Types of Dehydration

Dehydration is water deficiency in the body. In dehydration, fluids from the blood and the space
between the cells (together called extracellular space) are lost first, which is followed by loss of fluid
from the cells (intracellular space). Dehydration can be categorized into isotonic, hypertonic and
hypotonic, depending on how it affects the tonicity of the extracellular fluids 1.
What are osmosis and osmolality?
The movement of water through the membrane from a solution with lower tonicity to a solution with
higher tonicity is called osmosis. Substances that increase tonicity of solutions and thus trigger osmosis
are called osmotically active substances. Sodium is the main osmotically active substance in the
extracellular fluid and its amount can change significantly in dehydration. The measure of the amount of
osmotically active substances in the solution is osmolality, which is expressed in milliosmoles of a
solute per kilogram of water (mOsm/L). The normal range of the blood plasma osmolality is 285-295
mOsm/kg.

When dehydration does not affect the concentration of sodium in the extracellular fluid, it is
called isonatremic dehydration or isotonic or iso-osmolar dehydration.

When dehydration results in an increased sodium concentration of the extracellular fluid, it is

called hypernatremic dehydration or hypertonic or hyperosmolar dehydration.

When dehydration results in a decreased sodium concentration of the extracellular fluids, it is

called hyponatremic or hypotonic or hypoosmolar dehydration.

Why is it important to know if dehydration is iso-, hyper- or hypotonic? Because this can suggest the
cause of dehydration and because hypotonic dehydration must be treated with great caution to avoid
severe neurologic damage.
Isotonic Dehydration
When proportionally the same amount of water and sodium is lost from the body, the sodium
concentration of the extracellular fluid and hence its tonicity will not change this is isotonic
dehydration. Statistically, in most cases (~ 80%) dehydration is isotonic 2
Lab test values in isotonic dehydration:
Blood tests:

Osmolality: 285-295 mOsm/kg (normal range)

Sodium: 130-150 mmol/liter (normal or slightly below or above normal range, which is 135-145
mmol/L)

Urine tests:

24-hour urine volume: decreased

Urine specific gravity: increased

Possible Causes of Isotonic Dehydration:

Excessive sweating and not drinking enough

Repeated vomiting

Diarrhea, including secretory diarrhea in cholera 10

Severe bleeding

Hypertonic (Hypernatremic) Dehydration

When proportionally more water than sodium is lost from the body, the extracellular fluid has increased
concentration of sodium and becomes hypertonic regarding the intracellular fluid and therefore attracts
water from the cells. This results in the cell shrinkage, which may cause brain shrinkage.
Lab test values in hypertonic dehydration:
Blood tests:

Osmolality: >300 mOsm/kg

Sodium >150 meq/liter (hypernatremia).

BUN (Blood Urea Nitrogen): increased

Urine tests:

24-hour urine volume: decreased or increased

Specific gravity: increased

Possible Causes of Hypertonic Dehydration:

Diarrhea in children, especially young infants (in 20% of pediatric diarrhea) 2

Water deprivation

Excessive sweating (hot weather, exercise, marathon) 20

2

Hyperventilation (prolonged fever, anxiety)

Poorly treated diabetes mellitus (osmotic diuresis 17, ketoacidosis 18)

Diabetes insipidus (both central and nephrogenic) 19

Heat stroke 11

End-stage renal failure

Drinking sea water in attempt to treat dehydration

Accidental infusion of hypertonic solutions

Certain diuretics

Hypotonic (Hyponatremic) Dehydration

When proportionally more sodium than water is lost, the sodium concentration of the extracellular fluids
falls, which therefore becomes hypotonic in comparison to intracellular fluid, so water moves from the
extracellular fluid into the cells. This causes cell swelling, possibly resulting in the brain swelling
(cerebral edema) 1.
Lab test values in hypotonic dehydration
Blood tests:

Osmolality: <250 mOsm/kg

Sodium <130 meq/L (hyponatremia).

Urine tests:

24-hour urine: increased

Specific gravity: decreased

Sodium <20 meq/L

Possible Causes:

Treating dehydration in small children or marathon runners with fluids that contain little or no
sodium 8

Vomiting or diarrhea (in some cases) 8

3

Gastrointestinal obstruction, fistula, ileus 8

Heat stroke 3,4,11

Heat exhaustion 4

Pancreatitis 5,8

Burns 3,7,8

Trauma (muscle damage) 6

Addisons disease 5

Ketonuria 8

Chronic malnutrition 4

Cystic fibrosis with excessive salt loss in sweat 9

Renal tubular acidosis 7

Salt-wasting nephropathy 5,7

Diuretics:

NOTE: certain causes, such as diarrhea, can cause isotonic, hypertonic or hypotonic dehydration.
Summary of electrolyte imbalances in dehydration:

Dehydration can be present without any significant electrolyte imbalance.

Hypernatremia is a result of dehydration.

Hyponatremia is not a result of dehydration but a result of replacing lost fluid by plain water
without sodium.

Hyperkalemia may be triggered by dehydration; it can be also present in acute or chronic

kidney failure, Addisons disease and diabetes 1, or destruction of the red blood cells in burns
18,19
.

Hypokalemia can develop in vomiting or diarrhea 16.

Mild and transient hypermagnesemia 13 and hypercalcemia 14 may result from decreased
amount of water in the blood (pseudo-hypermagnesemia and pseudo-hypercalcemia).

Hypocalcemia and hyperphosphatemia can occur in severe diarrhea