Hyponatremia and Hypernatremia

Hyponatremia
Defined as sodium concentration < 135 mEq/L
Generally considered a disorder of water as
opposed to disorder of salt
Results from increased water retention
Normal physiologic measures allow a person to
excrete up to 10 liters of water per day which
protects against hyponatremia
Thus, in most cases, some impairment of renal
excretion of water is present
 Causes
Normal ADH response to low sodium is to be
suppressed to allow maximally dilute urine to be
excreted thereby raising serum sodium level
Psuedohyponatremia High blood sugar (DKA) or
protein level (multiple myeloma) can cause falsely
depressed sodium levels
Causes of Hyponatremia can be classified based on
either volume status or ADH level
Hypovolemic, Euvolemic or Hypervolemic
ADH inappropriately elevated or appropriately
suppressed
 ADH suppresion
Conditions which ADH is suppressed
Primary Polydipsia

Low dietary solute intake Tea and Toast syndrome

or Beer Potomania

Advanced Renal Failure

 ADH elevation
Conditions which ADH is elevated
Volume Depletion
True volume depletion (i.e. bleeding)
Effective circulating volume depletion (i.e. heart failure
and cirrhosis)
Exercised induced hyponatremia
Thiazide Diuretics
Adrenal insufficiency
SIADH
 First step in Assessment: Are symptoms
present?
Hyponatremia can be asymptomatic and found
by routine lab testing

It may present with mild symptoms such as

nausea and malaise (earliest) or headache and
lethargy

Or it may present with more severe symptoms

such as seizures, coma or respiratory arrest
 Presentation determines if immediate
action is needed
If severe symptoms are present, hypertonic saline
needs to be administered to prevent further decline
If severe symptoms are not present, can start by
initiating fluid restriction and determining cause of
hyponatremia
Oral fluid restriction is good first step as it will
prevent further drop in sodium
NOTE: This does not mean that you cant give
isotonic fluids to someone who is truly volume
depleted
 WHAT NEXT?
With no severe symptoms and fluid restriction
started, next step is to assess volume status to
help determine cause
Hypovolemic urine output, dry mucous
membranes, sunken eyes
Euvolemic normal appearing
Hypervolemic Edema, past medical history,
Jaundice (cirrhosis), S3 (CHF)
 Volume status helps predict cause
Hypovolemia
True Volume Depletion
Adrenal insufficiency
Thiazide overdose
Exercised induced hyponatremia
Euvolemia
SIADH
Primary Polydipsia
Hypervolemia
Cirrhosis and CHF
 Workup for Hyponatremia
3 mandatory lab tests
Serum Osmolality
Urine Osmolality
Urine Sodium Concentration
Additional labs depending on clinical suspicion
TSH, cortisol (Hypothryoidism or Adrenal
insufficiency)
Albumin, BMP, triglycerides and SPEP
(psuedohyponatremia, cirrhosis, MM)
 How to interpret the tests?
Serum Osmolality
Can differentiate between true hyponatremia,
pseudohyponatremia and hypertonic hyponatremia
Urine Osmolality
Can differentiate between primary polydipsia and
impaired free water excretion
Urine Sodium concentration
Can differentiate between hypovolemia
hyponatremia and SIADH
 Additional Tests
TSH high in hypothyroidism
Cortisol low in adrenal insufficiency, though
may be inappropriately normal in
infection/stressful state, therefore should get
Corti-Stim test to confirm
Head CT and Chest Xray May see evidence of
cerebral salt wasting or small cell carcinoma
which can both cause hyponatremia
 And of coursethe not so common
Iatrogenic infusion of hypotonic fluids (Surgeon
sign)
Ecstasy use increased water intake with
inappropriate ADH secretion
Underlying infections
NSIAD Nephrogenic syndrome of inappropriate
antidiuresis Hereditary disorder that presents with
low sodium levels in newborn males with
undetectable ADH levels
Reset Osmostat Occurs in elderly and pregnancy
where regulated sodium set point is lowered
SIADH: Important concept to understand
Caused by various etiologies
CNS disease tumor, infection, CVA, SAH, DTs
Pulmonary disease TB, pneumonia, positive
pressure ventilation
Cancer Lung, pancreas, thymoma, ovary,
lymphoma
Drugs NSAIDs, SSRIs, diuretics, TCAs
Surgery - Postoperative
Idopathic most common
 Main diagnostic criteria for SIADH
Clinical Euvolemia
Hypotonic Hyponatremia
Normal hepatic, renal and cardiac function
Normal thyroid and adrenal function
Urine osmolality greater than 100 mOsm/kg
though generally greater than 400-500 mOsm/kg in
setting of low serum osmolality (AKA
inappropriate)
Urine sodium level greater than 20 mEq/L
 Treatment is based on symptoms
Patients with serum sodium above 120 are
generally asymptomatic
Symptoms tend to occur at serum sodium levels
lower than 120 or when a rapid decline in
sodium levels occur
Patients can have mild symptoms at sodium
concentrations of 110-115 mEq/L when this
level is reached gradually
 Severe symptoms present
As stated earlier, symptoms dictate treatment
If severe symptoms are present, starting bolus of
100 ml of 3% hypertonic saline which generally
raise serum sodium level by 2-3 mEq/L
Goals for correction:
1.5 to 2 mEq/L per hour for first 3-4 hours until
symptoms resolve
Increase by no more than 10 mEq/L in first 24 hrs
Increase by no more than 18 mEq/L in first 48 hrs
What if little to no symptoms are present?
Oral fluid restriction is the first step
No more than 1500 mL per day
NOTE: This only pertains to oral fluid, isotonic IV
fluids do not count towards fluid intake
If volume depletion is present, isotonic (0.9%)
saline can be given intravenously
Careful monitoring should be used whether
symptoms are present or not
Serum sodium levels should be drawn every 4-6 hours or
more frequently if hypertonic saline is used
 Formulas that may help: How much
sodium does the patient need?
Sodium deficit = Total body water x (desired Na
actual Na)

Total body water is estimated as lean body

weight x 0.5 for women or 0.6 for men
 How about an example:
60 kg woman with sodium level of 116
How much sodium will bring him up to 124 in
the next 24 hours?
Sodium needed = 0.5 x 60 x (124-116) = 240
Hypertonic saline contains 500 mEq/L of
sodium
Normal saline contains 154 mEq/L of sodium
 Example (continued)
The patient needs 240 mEq in next 24 hours
That averages to 10 mEq per hour or 20 mL of
hypertonic saline per hour
However, this will only raise the serum sodium
by 0.33 per hour therefore, increasing the rate 60
mL to 90 mL will produce the desired rate of
serum sodium increase of 1.0 to 1.5 mEq per
hour until symptoms resolve
What if the sodium increases too fast?
The dreaded complication of increasing sodium
too fast is Central Pontine Myelinolysis which is
a form of osmotic demyelination
Symptoms generally occur 2-6 days after
elevation of sodium and usually either
irreversible or only partially reversible
Symptoms include: dysarthria, dysphagia,
paraparesis, quadriparesis, lethargy, coma or
even seizures
 Risk Factors for demyelination
Rate of correction over 24 hours more important
than rate of correction in any one particular hour
More common if sodium increases by more than 20
mEq/L in 24 hours
Very uncommon if sodium increases by 12 mEq/L
or less in 24 hours
CT but preferably MRI to diagnose demyelination if
suspected, though imaging studies may not be
positive for up to 4 weeks after initial correction
 Treatment Options
CPM is associated with poor prognosis

Prevention is key

Small studies have shown that plasmapharesis

done immediately after diagnosis may improve
clinical outcomes
 Summary of Hyponatremia
Hyponatremia has variety of causes
Treatment is based on symptoms
Severe symptoms = Hypertonic Saline
Mild or no symptoms = Fluid restriction
Overcorrection, more than 12 mEq increase in
24 hours must be avoided with monitoring
Serum Osmolality, Urine Osmolality and Urine
sodium concentration are initial tests to order
 Moving on to Hypernatremia
Produced by either administration of hypertonic
fluids or much more frequently, loss of thirst
Because of extremely efficient regulatory
mechanisms such as ADH and thirst,
hypernatremia generally occurs only in people
with prolonged lack of thirst mechanism
Patients with loss of ADH (Diabetes Insipidus)
usually can compensate with increased fluid
intake
 Causes of Hypernatremia
Insensible and sweat losses
GI losses
Diabetes Insipidus (both central and nephrogenic)
Osmotic Diuresis DKA or HHNK
Hypothalamic lesions which affect thirst function
Causes include tumors, granulomatous diseases or
vascular disease
Sodium Overload Infusion of Hypertonic sodium
bicarbonate for metabolic acidosis
 Symptoms of Hypernatremia
Initial symptoms include lethargy, weakness and
irritability
Can progress to twitching, seizures, obtundation or
coma
Resulting decrease in brain volume can lead to
rupture of cerebral veins leading to hemorrhage
Severe symptoms usually occur with rapid increase
to sodium concentration of 158 mEq or more
Sodium concentration greater than 180 mEq are
associated with high mortality
 Diagnosis of Hypernatremia
Same labs as workup for hyponatremia: Serum
osmolality, urine osmolality and urine sodium
Urine sodium should be lower than 25 mEq/L if
and water and volume loss are cause. It can be
greater than 100 mEq/L when hypertonic
solutions are infused or ingested
If urine osmolality is lower than serum osmolality
then DI is present
Administration of DDAVP (Desmopressin ) will
differentiate
Urine osmolality will increase in central DI, no response in
nephrogenic DI
 Treatment of Hypernatremia
First, calculate water deficit
Water deficit = CBW x ((plasma Na/desired Na
level)-1)
CBW = current body water assumed to be 50%
of body weight in men and 40% in women
So lets do a sample calculation:
60 kg woman with 168 mEq/L
How much water will it take to reduce her sodium to
140 mEq/L
 Calculation continued
Water deficit = 0.4 x 60 ([168/140]-1) = 4.8 L
But how fast should I correct it?
Same as hyponatremia, sodium should not be
lowered by more than 12 mEq/L in 24 hours
Overcorrection can lead to cerebral edema which can
lead to encephalopathy, seizures or death
So what does that mean for our patient?
The 4.8 L which will lower the sodium level by 28
should be given over 56-60 hours, or at a rate of 75-80
mL/hr
Typical fluids given in form of D5 water
 Summary of Hypernatremia
Loss of thirst usually has to occur to produce
hypernatremia
Rate of correction same as hyponatremia
D5 water infusion is typically used to lower
sodium level
Same diagnostic labs used: Serum osmolality,
Urine osmolality and Urine sodium
Beware of overcorrection as cerebral edema may
develop
Questions?

33
THANK YOU