Hyponatremia differential diagnosis: Difference between revisions
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|Clinical signs of hypovolemia, such as hypotension, dry mucous membranes, tachycardia, or postural hypotension, Negative fluid balance or weight loss, CVP < 6 cm of water | |Clinical signs of hypovolemia, such as hypotension, dry mucous membranes, tachycardia, or postural hypotension, Negative fluid balance or weight loss, CVP < 6 cm of water | ||
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Revision as of 19:11, 24 May 2018
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Hyponatremia Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Hyponatremia differential diagnosis On the Web |
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American Roentgen Ray Society Images of Hyponatremia differential diagnosis |
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Risk calculators and risk factors for Hyponatremia differential diagnosis |
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
Different disorders which cause hyponatremia are differentiated based on volume status, clinical presentation, serum and urine osmolality.
Differentiating etiologies of Hyponatremia
↔
| Disease | Clinical manifestations | Paraclinical Findings | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Symptoms and Signs | Lab Findings | |||||||||||||||
| Muscle weakness/ Cramps | 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% | ↓ | ↑ |
| SIAD/ 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% | ↓ | - |
Differentiation between SIAD and Cerebral-salt wasting syndrome:
| Condition | Urine sodium | Urine volume | Blood pressure | Serum uric acid | Serum urea concentration | Clinical features |
|---|---|---|---|---|---|---|
| SIAD | > 30 | ↔ , ↓ | ↔ | ↓ | ↔ , ↓ | No sign of hypovolemia, Normal or positive fluid balance with absence of weight loss, CVP > 6 cm of water |
| Cerebral-salt wasting syndrome | >> 30 | ↑ | ↔ , orthostatic hypotension | ↓ | ↔ , ↑ | Clinical signs of hypovolemia, such as hypotension, dry mucous membranes, tachycardia, or postural hypotension, Negative fluid balance or weight loss, CVP < 6 cm of water |
Approach to differential diagnosis
| Serum Na ≤ 135 meq/L | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Hypotonicity <275 mOsm/kg | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| UOsm < 100mOsm/kg | UOsm > 200mOsm/kg | UOsm 100–200mOsm/kg | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Variable UNa •Diuretic use Discontinue diuretics if UNa is still abnormal |
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| 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
- ↑ 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.
- ↑ 2.0 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.
- ↑ 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.
- ↑ 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.