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CAUSES,DIAGNOSIS,AND MANAGEMENT
BY A H M E D A B D E L G E L I L , M D
DEFINITION
two classification systems used for the etiology of hyponatremia with a low
serum osmolality: one stratifies patients according to whether circulating
antidiuretic hormone (ADH) levels are inappropriately elevated or
appropriately suppressed, and the other stratifies patients according to
volume status (hypovolemia, normovolemia, or hypervolemia)
A)According to serum ADH levelsUrinary excretion of a water load
requires the suppression of ADH release, which is mediated by the
reduction in serum osmolality. An inability to suppress ADH release is the
most common cause of hyponatremia:1-True volume depletion, which can
be due to gastrointestinal losses (eg, vomiting or diarrhea) or renal losses
(most often thiazide rather than loop diuretics).2-Decreased tissue
perfusion (also called effective arterial volume depletion) due to reduced
cardiac output in heart failure or to systemic vasodilation in cirrhosis.3-A
CAUSES AND CLASSIFICATION
CONTINUED
B)According to volume status:1-Hypovolemia due to gastrointestinal
losses (eg, vomiting or diarrhea) or renal losses (most often thiazide rather
than loop diuretics).2-Normovolemia, which is most often associated with
the SIADH but can also be seen with primary polydipsia and a low dietary
solute intake.3-Hypervolemia due to heart failure or cirrhosis
Serum osmolarity equation :Sosm (mmol/kg) = (2 x serum [Na]) +
(serum [glucose]/18) + (blood urea nitrogen/2.8)
The two most common causes of hyponatremia with a low serum osmolality
are effective arterial blood volume depletion and the syndrome of
inappropriate antidiuretic hormone (ADH) secretion, both of which are
associated with persistent ADH release.
CAUSES AND CLASSIFICATION
CONTINUED
Effective arterial blood volume depletion can occur by two mechanisms:
true volume depletion; and edematous patients with heart failure or
cirrhosis in whom tissue perfusion is reduced because of a low cardiac
output or arterial vasodilation, respectively. The reduction in tissue
perfusion is sensed by baroreceptors at three sites: in the carotid sinus and
aortic arch that regulate sympathetic activity and, with significant volume
depletion, the release of antidiuretic hormone; in the glomerular afferent
arterioles that regulate the activity of the renin-angiotensin system; and in
the atria and ventricles that regulate the release of natriuretic
peptides.decreased tissue perfusion is a potent stimulus to the secretion of
ADH.This response is mediated by baroreceptors in the carotid sinus, which
sense a reduction in pressure or stretch, and can overcome the inhibitory
effect of hyponatremia on ADH secretion. Thus, water retention and
CAUSES AND CLASSIFICATION
CONTINUED
HYPONATREMIA WITH A HIGH Serum osmolarity :1-advanced renal
failure, the associated elevation in blood urea nitrogen can counteract the
fall in serum osmolality induced by hyponatremia. However, the effective
serum osmolality is reduced in proportion to the hyponatremia in this
setting since urea is an ineffective:Corrected Sosm = Measured Sosm -
(BUN 2.8).
2-marked hyperglycemia in patients with diabetic ketoacidosis or
hyperosmolar hyperglycemic state (also known as nonketotic
hyperglycemia).
CAUSES AND CLASSIFICATION
CONTINUED
Hyponatremia with normal serum osmolarity:1-Nonconductive irrigation
solutionsIsosmotic hyponatremia can be produced by the addition of an
isosmotic (or near isosmotic) but non-sodium-containing fluid to the
extracellular space. This problem primarily results from the absorption of
variable quantities of nonconductive glycine or sorbitol irrigation solutions
during transurethral resection of the prostate or bladder or during
hysteroscopy or laparoscopic surgery.These patients may develop marked
hyponatremia (below 110 meq/L) and neurologic symptoms.
2-Pseudohyponatremia which is associated with a normal serum
osmolality, refers to those disorders in which marked elevations in serum
lipids or proteins result in a reduction in the fraction of serum that is water
and an artificially low serum sodium concentration
EVALUATION AND MANAGEMENT