Date post: | 22-Jan-2018 |
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DISTURBANE IN SODIUMAND WATER BALANCE
Dr Ayman Seddik ,MD
Ass.Prof.Nephrology Ain Shams University
Consultant nephrologist
Solute Composition of Body Water
• Predominant solutes in ECF: Sodium (Na+) Chloride (Cl−)
Bicarbonate (HCO3−) • Predominant solutes in ICF:
Potassium (K+) Protein− Phosphate−
Osmolality
•Posm=2×plasma Na+ +
Glucose/18 + BUN/2.8
Osmolality • Normal ECF osmolality: 280-290mOsm/kgH2O
• ECF and ICF are in osmotic equilibrium, at
steady state
• Vasopressin (antidiuretic hormone (ADH)
-osmotic stumuli
-nonosmotic stumuli: HF, Cirrhosis, vomiting, postoperative pain, pregnancy
Hyponatremia
• Serum Na <135 mEq/L
European Society of Intensive Care Medicine (ESICM) European Society of Endocrinology(ESE) European Renal Association – European Dialysis and Transplant Association (ERA–EDTA)
Hyponatremia
• Serum Na <135 mEq/L
Hyponatremia is a disorder of water balance
Dısorders of water and sodium balance CONTENT VERSUS SERUM CONC OF NA
• Hyponatremia (too much water)
• Hypernatremia (too little water)
• Hypovolemia (too little sodium, the main
extracellular solute)
• Edema (too much sodium with associated
water retention)
Hyponatremia
• almost always due to the oral or intravenous
intake of water that cannot be completely
excreted
• impaired water excretion that is most often
due to an inability to suppress the release of
antidiuretic hormone (ADH) or to advanced
renal failure
Diagnosis
• Volume status and serum osmolality are
essential to determine etiology
• Hyponatremia usually reflects excess water
retention relative to sodium rather than sodium
deficiency, the sodium concentration is not a
measure of total body sodium
• Hypotonic fluids commonly cause hyponatremia
in hospitalized patients
Symptoms and Sing of Hyponatremia
• symptoms depends on severity and acuity hyponatremia
• the symptoms reflect neurologic dysfunction induced by cerebral edema and possible adaptive
responses of brain cels to osmotic swelling
• Nausea, malaise, headache, lethargy, seizures, coma, respiratory arrest
• the physical examination should help categorize the patient's volume status into hypovolemia,
euvolemia, or hypervolemia.
Classification of symptoms of hyponatraemia
Clinical practice guideline on diagnosis and treatment of hyponatraemia; Nephrol Dial Transplant (2014) 0: 1–39
Adaptation of the brain to hypotonicity
Adrogue HJ & Madias NE. Hyponatremia. NEJM; 2000 342 1581–1589
Complications of hyponatraemia
Hyponatraemia with severe symptoms
PRACTICAL POINT learned from Dr Railey in DH • NORMAL SALINE 153 MMOL/DL
• 3.8% SALINE 531 MMOL /DL
• 200ML 3.8% HYPERTONIC
• 200*531/1000= 106 MMOL NA
• 800ML SODIUM CHLORIDE =122 MMOL NA
• 1 LITRE 228 MMOL SODIUM
• SMOOTH CORRECTION …. FOLLOW UP EVERY 6 HOURS …. STOP WHEN NA INCREASE > 8 MMOL /DAY …… NORMAL SALINE CONTINUE
7.2. Hyponatraemia with moderately severe symptoms
7.3. Acute hyponatraemia without severe or moderately severe symptoms
7.4. Chronic hyponatraemia without severe or moderately severe symptoms
7.4. Chronic hyponatraemia without severe or moderately severe symptoms
7.4. Chronic hyponatraemia without severe or moderately severe symptoms
Na+ deficit ≈
body weight X 0.6 X
(desired plasma Na+ concentration –
plasma Na+ concentration)
1mg/dl/ h
10-12mg/dl /24h
Hypernatremia
• Serum Na>145 mEq/L
Symptoms and Sings of Hypernatremia
• Dehydrated patient → orthostatic hypotension and oliguria
• Rise in plasma Na and osmolality →water movement out of the brain →rupture of the cerebral veins →focal intracerebral and subarachnoidal
hemorrages→possible ireversible neurologic damage
• Lethargy, weaknees, irritability, twitching,
seuzures, coma • Osmotic demyelination (uncommon)
Laboratory Findings
• Urine osmolality > 400 mosm/kg → renal
water-conserving ability is functioning (hypotonic
fluid losses from excessive sweating, the respiratory tract, or bowel movements and lactulose)
• Urine osmolality < 250 mosm/kg →
characteristic of DI
-Central DI: inadequate ADH release
-Nephrogenic DI: renal insensitivity to ADH (lithium, demeclocycline, relief of urinary obstruction, interstitial nephritis, hypercalcemia, and hypokalemia)
• Water deficit ≈
body weight X 0.6 X
(plasma Na concentration/
desired plasma Na concentration) - 1