Hyponatremia and hypernatremia

are disorders of water balance

Hyponatremia

Problem statement

Hyponatremia is a common clinical problem developing in around 2.5% of hospitalized patients. The case fatality rate was 60 times higher in patients in whom hyponatremia was present.
Deepak Madhu

Sodium is the main extracellular osmole, A reduction in serum sodium is associated with a reduction in osmolarity. The clinical approach to hyponatremia begins by excluding conditions in which osmolarity is not reduced.

Deepak Madhu

All conditions in which hyponatremia does not result in hypo-osmolarity is called pseudohyponatremia There are two conditions in which pseudohyponatremia is really a laboratory artifact namely hyperlipidemia and hyperproteinemia. Serum osmolarity is normal in such cases.
Deepak Madhu

Conditions in which an osmotically active substance such as glucose or mannitol accumulates in the serum and draws water out of the intracellular space also is referred to as a kind of pseudohyponatremia. Serum osmolarity is increased here Deepak Madhu

Once pseudohyponatremia is excluded, hyponatremia may be classified on the basis of ECF volume status.

Deepak Madhu

Hyponatremia
Serum OSM Low
Hypotonic Hyponatremia

Normal
Marked hyperlipidemia (lipemia, TG >35mM) Hyperproteinemia (Multiple myeloma)

High
Hyperglycemia Mannitol

*Note: all have ADH

ECFv * Low

SIADH: inappropriate Rest: appropriate

Normal
Hypothyroidism AI SIADH Reset Osmostat Water Intoxication 1 Polydipsia TURP post-op

High
CHF Cirrhosis Nephrosis

Renal loss (UNa > 20) Extra-renal loss (UNa <10) Diuretics Bleeding Thiazide Burns K-sparing GI (N/V, diarrhea) ACE-I, ARB Pancreatitis IV RTA, Hypoaldo Deepak Madhu Cerebral salt wasting

Hyponatremia: Clinical Manifestations

Depend on magnitude of the hyponatremia and rapidity of its development.
Acute (< 48 hrs): Symptoms at [Na+] of 125 mEq/L. Seizures and coma at 115 mEq/L. Chronic: often asymptomatic
Deepak Madhu

Symptoms - mainly CNS

Early: nausea, malaise, headache, muscle twitching, lethargy Late/Severe: obtundation, seizures, coma, respiratory arrest Deepak Madhu

Hyponatremia with extracellular volume depletion

Patients with ECF volume depletion and hyponatremia have a deficit in total body Na that is more than the deficit in water.

Deepak Madhu

Hyponatremia with extracellular fluid volume depletion (cont)

There is depletion of body solutes and a concomitant failure to excrete water as the osmoreceptor and volume receptor receive opposing stimuli and the osmotic set-point is lowered.
Deepak Madhu

Hyponatremia with extracellular fluid volume depletion

Clinical: Orthostasis, Flat neck veins Decreased skin turgor Dry mucous membranes Tachycardia
Deepak Madhu

H y p o v o

UR E x e Nn t aa r a l >r 2l e e 0o n m s a l s c

h y p o n a t

Deepak Madhu

Renal loss

Diuretic excess Mineralocorticoid deficiency Salt losing nephropathy Bicarbonaturia with RTA and metabolic alkalosis Cerebral salt wasting
Deepak Madhu

Extra renal loss

Vomiting Diarrhoea Third spacing Burns Pancreatitis Trauma

Deepak Madhu

Hyponatremia with excess ECF volume

Here total body water increases Total body sodium also increases The rise in total body water exceeds the rise in total body sodium

Deepak Madhu

H y p e r v o

UN A C c a i e Np u r ah t d r e i h r >a <o 2t o c s 0i r e F s c m a C h i c r l o u n r i e c

Hypervolemic hyponatremia

r e

Deepak Madhu

Congestive Cardiac Failure

Decreased cardiac output results in limited delivery of tubule fluid to the distal nephron. Decrement in arterial filling are sensed by aortic and carotid sinus baroreceptors and stimulate AVP release.
Deepak Madhu

Hepatic failure

Patients with advanced cirrhosis develop hyponatremia due to their inability to excrete a water load. Effective arterial blood volume is contracted due to decreased osmolality as a result of hypoalbuminemia and due to splanchnic pooling of blood. This results in a high AVP state
Deepak Madhu

Nephrotic syndrome

Hypoalbuminemia results in intravascular volume contraction and a high AVP state that results in an inability to excrete a water load.

Deepak Madhu

Renal failure

A decrement in GFR and an increase in thirst underlies the hyponatremia of renal failure

Deepak Madhu

Hyponatremia with normal ECF volume

Not orthostatic Not dehydrated Not edematous .

Deepak Madhu

Causes

Glucocorticoid deficiency Hypothyroidism Psychosis- primary polydipsia Postoperative hyponatremia Strenuous exercise Pharmacologic agents SIADH
Deepak Madhu

Glucocorticoid deficiency

Isolated glucocorticoid deficiency occurs with secondary adrenal insufficiency caused by pituitary disorders that impair normal ACTH secretion but leaveMadhu other stimuli to Deepak

Glucocorticoid deficiency (cont)

Hyponatremia occurs relatively frequently in patients with pituitary insufficiency who do not have diabetes insipidus

Deepak Madhu

Hypothyroidism

The exact mechanism by which hypothyroidism causes hyponatremia is not known Impaired water excretion is often present and diminished distal fluid delivery and persistent avp release mediate the impaired water excretion in this disorder.
Deepak Madhu

Psychosis Primary polydipsia

Defects in osmoregulation that results in AVP secretion at plasma osmolalities lower than normal Psychotic exacerbations are also associated with increased vasopressin levels in schizophrenic patients with hyponatremia. Thirst perception is also increased.
Deepak Madhu

Post-operative hyponatremia
Primarily as a cosequence of hypotonic fluid administration, hyponatremia can also occur in this high AVP state even when isotonic fluids are given

Deepak Madhu

Strenuous excercise

Military training, marathons, triathlons Associated with weight gain related to excessive fluid intake Symptomatic hyponatremia can result
Deepak Madhu

Drugs

ADH analogues Drugs that enhance AVP Drugs that potentiate renal action renal action of AVP Drugs that cause hyponatremia by unknown mechanism
Deepak Madhu

ADH hormone analogues

Desmopressin acetate Oxytocin

Deepak Madhu

Drugs that enhance AVP

Chlorpropamide Clofibrate Carbamazepine Vincristine Nicotine Narcotics Antipsychotics, antidepressants Ifosfamide

Deepak Madhu

Drugs that potentiate renal action of AVP

Chlorpropamide Cyclophosphamide NSAIDs Acetaminophen

Deepak Madhu

Drugs that cause hyponatremia by unknown mechanisms

Haloperidol Fluphenazine Amitryptiline Thioridazine SSRI Ecstacy
Deepak Madhu

SIADH

Deepak Madhu

SIADH

SIADH is the most common cause of euvolemic hyponatremia The criteria was defined by Bartter and Schwartz in 1967 in the original classic article that described the syndrome
Deepak Madhu

SIADH - Criteria

1.

True ECF hypo-osmolarity must be present. Pseudohyponatremia and hyperglycemia must be excluded. Urinary osmolality must be inappropriate. With serum hypo-osmolarity, urine should be less than maximally dilute (Uosm >100)

2.

Deepak Madhu

SIADH Criteria (cont)

3.

Clinical euvolemia must be present. Urine sodium >20 the presence or absence of this, does not, however diagnose or exclude SIADH.
Deepak Madhu

4.

5.

Other causes should be excluded.

SIADH - Causes

Carcinomas Pulmonary disorders CNS disorders Other

Deepak Madhu

SIADH causing carcinomas

Bronchogenic carcinoma Carcinoma of the duodenum Carcinoma of the pancreas Thymoma Carcinoma of the stomach Lymphoma Ewing sarcoma
Deepak Madhu

SIADH causing carcinomas (cont)

Carcinoma of the bladder Prostatic carcinoma Oropharyngeal tumor

Deepak Madhu

Neurological disorders

Encephalitis Meningitis Head trauma Brain abscess GBS Acute intermittent porphyria SAH

Deepak Madhu

Neurologic disorders (cont)

Cerebellar and cerebral atrophy Cavernous sinus thrombosis Neonatal hypoxia Shy Drager syndrome Rocky mountain spotted fever Delirium tremens CVA
Deepak Madhu

Neurologic disorders (cont)

Acute psychosis Peripheral neuropathy Multiple sclerosis

Deepak Madhu

NSIAD

Nephrogenic syndrome of inappropriate antidiuresis. Gain of function mutations in the V2R results in antidiuresis in the absence of AVP.
Deepak Madhu

Management of hyponatremia

Deepak Madhu

Rate of correction

Overly rapid correction of hyponatremia can result in osmotic demyelination This can occur irrespective of the etiology of hyponatremia or the method used to correct it
Deepak Madhu

Rate limits

Limits for the correction of hyponatremia:

<10-12mEq/L in 24 hrs and upto <18 mEq/L in 48 hrs

Deepak Madhu

High risk groups for ODS

Subgroups at increased risk for ODS:

Severe malnutrition Alcoholism Advanced liver disease

In these patients, correction rate should be well below the normal correction limits.
Deepak Madhu

Rate of correction should neither be too slow nor too fast

Correction by <3-4 mEq/L in 24hrs maybe associated with excess mortality But correction in excess of 10mmol/L in 24 hrs or 18 mEq/L in 48hrs have not been shown to improve outcome.

Deepak Madhu

Correction of hypovolemic hyponatremia

If volume depletion is present, the volume deficit has to be corrected. And the relative water excess will correct itself

Deepak Madhu

Correction of hypovolemic hyponatremia (cont)

Voulme resuscitation has to be done with isotonic fluid until the patient has attained clinical euvolemia.

Deepak Madhu

Correction of hypovolemic hyponatremia (cont)

When the initial volume estimate is equivocal, a fluid challenge with 0.5 to 1 L of isotonic saline can be both therapeutic and diagnostic.

Deepak Madhu

Hypovolemic hyponatremia associated with excess gastrointestinal loss

Isotonic saline is the mainstay of treatment KCl should be added if hypokalemia and metabolic alkalosis are present due to vomiting An isonatric mixture of NaCl and NaHCO3 may be used if metabolic acidosis is present due to diarrhoea
Deepak Madhu

Specific therapy for the underlying disorder should be initiated, and antiemetics and antidiarrhoeals used as appropriate

Deepak Madhu

Hypovolemic hyponatremia associated with excess sweating

Obvious signs of dehydration and volume depletion to be treated promptly with rehydration using isotonic saline.

Deepak Madhu

In the absence of obvious dehydration, if hyponatremia is present, guidelines for EAH to be followed. Isotonic saline should not be started.

Deepak Madhu

Hypovolemic hyponatremia associated with diuretic therapy

All diuretics to be withheld The patient has to be repleted with isotonic fluid if the CNS abnormalities are mild Hypertonic saline maybe used to raise the serum sodium level 4-5 mEq/L when seizures or significant altered sensorium is present
Deepak Madhu

Patients with thiazide induced hyponatremia are at high risk of recurrence and should not be rechallenged with a thiazide.

Deepak Madhu

Cerebral salt wasting

Patients with volume depletion from CSW should be resuscitated by administration of isotonic saline until they are euvolemic and maintained in neutral fluid balance Hypertonic saline to be used if altered sensorium believed to be due to hyponatremia is present.
Deepak Madhu

Case 1

83 year old lady presented with a 3 week history of memory disturbances. She has a history of hypertension and has recently started antihypertensive medication, hydrochlorothiazide tablets. Otherwise she is healthy and does not take any other medications.

Deepak Madhu

Case 1 (cont)

She also reports no nausea, vomiting or diarrhoea, and the rest of her systems review is normal. Her heart rate is 100bpm and her BP is 110/70 mm Hg. When standing her pulse rate increases to 110/min and BP decreases to 90/60 mm Hg. RR 12 bpm

Deepak Madhu

Case 1 (cont)

The physical examination reveals an elderly woman in no acute distress. She is alert and oriented. The patient has dry mucous membranes and poor skin turgor. The rest of her examination is within normal limits. Laboratory data show that the patient has dry mucous membranes and poor skin turgor.

Deepak Madhu

Case 1 (cont)

The rest of her examination is within normal limits. Laboratory data show that the patient has Na -125Meq/L, a K-3.4 Meq/L, a plasma osmolality of 270 mOsm/Kg H2O, UNa 23 MEq/Kg; BUN 48mg/dl, S.Cr 1.2mg/dl and a Urine osmolality of 400 mOsm/Kg of water.

Deepak Madhu

Q: Case1

What is the likely diagnosis for the patient?

a) b) c) d)

SIADH Thiazide induced hyponatremia Hypertonic hyponatremia Renal insufficiency

Deepak Madhu

Ans Q1

What is the likely diagnosis for the patient?

a) b) c) d)

SIADH Thiazide induced hyponatremia Hypertonic hyponatremia Renal insufficiency

Deepak Madhu

Q2

What is the next step in management?

a) b) c)

Start IV normal saline Start aggressive oral hydration Start 3% saline to reach a 5% increase in Na for the next 24 hours. Discontinue thiazide and continue hydration using IV normal saline.
Deepak Madhu

d)

Ans Q2

What is the next step in management?

a) b) c)

Start IV normal saline Start aggressive oral hydration Start 3% saline to reach a 5% increase in Na for the next 24 hours. Discontinue thiazide and continue hydration using IV normal saline.
Deepak Madhu

d)

Discussion Case 1

Kindly note that it is wise to check Na levels 1 week after starting thiazide diuretic

Deepak Madhu

Dicsussion Case 1 ( Cont)

The differences in the risk of hyponatremia between thiazides and loop diuretics is due to the difference in their mechanism of action. With loop diuretics, the reabsorption of water due to ADH is interfered , even though loop diuretics also increase ADH levels by inducing volume depletion

Deepak Madhu

Discussion Case 1 (cont)

Thiazide induced hyponatremia occurs in the first 1-2 weeks after starting thiazides . Elderly women are more at risk.

Deepak Madhu

Euvolemic HyponatremiaSIADH Management

Acute symptomatic hyponatremia 3% saline IV furosemide 20-40mg to be given to prevent fluid overload

Deepak Madhu

SIADH - Management

Infusion rate of hypertonic saline: body wt(kg)Xrate of correction desired(mEq/L/hr) For example a 70 kg man requiring 1meq/l/hr requires 70ml/hr of 3% saline.
Deepak Madhu

Acute treatment should be interrupted once any of the three end points are achieved:
1. 2.

Patient s symptoms are abolished A safe serum Na+ level >120mEq/L is achieved A magnitude of correction18mEq/L is achieved
Deepak Madhu

3.

In SIADH with reset osmostat, no treatment is required Most other cases of mild-moderate hyponatremia can be managed with fluid restriction.

Deepak Madhu

Fluid restriction measures

1.

All fluids not only water, should be included in this restriction. The degree of restriction required depends on urine output plus insensible fluid loss- non food fluids restricted to 500ml/day below the average daily urine volume. Several days of restriction are necessary Only fluid, not sodium, should be restricted

2.

3.

4.

Deepak Madhu

Fluid restriction measures (cont)

5.

Because of the high negative sodium balance, patients with SIADH need to be started on a high NaCl diet unless otherwise contraindicated. Any drug potentially causing SIADH should be Deepak Madhu substituted/discontinued

7.

Pharmacologic therapy of SIADH

Pharmacologic therapy is reserved for cases refractory to fluid restriction. SIADH associated with tumors will resolve with treatment of the lesion. Pharmacologic therapy Deepak Madhu Demeclocycline 600-1200 mg/day

Pharmacologic therapy of SIADH(cont)

Urea 30g/day PO may also be used. Vaptans are a new group of drugs that have been found to be effective.

Deepak Madhu

NSIAD

Same as SIADH Urea therapy has been found to be particularly effective Urea has to be dissolved in orange juice or any such solvent to camouflage the taste.
Deepak Madhu

Glucocorticoid deficiencymanagement
If there is suspicion of adrenal insufficiency, glucocorticoid replacement should be started immediately after a rapid ACTH stimulation test

Deepak Madhu

Glucocorticoid deficiency management (cont)

Prompt water diuresis after initiation of glucocorticoid therapy confirms diagnosis Absence of a quick response does not negate this diagnosis In such cases, primary treatment of the hyponatremia is indicated if the patient is symptomatic
Deepak Madhu

Hypothyroidism

Hyponatremia associated with hypothyroidism is generally mild and only modest fluid restriction necessary Symptomatic hyponatremia is seen in patients with more severe hypothyroidism and altered mental status, primary treatment of the hyponatremia is indicated

Deepak Madhu

Exercise associated hyponatremia

Can be severe and life threatening as a result of cerebral oedema and non-cardiogenic pulmonary oedema.

Deepak Madhu

Exercise associated hyponatremia (cont)

Runners are frequently fatigued, light headed, pre-syncopal, or dizzy at the conclusion of exercise but seizures, profoundly altered level of consciousness, ataxia or focal neurological deficits should raise suspicion of hyponatremia

Deepak Madhu

Exercise associated hyponatremia (cont)

With significant CNS impairment, hypertonic saline should be started at once and continued till S. Na is >125 or symptoms resolve.

Deepak Madhu

Psychosis-polydipsia management
Clozapine has been found to be useful in reducing and preventing recurrent hyponatremia in a subset of patients

Deepak Madhu

Case 2

The patient is a 78 year old man who is a cigarette smoker and presents with increasing cough, hemoptysis, and drowsiness. He is taking no medications. During the last one year he has lost approximately 8 Kg and his current weight is 72 Kg.
Deepak Madhu

Case 2 (cont)

His mucous membranes are moist, skin turgor normal and does not have an orthostatic fall in BP. Other than nicotine staining of right index and middle fingers, his physical examination is normal. His chest examination reveals a 4 cms lung mass in the right.
Deepak Madhu

Case2 (cont)

His S. Na is 123Meq/L , K is 4.3 Meq/L and creatinine is 1.1mg/dl. Measured osmolality is 270mOsm/Kg. Uric acid level is 4.2mg/dl. And U Na 45mEq/L. The TSH level is normal
Deepak Madhu

Case 2: Q 1

What is the cause of the patients hyponatremia?

a)

Renal failure Treatment with thiazides Hypothyroidism SIADH

Deepak Madhu

b)

c)

d)

Case2:A1

What is the cause of the patients hypoonatremia?

a)

Renal failure Treatment with thiazides Hypothyroidism SIADH

Deepak Madhu

b)

c)

d)

Further

The patient insists on being treated at home and agrees to restrict his fluid intake to 800ml each day. The next morning the patients son brings the patient with complaints of disorientation and unresponsiveness
Deepak Madhu

The patient is comatose on examination and does not respond to verbal or painful stimuli. His physical examination, apart from mental status changes, is significant for depressed reflexes. His repeat electrolytes are as follows: S.Na 108mEq/L, K -4.0, S.Cr-4.0, S. Osm 264mOsm/Kg, Urine Osm 600mOsm/Kg H20.

Deepak Madhu

Case2:Q2

How sould the patient be managed?

a)

Begin fluid restriction and administer NS Begin 3%saline and administer vasopressin Begin fluid restriction and administer 3% saline infusion. Administer vasopressin and furosemide

b)

c)

d)

Deepak Madhu

Case2:A1

How sould the patient be managed?

a)

Begin fluid restriction and administer NS Begin 3%saline and administer vasopressin Begin fluid restriction and administer 3% saline infusion. Administer vasopressin and furosemide

b)

c)

d)

Deepak Madhu

Hypervolemic hyponatremia-CHF
CHF Fluid restriction is the approach. Other options include demeclocycline, Urea, and fluid restriction.

Deepak Madhu

Hypervolemic hyponatremia - Cirrhosis

Cirrhosis: Fluid restriction should be instituted. Demeclocycline contraindicated due to the high incidence of nephrotoxicity. Urea has not been tried often

Deepak Madhu

Nephrotic syndrome, ARF and CRF

Fluid restriction is the only option

Deepak Madhu

Case 3

The patient is a 64 year old man who presents with increasing shortness of breath, fatigue, paroxysmal nocturnal dyspnoea and marked oedema. He has a long history of coronary artery disease and underwent coronary bypass surgery 6 years ago.
Deepak Madhu

Case 3 (cont)

The patients physical examination reveals JVD, rales and S3. His chest radiographs show B/L pleural effusions, cardiomegaly and interstitial infiltrates. His sodium levels is 121mEq/L, his K -3.5, his urine sodium -5 mEq/L and plasma osmolality 260 mOsm/Kg of H2O
Deepak Madhu

Case3:Q1
Which is the appropriate diagnosis for the patient?
a) b) c) d)

Iso-osmotic hyponatremia Isovolemic hypo-osmotic hyponatremia Hypovolemic hypo-osmotic hyponatremia Hypervolemic hypo-osmotic hyponatremia

Deepak Madhu

Case3:A1
Which is the appropriate diagnosis for the patient?
a) b) c) d)

Iso-osmotic hyponatremia Isovolemic hypo-osmotic hyponatremia Hypovolemic hypo-osmotic hyponatremia Hypervolemic hypo-osmotic hyponatremia

Deepak Madhu

Case3:Q2

What is the reason for the hyponatremia in this patient?

a)

Impairment of water excretion due to ADH excess Increased water intake SIADH
Deepak Madhu

b)

c)

d)

Adrenal failure

Case3:A2

What is the reason for the hyponatremia in this patient?

a)

Impairment of water excretion due to ADH excess Increased water intake SIADH
Deepak Madhu

b)

c)

d)

Adrenal failure

Case3:Q3

How should the patient be treated?

a) b) c)

Administer IV 3% saline solution Start IV normal saline and loop diuretics Implement fluid restriction and start loop diuretics Start high doses of beta blockers
Deepak Madhu

d)

Case3:A3

How should the patient be treated?

a) b) c)

Administer IV 3% saline solution Start IV normal saline and loop diuretics Implement fluid restriction and start loop diuretics Start high doses of beta blockers
Deepak Madhu

d)

Infusates

Infusate Normal Saline 3% saline

Meq/L 154 513

Deepak Madhu

Common salt

Sodium chloride consists of 40% w/w Na and 60% w/w Cl. One level teaspoon (US) contains 5750mg salt which is 2300mg sodium which is inturn 100mEq of Na
Deepak Madhu

Correction of Hyponatremiasteps
1. 2.

Estimate total body water Estimate the change in Na per litre of infusate Calculate the amount of infusate required Calculate the rate of infusion
Deepak Madhu

3.

4.

For example

A 70 kg man of age 45 years, with Na 0f 110 mEq/L, is obtunded . The goal: his S.Na should increase rapidly by 4 mEq/L over the next 2-4 hours.

Deepak Madhu

Calculation of total body water

TBW = total body water This is calculated by multiplying body weight with a correction factor The correction factors vary with age and sex and is as follows
Deepak Madhu

Correction factors
Patient Pediatric Male, non elderly Female, non elderly Male, elderly Female, elderly
Deepak Madhu

Correction factor 0.6 0.6 0.5 0.5 0.45

Formulas for calculating changes in sodium levels in hypo/hyper-natremia

Deepak Madhu

The patients hyponatremia correction

Deepak Madhu

Aquaretics

Antagonists of the kidney vasopressin V2 receptors (nicknamed vaptans) have long been predicted to be the ideal agent for treatment of patients with dilutional hyponatremia.
Deepak Madhu

Aquaretics (cont)

These agents stimulate renal free water excretion (aquaresis) and thereby lead to increased serum [Na+] in most patients with dilutional hyponatremia due to SIADH, congestive heart failure, or cirrhosis.
Deepak Madhu

Conivaptan

In 2005 the U.S. Food and Drug Administration (FDA) approved conivaptan, a combined V1a and V2 vasopressin receptor antagonist, for treatment of euvolemic hyponatremia, and in 2006 this approval was extended to patients with hypervolemic hyponatremia.

Deepak Madhu

Conivaptan (cont)

Phase 3 clinical trials of conivaptan demonstrated a prompt correction of serum [Na+] in most treated hyponatremic patients, averaging 6 to 8 mEq/L over a 2- to 4-day course of treatment.
Deepak Madhu

Conivaptan (cont)

Conivatan is an inhibitor of the hepatic cytochrome P450 isoenzyme CYP3A4, and hence inhibits metabolism of many drugs therefore, its use has been limited to short-term (<4 days) intravenous administration in hospitalized patients. Deepak Madhu

Conivaptan (cont)

Conivaptan was found to be useful in that it corrected serum [Na+] more rapidly than fluid restriction in patients with nonlifethreatening degrees of hyponatremia.
Deepak Madhu

Tolvaptan

Tolvaptan, a selective V2 vasopressin receptor antagonist, was approved by the FDA in 2009 for treatment of euvolemic and hypervolemic hyponatremia.

Deepak Madhu

Tolvaptan (cont)

Clinical trials of tolvaptan showed normalization of serum [Na+] in most hyponatremic patients treated, and this effect was sustained over a 30-day treatment period with recurrence of the hyponatremia by 7 days after cessation of the drug.
Deepak Madhu

Tolvaptan (cont)

The use of tolvaptan in the United States is limited to patients with severe hyponatremia (serum [Na+] < 125 mEq/L) and those with milder degrees of hyponatremia who are symptomatic and for whom treatment with fluid restriction has failed.

Deepak Madhu

Hypernatremia

Hypernatremia is a rise in serum sodium concentration to a value exceeding 145 mEq/L. Hypernatremia invariably denotes hypertonic hyperosmolality and always causes cellular dehydration atleast transiently
Deepak Madhu

Hypernatremia can result from

Net water loss or hypertonic sodium gain Net water loss accounts for the majority of cases Net water loiss can be pure water loss (no sodium deficit) or hypotonic fluid loss.
Deepak Madhu

Hypertonic sodium gain usually results from accidental sodium loading.

Deepak Madhu

Pure water loss

Insensible losses Hypodipsia Neurogenic diabetes insipidus Congenital nephrogenic diabetes insipidus Acquired nephrogenic diabetes Deepak Madhu insipidus

Hypotonic fluid loss

Renal causes: loop diuretics, Osmotic diuretics, Postobstructive diuresis, polyuric phase of ATN, intrinsic renal disease GI causes: Vomiting, nasogastric drainage, enterocutaneous fistula, diarrhoea, use of osmotic cathartic agents
Deepak Madhu

Cutaneous causes: excessive sweating, burns

Deepak Madhu

Hypertonic sodium gain

Hypertonic sodabicarb infusion Hypertonic feeding preparation Ingestion of sodium chloride Ingestion of sea water Sodium chloride rich emetics Hypertonic saline enemas
Deepak Madhu

Hypertonic sodium gain (cont)

Intrauterine injection of hypertonic saline Hypertonic sodium chloride infusions Hypertonic dialysis Primary hyperaldosteronism Cushings syndrome
Deepak Madhu

Clinical manifestations of hypernatremia (cont)

Symptoms may start as lethargy, weakness and irritability May progress to twitching, seizures, obtundation or coma Cell dehydration and resulting decrease in brain volume can lead to rupture of cerebral veins leading to hemorrhage
Deepak Madhu

Clinical manifestations of hypernatremia (cont)

Severe symptoms usually occur with rapid increase of sodium concentration to 158 mEq or more Sodium concentration greater than 180 mEq are associated with high mortality
Deepak Madhu

Management

Two pronged apprroach which requires management of the underlying cause as well as management of the hypernatremia itself

Deepak Madhu

Management (cont)

Hypernatremia that developed over a period of hours can be corrected rapidly. In such patients, the sodium maybe reduced at a rate of 1mEq/L/hr
Deepak Madhu

Management (cont)

In hypernatremia of longer or unknown duration, a slower rate of correction is required. The maximum rate of correction in such patients is 0.5mEq/L/hr.

Deepak Madhu

Management (cont)

In a hypovolemic patient, volume resuscitation for a hemodynamically unstable patient should be accomplished by isotonic 0.9% saline. One the patient is hemodynamically stable, intravenous fluids should be changed to a hypotonic 0.45% saline.

Deepak Madhu

Management (cont)

The euvolemic patient: pure water replacement with iv hypotonic saline or free water. Dextrose containing solutions may be used but blood sugar should be monitored as hyperglycemia would contribute to osmolarity
Deepak Madhu

Management (cont)

For significantly hypernatremic individuals in whom central DI is considered, 5-10 units of aqueous vasopressin should be given subcutaneously every 3-4 hours.

Deepak Madhu

Management (cont)

Sodium levels in the serum should be checked every 4 hours. Cerebral oedema is an important complication of hyponatremia correction.

Deepak Madhu

Management (cont)

In order to avoid cerebral oedema, a maximum decrease of 10 mEq/L per 24 hour period is recommended. The free water deficit has to be calculated first,and no more than half of the water deficit is to be corrected in the first 24 hours and the remainder has to be corrected over the next 1-2 days.
Deepak Madhu

Calculation of free water deficit

Deepak Madhu

Calculation of total body water

TBW = total body water This is calculated by multiplying body weight with a correction factor The correction factors vary with age and sex and is as follows
Deepak Madhu

Correction factors
Patient Pediatric Male, non elderly Female, non elderly Male, elderly Female, elderly
Deepak Madhu

Correction factor 0.6 0.6 0.5 0.5 0.45

For example

Deepak Madhu

How is the free water deficit corrected?

The free water deficit maybe corrected over 3 days. Total intake = (total output + insensible + 1/3 1/2 water deficit) each day for the next three days.
Deepak Madhu

Formulas for calculating changes in sodium levels in hypo/hyper-natremia

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Infusate composition
Infusate 5%D Infusate Na 0 ECF distribution 40 55 73 97 100

0.2% NaCl in 5%D 34 0.45% NaCl in water Ringers lactate

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77 130

0.9% NaCl in water 154

Case 4

A 76-year-old man presents with a severe obtundation, dry mucous membranes, decreased skin turgor, fever, tachypnea, and a blood pressure of 142/82mm Hg without orthostatic changes. The serum sodium concentration is 168 mmol per liter, and the body weight is 68 kg. How would you manage the patient?
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The patients serum glucose level also has to be monitored regularly and insulin given at the slightest signs of hyperglycemia Other parameters have to be monitored atleast every 6 hours.

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Case 5

A 58-year-old woman with postoperative ileus is undergoing nasogastric suction. She is obtunded and has diminished skin turgor and mild orthostatic hypotension. The serum sodium concentration is 158 mEq per liter, the potassium concentration is 4.0 mEq per liter, and the body weight is 63 kg. how would she be managed?
Deepak Madhu

She has hyponatremia due to hypotonic fluid loss and therefore an infusion of 0.45 percent NaCl maybe planned. The initial administration of isotonic saline is not warranted as her hemodynamic status is not so compromised as to require it.
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Q continued

The patients S.Na levels rechecked came as 155mEq/L at the end of 12 hours and the patient continues to be somnolent.How would you proceed?

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More aggressive lowering of the S.Na levels is required and the patient maybe shifted to an alternative agent, say, 0.2% saline. Therapy maybe resumed with the aim of reducing the S.Na levels by 10mmols over the next 24 hours.
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One litre of 0.2%NaCl is expected to reduce the S.Na levels by 3.7L and thus 2.7 L of fluid is required to achieve the goal. With the allowance for ongoing loss + urine output + insensible loss, say 2L, the total fluid required, 4.7L, maybe given IV over 24 hours at the rate of 200ml/hr.

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Case 6

A 60-year-old man has received 10 ampules of sodium bicarbonate over a period of six hours during resuscitation after recurrent cardiac arrest. He is stuporous and is undergoing mechanical ventilation..
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His blood pressure is 138/86 mm Hg, and peripheral edema (+++) is present. The serum sodium concentration is 156 mmol per liter, the body weight is 85 kg, and the urinary output is 30 ml per hour. How will you proceed to manage this patient? Deepak Madhu

The patient has hyponatremia due to hypertonic sodium gain and its correction requires excess sodium and water to be excreted. The administration of furosemide along with electrolyte free water will be required. The estimated TBW =0.6*85 = 51L
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The retention of 1 L of 5%D is expected to decrease S.Na levels by 3mEq/L and 2L maybe infused over 8 hours. The patients volume status and clinical status should be closely watched. The correction will be opposed by hypotonic renal and extrarenal loss. Allowance for ongoing fluid but not sodium loss may also be taken into account.
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Complications of hypo/hypernatremia
Rapid overcorrection of hyponatremia and hypernatremia can result in osmotic demyelination and cerebral oedema respectively. Rapid transcellular shift of water can result in cellular damage, particularly in the CNS
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As an initial compensatory mechanism to preserve cell volume, there is rapid shift of sodium , potassium, chloride and water out of the cells in hyponatremia and into the cells in hypernatremia.
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After 48 72 hours, a slower adaptive phase takes effect. Cells mobilize organic osmolytes, comprised mostly of amino acids, to continue efforts to maintain normal cellular volume
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The initial and gradual flux of ions help maintain normal cellular volume. Excessively rapid correction of hypo and hypernatremia can result in extreme cellular volume changes and cellular damage
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Osmotic demyelination syndrome

Occurs when water moves too rapidly out of brain cells during administration of relatively hypertonic saline solutions. Classically described in the pons, this has also been described in other parts of the brain also
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ODS

These patients classically present with deteriorating mental status and progressive neurological deficits, such as pseudobulbar palsies and spastic quadriparesis, after a transient period of improvement with fluid administration. Deepak Madhu

ODS

ODS typically occurs 1 to 6 days after treatment. It is associated with dismal prognosis and has no effective treatment. Chronic alcoholism and malnutrition have also been assoiciated with ODS.
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Thank You