Background
- Usually indicative of hypo-osmolality of body fluid due to excess of water relative to solute
- In dilutional hyponatraemia kidney responds by retaining salt and water as if the individual were intravascular volume depleted
- Urinary Na+ generally very low (less than 10 meq per litre)
- Urine osmolality elevated in the absence of diuretics
Clinical
Symptoms:
- Always present when osmolality less than 240 meq
- Rate of fall important
- Increased severity in children and women of child bearing age
- > 125 mmol/l usually asymptomatic
- 125 to 115 mmol/l subtle changes in mental status, e.g. confusion
- < 115 mmol/l stupor ,neuromuscular hyper-excitability (but hyporeflexia, convulsions, coma
- Initial improvement may be followed by delayed neurological symptoms
- Central pontine myelinolysis is uncommon
Causes:
- Factitious (hyper-proteinaemia / lipidaemia / glycaemia and mannitol)
- Water retention (renal, hepatic and cardiac failure, hypothyroidism)
- SIADH
- Polydipsia
- Salt loss (adrenal cortical insufficiency, diuretics, fluid therapy, post-trauma and stress)
- Cerebral salt wasting syndrome
SIADH
Criteria
- Hyponatraemia
- Hypotonicity
- Urinary sodium > 20 mmol/l
- Urine osmolality > plasma osmolality
- Normovolaemia
- Elevated serum ADH
- Correction with water restriction
- Failure to drop urinary osmolality with fluid challenge
- Absence of renal, hepatic, cardiac, thyroid disease
- Absence of drugs that effect renal water handling
Causes of SIADH
- Tumour
- Neurological
- Pulmonary
- dDrugs (tolbutamide, carbamazepine, fluphenazine, anti-depressants, barbiturates)
Treatment of SIADH
- Treat underlying cause
- Fluid restrict to 500 - 1000 mls/day
- 5% NaCl (1.8ml/kg) only if rapid correction required (e.g. seizing)
- Ledermycin (tetracycline with ADH antagonist properties)
Management hyponatraemia
Acute hyponatraemia treated with IV normal saline (particularly in volume depleted)
Chronic hyponatraemia should be corrected SLOWLY (days)
- Amount of sodium necessary to raise serum sodium to 125 mmol/l can be approximated by sodium (mmol/l = 125 mmol/l - serum sodium (mmol/l) x TBW)
Na+ deficit in hyponatraemia
Na+ requirement (mmol) = total body water x (target Na+ - serum Na+ ).
Rate of infusion (ml/hr) = (Na+ requirement (mmol) x 1000) / (infused Na+ (mmol/L) x time (hours)).
If SIADH suspected then
- Treat underlying cause
- Fluid restrict to 500 - 1000 mls/day
- 5% NaCl (1.8ml/Kg) only if rapid correction required (e.g. seizing)
- Ledermycin (tetracycline with ADH antagonist properties)
Links
- Ref: Adrogue, HJ, Madias, NE. Hyponatremia. NEJM 2000; 342(21):1581-1589