HIPONATREMIA

HIPONATREMIA
● Plasma concentration Na <135 mEq/L
● Common cause:
● ADH increment or low intake
● 3 classifications:
○ Hypovolemia
○ Euvolemia
○ Hypervolemia
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CORRECTING
PSEUDOHYPONATREMIA
Hyperglycemic patients
Add 1,6/100ml in glucose level >100 mg/dL
Example: Na = 126 mEq/L. Glucose = 600 mg/dL:
 600 - 100 = 500
 5 x 1.6 = 8
126 + 8 =134
True sodium equals 134 mEq/L
To remember 1.6 think “Sweet 16” 
STEP 1
● History and examination needed
● Vomiting, diarrhea with hypotonic fluid ingestion, recent surgery, improper
IV fluid administration
● Associated diseases (i.e. psychiatric illness, CHF, cirrhosis, renal failure)
● Recent head injury, intracranial surgery, subarachnoid hemorrhage, stroke,
brain tumor, meningitis or brain abscess can cause SIADH.
● Cough, shortness of breath, or pleuritic chest pain should prompt
consideration of respiratory causes of SIADH
● Use of medications
● Skin turgor, mucous membrane appearance and postural hypotension
● Detection of ascites, peripheral edema, pulmonary rales and S3
● Measuring blood pressure, JVP, CVP and PCWP
HYPONATREMIA
INDUCING
DRUGS
STEP 2
● Measure plasma osmolality with osmometer. Osmometer provides actual
(correct) osmolality. Normal plasma osmolality is 280 - 295 mOsm/kg
● Low plasma osmolality (POsm < 280 mOsm/kg) confirms
diagnosis
● Normal plasma osmolality (POsm 280–295 mOsm/kg) suggests
isotonic pseudo hyponatremia : check for hyperproteinemia,
hyperlipidemia
● High plasma osmolality (POsm > 295 mOsm/kg) suggests
hypertonic hyponatremia : check for hyperglycemia, mannitol therapy and
contrast dyes.
● Urine osmolality <100 mOsm/kg
○ antidiuretic hormone (ADH) suppressed

● Urine osmolality >100 mOsm/kg

○ impaired water excretion which reflects impaired renal

diluting mechanism (SIADH)

STEP 3
● Classified into

○ Hypovolemic: Gold standard dx hiponatremia

hipovolemi = Konsentrasi Na plasma normal
setelah hidrasi dengan NS

○ Hypervolemic

○ Euvolemic
● Treatment protocols are absolutely different in all
three categories
● UNa should be measured
STEP 4
Specific etiologic test

1. Blood sugar  hyperglycemia

2. Serum creatinine  renal failure
3. Serum protein  High in multiple myeloma and low in cirrhosis
4. Serum triglycerides  pseudohyponatremia
5. Serum potassium  High in Addison's disease and low in person with
diuretics therapy, diarrhea and vomiting
6. Thyroid function tests  hypothyroidism
7. Adrenal functions  Addison's disease
8. Acid-base balance:
○ Metabolic alkalosis occurs in diuretic use or vomiting.
○ Metabolic acidosis occurs in diarrhea or laxative abuse and primary
adrenal insufficiency.
9. Head CT scan and Chest X-ray  cerebral salt wasting syndromes
KLINIS HIPONATREMI

● General cell edema (water move from ECF → ICF)

● Neurological symptoms → cerebral edema
● Intracellular ion efflux of brain cells
● Initial symptoms  when Na < 125 mM
● Nausea and vomiting, headache
● Advanced symptoms
● Seizures, brain stem herniation, coma, death
SIADH DIAGNOSTIC CRITERIA
● Decreased measured serum osmolality (<275 mOsm/kg H2O)
● Clinical euvolaemia. Exclude hypovolemia and hypervolemia
● Urinary osmolality >100 mOsm/kg H2O during hypo- osmolality
● Urinary [Na+] >40 mmol/L with normal dietary sodium intake
● Normal thyroid and adrenal function. Exclude renal failure and use of diuretic agents
within the week prior to evaluation
● No hypokalemia, no acid base disorders

Supporting diagnostic criteria for SIADH

● Serum uric acid <4 mg/dL
● Blood urea nitrogen <10 mg/dL
● Fractional sodium excretion >1%; fractional urea excretion >55%c
● Failure to improve or worsening of hyponatremia after 0.9% saline infusion
● Improvement of hyponatremia with fluid restriction
TERAPI HIPONATREMIA
● Euvolemic (SIAD, Hipotiroid, ggn adrenal sekunder)
○ Treat underlying disorder
● Hypovolemic
○ Hydration  NS IV
● Hypervolemic
○ Due to CHF treat cardiomyopathy (e.g.: ACEi)
● Beer protomania, low solute intake
○ IV NS dan normal diet
○ Risiko tinggi ODS (karena berkaitan dengan hipokalemia, alkoholism,
malnutrisi)
● Water retention → plasma: urine electrolyte ratio (urin [Na] + [K] / plasma
[Na])
● Ratio>1 = aggressive restriction(<500 mL/d)
● Ratio ~1 = 500-700 mL/d
● Ratio <1 = <1 L/d
TREATMENT
Sodium disorders are diagnosed by findings from the history,
physical examination, laboratory studies, and evaluation of
volume status.
Treatment is based on symptoms and underlying causes. In
general, hyponatremia is treated with fluid restriction (in the
setting of euvolemia), isotonic saline (in hypovolemia), and
diuresis (in hypervolemia).
Hypertonic saline is used to treat severe symptomatic
hyponatremia.
Normal osmolality : 275-295 mOsm/kg
TREATMENT OF
SEVERE
SYMPTOMATIC
HYPONATREMIA
Vaptans (conivaptan [Vaprisol] and tolvaptan [Samsca]) are
vasopressin-receptor antagonists approved for the treatment
of hospitalized patients with severe hypervolemic and
euvolemic hyponatremia.
However, their use in the management of hyponatremia is
controversial. Several trials have demonstrated that vaptans
increase sodium levels in patients with cirrhosis and heart
Regardless of their effectiveness in increasing sodium levels,
vaptans—specifically tolvaptan—should not be used in
patients with hepatic impairment because they may worsen
liver function.
TREATMENT
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