Hyponatremia causes

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

Overview

Disease name] may be caused by [cause1], [cause2], or [cause3].

OR

Common causes of [disease] incl ude [cause1], [cause2], and [cause3].

OR

The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].

OR

The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click here.

Causes

Common Causes

Diagnostic criteria of SIADH/SIAD
serum sodium <135 mEq/L Plasma osmolality <275 mOsm/kg , ( NL=275–295 mOsm/kg) urine concentration UOsm >100mOsm/kg H2O, (NL=500-800 mOsm/kg H2O) Urine sodium >30 (20-40) mmol/L, with normal salt and water intake, (NL=20 mEq/L)^† Clinical euvolemia Exclusion of glucocorticoid deficiency or hypothyroidism

† Mmol and Meq are the same for univalent ions like sodium

Causes of Hyponatremia based upon Serum Osmolality:

Classification	Serum Osmolality	Etiology
Hypertonic Hyponatremia	> 295 mOsm/kg	Hyperglycemia‡, Mannitol, Glycerol, Sorbitol
Isotonic Hyponatremia	280 – 295 mOsm/kg	Lab/blood draw error, Hyper paraproteinemia (monoclonal gammopathy of undetermined significance (MGUS), Multiple Myeloma), Hyperlipidemia, Post TURP (bladder irrigation with osmotic solutions)
Hypotonic Hyponatremia	< 280 mOsm/kg	Etiology depends upon volume status (Hypervolemic/ Euvolemic/ Hypovolemic)

Causes of Hyponatremia based on volume status ^[1] :

Volume status	Sodium status	Causes
Hypovolemic Hyponatremia^[2]	total body water ↓ total body sodium ↓↓	GI loss: Vomiting, diarrhea, tube drainage Insensible loss: Sweating, burns Renal loss: Salt-wasting nephropathy (Inappropriate loss of Na+-Cl– in the urine), Bicarbonaturia ( Renal tubular acidosis, Metabolic alkalosis), Osmotic diuresis Third spacing of fluids : Pancreatitis, hypoalbuminemia Cerebral salt-wasting syndrome : Stroke ,SAH (urinary salt wasting, brain natriuretic peptide ↑) Mineralocorticoid deficiency: Addison disease Excessive diuretic administration
Hypervolemic Hyponatremia	total body water ↑↑ total body sodium ↑	Renal disease: Acute or chronic kidney disease or injury (due to relatively higher water versus salt intake and poor excretion),Nephrotic syndrome Congestive heart failure Cirrhosis Iatrogenic
Euvolemic Hyponatremia	total body water ↑ total body sodium ↔	Drugs:Vasopressin, diuretics, antidepressants, opioids SIADH: Malignancy, central nervous system (CNS) disorders, pulmonary disease, or drugs, postoperative nausea, pain,stress,Neoplasia (common),trauma,pregnancy High fluid intake: Physical activity, surgery, primary polydipsia, potomania (caused by a low intake of solutes with relatively high fluid intake) Medical testing (excess fluid intake) :Colonoscopy or cardiac catheterization Hypothyroidism Glucocorticoid deficiency Reset osmostat ^† Iatrogenic

† Altered sensitivity to serum osmolality by the hypothalamic osmoreceptors

Drugs ^[3] :

Drug Mechanisms	Drug Classification
Increase ADH secretion	Antidepressants:Tricyclic antidepressants ( Amitryptiline, Protriptyline, Desipramine),Selective serotonin reuptake inhibitors, Monoamine oxidase inhibitors Antipsychotic drugs: Phenothiazines (Thioridazine, Trifluoperazine), Butyrophenones (Haloperidol) Antiepileptic drugs: Carbamazepine, Oxcarbazepine, Sodium valproate Anticancer agents: Vinca alkaloids (Vincristine, Vinblastine), Platinum compounds (Cisplatin, Carboplatin) Alkylating agents: Intravenous, Cyclophosphamide, Melphalan, Ifosfamide Miscellaneous: Methotrexate, Interferon, Levamisole, Pentostatin, Monoclonal antibodies, MDMA, Nicotine Opiates
Increase ADH effect	Antiepileptic drugs: Carbamazepine, Lamotrigine Antidiabetic drugs: Chlorpropamide, Tolbutamide Anticancer agents: Alkylating agents (Intravenous cyclophosphamide) NSAIDS
Drugs affecting water and sodium homeostasis	Diuretics:Thiazides, Indapamide, Amiloride, Loop diuretics
Reset omostat ^‡	Antidepressants: Venlafaxine Antiepileptic drugs:Carbamazepine

‡ Altered sensitivity to serum osmolality by the hypothalamic osmoreceptors

Causes by Organ System

Cardiovascular	Congestive heart failure
Chemical / poisoning	No underlying causes
Dermatologic	Burns
Drug Side Effect	ACE inhibitors, Ajuga nipponensis makino , Asenapine maleate, Cefpodoxime, Chlorpropamide, Cyclophosphamide, Desmopressin, Diuretics, Duloxetine, Eslicarbazepine acetate, Ethacrynic Acid, Felbamate, Fluvoxamine, Interferon gamma, Ixabepilone, Losartan and Hydrochlorothiazide, Nilotinib, Nivolumab, Nonsteriodal anti-inflammatory drugs , Oxcarbazepine, Pramipexole, Rifaximin, Tiagabine, Tolazamide, Zonisamide, Tolbutamide, Vortioxetine
Ear Nose Throat	No underlying causes
Endocrine	Addison's disease, Corticosterone methyloxidase type I deficiency , Diabetes mellitus, Diabetic coma, Glucocorticoid deficiency, Familial hyperreninemic hypoaldosteronism type 2, Hypothyroidism, Mineralocorticoid deficiency, Myxedema coma , Syndrome of inappropriate antidiuretic hormone , Thyrotropin deficiency, 18-Hydroxylase deficiency , Familial hypoaldosteronism
Environmental	No underlying causes
Gastroenterologic	Acute liver failure , Cirrhosis, Congenital chloride diarrhea , Diarrhea, Gastrointestinal fistula, Ileus, Necrotizing enterocolitis , Pancreatitis, Peritonitis, Vomiting, Cystic fibrosis
Genetic	18-Hydroxylase deficiency , Bartter Syndrome type 4 , Cystic fibrosis, Familial hypoaldosteronism , Corticosterone methyloxidase type I deficiency , Familial hyperreninemic hypoaldosteronism type 2, Congenital chloride diarrhea
Hematologic	No underlying causes
Iatrogenic	After pituitary surgery, After surgery, Ascitic tap, Gastric drainage, Hypotonic infusions, Pleuracentesis
Infectious Disease	Malignant boutonneuse fever , Neonatal bacterial meningitis , Peritonitis
Musculoskeletal / Ortho	No underlying causes
Neurologic	Intracranial hemorrhage, Subarachnoid hemorrhage, Pituitary cancer
Nutritional / Metabolic	Hyperlipidemia, Hyperproteinemia, Hypoalbuminemia, Low sodium diet, Metabolic acidosis, Diabetic coma
Obstetric/Gynecologic	Pregnancy
Oncologic	Pituitary cancer
Opthalmologic	No underlying causes
Overdose / Toxicity	Water intoxication
Psychiatric	Psychogenic polydipsia, Psychosis, Self-induced water intoxication and schizophrenic disorders syndrome
Pulmonary	Cystic fibrosis
Renal / Electrolyte	Acute kidney disease, Chronic kidney disease, Diuresis, Glucosuria, Ketonuria, Nephrotic syndrome, Renal Tubular Acidosis, Tubulointerstitial kidney disease, Bartter Syndrome type 4 , Corticosterone methyloxidase type I deficiency , Renal failure
Rheum / Immune / Allergy	Addison's disease, Nephrotic syndrome
Sexual	Cystic fibrosis
Trauma	Burns
Urologic	No underlying causes
Dental	No underlying causes
Miscellaneous	Beer potomania, Ecstasy abuse , Factitious hyponatremia, Hydration, Massive edema, Pseudohyponatremia, Water Intoxication , Hyperlipidemia, Hyperproteinemia, Hypoalbuminemia, Exercise associated hyponatremia

Causes in Alphabetical Order

References

↑ Guillaumin, Julien; DiBartola, Stephen P. (2017). "A Quick Reference on Hyponatremia". Veterinary Clinics of North America: Small Animal Practice. 47 (2): 213–217. doi:10.1016/j.cvsm.2016.10.003. ISSN 0195-5616.
↑ Rondon-Berrios, Helbert; Agaba, Emmanuel I.; Tzamaloukas, Antonios H. (2014). "Hyponatremia: pathophysiology, classification, manifestations and management". International Urology and Nephrology. 46 (11): 2153–2165. doi:10.1007/s11255-014-0839-2. ISSN 0301-1623.
↑ Liamis, George; Milionis, Haralampos; Elisaf, Moses (2008). "A Review of Drug-Induced Hyponatremia". American Journal of Kidney Diseases. 52 (1): 144–153. doi:10.1053/j.ajkd.2008.03.004. ISSN 0272-6386.

[GuillauminDiBartola2017-1] Guillaumin, Julien; DiBartola, Stephen P. (2017). "A Quick Reference on Hyponatremia". Veterinary Clinics of North America: Small Animal Practice. 47 (2): 213–217. doi:10.1016/j.cvsm.2016.10.003. ISSN 0195-5616.

[Rondon-BerriosAgaba2014-2] Rondon-Berrios, Helbert; Agaba, Emmanuel I.; Tzamaloukas, Antonios H. (2014). "Hyponatremia: pathophysiology, classification, manifestations and management". International Urology and Nephrology. 46 (11): 2153–2165. doi:10.1007/s11255-014-0839-2. ISSN 0301-1623.

[LiamisMilionis2008-3] Liamis, George; Milionis, Haralampos; Elisaf, Moses (2008). "A Review of Drug-Induced Hyponatremia". American Journal of Kidney Diseases. 52 (1): 144–153. doi:10.1053/j.ajkd.2008.03.004. ISSN 0272-6386.

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