hyponatremia and hypernatremia disorders of water...
TRANSCRIPT
Hyp
onat
rem
iaan
d H
yper
natr
emia
Dis
ord
ers
of W
ater
Bal
ance
Wat
er B
alan
ce
•W
ater
con
stitu
tes
app
roxi
mat
ely
55 -
60%
o
f th
e hu
man
bod
y (T
BW
).
•T
BW
is d
ivid
ed in
to:
•In
trac
ellu
lar
–2
/3
•E
xtra
cellu
lar
–1
/3•
Pla
sma
–¼
•In
ters
titia
l Flu
id –
¾
Dia
gram
fro
m U
pto
dat
e.
Dia
gram
fro
m U
pto
dat
e
•P
lasm
a os
mo
lalit
yin
hea
lthy
adu
lts is
m
ain
tain
ed w
ithin
a n
arro
w r
ange
27
5 –
290
mO
sm/k
g.
Stim
ulu
s fo
r A
VP
rel
ease
Dia
gram
fro
m U
pto
dat
e
•
Osm
otic
Reg
ulat
iono
f AD
H R
elea
se
Hyp
ovo
lem
icS
timul
usto
AD
H R
elea
se
An
ti D
iure
tic H
orm
on
eArg
inin
eV
aso
pre
ssin
(A
VP
)
Dia
gra
m f
rom
Upt
oda
te.
AV
P
•T
her
e ar
e tw
o m
ajo
r re
cep
tors
for
AV
P:
•T
he
V1
(V1
a an
d V
1b)
and
V2
rece
pto
rs.
•A
ctiv
atio
n o
f th
e V
1 r
ecep
tors
ind
uces
va
soco
nst
rictio
n an
d en
hanc
emen
t of
pro
stag
lan
din
rel
ease
.
•A
ctiv
atio
n o
f th
e V
2 r
ecep
tors
med
iate
s th
e an
tidiu
retic
resp
ons
e.
Vas
opr
essi
n b
ind
s to
V2
rec
epto
r ac
tivat
es a
den
ylcy
clas
ean
d p
rom
ote
s cA
MP
pro
duct
ion
, wh
ich
st
imu
late
s p
rote
in k
inas
eA
(P
KA
) an
d p
hosp
hor
ylat
esaq
uap
orin
2.
Th
is c
ause
s A
quap
orin
mo
vem
ent t
o
and
exo
cytic
inse
rtio
n o
f th
e ve
sicl
e in
to th
e ap
ica
l me
mb
ran
es.
Ren
al A
quap
orin
s: A
n o
verv
iew
. N
iels
en, S
, BJU
Int
. 200
2
Sch
emat
ic r
epre
sent
atio
n of
the
loca
lizat
ion
of r
enal
aq
uapo
rins
and
dist
ribut
ion
of a
quap
orin
1,2,
3 an
d 4
in th
e ki
dney
. Re
nal A
qua
porin
s: A
n ov
erv
iew
. N
iels
en,
S.
BJU
Int
. 2
002
Hyp
onat
rem
ia
•M
ost
co
mm
on
ele
ctro
lyte
dis
ord
er in
ho
spita
lized
p
atie
nts.
Stu
dy
by
Ho
orn
et a
l, in
Nep
hro
lDia
l Tra
nsp
lan
t 20
06, l
ooke
d a
t 2
,907
ho
spita
lized
pat
ien
ts o
ver
3 m
ont
hs th
e in
cid
en
ce o
f h
ypo
nat
rem
iaw
as 3
0% a
nd
seve
re h
ypo
nat
rem
ia(<
125
Meq
/L)
was
3%
.
•G
ener
ally
def
ined
as
S. N
a le
vel l
ess
than
13
6
mm
ol/L
, th
ou
gh d
efin
itio
n o
f sev
ere
hyp
on
atre
mia
varie
s fr
om 1
10
to 1
25
mm
ol/L
.
Hyp
onat
rem
ia
•P
artic
ular
ly p
reva
lent
in th
e el
derly
pop
ulat
ion
due to
:•
Ag
e re
late
d d
eclin
e in
ren
al fu
nct
ion
.•
Th
irst m
ech
anis
m d
imin
ish
es w
ith a
ge,
incr
easi
ng r
isk
of
volu
me
dep
letio
n.•
Dec
reas
ed a
bili
ty to
dilu
te th
e ur
ine.
•In
crea
sed
sec
retio
n o
f AV
P p
er u
nit i
ncr
ease
in p
lasm
a os
mo
lalit
yin
old
er p
atie
nts
.
•In
a s
tudy
of 1
19 N
ursi
ng H
om
e re
side
nts
over
the
age
of
60, 5
3% o
f res
iden
ts h
ad a
t lea
st o
ne e
piso
de o
f hy
pona
trem
iadu
ring
a 12
mon
th fo
llow
-up.
(M
iller
et
al,
Jour
nal A
mer
ican
Ger
iatr
ic S
ocie
ty 1
995)
Hyp
onat
rem
ia
•C
har
acte
rized
by
an e
xces
s o
f ext
race
llula
rw
ater
rel
ativ
e to
ext
race
llula
rso
diu
m.
•T
her
efor
e mai
nly
a p
rob
lem
of w
ater
b
alan
ce, t
hou
gh
the
tota
l sod
ium
con
ten
t in
p
atie
nts
with
hyp
ona
trem
iam
ay b
e no
rmal
, d
ecre
ased
or
even
incr
ease
d.
•E
xcre
tion
and
ab
sorp
tion
of fr
ee w
ater
by
kidn
eys
in u
nder
the
con
trol
of A
DH
Eva
luat
ion
of H
ypon
atre
mia
•In
itial
lab
s N
eed
ed:
•S
erum
Osm
olal
ity
•U
rine
Osm
ola
lity
–if
>10
0mm
ol/k
g th
ere
is e
leva
ted
AD
H p
rese
nt.
•U
rine
spo
t sod
ium
•O
ther
hel
pfu
l lab
s;•
Ser
um U
ric
acid
–lo
w in
SIA
DH
an
d sa
lt w
astin
g ne
phro
path
y
•T
SH
, Cor
tisol
, Cre
atin
ine
Eva
luat
ion
of H
ypon
atre
mia
Div
ided
into
:
•E
leva
ted
S. O
smo
lalit
y:
•H
yper
gly
cem
ia o
r m
ann
itoli
nfu
sion
•N
orm
al S
. Osm
ola
lity:
•
Hyp
erp
rote
inem
iao
r h
yper
lipid
emia
(pse
ud
ohyp
on
atre
mia
)
•D
ecre
ased
S. O
smo
lalit
y: W
ide
diff
eren
tial.
Pse
ud
ohy
po
nat
rem
ia
Clin
ical
Dia
gnos
tic
Alg
orit
hm f
or H
ypon
atre
mia
John
son
and
Fee
hally
(tex
tboo
k)
Hyp
ovol
emia
asso
ciat
ed w
ith d
ecr
ease
d to
tal b
ody
sod
ium
•G
I los
ses
and
Thi
rd S
pace
Seq
uest
ered
Los
ses:
•U
rine
Na
will
be
low
, u
sual
ly <
10m
mo
l/L a
nd
the
ur
ine
is
hyp
ero
smo
lar.
•In
pat
ien
ts w
ith v
om
iting
and
met
abol
ic a
lkal
osi
s, b
icar
bon
atur
iao
ccur
s an
d H
CO
3 is
lost
with
Na,
so
the
urin
e N
a m
ay
be
gre
ater
th
an 2
0m
mo
l/L,
the
Clh
ow
ever
will
stil
l be
<10
mm
ol/L
•D
iure
tics
•A
sso
ciat
ed w
ith h
igh
urin
e N
a >
20m
mo
l/L.
•H
ypon
atre
mia
occ
urs
alm
ost
exc
lusi
vely
with
the
use
of t
hia
zid
ed
iure
tics.
•U
nder
wei
ght
wo
men
and
eld
erly
pat
ien
ts m
ore
pro
ne
to it
.
•H
ypon
atre
mia
usu
ally
occ
urs
with
in 1
4 d
ays
of i
niti
ati
on o
f th
erap
y.
•S
alt L
osin
g N
ephr
opat
hy•
Occ
urs
in p
atie
nts
with
ad
vanc
ed C
KD
, and
dis
ord
ers
su
ch a
s B
arte
rs a
nd G
itlem
ans
synd
rom
e a
mo
ng
oth
ers,
an
d is
ch
arac
teriz
ed b
y h
ypo
nat
rem
iaan
d h
ypo
vole
mia
.
•M
iner
aloc
ortic
oid
defic
ienc
y•
Urin
e N
a >
20m
mo
l/L.
•D
ecre
ased
EC
F v
olu
me
pro
vid
es th
e s
timu
lus
for
vaso
pres
sin
rele
ase.
•O
smot
ic d
iure
sis
•D
iab
etic
pat
ient
with
sev
ere
hyp
erg
lyce
mia
, m
ann
itol
diur
esis
or
ure
a d
iure
sis
afte
r re
lief o
f urin
ary
trac
t obs
tru
ctio
n
•U
rinar
y N
a ty
pica
lly >
20
mm
ol/L
. N
a w
astin
g in
dia
betic is
ac
cen
tuat
ed b
y ke
ton
uria
.
•C
ereb
ral s
alt w
astin
g•
Usu
ally
occ
urs
with
sub
arac
hnoi
dh
emor
rhag
e. M
ech
ani
sm
pos
tula
ted
to b
e re
leas
e of
BN
P fr
om
bra
in w
ith r
esul
tan
t in
crea
se
in N
a ex
cret
ion
an
d h
ypov
ole
mia
Hyp
ervo
lem
iaas
soci
ated
with
incr
ease
d to
tal b
ody
sod
ium
•C
onge
stiv
e H
eart
Fai
lure
•D
ecre
ased
intr
avas
cula
r ci
rcul
atin
g v
olu
me.
•U
rine
Na
< 2
0mm
ol/L
•H
epat
ic F
ailu
re•
Sh
are
sam
e p
ath
oph
ysio
log
icm
ech
anis
ms
with
pat
ien
ts w
ith h
eart
fa
ilure
.
•N
ephr
otic
Syn
drom
e•
So
me
pat
ien
ts h
ave
intr
avas
cula
r vo
lum
e d
eple
tion
res
ulti
ng fr
om
hyp
oal
bu
min
emia
and
low
ered
pla
sma
onco
ticpr
essu
re.
•A
dvan
ced
CK
D•
Incr
ease
d in
frac
tion
al e
xcre
tion
of N
a an
d na
rro
w r
ang
e of
wat
er
han
dlin
g le
ads
to u
rine
Na
>20
mm
ol/L
and
wat
er r
ete
ntio
n.
Hyp
onat
rem
iaa
ssoc
iate
d w
ith n
orm
al
tota
l bo
dy s
odiu
m
•G
luco
cort
icoi
dde
fienc
y
•H
ypot
hyro
idis
m
•P
sych
osis
•P
osto
pera
tive
hypo
natr
emia
•D
rugs
•S
IAD
Syn
drom
e of
Inap
prop
riate
Ant
idiu
resi
sS
IAD
•N
ew
er te
rmin
olo
gy
sin
ce n
ot a
ll p
atie
nts
hav
e el
evat
ed c
ircu
latin
g le
vels
of A
VP
. It i
s d
ivid
ed
into
:•
SIA
DH
–S
ecre
tion
of A
VP
is in
depe
nden
t of s
erum
os
mol
ality
.•
Res
et O
smo
stat
–A
VP
doe
s be
com
e fu
lly s
uppr
esse
d,
resu
lting
in d
ilute
urin
e, b
ut a
t a S
. Na
low
er th
an
norm
al•
Mut
atio
ns in
the
wat
er c
hann
el r
egul
atin
g va
sopr
ess
in
rece
ptor
, res
ultin
g in
con
cent
rate
d ur
ine
in th
e ab
senc
e of
AV
P.
Dia
gnot
icC
riter
ia fo
r S
IAD
•E
ssen
tial f
eatu
res:
•S
. Osm
o<
275
mO
sm/K
g of
wat
er•
U.
Osm
o>
100
mO
sm/K
g of
wat
er•
Clin
ical
Euv
olem
ia•
Uri
nary
sod
ium
>40
mm
ol/L
(w
ith n
orm
al d
iete
rysa
lt in
take
).•
Nor
mal
thyr
oid,
adr
enal
and
ren
al fu
nctio
n.•
No
rece
nt u
se o
f ant
idiu
retic
s•
Su
pp
lem
enta
l fea
ture
s:•
Pla
sma
uric
aci
d <
4 m
g/dl
•B
UN
< 1
0m
g/dl
•F
eNa
>1%
: Feu
rea
>55
%•
Fai
lure
to c
orre
ct h
ypon
atem
iaaf
ter
0.9%
sal
ine.
Dru
gs a
ssoc
iate
d w
ith h
ypon
atre
mia
Joh
nso
n an
d F
eeh
ally
(Tex
tbo
ok)
Hyp
onat
rem
iano
t rel
ated
to
incr
ease
d A
DH
sec
retio
n•
If in
itial
urin
e o
smo
lalit
yis
< 1
00m
osm
ol/k
g:
•P
sych
ogen
ic P
olyd
ipsi
a
•B
eer
Pot
oman
ia
•If
initi
al u
rine
osm
ola
lity
is >
100
mo
smo
l/kg
:•
Res
et o
smos
tat
•S
alt l
osin
g ne
phro
path
y (r
enal
sod
ium
exc
retio
n fr
om
th
e ex
cess
ive
rele
ase
of n
atri
uret
icfa
ctor
in th
e b
rain
)
Low
Die
tary
Sol
ute
Inta
ke
•M
ost p
eopl
e ta
ke in
and
exc
rete
600
–10
00m
osm
ol/k
g.
Uri
nary
osm
oles
are
mai
nly
salt
and
urea
(gl
ucos
e us
ually
ge
ts m
etab
oliz
ed).
•E
xam
ple:
Per
son
is ta
king
in a
nd e
xcre
ting
600m
osm
ol/k
g.
If yo
u ca
n di
lute
you
r ur
ine
dow
n to
60m
osm
ol/k
g –
you
ca
n ex
cret
e up
to10
L ur
ine/
day.
•If
som
eone
onl
y ta
kes
in 2
40m
osm
ol/k
g, th
en a
t the
lo
wes
t ur
ine
osm
olal
ity(6
0 m
osm
ol/k
g), t
hey
can
only
exc
rete
ab
out 4
L of
uri
ne/d
ay.
The
refo
re, i
f tha
t per
son
dri
nks
any
mor
e th
an 4
L/da
y, th
e ex
tra
wat
er s
tays
beh
ind
and
caus
es
hypo
natr
emia
.
Psy
chog
enic
Pol
ydip
sia
•S
ame
con
cep
t app
lies:
•If
a p
erso
n is
taki
ng
in 6
00
mo
smo
l/kg
, at
max
imu
m u
rine
dilu
tion
( 6
0 m
osm
ol/k
g),
they
ca
n o
nly
get
rid
of
10
L o
f w
ater
. If
they
drin
k m
ore
than
th
at th
ey w
ill r
etai
n w
ater
an
d
bec
om
e h
ypo
nat
rem
ic.
Ran
ge o
f Sym
ptom
s of
H
ypon
atre
mia
•N
on
-sp
ecifi
c N
euro
log
ical
Sym
pto
ms:
•C
onfu
sion
•H
eada
che
•N
ause
a an
d vo
miti
ng•
Mus
cle
cram
ps•
Sev
ere
Ne
uro
log
ical
Co
mp
licat
ion
s:•
Sei
zure
s•
Bra
inst
em h
erni
atio
n•
Co
ma
•D
eath
Bra
in A
dapt
atio
n to
Hyp
onat
rem
ia
•O
smo
tic c
ereb
ral o
edem
ath
at o
ccur
s w
ith
pla
sma
hypo
-osm
ola
lity
and
hyp
ona
trem
iaaf
fect
s bo
th in
trac
ellu
lar
and
ext
race
llula
rco
mpa
rtm
ents
in th
e g
ray
and
wh
ite m
atte
r.
•C
ereb
ral o
edem
ais
cou
nte
ract
ed b
y an
ad
aptiv
e p
roce
ss k
now
n as
reg
ula
tory
vo
lum
e de
crea
se (
RV
D)
that
no
rmal
izes
cel
l vo
lum
e.
Bra
in A
dapt
atio
n to
Hyp
onat
rem
ia
•R
VD
(R
egul
ator
y V
olum
e D
ecre
ase)
:
•1-
Dis
plac
emen
t of f
luid
fro
m th
e in
ters
titia
l to
the ce
rebr
ospi
nal f
luid
and
sys
tem
ic c
ircul
atio
n (d
rive
n by
hy
dros
tatic
pre
ssur
e).
•2-
Ext
rusi
on fr
om
the
brai
n ce
lls o
f ino
rgan
ic,
osm
otic
ally
activ
e so
lute
s in
clud
ing
sodi
um c
hlor
ide
(l
ost w
ithin
min
utes
), p
otas
sium
(m
ore
gra
dual
ly –
com
plet
e in
abo
ut 3
hrs
).•
3-E
xtru
sion
fro
m th
e br
ain
of o
rgan
ic o
smol
ytes
, pr
imar
ily a
min
oaci
ds(m
yoin
osito
lis
the
mos
t pre
vale
nt
orga
nic
osm
olyt
ein
the
hum
an b
rain
) –
occu
rs o
ver
next
48
hrs.
•In
ani
mal
stu
dies
we
have
see
n th
ese
adap
tive
resp
onse
s lim
it th
e in
crea
se in
bra
in w
ater
to 4
% h
ighe
r th
an n
orm
onat
rem
ican
imal
. W
ithou
t the
ext
rusi
on o
f
the
orga
nic
osm
olyt
es, t
he in
crea
se in
bra
in w
ater
w
ould
be
>10
% -
whi
ch is
inco
mpa
tible
with
sur
viva
l.
Bra
in A
dapt
atio
n to
Hyp
onat
rem
ia
•A
cute
hyp
onat
rem
ia(o
ver
< 2
4 h
r) c
an
ove
rwh
elm
this
pro
tect
ive
mec
han
ism
.
•If
the
dec
line
in s
erum
Na
is s
low
and
g
radu
al (
> 4
8hr
s), c
ereb
ral s
wel
ling
and
the
neu
rolo
gic
al s
ympt
om
s ar
e m
inim
ized
.
Cor
rect
ion
of H
ypon
atre
mia
•T
he
pla
sma
sod
ium
co
nce
ntr
atio
n c
an b
e ra
ised
in
hyp
onat
rem
icp
atie
nts
eith
er b
y:•
Res
tric
ting
wat
er in
take
.
•B
y gi
ving
sal
t.
•B
y gi
ving
vas
opre
ssin
rec
epto
r an
tago
nist
.
•T
he
cho
ice
of t
her
apy
is p
rimar
ily g
ove
rned
by
the
cau
se a
nd
sev
erity
of t
he
hyp
on
atre
mia
.
Cor
rect
ion
of H
ypon
atre
mia
•S
ymto
mat
ic/A
cute
Hyp
onat
rem
ia-
corr
ect
by
1.5
–2
.0 M
eq/l
per
hr.
in fi
rst 4
hrs
, bu
t to
tal c
orre
ctio
n fo
r 24
hr.
sho
uld
stil
l be
abo
ut 1
2 M
EQ
/L p
er d
ay.
•A
sym
pto
mat
ic/C
hron
ic H
ypon
atre
mia
–co
rrec
t by
0.5
Meq
/L p
er h
r., o
r 1
0 –
12
Meq
/L p
er d
ay.
Cal
cula
ting
the
rate
of c
orre
ctio
nfo
r se
vere
sym
ptom
atic
hyp
onat
rem
iaw
ith 3
% s
alin
e b
ased
on
Na
defic
iet
Exa
mpl
e: 7
0kg
patie
nt w
ith S
. Na
of 1
10.
•(
0.6
x 70
kg)
x (
120
-110
) =
420
ME
Q d
efic
eito
f Na
.•
Cor
rect
at r
ate
of 1
.5m
eq/L
/hr
you
wou
ld r
equi
re to
giv
e 42
0meq
ove
r 6.
6hr.
-64
meq
/hr.
•3%
NS
has
513
ME
Q/L
of N
a –
ther
efor
e ro
ughl
y ev
ery
2cc
of 3
% s
alin
e w
ill h
ave
1meq
of N
a. Y
ou w
oul
d h
ave
to g
ive
128c
c/hr
.•
Thi
s sh
ould
be
the
initi
al c
orre
ctio
n ra
te fo
r th
e fir
st 4
hrs
, ch
ecki
ng th
e la
bs q
2hr
. Rem
em
ber
you
wan
t to
corr
ect
10
-12
ME
Q to
tal o
ver
24 h
rs.
Why
not
use
0.9
% N
S a
lone
to c
orre
ct S
. Na
in S
IAD
H•
Urin
e o
smo
lalit
yis
60
0m
osm
ols
/kg
and
we
giv
e N
S w
hic
h h
as a
pp
roxi
mat
ely
15
0m
eq o
r b
oth
Na
and
Cl(
tota
l 30
0m
osm
ol).
•N
aCle
xret
ion
is in
tact
in S
IAD
H.
•T
hen
the
30
0m
osm
ol w
ill b
e ex
cret
ed in
50
0cc
of
urin
e, le
avin
g b
ehin
d 5
00
free
wat
er a
nd
th
eref
ore
w
ors
enin
g u
nd
erly
ng
hyp
on
atre
mia
.•
In S
IAD
H, y
ou
nee
d to
hav
e in
take
wh
ich
is m
ore
co
nce
ntr
ated
than
the
urin
e (e
gw
ater
res
tric
tion
, sa
lt ta
blet
s, 3
% N
S o
r sa
line
plu
s la
six)
.
Tre
atm
ent o
f Chr
onic
Hyp
onat
rem
iadu
e to
SIA
D
•R
estr
ict f
luid
inta
ke
•E
nco
ura
ge d
ieta
ry in
take
of s
alt a
nd p
rote
in
•D
emec
locy
line
300
–6
00m
g b
id o
r u
rea
15
-60
gm d
aily
•V
asop
ress
in r
ecep
tor
anta
gon
ist (
whe
n
avai
lab
le o
rally
).
Tre
atm
ent o
f chr
onic
asy
mto
mat
ichy
pona
trem
iaJo
hns
on
and
Fee
hal
ly(T
extb
ook
)
Vap
tans
•A
VP
(A
rgin
ine
Vas
op
asin
) re
cep
tor
anta
gon
ist.
•C
on
ivap
tan
–IV
ag
en
t wo
rks
on b
oth
V2
an
d V
1
rece
pto
rs. A
pp
rove
d b
y F
DA
for
trea
tmen
t o
f eu
vole
mic
hyp
on
atre
mia
in h
osp
italiz
ed p
atie
nts
.
•Li
xiva
pta
nan
d T
olv
apta
n–
ora
l ag
ent,
acts
on
V2
re
cep
tors
.
•M
ain
sid
e af
fect
s se
em to
be
thirs
t.
Osm
otic
Dem
ylin
atio
nS
yndr
ome
•O
verl
y ra
pid
corr
ectio
n of
S.N
are
sults
in d
ehyd
rati
on o
f ne
uron
s an
d gl
iaw
hich
lead
s to
OD
S.
•C
orre
ctio
n of
hyp
onat
rem
iaca
uses
effl
ux o
f wat
er fr
om
the
brai
n, tr
igge
ring
a “
de-a
dapt
atio
n pr
oces
s”•
The
inor
gani
c an
d or
gani
c os
mol
ytes
whi
ch w
ere
lost
du
ring
RV
D (
regu
lato
ry v
olum
e de
crea
se)
re-e
nete
rth
e br
ain
and
re-e
stab
lish
osm
otic
equ
ilibr
ium
. •
The
reu
ptak
e of
org
anic
osm
olyt
esaf
ter
corr
ectio
n o
f hy
pona
trem
iais
slo
wer
than
the
initi
al lo
ss d
urin
g th
e ad
apta
tion
to h
ypon
atre
mia
.•
Peo
ple
with
mal
nutr
ition
, Chr
onic
ET
OH
abu
se a
nd
hypo
kale
mia
are
mor
e at
ris
k of
OD
S.
Osm
otic
Dem
ylin
atio
nS
yndr
ome
•In
clud
es b
oth
cen
tral
pon
tine
and
ex
trap
ontin
em
yelin
oly
isis
.
•B
egin
s w
ith le
thar
gy
and
affe
ctiv
e ch
ange
s,
follo
wed
by
mu
tism
or
dysa
rthr
ia, s
pas
tic
qua
drip
arei
sis
and
pse
udo
bulb
arpa
lsy.
Pat
ien
ts a
t ris
k fo
r n
euro
log
icco
mp
licat
ion
sJo
hns
on
and
Fee
hal
ly(t
extb
ook)
Hyp
erna
trem
iaP
atho
gene
sis
of H
yper
natr
emia
•D
ecre
ased
free
wat
er s
uppl
y.
•P
oor
acce
ss to
free
wat
er.
•H
ypot
hala
mic
lesi
ons
affe
ctin
g th
irst
.
•W
ater
loss
•R
enal
: Osm
otic
diu
resi
s, C
entr
al o
r N
ephr
ogen
icD
I.
•G
I: O
smot
ic d
iarr
hea
•In
sens
ible
loss
es: F
ever
, Exe
rcis
e an
d ex
posu
re to
he
at.
•S
olut
e lo
ad
•A
dm
inis
trat
ion
of h
yper
toni
c so
dium
con
tain
ing
solu
tions
.
Wor
kup
of H
yper
natr
emia
•W
hy
is th
e p
atie
nt n
ot d
rinki
ng?
•Is
ther
e in
crea
sed
free
wat
er lo
ss:
•?P
oly
uria
•U
osm
: if <
250
–D
I
•U
osm
: if >
300
–S
olut
e di
ures
is
•?G
I (O
smo
tic d
iarr
hea)
•Is
the
pat
ien
t get
ting
too
mu
ch s
olu
te?
Tre
atm
ent o
f Hyp
erna
trem
ia
•P
rovi
de
free
wat
er.
•C
alcu
late
the
free
wat
er d
efic
it:•
0.5
x b
od
y w
eig
ht x
(P
Na/
14
0 –
1)
for
me
n
•0
.4 x
bo
dy
wei
gh
t c (
PN
a/1
40
–1
) fo
r w
om
en
•R
ate
of c
orr
ectio
n fo
r N
a 0
.5m
eq/h
r.
Exa
mpl
e of
Hyp
erna
tre
mia
•6
0 ye
ar o
ld fe
mal
e w
ith A
RD
S o
n v
entil
ato
r su
ppo
rt o
n p
ress
ors
and
TP
N.
Hem
odyn
amic
ally
stab
le.
•P
Na
= 1
50
. U
rine
ou
tput
15
0m
l/hr
•U
osm
= 5
04
U N
a =
40
meq
•U
rine
dip
stic
k =
2+
S g
luco
se =
40
0
•W
hat
is th
e ca
use
of h
yper
nat
rem
ia?
•H
ow
wou
ld y
ou tr
eat h
im?
Cal
cula
ton
of w
ater
def
icit
•C
alcu
late
am
oun
t of w
ater
:•
0.4
x b
od
y w
eig
ht x
(P
Na/
14
0 -
1)
•0
.4 x
50
x (
15
0/1
40
-1
) =
1.4
lite
rs
•In
sen
sib
le lo
sses
=
1.0
lite
rs
•T
ota
l vo
lum
e =
2.4
lite
rs
•R
ate
(0.5
meq
/hou
r)•
Fo
r N
a to
go
fro
m 1
50
to 1
40 =
20
hrs
.
•P
resc
riptio
n: 2
400
/20
= 1
20m
l/hr
free
wat
er
Adr
ogu
eet
al.
Hyp
ern
atre
mia
. N
EJM
200
0; 3
42(2
0) 1
493
-149
8
•E
nd