Hyponatremia differential diagnosis: Difference between revisions

	Hyponatremia Microchapters
Home
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
X-ray
Echocardiogram or Ultarsound
CT scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Hyponatremia differential diagnosis On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Hyponatremia differential diagnosis All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Hyponatremia differential diagnosis
CDC on Hyponatremia differential diagnosis
Hyponatremia differential diagnosis in the news
Blogs on Hyponatremia differential diagnosis
Directions to Hospitals Treating hyponatremia
Risk calculators and risk factors for Hyponatremia differential diagnosis

← Older edit Newer edit →

VisualWikitext

Revision as of 13:34, 7 June 2018

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
	Muscle weakness/ Cramps	Oliguria	Vomiting/ Diarrhea	Volume status	JVP	Edema	Crackles	Ascites	Tachycardia	Hypotension	Dry mucous membranes	Urine Na	Urine Osm	FeNa	Serum Osmolality	ADH levels
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

Laboratory Findings

Approach to differential diagnosis

Biochemical evaluation for finding the etiologies of hyponatremia ^[5]^[6]^[7]:

2

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 • Severe azotemia

Hypotonicity
<275 mOsm/kg

U_Osm < 100mOsm/kg

U_Osm > 200mOsm/kg

U_Osm 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

U_Na < 30 mEq/L

Variable U_Na

U_Na > 30 mEq/L

U_Na < 30 mEq/L

U_Na > 30 mEq/L

Variable U_Na

U_Na < 20 mEq/L

> 20 U_Na < 40 mEq/L

U_Na > 40 mEq/L

Extrarenal losses
•Vomiting (U_cl ↓) •Diarrhea •Pancreatitis •Sweating •Small bowel obstruction

Variable U_Na
•Diuretic use
Discontinue diuretics if U_Na 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 P_Na 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 P_Na

Administer 1–2 L 0.9% saline

Failure to normalize P_Na

Hypovolemia

P_Na decreases or no change

P_Na increases

Decreasing U_Osm

No change in U_Osm but U_Na increases

SIAD

No change in U_Osm but U_Na increases

Decreased U_Na

Hypovolemia

Salt-depleted SIAD

Hypovolemia

Decreasing U_osm

Administer additional saline

No change in U_Osm
but U_Na 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.
↑ Wiebke Fenske, Sebastian K. G. Maier, Anne Blechschmidt, Bruno Allolio & Stefan Stork (2010). "Utility and limitations of the traditional diagnostic approach to hyponatremia: a diagnostic study". The American journal of medicine. 123 (7): 652–657. doi:10.1016/j.amjmed.2010.01.013. PMID 20609688. Unknown parameter |month= ignored (help)
↑ E. J. Hoorn, M. L. Halperin & R. Zietse (2005). "Diagnostic approach to a patient with hyponatraemia: traditional versus physiology-based options". QJM : monthly journal of the Association of Physicians. 98 (7): 529–540. doi:10.1093/qjmed/hci081. PMID 15955797. Unknown parameter |month= ignored (help)

Template:WH Template:WS

[pmid5782121-1] 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.

[pmid1610976-2] 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.

[pmid19666518-3] 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.

[pmid16843086-4] 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.

[SpasovskiVanholder2014-5] 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.

[6] Wiebke Fenske, Sebastian K. G. Maier, Anne Blechschmidt, Bruno Allolio & Stefan Stork (2010). "Utility and limitations of the traditional diagnostic approach to hyponatremia: a diagnostic study". The American journal of medicine. 123 (7): 652–657. doi:10.1016/j.amjmed.2010.01.013. PMID 20609688. Unknown parameter |month= ignored (help)

[7] E. J. Hoorn, M. L. Halperin & R. Zietse (2005). "Diagnostic approach to a patient with hyponatraemia: traditional versus physiology-based options". QJM : monthly journal of the Association of Physicians. 98 (7): 529–540. doi:10.1093/qjmed/hci081. PMID 15955797. Unknown parameter |month= ignored (help)

[1]

[2]

[3]

[4]

[5]

[6]

[7]

@@ Line 433: / Line 433: @@
 <small>
+{{familytree/start}}
+{{familytree | | | | | | | | | A01 | | | | | |A01=[[Serum Na]] ≤ 135 meq/L}}
+{{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 | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| |}}
+{{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<br>• Severe azotemia</td></tr></table>|C03='''Hypotonicity'''<br>'''<275 mOsm/kg'''}}
+{{familytree | | | | | | | | | | | | | | | | |!| }}
+{{familytree | | | | | | | | | | | | |,|-|-|-|+|-|-|-|-|.|}}
+{{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 | | | | | | | | | | | | 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 [[SIADH|SIAD]]</td></tr></table>}}
+{{familytree | | | | | | |,|-|-|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|-|-|-|.| |}}
+{{familytree | | | | | | F01 | | | | | | | | F02 | | | | | | | | | | | F03 | |F01='''Hypovolemia'''<br>Based on [[history]] & [[physical exam]]|F03='''Euvolemia'''|F02='''Hypervolemia'''}}
+{{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 | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| |}}
+{{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>•[[Cerebral salt wasting syndrome|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>•[[SIADH|SIAD]]<br>•[[Cortisol deficiency]]<br>•[[Hypothyroidism]] | C07= Discontinue diuretics if P<sub>Na</sub> normalize it's not [[SIADH|SIAD]] if it's not normalized}}
+{{familytree | | |`|-|-|-|+|-|-|-|'| | | | | | | | | | | |`|-|-|-|^|-|v|-|^|-|-|-|'| | |}}
+{{familytree | | |,|-|-| A01 | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | |A01=Administer 0.9% saline}}
+{{familytree | | A02 | | |!| | | | | | | | | | | | | | | | | | | | | H01 | | | | | | |A02=Normalize P<sub>Na</sub>|H01=Administer 1–2 L 0.9% saline}}
+{{familytree | | |!| | | A03 | | | | | | | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| |A03=Failure to normalize P<sub>Na</sub>}}
+{{familytree | | A04 | | |!| | | | | | | | | | | | | | C01 | | | | | | | |,|-|-|-| C02 |C01=P<sub>Na</sub> decreases or no change|C02=P<sub>Na</sub> increases|A04=Hypovolemia}}
+{{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=[[SIADH|SIAD]]|D03=Decreased U<sub>Na</sub>|D02=No change in U<sub>Osm</sub> but U<sub>Na</sub> increases}}
+{{familytree | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | |!| |}}
+{{familytree | | | | A05 | | A06 | | | | | | | | | | | | | | | D07 |-|-| D06 |-|-| D04 |D04=Administer additional saline|D06=Decreasing U<sub>osm</sub>|D07=Hypovolemia|A05= Hypovolemia |A06=Salt-depleted [[SIADH|SIAD]]}}
+{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| |}}
+{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | D08 |D08=No change in U<sub>Osm</sub><br> but U<sub>Na</sub> increases}}
+{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| |}}
+{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | D09 |D09=Salt-depleted [[SIADH|SIAD]]}}
+{{familytree/end}}
 </small>

Hyponatremia differential diagnosis: Difference between revisions

Revision as of 13:34, 7 June 2018

Overview

Differentiating etiologies of Hyponatremia

Laboratory Findings

Approach to differential diagnosis

References

Navigation menu

Search