HYPONATREMIA & HYPERNATREMIAProf. Dr. E. J. Joseph, SpPD-KGH

HYPONATREMIAPlasma Sodium Concentration < 135 mEq/L ( Normal : 135 150 mEq/L ) Classification : - Hypovolemic - Euvolemic - Hypervolemic

HYPOVOLEMIA : Hyponatremia Associated with Decreased Total Body Sodium :Gastrointestinal and Third-Space Sequestered Losses (Diarrhe or Vomiting)Diuretics (Loop Diuretics)Salt-Losing Nephropathy (Chronic Kidney Diseases)Mineralocorticoid Defiiciency

HYPERVOLEMIC : Hiponatremia Associated with Increased Total Body SodiumCongestive Heart FailureHepatic Failure (Cirrhosis)Nephrotic SyndromeRenal Disease (Advanced)

EUVOLEMIA, HYPONATREMIA ASSOCIATED WITH NORMAL TOTAL BODY SODIUMGlucocorticoid Deficiency (Primary and secondary Adrenal Insufficiency)HypothyroidismPsychosisPost operative HyponatremiaDrug Causing Hyponatremia (Vasopresin Analog Clofibrate)Syndrome of Inappropriate ADH Secretion (SIADH)

CAUSES OF SIADH : a. Carcinoma :Bronchogenic CarcinomaCarcinoma of the DuodenumCarcinoma of the PancreasCarcinoma of the StomachLymphoma

PULMONARY DISORDERS :Viral PneumoniaTuberculosisAsthmaPneumothoraxBacterial Pneumonia

NERVOUS SYSTEM DISORDERS :ENCEPHALITISMENINGITISHEAD TRAUMABRAIN TUMORSGUILLIAN-BARRE SYNDROMESUBARACHNOID HEMORAGICCEREBELLAR and CEREBRAL ATROPHYCAVERNUS SINUS THROMBOSISCEREBROVASCULAR ACCIDENTACUTE PSYCHOSIS OTHERS : IDIOPATIC (ELDERLY)

SYMPTOMS OF HYPONATREMIA :Serum Na > 125 mmol/L AsymptomaticSerum Na

TREATMENT OF THE HYPONATREMIC PATIENT :Treatment the cause of HyponatremiaRestriction of water IntakeDemeclochlortetracycline Administration (In a patient with chronic SIADH who will not voluntarily restrict water Intake)Furosemide and Hypertonic Saline (Nacl 3 %)

HYPERNATREMIAPlasma Sodium Concentration > 150 mEq/L. Based Upon the Volume Categories:- Hypovolemic - Euvolemic - Hypervolemic

Hypovolemia : Hypernatremia Assocrated with Low Total Body SodiumLosses of Both Na and Water, But with a Relative Greater Loss of waterRenal Losses :- Intrinsic Renal DiseaseExtrarenal Losses :- Excess Sweating- Burns- Diarrhea

Hypervolemia : Hypernatremia Associated with Increased Total Body SodiumThe Administrator of Hypertonic Solution (NaCl 3%)Euvolemia : Hypernatremia Associated with Normal Body SodiumRenal Losses : - Diabetes InsipidusExtrarenal Losses : - Insensible Losses

DIABETES INSIPIDUS :Is a Disease Characterized by Polyuria and Polydipsia and Caused by Defects In Vasopressin Action ( ADH )Central Diabetes Insipidus :Inadequate Vasopresin ReleaseNephrogenic Diabetes Insipidus :Inpaired Renal Response to Vasopressin

Nephrogenic Diabetic Insipidus :-Congenital-AcquiredAcquired Nephrogenic Diabetic Insipidus : a. Chronic Kidney Disease (Failure) b. Electrolyte Disoerders :- Hypokalemiac. Pharmacologic Agents :- Amphotericin- Lithium

d. Sickle Cell Anemiae. Gestational Diabetes Insipidus : - Increase Circulating Vasopressinase product by the Placenta

Signs and Symptoms of Hypernatremia :

Mostly Relate to the CNS : - Altered Mental Status- Lethargy- Irritability- Hyper Reflexia- Intense Thirst

Treatment of Hypernatremic Patients :Restoration of Serum Tonicity :- Isotonic Saline- Diuretic plus 5% Dextrose

HYPOKALEMIA- Serum Potassium Concentration < 3,8 mEq/L (Normal : 3,8 5,0 mEq/L)A. Hypokalemia Secondary to Redistribution :- Alkalosis- Insulin Excess- Hypokalemic Periodic Paralysis (Recurrent Attacks of Flaccid Paralysis)

B. Potassium Depletion :1. Extrarenal Potassium Loss :- Excessive Sweating- Chronic Diarrhea- Vomiting- Nasogastric Suctoon2. Renal Potassium Loss:- Occur from Medicatoous , Endogenous Hormone Production, Intrinsic Renal Defect

Drugs : - Thiazide- Loop DiureticsEndogenous Hormone :- AldosteroneIntrinsic Renal Defect : - Bartter's Syndrome - Liddle's Syndrome

Clinical Manifestations of Hypokalemia : - Cardiac : - Predisposition to digitalis intoxication- Abnormal ECG- Atrial and ventricular ectopic beats- Cardiac necrosis (rare)

Neuromuscular :- Gastrointestinal : constipation ileus- Striated muscle : weakness, paralysis- Life threatining respiratory paralysis - Rhabdomyolysis

Kidney - Reversible decrease in GFR, mild- Polyuria and Polydipsia- Concentrating defect- Thirst stimulation- Increased renal ammonia production- Predisposition to hepatic coma - Sodium Retention- Hyponatremia (with concomitant diuretic terapy)- Chloride wasting- Matabolic alkalosis

Endocrin - Decrease in aldosterone- Increase in renin- Increase in prostaglandins- Decrease in insulin- Carbohydrate intolerance

Treatment : - Tx Underlying Cause- Additional Potassium :- Oral- Parenteral (Drips)

HYPERKALEMIA* Serum Potassium Concentration >5,0 mEq/L- A Potential Complication In Any Setting with Oliguria or Serious Compromise of Renal FunctionEtiology : 1. Redistribution- Acidosis- Insulin Deficiency

2. Increase In Total Body Potassium :- Renal Failure (Potassium Retention)- Mineralo Corticoid Deficiency (Hyperchloremic Acidosis)

3. Drug Induced Hyperkalemia :- Spiromolactone- Amiloride- Cyclosporine- Tacrolimus

Clinical Manifestations :- May be Asimptomatic or Life- Threatening- Cardiac Conduction System (Ventricular Fibrillatin, Vetricular Asystole)- Muscle Weakness- Paralyses of Diaphragm

Treatment :- Minimize the Cardiac Effect- Induce Potassium Uptake by cells- Removal Potassium from the Body (orally,Calcium Gluconate 10% Solution 10 ml i.v over 10 minute, Regular insulin 10 u i.v, with Dextrose 50% 50 ml, Hemodialysis)