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{{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}}

Revision as of 18:44, 21 May 2018

Hyponatremia Microchapters

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Patient information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Hyponatremia from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

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Echocardiogram or Ultarsound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

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Cost-Effectiveness of Therapy

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Case #1

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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[1] +/- +/- +/- - Hypervolemic + + + + - - - >20 - >1% ↓ Normal or ↑
Congestive heart failure[2] +/- +/- - - Hypervolemic + + + + - - - <10 - <1% ↓ ↑
Cirrhosis[2] +/- +/- - - Hypervolemic + + + + - - - <10 - <1% ↓ ↑
SIADH[3][4] +/- +/- - - 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


 
 
 
 
 
 
 
 
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
 
Variable UNa
•Diuretic use
Discontinue diuretics if UNa is still abnormal
 
Renal losses
•Osmotic diuresis (glucose, urea,bicarbonaturia)
•Salt-Iosing nephropathy
•Addison disease
•CSW
 
Conditions
•Heart failure
•Liver disease
•Nephrotic syndrome
 
Conditions
•Chronic kidney disease
•Diuretic use in:
Heart failure
Liver disease
Nephrotic syndrome
 
Discontinue diuretics if PNa normalize it's not SIAD if it's not normalized
 
Probable hypovolemia
 
Hypovolemia or euvolemia
 
•Probable euvolemia
•SIAD
•Cortisol deficiency
•Hypothyroidism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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

  1. ↑ Tannen RL, Regal EM, Dunn MJ, Schrier RW (May 1969). "Vasopressin-resistant hyposthenuria in advanced chronic renal disease". N. Engl. J. Med. 280 (21): 1135–41. doi:10.1056/NEJM196905222802101. PMID 5782121.
  2. ↑ 2.0 2.1 Schrier RW (May 1992). "An odyssey into the milieu intérieur: pondering the enigmas". J. Am. Soc. Nephrol. 2 (11): 1549–59. PMID 1610976.
  3. ↑ Tian W, Fu Y, Garcia-Elias A, Fernández-Fernández JM, Vicente R, Kramer PL, Klein RF, Hitzemann R, Orwoll ES, Wilmot B, McWeeney S, Valverde MA, Cohen DM (August 2009). "A loss-of-function nonsynonymous polymorphism in the osmoregulatory TRPV4 gene is associated with human hyponatremia". Proc. Natl. Acad. Sci. U.S.A. 106 (33): 14034–9. doi:10.1073/pnas.0904084106. PMC 2729015. PMID 19666518.
  4. ↑ Gitelman SE, Feldman BJ, Rosenthal SM (July 2006). "Nephrogenic syndrome of inappropriate antidiuresis: a novel disorder in water balance in pediatric patients". Am. J. Med. 119 (7 Suppl 1): S54–8. doi:10.1016/j.amjmed.2006.05.008. PMID 16843086.

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