Skip to main content

Advertisement

SpringerLink
Log in

Clinical practice guideline on diagnosis and treatment of hyponatraemia

  • Guidelines
  • Published:
Intensive Care Medicine Aims and scope Submit manuscript

An Erratum to this article was published on 30 July 2014

An Erratum to this article was published on 25 March 2014

Abstract

Hyponatraemia, defined as a serum sodium concentration <135 mmol/L, is the most common disorder of body fluid and electrolyte balance encountered in clinical practice. Hyponatraemia is present in 15–20 % of emergency admissions to hospital and occurs in up to 20 % of critically ill patients. Symptomatology may vary from subtle to severe or even life threatening. Despite this, the management of patients remains problematic. Against this background, the European Society of Intensive Care Medicine, the European Society of Endocrinology and the European Renal Association–European Dialysis and Transplant Association, represented by European Renal Best Practice have developed a Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Funk GC, Lindner G, Druml W et al (2010) Incidence and prognosis of dysnatremias present on ICU admission. Intens Care Med 36:304–311

    Article  Google Scholar 

  2. Beukhof CM, Hoorn EJ, Lindemans J, Zietse R (2007) Novel risk factors for hospital-acquired hyponatraemia: a matched case-control study. Clin Endocrinol 66:367–372

    Article  Google Scholar 

  3. Upadhyay A, Jaber BL, Madias NE (2009) Epidemiology of hyponatremia. Semin Nephrol 29:227–238

    Article  CAS  PubMed  Google Scholar 

  4. Hoorn EJ, Lindemans J, Zietse R (2006) Development of severe hyponatraemia in hospitalized patients: treatment-related risk factors and inadequate management. Nephrol Dial Transpl 21:70–76

    Article  Google Scholar 

  5. Waikar SS, Mount DB, Curhan GC (2009) Mortality after hospitalization with mild, moderate, and severe hyponatremia. Am J Med 122:857–865

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  6. Doshi SM, Shah P, Lei X, Lahoti A, Salahudeen AK (2012) Hyponatremia in hospitalized cancer patients and its impact on clinical outcomes. Am J Kidney Dis 59:222–228

    Article  CAS  PubMed  Google Scholar 

  7. Sterns RH (1987) Severe symptomatic hyponatremia: treatment and outcome. A study of 64 cases. Ann Intern Med 107:656–664

    Article  CAS  PubMed  Google Scholar 

  8. Gill G, Huda B, Boyd A et al (2006) Characteristics and mortality of severe hyponatraemia—a hospital-based study. Clin Endocrinol 65:246–249

    Article  Google Scholar 

  9. Arieff AI, Llach F, Massry SG (1976) Neurological manifestations and morbidity of hyponatremia: correlation with brain water and electrolytes. Medicine 55:121–129

    Article  CAS  PubMed  Google Scholar 

  10. Halberthal M, Halperin ML, Bohn D (2001) Lesson of the week: acute hyponatraemia in children admitted to hospital: retrospective analysis of factors contributing to its development and resolution. BMJ 322:780–782

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  11. Darmon M, Diconne E, Souweine B et al (2013) Prognostic consequences of borderline dysnatremia: pay attention to minimal serum sodium change. Crit Care 17:R12

    Article  PubMed Central  PubMed  Google Scholar 

  12. Sakr Y, Rother S, Ferreira AMP et al (2013) Fluctuations in serum sodium level are associated with an increased risk of death in surgical ICU patients. Crit Care Med 41:133–142

    Article  CAS  PubMed  Google Scholar 

  13. Stelfox HT, Ahmed SB, Khandwala F, Zygun D, Shahpori R, Laupland K (2008) The epidemiology of intensive care unit-acquired hyponatraemia and hypernatraemia in medical-surgical intensive care units. Crit Care 12:R162

    Article  PubMed Central  PubMed  Google Scholar 

  14. Pirzada NA, Ali II (2001) Central pontine myelinolysis. Mayo Clin Proc 76:559–562

    Article  CAS  PubMed  Google Scholar 

  15. Arieff AI (1986) Hyponatremia, convulsions, respiratory arrest, and permanent brain damage after elective surgery in healthy women. N Engl J Med 314:1529–1535

    Article  CAS  PubMed  Google Scholar 

  16. Ayus JC, Wheeler JM, Arieff AI (1992) Postoperative hyponatremic encephalopathy in menstruant women. Ann Intern Med 117:891–897

    Article  CAS  PubMed  Google Scholar 

  17. Nzerue CM, Baffoe-Bonnie H, You W, Falana B, Dai S (2003) Predictors of outcome in hospitalized patients with severe hyponatremia. J Natl Med Assoc 95:335–343

    PubMed Central  PubMed  Google Scholar 

  18. Arieff AI, Ayus JC, Fraser CL (1992) Hyponatraemia and death or permanent brain damage in healthy children. BMJ 304:1218–1222

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  19. Verbalis JG, Drutarosky MD, Ertel RJ, Vollmer RR (1989) Adaptive responses to sustained volume expansion in hyponatraemic rats. J Endocrinol 122:421–431

    Article  CAS  PubMed  Google Scholar 

  20. Verbalis JG, Gullans SR (1991) Hyponatremia causes large sustained reductions in brain content of multiple organic osmolytes in rats. Brain Res 567:274–282

    Article  CAS  PubMed  Google Scholar 

  21. Sterns RH, Silver SM (2006) Brain volume regulation in response to hypo-osmolality and its correction. Am J Med 119:S12–S16

    Article  CAS  PubMed  Google Scholar 

  22. Melton JE, Patlak CS, Pettigrew KD, Cserr HF (1987) Volume regulatory loss of Na, Cl, and K from rat brain during acute hyponatremia. Am J Physiol 252:F661–F669

    CAS  PubMed  Google Scholar 

  23. Sterns RH, Thomas DJ, Herndon RM (1989) Brain dehydration and neurologic deterioration after rapid correction of hyponatremia. Kidney Int 35:69–75

    Article  CAS  PubMed  Google Scholar 

  24. Verbalis JG, Martinez AJ (1991) Neurological and neuropathological sequelae of correction of chronic hyponatremia. Kidney Int 39:1274–1282

    Article  CAS  PubMed  Google Scholar 

  25. Videen JS, Michaelis T, Pinto P, Ross BD (1995) Human cerebral osmolytes during chronic hyponatremia. A proton magnetic resonance spectroscopy study. J Clin Invest 95:788–793

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  26. Hoorn EJ, Zietse R (2008) Hyponatremia revisited: translating physiology to practice. Nephron Physiol 108:46–59

    Article  Google Scholar 

  27. Hsu Y-J, Chiu J-S, Lu K-C, Chau T, Lin S-H (2005) Biochemical and etiological characteristics of acute hyponatremia in the emergency department. J Emerg Med 29:369–374

    Article  PubMed  Google Scholar 

  28. Sterns RH (1994) Treating hyponatremia: why haste makes waste. South Med J 87:1283–1287

    Article  CAS  PubMed  Google Scholar 

  29. Renneboog B, Musch W, Vandemergel X, Manto MU, Decaux G (2006) Mild chronic hyponatremia is associated with falls, unsteadiness, and attention deficits. Am J Med 119(71):e71–e78

    Google Scholar 

  30. Fazekas AS, Funk G-C, Klobassa DS et al (2012) Evaluation of 36 formulas for calculating plasma osmolality. Intens Care Med 39:302–308

    Article  Google Scholar 

  31. Adrogue HJ, Madias NE (2000) Hyponatremia. N Engl J Med 342:1581–1589

    Article  CAS  PubMed  Google Scholar 

  32. Hoorn EJ, Halperin ML, Zietse R (2005) Diagnostic approach to a patient with hyponatraemia: traditional versus physiology-based options. Q J Med 98:529–540

    Article  CAS  Google Scholar 

  33. Chung HM, Kluge R, Schrier RW, Anderson RJ (1987) Clinical assessment of extracellular fluid volume in hyponatremia. Am J Med 83:905–908

    Article  CAS  PubMed  Google Scholar 

  34. McGee S, Abernethy WB 3rd, Simel DL (1999) The rational clinical examination. Is this patient hypovolemic? JAMA 281:1022–1029

    Article  CAS  PubMed  Google Scholar 

  35. Hillier TA, Abbott RD, Barrett EJ (1999) Hyponatremia: evaluating the correction factor for hyperglycemia. Am J Med 106:399–403

    Article  CAS  PubMed  Google Scholar 

  36. Schwartz WB, Bennett W, Curelop S, Bartter FC (1957) A syndrome of renal sodium loss and hyponatremia probably resulting from inappropriate secretion of antidiuretic hormone. Am J Med 23:529–542

    Article  CAS  PubMed  Google Scholar 

  37. Janicic N, Verbalis JG (2003) Evaluation and management of hypo-osmolality in hospitalized patients. Endocrinol Metab Clin N Am 32:459–481 vii

    Article  CAS  Google Scholar 

  38. Aviram A, Pfau A, Czaczkes JW, Ullmann TD (1967) Hyperosmolality with hyponatremia, caused by inappropriate administration of mannitol. Am J Med 42:648–650

    Article  CAS  PubMed  Google Scholar 

  39. Desmond J (1970) Serum osmolality and plasma electrolytes in patients who develop dilutional hyponatremia during transurethral resection. Can J Surg 13:116–121

    CAS  PubMed  Google Scholar 

  40. Lindner G, Zapletal B, Schwarz C, Wisser W, Hiesmayr M, Lassnigg A (2012) Acute hyponatremia after cardioplegia by histidine–tryptophane–ketoglutarate—a retrospective study. J Cardiothorac Surg 7:52

    Article  PubMed Central  PubMed  Google Scholar 

  41. Sirken G, Raja R, Garces J, Bloom E, Fumo P (2004) Contrast-induced translocational hyponatremia and hyperkalemia in advanced kidney disease. Am J Kidney Dis 43:e31–e35

    Article  PubMed  Google Scholar 

  42. Palevsky PM, Rendulic D, Diven WF (1993) Maltose-induced hyponatremia. Ann Intern Med 118:526–528

    Article  CAS  PubMed  Google Scholar 

  43. Oster JR, Singer I (1999) Hyponatremia, hyposmolality, and hypotonicity: tables and fables. Arch Intern Med 159:333–336

    Article  CAS  PubMed  Google Scholar 

  44. Lai M-Y, Lin C-C, Chung S-L, Wu C-H, Yang W-C, Tseng Y-T (2009) Milky plasma, diabetes, and severe hyponatremia. Kidney Int 75:996

    Article  PubMed  Google Scholar 

  45. Lawn N, Wijdicks EF, Burritt MF (1998) Intravenous immune globulin and pseudohyponatremia. N Engl J Med 339:632

    Article  CAS  PubMed  Google Scholar 

  46. Vaswani SK, Sprague R (1993) Pseudohyponatremia in multiple myeloma. South Med J 86:251–252

    Article  CAS  PubMed  Google Scholar 

  47. Sherlock M, O’Sullivan E, Agha A et al (2006) The incidence and pathophysiology of hyponatraemia after subarachnoid haemorrhage. Clin Endocrinol 64:250–254

    Article  Google Scholar 

  48. Brimioulle S, Orellana-Jimenez C, Aminian A, Vincent JL (2008) Hyponatremia in neurological patients: cerebral salt wasting versus inappropriate antidiuretic hormone secretion. Intensive Care Med 34:125–131

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. State University Hospital Skopje, Skopje, Macedonia

    Goce Spasovski

  2. Ghent University Hospital, Ghent, Belgium

    Raymond Vanholder & Wim Van Biesen

  3. Würzburg University Hospital, Würzburg, Germany

    Bruno Allolio & Wiebke Fenske

  4. Raymond Poincaré Hospital, University of Versailles Saint Quentin, Paris, France

    Djillali Annane

  5. Newcastle Hospitals and Newcastle University, Newcastle, UK

    Steve Ball

  6. Consultant Nephrologist, Sacré-Coeur Hospital, University of Montreal, Montreal, Canada

    Daniel Bichet

  7. Erasmus University Hospital, Brussels, Belgium

    Guy Decaux & Alain Soupart

  8. Erasmus Medical Centre, Rotterdam, The Netherlands

    Ewout Hoorn & Robert Zietse

  9. Nice University Hospital, Nice, France

    Carole Ichai

  10. Innsbruck University Hospital, Innsbruck, Austria

    Michael Joannidis

  11. ERBP Methods Support Team, Ghent University Hospital, Ghent, Belgium

    Maria Haller, Sabine van der Veer & Evi Nagler

  12. KH Elisabethinen Linz, Linz, Austria

    Maria Haller

  13. Centre for informatics, Amsterdam Medical Centre, Amsterdam, The Netherlands

    Sabine van der Veer

Authors
  1. Goce Spasovski
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Raymond Vanholder
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Bruno Allolio
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Djillali Annane
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Steve Ball
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Daniel Bichet
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Guy Decaux
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Wiebke Fenske
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Ewout Hoorn
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Carole Ichai
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Michael Joannidis
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Alain Soupart
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Robert Zietse
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Maria Haller
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Sabine van der Veer
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Wim Van Biesen
    View author publications

    You can also search for this author in PubMed Google Scholar

  17. Evi Nagler
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Wim Van Biesen.

Electronic supplementary material

Rights and permissions

Reprints and permissions

About this article

Cite this article

Spasovski, G., Vanholder, R., Allolio, B. et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Intensive Care Med 40, 320–331 (2014). https://doi.org/10.1007/s00134-014-3210-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00134-014-3210-2

Keywords

Search

Navigation