Hyponatremia

Key Features

Essentials of Diagnosis

Thorough history and volume status examination are essential to determining etiology

Hyponatremia reflects excess water relative to sodium; total body sodium may be appropriate, low, or high

Hypotonic fluids commonly contribute to hyponatremia in hospitalized patients

General Considerations

• Most common electrolyte abnormality in hospitalized patients

• Defined as a serum sodium concentration < 135 mEq/L (135 mmol/L)

• Can be subclassified as

  • Mild (130–134 mEq/L)

  • Moderate (125–129 mEq/L)

  • Severe (< 125 mEq/L)

• A diagnostic algorithm using serum osmolality and volume status separates the causes of hyponatremia into therapeutically useful categories (Figure 21–1)

Clinical Findings

History and physical examination

• Obtain careful history, including

  • New medications

  • Changes in fluid and solute intake (polydipsia, anorexia, intravenous fluid rates, and composition)

  • Fluid output (vomiting, diarrhea, ostomy output, polyuria, oliguria, insensible losses)

• The physical examination should help categorize the patient’s volume status into

  • Hypovolemia

  • Euvolemia

  • Hypervolemia

Symptoms and Signs

• Mild hyponatremia (sodium concentrations of 130–135 mEq/L)

  • Usually asymptomatic

  • Gait disturbances, falls, and fractures may occur

• Nausea and malaise may progress to headache, lethargy, and disorientation as the sodium concentration drops

• Most serious symptoms are seizure and, very rarely, coma, brainstem herniation, and death

Diagnosis

• Laboratory assessment should include

  • Serum electrolytes

  • Creatinine

  • Osmolality

  • Urine sodium, potassium, and osmolality

• Additional tests of thyroid and adrenal function may be necessary

Treatment

• Hypovolemic hyponatremia

  • Patients require adequate fluid resuscitation, usually with isotonic fluid

  • Diuretics should be withheld in hypovolemic patients

  • Underlying cause of volume depletion should be addressed

  • Patients believed to have cerebral salt wasting may benefit from hypertonic saline (with close monitoring)

• Hypotonic hypervolemic hyponatremia

  • Loop diuretics are generally required

  • Dialysis may be needed in severe acute or chronic kidney injury

  • V₂ receptor antagonists (such as tolvaptan) may be helpful for severe hypervolemic hyponatremia from heart failure but are contraindicated in cirrhosis

• Hypotonic euvolemic hyponatremia

  • Should be treated based on the underlying etiology

  • Psychogenic polydipsia can correct quickly with water restriction alone

  • Mild to moderate hypotonic euvolemic hyponatremia

    • Often responds to fluid restriction and withholding offending medications or treating pain and nausea when due to secondary to SIADH (see SIADH)

    • Increased solute intake and loop diuretics can also be used to increase water clearance in refractory cases that are not severe

  • Acute severe symptomatic hyponatremia ...