Hyponatremia differential diagnosis: Difference between revisions

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{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Serum Na ≤ 135 meq/L}}
{{familytree | | | | | | | | | A01 | | | | | |A01=[[Serum Na]] ≤ 135 meq/L}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | B01 | | | | | |B01=<table><tr><th>Check for:</th></tr><tr><td>• Serum osmolality<br>• Urine osmolality<br>• Urea<br>• Glucose<br>• Urine chloride<br>• Urine Na</td></tr></table>}}
{{familytree | | | | | | | | | B01 | | | | | |B01=<table><tr><th>Check for:</th></tr><tr><td>• [[Serum osmolality]]<br>• [[Urine osmolality]]<br>• [[Urea]]<br>• Glucose<br>• [[Urine chloride]]<br>• [[Urine Na]]</td></tr></table>}}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| |}}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| |}}
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01=<table><tr><th>Normotonicity<br>275–295 mOsm/kg</th></tr><tr><td>•Hyperlipidemia<br>•Hyperproteinemia<br>•Glycine </td></tr></table>|C02=<table><tr><th>Hypertonicity<br>> 295 mOsm/kg</th></tr><tr><td>
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01=<table><tr><th>Normotonicity<br>275–295 mOsm/kg</th></tr><tr><td>•[[Hyperlipidemia]]<br>•[[Hyperproteinemia]]<br>•Glycine </td></tr></table>|C02=<table><tr><th>Hypertonicity<br>> 295 mOsm/kg</th></tr><tr><td>
• Glucose<br>• Mannitol<br>• Glycine</td></tr></table>|C03='''Hypotonicity'''<br>'''<275 mOsm/kg'''}}
• Glucose<br>• Mannitol<br>• Glycine</td></tr></table>|C03='''Hypotonicity'''<br>'''<275 mOsm/kg'''}}
{{familytree | | | | | | | | | | | | | | | | |!| }}
{{familytree | | | | | | | | | | | | | | | | |!| }}
Line 355: Line 355:
{{familytree | | | | | | | | | | | | E02 | | E03 | | | E04 |E04='''U<sub>Osm</sub> 100–200mOsm/kg'''|E02='''U<sub>Osm</sub> <  100mOsm/kg'''|E03='''U<sub>Osm</sub> > 200mOsm/kg'''}}
{{familytree | | | | | | | | | | | | E02 | | E03 | | | E04 |E04='''U<sub>Osm</sub> 100–200mOsm/kg'''|E02='''U<sub>Osm</sub> <  100mOsm/kg'''|E03='''U<sub>Osm</sub> > 200mOsm/kg'''}}
{{familytree | | | | | | | | | | | | |!| | | |!| | | | |!| | }}
{{familytree | | | | | | | | | | | | |!| | | |!| | | | |!| | }}
{{familytree | | | | | | | | | | | | F01 | | |!| | | | F03 |F01=<table><tr><th>Conditions</th></tr><tr><td>•Polydipsia<br>•↓ solute excertion<br>(Beer potomania<br>,Tea & toast diet)</td></tr></table>|F03=<table><tr><th>Conditions</th></tr><tr><td>•Polydipsia<br>•↓ solute excertion<br>(Beer potomania<br>,Tea & toast diet)<br>•Rule out SIAD</td></tr></table>|F02=F03}}
{{familytree | | | | | | | | | | | | F01 | | |!| | | | F03 |F01=<table><tr><th>Conditions</th></tr><tr><td>•[[Polydipsia]]<br>•↓ solute excertion<br>(Beer potomania<br>,Tea & toast diet)</td></tr></table>|F03=<table><tr><th>Conditions</th></tr><tr><td>•[[Polydipsia]]<br>•↓ [[solute excertion]]<br>(Beer potomania<br>,Tea & toast diet)<br>•Rule out [[SIAD]]</td></tr></table>|F02=F03}}
{{familytree | | | | | | |,|-|-|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|-|-|-|.| |}}
{{familytree | | | | | | |,|-|-|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|-|-|-|.| |}}
{{familytree | | | | | | F01 | | | | | | | | F02 | | | | | | | | | | | F03 | |F01='''Hypovolemia'''<br>Based on history & physical exam|F03='''Euvolemia'''|F02='''Hypervolemia'''}}
{{familytree | | | | | | F01 | | | | | | | | F02 | | | | | | | | | | | F03 | |F01='''Hypovolemia'''<br>Based on [[history]] & [[physical exam]]|F03='''Euvolemia'''|F02='''Hypervolemia'''}}
{{familytree | | |,|-|-|-|+|-|-|-|.| | | |,|-|^|-|.| | | |,|-|-|-|v|-|-|^|v|-|-|-|.| |}}
{{familytree | | |,|-|-|-|+|-|-|-|.| | | |,|-|^|-|.| | | |,|-|-|-|v|-|-|^|v|-|-|-|.| |}}
{{familytree | | A01 | | A12 | | A13 | | B01 | | B02 | | C12 | | C13 | | C01 | | C02 |A01='''U<sub>Na</sub> < 30 mEq/L'''|A12='''Variable U<sub>Na</sub>'''|A13='''U<sub>Na</sub> > 30 mEq/L'''|B01='''U<sub>Na</sub> < 30 mEq/L'''|B02='''U<sub>Na</sub> > 30 mEq/L'''|C12='''Variable U<sub>Na</sub>'''|C13='''U<sub>Na</sub> < 20 mEq/L'''|C01='''> 20 U<sub>Na</sub> < 40 mEq/L'''|C02='''U<sub>Na</sub> > 40 mEq/L'''}}
{{familytree | | A01 | | A12 | | A13 | | B01 | | B02 | | C12 | | C13 | | C01 | | C02 |A01='''U<sub>Na</sub> < 30 mEq/L'''|A12='''Variable U<sub>Na</sub>'''|A13='''U<sub>Na</sub> > 30 mEq/L'''|B01='''U<sub>Na</sub> < 30 mEq/L'''|B02='''U<sub>Na</sub> > 30 mEq/L'''|C12='''Variable U<sub>Na</sub>'''|C13='''U<sub>Na</sub> < 20 mEq/L'''|C01='''> 20 U<sub>Na</sub> < 40 mEq/L'''|C02='''U<sub>Na</sub> > 40 mEq/L'''}}
{{familytree | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| |}}
{{familytree | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| |}}
{{familytree | | A02 | | A03 | | A04 | | B03 | | B04 | | C07 | | C08 | | C10 | | C09 |A02=<table><tr><th>Extrarenal losses</th></tr><tr><td>•Vomiting (U<sub>cl</sub> ↓)<br>•Diarrhea<br>•Pancreatitis<br>•Sweating<br>•Small bowel obstruction</td></tr></table>|A04=<table><tr><th>Renal losses</th></tr><tr><td>•Osmotic diuresis (glucose, urea,bicarbonaturia)<br>•Salt-Iosing nephropathy<br>•Addison disease<br>•CSW</td></tr></table>|A03='''Variable U<sub>Na</sub>'''<br>•Diuretic use<br>Discontinue diuretics if U<sub>Na</sub> is still abnormal|B03=<table><tr><th>Conditions</th></tr><tr><td>•Heart failure<br>•Liver disease<br>•Nephrotic syndrome </td></tr></table>| B04=<table><tr><th>Conditions</th></tr><tr><td>•Chronic kidney disease<br>•Diuretic use in:<br>Heart failure<br>Liver disease<br>Nephrotic syndrome</td></tr></table>|C08=Probable hypovolemia|C10=Hypovolemia or euvolemia|C09=•Probable euvolemia<br>•SIAD<br>•Cortisol deficiency<br>•Hypothyroidism|C07=Discontinue diuretics if P<sub>Na</sub> normalize it's not SIAD if it's not normalized}}
{{familytree | | A02 | | A03 | | A04 | | B03 | | B04 | | C07 | | C08 | | C10 | | C09 |A02=<table><tr><th>Extrarenal losses</th></tr><tr><td>•[[Vomiting]] (U<sub>cl</sub> ↓)<br>•[[Diarrhea]]<br>•[[Pancreatitis]]<br>•[[Sweating]]<br>•[[Small bowel obstruction]]</td></tr></table>|A04=<table><tr><th>Renal losses</th></tr><tr><td>•[[Osmotic diuresis]] ([[glucose]], [[urea]],[[bicarbonaturia]])<br>•[[Salt-Iosing nephropathy]]<br>•[[Addison disease]]<br>•CSW</td></tr></table>|A03='''Variable U<sub>Na</sub>'''<br>•[[Diuretic]] use<br>Discontinue [[diuretics]] if U<sub>Na</sub> is still abnormal|B03=<table><tr><th>Conditions</th></tr><tr><td>•[[Heart failure]]<br>•[[Liver disease]]<br>•[[Nephrotic syndrome]] </td></tr></table>| B04=<table><tr><th>Conditions</th></tr><tr><td>•[[Chronic kidney disease]]<br>•[[Diuretic]] use in:<br>[[Heart failure]]<br>[[Liver disease]]<br>[[Nephrotic syndrome</td></tr></table>|C08=Probable hypovolemia|C10=Hypovolemia or euvolemia|C09=•Probable euvolemia<br>•[[SIAD]]<br>•[[Cortisol deficiency]]<br>•[[Hypothyroidism]]|C07=Discontinue diuretics if P<sub>Na</sub> normalize it's not [[SIAD]] if it's not normalized}}
{{familytree | | |`|-|-|-|+|-|-|-|'| | | | | | | | | | | |`|-|-|-|^|-|v|-|^|-|-|-|'| | |}}
{{familytree | | |`|-|-|-|+|-|-|-|'| | | | | | | | | | | |`|-|-|-|^|-|v|-|^|-|-|-|'| | |}}
{{familytree | | |,|-|-| A01 | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | |A01=Administer 0.9% saline}}
{{familytree | | |,|-|-| A01 | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | |A01=Administer 0.9% saline}}
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{{familytree | | A04 | | |!| | | | | | | | | | | | | | C01 | | | | | | | |,|-|-|-| C02 |C01=P<sub>Na</sub> decreases or no change|C02=P<sub>Na</sub> increases|A04=Hypovolemia}}
{{familytree | | A04 | | |!| | | | | | | | | | | | | | C01 | | | | | | | |,|-|-|-| C02 |C01=P<sub>Na</sub> decreases or no change|C02=P<sub>Na</sub> increases|A04=Hypovolemia}}
{{familytree | | | | |,|-|^|-|.| | | | | | | | | | | | |!| | | | | | | | |!| | | | |!| |}}
{{familytree | | | | |,|-|^|-|.| | | | | | | | | | | | |!| | | | | | | | |!| | | | |!| |}}
{{familytree | | | | A05 | | A06 | | | | | | | | | | | D01 |-|-|-|-|-|-| D02 | | | D03 |A05= Decreasing U<sub>Osm</sub>|A06=No change in U<sub>Osm</sub> but U<sub>Na</sub> increases| D01=SIAD |D03=Decreased U<sub>Na</sub>|D02=No change in U<sub>Osm</sub> but U<sub>Na</sub> increases}}
{{familytree | | | | A05 | | A06 | | | | | | | | | | | D01 |-|-|-|-|-|-| D02 | | | D03 |A05= Decreasing U<sub>Osm</sub>|A06=No change in U<sub>Osm</sub> but U<sub>Na</sub> increases| D01=[[SIAD]] |D03=Decreased U<sub>Na</sub>|D02=No change in U<sub>Osm</sub> but U<sub>Na</sub> increases}}
{{familytree | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | |!| |}}
{{familytree | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | |!| |}}
{{familytree | | | | A05 | | A06 | | | | | | | | | | | | | | | D07 |-|-| D06 |-|-| D04 |D04=Administer additional saline|D06=Decreasing U<sub>osm</sub>|D07=Hypovolemia|A05= Hypovolemia |A06=Salt-depleted SIAD}}
{{familytree | | | | A05 | | A06 | | | | | | | | | | | | | | | D07 |-|-| D06 |-|-| D04 |D04=Administer additional saline|D06=Decreasing U<sub>osm</sub>|D07=Hypovolemia|A05= Hypovolemia |A06=Salt-depleted SIAD}}
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{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | D08 |D08=No change in U<sub>Osm</sub><br> but U<sub>Na</sub> increases}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | D08 |D08=No change in U<sub>Osm</sub><br> but U<sub>Na</sub> increases}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | D09 |D09=Salt-depleted SIAD}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | D09 |D09=Salt-depleted [[SIAD]]}}
{{familytree/end}}
{{familytree/end}}
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Revision as of 18:31, 21 May 2018

Hyponatremia Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2] Saeedeh Kowsarnia M.D.[3]

Overview

Hyponatremia must be differentiated from other diseases that cause muscle weakness or cramps, oliguria, vomiting or diarrhea and seizures.

Differentiating Hyponatremia from other Diseases

Disease Clinical manifestations Paraclinical Findings
Symptoms and Signs Lab Findings
Muscle weakness/ Cramps Seizures Oliguria Vomiting/ Diarrhea Volume status JVP Edema Crackles Ascites Tachycardia Hypotension Dry mucous membranes Urine Analysis Serum Osmolality ADH levels
Urine Na Urine Osm FeNa
Renal failure +/- +/- +/- - Hypervolemic + + + + - - - >20 - >1% ↓ Normal or ↑
Congestive heart failure +/- +/- - - Hypervolemic + + + + - - - <10 - <1% ↓ ↑
Cirrhosis +/- +/- - - Hypervolemic + + + + - - - <10 - <1% ↓ ↑
SIAD/ SIADH +/- +/- - - Euvolemic - - - - - - - - >100 - ↓ ↑
Hypothyroidism +/- +/- - - Euvolemic - - - - - - - - >100 - ↓ ↑
Adrenal insufficiency +/- +/- - - Euvolemic - - - - - - - - >100 - ↓ ↑
Psychogenic polydipsia +/- +/- - - Euvolemic - - - - - - - - <100 - ↓ ↑
Beer drinker's potomania +/- +/- - - Euvolemic - - - - - - - - <100 - ↓ ↓
Pregnancy +/- +/- - - Euvolemic - - - - - - - - Variable - ↓ ↓
Anorexia (Chronic malnutrition) +/- +/- - - Euvolemic - - - - - - - - Variable - ↓ -
Diuretic induced hyponatremia +/- +/- + - Hypovolemic - - - - + + + >20 - >1% ↓ -
Non oliguric ATN +/- +/- - - Hypovolemic - - - - + + + >20 - >1% ↓ -
Diseases causing 3rd spacing (Pancreatitis, SBO) +/- +/- + +/- Hypovolemic - - - - + + + <10 - <1% ↓ -
Gastroenteritis +/- +/- + + Hypovolemic - - - - + + + <10 - <1% ↓ -
Sweating +/- +/- + - Hypovolemic - - - - - +/- +/- <10 - <1% ↓ -
Cerebral salt-losing syndrome +/- +/- - +/- Euvolemic - - - - - +/- - >20 >100 > 1% ↓ -

Approach to differential diagnosis


{{familytree | | A02 | | A03 | | A04 | | B03 | | B04 | | C07 | | C08 | | C10 | | C09 |A02=
 
 
 
 
 
 
 
 
Serum Na ≤ 135 meq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check for:
• Serum osmolality
• Urine osmolality
• Urea
• Glucose
• Urine chloride
• Urine Na
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normotonicity
275–295 mOsm/kg
•Hyperlipidemia
•Hyperproteinemia
•Glycine
 
 
 
 
Hypertonicity
> 295 mOsm/kg
• Glucose
• Mannitol
• Glycine
 
 
 
 
Hypotonicity
<275 mOsm/kg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
UOsm < 100mOsm/kg
 
UOsm > 200mOsm/kg
 
 
UOsm 100–200mOsm/kg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Conditions
•Polydipsia
•↓ solute excertion
(Beer potomania
,Tea & toast diet)
 
 
 
 
 
 
 
Conditions
•Polydipsia
•↓ solute excertion
(Beer potomania
,Tea & toast diet)
•Rule out SIAD
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypovolemia
Based on history & physical exam
 
 
 
 
 
 
 
Hypervolemia
 
 
 
 
 
 
 
 
 
 
Euvolemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
UNa < 30 mEq/L
 
Variable UNa
 
UNa > 30 mEq/L
 
UNa < 30 mEq/L
 
UNa > 30 mEq/L
 
Variable UNa
 
UNa < 20 mEq/L
 
> 20 UNa < 40 mEq/L
 
UNa > 40 mEq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Extrarenal losses
•Vomiting (Ucl ↓)
•Diarrhea
•Pancreatitis
•Sweating
•Small bowel obstruction

|A04=

Renal losses
•Osmotic diuresis (glucose, urea,bicarbonaturia)
•Salt-Iosing nephropathy
•Addison disease
•CSW

|A03=Variable UNa
•Diuretic use
Discontinue diuretics if UNa is still abnormal|B03=

Conditions
•Heart failure
•Liver disease
•Nephrotic syndrome

| B04=

Conditions
•Chronic kidney disease
•Diuretic use in:
Heart failure
Liver disease
[[Nephrotic syndrome

|C08=Probable hypovolemia|C10=Hypovolemia or euvolemia|C09=•Probable euvolemia
•SIAD
•Cortisol deficiency
•Hypothyroidism|C07=Discontinue diuretics if PNa normalize it's not SIAD if it's not normalized}}

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Administer 0.9% saline

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Normalize PNa

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Administer 1–2 L 0.9% saline

 
 
 
 
 
 
 
 
 
 
 
 

Failure to normalize PNa

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Hypovolemia

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

PNa decreases or no change

 
 
 
 
 
 
 
 
 
 
 
 

PNa increases

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Decreasing UOsm

 

No change in UOsm but UNa increases

 
 
 
 
 
 
 
 
 
 

SIAD

 
 
 
 
 
 

No change in UOsm but UNa increases

 
 

Decreased UNa

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Hypovolemia

 

Salt-depleted SIAD

 
 
 
 
 
 
 
 
 
 
 
 
 
 

Hypovolemia

 
 

Decreasing Uosm

 
 

Administer additional saline

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

No change in UOsm
but UNa increases

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Salt-depleted SIAD

References

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