Hyponatremia differential diagnosis: Difference between revisions
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===<big>Approach to differential diagnosis</big>=== | ===<big>Approach to differential diagnosis</big>=== | ||
<br> | <ref name="SpasovskiVanholder2014">{{cite journal|last1=Spasovski|first1=Goce|last2=Vanholder|first2=Raymond|last3=Allolio|first3=Bruno|last4=Annane|first4=Djillali|last5=Ball|first5=Steve|last6=Bichet|first6=Daniel|last7=Decaux|first7=Guy|last8=Fenske|first8=Wiebke|last9=Hoorn|first9=Ewout J.|last10=Ichai|first10=Carole|last11=Joannidis|first11=Michael|last12=Soupart|first12=Alain|last13=Zietse|first13=Robert|last14=Haller|first14=Maria|last15=van der Veer|first15=Sabine|last16=Van Biesen|first16=Wim|last17=Nagler|first17=Evi|title=Clinical practice guideline on diagnosis and treatment of hyponatraemia|journal=Nephrology Dialysis Transplantation|volume=29|issue=suppl_2|year=2014|pages=i1–i39|issn=1460-2385|doi=10.1093/ndt/gfu040}}</ref><br> | ||
<small> | <small> | ||
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Revision as of 18:49, 31 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
Laboratory Findings
Biochemical evaluation for finding the etiologies of hyponatremia :
The unnamed parameter 2= is no longer supported. Please see the documentation for {{columns-list}}.
2
| 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.
- ↑ Spasovski, Goce; Vanholder, Raymond; Allolio, Bruno; Annane, Djillali; Ball, Steve; Bichet, Daniel; Decaux, Guy; Fenske, Wiebke; Hoorn, Ewout J.; Ichai, Carole; Joannidis, Michael; Soupart, Alain; Zietse, Robert; Haller, Maria; van der Veer, Sabine; Van Biesen, Wim; Nagler, Evi (2014). "Clinical practice guideline on diagnosis and treatment of hyponatraemia". Nephrology Dialysis Transplantation. 29 (suppl_2): i1–i39. doi:10.1093/ndt/gfu040. ISSN 1460-2385.