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Old 04-17-2012
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Question Management of Hyponatremia

How we treat mild asymptomatic mild hyponatremia and how does it present clinically?

since most of the time i found that mild hyponatremia we treat with normal saline with furosemide and symptomatic severe patient with hypertonic saline.

so when is the water restriction and demeclocycline are the options...can any one plz explain??
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Old 04-17-2012
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Asymptomatic hyponatremia may present with some malaise or nausea but no neurological symptoms. It is treated by slowly correcting the hyponatremia, usually with free water restriction (depends on etiology of the hyponatremia, right?).

With symptomatic (neurological symptoms) hyponatremia, the initial correction is faster (just the first hour or two until the symptoms resolve), usually with hypertonic saline. Too rapid a correction of a hyponatremia that has developed over a long period (i.e. is already compensated) can lead to central pontine myelinolysis.

Once any rapid correction is done, treatment depends on characterizing the underlying cause of the hyponatremia, and this starts with history and physical, especially assessment of volume status:
  • Hypovolemic
    • work up by measuring UrCr, UrNa, so you can calculate FENa to differentiate between renal and non-renal sodium loss
    • treat with normal saline, treatment of underlying cause (i.e. removal of diuretics)
  • Euvolemic
    • work up with UrOsm, serum uric acid. History will often give a clue about underlying cause, so that can be worked up (i.e. CXR, TSH)
    • treatment starts with free water restriction. If this doesn't work, then move to salt tablets (obviously CHF would be a contraindication), demeclocycline (induces a nephrogenic DI, not a long-term treatment), or the very-expensive vaptans (V2 vasopressin receptor antagonists).
  • Hypervolemic
    • work up with UrCr, UrNa, again to differentiate renal failure v. non-renal cause (i.e CHF, hepatorenal syndrome)
    • treatment starts with free water restriction, salt restriction, loop diuretics. Treat underlying cause, and sequelae. Increasing effective arterial volume (i.e. with albumin) can reduce production of ADH, if the hyponatremia is secondary to a state of hypoperfusion. The vaptans are also an option here.

(feeling super-nerdy, just finished my nephrology rotation!)
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Old 04-18-2012
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thanks for nice explanation....this topics are always so confusing...
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