eMedicine Specialties > Nephrology > Acid-Base, Fluid, and Electrolyte Disorders

Hyponatremia: Follow-up

Author: Eric E Simon, MD, Associate Professor, Department of Medicine, Tulane University School of Medicine; Co-Director of Nephrology Training, Medical Director, Dialysis Clinic, Inc
Coauthor(s): Seyed Mehrdad Hamrahian, MD, Staff Nephrologist, Ochsner Medical Center
Contributor Information and Disclosures

Updated: May 29, 2009

Follow-up

Further Inpatient Care

  • Patients with hyponatremia from any cause require close attention to their electrolyte and fluid status.
  • Patients with symptomatic hyponatremia who are being actively treated often require several daily measurements of serum sodium to avoid a rate of correction that is too rapid.
  • After acute treatment, follow-up generally is dictated by the underlying etiology of the hyponatremia.

Complications

  • Clinical manifestations include clouding of consciousness, confusion, stupor, or coma. Seizures commonly occur with rapid reductions in serum sodium or with serum sodium concentrations of less than 115-120 mEq/L.
  • For unknown reasons, premenopausal women seem to have a less efficient osmotic adaptation. This increases their susceptibility to severe hyponatremia and rapid progression from minimal symptoms (eg, headache, nausea) to respiratory arrest. Cerebral edema and herniation have been found at autopsy.27
  • Correction of hyponatremia that is too rapid may cause permanent neurologic impairment.
    • Central pontine myelinolysis (CPM) and extrapontine myelinolysis (EPM), complications of excessive correction of chronic hyponatremia, are now diagnosed by diffusion-weighted magnetic resonance imaging (MRI). Of note is that conventional CT and MRI scan findings typically lag behind the clinical manifestations of myelinosis by 2-4 weeks.28
    • The clinical course of the patient — initially encephalopathic secondary to hyponatremia, then improving as the plasma Na concentration increases, and finally deteriorating several days later — can resolve completely or result in permanent disability and fatalities. This typical clinical course has been called the osmotic demyelination syndrome (ODS). The clinical neurologic picture may be confusing, including a variety of findings from psychiatric, behavioral, and movement disorders to dysphagia, flaccid or spastic quadriparesis depending on the involvement of extrapontine or central pontine. Disruption of the blood-brain barrier is presumed to play an important role in the pathogenesis of osmotic demyelination.
    • An increased susceptibility to osmotic demyelination is also observed in cirrhotic patients. In this setting, myoinositol, the most abundant organic osmolyte, is depleted because of glutamine- and hyponatremia-induced brain cell swelling. CPM is a common and often fatal complication of orthotopic liver transplantation, affecting up to 10% of patients who were hyponatremic prior to transplant.29

Prognosis

  • The prognosis for hyponatremia is predicated upon the underlying etiology.

Patient Education

  • Patients to be treated with a fluid restriction often require education regarding the free water content of foods and an explanation of the need to limit the intake of liquids to a predetermined level.

Miscellaneous

Medicolegal Pitfalls

  • Inappropriate correction of hyponatremia that is too rapid may cause permanent neurologic sequelae. Recognizing hyponatremia early on, in order to take appropriate steps to prevent its worsening, is important. Recognizing hospitalized patients who are at risk for intolerance of free water loads also is necessary; monitor those patients carefully.

Special Concerns

  • The care of elderly patients often is complicated by any existing medical comorbidity; thus, a full medical assessment is required, with special attention paid to a patient's cardiovascular status.
  • In pregnancy, reset osmostat is a common cause of hyponatremia and is distinct from SIADH.
 


More on Hyponatremia

Overview: Hyponatremia
Differential Diagnoses & Workup: Hyponatremia
Treatment & Medication: Hyponatremia
Follow-up: Hyponatremia
References
Further Reading
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References

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Keywords

hyponatremia, SIADH, electrolyte, electrolytes, electrolyte imbalance, sodium deficiency, furosemide, hypertonic hyponatremia, hyponatraemia, hyponatremia treatment, hyponatremia causes, hyponatremia correction, tolvaptan, conivaptan, cerebral salt wasting, normotonic hyponatremia, hypotonic hyponatremia, normovolemic hypotonic hyponatremia, euvolemic hypotonic hyponatremia, abnormal electrolyte level, abnormal electrolyte distribution, congestive heart failure, liver failure, renal failure, hyperlipidemia, paraproteinemia, pseudohyponatremia, liver cirrhosis, nephrotic syndrome, severe hypoproteinemia, syndrome of inappropriate ADH secretion, severe hypothyroidism, adrenal insufficiency

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Contributor Information and Disclosures

Author

Eric E Simon, MD, Associate Professor, Department of Medicine, Tulane University School of Medicine; Co-Director of Nephrology Training, Medical Director, Dialysis Clinic, Inc
Eric E Simon, MD is a member of the following medical societies: American Federation for Medical Research, American Heart Association, American Society for Cell Biology, American Society of Nephrology, Association for Psychological Science, Central Society for Clinical Research, International Society of Nephrology, National Kidney Foundation, Phi Beta Kappa, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

Coauthor(s)

Seyed Mehrdad Hamrahian, MD, Staff Nephrologist, Ochsner Medical Center
Seyed Mehrdad Hamrahian, MD is a member of the following medical societies: American Society of Nephrology and National Kidney Foundation
Disclosure: Nothing to disclose.

Medical Editor

James H Sondheimer, MD, Director of Hemodialysis Unit, Harper Hospital; Associate Professor, Department of Internal Medicine, Division of Nephrology, Wayne State University School of Medicine
James H Sondheimer, MD is a member of the following medical societies: American College of Physicians and American Society of Nephrology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eleanor Lederer, MD, Consulting Staff, Louisville VA Hospital; Professor of Medicine, Director of Nephrology Training Program, Kidney Disease Program, University of Louisville School of Medicine; Director, Metabolic Stone Clinic
Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Rebecca J Schmidt, DO, FACP, FASN, Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine
Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association
Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Amgen Honoraria Speaking and teaching; Ortho Biotech Honoraria Speaking and teaching

Chief Editor

Vecihi Batuman, MD, FACP, FASN, Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System
Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology
Disclosure: Nothing to disclose.

 
 
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