eMedicine Specialties > Nephrology > Acid-Base, Fluid, and Electrolyte Disorders
Hypernatremia: Differential Diagnoses & Workup
Updated: Apr 27, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
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Differential Diagnoses
Cirrhosis
Diabetes Mellitus, Type 1
Hypocalcemia
Hyponatremia
Other Problems to Be Considered
Other problems to consider include all other etiologies for metabolic or drug-induced encephalopathy (eg, cirrhosis, hyponatremia).
Metabolic encephalopathy accompanied by a history of poor oral intake, nursing home residency, the use of certain medications, the presence of appropriate comorbid conditions, increased volume, or insensible loss and obtundation should raise the suspicion of an elevated serum sodium concentration as a possible etiology for mental status changes.
Workup
Laboratory Studies
Diagnosis of hypernatremia is based on an elevated serum sodium concentration (Na+ >145 mEq/L). It is necessary to obtain the following lab studies:
- Serum electrolytes (Na+, K+, Ca2 +)
- Glucose level
- Urea
- Creatinine
- Urine electrolytes (Na+, K+)
- Urine and plasma osmolality
- 24-hour urine volume
- Plasma AVP level (if indicated)
The first step in the diagnostic approach is to estimate the volume status (intravascular volume) of the hypernatremic patient. The associated volume contraction may be mirrored in a low urine Na+ (usually <10 mEq/L).
In the hypovolemic patient, a hypertonic urine with a UNa+ <10 mEq/L will point towards extrarenal fluid losses (GI, dermal), whereas an isotonic or hypotonic urine with a UNa+ >20 mEq/L indicates renal fluid loss (diuretics, osmotic diuresis, intrinsic renal disease).
In the euvolemic patient with preserved intravascular volume, hypernatremia is most likely due to pure-water losses. In the presence of hypernatremia, urine osmolality normally should be maximally concentrated (>800 mOsm/kg H2 O). Measurement of the urine osmolality will allow differentiation of the following:
- Nonrenal causes with appropriately high urine osmolality - Isolated hypodipsia, increased insensible losses
- Renal water loss indicated by inappropriately low urine osmolality - Diabetes insipidus (often Uosm <300 mOsm/kg H2 O [central, nephrogenic, partial, gestational diabetes insipidus])
Caveat: Unfortunately, concentrating ability tends to fall with age; the maximum Uosm in an elderly patient may be only 500-700 mOsm/kg.
To distinguish between central and nephrogenic diabetes insipidus, first obtain a plasma AVP level and then determine the response of the urine osmolality to a dose of AVP (or preferably, the V2-receptor agonist DDAVP). Generally, an increase in urine osmolality of greater than 50% reliably indicates central diabetes insipidus, while an increase of less than 10% indicates nephrogenic diabetes insipidus; responses between 10% and 50% are indeterminate. Hyperosmolar patients with an elevated AVP level have nephrogenic diabetes insipidus; those with central diabetes insipidus will have inadequately low AVP level.
If the patient has polyuria without hypernatremia and will be evaluated for diabetes insipidus, the plasma sodium has to be above 145 mOsm/kg H 2 O prior to testing (via water deprivation test, hypertonic saline).
It is also clinically very useful to calculate the free-water clearance (cH 2 O), and it is even more important to calculate the electrolyte – free-water clearance (cH 2 Oe), to estimate the ongoing renal losses of hypotonic fluid (cH 2 O = Vurine [1-(UOsm/SOsm) ]; cH 2 Oe = Vurine [1-(UNa +UK)/SNa])
An example of the use of above calculations is a follows: An 80-year-old, partially demented man with poor nutritional status is admitted to the hospital because of pneumonia. Hyperalimentation with high protein supplementation is started (containing 30 mEq/L each of Na+ and K+). Following 5 days:
- Urine output: 4 L/day
- BUN: 20-88 mg/dL
- Cr: Stable at 1.4 mg/dL
- [Na+]: From 140 mEq/L up to 156 mEq/L (despite a relatively high fluid intake)
- Posm: 342 mOsm/kg
- Uosm: 510 mOsm/kg
- UNa+: 10 mEq/L
- UK+: 42 mEq/L
The free-water clearance is calculated as follows:
By this calculation, taking all osmoles into account, the patient retains 2 liters of water, improving hypernatremia; however, he is actually getting worse.cH2O = 4 x ( 1 - [510 ÷ 342] ) = -2 L/day
The electrolyte free-water clearance is calculated as follows:
The etiology of the hypernatremia is now apparent; the patient is losing approximately 2.7 L of free water per day in his urine, likely secondary to osmotic diuresis from hyperalimentation.eCH 2 O = 4 (1 - [(10 + 41) ÷ 156] ) = 2.7 L/day
Imaging Studies
- A magnetic resonance imaging (MRI) or computed tomography (CT) scan of the brain may be helpful in cases of central diabetes insipidus eventuating from head trauma or infiltrative lesions.
Histologic Findings
Histologic findings usually are noncontributory (although they may be helpful in central diabetes insipidus).
More on Hypernatremia |
| Overview: Hypernatremia |
 Differential Diagnoses & Workup: Hypernatremia |
| Treatment & Medication: Hypernatremia |
| Follow-up: Hypernatremia |
| Multimedia: Hypernatremia |
| References |
| Further Reading |
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References
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