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HYPOTONIC HYPONATREMIA
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Hypotonic hyponatremia is true hyponatremia in a physiologic sense In this abnormality, water shifts into the cell, usually resulting in increased ICF Because the capacity of the kidney to excrete electrolytefree water is potentially great up to 20 30 L/d in the presence of a normal glomerular filtration rate (GFR) (100 L/d), electrolyte-free water intake must theoretically exceed
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Ca and Mg are measured as their total concentration Ca ion concentration is about half the total calcium concentration, while Mg ion concentration is about two-thirds the total magnesium concentration Modified and reproduced, with permission, from Cogan MG Fluid and Electrolytes: Physiology and Pathophysiology McGraw-Hill, 1991
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Fluid & Electrolyte Disorders
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HYPONATREMIA Serum osmolality
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Normal (280 295 mosm/kg) Isotonic hyponatremia 1 Hyperproteinemia 2 Hyperlipidemia (chylomicrons, triglycerides, rarely cholesterol)
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Low (< 280 mosm/kg) Hypotonic hyponatremia
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High (> 295 mosm/kg) Hypertonic hyponatremia 1 Hyperglycemia 2 Mannitol, sorbitol, glycerol, maltose 3 Radiocontrast agents
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Hypovolemic
Euvolemic
Hypervolemic
UNa+< 10 mEq/L Extrarenal salt loss 1 Dehydration 2 Diarrhea 3 Vomiting
UNa+> 20 mEq/L Renal salt loss 1 Diuretics 2 ACE inhibitors 3 Nephropathies 4 Mineralocorticoid deficiency 5 Cerebral sodiumwasting syndrome
1 SIADH 2 Postoperative hyponatremia 3 Hypothyroidism 4 Psychogenic polydipsia 5 Beer potomania 6 Idiosyncratic drug reaction (thiazide diuretics, ACE inhibitors) 7 Endurance exercise 8 Adrenocorticotropin deficiency
Edematous states 1 Congestive heart failure 2 Liver disease 3 Nephrotic syndrome (rare) 4 Advanced renal failure
Figure 21 1 Evaluation of hyponatremia using serum osmolality and extracellular fluid volume status ACE, angiotensin-converting enzyme; SIADH, syndrome of inappropriate antidiuretic hormone (Adapted, with permission, from Narins RG et al Diagnostic strategies in disorders of fluid, electrolyte and acid-base homeostasis Am J Med 1982 Mar;72(3):496 520)
30 L/d for hyponatremia to develop Instead, in hypotonic hyponatremia, retention of electrolyte-free water nearly always occurs because of impaired excretion (renal failure, inappropriate ADH excess, etc) Determinations of the urine osmolality and urine sodium are useful diagnostic tools Once a diagnosis of hypotonic hyponatremia has been made, an accurate determination of the patient s volume status is essential in directing further evaluation
osmolality Observations in patients with subarachnoid hemorrhage suggest that the cerebral salt-wasting syndrome is caused by increased secretion of brain natriuretic peptide with suppression of aldosterone secretion
B Euvolemic Hypotonic Hyponatremia
1 Syndrome of inappropriate antidiuretic hormone secretion (Table 21 3) Hypovolemia physiologically stimulates ADH secretion, so the diagnosis of SIADH is made only if the patient is euvolemic In SIADH, increased ADH release occurs without osmolality-dependent or volume-dependent physiologic stimulation Normal regulation of ADH release occurs from both the central nervous system and the chest via baroreceptors and neural input It follows that the causes of SIADH are disorders affecting the central nervous system structural, metabolic, psychiatric, or pharmacologic or the lungs Furthermore, some carcinomas, such as small cell lung carcinoma, synthesize ADH Other states associated with SIADH include administration of drugs that either increase ADH secretion or potentiate its action Patterns of abnormal ADH secretion include (1) random secretion, (2) reset osmostat, and (3) leakage of ADH In random secretion, ADH release is unrelated to osmoregulation This pattern is seen in carcinomas and central
A Hypovolemic Hypotonic Hyponatremia
Hyponatremia with decreased ECF volume occurs in the setting of renal or extrarenal volume loss (Figure 21 1) Total body sodium is decreased To maintain intravascular volume, ADH secretion increases, and free water is retained The drive to replenish intravascular volume overrides the need to sustain normal osmolality; losses of salt and water are replaced by water alone The combination of low fractional excretion of sodium (< 05%) and low fractional urea clearance (< 55%) is the best way to predict improvement with saline therapy Hyponatremia has been shown to develop in patients with intracranial diseases through renal sodium wasting Unlike those with syndrome of inappropriate ADH (SIADH) secretion, these patients are hypovolemic, though plasma levels of ADH are inappropriately high for the
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