Hyponatremia causes: Difference between revisions

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{{CMG}}; {{AE}} {{Saeedeh}}
{{CMG}}; {{AE}} {{Saeedeh}}
==Overview==
==Overview==
Disease name] may be caused by [cause1], [cause2], or [cause3].
Hyponatremia is caused by either increase [[ADH]] action/ secretion or kidney function impairment. [[SIADH|SIAD]] is the most common cause of euvolemic hyponatremia. After [[SIAD]], [[polydipsia]], [[drugs]] and clinical disorders are the most encountered etiologies in clinical practice.


OR
==Causes==
'''''To review the mechanisms of developing hyponatremia, click [[Hyponatremia pathophysiology#Pathophysiology|here]].'''''<small>
* '''<big>Etiologies of SIAD:</big>'''
{| class="wikitable"
! colspan="2" |'''<big>Conditions</big>'''
|-
!<big>Malignant disorders</big>
|'''Carcinoma:''' Lung ( [[small cell carcinoma]], [[mesothelioma]]), oropharynx, stomach, duodenum, pancreas, ureter, bladder, prostate, endometrium, [[thymoma]]


Common causes of [disease] incl ude [cause1], [cause2], and [cause3]. 
'''Lymphomas'''


OR
'''Sarcomas:''' [[Ewing's sarcoma]]


The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].
'''Olfactory neuroblastoma'''
|-
!<big>Pulmonary diseases</big>
|'''Infections:''' [[Bacterial pneumonia]], [[viral pneumonia]], [[pulmonary abscess]], [[tuberculosis]], [[aspergillosis]]


OR
'''Others:''' [[Asthma]], [[cystic fibrosis]], [[respiratory failure]], [[emphysema]], [[COPD]],[[coronavirus]] disease, positive-pressure ventilation
|-
!<big>CNS disorders</big>
|'''Infections:''' Encephalitis, meningitis, brain abscess, [[RMSF]], [[AIDS]], [[malaria]]


The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click [[Pericarditis causes#Overview|here]].
'''Vascular and SOP:''' [[Subarachnoid hemorrhage]], [[stroke]], [[brain tumors]], [[head trauma]]


==Causes==
'''Others:''' [[Hydrocephalus]], [[cavernous sinus thrombosis]], [[Multiple sclerosis]], Guillain–Barré syndrome, Shy–Drager syndrome,


[[delirium tremens]], [[Acute intermittent porphyrias|acute intermittent porphyria]], chronic psychosis, pituitary stalk section, transsphenoidal adenomectomy
|-
!<big>Other causes</big>
|'''Hereditary:''' Gain-of-function mutation of V2 receptors
'''Idiopathic'''


'''[[#Drugs cause hyponatremia|Drugs]]'''


† ''Mmol and Meq are the same for univalent ions like sodium''
'''Transient:''' [[Exercise]], [[general anesthesia]], nausea, pain, stress
* Causes of acute hyponatremia
|}
<br>
* Causes of '''<big>acute hyponatremia:</big> '''  (develops in < 48 hrs)
{| class="wikitable"
{| class="wikitable"
!Etiology
|-
|-
|Post operative phase
|
Polydipsia
* Post operative phase
 
* Transurethral or endoscopic procedure (mannitol, sorbitol, glycine)
Exercise
* Colonoscopy preparation 
 
* Polydipsia
Oxyctocin
* Exercise
 
* Oxytocin
Cyclophosphamide
* Cyclophosphamide
 
* Ecstasy( 3,4-Methylenedioxymethamphetamine, MDMA)
Ecstasy( 3,4-Methylenedioxymethamphetamine, MDMA)
* Thiazide
 
* Halopridol
Thiazide
* Recently started desmopressin, terlipressin, vasopressin
|}
|}
( Etiologies that cause hyperacute and acute hyponatremia are applicable to each category interchangeably depending on the onset of symptoms)
<small>( Etiologies that cause hyperacute and acute hyponatremia are applicable to each category interchangeably depending on the onset of symptoms)</small>
 
<br>
* Causes of '''<big>Hyponatremia</big>''' based upon '''Serum Osmolality:'''
* Causes of '''<big>Hyponatremia</big>''' based upon '''Serum Osmolality:'''
{| class="wikitable"
{| class="wikitable"
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|'''<big>Hypertonic or Isotonic Hyponatremia</big>'''
|'''<big>Hypertonic or Isotonic Hyponatremia</big>'''
|> 295 mOsm/kg
|> 295 mOsm/kg
|Hyperglycemia<sup>‡</sup>, Mannitol, Glycine, Maltose  
|[[Hyperglycemia]]<sup>‡</sup>, [[Mannitol]], [[Glycine]], [[Maltose]], severe [[azotemia]]
|-
|-
|'''<big>Isotonic Hyponatremia</big>'''
|'''<big>Isotonic Hyponatremia</big>'''
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intravenous immunoglobulin (IVIg), Hyperlipidemia ( triglyceride, cholesterol ),
intravenous immunoglobulin (IVIg), Hyperlipidemia ( triglyceride, cholesterol ),


Hyper paraproteinemia (monoclonal gammopathy of undetermined significance (MGUS),  
hyper paraproteinemia (monoclonal gammopathy of undetermined significance (MGUS),  


Multiple Myeloma),  
multiple myeloma),  
|-
|-
|'''<big>Hypotonic Hyponatremia</big>'''
|'''<big>Hypotonic Hyponatremia</big>'''
|< 275 mOsm/kg
|< 275 mOsm/kg
|Glycerol, Sorbitol, Etiology depends upon volume status (Hypervolemic/ Euvolemic/ Hypovolemic)
|[[Glycerol]], [[Sorbitol]], Etiology depends upon volume status (Hypervolemic/ Euvolemic/ Hypovolemic)
|-
|-
| colspan="3" |Alcohol, Urea, Ethylen glycol  are ineffective osmoles, cause hyperosmolar isotonic serum but not hyponatremia.
| colspan="3" |<small>[[Alcohol]], [[Urea]], Ethylen glycol  are ineffective osmoles, cause hyperosmolar isotonic serum but not hyponatremia.</small>
|}
|}
‡ Hyperglycemia causes osmotic diuresis results in a rise in serum  sodium concentration, on the other hand it leads to extracellular shift of water due to osmotic gradient which causes relative hyponatremia , depends on which effect is stronger, there would be hypertonicity or hypotonicity<ref>{{Cite journal
<small>‡ Hyperglycemia causes osmotic diuresis results in a rise in serum  sodium concentration, on the other hand it leads to extracellular shift of water due to osmotic gradient which causes relative hyponatremia , depends on which effect is stronger, there would be hypertonicity or hypotonicity<ref>{{Cite journal


  | author = [[A. I. Arieff]] & [[H. J. Carroll]]
  | author = [[A. I. Arieff]] & [[H. J. Carroll]]
Line 86: Line 108:
  | pmid = 5013637
  | pmid = 5013637


}}</ref>.   
}}</ref>.</small>   
* Causes of '''<big>Hyponatremia</big>''' based on '''volume status''' '''<ref name="GuillauminDiBartola2017">{{cite journal|last1=Guillaumin|first1=Julien|last2=DiBartola|first2=Stephen P.|title=A Quick Reference on Hyponatremia|journal=Veterinary Clinics of North America: Small Animal Practice|volume=47|issue=2|year=2017|pages=213–217|issn=01955616|doi=10.1016/j.cvsm.2016.10.003}}</ref> :'''
* Causes of '''<big>Hyponatremia</big>''' based on '''volume status''' '''<ref name="GuillauminDiBartola2017">{{cite journal|last1=Guillaumin|first1=Julien|last2=DiBartola|first2=Stephen P.|title=A Quick Reference on Hyponatremia|journal=Veterinary Clinics of North America: Small Animal Practice|volume=47|issue=2|year=2017|pages=213–217|issn=01955616|doi=10.1016/j.cvsm.2016.10.003}}</ref> :'''
{| class="wikitable"
{| class="wikitable"
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* total body sodium ↓↓
* total body sodium ↓↓
|
|
* '''GI loss:''' Vomiting, diarrhea, tube drainage
* '''GI loss:''' [[Vomiting]], [[Diarrheal|diarrhea]], tube drainage
* '''Insensible loss:''' Sweating, burns
* '''Insensible loss:''' [[Sweating]], [[burns]]
* '''Renal loss:''' Salt-wasting nephropathy (Inappropriate loss of Na+-Cl– in the urine),
* '''Renal loss:''' Salt-wasting nephropathy (inappropriate loss of Na+-Cl– in the urine),
Bicarbonaturia ( Renal tubular acidosis, Metabolic alkalosis), osmotic diuresis, diuretic use,  
bicarbonaturia ( renal tubular acidosis, metabolic alkalosis), [[osmotic diuresis]], [[diuretic use]],  


Cerebral salt-wasting syndrome (Stroke ,SAH ,↑ brain natriuretic peptide and ↑ renal sodium loss )
[[cerebral salt-wasting syndrome]] ([[Stroke]] ,[[SAH]] ,↑ [[brain natriuretic peptide]] and ↑ renal sodium loss )
* '''Third spacing of fluids :''' Pancreatitis, hypoalbuminemia, Small bowel obstruction
* '''Third spacing of fluids :''' [[Pancreatitis]], [[hypoalbuminemia]], [[Small bowel obstruction]]


* '''Mineralocorticoid deficiency:''' Addison disease (primary)  
* '''Mineralocorticoid deficiency:''' [[Addison disease]] (primary)  


* '''Excessive diuretic administration'''
* '''Excessive diuretic administration: ''' mostly thiazide diuretics
|-
|-
|'''<big>Hypervolemic</big>'''
|'''<big>Hypervolemic</big>'''
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|
|
* '''Renal disease:''' Acute or chronic kidney disease or injury
* '''Renal disease:''' Acute or chronic kidney disease or injury
(due to relatively higher water versus salt intake and poor excretion),Nephrotic syndrome
(due to relatively higher water versus salt intake and poor excretion), nephrotic syndrome
* '''Congestive heart failure'''
* '''Congestive heart failure'''
* '''Cirrhosis'''
* '''Cirrhosis'''
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* total body sodium ↔
* total body sodium ↔
|
|
* '''Drugs:''' Vasopressin, diuretics, antidepressants, opioids
* '''Drugs:''' [[Vasopressin]], [[diuretics]], [[antidepressants]], [[opioids]]
* '''SIAD:''' SIADH (Malignancy, central nervous system (CNS) disorders, pulmonary disease, or drugs,
* '''SIAD:''' [[SIADH]] (Malignancy, central nervous system (CNS) disorders, pulmonary disease, or drugs,
postoperative nausea, pain, stress, neoplasia (common), trauma, pregnancy)
postoperative nausea, pain, stress, neoplasia (common), trauma, pregnancy)


''',''' nephrogenic SIAD (Gain-of-function mutation of v2 receptors)
''',''' nephrogenic SIAD (Gain-of-function mutation of v2 receptors)
* '''High fluid intake:''' Physical activity, surgery, primary polydipsia, potomania
* '''High fluid intake:''' Physical activity, surgery, primary polydipsia, potomania, tea & toast diet
(caused by a low intake of solutes with relatively high fluid intake)
(caused by a low intake of solutes with relatively high fluid intake)
* '''Medical testing''' (excess fluid intake) ''':'''Colonoscopy or cardiac catheterization
* '''Medical testing''' (excess fluid intake) ''':'''[[Colonoscopy]] or [[cardiac catheterization]]
* '''Hypothyroidism'''
* '''Hypothyroidism'''
* '''Hormonal:''' Glucocorticoid deficiency, pituitary failure (secondary), hypothalamic failure (tertiary)
* '''Hormonal:''' [[Glucocorticoid deficiency 1|Glucocorticoid deficiency]], [[pituitary failure]] (secondary), hypothalamic failure (tertiary)


* '''Reset osmostat <sup>†</sup> :''' Drugs, pregnancy
* '''Reset osmostat <sup>†</sup> :''' Drugs, pregnancy
* '''Iatrogenic'''
* '''Iatrogenic'''
|}
|}
''† Altered sensitivity to serum osmolality by the hypothalamic osmoreceptors''
''<small>† Altered sensitivity to serum osmolality by the hypothalamic osmoreceptors</small>''
* '''<big>Drugs <ref name="LiamisMilionis2008">{{cite journal|last1=Liamis|first1=George|last2=Milionis|first2=Haralampos|last3=Elisaf|first3=Moses|title=A Review of Drug-Induced Hyponatremia|journal=American Journal of Kidney Diseases|volume=52|issue=1|year=2008|pages=144–153|issn=02726386|doi=10.1053/j.ajkd.2008.03.004}}</ref></big>'''<big> cause hyponatremia''':'''</big>
<br>
* <big>'''Drugs''' which cause '''hyponatremia:'''</big>
 
{| class="wikitable"
{| class="wikitable"
!'''<big>Drug Mechanisms</big>'''
!'''<big>Drug Mechanisms <ref name="LiamisMilionis200822">{{cite journal|last2=Milionis|first2=Haralampos|last3=Elisaf|first3=Moses|year=2008|title=A Review of Drug-Induced Hyponatremia|journal=American Journal of Kidney Diseases|volume=52|issue=1|pages=144–153|doi=10.1053/j.ajkd.2008.03.004|issn=02726386|last1=Liamis|first1=George}}</ref></big>'''
!'''<big>Drug Classification</big>'''
!'''<big>Drug Classification</big>'''
|-
|-
!'''<big>Increase ADH secretion</big>'''
!'''<big>Increase ADH secretion</big>'''
|'''Antidepressants:'''Tricyclic antidepressants ( Amitryptiline,
|'''Antidepressants:'''[[Tricyclic antidepressants]] ( [[Amitryptiline]],
Protriptyline, Desipramine),Selective serotonin reuptake inhibitors,
[[Protriptyline]], [[Desipramine]]),[[Selective serotonin reuptake inhibitors]],


Monoamine oxidase inhibitors
[[Monoamine oxidase inhibitors]]


'''Antipsychotic drugs:''' Phenothiazines (Thioridazine, Trifluoperazine),
'''Antipsychotic drugs:''' [[Phenothiazines]] ([[Thioridazine]], [[Trifluoperazine]]),


Butyrophenones (Haloperidol)
[[Butyrophenones]] ([[Haloperidol]])


'''Antiepileptic drugs:''' Carbamazepine, Oxcarbazepine, Sodium valproate
'''Antiepileptic drugs:''' [[Carbamazepine]], [[Oxcarbazepine]], [[Sodium valproate]]


'''Anticancer agents:''' Vinca alkaloids (Vincristine, Vinblastine),
'''Anticancer agents:''' [[Vinca alkaloids]] ([[Vincristine]], [[Vinblastine]]),


Platinum compounds (Cisplatin, Carboplatin)
Platinum compounds ([[Cisplatinum|Cisplatin]], [[Carboplatinum|Carboplatin]])


'''Alkylating agents:''' Intravenous, Cyclophosphamide, Melphalan, Ifosfamide
'''Alkylating agents:''' Intravenous [[Cyclophosphamide lyophilized|Cyclophosphamide]], [[Melphalan]], [[Ifosfamide]]


'''Miscellaneous:''' Methotrexate, Interferon, Levamisole, Pentostatin, Monoclonal antibodies, MDMA, Nicotine
'''Miscellaneous:''' [[Methotrexate Sodium|Methotrexate]], [[Interferon]], [[Levamisole]], [[Pentostatin]], [[Monoclonal antibodies]], [[MDMA]], [[Nicotine]]


'''Opiates'''
'''Opiates'''
|-
|-
!<big>Increase ADH effect</big>
!<big>Increase ADH effect</big>
|'''Antiepileptic drugs:''' Carbamazepine, Lamotrigine
|'''Antiepileptic drugs:''' [[Carbamazepine]], [[Lamotrigine]]
'''Antidiabetic drugs:''' Chlorpropamide, Tolbutamide
'''Antidiabetic drugs:''' [[Chlorpropamide]], [[Tolbutamide]]


'''Anticancer agents:''' Alkylating agents (Intravenous cyclophosphamide)
'''Anticancer agents:''' Alkylating agents (Intravenous [[Cyclophosphamide lyophilized|cyclophosphamide]])


'''NSAIDS'''
'''NSAIDS'''
|-
|-
!<big>Drugs affecting water and sodium homeostasis</big>
!<big>Drugs affecting water and sodium homeostasis</big>
|'''Diuretics:'''Thiazides, Indapamide, Amiloride, Loop diuretics
|'''Diuretics:''' [[Thiazides]], [[Indapamide]], [[Amiloride]], [[Loop diuretics]]
|-
|-
!<big>Reset omostat <sup>‡</sup></big>
!<big>Reset omostat <sup>‡</sup></big>
|'''Antidepressants:''' Venlafaxine
|'''Antidepressants:''' [[Venlafaxine]]
'''Antiepileptic drugs:'''Carbamazepine
'''Antiepileptic drugs:''' [[Carbamazepine]]
|-
!<big>Vasopressin analogues</big>
|[[Desmopressin]], [[oxytocin]], [[terlipressin]], [[Vasopressin analogue|vasopressin]]
|}
|}
‡ ''Altered sensitivity to serum osmolality by the hypothalamic osmoreceptors''
<small>‡ ''Altered sensitivity to serum osmolality by the hypothalamic osmoreceptors''
<br>
</small>


<br>
===Causes by Organ System===
===Causes by Organ System===


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|- bgcolor="lightsteelblue"
|- bgcolor="lightsteelblue"
| '''Drug Side Effect'''
| '''Drug Side Effect'''
| bgcolor="beige" | [[ACE inhibitors]], [[Ajuga nipponensis makino ]] , [[Asenapine maleate]], [[Cefpodoxime]], [[Chlorpropamide]], [[Cyclophosphamide]], [[Desmopressin]], [[Diuretics]], [[Duloxetine]], [[Eslicarbazepine acetate]], [[Ethacrynic Acid]], [[Felbamate]], [[Fluvoxamine]], [[Interferon gamma]], [[Ixabepilone]], [[Losartan and Hydrochlorothiazide]], [[Nilotinib]], [[Nivolumab]], [[Nonsteriodal anti-inflammatory drugs ]] , [[Oxcarbazepine]], [[Pramipexole]], [[Rifaximin]], [[Tiagabine]], [[Tolazamide]], [[Zonisamide]], [[Tolbutamide]], [[Vortioxetine]]
| bgcolor="beige" | [[ACE inhibitors]], [[Ajuga nipponensis makino ]] , [[Asenapine maleate]], [[Cefpodoxime]], [[Chlorpropamide]], [[Cyclophosphamide]], [[Desmopressin]], [[Diuretics]], [[Duloxetine]], [[Eslicarbazepine acetate]], [[Ethacrynic Acid]], [[Felbamate]], [[Fluvoxamine]], [[Interferon gamma]], [[Ixabepilone]], [[Losartan and Hydrochlorothiazide]], [[Nilotinib]],[[Nivolumab]]<ref name="HataSakaguchi2021">{{cite journal|last1=Hata|first1=Koichi|last2=Sakaguchi|first2=Chikara|last3=Tsuchiya|first3=Michiko|last4=Nagasaka|first4=Yukio|title=Abdominal pain as an initial symptom of isolated ACTH deficiency induced by nivolumab in a patient with malignant mesothelioma|journal=BMJ Case Reports|volume=14|issue=7|year=2021|pages=e243093|issn=1757-790X|doi=10.1136/bcr-2021-243093}}</ref>, [[Nonsteriodal anti-inflammatory drugs ]] , [[Oxcarbazepine]], [[Pramipexole]], [[Rifaximin]], [[Tiagabine]], [[Tolazamide]], [[Zonisamide]], [[Tolbutamide]], [[Vortioxetine]], [[Brivanib]] <ref name="pmidhttps://www.ncbi.nlm.nih.gov/pubmed/27167519">{{cite journal| author=Berardi R, Santoni M, Rinaldi S, Nunzi E, Smerilli A, Caramanti M | display-authors=etal| title=Risk of Hyponatraemia in Cancer Patients Treated with Targeted Therapies: A Systematic Review and Meta-Analysis of Clinical Trials. | journal=PLoS One | year= 2016 | volume= 11 | issue= 5 | pages= e0152079 | pmid=https://www.ncbi.nlm.nih.gov/pubmed/27167519 | doi=10.1371/journal.pone.0152079 | pmc=4864354 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27167519  }} </ref>, [[Cetuximab]] <ref name="pmidhttps://www.ncbi.nlm.nih.gov/pubmed/27167519">{{cite journal| author=Berardi R, Santoni M, Rinaldi S, Nunzi E, Smerilli A, Caramanti M | display-authors=etal| title=Risk of Hyponatraemia in Cancer Patients Treated with Targeted Therapies: A Systematic Review and Meta-Analysis of Clinical Trials. | journal=PLoS One | year= 2016 | volume= 11 | issue= 5 | pages= e0152079 | pmid=https://www.ncbi.nlm.nih.gov/pubmed/27167519 | doi=10.1371/journal.pone.0152079 | pmc=4864354 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27167519  }} </ref>
|-
|-
|- bgcolor="lightsteelblue"
|- bgcolor="lightsteelblue"
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|- bgcolor="lightsteelblue"
|- bgcolor="lightsteelblue"
| '''Gastroenterologic'''
| '''Gastroenterologic'''
| bgcolor="beige" | [[Acute liver failure ]] , [[Cirrhosis]], [[Congenital chloride diarrhea ]] , [[Diarrhea]], [[Gastrointestinal fistula]], [[Ileus]], [[Necrotizing enterocolitis ]] , [[Pancreatitis]], [[Peritonitis]], [[Vomiting]], [[Cystic fibrosis]]
| bgcolor="beige" | [[Acute liver failure ]] , [[Cirrhosis]], [[Congenital chloride diarrhea ]] , [[Diarrhea]], [[Gastrointestinal fistula]], [[Ileus]], [[complicated appendicitis]]<ref name="KimNassiri2015">{{cite journal|last1=Kim|first1=Dennis Y.|last2=Nassiri|first2=Nariman|last3=de Virgilio|first3=Christian|last4=Ferebee|first4=Michael P.|last5=Kaji|first5=Amy H.|last6=Hamilton|first6=Camille E.|last7=Saltzman|first7=Darin J.|title=Association Between Hyponatremia and Complicated Appendicitis|journal=JAMA Surgery|volume=150|issue=9|year=2015|pages=911|issn=2168-6254|doi=10.1001/jamasurg.2015.1258}}</ref>, [[Necrotizing enterocolitis ]] , [[Pancreatitis]], [[Peritonitis]], [[Vomiting]], [[Cystic fibrosis]]
|-
|-
|- bgcolor="lightsteelblue"
|- bgcolor="lightsteelblue"
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|- bgcolor="lightsteelblue"
|- bgcolor="lightsteelblue"
| '''Iatrogenic'''
| '''Iatrogenic'''
| bgcolor="beige" | [[After pituitary surgery]], [[After surgery]], [[Ascitic tap]], [[Gastric drainage]], [[Hypotonic infusions]], [[Pleuracentesis]]
| bgcolor="beige" | [[After pituitary surgery]], [[After surgery]], [[Ascitic tap]], [[Gastric drainage]], [[Hypotonic infusions]], [[Pleuracentesis]], [[Tumor lysis syndrome]] (TLS) associated with pediatric hematologic malignancies, and managed with aggressive intravenous hydration can cause fluid overload (FO) and [[acute kidney injury]] (AKI). <ref name="FloodRozmus2021">{{cite journal|last1=Flood|first1=Kayla|last2=Rozmus|first2=Jacob|last3=Skippen|first3=Peter|last4=Matsell|first4=Douglas G.|last5=Mammen|first5=Cherry|title=Fluid overload and acute kidney injury in children with tumor lysis syndrome|journal=Pediatric Blood & Cancer|year=2021|issn=1545-5009|doi=10.1002/pbc.29255}}</ref>
 
|-
|-
|- bgcolor="lightsteelblue"
|- bgcolor="lightsteelblue"
| '''Infectious Disease'''
| '''Infectious Disease'''
| bgcolor="beige" | [[Malignant boutonneuse fever ]] , [[Neonatal bacterial meningitis ]] , [[Peritonitis]]
| bgcolor="beige" | [[Malignant boutonneuse fever ]] , [[Neonatal bacterial meningitis ]] , [[Peritonitis]], [[influenza]] and other respiratory viruses, [[HIV]] infection, [[Corona virus]] infections, [[community acquired pneumonia]] from bacterial (streptococcus pneumonia, legionella etc) <ref name="pmid32718076">{{cite journal| author=Królicka AL, Kruczkowska A, Krajewska M, Kusztal MA| title=Hyponatremia in Infectious Diseases-A Literature Review. | journal=Int J Environ Res Public Health | year= 2020 | volume= 17 | issue= 15 | pages=  | pmid=32718076 | doi=10.3390/ijerph17155320 | pmc=7432506 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32718076  }} </ref>
|-
|-
|- bgcolor="lightsteelblue"
|- bgcolor="lightsteelblue"
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|- bgcolor="lightsteelblue"
|- bgcolor="lightsteelblue"
| '''Neurologic'''
| '''Neurologic'''
| bgcolor="beige" | [[Intracranial hemorrhage]], [[Subarachnoid hemorrhage]], [[Pituitary cancer]]
| bgcolor="beige" | [[Intracranial hemorrhage]], [[Subarachnoid hemorrhage]], [[Pituitary cancer]], [[ stroke]] <ref name="pmid31722353">{{cite journal| author=Liamis G, Barkas F, Megapanou E, Christopoulou E, Makri A, Makaritsis K | display-authors=etal| title=Hyponatremia in Acute Stroke Patients: Pathophysiology, Clinical Significance, and Management Options. | journal=Eur Neurol | year= 2019 | volume= 82 | issue= 1-3 | pages= 32-40 | pmid=31722353 | doi=10.1159/000504475 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31722353  }} </ref>, [[Post traumatic brain injury]] [[hypopituitarism]] causing [[adrenal insufficiency]]. <ref name="AwanMat2021">{{cite journal|last1=Awan|first1=Nusrat Mehmood|last2=Mat|first2=Arimin|last3=Canavan|first3=Ronan|title=Retracing the tracks for SIAD: hyponatraemia due to post-traumatic brain injury hypopituitarism|journal=BMJ Case Reports|volume=14|issue=7|year=2021|pages=e242764|issn=1757-790X|doi=10.1136/bcr-2021-242764}}</ref>
 
|-
|-
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|- bgcolor="lightsteelblue"
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|- bgcolor="lightsteelblue"
|- bgcolor="lightsteelblue"
| '''Obstetric/Gynecologic'''
| '''Obstetric/Gynecologic'''
| bgcolor="beige" | [[Pregnancy]]
| bgcolor="beige" | [[Pregnancy]], postpartum in patients with [[preeclampsia]] <ref name="HsuTong2021">{{cite journal|last1=Hsu|first1=Richard|last2=Tong|first2=Anna|last3=Hsu|first3=Chaur-Dong|last4=Takeuchi|first4=Kyousuke|title=Hypervolemic Hyponatremia as a Reversible Cause of Cardiopulmonary Arrest in a Postpartum Patient with Preeclampsia|journal=Case Reports in Obstetrics and Gynecology|volume=2021|year=2021|pages=1–3|issn=2090-6692|doi=10.1155/2021/8850725}}</ref>
 
|-
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|- bgcolor="lightsteelblue"
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Latest revision as of 13:48, 18 August 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Saeedeh Kowsarnia M.D.[2]

Overview

Hyponatremia is caused by either increase ADH action/ secretion or kidney function impairment. SIAD is the most common cause of euvolemic hyponatremia. After SIAD, polydipsia, drugs and clinical disorders are the most encountered etiologies in clinical practice.

Causes

To review the mechanisms of developing hyponatremia, click here.

  • Etiologies of SIAD:
Conditions
Malignant disorders Carcinoma: Lung ( small cell carcinoma, mesothelioma), oropharynx, stomach, duodenum, pancreas, ureter, bladder, prostate, endometrium, thymoma

Lymphomas

Sarcomas: Ewing's sarcoma

Olfactory neuroblastoma

Pulmonary diseases Infections: Bacterial pneumonia, viral pneumonia, pulmonary abscess, tuberculosis, aspergillosis

Others: Asthma, cystic fibrosis, respiratory failure, emphysema, COPD,coronavirus disease, positive-pressure ventilation

CNS disorders Infections: Encephalitis, meningitis, brain abscess, RMSF, AIDS, malaria

Vascular and SOP: Subarachnoid hemorrhage, stroke, brain tumors, head trauma

Others: Hydrocephalus, cavernous sinus thrombosis, Multiple sclerosis, Guillain–Barré syndrome, Shy–Drager syndrome,

delirium tremens, acute intermittent porphyria, chronic psychosis, pituitary stalk section, transsphenoidal adenomectomy

Other causes Hereditary: Gain-of-function mutation of V2 receptors

Idiopathic

Drugs

Transient: Exercise, general anesthesia, nausea, pain, stress


  • Causes of acute hyponatremia: (develops in < 48 hrs)
Etiology
  • Post operative phase
  • Transurethral or endoscopic procedure (mannitol, sorbitol, glycine)
  • Colonoscopy preparation 
  • Polydipsia
  • Exercise
  • Oxytocin
  • Cyclophosphamide
  • Ecstasy( 3,4-Methylenedioxymethamphetamine, MDMA)
  • Thiazide
  • Halopridol
  • Recently started desmopressin, terlipressin, vasopressin

( Etiologies that cause hyperacute and acute hyponatremia are applicable to each category interchangeably depending on the onset of symptoms)

  • Causes of Hyponatremia based upon Serum Osmolality:
Classification Serum Osmolality Etiology
Hypertonic or Isotonic Hyponatremia > 295 mOsm/kg Hyperglycemia‡, Mannitol, Glycine, Maltose, severe azotemia
Isotonic Hyponatremia

(Pseudohyponatremia)

275 – 295 mOsm/kg Lab/blood draw error, Post TURP (bladder irrigation with osmotic solutions),

intravenous immunoglobulin (IVIg), Hyperlipidemia ( triglyceride, cholesterol ),

hyper paraproteinemia (monoclonal gammopathy of undetermined significance (MGUS),

multiple myeloma),

Hypotonic Hyponatremia < 275 mOsm/kg Glycerol, Sorbitol, Etiology depends upon volume status (Hypervolemic/ Euvolemic/ Hypovolemic)
Alcohol, Urea, Ethylen glycol are ineffective osmoles, cause hyperosmolar isotonic serum but not hyponatremia.

‡ Hyperglycemia causes osmotic diuresis results in a rise in serum sodium concentration, on the other hand it leads to extracellular shift of water due to osmotic gradient which causes relative hyponatremia , depends on which effect is stronger, there would be hypertonicity or hypotonicity[1].   

  • Causes of Hyponatremia based on volume status [2] :
Volume status Sodium status Causes
Hypovolemic

Hyponatremia[3]

  • total body water ↓
  • total body sodium ↓↓
  • GI loss: Vomiting, diarrhea, tube drainage
  • Insensible loss: Sweating, burns
  • Renal loss: Salt-wasting nephropathy (inappropriate loss of Na+-Cl– in the urine),

bicarbonaturia ( renal tubular acidosis, metabolic alkalosis), osmotic diuresis, diuretic use,

cerebral salt-wasting syndrome (Stroke ,SAH ,↑ brain natriuretic peptide and ↑ renal sodium loss )

  • Excessive diuretic administration: mostly thiazide diuretics
Hypervolemic

Hyponatremia

  • total body water ↑↑
  • total body sodium ↑
  • Renal disease: Acute or chronic kidney disease or injury

(due to relatively higher water versus salt intake and poor excretion), nephrotic syndrome

  • Congestive heart failure
  • Cirrhosis
  • Iatrogenic
Euvolemic

Hyponatremia

  • total body water ↑
  • total body sodium ↔

postoperative nausea, pain, stress, neoplasia (common), trauma, pregnancy)

, nephrogenic SIAD (Gain-of-function mutation of v2 receptors)

  • High fluid intake: Physical activity, surgery, primary polydipsia, potomania, tea & toast diet

(caused by a low intake of solutes with relatively high fluid intake)

  • Reset osmostat † : Drugs, pregnancy
  • Iatrogenic

† Altered sensitivity to serum osmolality by the hypothalamic osmoreceptors

  • Drugs which cause hyponatremia:
Drug Mechanisms [4] Drug Classification
Increase ADH secretion Antidepressants:Tricyclic antidepressants ( Amitryptiline,

Protriptyline, Desipramine),Selective serotonin reuptake inhibitors,

Monoamine oxidase inhibitors

Antipsychotic drugs: Phenothiazines (Thioridazine, Trifluoperazine),

Butyrophenones (Haloperidol)

Antiepileptic drugs: Carbamazepine, Oxcarbazepine, Sodium valproate

Anticancer agents: Vinca alkaloids (Vincristine, Vinblastine),

Platinum compounds (Cisplatin, Carboplatin)

Alkylating agents: Intravenous Cyclophosphamide, Melphalan, Ifosfamide

Miscellaneous: Methotrexate, Interferon, Levamisole, Pentostatin, Monoclonal antibodies, MDMA, Nicotine

Opiates

Increase ADH effect Antiepileptic drugs: Carbamazepine, Lamotrigine

Antidiabetic drugs: Chlorpropamide, Tolbutamide

Anticancer agents: Alkylating agents (Intravenous cyclophosphamide)

NSAIDS

Drugs affecting water and sodium homeostasis Diuretics: Thiazides, Indapamide, Amiloride, Loop diuretics
Reset omostat ‡ Antidepressants: Venlafaxine

Antiepileptic drugs: Carbamazepine

Vasopressin analogues Desmopressin, oxytocin, terlipressin, vasopressin

‡ Altered sensitivity to serum osmolality by the hypothalamic osmoreceptors


Causes by Organ System

Cardiovascular Congestive heart failure
Chemical / poisoning No underlying causes
Dermatologic Burns
Drug Side Effect ACE inhibitors, Ajuga nipponensis makino , Asenapine maleate, Cefpodoxime, Chlorpropamide, Cyclophosphamide, Desmopressin, Diuretics, Duloxetine, Eslicarbazepine acetate, Ethacrynic Acid, Felbamate, Fluvoxamine, Interferon gamma, Ixabepilone, Losartan and Hydrochlorothiazide, Nilotinib,Nivolumab[5], Nonsteriodal anti-inflammatory drugs , Oxcarbazepine, Pramipexole, Rifaximin, Tiagabine, Tolazamide, Zonisamide, Tolbutamide, Vortioxetine, Brivanib [6], Cetuximab [6]
Ear Nose Throat No underlying causes
Endocrine Addison's disease, Corticosterone methyloxidase type I deficiency , Diabetes mellitus, Diabetic coma, Glucocorticoid deficiency, Familial hyperreninemic hypoaldosteronism type 2, Hypothyroidism, Mineralocorticoid deficiency, Myxedema coma , Syndrome of inappropriate antidiuretic hormone , Thyrotropin deficiency, 18-Hydroxylase deficiency , Familial hypoaldosteronism
Environmental No underlying causes
Gastroenterologic Acute liver failure , Cirrhosis, Congenital chloride diarrhea , Diarrhea, Gastrointestinal fistula, Ileus, complicated appendicitis[7], Necrotizing enterocolitis , Pancreatitis, Peritonitis, Vomiting, Cystic fibrosis
Genetic 18-Hydroxylase deficiency , Bartter Syndrome type 4 , Cystic fibrosis, Familial hypoaldosteronism , Corticosterone methyloxidase type I deficiency , Familial hyperreninemic hypoaldosteronism type 2, Congenital chloride diarrhea
Hematologic No underlying causes
Iatrogenic After pituitary surgery, After surgery, Ascitic tap, Gastric drainage, Hypotonic infusions, Pleuracentesis, Tumor lysis syndrome (TLS) associated with pediatric hematologic malignancies, and managed with aggressive intravenous hydration can cause fluid overload (FO) and acute kidney injury (AKI). [8]
Infectious Disease Malignant boutonneuse fever , Neonatal bacterial meningitis , Peritonitis, influenza and other respiratory viruses, HIV infection, Corona virus infections, community acquired pneumonia from bacterial (streptococcus pneumonia, legionella etc) [9]
Musculoskeletal / Ortho No underlying causes
Neurologic Intracranial hemorrhage, Subarachnoid hemorrhage, Pituitary cancer, stroke [10], Post traumatic brain injury hypopituitarism causing adrenal insufficiency. [11]
Nutritional / Metabolic Hyperlipidemia, Hyperproteinemia, Hypoalbuminemia, Low sodium diet, Metabolic acidosis, Diabetic coma
Obstetric/Gynecologic Pregnancy, postpartum in patients with preeclampsia [12]
Oncologic Pituitary cancer
Opthalmologic No underlying causes
Overdose / Toxicity Water intoxication
Psychiatric Psychogenic polydipsia, Psychosis, Self-induced water intoxication and schizophrenic disorders syndrome
Pulmonary Cystic fibrosis
Renal / Electrolyte Acute kidney disease, Chronic kidney disease, Diuresis, Glucosuria, Ketonuria, Nephrotic syndrome, Renal Tubular Acidosis, Tubulointerstitial kidney disease, Bartter Syndrome type 4 , Corticosterone methyloxidase type I deficiency , Renal failure
Rheum / Immune / Allergy Addison's disease, Nephrotic syndrome
Sexual Cystic fibrosis
Trauma Burns
Urologic No underlying causes
Dental No underlying causes
Miscellaneous Beer potomania, Ecstasy abuse , Factitious hyponatremia, Hydration, Massive edema, Pseudohyponatremia, Water Intoxication , Hyperlipidemia, Hyperproteinemia, Hypoalbuminemia, Exercise associated hyponatremia

Causes in Alphabetical Order


References

  1. ↑ A. I. Arieff & H. J. Carroll (1972). "Nonketotic hyperosmolar coma with hyperglycemia: clinical features, pathophysiology, renal function, acid-base balance, plasma-cerebrospinal fluid equilibria and the effects of therapy in 37 cases". Medicine. 51 (2): 73–94. PMID 5013637. Unknown parameter |month= ignored (help)
  2. ↑ Guillaumin, Julien; DiBartola, Stephen P. (2017). "A Quick Reference on Hyponatremia". Veterinary Clinics of North America: Small Animal Practice. 47 (2): 213–217. doi:10.1016/j.cvsm.2016.10.003. ISSN 0195-5616.
  3. ↑ Rondon-Berrios, Helbert; Agaba, Emmanuel I.; Tzamaloukas, Antonios H. (2014). "Hyponatremia: pathophysiology, classification, manifestations and management". International Urology and Nephrology. 46 (11): 2153–2165. doi:10.1007/s11255-014-0839-2. ISSN 0301-1623.
  4. ↑ Liamis, George; Milionis, Haralampos; Elisaf, Moses (2008). "A Review of Drug-Induced Hyponatremia". American Journal of Kidney Diseases. 52 (1): 144–153. doi:10.1053/j.ajkd.2008.03.004. ISSN 0272-6386.
  5. ↑ Hata, Koichi; Sakaguchi, Chikara; Tsuchiya, Michiko; Nagasaka, Yukio (2021). "Abdominal pain as an initial symptom of isolated ACTH deficiency induced by nivolumab in a patient with malignant mesothelioma". BMJ Case Reports. 14 (7): e243093. doi:10.1136/bcr-2021-243093. ISSN 1757-790X.
  6. ↑ 6.0 6.1 Berardi R, Santoni M, Rinaldi S, Nunzi E, Smerilli A, Caramanti M; et al. (2016). "Risk of Hyponatraemia in Cancer Patients Treated with Targeted Therapies: A Systematic Review and Meta-Analysis of Clinical Trials". PLoS One. 11 (5): e0152079. doi:10.1371/journal.pone.0152079. PMC 4864354. PMID https://www.ncbi.nlm.nih.gov/pubmed/27167519 Check |pmid= value (help).
  7. ↑ Kim, Dennis Y.; Nassiri, Nariman; de Virgilio, Christian; Ferebee, Michael P.; Kaji, Amy H.; Hamilton, Camille E.; Saltzman, Darin J. (2015). "Association Between Hyponatremia and Complicated Appendicitis". JAMA Surgery. 150 (9): 911. doi:10.1001/jamasurg.2015.1258. ISSN 2168-6254.
  8. ↑ Flood, Kayla; Rozmus, Jacob; Skippen, Peter; Matsell, Douglas G.; Mammen, Cherry (2021). "Fluid overload and acute kidney injury in children with tumor lysis syndrome". Pediatric Blood & Cancer. doi:10.1002/pbc.29255. ISSN 1545-5009.
  9. ↑ Królicka AL, Kruczkowska A, Krajewska M, Kusztal MA (2020). "Hyponatremia in Infectious Diseases-A Literature Review". Int J Environ Res Public Health. 17 (15). doi:10.3390/ijerph17155320. PMC 7432506 Check |pmc= value (help). PMID 32718076 Check |pmid= value (help).
  10. ↑ Liamis G, Barkas F, Megapanou E, Christopoulou E, Makri A, Makaritsis K; et al. (2019). "Hyponatremia in Acute Stroke Patients: Pathophysiology, Clinical Significance, and Management Options". Eur Neurol. 82 (1–3): 32–40. doi:10.1159/000504475. PMID 31722353.
  11. ↑ Awan, Nusrat Mehmood; Mat, Arimin; Canavan, Ronan (2021). "Retracing the tracks for SIAD: hyponatraemia due to post-traumatic brain injury hypopituitarism". BMJ Case Reports. 14 (7): e242764. doi:10.1136/bcr-2021-242764. ISSN 1757-790X.
  12. ↑ Hsu, Richard; Tong, Anna; Hsu, Chaur-Dong; Takeuchi, Kyousuke (2021). "Hypervolemic Hyponatremia as a Reversible Cause of Cardiopulmonary Arrest in a Postpartum Patient with Preeclampsia". Case Reports in Obstetrics and Gynecology. 2021: 1–3. doi:10.1155/2021/8850725. ISSN 2090-6692.
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