiazide diuretics and nonsteroidal anti-inflammatory drugs [NSAIDs]).
Clinical disorders ( congestive heart failure, nephrotic syndrome, cirrhosis) with the reduction in effective arterial blood volume, resulting in persistent ADH activity despite hypo-osmolar plasma.
Acute or chronic renal failure results in reduced functional nephron mass, decreased glomerular filtration rate, and therefore decreased capacity for water excretion.

Causes of Hyponatremia based upon Serum Osmolality:

Classification	Serum Osmolality	Etiology
Hypertonic Hyponatremia		Hyperglycemia, Mannitol, Glycerol, Sorbitol
Isotonic Hyponatremia		Lab/blood draw error,Hyperparaproteinemia,Hyperlipidemia,Post TURP (bladder irrigation with osmotic solutions)
Hypotonic Hyponatremia		Etiology depends upon volume status (Hypervolemic/ Euvolemic/ Hypovolemic

Common Causes

Diagnostic criteria of SIADH/SIAD
serum sodium <135 mEq/L Plasma osmolality <275 mOsm/kg , ( NL=275–295 mOsm/kg) urine concentration UOsm >100mOsm/kg H2O, (NL=500-800 mOsm/kg H2O) Urine sodium >30 (20-40) mmol/L, with normal salt and water intake, (NL=20 mEq/L)^† Clinical euvolemia Exclusion of glucocorticoid deficiency or hypothyroidism

† Mmol and Meq are the same for univalent ions like sodium

Causes based on volume status ^[1]

Volume status	Sodium status	Causes
Hypovolemic Hyponatremia^[2]	total body water ↓ total body sodium ↓↓	GI loss: Vomiting, diarrhea, tube drainage Insensible loss: Sweating, burns Renal loss: Salt-wasting nephropathy (Inappropriate loss of Na+-Cl– in the urine), Bicarbonaturia ( Renal tubular acidosis, Metabolic alkalosis), Osmotic diuresis Third spacing of fluids : Pancreatitis, hypoalbuminemia Cerebral salt-wasting syndrome : Stroke ,SAH (urinary salt wasting, brain natriuretic peptide ↑) Mineralocorticoid deficiency: Addison disease Excessive diuretic administration
Hypervolemic Hyponatremia	total body water ↑↑ total body sodium ↑	Renal disease: Acute or chronic kidney disease or injury (due to relatively higher water versus salt intake and poor excretion),Nephrotic syndrome Congestive heart failure Cirrhosis Iatrogenic
Euvolemic Hyponatremia	total body water ↑ total body sodium ↔	Drugs:Vasopressin, diuretics, antidepressants, opioids SIADH: Malignancy, central nervous system (CNS) disorders, pulmonary disease, or drugs, postoperative nausea, pain,stress,Neoplasia (common),trauma,pregnancy High fluid intake: Physical activity, surgery, primary polydipsia, potomania (caused by a low intake of solutes with relatively high fluid intake) Medical testing (excess fluid intake) :Colonoscopy or cardiac catheterization Hypothyroidism Glucocorticoid deficiency Reset osmostat ^† Iatrogenic

† Altered sensitivity to serum osmolality by the hypothalamic osmoreceptors

Drugs ^[3] :

Drug Mechanisms	Drug Classification
Increase ADH secretion	Antidepressants:Tricyclic antidepressants ( Amitryptiline, Protriptyline, Desipramine),Selective serotonin reuptake inhibitors, Monoamine oxidase inhibitors Antipsychotic drugs: Phenothiazines (Thioridazine, Trifluoperazine), Butyrophenones (Haloperidol) Antiepileptic drugs: Carbamazepine, Oxcarbazepine, Sodium valproate Anticancer agents: Vinca alkaloids (Vincristine, Vinblastine), Platinum compounds (Cisplatin, Carboplatin) Alkylating agents: Intravenous, Cyclophosphamide, Melphalan, Ifosfamide Miscellaneous: Methotrexate, Interferon, Levamisole, Pentostatin, Monoclonal antibodies, MDMA, Nicotine Opiates
Increase ADH effect	Antiepileptic drugs: Carbamazepine, Lamotrigine Antidiabetic drugs: Chlorpropamide, Tolbutamide Anticancer agents: Alkylating agents (Intravenous cyclophosphamide) NSAIDS
Drugs affecting water and sodium homeostasis	Diuretics:Thiazides, Indapamide, Amiloride, Loop diuretics
Reset omostat ^‡	Antidepressants: Venlafaxine Antiepileptic drugs:Carbamazepine

‡ Altered sensitivity to serum osmolality by the hypothalamic osmoreceptors

Causes by Organ System

Cardiovascular	Congestive heart failure
Chemical / poisoning	No underlying causes
Dermatologic	Burns
Drug Side Effect	ACE inhibitors, Ajuga nipponensis makino , Asenapine maleate, Cefpodoxime, Chlorpropamide, Cyclophosphamide, Desmopressin, Diuretics, Duloxetine, Eslicarbazepine acetate, Ethacrynic Acid, Felbamate, Fluvoxamine, Interferon gamma, Ixabepilone, Losartan and Hydrochlorothiazide, Nilotinib, Nivolumab, Nonsteriodal anti-inflammatory drugs , Oxcarbazepine, Pramipexole, Rifaximin, Tiagabine, Tolazamide, Zonisamide, Tolbutamide, Vortioxetine
Ear Nose Throat	No underlying causes
Endocrine	Addison's disease, Corticosterone methyloxidase type I deficiency , Diabetes mellitus, Diabetic coma, Glucocorticoid deficiency, Familial hyperreninemic hypoaldosteronism type 2, Hypothyroidism, Mineralocorticoid deficiency, Myxedema coma , Syndrome of inappropriate antidiuretic hormone , Thyrotropin deficiency, 18-Hydroxylase deficiency , Familial hypoaldosteronism
Environmental	No underlying causes
Gastroenterologic	Acute liver failure , Cirrhosis, Congenital chloride diarrhea , Diarrhea, Gastrointestinal fistula, Ileus, Necrotizing enterocolitis , Pancreatitis, Peritonitis, Vomiting, Cystic fibrosis
Genetic	18-Hydroxylase deficiency , Bartter Syndrome type 4 , Cystic fibrosis, Familial hypoaldosteronism , Corticosterone methyloxidase type I deficiency , Familial hyperreninemic hypoaldosteronism type 2, Congenital chloride diarrhea
Hematologic	No underlying causes
Iatrogenic	After pituitary surgery, After surgery, Ascitic tap, Gastric drainage, Hypotonic infusions, Pleuracentesis
Infectious Disease	Malignant boutonneuse fever , Neonatal bacterial meningitis , Peritonitis
Musculoskeletal / Ortho	No underlying causes
Neurologic	Intracranial hemorrhage, Subarachnoid hemorrhage, Pituitary cancer
Nutritional / Metabolic	Hyperlipidemia, Hyperproteinemia, Hypoalbuminemia, Low sodium diet, Metabolic acidosis, Diabetic coma
Obstetric/Gynecologic	Pregnancy
Oncologic	Pituitary cancer
Opthalmologic	No underlying causes
Overdose / Toxicity	Water intoxication
Psychiatric	Psychogenic polydipsia, Psychosis, Self-induced water intoxication and schizophrenic disorders syndrome
Pulmonary	Cystic fibrosis
Renal / Electrolyte	Acute kidney disease, Chronic kidney disease, Diuresis, Glucosuria, Ketonuria, Nephrotic syndrome, Renal Tubular Acidosis, Tubulointerstitial kidney disease, Bartter Syndrome type 4 , Corticosterone methyloxidase type I deficiency , Renal failure
Rheum / Immune / Allergy	Addison's disease, Nephrotic syndrome
Sexual	Cystic fibrosis
Trauma	Burns
Urologic	No underlying causes
Dental	No underlying causes
Miscellaneous	Beer potomania, Ecstasy abuse , Factitious hyponatremia, Hydration, Massive edema, Pseudohyponatremia, Water Intoxication , Hyperlipidemia, Hyperproteinemia, Hypoalbuminemia, Exercise associated hyponatremia

Causes in Alphabetical Order

References

↑ Guillaumin, Julien; DiBartola, Stephen P. (2017). "A Quick Reference on Hyponatremia". Veterinary Clinics of North America: Small Animal Practice. 47 (2): 213–217. doi:10.1016/j.cvsm.2016.10.003. ISSN 0195-5616.
↑ Rondon-Berrios, Helbert; Agaba, Emmanuel I.; Tzamaloukas, Antonios H. (2014). "Hyponatremia: pathophysiology, classification, manifestations and management". International Urology and Nephrology. 46 (11): 2153–2165. doi:10.1007/s11255-014-0839-2. ISSN 0301-1623.
↑ Liamis, George; Milionis, Haralampos; Elisaf, Moses (2008). "A Review of Drug-Induced Hyponatremia". American Journal of Kidney Diseases. 52 (1): 144–153. doi:10.1053/j.ajkd.2008.03.004. ISSN 0272-6386.

[GuillauminDiBartola2017-1] Guillaumin, Julien; DiBartola, Stephen P. (2017). "A Quick Reference on Hyponatremia". Veterinary Clinics of North America: Small Animal Practice. 47 (2): 213–217. doi:10.1016/j.cvsm.2016.10.003. ISSN 0195-5616.

[Rondon-BerriosAgaba2014-2] Rondon-Berrios, Helbert; Agaba, Emmanuel I.; Tzamaloukas, Antonios H. (2014). "Hyponatremia: pathophysiology, classification, manifestations and management". International Urology and Nephrology. 46 (11): 2153–2165. doi:10.1007/s11255-014-0839-2. ISSN 0301-1623.

[LiamisMilionis2008-3] Liamis, George; Milionis, Haralampos; Elisaf, Moses (2008). "A Review of Drug-Induced Hyponatremia". American Journal of Kidney Diseases. 52 (1): 144–153. doi:10.1053/j.ajkd.2008.03.004. ISSN 0272-6386.

[1]

[2]

[3]