Hyponatremia natural history, complications and prognosis

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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]

Overview

If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].

OR

Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].

OR

Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.

Natural History, Complications, and Prognosis

Natural History

• acute hyponatraemia, the main pathological consequence is the development of cerebral edema, which leads to raised intracranial pressure with the risk of cerebral herniation,hypoxia and even death .
• The symptoms of (disease name) usually develop in the first/ second/ third decade of life, and start with symptoms such as ___.
• The symptoms of (disease name) typically develop ___ years after exposure to ___.
• If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].

Complications

Hyponatremic Encephalopathy :Early symptoms of hyponatremia from any cause may include apathy, weakness, muscular cramps, nausea, vomiting, and headache. More advanced clinical manifestations include impaired response to verbal and painful stimuli, hallucinations, urinary incontinence, and pulmonary edema. As edema worsens, clinical manifestations of hyponatremia are related to the degree of increased intracranial pressure and brain herniation. These manifestations may include decorticate posturing, hypothermia and hyperthermia, central diabetes insipidus, seizures, respiratory arrest, coma, permanent brain damage, and death .

Stage	Clinical manifestation of hyponatremic encephalopathy
Early	Anorexia, headache, nausea, emesis, muscule cramps,weakness
Advanced	Impaired response to verbal stimuli, impaired response to painful stimuli, bizarre (inappropriate) behavior, hallucinations (auditory or visual), asterixis, obtundation, incontinence (urinary or fecal), respiratory insufficiency
Severe	Decorticate and/or decerebrate posturing, bradycardia, hyper- or hypotension, altered temperature regulation (hypo- or hyperthermia), dilated pupils, seizure activity (usually grand mal), respiratory arrest, coma, polyuria (secondary to central diabetes insipidus)

Brain herniation :In acute hyponatremia, if the brain adaptation to hyponatremia is impaired especially solute excretion of brain cells to achieve osmotic equilibrium, it causes brain cells swelling, increased intracranial pressure, cerebral edema, and eventual tentorial herniation .

Osmotic Demyelination :Hyponatremia, serum sodium < 135 mEq/L, causes brain edema due to shift of water from extracellular in to the brain cells. In the next 24 to 48 hours, brain starts to compensate by excreting solutes and water. If serum sodium is corrected too rapidly, brain cells do not have time to replace the solutes which results in dehydration of the brain cells named osmotic demyelination syndrome .

Signs and symptoms of ODS
Change in mental status Dysphagia Reduced attention span Loss of memory Rapid development of quadriparesis Dysarthria Reduced speed of processing information Ataxia and Parkinson-like symptoms

Risk of developing Osmotic Demyelination Syndrome:

• Serum sodium concentration ≤105 mmol/L
• Hypokalemia
• Alcoholism
• Malnutrition
• Advanced liver disease

Prolonged mild or chronic cases of hyponatremia are associated with increased osteoporosis, fall and hip fracture.

Prognosis

• Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.
• Depending on the extent of the [tumor/disease progression/etc.] at the time of diagnosis, the prognosis may vary. However, the prognosis is generally regarded as poor/good/excellent.
• The presence of [characteristic of disease] is associated with a particularly [good/poor] prognosis among patients with [disease/malignancy].
• [Subtype of disease/malignancy] is associated with the most favorable prognosis.
• The prognosis varies with the [characteristic] of tumor; [subtype of disease/malignancy] have the most favorable prognosis.