Hyponatremia: Difference between revisions

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{{DiseaseDisorder infobox |
__NOTOC__
  Name        = Hyponatremia |
{| class="infobox" style="float:right;"
  Image      = Na-TableImage.png  |
|-
  Caption    = [[Sodium]] |
| [[File:Siren.gif|30px|link=Hyponatremia resident survival guide]]|| <br> || <br>
  ICD10      = {{ICD10|E|87|1|e|70}} |
| [[Hyponatremia resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
  ICD9        = {{ICD9|276.1}} |
|}
}}
'''For patient information, click [[Hyponatremia (patient information)|here]]'''
{{Hyponatremia}}
{{Hyponatremia}}{{CMG}}{{AE}}{{Saeedeh}}


'''For patient information click [[Hyponatremia (patient information)|here]]'''
{{SK}} Hyponatraemia; Low sodium.


{{CMG}}
== [[Hyponatremia overview|Overview]] ==


{{SK}} Hyponatraemia
== [[Hyponatremia historical perspective|Historical Perspective]] ==


==Overview==
== [[Hyponatremia classification|Classification]] ==
The [[electrolyte disturbance]] '''hyponatremia''' exists in humans when the [[sodium]] (''Natrium'' in [[Latin]]) concentration in the [[blood plasma|plasma]] falls below 130 mmol/L. At lower levels [[water intoxication]] may result, an urgently dangerous condition. Hyponatremia is an abnormality that can occur in isolation or, as most often is the case, as a complication of other medical illnesses.


== [[Hyponatremia pathophysiology|Pathophysiology]] ==


== [[Hyponatremia causes|Causes]]==
==[[Hyponatremia differential diagnosis|Differentiating Hyponatremia]]==


=== Pseudohyponatremia ===
== [[Hyponatremia epidemiology and demographics|Epidemiology and Demographics]] ==
Certain conditions that interfere with laboratory tests of serum sodium concentration (such as extraordinarily high blood levels of [[lipid]] or [[protein]]) may lead to an erroneously low ''measurement'' of sodium.  This is called pseudohyponatremia, and can occur when laboratories use the flame-photometric and indirect (but not direct) ion-selective electrode assays.<ref>Weisberg LS. (1989) Pseudohyponatremia: a reappraisal. Am J Med, 86(3):315-8.  PMID 2645773 </ref><ref>Nguyen MK et al. (2007) A new method for determining plasma water content: application in pseudohyponatremia. Am J Phys - Renal, 292(5):F1652-6.  PMID 17299138</ref>  This is distinct from a true dilutional hyponatremia that can be caused by an osmotic shift of water from cells to the bloodstream after large infusions on [[mannitol]] or [[IVIG|intravenous immunoglobulin]].


=== Hypoosmolar hyponatremia ===
== [[Hyponatremia risk factors|Risk Factors]] ==
When the plasma osmolarity is low, the extracellular fluid volume status may be in one of three states:
*'''Low volume'''. Loss of water is accompanied by loss of sodium.
**Excessive [[sweat]]ing
**[[Burn (injury)|Burns]]
**[[Vomit]]ing
**[[Diarrhea]]
**[[Urine|Urinary]] loss
***[[Diuretic]] drugs (especially [[thiazide]]s)
***[[Addison's disease]]
***[[Cerebral salt-wasting syndrome]]
***Other salt-wasting [[kidney]] diseases


Treat underlying cause and give IV isotonic saline. It is important to note that sudden restoration of blood volume to normal will turn off the stimulus for continued ADH secretion. Hence, a prompt water diuresis will occur. This can cause a sudden and dramatic increase the serum sodium concentration and place the patient at risk for so-called "[[central pontine myelinolysis]]" (CPM). That disorder is characterized by major neurologic damage, often of a permanent nature.
== [[Hyponatremia screening|Screening]] ==


Because of the risk of CPM, patients with low volume hyponatremia may eventually require water infusion as well as volume replacement. Doing so lessens the chance of a too rapid increase of the serum sodium level as blood volume rises and ADH levels fall.
== [[Hyponatremia natural history, complications and prognosis|Natural History, Complications and Prognosis]] ==
*'''Normal volume'''.
**[[SIADH]] (syndrome of inappropriate [[antidiuretic hormone]])
**Some cases of psychogenic [[polydipsia]]


The cornerstone of therapy for SIADH is reduction of water intake.  If hyponatremia persists, then [[demeclocycline]] (an antibiotic with the side effect of inhibiting ADH) can be used.  SIADH can also be treated with specific antagonists of the [[antidiuretic hormone|ADH]] receptors, such as [[conivaptan]] or [[tolvaptan]].
== Diagnosis ==


*'''High volume'''. There is retention of water.
[[Hyponatremia diagnostic study of choice|Diagnostic Study of choice]] | [[Hyponatremia history and symptoms|History and Symptoms]] | [[Hyponatremia physical examination|Physical Examination]] | [[Hyponatremia laboratory findings|Laboratory Findings]] | [[Hyponatremia electrocardiogram|Electrocardiogram]] | [[Hyponatremia X-ray|X-ray]] | [[Hyponatremia echocardiogram or ultrasound|Echocardiogram or Ultarsound]] | [[Hyponatremia CT|CT scan]] | [[Hyponatremia MRI|MRI]] | [[Hyponatremia other imaging findings|Other Imaging Findings]] | [[Hyponatremia other diagnostic studies|Other Diagnostic Studies]]
**[[Congestive heart failure]]
**[[Hypothyroidism]] and [[hypocortisolism]]
**[[Liver]] [[cirrhosis]]
**[[Nephrotic syndrome]]
**[[Psychogenic polydipsia]]


Placing the patient on water restriction can also help in these cases.
== Treatment ==


Severe hyponatremia may result from a few hours of heavy exercise in high temperature conditions, such as hiking in desert areas, or from endurance athletic events when electrolytes are not supplied. (Such an incident notably happened to long-distance athlete Craig Barrett in 1998).
[[Hyponatremia medical therapy|Medical Therapy]] | [[Hyponatremia surgery|Surgery]] | [[Hyponatremia primary prevention|Primary Prevention]] | [[Hyponatremia secondary prevention|Secondary Prevention]] | [[Hyponatremia cost-effectiveness of therapy|Cost Effectiveness of Therapy]] | [[Hyponatremia future or investigational therapies|Future or Investigational Therapies]]


==Diagnosis==
== Case Studies ==
===Laboratory Findings===
* [[Serum osmolality]]
* [[Blood urea nitrogen]] ([[BUN]])/[[creatinine]]
* [[Calcium]]
* [[Magnesium]]
* [[Urine sodium]]
* [[Thyroid stimulating hormone]] ([[TSH]])
* [[Serum glucose]]


== Related Chapters ==
[[Hyponatremia case study one|Case #1]]
*[[Water intoxication]]
*[[Hypernatremia]]
*[[Edible salt]]
*[[Osmotic demyelination syndrome]]
 
==References==
{{Reflist|2}}


{{Endocrine, nutritional and metabolic pathology}}
{{Endocrine, nutritional and metabolic pathology}}
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Latest revision as of 19:59, 25 July 2018
Resident
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Saeedeh Kowsarnia M.D.[2]

Synonyms and keywords: Hyponatraemia; Low sodium.

Overview

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Classification

Pathophysiology

Causes

Differentiating Hyponatremia

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

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