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Overview of the treatment of hyponatremia

INTRODUCTION

Hyponatremia represents a relative excess of water in relation to sodium. It can be induced by a marked increase in water intake (primary polydipsia) or, in the great majority of cases, by impaired water excretion resulting from advanced renal failure or from persistent release of antidiuretic hormone (ADH) induced by reduced effective arterial blood volume, the syndrome of inappropriate ADH secretion (SIADH), thiazide diuretics, adrenal insufficiency, or hypothyroidism. (See "Causes of hyponatremia in adults".)

Most patients with hyponatremia have chronic (ie, gradual onset) hyponatremia, a serum sodium concentration above 120 meq/L, and appear asymptomatic, although subtle neurologic abnormalities may be present when the serum sodium is between 120 and 130 meq/L. (See 'Necessity for therapy' below.)

Initial treatment in such patients typically consists of slow correction of the hyponatremia via fluid restriction or, if volume depletion is present, the administration of isotonic saline (or oral salt tablets) [1-3]. Vasopressin receptor antagonists also may be helpful. Among patients with SIADH, isotonic saline may worsen the hyponatremia. (See 'SIADH' below.)

More aggressive therapy is indicated in patients who have symptomatic or severe hyponatremia (serum sodium concentration below 120 meq/L). In this setting, initial therapy usually consists of hypertonic saline with or without vasopressin receptor antagonists.

The following issues are reviewed in this topic:

                          

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Literature review current through: Mar 2014. | This topic last updated: May 29, 2013.
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References
Top
  1. Sterns RH, Nigwekar SU, Hix JK. The treatment of hyponatremia. Semin Nephrol 2009; 29:282.
  2. Rose BD, Post TW. Clinical Physiology of Acid-Base and Electrolyte Disorders, 5th ed, McGraw-Hill, New York 2001. p.716.
  3. Verbalis JG, Goldsmith SR, Greenberg A, et al. Hyponatremia treatment guidelines 2007: expert panel recommendations. Am J Med 2007; 120:S1.
  4. Adrogué HJ, Madias NE. Hyponatremia. N Engl J Med 2000; 342:1581.
  5. Greenberg A, Verbalis JG. Vasopressin receptor antagonists. Kidney Int 2006; 69:2124.
  6. Oh MS, Uribarri J, Barrido D, et al. Danger of central pontine myelinolysis in hypotonic dehydration and recommendation for treatment. Am J Med Sci 1989; 298:41.
  7. Kamel KS, Bear RA. Treatment of hyponatremia: a quantitative analysis. Am J Kidney Dis 1993; 21:439.
  8. EDELMAN IS, LEIBMAN J. Anatomy of body water and electrolytes. Am J Med 1959; 27:256.
  9. Steele A, Gowrishankar M, Abrahamson S, et al. Postoperative hyponatremia despite near-isotonic saline infusion: a phenomenon of desalination. Ann Intern Med 1997; 126:20.
  10. Furst H, Hallows KR, Post J, et al. The urine/plasma electrolyte ratio: a predictive guide to water restriction. Am J Med Sci 2000; 319:240.
  11. LARAGH JH. The effect of potassium chloride on hyponatremia. J Clin Invest 1954; 33:807.
  12. Fichman MP, Vorherr H, Kleeman CR, Telfer N. Diuretic-induced hyponatremia. Ann Intern Med 1971; 75:853.
  13. Berl T, Rastegar A. A patient with severe hyponatremia and hypokalemia: osmotic demyelination following potassium repletion. Am J Kidney Dis 2010; 55:742.
  14. Rose BD. New approach to disturbances in the plasma sodium concentration. Am J Med 1986; 81:1033.
  15. Jovanovich AJ, Berl T. Where vaptans do and do not fit in the treatment of hyponatremia. Kidney Int 2013; 83:563.
  16. Schrier RW, Gross P, Gheorghiade M, et al. Tolvaptan, a selective oral vasopressin V2-receptor antagonist, for hyponatremia. N Engl J Med 2006; 355:2099.
  17. Berl T, Quittnat-Pelletier F, Verbalis JG, et al. Oral tolvaptan is safe and effective in chronic hyponatremia. J Am Soc Nephrol 2010; 21:705.
  18. Higashihara E, Torres VE, Chapman AB, et al. Tolvaptan in autosomal dominant polycystic kidney disease: three years' experience. Clin J Am Soc Nephrol 2011; 6:2499.
  19. Torres VE, Chapman AB, Devuyst O, et al. Tolvaptan in patients with autosomal dominant polycystic kidney disease. N Engl J Med 2012; 367:2407.
  20. Samsca (tolvaptan): Drug Warning - Potential Risk of Liver Injury. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm336669.htm?source=govdelivery (Accessed on January 28, 2013).
  21. Samsca (Tolvaptan): Drug Safety Communication - FDA Limits Duration and Usage Due To Possible Liver Injury Leading to Organ Transplant or Death. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm350185.htm (Accessed on May 20, 2013).
  22. Mohmand HK, Issa D, Ahmad Z, et al. Hypertonic saline for hyponatremia: risk of inadvertent overcorrection. Clin J Am Soc Nephrol 2007; 2:1110.
  23. Berl T. The Adrogue-Madias formula revisited. Clin J Am Soc Nephrol 2007; 2:1098.
  24. Mount DB. The brain in hyponatremia: both culprit and victim. Semin Nephrol 2009; 29:196.
  25. Sterns RH, Silver SM. Brain volume regulation in response to hypo-osmolality and its correction. Am J Med 2006; 119:S12.
  26. Chow KM, Kwan BC, Szeto CC. Clinical studies of thiazide-induced hyponatremia. J Natl Med Assoc 2004; 96:1305.
  27. Sterns RH. Severe symptomatic hyponatremia: treatment and outcome. A study of 64 cases. Ann Intern Med 1987; 107:656.
  28. Sterns RH, Cappuccio JD, Silver SM, Cohen EP. Neurologic sequelae after treatment of severe hyponatremia: a multicenter perspective. J Am Soc Nephrol 1994; 4:1522.
  29. Soupart A, Penninckx R, Stenuit A, et al. Treatment of chronic hyponatremia in rats by intravenous saline: comparison of rate versus magnitude of correction. Kidney Int 1992; 41:1662.
  30. Ayus JC, Wheeler JM, Arieff AI. Postoperative hyponatremic encephalopathy in menstruant women. Ann Intern Med 1992; 117:891.
  31. Karp BI, Laureno R. Pontine and extrapontine myelinolysis: a neurologic disorder following rapid correction of hyponatremia. Medicine (Baltimore) 1993; 72:359.
  32. Adrogué HJ, Madias NE. The challenge of hyponatremia. J Am Soc Nephrol 2012; 23:1140.
  33. Sterns RH, Hix JK, Silver S. Treatment of hyponatremia. Curr Opin Nephrol Hypertens 2010; 19:493.
  34. Moritz ML, Ayus JC. The pathophysiology and treatment of hyponatraemic encephalopathy: an update. Nephrol Dial Transplant 2003; 18:2486.
  35. Berl T. Treating hyponatremia: damned if we do and damned if we don't. Kidney Int 1990; 37:1006.
  36. Ayus JC, Arieff AI. Chronic hyponatremic encephalopathy in postmenopausal women: association of therapies with morbidity and mortality. JAMA 1999; 281:2299.
  37. Nzerue CM, Baffoe-Bonnie H, You W, et al. Predictors of outcome in hospitalized patients with severe hyponatremia. J Natl Med Assoc 2003; 95:335.
  38. Soupart A, Decaux G. Therapeutic recommendations for management of severe hyponatremia: current concepts on pathogenesis and prevention of neurologic complications. Clin Nephrol 1996; 46:149.
  39. Ayus JC, Krothapalli RK, Arieff AI. Changing concepts in treatment of severe symptomatic hyponatremia. Rapid correction and possible relation to central pontine myelinolysis. Am J Med 1985; 78:897.
  40. Gross P, Reimann D, Neidel J, et al. The treatment of severe hyponatremia. Kidney Int Suppl 1998; 64:S6.
  41. Arieff AI, Ayus JC. Endometrial ablation complicated by fatal hyponatremic encephalopathy. JAMA 1993; 270:1230.
  42. Ayus JC, Arieff A, Moritz ML. Hyponatremia in marathon runners. N Engl J Med 2005; 353:427.
  43. Hew-Butler T, Ayus JC, Kipps C, et al. Statement of the Second International Exercise-Associated Hyponatremia Consensus Development Conference, New Zealand, 2007. Clin J Sport Med 2008; 18:111.
  44. Sarnaik AP, Meert K, Hackbarth R, Fleischmann L. Management of hyponatremic seizures in children with hypertonic saline: a safe and effective strategy. Crit Care Med 1991; 19:758.
  45. Worthley LI, Thomas PD. Treatment of hyponatraemic seizures with intravenous 29.2% saline. Br Med J (Clin Res Ed) 1986; 292:168.
  46. Siegel AJ, Verbalis JG, Clement S, et al. Hyponatremia in marathon runners due to inappropriate arginine vasopressin secretion. Am J Med 2007; 120:461.e11.
  47. Sood L, Sterns RH, Hix JK, et al. Hypertonic saline and desmopressin: a simple strategy for safe correction of severe hyponatremia. Am J Kidney Dis 2013; 61:571.
  48. Renneboog B, Musch W, Vandemergel X, et al. Mild chronic hyponatremia is associated with falls, unsteadiness, and attention deficits. Am J Med 2006; 119:71.e1.