Investigation and Management of Hyponatraemia
NICOLA’S LOW SODIUM ‘TREE’
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Low sodium
History and Examination
Is there something obvious? eg
Medications!
Just had TURP or bowel prep
Decompensated liver disease
Do a chest X-ray in smokers
If yes, treat the underlying cause and monitor Na
On examination, patients fall in to one of 3 groups (see below):
If no improvement
Hypovolaemic
Urinary sodium 20
Renal losses eg
Diuretics
Mineralocorticoid deficiency
Osmotic diuresis
Salt-losing nephropathy (rare!)
Euvolaemic
Urinary sodium >20
Glucocorticoid deficiency
Hypothyroidism
SIADH*:
Medications!
Pulmonary disease
CNS disease
Hypervolaemic
Urinary sodium 20
Renal failure
Isotonic saline
Water restriction
Salt and water restriction
*SIADH is the most common cause of euvolaemic hyponatraemia. Before making a diagnosis of SIADH and water restricting a patient, it is essential to follow this ‘tree’. Essential diagnostic criteria for SIADH are: reduced serum osmolality (100, urinary sodium >40 with normal dietary salt intake, clinical euvolaemia, no diuretic use, and normal renal, adrenal, liver and thyroid function (do a short synacthen test – random cortisol can be normal in some patients with Addison’s).
Measure serum Na and osmolality and urine Na and osmolality
START HERE!
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