HYPONATREMIA

&
HYPERNATREMIA
Prof. Dr. E. J. Joseph, SpPD-KGH

HYPONATREMIA

Plasma Sodium Concentration < 135

mEq/L ( Normal : 135 150 mEq/L )
Classification :
- Hypovolemic
- Euvolemic
- Hypervolemic

HYPOVOLEMIA : Hyponatremia
Associated with Decreased
Total Body Sodium :

Gastrointestinal and Third-Space

Sequestered Losses (Diarrhe or
Vomiting)
Diuretics (Loop Diuretics)
Salt-Losing Nephropathy
(Chronic Kidney Diseases)
Mineralocorticoid Defiiciency

HYPERVOLEMIC :
Hiponatremia Associated
with Increased Total Body
Sodium

Congestive Heart Failure

Hepatic Failure (Cirrhosis)
Nephrotic Syndrome
Renal Disease (Advanced)

EUVOLEMIA, HYPONATREMIA
ASSOCIATED WITH NORMAL
TOTAL BODY SODIUM

Glucocorticoid Deficiency (Primary

and secondary Adrenal Insufficiency)

Hypothyroidism

Psychosis

Post operative Hyponatremia

Drug Causing Hyponatremia

(Vasopresin Analog Clofibrate)

Syndrome of Inappropriate ADH

Secretion (SIADH)

CAUSES OF SIADH :
a. Carcinoma :

Bronchogenic Carcinoma
Carcinoma of the Duodenum
Carcinoma of the Pancreas
Carcinoma of the Stomach
Lymphoma

PULMONARY
DISORDERS :

Viral Pneumonia
Tuberculosis
Asthma
Pneumothorax
Bacterial Pneumonia

NERVOUS SYSTEM DISORDERS :

ENCEPHALITIS
MENINGITIS
HEAD TRAUMA
BRAIN TUMORS
GUILLIAN-BARRE SYNDROME
SUBARACHNOID HEMORAGIC
CEREBELLAR and CEREBRAL ATROPHY
CAVERNUS SINUS THROMBOSIS
CEREBROVASCULAR ACCIDENT
ACUTE PSYCHOSIS
OTHERS : IDIOPATIC (ELDERLY)

SYMPTOMS OF HYPONATREMIA :
Serum Na > 125 mmol/L Asymptomatic
Serum Na <125 mmol/L
Neuropsychiatric Symptoms (Cerebral
Edema) :

Headache
Lethargy
Ataxia
Psychosis
Seizures

- Coma

TREATMENT OF THE
HYPONATREMIC PATIENT :

Treatment the cause of Hyponatremia

Restriction of water Intake
Demeclochlortetracycline
Administration
(In a patient with
chronic SIADH who will not
voluntarily restrict water Intake)
Furosemide and Hypertonic Saline
(Nacl 3 %)

HYPERNATREMIA
Plasma Sodium Concentration > 150
mEq/L. Based Upon the Volume
Categories:
- Hypovolemic
- Euvolemic
- Hypervolemic

Hypovolemia : Hypernatremia
Assocrated with Low Total Body
Sodium
Losses of Both Na and Water, But with a
Relative Greater Loss of water
Renal Losses :
- Intrinsic Renal Disease
Extrarenal Losses :
- Excess Sweating
- Burns
- Diarrhea

Hypervolemia : Hypernatremia
Associated with Increased Total
Body Sodium

The Administrator of Hypertonic Solution

(NaCl 3%)

Euvolemia : Hypernatremia
Associated with Normal Body
Sodium
Renal Losses : - Diabetes Insipidus
Extrarenal Losses : - Insensible Losses

DIABETES INSIPIDUS :

Is a Disease Characterized by Polyuria and

Polydipsia and Caused by Defects In
Vasopressin Action ( ADH )

Central Diabetes Insipidus :

Inadequate Vasopresin Release

Nephrogenic Diabetes Insipidus :

Inpaired Renal Response to Vasopressin

Nephrogenic Diabetic Insipidus :

-Congenital
-Acquired

Acquired Nephrogenic Diabetic Insipidus :

a. Chronic Kidney Disease (Failure)
b. Electrolyte Disoerders :
- Hypokalemia
c. Pharmacologic Agents :
- Amphotericin
- Lithium

d. Sickle Cell Anemia

e. Gestational Diabetes Insipidus :
- Increase Circulating
Vasopressinase product by the
Placenta

Signs and Symptoms of

Hypernatremia :

Mostly Relate to the CNS :

- Altered Mental Status
- Lethargy
- Irritability
- Hyper Reflexia
- Intense Thirst

Treatment of Hypernatremic
Patients :

Restoration of Serum Tonicity

:
- Isotonic Saline
- Diuretic plus 5% Dextrose

HYPOKALEMIA
- Serum Potassium Concentration
< 3,8 mEq/L (Normal : 3,8 5,0
mEq/L)
A. Hypokalemia Secondary to Redistribution :
- Alkalosis
- Insulin Excess
- Hypokalemic Periodic Paralysis
(Recurrent Attacks of Flaccid Paralysis)

B. Potassium Depletion :
1. Extrarenal Potassium Loss :

- Excessive Sweating
- Chronic Diarrhea
- Vomiting
- Nasogastric Suctoon
2. Renal Potassium Loss:
- Occur from Medicatoous , Endogenous
Hormone Production, Intrinsic Renal
Defect

Drugs : - Thiazide
- Loop Diuretics
Endogenous Hormone :
- Aldosterone
Intrinsic Renal Defect :
- Bartter's Syndrome
- Liddle's Syndrome

Clinical Manifestations of
Hypokalemia :
- Cardiac :
- Predisposition to digitalis
intoxication
- Abnormal ECG
- Atrial and ventricular ectopic
beats
- Cardiac necrosis (rare)

Neuromuscular :
- Gastrointestinal : constipation
ileus
- Striated muscle : weakness,
paralysis
- Life threatining respiratory
paralysis
- Rhabdomyolysis

Kidney
- Reversible decrease in GFR,
mild
- Polyuria and Polydipsia
- Concentrating defect
- Thirst stimulation
- Increased renal ammonia
production
- Predisposition to hepatic coma
- Sodium Retention
- Hyponatremia (with concomitant
diuretic terapy)
- Chloride wasting
- Matabolic alkalosis

Endocrin
- Decrease in aldosterone
- Increase in renin
- Increase in prostaglandins
- Decrease in insulin
- Carbohydrate intolerance

Treatment :
- Tx Underlying Cause
- Additional Potassium :
- Oral
- Parenteral (Drips)

HYPERKALEMIA
* Serum Potassium Concentration
>5,0 mEq/L
- A Potential Complication In Any
Setting with Oliguria or Serious
Compromise of Renal Function
Etiology :
1. Redistribution
- Acidosis
- Insulin Deficiency

2. Increase In Total Body

Potassium :
- Renal Failure (Potassium
Retention)
- Mineralo Corticoid Deficiency
(Hyperchloremic Acidosis)

3. Drug Induced Hyperkalemia :

- Spiromolactone
- Amiloride
- Cyclosporine
- Tacrolimus

Clinical Manifestations :
- May be Asimptomatic or LifeThreatening
- Cardiac Conduction System
(Ventricular Fibrillatin, Vetricular
Asystole)
- Muscle Weakness
- Paralyses of Diaphragm

Treatment :
- Minimize the Cardiac Effect
- Induce Potassium Uptake by cells
- Removal Potassium from the
Body
(orally,Calcium Gluconate 10%
Solution 10 ml i.v over 10 minute,
Regular insulin 10 u i.v, with
Dextrose 50% 50 ml, Hemodialysis)