Hyponatremia

By James Yost, MD, MS, MBA Emory Family Medicine

Hyponatremia
Definition Epidemiology Physiology Pathophysiology Types Clinical Manifestations Diagnosis Treatment

Hyponatremia
Definition:
Commonly defined as a serum sodium concentration
135 meq/L Hyponatremia represents a relative excess of water in relation to sodium.

Hyponatremia
Epidemiology:
Frequency

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Hyponatremia is the most common electrolyte disorder incidence of approximately 1% prevalence of approximately 2.5% surgical ward, approximately 4.4% 30% of patients treated in the intensive care unit

Hyponatremia
Epidemiology Cont.
Mortality/Morbidity
Acute hyponatremia (developing over 48 h or less) are subject to more severe degrees of cerebral edema
sodium level is less than 105 mEq/L, the mortality is over 50%

Chronic hyponatremia (developing over more than 48 h) experience milder degrees of cerebral edema
Brainstem herniation has not been observed in patients with chronic hyponatremia

Hyponatremia
Epidemiology Cont.
Age
Infants
fed tap water in an effort to treat symptoms of gastroenteritis Infants fed dilute formula in attempt to ration

Elderly patients with diminished sense of thirst, especially when physical infirmity limits independent access to food and drink

Hyponatremia
Physiology
Serum sodium concentration regulation:
stimulation of thirst secretion of ADH feedback mechanisms of the reninangiotensin-aldosterone system renal handling of filtered sodium

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Hyponatremia
Physiology Cont.
Stimulation of thirst
Osmolality increases
Main driving force Only requires an increase of 2% - 3%

Blood volume or pressure is reduced

Requires a decrease of 10% - 15%

Thirst center is located in the anteriolateral center of the hypothalamus

Respond to NaCL and angiotensin II

Hyponatremia
Physiology Cont.
Secretion of ADH
Synthesized by the neuroendocrine cells in the supraoptic and paraventricular nuclei of the hypothalamus Triggeres:
Osmolality of body fluids A change of about 1% Volume and pressure of the vascular system

Increases the permeability of the collecting duct to water and urea

Hyponatremia
Physiology Cont
renin-angiotensin-aldosterone
Renin
Stemuli are perfusion pressure, sympathetic activity, and NaCl delivery to the macula densa Increase in NaCl delivery to the macula decreases the GFR by decrease in the renin secretion

Aldosterone
Reduces NaCl excretion by stimulating its resorption Ascending loop of Henle Distal tubule Collecting duct

Hyponatremia

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Hyponatremia
Physiology Cont.
extracellular-fluid and intracellular-fluid compartments make up 40 percent and 60 percent of total body water renal handling of water is sufficient to excrete as much as 15-20 L of free water per day sodium is the predominant osmole in the extracellular fluid (ECF) compartment and serum

Hyponatremia
Pathophysiology
hyponatremia can only occur when some condition impairs normal free water excretion acute drop in the serum osmolality:
neuronal cell swelling occurs due to the water shift from the extracellular space to the intracellular space Swelling of the brain cells elicits 2 responses for osmoregulation, as follows:
It inhibits ADH secretion and hypothalamic thirst center immediate cellular adaptation

Hyponatremia
Types
Hypovolemic hyponatremia Euvolemic hyponatremia Hypervolemic hyponatremia Redistributive hyponatremia Pseudohyponatremia

Hypovolemic hyponatremia
develops as sodium and free water are lost and/or replaced by inappropriately hypotonic fluids Sodium can be lost through renal or non-renal routes

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Hypovolemic hyponatremia
Nonrenal loss
GI losses
Vomiting, Diarrhea, fistulas, pancreatitis

Excessive sweating Third spacing of fluids

ascites, peritonitis, pancreatitis, and burns

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Cerebral salt-wasting syndrome

traumatic brain injury, aneurysmal subarachnoid hemorrhage, and intracranial surgery Must distinguish from SIADH

Hypovolemic hyponatremia
Renal Loss
Acute or chronic renal insufficiency Diuretics

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Euvolemic hyponatremia
Normal sodium stores and a total body excess of free water
Psychogenic polydipsia, often in psychiatric patients Administration of hypotonic intravenous or irrigation fluids in the immediate postoperative period

Euvolemic hyponatremia
administration of hypotonic maintenance intravenous fluids Infants who may have been given inappropriate amounts of free water bowel preparation before colonoscopy or colorectal surgery

Euvolemic hyponatremia
SIADH
downward resetting of the osmostat Pulmonary Disease
Small cell, pneumonia, TB, sarcoidosis

Cerebral Diseases
CVA, Temporal arteritis, meningitis, encephalitis

Medications
SSRI, Antipsychotics, Opiates, Depakote, Tegratol

Hypervolemic hyponatremia
Total body sodium increases, and TBW increases to a greater extent. Can be renal or non-renal
acute or chronic renal failure
dysfunctional kidneys are unable to excrete the ingested sodium load

cirrhosis, congestive heart failure, or nephrotic syndrome

Redistributive hyponatremia
Water shifts from the intracellular to the extracellular compartment, with a resultant dilution of sodium. The TBW and total body sodium are unchanged.
This condition occurs with hyperglycemia Administration of mannitol

Hyponatremia

Pseudohyponatremia
The aqueous phase is diluted by excessive proteins or lipids. The TBW and total body sodium are unchanged.
hypertriglyceridemia multiple myeloma

Hyponatremia
Clinical Manifestations
most patients with a serum sodium concentration exceeding 125 mEq/L are asymptomatic Patients with acutely developing hyponatremia are typically symptomatic at a level of approximately 120 mEq/L Most abnormal findings on physical examination are characteristically neurologic in origin patients may exhibit signs of hypovolemia or hypervolemia

Hyponatremia
Diagnosis
CT head, EKG, CXR if symptomatic Repeat Na level Correct for hyperglycemia Laboratory tests provide important initial information in the differential diagnosis of hyponatremia
Plasma osmolality Urine osmolality Urine sodium concentration Uric acid level FeNa

Hyponatremia
Laboratory tests Cont.
Plasma osmolality
normally ranges from 275 to 290 mosmol/kg If >290 mosmol/kg :
Hyperglycemia or administration of mannitol

If 275 290 mosmol/kg :

hyperlipidemia or hyperproteinemia

If <275 mosmol/kg :
Eval volume status

Hyponatremia
Laboratory tests Cont.
Plasma osmolality < 275 mosmol/kg
Increased volume:
CHF, cirrhosis, nephrotic syndrome

Euvolemic
SIADH, hypothyroidism, psychogenic polydipsia, beer potomania, postoperative states

Decreased volume
GI loss, skin, 3rd spacing, diuretics

Hyponatremia
Laboratory tests Cont.
Urine osmolality
Normal value is > 100 mosmol/kg Normal to high:
Hyperlipidemia, hyperproteinemia, hyperglycemia, SIADH

< 100 mosmol/kg

hypoosmolar hyponatremia
Excessive sweating Burns Vomiting Diarrhea Urinary loss

Hyponatremia
Laboratory tests Cont.
Urine Sodium
>20 mEq/L
SIADH, diuretics

<20 mEq/L
cirrhosis, nephrosis, congestive heart failure, GI loss, skin, 3rd spacing, psychogenic polydipsya

Uric Acid Level

< 4 mg/dl consider SIADH

FeNa
Help to determine pre-renal from renal causes

Hyponatremia
Treatment
four issues must be addressed
Asyptomatic vs. symptomatic acute (within 48 hours) chronic (>48 hours) Volume status

1st step is to calculate the total body water

total body water (TBW) = 0.6 body weight

Hyponatremia
Treatment Cont.
next decide what our desired correction rate should be Symptomatic
immediate increase in serum Na level by 8 to 10 meq/L in 4 to 6 hours with hypertonic saline is recommended

acute hyponatremia
more rapid correction may be possible
8 to 10 meq/L in 4 to 8 hours

chronic hyponatremia
slower rates of correction
12 meq/L in 24 hours

Hyponatremia
Symptomatic or Acute
Treatment Cont. - Here comes the Math!!!
estimate SNa change on the basis of the amount of Na in the infusate SNa = {[Na + K]inf SNa} (TBW + 1)
SNa is a change in SNa [Na + K]inf is infusate Na and K concentration in 1 liter of solution

OH MY GOD, what did he just say!!!!!!!!!!!!!!!!!!

Hyponatremia
IV Fluids
One liter of Lactated Ringer's Solution contains:
130 mEq of sodium ion = 130 mmol/L 109 mEq of chloride ion = 109 mmol/L 28 mEq of lactate = 28 mmol/L 4 mEq of potassium ion = 4 mmol/L 3 mEq of calcium ion = 1.5 mmol/L

One liter of Normal Saline contains:

154 mEq/L of Na+ and Cl

One liter of 3% saline contains:

514 mEq/L of Na+ and Cl

Hyponatremia
Example:
a 60 kg women with a plasma sodium of 110 meq/L Formula:
SNa = {[Na + K]inf SNa} (TBW + 1)

What is the TBW? How high will 1 liter of normal saline raise the plasma sodium?

Answer:
TBW is 30 L Serum sodium will increase by approximately 1.4 meq/L for a total SNa of 111.4 meq/L

 Example:

Hyponatremia

a 90 kg man with a plasma sodium of 110 meq/L Formula:

SNa = {[Na + K]inf SNa} (TBW + 1)

What is the TBW? How high will 1 liter of 3% saline raise the plasma sodium?

Answer:
TBW is 54 L Serum sodium will increase by approximately 7.3 meq/L for a total SNa of 117.3 meq/L

Hyponatremia
Asymptomatic or Chronic
SIADH
response to isotonic saline is different in the SIADH In hypovolemia both the sodium and water are retained sodium handling is intact in SIADH administered sodium will be excreted in the urine, while some of the water may be retained
possible worsening the hyponatremia

Hyponatremia
Asypmtomatic or Chronic
SIADH
Water restriction
0.5-1 liter/day

Salt tablets Demeclocycline

Inhibits the effects of ADH Onset of action may require up to one week

Hyponatremia
Example:
85 y/o male with weakness and head ache SNa is 118 mEq/L Plasma osmolality is 254 mosmol/kg Urine osmolality is 130 mosmol/kg Urine sodium >20 mEq/L Uric acid is 3mg/dl

What type of hyponatremia does this patient have? What additional labs/studies would you want?

Ouch!!!!!

Hyponatremia
Example Cont.:
Noncontrast CT Head:

Tx
Call Neurology and neurosurgery Free water restriction
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Hyponatremia
Example:
63 y/o female at 75 Kg with N/V/D for 4 days SNa is 108 mEq/L She has had one seizure in the ambulance
Plasma osmolality is 251 mosmol/kg Urine osmolality is 47 mosmol/kg Uric acid is 6mg/dl

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What type of hyponatremia does this patient have? What additional labs/studies would you want?

 How will you Tx her?

0.5 x weight = 37.5 L

Hyponatremia

Calculate the total body water

What rate of correction do you want?

8 to 10 mEq/L in 6 to 8 hours

What fluid will you use?

3% Saline

How will you calculate the amount of sodium to give her?

SNa = {[Na + K]inf SNa} (TBW + 1)

How will her sodium increase after 1 liter of 3% saline?

By 10.8 mEq/L to 118.8 mEq/L

Hyponatremia
What other medication will she need?
Lasix and a foley

Her sodium increases to 118.8 mEq/L over the next 8-10 hours. How will you continue to correct her hyponatremia?
SNa = {[Na + K]inf SNa} (TBW + 1) SNa = 154mEq/L 118.8mEq/L 38.5L = 0.9 mEq/L

So 2 liters of normal saline over the next 14 hours

Hyponatremia
Congrats!!!!!!!! You saved her!

Questions????