Name = Hyponatremia
DiseasesDB = 6483
ICD10 = ICD10|E|87|1|e|70
ICD9 = ICD9|276.1
eMedicineSubj = emerg
eMedicineTopic = 275
eMedicine_mult = eMedicine2|med|1130 eMedicine2|ped|1124
Hyponatremia (British: "hyponatraemia") is an
electrolyte disturbance(disturbance of the salts in the blood) in which the sodium("Natrium" in Latin) concentration in the plasma is too low ("hypo" in Greek; in this case, below 135 mmol/L).
Severe or rapidly progressing hyponatremia can result in swelling of the brain (
cerebral edema), and the symptoms of hyponatremia are mainly neurological. Hyponatremia is most often a complication of other medical illnesses in which either fluids rich in sodium are lost (for example because of diarrheaor vomiting), or excess water accumulates in the body at a higher rate than it can be excreted (for example in polydipsiaor syndrome of inappropriate antidiuretic hormone, SIADH). There may also be spurious hyponatremia (pseudohyponatremia) if other substances expand the serum and dilute the sodium (for example, high blood levels of fats in hypertriglyceridemiaor high blood sugar in hyperglycemia).
The diagnosis of hyponatremia relies mainly on the
medical history, clinical examinationand blood and urine tests. Treatment can be directed at the cause (for example, corticosteroidsin Addison's disease) or involve restriction of water intake, intravenoussaline or drugs like diuretics, demeclocycline, ureaor vaptans( antidiuretic hormone receptor antagonists). Correcting the salt and fluid balance needs to occur in a controlled fashion, as too rapid correction can lead to severe complications such as heart failureor central pontine myelinolysis.
Most patients with chronic water intoxication are asymptomatic, but may have
symptoms related to the underlying cause.
Severe hyponatremia may cause osmotic shift of water from the plasma into the
braincells. Typical symptoms include nausea, vomiting, headacheand malaise. As the hyponatremia worsens, confusion, diminished reflexes, convulsions, stuporor comamay occur. Since nausea is, itself, a stimulus for the release of ADH, which promotes the retention of water, a positive feedback loopmay be created and the potential for a vicious circle of hyponatremia and its symptoms exists.
An abnormally low plasma sodium level is best considered in conjunction with the person's plasma
osmolarityand extracellular fluidvolume status.
Most cases of hyponatremia are associated with reduced
plasma osmolarity. In fact, the vast majority of adult cases are due to increased vasopressin, i.e., anti-diuretic hormone(ADH). Vasopressin is a hormone that causes retention of water; salt is also retained but to a lesser extent. Hence, the patient with hyponatremia can be viewed as the patient with increased ADH activity. It is the physician's task to identify the cause of the increased ADH activity in each case.
In patients who are volume depleted, i.e., their blood volume is too low, ADH secretion is increased, since volume depletion is a potent stimulus for ADH secretion. As a result, the kidneys of such patients recover water and produce a fairly concentrated urine. Treatment is simple (if not without risk) — simply restore the patient's blood volume, thereby turning off the stimulus for ongoing ADH release and water retention.
Some patients with hyponatremia have normal blood volume. In those patients, the increased ADH activity and subsequent water retention may be due to "physiologic" causes of ADH release such as pain or nausea. Alternatively, they may have the Syndrome of Inappropriate ADH (
SIADH). SIADH represents the sustained, non-physiologic release of ADH and most often occurs as a side effect of certain medicines, lung problems such as pneumonia or abscess, brain disease, or certain cancers (most often small cell lung carcinoma).
A third group of patients with hyponatremia are often said to be "hypervolemic". They are identified by the presence of peripheral edema. In fact, the term "hypervolemic" is misleading since their blood volume is actually low. The edema underscores the fact that fluid has left the circulation, i.e., the edema represents fluid that has exited the circulation and settled in dependent areas. Since such patients do, in fact, have reduced blood volume, and since reduced blood volume is a potent stimulus for ADH release, it is easy to see why they have retained water and become hyponatremic. Treatment of these patients involves treating the underlying disease that caused the fluid to leak out of the circulation in the first place. In many cases, this is easier said than done when one recognizes that the responsible underlying conditions are diseases such as liver cirrhosis or heart failure — conditions that are notoriously difficult to manage, let alone cure.
It is worth considering separately, the hyponatremia that occurs in the setting of diuretic use. Patients taking diuretic medications such as
furosemide(Lasix), hydrochlorothiazide, chlorthalidone, etc., become volume depleted. That is to say that their diuretic medicine, by design, has caused their kidneys to produce more urine than they would otherwise make. This extra urine represents blood volume that is no longer there, that has been lost from the body. As a result, their blood volume is reduced. As mentioned above, lack of adequate blood volume is a potent stimulus for ADH secretion and thence water retention.
Hyponatremia can also result from
adrenal insufficiency, congenital adrenal hyperplasia, hypothyroidism, and some medications. However, the vast majority of cases, and perhaps all, of medication-associated hyponatremia is not due to the medication "per se". Rather, the medication has caused SIADH or has led to volume depletion (see above)
Recent deaths from hyponatremia have been attributed to overintake of water while under the influence of
MDMA. This may also be related to inappropriate release of ADH that is stimulated by the drug [cite journal |author=Wolff K, Tsapakis EM, Winstock AR, "et al" |title=Vasopressin and oxytocin secretion in response to the consumption of ecstasy in a clubbing population |journal=J. Psychopharmacol. (Oxford) |volume=20 |issue=3 |pages=400–10 |year=2006 |month=May |pmid=16574714 |doi=10.1177/0269881106061514 |url=] . Detox diets, especially water fastingcan lead to hyponatremia if the intake of electrolytes is too low. [ [http://news.bbc.co.uk/2/hi/uk_news/7520756.stm Woman left brain damaged by detox] , BBC News, 2008-07-23]
Exercise Associated Hyponatremia
Almond "et al."cite journal |author=Almond CS, Shin AY, Fortescue EB, "et al" |title=Hyponatremia among runners in the Boston Marathon |journal=N. Engl. J. Med. |volume=352 |issue=15 |pages=1550–6 |year=2005 |month=April |pmid=15829535 |doi=10.1056/NEJMoa043901 |url=] found hyponatremia in as many as 13% of runners in a recent Boston Marathon, with life-threatening hyponatremia (serum Na below 120 mmol/L) in 0.6%. The runners at greatest risk of serious
water intoxicationhad moderate weight gain during the race due to excessive water consumption.
Exercise associated hyponatremia (EAH) is predominantly the occurrence of dilutional hyponatremia during or up to 24 hours after prolonged physical activity, caused by an increase in total body water relative to the amount of total body exchangeable sodium. This means consumption of fluids in excess of total body fluid losses and/or impaired renal water clearance: maximal urinary excretory rate is about 1 L/h in normal adults under resting conditions.
Inappropriate secretion of the hormone arginine vasopressin (AVP), or antidiuretic hormone, is also a contributory factor to the development of EAH. This excess hormone secretion prevents the kidneys from excreting the excess water in the urine.The primary means of avoiding EAH is to avoid excess fluid retention (weight gain during or after exercise). This can be accomplished by drinking only according to thirst and monitoring body weight before and during exercise - it is best to lose around two percent of body weight and never gain weight during exercise.
Ingestion of electrolyte-containing sports drinks cannot prevent the development of EAH in athletes who drink to excess.cite web |url=http://www.overhydration.org/downloads/EAH_Statement_2008.pdf |title=Statement of the Second International Exercise-Associated Hyponatremia Consensus Development Conference 2007 |format= |work= |accessdate=] cite journal |author=Siegel AJ, Verbalis JG, Clement S, "et al" |title=Hyponatremia in marathon runners due to inappropriate arginine vasopressin secretion |journal=Am. J. Med. |volume=120 |issue=5 |pages=461.e11–7 |year=2007 |month=May |pmid=17466660 |doi=10.1016/j.amjmed.2006.10.027 |url=]
Certain conditions that interfere with laboratory tests of serum sodium concentration (such as extraordinarily high blood levels of
lipidor protein) may lead to an erroneously low "measurement" of sodium. This is called pseudohyponatremia, and can occur when laboratories use the flame-photometric and indirect (but not direct) ion-selective electrode assays. [cite journal |author=Weisberg LS |title=Pseudohyponatremia: a reappraisal |journal=Am. J. Med. |volume=86 |issue=3 |pages=315–8 |year=1989 |month=March |pmid=2645773 |doi= |url=] [cite journal |author=Nguyen MK, Ornekian V, Butch AW, Kurtz I |title=A new method for determining plasma water content: application in pseudohyponatremia |journal=Am. J. Physiol. Renal Physiol. |volume=292 |issue=5 |pages=F1652–6 |year=2007 |month=May |pmid=17299138 |doi=10.1152/ajprenal.00493.2006 |url=] This is distinct from a true dilutional hyponatremia that can be caused by an osmotic shift of water from cells to the bloodstream after large infusions on mannitolor intravenous immunoglobulin.
When the plasma osmolarity is low, the extracellular fluid volume status may be in one of three states:
*Low volume. Loss of water is accompanied by loss of sodium.
Diureticdrugs (especially thiazides)
Cerebral salt-wasting syndrome
Treat underlying cause and give IV isotonic saline. It is important to note that sudden restoration of blood volume to normal will turn off the stimulus for continued ADH secretion. Hence, a prompt water diuresis will occur. This can cause a sudden and dramatic increase the serum sodium concentration and place the patient at risk for so-called "
central pontine myelinolysis" (CPM). That disorder is characterized by major neurologic damage, often of a permanent nature.
Because of the risk of CPM, patients with low volume hyponatremia may eventually require water infusion as well as volume replacement. Doing so lessens the chance of a too rapid increase of the serum sodium level as blood volume rises and ADH levels fall.
SIADH(syndrome of inappropriate antidiuretic hormone)
**Some cases of psychogenic
The cornerstone of therapy for SIADH is reduction of water intake. If hyponatremia persists, then
demeclocycline(an antibiotic with the side effect of inhibiting ADH) can be used. SIADH can also be treated with specific antagonists of the ADH receptors, such as conivaptanor tolvaptan.
*High volume. There is retention of water.
Congestive heart failure
Placing the patient on water restriction can also help in these cases.
* Craig Barrett, a New Zealand athlete, collapsed during a 50 km walk, probably due to
Matthew Carrington, a student at California State University in Chico, California, died of hyponatremia in February 2005 during a fraternity hazingritual [Cite web
title = A Fraternity Hazing Gone Wrong : NPR
accessdate = 2008-05-26
url = http://www.npr.org/templates/story/story.php?storyId=5012154] .
* James McBride, a police officer with the
Metropolitan Police Department of the District of Columbia, died of hyponatremia on August 10, 2005. Officer McBride had been participating in a strenuous bicycle patrol training course. During a 12-mile (19 km) training ride on the second day of the course, Officer McBride drank as much as three gallons (11 liters) of water [Cite web
title = Fallen Officer's Zeal Will Roll On
accessdate = 2008-05-26
url = http://www.washingtonpost.com/wp-dyn/content/article/2005/08/11/AR2005081101924_pf.html] .
Leah Betts[cite web | url=http://thedea.org/hyponatremia.html | title=Hyponatremia ("Water Intoxication") | publisher=The DEA.org | accessdate=2007-05-10] died on the 16th of November 1995 after taking an ecstasy tablet at her 18th birthday party and subsequently drinking too much water; the case received mass media coverage throughout the United Kingdom, which focused on the dangers of ecstasy.
* In January 2007 Jennifer Strange, a woman in
Sacramento, California, died following a water-drinking contest sponsored by a local radio station, Sacramento-based KDND-FM. [ [http://www.cnn.com/2007/US/01/13/water.intox.ap/index.html] ] The fact that the contest was called, "Hold your wee for a Wii" has led some to believe that not urinatingis related to hyponatremia. This is untrue; this type of water intoxication is caused by excessive and rapid consumption of (sodium-free) water.
* After completing the 2007 London Marathon, 22-year-old David Rogers collapsed and later died as a result of hyponatremia. [ [http://www.thesun.co.uk/article/0,,2007180872,00.html#cid=OTC-RSS&attr=TheSun:News] ]
* Professional Wrestler,
Michelle McCool, was hospitalized for 16 days in 2006 because of hyponatremia.Fact|date=July 2008
Sodium deficiency exists in grazing animals where soil sodium levels have been depleted by leaching. This is more common in mountainous regions.
Agricultural scienceresearch conducted in the northern Thai highlandsin the 1970s found that an endemic sodium deficiency masked all other nutrient deficiencies across all seasons and reduced productivity. Sodium supplementation increased liveweight gain by around 30% and also reproductive rates by around 30%. Simple salt supplementation is now recommended in this region and neighbouring mountains, as both a herd management tool and for increased productivity (see sources below).
Osmotic demyelination syndrome
* [http://sportsmedicine.about.com/cs/hydration/a/aa051200.htm Sports Medicine]
Lindsay Falvey(1979) 'Factors Limiting Cattle Production in the Northern Thailand Highlands'. Ph.D.Dissertation, University of Queensland, Australia.
* [http://www.rice.edu/~jenky/sports/salt.html Salt levels in sports]
* [http://www.carbboom.com/education/hyponatremia.php Hyponatremia and Endurace Exercise]
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Look at other dictionaries:
Hyponatremia — An abnormally low concentration of sodium in the blood. Too little sodium can cause cells to malfunction, and extremely low sodium can be fatal. The symptoms of hyponatremia include bloating and puffiness in the face and fingers, nausea, vomiting … Medical dictionary
hyponatremia — hy·po·na·tre·mi·a (hī pō nə trēʹmē ə) n. A deficiency of sodium in the blood. [hypo + New Latin natrium, sodium; see hypernatremia + emia.] * * * … Universalium
hyponatremia — noun An abnormally low concentration of sodium (or salt) in blood plasma. Ant: hypernatremia … Wiktionary
hyponatremia — n. low level of sodium in the blood (Medicine) … English contemporary dictionary
hyponatremia — hy·po·na·tre·mia … English syllables
hyponatremia — noun abnormally low level of sodium in the blood; associated with dehydration • Ant: ↑hypernatremia • Hypernyms: ↑symptom * * * ˌ ̷ ̷ ̷ ̷+nəˈtrēmēə noun ( s) Etymology: New Latin … Useful english dictionary
depletional hyponatremia — euvolemic h … Medical dictionary
dilutional hyponatremia — low plasma concentration of sodium resulting from loss of sodium from the body with nonosmotic retention of water, such as that induced by vasopressin; there may also be hypovolemia … Medical dictionary
euvolemic hyponatremia — low plasma concentration of sodium associated with low total body sodium and normal blood volume; called also depletional h … Medical dictionary
Syndrome of inappropriate antidiuretic hormone — Infobox Disease Name = Syndrome of inappropriate antidiuretic hormone | Caption = DiseasesDB = 12050 ICD10 = ICD10|E|22|2|e|20 ICD9 = ICD9|253.6 ICDO = OMIM = MedlinePlus = 003702 eMedicineSubj = emerg eMedicineTopic = 784 eMedicine mult =… … Wikipedia