Disorders of Water Balance Hypo/Hypernatremia. Water-drinking contestants say they weren't told of...
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Transcript of Disorders of Water Balance Hypo/Hypernatremia. Water-drinking contestants say they weren't told of...
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Disorders of Water BalanceHypo/Hypernatremia
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Water-drinking contestants say they weren't told of health risks
From Associated Press7:18 PM PST, January 15, 2007
SACRAMENTO (AP) -- Two people who competed in a radio station's water drinking contest with a 28-year-old mother of three who later died said they were never warned they were putting their health at
risk, a newspaper reported Monday.
Gina Sherrod said that family members listening in on KDND-FM's "Hold Your Wee for a Wii" contest told her that a nurse called into the
program to warn that drinking too much water was dangerous, but that she did not worry until she learned of Jennifer Lea Strange's
death.
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Outline
• Hyponatremia: Physiology, differential, treatment. Case.
• Hypernatremia. Physiology, differential, treatment.
• Case
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Question
• How is water balance achieved in the face of increased water intake?
• By the excretion of dilute urine.
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Changes in Urinary Volume and Osmolality along the Nephron
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Defense against hyponatremia
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Control of Serum Na
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Retain 1L Water
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Serum Na Falls by 5meq/l
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Decreases Vasopression Release
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Approach to the hyponatremic patient
Hyponatremia
High Osmolality Normal Osmolality Low Osmolality
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Hyponatremia with high or Nml Osmolality
• TRANSLOCATION• GLUCOSE• MANNITOL• GLYCINE• MALTOSE
• PSEUDOHYPONATRE• PROTEIN• LIPIDS
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Pseudohyponatremia
• Normally serum is 93%water and 7% lipids.• If non aqueous portion of serum rose to 20%• Serum measured Na would be:• 150x0.8=120 as opposed to 150x0.93
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Pseudohyponatremia
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Approach to the hyponatremic patient with Low plasma osm
Hyponatremia with low Osm
Normally Dilute urine<100mosm
Uosm>100mosm
Psychogenic Polydipsia Low Solute intake
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Low Solute intake
Urine flow= urinary solute excretionurinary osmolality
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Sources of urinary solutes
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Psychogenic Polydipsia
• Usually acute• Common in institutionalized schizophrenics• Abnormal weight gains (as much as 10%)• Episodic symptoms that resolve with water
restriction
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Beer Potomania
• Large intake of fluid with beer as sole source of nutrition
• Beer sodium content <2meq/L• Beer Potassium content 10-12meq/L
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Beer Potomania
• Assume Beer consumption of 5L• Na intake 10mM• K intake 50mM• Obligatory urea excre 80mM
• V=Soluteexcretion 5=200• Uosm 40
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Approach to the hyponatremic patient with low plasma osm
Low plasma osm
Normally dilute urineUosm<100
Uosm>100mosmAlmost always vasopressin
mediated
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Diuretic Induced Hyponatremia
• Thiazides block diluting segment• May appear euvolemic• Most common in small elderly women• Associated with increased water intake and
low protein intake
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Hyponatremia in Edematous disorders
• Reflects advanced disease and poor prognosis• Decreased delivery to diluting sites• Increased vasopressin levels• Increased AQP2 expression
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Cerebral Salt wasting
• Most common in subarachnoid hemorrhage• Increased ANP and BNP• Loss of sodium, volume depletion which then
leads to increased ADH.• Different from SIADH as volume depleted.• Treat with saline
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Hyponatremia and SSRIs
• Four fold higher incidence than non users• First 2 weeks• More common in elderly• Not related to drug levels
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Features of SIADH
• Clinically euvolemic• Uosm>100mosm• Una=Na intake usually >20meq/L• Low bun and Uric acid
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Malignancies and SIADH
• Most common with small cell lung ca (10-15%)• mRNA for AVP in tumor• Head and neck tumors• Other isolated cases
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Treatment of Hyponatremia
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Treatment of Hyponatremia
• Three key Questions• How long has the hyponatremia been
present?• Does the patient have symptoms?• Does the patient have risk factors for the
development of neurologic complications?
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Duration of Hyponatremia acute
• <48hrs• Severe brain edema• Rapid correction is well tolerated• BUT WHEN IN DOUBT…Treat as chronic
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SXS of Hyponatremia
• Seizures• Herniation• Coma• Respiratory depression• death
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Patients at increased risk for neurologic complications
• Post op menstruant females• Elderly women on HCTZ• Children• Hypoxemic patients• Psychogenic polydipsia
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Duration of Hyponatremia Chronic
• 48hrs or unknown duration• Mild cerebral edema <10%• Sensitive to correction
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SXS of Chronic hyponatremia
• Nausea and vomitting• Muscle cramps and weakness• Ataxia• Confusion and personality changes• Seizure
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Symptomatic vs Asymptomatic
• Symptomatic hyponatremia warrents aggressive correction. (sz, severe neuro abnormalities). Most likely to occur in acute setting such as:
• Post op menstruating females• Exercise induced hyponatremia• Hyponatremia associated with ecstasy• Hyponatremia in patients with intracerebral
pathology, • Self induced water intoxication
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Symptomatic hyponatremia
• Aggressive correction at a rate of 1.5-2meq/L per hour for 3-4 hrs or until sxs resolve.
• Usually with hypertonic saline at 0.5ml/kg/hr• However no more than 10-12meq/24hrs and
18meq/48hrs.
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Asymptomatic but <115 or 110
• Such patient if they have sxs such as confusion, lethargy, gait disturbances will benefit from rise of 1meq/L/hr for 3-4 hrs but no faster than 8meq/24hrs.
• IF asymptomatic and >120meq/L then would benefit from free water restriction or treatment of volume depletion but no faster than 6-8meq/24hrs.
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Risk factors for Development of Osmotic demyelination
• Alcoholism• Malnutrition• Burns• Severe Potassium depletion• Elderly women on thiazide diuretics
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Case: acute Hyponatremia
• 31 yo female weighing 60Kg was admitted for elective hysterectomy. Normal preop exam and electrolytes. Underwent surgery with minimal intraop blood loss. During a 4 hr course in recovery she received 2 L NS and then ½ NS at 125cc/hr. At 12 hrs post op she made 1500cc urine. She complained of nausea and vomitting complicated by pain for which she received demerol. No record of oral intake. ½ NS continued.
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Case: acute Hyponatremia
• 30 hrs post op mental status changes developed. Serum Na was measured at 114meq/L. IV changed to NS at 200cc/hr for 5hrs during which she put out 750cc of urine. Una was 140meq and Uk was 52meq/L. The patient had a sz with respiratory arrest and death. Repeat Na was 112 meq/L
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Urine flow= urinary solute excretionurinary osmolality
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V2 Receptor antag
• Conivaptan is the only IV antagonist available in the US
• FDA approved for hospitalized euvolemic SIADH• Unclear of the rate of rise • Suggest use with 3% saline is symptomatic
hyponatremia.• Contraindicated in Liver patients as increased
variceal bleed and hypotension
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Hypernatremia
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Causes of hypernatremia
• 1. Inappropriately high water losses• 2. Insufficient water intake• 3. High Na intake without adequate water• 4. Thirst center/osmoreceptor lesion
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4. Impaired thirst or osmoreceptors
• Causes usually tumor, granulomatous dz, ischemia, primary aldosteronism, age.
• Na>146 but not thirsty. Dilute urine after any H20 with impaired osmoreceptors
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3. High NaCl intake without water
• Rare• Seawater ingestion• NaCl poisoning• Hypertonic Na or bicarb boluses.
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2. Insufficient water Intake
• Usually when ill or in the hospital setting• Inadequate Free water• Common after surgery, high nutrient intake
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1. Inappropriately high water losses
Sites of water loss1. insensible (sweat, breath)2. GI (vomitting, NG, Diarrhea)3. Kidney
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1. Inappropriately high water losses
• Renal losses• Osmotic diuresis- urea, mannitol, glucose,
diuretics• DI
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DI
• Vasopressinase production• Central (neurogenci) DI• Nephrogenic DI
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Vasopressin (ADH) Receptors
• V2 • Makes collecting duct permeable to water• V1• Increases systemic BP• Expressed in vasculature, liver and brain
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DI – lack of vasopressin
• Gestational DI• Central DI
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Gestational DI
• 1 in 300,000 pregnancies• Increased action of vasopressinase normally
from the placenta• Vasopressinase does not attack DDAVP as
rapidly
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Central (neurogenic) DI
• Acquired- tumor, trauma, autoimmune, granulomatous, vascular
• Congenital- autosomal dominant
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Nephrogenic
• Congenital• Acquired• Drugs- LI, demeclocycline• Hypercalcemia• Hypokalemia• Uretral obstruction• Renal insufficiency
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Treatment
• Acute<24hrs• Osmotic loss of brain water• Accumulation of electrolytes: Na, K• Chronic >24hrs• Accumulation of organic solutes such as myo-
inositol, sorbitol, others.
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Conclusions
• Hyponatremia and hypernatremia are critical. • Understand the physiology.• Slower correction unless the patient is
decompensting.• Always assume chronic when in doubt.• Multiple formulas but always recheck values at
several time points.• New drugs on the horizon. Unclear of benefit.