Hyponatremia

definition

- Normal Na+
 Hyponatremia is low sodium level in the blood
level:
 Plasma sodium <135mmol/L 135-145
 Most common disorder encountered in clinical mmol/L
practice - Functions to
regulate in
 Symptoms occurring is related to speed rather
and out flow
than severity
of water
Types

1. Hypovolumic 2. Euvolumic 3. Hypervolumic

hyponatremia hyponatremia hyponatremia
-Both Sodium and water -Water retention alone - Sodium retention with
deficit relatively greater water
-Patient not edematous
-Patient
becomes retention
dehydrated -Dilutional
- Patient edematous
hyponatremia
-Common causes:
Vomiting, diarrhea, -Common causes: - Common causes:
burns, hemorrhage, SIADH, hypothyroidism, CCF, Nephrotic
diuretics, Primary Polydypsia syndrome, CRF
hyperglycemia
Investigations

Laboratory Imaging
 Serum osmolality • CT Scan

 Urine osmolality
 Urinary sodium concentration
 Serum uric acid
 Serum cortisol
 Thyroid function test
 PLASMA AND URINE ELECTROLYTES AND OSMOLALITY
ARE USUALLY THE ONLY TESTS REQUIRED TO
CLASSIFY THE HYPONATREMIA
Urine osmolality

 Normal: 500-800 mmol/kg

 To detect any impairment of the kidney function
 <100mmol/kg (diluted)  Primary polydipsia,malnutrition
 >100mmol/kg (concentrated)  Impaired kidney
function, secondary to increased ADH
Urine sodium concentration

 To differentiate hypovolemic hyponatremia (>20mEq/L)

and SIADH (>40mEq/L)
 Management

 Treatment is critically dependent on its rate of development,

severity and underlying cause
 In symptomatic acute onset, patient with seizures or coma,
<48 hours:
Give 3% hypertonic solution
- Must be given very slowly
- Aim to increase plasma Na+ by 4-6mmol/L in first 4 hours
- Shouldn’t exceed 15-20mmol/L over 48 hours
 In asymptomatic chronic onset, 3% hypertonic solution is still
given as clinically it is difficult to know how long the
hyponatremia has been present
Management

 Rapid correction of hyponatremia that has developed slowly (over

weeks to months) can be hazardous since brain cells adapt to
slowly developing hypo-osmolality by reducing the intracellular
thus maintaining normal cell volume.
 An abrupt increase in extracellular osmolality can lead to water
shifting out of neuron abruptly reducing their volume and causing
them to detach from their myelin sheath (Myelinolysis)
 Permanent structural and functional damage to mid-brain
structures and is fatal
 Rate of correction of plasma Na concentration in chronic
asymptomatic hyponatremia should not exceed 10mmol/l/day
and even slower rate is generally safer
Hypovolemic hyponatremia

 Treat the primary cause

 Give oral electrolyte-glucose mixtures
 Increase salt intake
 Administer IV fluids with K+ supplements
Hyponatremia with euvolemia

 Fluid restriction ( 600-1000ml/day)

 Withdrawal of precipitating stimulus
 Demeclocycline(600-900mg/day)
 Tolvaptan( oral vasopressin receptor antagonists)