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Hyponatremia!!! Hyponatremia!!! Sunil Agrawal, MD, FASN Disclosures • Employed by Nephrology Specialist of Oklahoma • Otsuka Speaker Bureau for Jynrque • Local DaVita Medical Director - In-Center and Home Dialysis HYPONATREMIA!!! Confused? PTSD from training!! NOW WHAT????? HYPONATREMIA!!! Natural Inclination: FLUID RESTRICTION THIS NOT THE ANSWER MOST OF THE TIME!!! (ignores causation) USUALLY HAVE TO RESITRICT: < 800 ml/Day!!! Outline • Introduction • Brief Physiology of Water Handling • Diagnosis • Special Cases of Hyponatremia • Treatment → Acute vs. Chronic • Summary Introduction • What is Hyponatremia? • Serum Sodium : <135 • Acute <48 hours • Chronic >48 hours or duration unkown • Why do we care? • 15-22% of Hospital Patients • Substantial Morbidity and Mortality • Growing Geriatric Population at Risk • “Companion Diagnosis” with many Disease States Introduction • Hyponetremia → Free water intake > water secretion • Serum [Na+]∝ Na + K / Total Body Water • Decrease in numerator • Increase in denominator Water Physiology Water Physiology • Concentrating and Diluting Capacity: • Concentration → 1200 mOsm/kg, UOP <1 L/ day • Diluting → 50 to 100 mOsm/kg, UOP ~ 14 L / day • Kangaroo Rat → concentration capacity of 6,000 mOsm/kg! Water Physiology • What is responsible for changes in urine volume and tonicity? • ADH → vasopressin • Made in hypothalamus • Cleaved to active ADH, neurophysin II, & copeptin • Stored in posterior pituitary Water Physiology Stimulated by: • ADH ✓ Hypertonicity • Releases due to ✓ Hypovolemia increase in Posm • >285 mOsm/kg • Acts on the collecting duct of the kidney (high permeability to water) • Passive water absorption Water Physiology • ADH receptors: • V1a – Vasoconstriction and Increase Prostaglandin release (E2 and prostacyclin), • Platelet aggregation • Cytokine Release • Glycogenolysis • V2 – Mediates ADH action • Free water absorption • V3 (V1b) – Acts on the pituitary, ACTH release Water Physiology • Actions of ADH: • Renal: • Water reabsorption via the Aquoprin 2 • Reabsorption of Urea • Renal Prostoglandin secretion • Na and K in the collecting duct? • Extrarenal: • Vasoconstriction • Release of factor VIII and von Willebrand's factor Water Physiology • Countercurrent Multiplication: • Active NaCl transport from ascending loop of Henle • Low water permeability of ascending loop of Henle • High water permeability of decending loop of Henle • Passive reabsorption of Urea in collecting duct Water Physiology • Aquaporin Water Channels • 16 known channels → likely more • Found in extrarenal locations • Aquaporin 1-4 most studied • Aquaporin 1 associated with proximal tubule • Aquaporin 2 associated with ADH • Aquaporin 4 associated with the blood-brain barrier Water Physiology • Why go through physiology? • ADH Derangement!!!! Diagnosis Diagnosis • The two most important diagnostic tests: • HISTORY • PHYSICAL EXAM • Typical Classifications: • Serum Osmolality • Volume Status Diagnosis What to order: ✓ Urine Sodium* ✓ Urine Creatinine ✓ Urine Potassium ✓ Urine Osmolality ✓ Serum Osmolality ✓ Serum Uric Acid ✓ TSH* Famous Renal Attending: Dr. Neph Ron ✓ Cortisol* ✓ Frequent Monitoring of Serum Sodium Quick Definitions • Difference between Osmolarity • What is Tonicity? and Osmolality: • the concentration of osmoles → (known as effective osmoles) • Osmolality → is the number of that do not freely cross cell osmoles of solute in a kilogram membranes. of solvent • Concentration of the particles that is dissolved in a fluid* • Osmolarity →is the number of osmoles of solute in a liter of solution. • Concentration of an osmotic solution *can be directly measured by osmometer Diagnosis • Step #1: • Serum Osmolarity: • Hypertonic (Posmo >290) • Isotonic (Normal Posmo 275-290) • Hypotonic (Posmo <275)* *Physical Exam → very important Diagnosis • Isotonic Hyponatremia: • Pseudo-hyponatremia • Secondary to increase lipids and proteins • Hyperlipidemia • Paraproteinemia • Plasma: 93% Water, 7% Proteins • Decrease in fraction of the plasma sample in aqueous • Can be avoided by using Direct Potentiometry (ISE) → no dilution of sample • To confirm Dx → check Lipid panel or Osmolar Gap Diagnosis • Special Cases of Isotonic Hyponatremia: • Transurethral prostate surgery • Endoscopic Intrauterine Surgery • Typically Due to Type of Irrigant: • Glycine → directly neurotoxic • Sorbitol • Why Isotonic? • Rapidly Absorbed with water • Expansion of space with fluid Diagnosis • Osmolar Gap → can be helpful det cal • OG = Plasmaosm – Plasmaosm cal • Plasmaosm = 2Na + BUN/2.8 + Glu/18 + EtOH/4.6 • Delta > 10 considered Abnormal Diagnosis • Hypertonic Hyponatremia • Increase Osmolar Gap > 10 • Typically Caused by: • Mannitol • Ig Infusion (sucrose) • Maltose • Hyperglycemia → corrected by 2.4 meq/L per 100 mg/dl of glucose Decision Tree of Serum Osmolality Diagnosis • Hypotonic Hyponatremia • Most common presentation of Hyponatremia • ADH typically the driving force • PHYSICAL EXAM VERY IMPORTANT! • Hypervolemic • Hypovolemic • Euvolemic Diagnosis • What to look for on exam: • Vitals • JVP • Skin Turgor • Mucous Membranes • Peripheral Edema Diagnosis • Urinary Indices: • Urinary Sodium: • Is the Kidney Sodium Avid? • Pre-Renal State → UNa <10 • Hypovolemic * • Extra-Renal Volume Loss • Hypervolemic • CHF, Cirrhosis, Nephrosis * Diuretic use → UNa, PNa, PK, ECV Diagnosis • Urine Sodium Continued: • What if the Urine sodium is > 20? • Hypovolemic → Renal loss of volume • Hypervolemic → Renal Failure • CONFUSED? Diagnosis • Remember: • Sodium Avid state → kidney fucntioning properly • Higher urine sodium in the face of hypovolemia and hypervolemia the kidney is to blame! Break Diagnosis • Urine Osmolarity: • Helpful only if <100 mOSm/L • Primary Polydipsia (Euvolemic Hyponatremia) • Low Solute “tea and toast” (Euvolemic Hyponatremia) • Not Helpful to decern states with elevated ADH all will have Uosmo > 100 mOsm/L Diagnosis • Euvolemic Hyponatremia: • To be SIADH, Or not to be SIADH, that is the question…. • Most misunderstood state • Clinical Exam of ECV not very sensitive Diagnosis • What to look for in SIADH: • Additional Data: ① Euvolemic by Exam • Fractional Excretion of uric acid >10% ② Serum Osmolarity <275 mOsm/kg • Uric Acid < 4 mg/dl (low BUN) ③ Urine Sodium > 40 meq/L • Worsening hyponatremia with Normal Saline ④ Urine Osmolarity > 100 mOsm/L • Plasma vasopressin level inappropriate relative to ⑤ Normal Adrenal, Thyroid, serum osmolality and Kidney Function ⑥ Absence of Advanced CKD, cirrhosis, or HF Diagnosis • Differential to SIADH that must be R/O: • Cerebral Salt Wasting • Decrease in EFV • increase in HCT/alb/BUN/creatinine • Reset Osmostat Diagnosis • Common Etiologies of • Drugs: SIADH • Ecstasy (MDMA) • Tumors: • Oxytocin • Pulmonary/mediastinal • Acei • Small Cell Lung CA • SSRI • Pancreatic CA • Opioids • Leukemia • Amiodarone • CNS disorders: • Pulmonary Disease: • Mass lesions • Infection • Inflammation • COPD • Gullian-Barre • Others: • Delirium Tremens • AIDS/HIV • ICH • Trauma Summary of Hypotonic Hyponatremia Hypervolemia Euvolemia Hypovolemia Heart Failure SIADH Thiazide diuretics Cirrhosis Adrenal Insufficiency Cerebral salt wasting (Glucocorticoid def) Nephrotic Syndrome Hypothyroidism Mineralocortcoid def Renal “Failure” Primary Polydipsia Slat-wasting nephropathy Pregnancy Glucosuria Sepsis Third space losses Sweat Losses Diagnosis Summary of Serum Osmolality Hypertonic Isontonic Hypotonic Hyponatremia Hponatremia Hyponatremia Serum Osmo: Serum Osmo: Serum Osmo: >295 msmo/kg 275-295 msmo/kg <275 msmo/kg Hyperglycemia Pseudohyponatremia Hypervolemia Mannitol Paraproteins Euvolemia Glycine Hyperlipidemia Hypovolemia Special Cases Edematous Disorders Exercise Associated Hyponatremia Exercise Associated Hyponatremia • Incidence: variable ~ 0-2% (depending on source) • Typically seen in the following activities: • Intense Endurance: • Marathons • Triathlons • Ultradistance • Military Operations Exercise Associated Hyponatremia • Risk Factors: • Low BMI • High fluid intake during and • Female Gender* after • Athletic Drinks DO NOT • Less Experinced Runners reduce risk • All re hypotonic • NSAIDs* compared to Plasma Osmo • High sodium sweat concentration • Minimal Weight loss/Weight • Heat acclimation can gain during activity reduce Na in sweat • Longer race time (~ 5 h 10 min)* Exercise Associated Hyponatremia • Water Loading alone? • Need ADH surge • Possible eitologies on increased ADH: • Nausea and/or vomiting • Hypoglycemia • Plasma volume contraction • Angiotensin II • Nonspecific stresses such as pain and emotion Exercise Associated Hyponatremia • Other Possible Mechanisms: • IL-6 produced from contraction muscles* • Oxytocin (especially in women) • How to reduce risk: • Drink to thirst • Pre-weights • Education Post Operative Hyponatremia Post Operative Hyponatremia • ADH are increase ≥ 2 days after surgery • Hypotonic Fluid Administration can be risky • Seen in pediatric population • REMEMBER → Fluids are medications! Drug Induced Hyponatremia Drug Induced Hyponatremia • One the most common causes of hyponatremia • HCTZ → most common cause of community acquired hyponatremia • Those at risk: elderly, women, low BMI • Vasopressin Analogs: • Oxytocin • Desmopressin • Mood Disorder drugs: • TCA(s) • SSRI(s) • Especially Venlafaxine (Effexor) Drug Induced Hyponatremia • Vasopressin Analogs (continued): • Antiepileptic Drugs • Carbamazepine • Lamotrigine • Nicotine • Narcotics Drug Induced Hyponatremia • Drugs that potentiate renal vasopressin • NSAIDs • Tylenol • Cyclosphosphamide • Unknown Mechanism
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