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Sodium disorders
Prof Tahir Shafi
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Overview
Hyponatremia Pathophysiolgy Diagnostic approach Clinical sequeli
Acute Chronic hyponatremia
Hypernatremia Diffirenial diagnosis, diagnostic approach Management
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Function of body sodium
Major electrolyte of ECF Responsible for maintaining serum &
ECF osmolality directly, Intracellular fluid and total body fluids indirectly
Serum osmolarity milliosmoles per liter =
18 6 Blood Sugar
2 (SNa+) + Blood Urea+
Osmolality milliosmoles per Kg
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Body sodium distribution
Total body sodium 60 mmole/kg ECF 50% ICF 5 % BONE 45 % Exchangeable 70% Normal serum sodium 135-145 meq/l Normal inracellular sodium 10-12
meq/l
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Definition hyponatremia
Serum sodium levels less than 135 meq/l
Disorder of water metabolism Relative excess of water in ECF Does not reflect total body sodium
which could be normal, high or low
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Definition hypernatremia
Serum sodium levels >145 meq/l Disorder of water metabolism Relative water deficit in ECF Does not reflect total body sodium
which could be normal, high or low
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Change in serum / ECF osmolality change in cell volume
Na
NaNa
NaNa
NaNa
Na
KK
KK
KKKK
KK
KKKK
KK
KK
KK
KK
ICF ECF
Na
Na Na
Na
Na
Na
Na
KK
KK
KKKK
KK
KKKK
KK
KK
KK
KK
ICF ECF
Na
Na
Na
Na
Na
Na
Effects of cell expansion/shrinkage apparent in case of brain cells
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Brain Edema
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What Prevents Hyponatremia
HigherintegrativecentersThirst inhibited
ingestion of waterdecreased
ADH
Excretion of waterIncreased
Hyportonicity
xSerum SodiumIncrease in osmolality
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What Prevents Hypernatremia
HigherintegrativecentersThirst stimulated
ingestion of waterincreased
ADH
Decreased excretion of water
Hypertonicity
Serum Sodiumin osmolality
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Impact of Hyponatremia & Hypovolemia on ADH Secretion
Retention f waterDecrease urine output
Hypotonicity
Arterial barorecpters
Cardiopulmonary receptors
Visceral osmorecptors
Hypovolemia
ADH
HypotonicityHypovolemia
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Regulation of serum osmolality
Plasma ADH declinesThirst inhibited
Plasma ADH risesThirst stimulated
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Regulation of ECF volume
Osmoregulation Volume regulation
What is sensed Plasma osmolality Effective circulatory volume
Sensors Hypothalamic osmoreceptors
Carotid sinus Afferent arterioleAtria
Effectors ADH/vasopressin thirst
Sympathetic nervous system, RAASANP/BNPVasopressin
What is affected Urine osmolality, water intake
Urinary sodium excretion
Black and Rose, Manual of Clinical Problems in Nephrology 1988
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Water Reabsorption by Kidneys
80 % reabsobed in proximal tubuleObligatory reabsorption
Remaining 20 %Facultative reabsorption
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Water Reabsorption by Kidneys
80 % reabsobed in proximal tubuleObligatory reabsorption
Remaining 20 %Facultative reabsorption
GFR = 100 ml/min144 liters in 24 hours80 % of 144 liters reabsorbed inProximal tubule = 115.2 L
Reabsorption of remaining 20 % i.e. 28.8 Liters under influence of ADH
Maximum amount of free water excretion
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Water reabsorption by kidneys
80 % reabsobed in proximal tubuleObligatory reabsorption
Remaining 20 %Facultative reabsorption
GFR = 10 ml/min14.4 liters in 24 hours80 % of 14.4 liters reabsorbed inProximal tubule = 11.52 L
Reabsorption of remaining 20 % i.e. 2.88 Liters under influence of ADH
Maximum amount of free water excretion
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Negative Free Water Excretion
1. Delivery
Filtration
Reabsorption
2. Separation
3. Control
Free water excretion
ADH Present
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Free Water Excretion
1. Delivery
Filtration
Reabsorption
2. Separation
3. Control
Free water excretion
No ADH
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Clinical Features of Hyponatremia
Headache Nausea.Vomiting Muscle cramps Lethargy. weakness Restlessness Disorientation, Ataxia, falls
fractures Depressed reflexes
Seizures Coma Permanent brain
damage Respiratory arrest Brain stem
herniation Death
Chronic Acute
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Bone injury from hyponatremia in the elderly
45 % of Na is present in bone
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Initial evaluation
History & Physical Medicines Past medical history ? Prior pituitary surgery ROS. Symptoms attributable to actue or chronic
hypernatremia Symptoms suggestive of cause. ? Dirrhea,
vomiting Chronicity acute vs chronic (>48 hours)
Examination Hypovolemia? JVP, orthostatic changes Hypervolemia? JVP, edema, chest examination
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Initial lab evaluation
Plasma osmolality Low – true hyponatremia Normal or elevated: Psuedo hyponatremia, renal
failure translocational Urine osmolality
< 100 mosm/kg primary polydipsia > 100 mosm/kg reduced water excretion
Urinary sodium < 20 meq/l: decreased effective volume > 20 meq/l: “euvolemic” causes or renal Na
wasting
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Further testing in hyponatremia
TSH - hypothyroid Random cortisol – primary or
secondary adrenal insufficiency Cosyntrophin stimulation test for
primary adrenal failure Chest Xray- Chest CT – lung
malignancy CT head brain, sinuses. Nasal cavity
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Types of hyponatremia
Hypervolemic Hypolemic Pseudo Translocational Hyponatremia hyponatremia hyponatremia hyponatremia
Normal Euvolemic Hyponatremia
HYPOTONIC ISOTONIC HYPERTONIC
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Isotonic Hyponatremia (Pseudo hypo/hypernatremia)
152 meq/lIn 850 ml
= 129
Serum proteinslipids
Serum water
15 G/L:150 ml
Measured osmolality> than calculatedosmolality
8 G/L: 80 ml
152 meq/lIn 920 ml
=140
4 G/L: 40 ml
152 meq/lIn 960 ml
=146
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Approach to Hyponatremia
Serum sodium < 135 meq/l
Plasma osmolality
Normal Low High280-295 <280 >295Isotonic Hypotonic HypertenonicHyperlipidemias TranslocationalParaproteinemias Hyperglycemia Mannitol therapy
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- CSWS
Urinary sodium urinary sodium
> 20 meq/l < 10 meq/l > 20 meq/l < 10 meq/l
Renal sod loss External sodium loss
- Diuretics- Osmotic diuretic - RTA with bicarbonate loss- Generation phase of metabolic alkalosis- Salt loosing nephropathies
- Skin loss- GIT
- Renal failure - CHF - Cirrhosis - Nephrotic syndrome
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Hypotonic hyponatremia
Normal ECFV
Urine osmolality
<100 mosm/l >300 mosm/l
Excessive water intakeLow solute intake
Approach to Hyponatremia
SIADH Reset osmostat Endocrinopathies Potassium depletion- Drugs - Hypothyroidism - diuretic use- Tumors - glucocorticoid deficiency- CNS disorders- Nauseas- Pain- Stress- others
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Treatment of Hyponatremia
Evaluation of Patient's volume status Duration and magnitude of the
hyponatremia Degree and severity of clinical
symptoms
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Treatment of Hyponatremia
Hypovolemic hyponatremia: Isotonic saline to replace the contracted intravascular volume
Hypervolemic hyponatremia: Salt and fluid restriction, Loop diuretics, Correction of the underlying condition. The use of a V2 receptor antagonist may be
considered (Conivaptans iv. Tolvaptans)
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Normovolemic (euvolemic), hyponatremica
Asymptomatic patients Free water restriction (< 1 L/d)
Patients with overtly symptomatic hyponatremia (eg, seizures, severe neurological deficits), Hypertonic (3%) saline Loop diuretics Water restriction
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Rate of correction Acute Hyponatremia
Increase the serum sodium level by 1-2 mEq/L/h for 3-4 hours, until the neurologic symptoms subside or until plasma Na is over 120 mEq/L
Chronic, severe symptomatic hyponatremia, The rate of correction 0.5-1 mEq/L/h, with a total
increase not to exceed 8-12 mEq/L/d and no more than 18 mEq/L in the first 48 h.
Correct the hyponatremia to a safe range (usually to no greater than 120 mEq/L) rather than to a normal value.
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SIADH
Essential features
• Decreased effective serum osmolality (<275 mOsm/kg)
• Urinary osmolality >100 mOsm/kg during hypotonicity of the serum
• Clinical euvolaemia
• Urinary sodium >40 mmol/L with normal dietary salt intake
• Normal thyroid and adrenal function
• No recent use of diuretics
Supplemental features
• Serum uric acid <4 mg/dL
• Serum urea <3 mg/dl• low normal serum creatinine• Fractional sodium excretion >1%,
fractional urea excretion >55%• Failure to correct hyponatraemia
after 0.9% saline infusion• Correction of hyponatraemia
through fluid restriction
• Abnormal water loading test (excretion <80% of a 20 mL/kg water load in 4 h)
• Elevated vasopressin levels despite hypotonicity and clinical euvolaemia ??
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CSWS vs SIADH
Symptoms CSWS SIADH
BP Orthostatic hypotension
Normal
CVP Decreased Elevated
Heart rate Tachycardia Tachycardia
Serum osmolality
Low Low
Serum uric acid High Low
Urinary Sodium High High
Urine volume High High
Weight Decreased Increased
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SIADH vs CSWHyponatremia
(No edema, no asities)
Urinary Sodium > 20 meq/l
CVP measurement
< 6 cm H2O > 6 cm H2O
CSWS SIADH
Fluid replacement Fluid restriction
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Treatment of SIADH
Fluid restriction Treatment of cause Hypertonic saline plus loop
diuretics Demeclocycline Aquaretics: Conivaptans,
tolvaptans
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Case A 62-year-old long-term cigarette smoking
man was noted to have a serum sodium of 129 mEq/L on a routine examination and was completely asymptomatic.
Past Hx. Prostate cancer treated by radical
prostatectomy without recurrence Physical examination; in no distress,
examination was unremarkable.
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Past medical records; Serum Na in range of 129-134 and urine osmolality was consistently greater than the serum osmolality and was as high as 938 mOsmol/kg water.
An extensive workup: thyroid function test, plasma cortisol, prostate-specific antigen test, abdomen and chest computed tomography, colonoscopy, bronchoscopy, and brain magnetic resonance imaging all unrevealing.
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A 1.5-L water-loading test was carried out, with results shown in Table .
Vasopressin level undetectable
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Which of the following statements regarding water-loading test is correct?
A. Total urine output in 4 hours in this patient is 10% below expected amount in normal individuals
B. The water-loading test is most compatible with a diagnosis of the nephrogenic syndrome of inappropriate antidiuretic hormone secretion (NSIAD)
C. The water-loading test is compatible with reset osmostat
D. The significant decrease in urine osmolality is against a diagnosis of SIADH
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Response to changes in serum osmolality
1% serum osmolality ~ vasopressin1 ng/l Urine osm 200 mosm
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Ewout J. Hoorn et al. NDT Plus 2009;2:iii5-iii11
A. Unregulated secretion of vasopressin
B. Raised basal level of vasopressin
C. Reset osmostatD. Undetectable vasopressin
level gain of function mutation of V2 recepter
Types of SIADH
260 270 280 290 300
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Action of ADH
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Case A 69-year-old man is admitted with
increased confusion, eating poorly and still taking in water. He was taking lithium because of bipolar disorder, with nephrogenic diabetes insipidus
An elderly man in no distress, disoriented to time and place.
Afebrile, BP 83/34 mmHg, heart rate 101 beats per minute, temperature 36C, and O2 saturation 99% on room air.
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Lab results
The patient received 2 L of normal saline solution. Urine volume rose to 400 ml after 12 hours and 126 mEq/L in 24 hours, with urine studies of Na 8, mEq/L, K ,4.6 mEq/L, and osmolality 70 mOsm/kg
Na 106meq/lK 4.0 meq/lCl 71 meq/lBUN 25 mg/dlGlucose 126 mg/dl
BUN 25 mg/dlCreatinine 1.1mg/dlBaseline Cr 0.9UNa 10 meq/lUK 17 meq/lOsmolality 184 mosm/kg
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How much of the urine excreted at this time is made up of electrolyte-free water (CeH2O)?
A. 90% of urine output is CeH2O
B. 73% of the urine is CeH2O
C. CeH2O cannot be calculated without measurement of anions in the urine
D. CeH2O cannot be calculated without measuring a simultaneous serum osmolality
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CeH2O
CeH2O = V (1 - )UNa + UKSerum sodium
= 400 (1 - )8+4.6126
= 400 ( 1-0.1) =400*0.9 =36090 % of 400
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Which of the following is the best way to treat this patient at this time?
A. Increase D5W to 110% of urinary loss per hour
B. Use desmopressin and continue with D5W with goal of decreasing serum sodium to 112 mEq/L
C. Use desmopressin and continue with D5W with the goal of stabilizing serum sodium at 120 mEq/L
D. Desmopressin alone is adequate because he is nowasymptomatic
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Case
A 49-year-old woman with no previous medical history completed 42-km run in 5 hours in a marathon. During the race, she consumed mineral water and ate several energy bars. Four hours after finishing the marathon, she felt dizzy, nauseous, and extremely weak, and vomited three times. Subsequently, she became disoriented and confused and was brought to the emergency room 7 hours after her symptoms began.
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On admission, she was conscious but disoriented and obtunded, Her body weight 3.4 kg above her normal weight. She was afebrile and vital signs were normal. The neurologic examination showed no focal findings and plantar reflexes were flexor.
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Laboratory data
Serum Na 121meq/l Serum K, 3.3meq/l Serum Cl 88 meq/l Serum HCO3 18 mol/l Uric acid 3.6 mg/dlBUN 8 mg/dlCreatinine 0.8 mg/dlGlucose 153 mg/dl
Plasma osmolality, 260 urine osmolality 489 mOsm/kgUrine Na 86 mg/dlUrine K, 75 mmol/L
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SNa meq/l
IV fluids
Time hrs
Urine in ml
0 3
750 ml NSS
Tonic/clonicConvulsionsIV clonazepam
118 hrs
2.5 L NSS
121 128 136
15 18
3% SS 50 cc/h200 cc
1000 1900 750 ml
121
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SNa meq/l
IV fluids
Time hrs
Urine in ml
0 3
750 ml NSS
Convulsions ?
118 hrs
2.5 L NSS
121 128 136
15 18
3% SS 50 cc/h200 cc
1000 1900 750 ml
121
Why did she develop hyponatremia?A.She lost salt and water due to sweating, replaced with free waterB.Because of candies , she had hyperglycemia osmotic diuresis, sodium lossC.Because of hyperglycemia she had translocational hyponatremiaD.She had SIADH
Why did she develop
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SNa meq/l
IV fluids
Time hrs
Urine in ml
0 3
750 ml NSS
Convulsions ?
118 hrs
2.5 L NSS
121 128 136
15 18
3% SS 50 cc/h200 cc
1000 1900 750 ml
121
Why did she developA. HyperglycemiaB. HypoglycemiaC. Acute hyponatremiaD. Rapid infusion of saline
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SNa meq/l
IV fluids
Time hrs
Urine in ml
0 3
750 ml NSS
118 hrs
2.5 L NSS
121 128 136
15 18
3% SS 50 cc/h200 cc
1000 1900 750 ml
121
Why her serum sodium did not improve ?SNa = [Na]inf-[Na]s
TBW+1
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SNa meq/l
IV fluids
Time hrs
Urine in ml
0 3
750 ml NSS
118 hrs
2.5 L NSS
121 128 136
15 18
3% SS 50 cc/h200 cc
1000 1900 750 ml
121
SNa = [Na]inf-[Na]s
TBW+1=2.5 meq/l
Why her serum sodium improved more than expected?
Why her serum sodium increased more than expected?
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Case A 55-year-old man with history of pituitary
surgery for nonfunctional pituitary macroadenoma 10 years previously. No other medical or psychiatric problems. He is admitted because of several days of anorexia, nausea, and vomiting, progressing to confusion, lethargy, and disorientation to time and place. In the emergency department, he has two generalized tonic-clonic seizures.
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Inj Hydrocortisone & Isotonic saline was given. 8 hours later serum sodium improved to 115 meq/l with improvement in mental status. Dischraged 6 days later with serum sodium 131 meq/l. Returned to ER next day with tremors and difficulty speaking and swallowing. He is fully conscious and oriented with a clear sensorium, but is irritable, suspicious, and restless , pacing the halls in anger, and accusing others of talking about him and teasing him with their gestures
SNa 102 meq/l BUN5mg/dlSK 4 meq/l Creatinine 0.5 mg/dlSCl 74 meq/l U Na 78 meq/lBicarb 22 meq/l UK 50 meq/lUosm 500 mosm/kg Levels of ACTH,TSH.FSH,LH
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Which one of the following statements is true about this patient?
A. Based on the patient’s symptoms, he most likely became hyponatremic because of polydipsia related to an underlying psychosis.
B. Patients presenting with a serum sodium concentration ,110 mEq/L have an expected mortality 50%.
C. The patient has pontine and extrapontine myelinolysis and his condition is likely to progress to death or to a permanent vegetative state.
D. The patient’s behavioral symptoms, tremors, and difficulty swallowing are most likely related to steroid-induced rapid correction of hyponatremia and they may resolve with time.
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Points for discussion1. Prognosis of severe hyponatremia;2. Association of hyponatremia with often
unsuspected panhypopituitarism or Addison’s disease and its susceptibility to unintentional overcorrection;
3. Prevention of unintentional rapid correction of hyponatremia;
4. Pathogenesis of osmotic demyelination; 5. Hyponatremia in polydipsic patients with
psychiatric disease;6. Bbehavioral and other atypical
manifestations of pontine and extrapontine myelinolysis;
7. Prognosis of the osmotic demyelination syndrome
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Prognosis of Severe Hyponatremia
Even mild hyponatremia is associated with increased mortality in both ambulatory and inpatient settings with a variety of underlying diseases, including heart failure, hepatic cirrhosis, kidney disease, critical illness, etc
Chronic hyponatremia is associated with gait disturbances, increased falls, and bone fragility and fractures in humans
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Mortality due to hyponatremia
Clin J Am Soc Nephrol 6: 960–965, 2011.
at least two additional acute severe progressive illnesses, most commonly sepsis and multiorgan failure.
medication-induced hyponatremia and severe underlying illnesses uncommon
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Hyponatremia with often unsuspected panhypopituitarism or Addison’s disease and its susceptibility to unintentional overcorrection
Addison’s disease.Lack of mineralcorticoids, decreased sodium reabsorption, Hypovolemia --- increased ADH secretion, decreased free water excretion- hyponatremia Treatment – Isotoinc saline
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Panhypopituitarism
Decreased in ACTH, decreased cortisol Lack of Cortisol induced tonic
inhibition of ADH , Increase ADH secretion, water retention, hyponatremia
Hypersecretion of ADH may be partly due to reduced systemic BP and cardiac output or, possibly, to increased renal sensitivity to ADH.
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Cortisone replacement – inhibition of ADH free water excretion,
Avoid rapid correction of hyponatremia
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Prevention of excessive correction
If a water diuresis is causing the serum sodium to increase too rapidly in a chronically hyponatremic patient with a serum sodium <120 mEq/L, there are two major options: nmatch urinary water losses with 5% dextrose in water, and nadminister 2–4 ug of parenteral desmopressin to stop the water diuresis
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Water deficit = TBW x ( - 1)S Na
140
Water excess = TBW x (1- )S Na
140
Electrolyte free water excretion
CeH2O = Urine volume x (1- )
UNa++UK+
S Na+CeH2O = Urine volume x ( 1- )
Blood glucose
+ U Glucose
UNa++UK+
S Na+
meq/l change in SNa after infusion of one liter= Infusate Na – S Na
TBW +1
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Auto-correction of the serum sodium
The administration of saline to patients with true volume depletion.
The administration of glucocorticoids to patients with adrenal insufficiency.
Discontinuation of drugs that cause the SIADH carbamazepine, desmopressin
Discontinuation of thiazide diuretics, Spontaneous resolution of a transient cause
for SIADH (eg, surgical stress, nausea, pneumonia).
Treatment with a vasopressin receptor antagonist
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ODS
Complication of treatment of hyponatremia
Too rapid correction Symptoms: headache, nausea,
vomiting, disorientation, seizures, coma, respiratory depression, death
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Pathogenesis of osmotic demyelination
Chronic hyponatremia – loss of potassium, sodium, osmolytes to lower the intracellular fluid osmolality
Rapid correction –rapid entry of sodium into cell raising intracellular sodium concentration
Osmolyte
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Case
74 years old women is admitted with 2 month h/o fatigue, anorexia, 6 kg weight loss. She had Chemotherapy for ovarian cancer 6 months ago. She is on hydrochlorthiazide for hypertension.
Temp 97.2OF, BP 132/75 mmHg, pulse 86/m no postural changes, no edema. Normal neurological cardiac and respiratory systems.
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Which one of these is cause of hyponatremiaA. HypovolemiaB. Low solute intakeC. PseudohyponatremiaD. Primary adrenal insufficiency
Blood urea – 5 mg/dlCreatinine 0.4 mnd/dlSodium 128meq/LPotassium 3.8 meq/lChloride 90Buicarb 25Serum osm 266 mosm/Kg H2O
Urinary sodium 12 meq/lPotassium 15 meq/lOsmolality 56 mos/kgH2O
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Case
An 84 years old man was admitted with fever for several days, anorexia, diarrhea and cough productive of yellow sputum
Moderate respiratory distress, BP 120/86 and pulse 74/min supine, BP 116/85, pulse 70/min on standing. Resp 24/min, temp 102oF, decreased breath sounds rt lung base
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Lab reports
Blood urea – 15 mg/dlCreatinine 0.8 mnd/dlSodium 120meq/LPotassium 3.8 meq/lChloride 87Buicarb 23Glucose 320 mg/dlSerum osm 260 mosm/Kg H2O
Urinary sodium 60 meq/lPotassium 30 meq/lOsmolality 500 mos/kgH2O
Which one of these is cause of hyponatremia
A.HypovolemiaB.SIADHC.HyperglycemiaD.Low solute intake
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Case
A 49 years old man presented with vomiting and diarrhea for last 3 days.
H/o smoking for > 20 years Reduced skin turgor, BP 120/75 sup,
100/55 standing. Chest examination – absent breath
sounds at left lung base, left pleural effusion and left upper lung mass on Xray
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Which one of these is cause of hyponatremiaA. HypovolemiaB. Low solute intakeC. PseudohyponatremiaD. Primary adrenal insufficiency
Blood urea – 22 mg/dlCreatinine 1.0 mnd/dlSodium 114 0meq/LPotassium 3.6 meq/lChloride 96 meq/lBicarb 23 meq/lUric acid 4 meq/l
Urine sodium 6 meq/lOsmolality 498Serum osm 245 mosm/Kg H2O
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Patient was treated with IV Normal saline. His serum sodium level improved to 122meq/l the next day. Saline infusion was continued, Repeat serum sodium level 120 meq/l. Repeat U Na 40 meq/l, urinary osmolality 600 mosm. Why the patient serum sodium level did not improve?
A. Pt still volume depletedB. Patient likely has underlying Addison’s diseaseC. Pt likely to have underlying SIADH
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Case
A 21 years old pregnant woman was admitted to hospital at 10th week of pregnancy because of confusion restlessness after having hyperemesis for 4 weeks and loss of 3 kg weight
She was dehydrated. BP 100/70, pulse 78/minute supine and upright BP 80/65mmHg and pulse 96/minute
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BloodSodium meq/l 107Potassium meq/l1.2Calcium mg/dl 9.6Mg mg/dl 1.1Phosphorus mg/dl 2.0Urea mg/dl 13Creatinine mg/dl0.9
Urine Sodium 2 meq/lPotassium 3 meq/lOsmolality 456 mosm/kg
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Treatment
NSS @100 cc/hrKCL 6 meq/l
5%DW 100 cc/hrKCl 6.6 meq/l
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The neurological symptoms worsened with the appearance of hypotonia, tremors and involuntary muscle spasms.
IV steroids, parental nutrition Pregnancy continued Unevenful delivery Patient able to continue her activity
with support
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Hypernatremia
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Pseudo hypernatremia
152 meq/lIn 920 ml
=140
152 meq/lIn 960 ml
= 146
Serum proteinslipids
Serum water
8 G/L: 80 ml 4 G/L:150 ml
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Causes of Hypernatremia
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A 42-year-old ultra marathon runner collapsed at the finish of the 100-mile race. She was confused and knew only her name. Blood pressure was 90/60 mmHg and pulse was 130 beats/minute; she could not stand up. No pre-marathon weight was available. Serum sodium concentration was 163 mEq/L. The most likely underlying cause of the hypernatremia is: a. Loss of hypotonic fluid across skin b. Lithium use c. Hereditary nephrogenic diabetes insipidus d. Pregnancy with increased placental vasopresinase activity e. DDAVP
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A 40-year-old man with a yet undiagnosed systemic disease, including pulmonary lesions, presents with increasing thirst, polydipsia, polyuria, and a serum sodium concentrate of 152 mEq/L. Simultaneous urine osmolality was 100 mosm/kg. He takes no mediation. The most likely systemic disease responsible for the hypernatremia is: a. Diabetes mellitus b. Sarcoidosis c. Adrenal insufficiency d. Primary aldosteronism e. Hereditary nephrogenic diabetes insipidus
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A 38-year-old woman with three children below the age of seven is seen by Psychiatry. A diagnosis of bipolar disease with depression is made and medication is prescribed. Four months later, she returns and states that she now is thirsty and is voiding frequently (quantitated as approximately 3.5 liters a day). Serum sodium concentration ranges from 143-145 mEq/L and BUN is 22 mg/dl. The most likely agent/process responsible for the polyuria is: a. Hypercalcemia b. Lithium c. Demeclocycline d. Sickle cell disease e. Prolonged low protein diet
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An 80-year-old, partially demented man with poor nutritional status is admitted to the hospital because of pneumonia. Hyperalimentation with high protein supplementation is started (containing 30 mEq/L each of Na+ and K+). Following 5 days: Urine output: 4 L/day
BUN: 20-88 mg/dL Cr: Stable at 1.4 mg/dL [Na +]: From 140 mEq/L up to 156 mEq/L (despite a relatively high fluid intake) Posm: 342 mOsm/kg Uosm: 510 mOsm/kgUNa +: 10 mEq/LUK +: 42 mEq/L.
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The free-water clearance is calculated as follows:cH2O = V x (1- )
cH2O = 4 x ( 1 - [510 ÷ 342] ) = -2 L/day
By this calculation, taking all osmoles into account, the patient retains 2 liters of water, improving hypernatremia; however, he is actually getting worse.
U osmS osm
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Electrolyte free-water clearance
eCH2O = 4 (1 - [(10 + 41) ÷ 156] ) = 2.7 L/day
The patient is losing approximately 2.7 L of free water per day in his urine, likely secondary to osmotic urea diuresis caused by hyperalimentation
UNa++UK+
S Na+eCH2O = Urine volume x (1- ) + Blood glucose + U Glucose
UNa++UK+
S Na+eCH2O = Urine volume x (1- )
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Treatment of Hypernatremia
Symptomatic hypernatremia Establish documented onset (acute, < 24 h;
chronic >24h) Acute hypernatremia,
Correction of serum sodium at an initial rate of 2-3 mEq/L/h (for 2-3 h) (maximum Total, 12 mEq/L/d).
Serum and urine electrolytes every 1-2 hours Serial neurologic examinations and decrease the
rate of correction with improvement in symptoms
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Treatment of Hypernatremia
Chronic hypernatremia with no or mild symptoms Correction at a rate not to exceed 0.5
mEq/L/h and a total of 8-10 mEq/d (eg, 160 mEq/L to 152 mEq/L in 24 h).
If a volume deficit and hypernatremia are present, intravascular volume should be restored with isotonic sodium chloride prior to free-water administration
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Calculation of Water Deficit
Water Deficit =(Plasma Sodium-140)
140X TBW
• Ongoing losses (insensible, renal) need to be added.
• Hypernatremia with volume overload (heart failure and pulmonary edema) may require diuretics or dialysis for correction.
In case of sodium and water deficit
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Approach to hypernatremia
Determine volume status Calculate water deficit
Water deficit = TBWx( -1) Choose replacement fluid Determine rate of repletion
[Na+]s = after one liter
Total fluid required =
Serum Sodium140
[Na+]infus -[Na+]s
TBW +1Net S Na change
[Na+]sAfter 1 liter
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Calculation of Na deficit
Deficit in mmols = 0.6x BW [Target Na- sNa]
Hypertonic saline 3% = 513 meq/l sodiumVolume of 3 % saline required in liters=Sodium deficit 500Rule of thumb; for each 1 meq/l requires
~ 70 ml hypertonic saline
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Determine ongoing insensible losses
Determine ongoing sensible losses Urine out put =C electrolytes +C electrolyte
free
CeH2O = V X ( 1 - )
Determine the cause if possible
UNa++ UK+
PNa+
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Treatment of Hypernatremia
Treatment of the underlying cause Free access to water Better control of diabetes mellitus. In
addition, correction of hypokalemia and hypercalcemia
Treatment for nephrogenic diabetes insipidus may be required.
Vasopressin (AVP, DDAVP) for the treatment of central diabetes insipidus.
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A 45-year-old man developed hypernatremia after several days in the surgical intensive care unit, during which he received enteral nutrition without sufficient free water. At this point you are asked to provide a prescription for correcting his free water deficit assuming no ongoing losses. His weight is 70 kg. His serum sodium is 155 mEq/L. He has no edema. Restoring his serum sodium to 140 mEq/L will require which ONE of the following prescriptions?A. 6.5 L of free waterB. 2.5 L of free waterC. 4.5 L of free waterD. 8.5 L of free water
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A 76-year-old man is sent to the hospital from his nursing home because of obtundation, decreased skin turgor, fever and a blood pressure of 140/80 mmHg. The serum sodium concentration is 168 mEq/L (it was 142 mEq/L four months earlier). The most likely cause of the hypernatremia is: A.Primary hypodipsia B.Prolonged low protein diet C.Hypercalcemia D.Inadequate solute-free water replacement for cutaneous pure water loss E.Lithium
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The treatment goal for this patient is: A.Reduce serum sodium concentration to normal in first 12 hours B.Reduce serum sodium concentration to normal in 24 hours C.Reduce serum sodium concentration to 150 mEq/L in 24 hours D.Maintain serum sodium concentration at 165 mEq/L for first 8 hoursE.Reduce serum sodium concentration by 10 mEq/L in 24 hours
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Case
A 55-year-old male diagnosed with schizophrenia was started on antipsychotic drugs 23 years back. His usual water intake 8-10 liters / days. He was having dizziness and calf cramps off and on. Now admitted for weakness of legs with serum sodium of 116 meq/l
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To increase the osmolality, 5% hypertonic salinewas infused intravenously at a regular rate (0.1 mlper kilogram per minute) for 120 minutes usinga constant-infusion pump, and blood sampleswere obtained before loading, and at 30, 60, 90 and120 minutes after the beginning of loading.
oral water loading (20 ml per kilogram of body weight) was administered over a period of 15 minutes,
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