Hyponatremia

Hyponatremia
Classification and external resources
Sodium
ICD-10	E87.1
ICD-9	276.1
DiseasesDB	6483
MedlinePlus	000394
eMedicine	emerg/275 med/1130 ped/1124
MeSH	D007010

Hyponatremia (American English) or hyponatraemia (British English) is an electrolyte disturbance in which the sodium ion concentration in the serum is lower than normal. Sodium is the dominant extracellular cation (positive ion) and cannot freely cross from the interstitial space through the cell membrane, into the cell. Its homeostasis (stability of concentration) inside the cell is vital to the normal function of any cell. Normal serum sodium levels are between 135 and 145 mEq/L. Hyponatremia is defined as a serum level of less than 135 mEq/L and is considered severe when the serum level is below 125 mEq/L.

In the vast majority of cases, hyponatremia occurs as a result of excess body water diluting the serum sodium (salt level in the blood).

Hyponatremia is often a complication of other medical illnesses in which excess water accumulates in the body at a higher rate than can be excreted (for example in congestive heart failure, syndrome of inappropriate antidiuretic hormone (SIADH), or polydipsia). Sometimes it may be a result of overhydration (drinking too much water).

Lack of sodium (salt) is very rarely the cause of hyponatremia, although it can promote hyponatremia indirectly. In particular, sodium loss can lead to a state of volume depletion (loss of blood volume in the body), with volume depletion serving as a signal for the release of ADH (anti-diuretic hormone).^{[citation needed]} As a result of ADH-stimulated water retention (too much water in the body), blood sodium becomes diluted and hyponatremia results.

Exercise-associated hyponatremia (EAH), however, is common at marathons and other endurance events. Researchers found, for instance, that 13% of the athletes who finished the 2002 Boston Marathon were in a clinically hyponatremic condition, i.e. their salt levels in their blood had fallen below an acceptable level. Tim Noakes' 2012 book "Waterlogged" addresses this phenomenon clearly.

Signs and symptoms

Symptoms of hyponatremia include nausea and vomiting, headache, confusion, lethargy, fatigue, loss of appetite, restlessness and irritability, muscle weakness, spasms, or cramps, seizures, and decreased consciousness or coma. The presence and severity of symptoms are associated with the level of serum sodium (salt level in the blood), with the lowest levels of serum sodium associated with the more prominent and serious symptoms (the less the salt the more severe the symptoms). However, emerging data suggest that mild hyponatremia (serum sodium levels at 131 mEq/L or above) is associated with numerous complications and undiagnosed symptoms.

Many medical illnesses, such as congestive heart failure, liver failure, kidney failure, or pneumonia may be associated with hyponatremia. These patients frequently show up in the medical exam room because of these other disease symptoms.

Neurological (brain) symptoms are often present with extremely low levels of sodium (salt). When sodium levels in the blood become too low, excess water enters cells and the cells swell. Swelling in the brain is dangerous because the brain is confined by the skull and is unable to expand. The disorder in the brain caused by hyponatremia is called hyponatremic encephalopathy. Symptoms include headache, nausea, vomiting and confusion, but can also include seizures, respiratory arrest (stopping breathing) and non-cardiogenic pulmonary edema (fluid in the lungs). Neurological symptoms most often are due to very low serum sodium levels (usually <115 mEq/L), resulting in brain swelling. This can lead to tentorial herniation, which is a squeezing of brain structures, and can lead to brain stem compression and respiratory arrest (stopping breathing), resulting in death in the most severe cases. The severity of symptoms depends on how fast and how severe the drop in blood salt level. A gradual drop, even to very low levels, may be tolerated well if it occurs over several days or weeks, because of neuronal adaptation. The presence of underlying neurological disease, like a seizure disorder, or non-neurological metabolic abnormalities, also affects the severity of neurologic symptoms.

Causes

Based on the above classification, some of the many specific causes of hyponatremia can be listed as follows:

Hypervolemic hyponatremia — Both sodium & water content increase: Increase in sodium content leads to hypervolemia and water content to hyponatremia. Total body water and sodium are regulated independently

• cirrhosis of the liver
• congestive heart failure
• nephrotic syndrome in the kidneys
• massive edema of any cause

Euvolemic hyponatremia — total body water increases, but the body's sodium content stays the same

• states of severe pain or nausea
• in the setting of trauma or other damage to the brain
• SIADH (and its many causes)
• Hypothyroidism
• Glucocorticoid (steroid) deficiency

Hypovolemic hyponatremia — The hypovolemia (extracellular volume loss) is consequent on total body sodium loss but, overall, total body water is decreased and is the aetiology of the hyponatremia

• any cause of hypovolemia such as prolonged vomiting, decreased oral intake, severe diarrhea
• diuretic use (due to the diuretic causing a volume depleted state and thence ADH release, and not a direct result of diuretic-induced urine sodium loss)
• Addison's disease in which the adrenal glands do not produce sufficient steroid hormones (combined glucocorticoid and mineralocorticoid deficiency)

Miscellaneous causes of hyponatremia that are not included under the above classification scheme include:

• factitious hyponatremia (due to massive increases in blood triglyceride levels, extreme elevation of immunoglobulins as may occur in multiple myeloma, and extreme hyperglycemia)
• hypothyroidism and adrenal insufficiency (both thyroid hormone and cortisol are required to excrete free water)
• beer potomania and other malnourished states where poor dietary protein intake leads to inadequate urine solute formation thereby impeding the kidney's ability to excrete free water
• primary polydipsia (where the amount of urine solute required to excrete huge quantities of ingested water exceeds the body's ability to produce it; this typically occurs when 12 or more litres of water are ingested per day)

Diagnosis

Examination includes taking vital signs when lying, sitting, and standing, and an assessment of how much blood is in the body. This determination (i.e. hypervolemic, euvolemic, hypovolemic) helps guide treatment decisions. A full assessment of other medical conditions (comorbidity) is also taken, because heart and brain conditions affect the results and the treatment decisions.

Pathophysiology

The hyponatremia can be spurious (false) and/or artifactual hyponatremia in which case there is no hypotonicity. Hypertonic hyponatremia, caused by resorption of water drawn by molecules such as glucose (hyperglycemia or diabetes) or mannitol (hypertonic infusion). Isotonic hyponatremia, more commonly called "pseudohyponatremia," is caused by lab error due to hypertriglyceridemia (most common) or hyperparaproteinemia.

True hyponatremia is Hypotonic hyponatremia and is by far the most common type, and is often simply referred to as "hyponatremia." Hypotonic hyponatremia is categorized in 3 ways based on the patient's blood volume status. Each category represents a different underlying reason for the increase in ADH that led to the water retention and thence hyponatremia:

• Hypervolemic hyponatremia, wherein there is decreased effective circulating volume (less blood flowing in the body) even though total body volume is increased (by the presence of edema or swelling, especially in the ankles). The decreased effective circulating volume stimulates the release of anti-diurectic hormone(ADH), which in turn leads to water retention. Hypervolemic hyponatremia is most commonly the result of congestive heart failure, liver failure (cirrhosis), or kidney disease (nephrotic syndrome).

• Euvolemic hyponatremia, wherein the increase in ADH is secondary to either physiologic but excessive ADH release (as occurs with nausea or severe pain) or inappropriate and non-physiologic secretion of ADH, i.e. syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH). Often categorized under euvolemic is hyponatremia due to inadequate urine solute (not enough chemicals or electrolytes to produce urine) as occurs in beer potomania or "tea and toast" hyponatremia, hyponatremia due to hypothyroidism or central adrenal insufficiency, and those rare instances of hyponatremia that are truly secondary to excess water intake (i.e., extreme psychogenic polydipsia)

• Hypovolemic hyponatremia, wherein ADH secretion is stimulated by or associated with volume depletion (not enough water in the body).

The volemic classification fails to include spurious (fake) and/or artifactual hyponatremia, which is addressed in the osmolar classification. This includes hyponatremia that occurs in the presence of massive hypertriglyceridemia, severe hyperglycemia, and extreme elevation of immunoglobulin levels.

In chronic hyponatremia, sodium (salt) levels drop gradually over several days or weeks and symptoms and complications are typically moderate. Chronic hyponatremia is often called asymptomatic hyponatremia in clinical settings because it is thought to have no symptoms; however, emerging data suggests that "asymptomatic" hyponatremia is not actually asymptomatic.

In acute hyponatremia sodium (salt) levels drop rapidly, resulting in potentially dangerous effects, such as rapid brain swelling, which can result in coma and death.

Treatment

The treatment of hyponatremia depends on the underlying cause and whether the patient's blood volume status is hypervolemic, euvolemic, or hypovolemic. In the setting of hypovolemia, intravenous administration of normal saline (salt) is usual, careful care taken not to raise the serum sodium level (salt level in the blood) too quickly (see below). Euvolemic hyponatremia is usually managed by fluid restriction and treatment to abolish any stimuli for ADH secretion such as nausea. Likewise, drugs causing SIADH are discontinued if possible. Patients with euvolemic hyponatremia that persists despite those measures may be candidates for a so-called vaptan drug as discussed below. Hypervolemic hyponatremia is usually treated by addressing the underlying heart or liver failure. If it is not be possible to do so, the treatment becomes the same as that for euvolemic hyponatremia (i.e. fluid restriction and/or use of a vaptan drug).

Hyponatremia is corrected slowly in order to lessen the chance of the development of central pontine myelinolysis (CPM), a severe neurological disease involving a breakdown of the myelin sheaths covering parts of nerve cells. In fact, overly rapid correction of hyponatremia is the most common cause of that potentially devastating disorder. During treatment of hyponatremia, the serum sodium (salt level in the blood) is not allowed to rise by more than 8 mmol/l over 24 hours (i.e. 0.33 mmol/l/h rate of rise). In practice, too rapid correction of hyponatremia and thence CPM is most likely to occur during the treatment of hypovolemic hyponatremia. In particular, once the hypovolemic state has been corrected, the signal for ADH release disappears. At that point, there will be an abrupt water diuresis (an increase in urination since there is no longer any ADH acting to retain the water). A rapid and profound rise in serum sodium (salt level in the blood) can then occur. Should the rate of rise of serum sodium exceed 0.33 mmol/l/h over several hours, vasopressin may be administered to prevent ongoing rapid water diuresis (excessive urination).

Pharmaceutically, vasopressin receptor antagonists can be used in the treatment of hyponatremia, especially in patients with SIADH, congestive heart failure or liver cirrhosis. A vasopressin receptor antagonist is an agent that interferes with the action at the vasopressin receptors. A new class of medication, the "vaptan" drugs has been specifically developed to inhibit the action of vasopressin on its receptors (V1A, V1B, and V2). These receptors have a variety of functions, with the V1A and V2 receptors are expressed peripherally and involved in the modulation of blood pressure and kidney function respectively, while the V1A and V1B receptors are expressed in the central nervous system. V1A is expressed in many regions of the brain, and has been linked to a variety of social behaviors in humans and animals.

Vaptan drugs

The “vaptan” class of drugs contains a number of compounds with varying selectivity, several of which are either already in clinical use or in clinical trials as of 2010.

Unselective (mixed V1A, V2)

• Conivaptan

V1A selective

• Relcovaptan

V1B selective

• Nelivaptan

V2 selective

• Lixivaptan

• Mozavaptan

• Satavaptan

• Tolvaptan

The V2-receptor antagonists tolvaptan and conivaptan allow excretion of electrolyte free water and are effective in increasing serum sodium in euvolemic and hypervolemic hyponatremia.

Complications

Chronic hyponatremia can lead to such complications as neurological impairments. These neurological impairments most often affect gait (walking) and attention, and can lead to falls, osteoporosis, and decreased reaction time.

Complications for chronic hyponatremia are most dangerous for geriatric patients. Falls are the leading cause of deaths related to injury among people 65 years or older. In a recent study the incidence of hyponatremia in elderly patients with large-bone fractures was more than double that of non-fracture patients. Recent work by Verbalis et al. suggests that hyponatremia induces osteoporosis and found the adjusted odds ratio for developing osteoporosis to be 2.87 times higher among adults with mild hyponatremia compared to those without.

Acute hyponatremia can lead to much more serious complications including brain disease, brain herniation, cardiopulmonary arrest (heart attack), cerebral edema (brain swelling), seizures, coma, and death.

Epidemiology

Hyponatremia is the most common electrolyte disorder. Electrolytes are sodium (salt), potassium, calcium, magnesium, chloride, hydrogen phosphate, and hydrogen carbonate. The disorder is more frequent in females, the elderly, and in patients who are hospitalized. The incidence of hyponatremia depends largely on the patient population. A hospital incidence of 15–20% is common, while only 3–5% of patients who are hospitalized have a serum sodium level (salt blood level) of less than 130 mEq/L. Hyponatremia has been reported in up to 30% of elderly patients in nursing homes and is also present in approximately 30% of depressed patients on selective serotonin reuptake inhibitors.

See also

• Water intoxication
• Hypernatremia
• Edible salt
• Osmotic demyelination syndrome

External links

• Sandy Craig, Erik D Schraga, Francisco Talavera, Howard A Bessen, John D Halamka (2010-04-13). "Hyponatremia in Emergency Medicine". Medscape. 
• James L. Lewis, III, MD (May 2009). "Hyponatremia". Merck Manual of Diagnosis and Therapy. 
• Kugler JP, Hustead T (June 2000). "Hyponatremia and hypernatremia in the elderly". Am Fam Physician 61 (12): 3623–30. PMID 10892634. 
• Elizabeth Quinn (2011-03-07). "What Is Hyponatremia: Hyponatremia or water intoxication — Can Athletes Drink Too Much Water?". About.com. 
• "Salt and the ultraendurance athlete". SportsMed Web. 1997. 
• Sean Rothwell (2010-06-07). "Kokoda Medicine". 
• Hyponatremia Mayo Clinic