Hyponatraemia

Sodium levels are very closely linked to fluid levels, as sodium is an extracellular
electrolyte.
As opposed to potassium which is intracellular.

Signs & Symptoms

Neurological:
Confusion
Lethargy
Seizures
Coma
Classification

Hypovolaemic hyponatraemia
The low blood volume is usually a result of the low sodium. The reduction in sodium is
usually relatively greater than the reduction of fluid volume
Renal causes:
Diuretics (particularly thiazide & loop diuretics)
Mineralocorticoid insufficiency (Addison’s)
Osmotic dieresis (low glucose, urea)
Nephropathy
GI
Vomiting
Diarrhoea
Other
Burns
Rhabdomyalosis
Pancreatitis
Peritonitis

Euvolaemic Hyponatraemia

Sodium levels are usually quite near to normal

Diuretics

SIADH – Syndrome of Inappropriate ADH secretion – persistent release of ADH despite

normovolaemia leading to water retention. Causes include:
CNS disturbances – infection, neoplasm, vascular, inflammatory, trauma, psychosis
Neoplasm – ectopic ADH secretion from SCLC (pancreas, head and neck)
Pain – post abdominal and thoracic surgery
Surgery – post transspehnoidal pituitary surgery in 20-35%
Pulmonary disease – especially pneumonia
Drugs – SSRI, carbamazepine, cyclophosphamide, opiates, MAOI, ECSTASY (can
also be associated with excessive water intake).
Idiopathic

Primary polydipsia – often seen in patients with psychiatric conditions esp. those in
anitpsychotics.
Also seen in those with lesions in hypothalamic thirst centre e.g. in sarcoidosis.

Low dietary Na
Advanced renal failure – inability of the kidneys to excrete free water. Minimum urine
osmolality can rise to 200mosm/kg despite no ADH. Low osmolality can be offset by
increase urea. However as urea can cross freely across cell membranes, it is an ineffective
osmole hence effective osmolality is decreased.

Hormonal insufficiency –
Addison’s
hypothyroid
pregnancy – HCG resets osmostat lower by 5mmol/L

Hypervolaemic Hyponatraemia
The high blood volume occurs due a high concentration of some other solute in relation to
sodium.
Heart failure
Renal failure
Liver failure

Hyperglycaemia
Diagnosis:
History – fluid loss, excessive water intake, malignancy, addisons, hypothyroid
Examination – oedema, extracellular water depletion
Investigations – serum osmolality (275-290), urine osmolality, urine Na
Management:

Treat underlying cause

Fluid restriction – below urine output. Used for oedematous states (heart and liver
failure), SIADH, primary polydipsia and advanced renal failure
Na replacement – true volume depletion (removes stimulus for ADH release) or
adrenal insufficiency (replaces Na lost from kidneys)
ADH antagonist
Avoid rapid early correction of hyponatraemia, especially severe (<115mmol/L). Replacing
Na too quickly can lead to osmotic demyelination syndrome. The brain compensates for
hyponatraemia associated oedema within the first day and is complete within a few
days. Replacing Na too quickly leads to fluid being drawn out of the CNS hence the brain
goes from too much fluid to too little causing demyelination. This occurs when Na
replacement exceeds 10-12mmol/L/24hrs or 18mmol/L/48hrs. Hence aim to replace Na by
<10mmol/L /24hrs and <18mmol/L/48hrs
Related Entries
Potassium
Rhabdomyolysis
The Anion Gap
Urea & Electrolytes
Chest X-Ray