Hyponatremia differential diagnosis
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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
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 |
Laboratory Findings
Approach to differential diagnosis
Biochemical evaluation for finding the etiologies of hyponatremia [5][6][7]:
The unnamed parameter 2= is no longer supported. Please see the documentation for {{columns-list}}.
2
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)