Hyponatremia FOSPED 2018

Transcription

1 Hyponatremia FOSPED 2018 Prof. Dr. Mirjam Christ-Crain Department of Endocrinology, Diabetology and Metabolism University Hospital Basel Schweizerische Gesellschaft für Endokrinologie und Diabetologie - SGED

2 Classification of Hyponatremia Symptoms - mild symptoms (headache, dizziness) versus - severe symptoms (Stupor, seizures, coma) Aetiology - Hypovolemia - Hypervolemia - SIADH - Beer potomania - Diuretics - Adrenal insufficiency - Hypothyroidism Severity - mild: <135mmol/L - profound: <125mmol/L Course - Acute (<48h) versus chronic

3 Definition, Prevalence & Symptoms Differential Diagnosis Therapy

4 Definition, Prevalence & Symptoms Schweizerische Gesellschaft für Endokrinologie und Diabetologie - SGED

5 Definition & prevalence of hyponatremia Definition: Serum Na + < 135 mmol/l Prevalence: Most common electrolyte disorder - mild hyponatremia ( ): 15-30% - profound hyponatremia (<125): 2-5% Heterogenous patients Not a disease

6 Despite high prevalence: Hyponatremia is often not diagnosed and not treated! Hyponatremia registry (225 centers in US & Europe): Diagnostic wrap-up in only 21% of hyponatremic patients 17% of patients with diagnostic wrap-up and final diagnosis did not receive treatment 80% of patients were still hyponatremic at discharge 50% of these with sodium <130mmol/L Greenberg et al., Kidney international 2015

7 Acute vs chronic hyponatremia Acute hyponatremia: <48 hours Chronic hyponatremia: >48 hours Impact on symptoms! (Ability of brain for adaptation is lower if hyponatremia develops fast) Patient with sodium levels <120mmol/L almost always have chronic hyponatremia

8 Symptoms of hyponatremia Depend from severity and especially from dynamic of hyponatremia none Dizziness, weakness, muscle cramps Headache Nausea, vomiting Cramps Agitation, confusion, stupor Coma, death

9 Other outcomes Mild chronic hyponatremia is associated with falls, fractures, gait disorders and attention deficits Renneboog et al., Am J Med 2006 Gait:

10 Hyponatremia is associated with high morbidity and mortality Wald et al., Arch Intern Med 2010

11 Does sodium correction reduce mortality? Corona et al., PloS one, 2015

12 Differential diagnosis Schweizerische Gesellschaft für Endokrinologie und Diabetologie - SGED

13 Hyponatremia Natrium<135mmol/l S-Osmo <275 Hypotonic hyponatremia Diarrhea, vomiting SIADH? Heart failure, liver cirrhosis Renal insufficiency Diuretic use Primary polydipsia, beer potomania Cerebral salt wasting Adrenal insufficiency Hypothyroidism

14 Differential diagnosis: 4 important parameters 1)Serum osmolality hypertonic vs hypotonic hyponatremia 2)Urinary osmolality Intact vs pathological AVP suppression 3)Urinary sodium (Spoturin) effective arterial blood volume reduced: U-Na <30 vs effective arterial blood volume normal: U-Na >30 4)Extracellular volume status (difficult! Sens & Spez ca. 50%!) Spasovski et al, new guidelines for hyponatremia, EJE, 2014

15 Algorithm for differential diagnosis Hypotonic hyponatremia 1) Serum osmolality 2) < 100 mosm/kg Urinary osmolality > 100 mosm/kg Primäre Polydipsie <30 mmol/l 3) Urinary sodium Bierpotomanie Low effective arterial volume >30 mmol/l Hypovolemia 4) Hypervolemia Patient on diuretics? yes No GIT loss (Diarrhoe, vomiting) Burns Pankreatitis Heart failure Liver cirrhosis Nephrotic syndrome Diuretics? Other etiology possible Euvolemia: SIADH Sec. Adrenal insufficiency Hypothyroidism Hypovolemia: Prim. Adrenal insufficiency Cerebral Salt Wasting Spasovski et al, new guidelines for hyponatremia, EJE, 2014

16 Diagnosis of SIADH essentiell: S-Na, S-Osmo U-Osmo >100 Clinical euvolemia U-Na >30 Normal thyroid and adrenal function additionally: Uric acid Urea Worsening of hyponatremia under 0.9% NaCl-Infusion Improvement of hyponatremia under fluid restriction Ellison D, NEJM, 2007

17 Aetiology of SIADH Pneumologic diseases Acute respiratory failure Infections Positive-pressure ventilation Pneumonia, Tbc Tumours Extrathoracic Mediastinal Pulmonary SIADH CNS diseases Acute psychosis Haemorrhage Inflammatory and demyelinating diseases Mass lesions Stroke Trauma Drugs Carbamazepine Chlorpropamide Clofibrate Cyclophosphamide Desmopressin Nicotine Oxytocin Opiates Phenothiazines Prostaglandinsynthesis inhibitors SSRIs MAO inhibitors Tricyclics Vincristine Miscellaneous HIV infection Idiopathic Pain Postoperative state Prolonged exercise Senile atrophy Severe nausea Verbalis JG et al, AJM 2007

18 Therapy Schweizerische Gesellschaft für Endokrinologie und Diabetologie - SGED

19 Hyponatremia with severe symptoms 3% NaCl! Given as bolus: - 100ml NaCl 3% over 10 min (increases sodium generally around 2mmol/L) - Repeated 3 times as needed - Increase in sodium of 4-6mmol/L often enough to correct acute symptoms

20 Treatment of hyponatremia depends on aetiology Henry, Ann Int Med 2015

21 Treatment of SIADH Fluid restriction: first-line treatment, but not effective in >50%! Predictors for non-response: - Urinary osmolality >500mOsm/kg - Sum of Urin-Na and K > Serum-Na - Increase of Na <2mmol/L in hours with fluid restriction of 1l/d Further options: Urea (15-60g/d), Vaptans Verbalis et al., Am J Med 2013 Winzeler et al., J Int Med 2016

22 Vaptans for treatment of SIADH - In CH so far no permission for treatment of SIADH - Cave over-correction! - Expensive - No outcome data Schrier et al., NEJM 2006

23 Limits of correction in chronic hyponatremia - Correction rate 4-8mmol/L/24h max.12mmol/24h, 18mmol/L/48h - If high risk for osmotic demyelinsation: 4-6mmol/L/24h Risk factors for osmotic demyelinisation: - Serum-Na <105mmol/L (medium risk if <120mmol/L) - Hypokalemia - Alcoholism - Malnutrition - Progressive liver disease

24 Re-Lowering if sodium was increased >limits If re-lowering needed: Desmopressin s.c. e.g. 2-4ug every 8 hours as needed Replace water orally or as 5% Dextrose (iv 3ml/kg/h) Verbalis, Am J Med 2013

25 Summary - Prevalence: common! - Symptoms: mild to severe, dependent of dynamic, acute vs chronic; associated with high morbidity and mortality - Differential diagnosis: Algorithm based on S-Osm, U-Osm, U-Na, volume status - Therapy: severe symptoms: 3% NaCl irrespective of aetiolgy - Otherwise: Dependent of aetiology - Therapy of SIADH: Fluid restriction (Non-response if urinary osmolality >500) Urea and vaptans - Correction: 4-8(-12)mmol/L/24h, less if risk for osmotic demyelinisation! Schweizerische Gesellschaft für Endokrinologie und Diabetologie - SGED