Hyponatræmia: analysis

Transcription

1 ESPEN Congress Nice 2010 Hyper- and hyponatraemia - serious and iatrogenic problems Hyponatræmia: analysis Mathias Plauth

2 Hyponatremia Case Analysis Mathias Plauth Klinik für Innere Medizin Städtisches Klinikum Dessau 32 nd ESPEN Congress Nice, September 5 8, 2010

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4 Hyponatremia Clinical Conditions Common Normoosmolar hyponatremia - Hyperglycemia - Mannitol infusion - Severe hyperlipidemia - Advanced myeloma Not genuine hyponatremias Common Hypoosmolar, genuine hyponatremia - Liver cirrhosis, heart failure and chronic renal failure (CKD IV, V) Hypervolemic hyponatremia Rare SIAD (formerly SIADH) Normovolemic hyponatremia Very common Reduced plasma volume - Vomiting, diarrhea - Hemorrhage - Heatstroke, etc. Hypovolemic hyponatremia Gross P. Inter Med 2008, 47:

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6 Severe Hyponatremia (<125 mmol/l) Do We React Adequately? (1) In 2003 for 3 months all Na + values (2907 in 5437 patients) were reviewed in a 831-bed urban university hospital (Rotterdam, NL) Hyponatremia Na + < 136 mmol/l 880/ % Severe hyponatremia Na + < 125 mmol/l 74/ % Hyponatremia not treated 19/74 26 % 7/19 died vs 7/55 p<0.05 Hoorn et al, Nephrol Dialys Transpl 2006, 21:70-76

7 Severe Hyponatremia (<125 mmol/l) Do We React Adequately? (2) On admission Hospital acquired Cases 38/ /2907 Na + (mmol/l) 121 ± ± 4 Treatment started on day 1.0 ± ± 10.6 < Length of stay (d) 18.2 ± ± 23.4 < 0.01 Rise in Na + after 24 h (mmol/l) 6 ± 4 4 ± 4 < 0.01 Rise in Na + after 48 h (mmol/l) 10 ± 6 6 ± 5 = Causes of hyponatremia Thiazides 0 8 < 0.01 ADH stimulating drugs 2 8 < 0.05 Surgery 0 10 < Hypotonic fluids i.v. 0 8 = 0.01 p Hoorn et al, Nephrol Dialys Transpl 2006, 21:70-76

8 Hyponatremia Signs and Symptoms Psychomotor Impairment of Mild Hyponatremia Serum Na mmol/l equal to serum ethanol 0.8 g/l Hyponatremia Normonatremia Falls and fractures 4 x the rate of age-matched normonatremic controls Renneboog et al, Am J Med 2006, 119:71e1

9 Mild Hyponatremia Clinical Outcome Risk Factor for Fractures in the Elderly Chart analysis of visits of patients 65 ys. in 01/ /2006 Gankam-Kengne et al, QJM 2008, 101:

10 Mild Hyponatremia Clinical Outcome Risk Factor for Fractures in the Elderly Causes of hyponatremia (Na + <135 mm) in elderly (81±9 ys) with fractures SSRI 16% Potomania 3% Idiopathic SIADH 35% Diuretics 35% Secondary SIADH 4% Antiepileptic drugs 1% Salt depletion 6% Gankam-Kengne et al, QJM 2008, 101:

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12 Severe Hyponatremia Case Management Algorithm yes Hoorn et al, QJM 2005, 98:

13 Severe Hyponatremia Case Management Algorithm yes??? Hoorn et al, QJM 2005, 98:

14 Hyponatremia Acute Severe Hyponatremia Acute severe hyponatremia (<115 mm) when the duration has been <36 to 48 h. Acute severe hyponatremia is a medical emergency. Normal Such patients often have advanced symptoms as a result of brain edema. It should be corrected rapidly to approximately 130 mm to prevent permanent brain damage. Brain Edema Gross et al. J Am Soc Nephrol 2001, 12: S10 S14 and Kidney Int 2001, 60:

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16 Severe Hyponatremia Case Management Algorithm yes yes Hoorn et al, QJM 2005, 98:

17 Severe Hyponatremia Case Management Algorithm yes yes Hoorn et al, QJM 2005, 98:

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20 Severe Hyponatremia Case Management Algorithm no Urine osmolality is high Plasma osmolality is low Patient is hypovolemic 354 mosmol/kg 240 mosmol/kg low CVP, history of vomiting Hoorn et al, QJM 2005, 98:

21 Severe Hyponatremia Case Management Algorithm no??? Urine osmolality is high no 354 mosmol/kg Hoorn et al, QJM 2005, 98:

22 Severe Hyponatremia Case Management Algorithm no?????? no no Urine osmolality is high 354 mosmol/kg Hoorn et al, QJM 2005, 98:

23 Hyponatremia Beer Potomania Pathophysiology Hyponatremia and low daily solute intake and excessive beer drinking At intake of 100 mosmol/d solute (20 g protein) a fluid intake > 2000 ml/d will result in net water retention and subsequent hyponatremia contains CHO, virtually no solute Review of 22 cases in the literature Na mmol/l K + 3 mmol/l BUN low urinary Na + low brisk diuresis in response to solute administration Sanghvi et al, Am J Kid Disease 2007, 50:673-80

24 Free Water Clearance Dependence on Daily Solute Excretion Beer potomania 100 mosm Thaler et al, Am J Kid Disease 1998, 31:

25 Hyponatremia Beer Potomania Clinical Management Sanghvi et al, Am J Kid Disease 2007, 50:673-80

26 Hyponatremia Beer Potomania Clinical Management Osmotic demyelination syndrome (ODS) No neurological sequelae Sanghvi et al, Am J Kid Disease 2007, 50:673-80

27 Hyponatremia Treatment Osmotic Demyelination Syndrome Synonyme (Central) pontine myelinolysis Features Upper motor neuron disorders Spastic quadriparesis Pseudobulbar palsy Mental disorders Confusion coma and death MRT Path. anatomy Laureno et al, Ann Intern Med 1997, 126:57-62

28 Severe Hyponatremia Case Management Algorithm no?????? no no - Diuretics, thiazides urinary K + high, metab. alcalosis no - Vomiting urinary K + high, Cl - low no - Addison s urinary Na + high possible - Cerebral salt wasting urinary Na + high, P. uric acid low possible Hoorn et al, QJM 2005, 98:

29 Severe Hyponatremia Case Management Algorithm Hoorn et al, QJM 2005, 98:

30 Severe Hyponatremia Case Management Algorithm yes Urine osmolality is high Plasma osmolality is low 354 mosmol/kg 240 mosmol/kg Hoorn et al, QJM 2005, 98:

31 Severe Hyponatremia Case Management Algorithm yes yes Patient is hypovolemic Non-osmotic ADH stimulus low CVP, history of vomiting nausea Hoorn et al, QJM 2005, 98:

32 Severe Hyponatremia Case Management Algorithm yes yes yes Urine osmolality is high Plasma osmolality is low Drug induced SIADH 354 mosmol/kg 240 mosmol/kg SSRI (venlafaxine), also MAO inhibitors, amitriptyline Hoorn et al, QJM 2005, 98:

33 Severe Hyponatremia Case Management Algorithm

34 Severe Hyponatremia Case Management Algorithm yes yes Hoorn et al, QJM 2005, 98:

35 Severe Hyponatremia Case Management Algorithm yes yes no Hoorn et al, QJM 2005, 98:

36 Severe Hyponatremia Case Management Algorithm yes yes no yes Hoorn et al, QJM 2005, 98:

37 Hyponatremia Handling of a Water Load in Health and Disease 20 ml water per kg b.w. as 5 % dextrose i.v. in 45 min Healthy controls Congestive heart failure SIAD Plasma level of sodium, mmol/l * * * * * * * p<0.05 vs initial values Mallie et al, Clin Invest Med 1997, 20:16-24 Time, hours

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