Diagnostic Considerations

Other problems to consider in the differential diagnosis are as follows:

Hyperlipidemia
Paraproteinemia
Pseudohyponatremia

Differential Diagnoses

Workup

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Table. Guidelines for Management of Hyponatremia

Table. Guidelines for Management of Hyponatremia

	United States Guidelines	European Guidelines
Symptomatic Acute Hyponatremia < 24-48 hours
Urgent correction goal to aim to prevent brain herniation	Increase serum Na+ by 4-6 mmol/L	Increase serum Na+ by 5 mmol/L
Treatment based on symptoms
Severe symptoms	Bolus 100 mL of 3% NaCl over 10 minutes x 3 as needed	Bolus 150 mL of 3% NaCl over 20 minutes, 2- 3 times as needed, checking Na every 20 minutes (First-hour management, regardless of acute or chronic condition)
Moderate symptoms with low risk of herniation	Continuous infusion of 3% NaCl at 0.5-2 mL/kg/h	Bolus 150 mL 3% NaCl over 20 minutes, x 1 to prevent further decrease in Na
Limit not to exceed	None in true acute hyponatremia	None in true acute hyponatremia
Chronic Hyponatremia > 48 hours
Correction rate
Goal in symptomatic patients using hypertonic saline	4-8 mmol/L/d if low risk for ODS 4-6 mmol/L/d if high risk of ODS For patients with severe symptoms, the first day’s increase can be accomplished during first 6 h	Avoid > 10 mmol/L in the first 24 h And > 8 mmol/l during every 24 h thereafter
Limit to avoid potential harm in asymptomatic patients	10-12 mmol/L/d, but max 18 mmol in 48 h if at low risk for ODS 8 mmol/L/d if at high risk of ODS	10 mmol/L in the first 24 h and 8 mmol/l during every 24 h thereafter
Managing Overcorrection of Chronic Hyponatremia
	Baseline serum Na+ ≥ 120 mmol/L: Intervention probably unnecessary	Start once above mentioned limits are exceeded
	Baseline serum Na+ < 120 mmol/L: Replace water orally or as D5W at 3 mL/kg/h with or without desmopressin (2-4 µg every 8 h parenterally) Withhold any vasopressin receptor antagonists (vaptans) used Consider dexamethasone, 4 mg every 6 hr for 24 hr following excessive correction	Consult an expert to discuss infusion containing electrolyte-free water (10 mL/kg) over 1 h with or without 2 µg desmopressin IV every 8 h
Other Treatment Options
Hypovolemic hyponatremia	Isotonic saline	Isotonic saline or balanced solution at 0.5-1.0 mL/kg/h
Euvolemic hyponatremia (SIADH)	Fluid restriction of 500 mL/d below the 24-h urine volume (first-line treatment) Urea, vaptan, or demeclocycline (second-line treatment)	Fluid restriction (first-line) Urea or loop diuretics + oral NaCl (second-line) Do not recommend vaptans Recommend against lithium or demeclocycline
Hypervolemic hyponatremia	Fluid restriction, loop diuretic Vaptans	Fluid restriction Recommend against vaptans and demeclocycine

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Author

Seyed Mehrdad Hamrahian, MD Associate Professor of Medicine (Nephrology), Sidney Kimmel Medical College of Thomas Jefferson University; Director of American Society of Hypertension-Designated Jefferson Hypertension Center; Medical Director, Jefferson Nephrology Outpatient Clinic; Medical Director, Jefferson Home Hemodialysis Program; Medical Director of Chronic Dialysis Unit, DaVita City Line Dialysis

Seyed Mehrdad Hamrahian, MD is a member of the following medical societies: American Heart Association, American Society of Nephrology

Disclosure: Nothing to disclose.

Coauthor(s)

Omar H Maarouf, MD Associate Professor of Medicine, Director of Renal Course, Division of Nephrology, Sidney Kimmel Medical College of Thomas Jefferson University; Director of Acute Dialysis Unit, Associate Program Director of Renal Fellowship, Jefferson Renal Associates, Thomas Jefferson University Hospital

Omar H Maarouf, MD is a member of the following medical societies: American Society of Nephrology, National Kidney Foundation

Disclosure: Nothing to disclose.

Federico J Teran, MD Assistant Professor of Clinical Medicine, Section of Nephrology and Hypertension, Tulane University School of Medicine; Chief of Nephrology, VA Southeast Louisiana Healthcare System

Federico J Teran, MD is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Nephrology, Louisiana State Medical Society, National Kidney Foundation, Renal Physicians Association

Disclosure: Nothing to disclose.

Eric E Simon, MD Professor of Medicine, Chief, Section of Nephrology and Hypertension, Tulane University School of Medicine; Director, Nephrology Training, Medical Director, Dialysis Clinic, Inc, Canal Street

Eric E Simon, MD is a member of the following medical societies: American Federation for Medical Research, American Heart Association, American Physiological Society, American Society for Cell Biology, American Society of Nephrology, Central Society for Clinical and Translational Research, International Society of Nephrology, National Kidney Foundation, Phi Beta Kappa, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eleanor Lederer, MD, FASN Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD, FASN is a member of the following medical societies: American Association for the Advancement of Science, 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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: American Society of Nephrology<br/>Received income in an amount equal to or greater than $250 from: Healthcare Quality Strategies, Inc.

Chief Editor

Vecihi Batuman, MD, FASN Professor of Medicine, Section of Nephrology-Hypertension, Deming Department of Medicine, Tulane University School of Medicine

Vecihi Batuman, MD, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

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