Hyponatraemia: Pathophysiology, treatment and future directions
Keywords:
MedicineAbstract
Hyponatraemia is the most common electrolyte abnormality in clinical practice. While it may be an incidental discovery or manifest with subtle symptoms such as mild confusion, it can also be associated with severe neurological complications and may even result in death. Mismanagement of hyponatraemia with over-rapid correction of the electrolyte abnormality can cause serious and long-lasting neurological consequences. An understanding of the pathophysiology of hyponatraemia is necessary in order to select the appropriate treatment and avoid the complications associated with this condition and its management. The recent introduction of vasopressin receptor antagonists offers clinicians a new option in the management of this challenging condition.
References
1 Upadhyay A, Jaber BL, Madias NE, Incidence and prevalence of hyponatremia. Am J Med 2006 Jul;119(7 Suppl 1):S30-5.
2 Reddy P, Mooradian AD, Diagnosis and Management of Hyponatraemia in Hospitalised Patients, Int J Clin Pract. 2009 Oct; 63(10):1494–508.
3 Renneboog B, Musch W, Vandemergel X, Manto MU, Decaux G, Mild Chronic Hyponatremia is Associated with Falls, Unsteadiness and Attention Deficits. Am J Med. 2006 Jan;119(1):71.e1-8.
4 Hawkinds RC. Age and gender as risk factors for hyponatraemia and hyponatremia. Clin chem acta. 2003;337:169-172
5 Czerwiński E, Białoszewski D, Borowy P, Kumorek A, Białoszewski A, Epidemiology, clinical significance, costs and fall prevention in elderly people. Ortop Traumatol Rehabil. 2008 Sep-Oct;10(5):419-28
6 Verbalis JG, Barsony J, Sugimura Y, Tian Y, Adams DJ, Carter EA, Resnick HE. Hyponatremia-Induced Osteoporosis.J Bone Miner Res. 2009 Sep [Epub ahead of print]
7 Whelan B, Bennett k, O’Riordan D, B Silke, Serum Sodium a s a Risk Factor for in-Hospital Mortality in Acute Unselected General Medical Patients, Q J Med 2009;102:175–82.
8 Rossi J, Bayram M, Udelson JE, Lloyd-Jones D, Adams KF, O ‘Connor CM, et al Improvement in hyponatremia during hospitalization for worsening heart failure is associated with improved outcomes: insights from the acute and chronic therapeutic impact of a vasopressin antagonist in chronic heart failure (ACTIV in CHF) trial, Acute Card Care. 2007;9(2):82-6.
9 Karp BI, Laureno R, Central pontine and extrapontine myelinolysis after correction of hyponatraemia. The neurologist 2000;6:255–66.
10 Brandis K, Fluid physiology – an online text [cited 2009 Dec 22];Available from: URL http://www. anaesthesiamcq.com/FluidBook/index.php
11 Adrogué HJ, Madias NE. Hyponatremia. N Engl J Med. 2000 May 25;342(21):1581-9.
12 Nanji AA, Blank DW. Pseudohyponatremia and hyperviscosity. J Clin Pathol. 1983 Jul;36(7):834-5.
13 Ali N, Imbriano LJ, Maesaka J. The case: a 66-year-old male with hyponatremia. Kidney int 2009;76(2):233-4.
14 Kawai N, Baba A, Suzuki T, Shiraishi H. Roles of arginine vasopressin and atrial natriuretic peptide in polydipsia-hyponatremia of schizophrenic patients. Psychiatry Res. 2001 Feb 14;101(1):39-45.
15 RG, Fluid absorption in endoscopic surgery. Br J Anaesth. 2006 Jan;96(1):8-20.
16 Agraharkar M, Agraharkar A. Posthysteroscopic hyponatremia: evidence for a multifactorial cause. Am J Kidney Dis. 1997 Nov;30(5):717-9.
17 Ayus JC, Wheler JM, Arieff AI: Postoperative hyponatremic encephalopathy in menstruating women. Ann Intern Med1992: 117(11):891-897.
18 Ellison DH, Berl T. Clinical practice. The syndrome of inappropriate antidiuresis. N Engl J Med. 2007 May 17;356(20):2064-72. The term syndrome of
LITERATURE REVIEW
inappropriate antidiuresis (SIAD) rather than syndrome of inappropriate antidiuretic hormone (SIADH) is used in this article and throughout the above review as it is more appropriate considering a subset of patients with SIAD do not have a excess of vasopressin and have an inappropriately concentrated urine due to other defects, such as in the aquaporins in the the collecting duct.
19 Krahn J, Khajuria A. Osmolality gaps: diagnostic accuracy and long-term variability. Clin Chem. 2006 Apr;52(4):737-9.
20 Purssell RA, Lynd LD, Koga Y. The use of the osmole gap as a screening test for the presence of exogenous substances. Toxicol Rev. 2004;23(3):189-202.
21 Koga Y, Purssell RA, Lynd LD.The irrationality of the present use of the osmole gap: applicable physical chemistry principles and recommendations to improve the validity of current practices. Toxicol Rev. 2004;23(3):203-11.
22 Tally NJ, O’Connor S, Clinical examination: a systematic guide to physical diagnosis, 5th ed., Marrickville (Australia): Elsevier; 2006. p.21.
23 Milionis HJ, Liamis GL, Elisaf MS The hyponatremic patient: a systematic approach to laboratory diagnosis. CMAJ. 2002 Apr 16;166(8):1056-62.
24 Cerdà-Esteve M, Cuadrado-Godia E, Chillaron JJ, Pont-Sunyer C, Cucurella G, Fernández M, et al, Cerebral salt wasting syndrome, Eur J Intern Med. 2008 Jun;19(4):249-54.
25 Crook M, Algorithms in chemical pathology, Oxford : Butterworth-Heinemann; 1997. p 14-15
26 Karp BI, Laureno R, Pontine and extrapontine myelinolysis: a neurologic disorder following rapid correction of hyponatraemia, Medicine (Baltimore) 1993; 72:359-73.
27 Martin RJ et al. Central pontine and extra pontine myelinolysis: the osmotic demyelination syndromes J Neurosurg psychiatry, 2004 Sep;75 Suppl 3:iii22-8. 28 Verbalis JG, Goldsmith SR, Greenberg A, Schrier RW, Sterns RH. Hyponatremia treatment guidelines 2007: expert panel recommendations, Am J Med. 2007 Nov;120(11 Suppl 1):S1-21.
29.Adrogué HJ, Madias NE. Aiding fluid prescription for the dysnatremias, Intensive Care Med 1997;23:309- 16.
30. Gross P, Palm C Thiazides: do they kill? Nephrol Dial Transplant. 2005 Nov;20(11):2299-301.
31. Annane D, Decaux G, Smith N; Conivaptan Study Group. Efficacy and safety of oral conivaptan, a vasopressin-receptor antagonist, evaluated in a randomized, controlled trial in patients with euvolemic or hypervolemic hyponatremia. Am J Med Sci. 2009 Jan;337(1):28-36.
32. U.S. food and drug administration, Vaprisol: label and approval history 2008 Aug 10 [cited 2009 Dec22] Available from http://www.accessdata.fda.gov/ drugsatfda_docs/label/2008/021697s001lbl.pdf.
33 Oghlakian G, Klapholz M. Vasopressin and vasopressin receptor antagonists in heart failure. Cardiol Rev. 2009 Jan-Feb;17(1):10-5.
34 Hoque MZ, Arumugham P, Huda N, Verma N, Afiniwala M, Karia DH, Conivaptan: promise of treatment in heart failure. Expert Opin Pharmacother. 2009 Sep;10(13):2161-9.
35 Ghali JK, Hamad B, Yasothan U, Kirkpatrick P. Tolvaptan. Nat Rev Drug Discov. 2009 Aug;8(8):611-2. 36 Schrier RW, Gross P, Gheorghiade M, Berl T, Verbalis JG, Czerwiec FS, et al, Tolvaptan, a selective oral vasopressin V2-receptor antagonist, for hyponatremia. N Engl J Med. 2006 Nov 16;355(20):2099-112.
2 Reddy P, Mooradian AD, Diagnosis and Management of Hyponatraemia in Hospitalised Patients, Int J Clin Pract. 2009 Oct; 63(10):1494–508.
3 Renneboog B, Musch W, Vandemergel X, Manto MU, Decaux G, Mild Chronic Hyponatremia is Associated with Falls, Unsteadiness and Attention Deficits. Am J Med. 2006 Jan;119(1):71.e1-8.
4 Hawkinds RC. Age and gender as risk factors for hyponatraemia and hyponatremia. Clin chem acta. 2003;337:169-172
5 Czerwiński E, Białoszewski D, Borowy P, Kumorek A, Białoszewski A, Epidemiology, clinical significance, costs and fall prevention in elderly people. Ortop Traumatol Rehabil. 2008 Sep-Oct;10(5):419-28
6 Verbalis JG, Barsony J, Sugimura Y, Tian Y, Adams DJ, Carter EA, Resnick HE. Hyponatremia-Induced Osteoporosis.J Bone Miner Res. 2009 Sep [Epub ahead of print]
7 Whelan B, Bennett k, O’Riordan D, B Silke, Serum Sodium a s a Risk Factor for in-Hospital Mortality in Acute Unselected General Medical Patients, Q J Med 2009;102:175–82.
8 Rossi J, Bayram M, Udelson JE, Lloyd-Jones D, Adams KF, O ‘Connor CM, et al Improvement in hyponatremia during hospitalization for worsening heart failure is associated with improved outcomes: insights from the acute and chronic therapeutic impact of a vasopressin antagonist in chronic heart failure (ACTIV in CHF) trial, Acute Card Care. 2007;9(2):82-6.
9 Karp BI, Laureno R, Central pontine and extrapontine myelinolysis after correction of hyponatraemia. The neurologist 2000;6:255–66.
10 Brandis K, Fluid physiology – an online text [cited 2009 Dec 22];Available from: URL http://www. anaesthesiamcq.com/FluidBook/index.php
11 Adrogué HJ, Madias NE. Hyponatremia. N Engl J Med. 2000 May 25;342(21):1581-9.
12 Nanji AA, Blank DW. Pseudohyponatremia and hyperviscosity. J Clin Pathol. 1983 Jul;36(7):834-5.
13 Ali N, Imbriano LJ, Maesaka J. The case: a 66-year-old male with hyponatremia. Kidney int 2009;76(2):233-4.
14 Kawai N, Baba A, Suzuki T, Shiraishi H. Roles of arginine vasopressin and atrial natriuretic peptide in polydipsia-hyponatremia of schizophrenic patients. Psychiatry Res. 2001 Feb 14;101(1):39-45.
15 RG, Fluid absorption in endoscopic surgery. Br J Anaesth. 2006 Jan;96(1):8-20.
16 Agraharkar M, Agraharkar A. Posthysteroscopic hyponatremia: evidence for a multifactorial cause. Am J Kidney Dis. 1997 Nov;30(5):717-9.
17 Ayus JC, Wheler JM, Arieff AI: Postoperative hyponatremic encephalopathy in menstruating women. Ann Intern Med1992: 117(11):891-897.
18 Ellison DH, Berl T. Clinical practice. The syndrome of inappropriate antidiuresis. N Engl J Med. 2007 May 17;356(20):2064-72. The term syndrome of
LITERATURE REVIEW
inappropriate antidiuresis (SIAD) rather than syndrome of inappropriate antidiuretic hormone (SIADH) is used in this article and throughout the above review as it is more appropriate considering a subset of patients with SIAD do not have a excess of vasopressin and have an inappropriately concentrated urine due to other defects, such as in the aquaporins in the the collecting duct.
19 Krahn J, Khajuria A. Osmolality gaps: diagnostic accuracy and long-term variability. Clin Chem. 2006 Apr;52(4):737-9.
20 Purssell RA, Lynd LD, Koga Y. The use of the osmole gap as a screening test for the presence of exogenous substances. Toxicol Rev. 2004;23(3):189-202.
21 Koga Y, Purssell RA, Lynd LD.The irrationality of the present use of the osmole gap: applicable physical chemistry principles and recommendations to improve the validity of current practices. Toxicol Rev. 2004;23(3):203-11.
22 Tally NJ, O’Connor S, Clinical examination: a systematic guide to physical diagnosis, 5th ed., Marrickville (Australia): Elsevier; 2006. p.21.
23 Milionis HJ, Liamis GL, Elisaf MS The hyponatremic patient: a systematic approach to laboratory diagnosis. CMAJ. 2002 Apr 16;166(8):1056-62.
24 Cerdà-Esteve M, Cuadrado-Godia E, Chillaron JJ, Pont-Sunyer C, Cucurella G, Fernández M, et al, Cerebral salt wasting syndrome, Eur J Intern Med. 2008 Jun;19(4):249-54.
25 Crook M, Algorithms in chemical pathology, Oxford : Butterworth-Heinemann; 1997. p 14-15
26 Karp BI, Laureno R, Pontine and extrapontine myelinolysis: a neurologic disorder following rapid correction of hyponatraemia, Medicine (Baltimore) 1993; 72:359-73.
27 Martin RJ et al. Central pontine and extra pontine myelinolysis: the osmotic demyelination syndromes J Neurosurg psychiatry, 2004 Sep;75 Suppl 3:iii22-8. 28 Verbalis JG, Goldsmith SR, Greenberg A, Schrier RW, Sterns RH. Hyponatremia treatment guidelines 2007: expert panel recommendations, Am J Med. 2007 Nov;120(11 Suppl 1):S1-21.
29.Adrogué HJ, Madias NE. Aiding fluid prescription for the dysnatremias, Intensive Care Med 1997;23:309- 16.
30. Gross P, Palm C Thiazides: do they kill? Nephrol Dial Transplant. 2005 Nov;20(11):2299-301.
31. Annane D, Decaux G, Smith N; Conivaptan Study Group. Efficacy and safety of oral conivaptan, a vasopressin-receptor antagonist, evaluated in a randomized, controlled trial in patients with euvolemic or hypervolemic hyponatremia. Am J Med Sci. 2009 Jan;337(1):28-36.
32. U.S. food and drug administration, Vaprisol: label and approval history 2008 Aug 10 [cited 2009 Dec22] Available from http://www.accessdata.fda.gov/ drugsatfda_docs/label/2008/021697s001lbl.pdf.
33 Oghlakian G, Klapholz M. Vasopressin and vasopressin receptor antagonists in heart failure. Cardiol Rev. 2009 Jan-Feb;17(1):10-5.
34 Hoque MZ, Arumugham P, Huda N, Verma N, Afiniwala M, Karia DH, Conivaptan: promise of treatment in heart failure. Expert Opin Pharmacother. 2009 Sep;10(13):2161-9.
35 Ghali JK, Hamad B, Yasothan U, Kirkpatrick P. Tolvaptan. Nat Rev Drug Discov. 2009 Aug;8(8):611-2. 36 Schrier RW, Gross P, Gheorghiade M, Berl T, Verbalis JG, Czerwiec FS, et al, Tolvaptan, a selective oral vasopressin V2-receptor antagonist, for hyponatremia. N Engl J Med. 2006 Nov 16;355(20):2099-112.
Downloads
Published
2010-01-01
How to Cite
Liddy, A. M. (2010). Hyponatraemia: Pathophysiology, treatment and future directions. Trinity Student Medical Journal , 11(1), Page 29–35. Retrieved from https://ojs.tchpc.tcd.ie/index.php/tsmj/article/view/1848
Issue
Section
Reviews
License
Authors retain copyright and grant the journal the right of first publication with the work simultaneously licensed under a Creative Commons Attribution (CC-BY) 4.0 License that allows others to share the work with an acknowledgement of the work’s authorship and initial publication in this journal.
Provided they are the owners of the copyright to their work, authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal’s published version of the work (e.g., post it to an institutional repository, in a journal or publish it in a book), with an acknowledgement of its initial publication in this journal.
