hyponatremia treatment guidelines 2019 pdf
in central laboratories. 2-Cesar KR, Magaldi, AJ- Thiazide induces water absorption in the inner Oral tolvaptan is safe gap between what is known and what we do in renal medicine: improving Central osmoreceptors, expressing transient receptor potential vanilloid 1 (TRPV1), and peripheral osmoreceptors, expressing TRPV4, relay the information on osmolality [20, 21]. and safety of oral tolvaptan therapy in patients with the syndrome of We suggest checking the serum sodium concentration after 6 and 12 h and daily afterwards until the serum sodium concentration has stabilised under stable treatment (2D). Classification based on serum sodium concentration. The guideline specifically covers diagnosis and management of true hypotonic hyponatraemia. Hence, treatment strategies have been classified according to combinations of these criteria. Consultant Intensivist, Innsbruck University Hospital, Innsbruck, Austria. educate its stakeholders on this topic. 188.8.131.52. The numerator in formula 1 is a simplification of the expression in formula 2, with the value yielded by the equation (mmol/l). Correspondence . The guidance has been over-simplistic and does not reflect the range of clinical problems encountered in day-to-day practice. Breakdown of the myelin sheath insulating individual neurons can result in what is called the osmotic demyelination syndrome [80, 81, 82, 83]. Hence, we wanted to know which tests are most useful in differentiating causes of hypotonic hyponatraemia, in which order we should use them and what threshold values have the highest diagnostic value. TRPV1 is an osmotically activated channel expressed in the vasopressin producing magnocellular cells and in the circumventricular organs [22, 23]. Stop, if possible, medications and other factors that can contribute to or provoke hyponatraemia (not graded). We suggest limiting the increase in serum sodium concentration to 10 mmol/l in the first 24 h and 8 mmol/l during every 24 h thereafter, until a serum sodium concentration of 130 mmol/l is reached (2D). Unfortunately, we found no study evaluating the sensitivity and specificity of a particular threshold. Patients with an sNa less than 130 mEq/L should be considered for treatment. 2 Nagler EV, Webster AC, Bolignano D, Haller MC, Nistor I, van der with the additional data, we found that compared with placebo, vasopressin receptor antagonists did not reduce the number of deaths (RR 1.08, 95% CI 0.80–1.46). Although renal sodium retention tends to increase the extracellular volume, the effective circulating blood volume is generally reduced due to impaired cardiac output. The so-called salt-losing nephropathies, such as tubulopathy after chemotherapy or in analgesic nephropathy, medullary cystic kidney disease and certain pharmacological compounds can inhibit the kidney's ability to re-absorb appropriate amounts of sodium . The response to changes in osmolality remains intact. diagnosis and treatment of hyponatraemia . Recommendations can be for or against a certain strategy. of the four studies mentioned supporting the use of loop diuretics with A urine sodium concentration >30 mmol/l had high estimated sensitivities of 1.0 and 0.94 respectively in patients off and on diuretics, but low specificities of 0.69 and 0.24 respectively . A first review, published in 2010, included 15 randomised controlled trials and 1619 participants up to 2009 . Owing to its surrogate nature, the outcomes ‘change in serum sodium concentration’ and ‘correction of serum sodium concentration’ were considered less important than the critically and highly important clinical outcomes (Table 1). Because of the re-absorption of both sodium and urea from the lumen, the osmolality of the tip of the medulla may reach 1200 mOsm/l in case of water depletion. We are convinced it contributed to the clarity and ultimately to the overall quality of the guideline. Nevertheless, the guideline development group feels that the dramatic consequences of osmotic demyelinating syndrome warrant an attempt to re-lower the serum sodium concentration in case of overly rapid correction using an active intervention. SIAD is a diagnosis of exclusion. Effective osmolality or tonicity refers to the number of osmoles that contribute water movement between the intracellular and extracellular compartment. Decaux G, Fenske W, Hoorn E, Ichai C, . In 96% (52/54) of cases, the initial serum sodium concentration was <120 mmol/l, in 85% (46/54) <115 mmol/l. The appraisal was done by a panel of target guideline users external to the guideline development group. R, Thompson C. Diagnosis, Evaluation, and Treatment of Hyponatremia: Hypovolemic hyponatremia can be prevented by the use of balanced crystalloids and avoiding overdiuresis, especially when using loop diuretics. Andr?s Navarro has consulted for Otsuka When areas of uncertainty were identified, the guideline development group considered making suggestions for future research based on the importance to patients or the population and on ethical and technical feasibility. first place. mentioned above and patients to enhance the relevance of our document to 164(5): 725-732. Summary tables 2A, 2B, 13A). Consultant Nephrologist, Chair of ERBP, Ghent University Hospital, Belgium. As part of an ongoing process of introducing software to facilitate the guideline development process, the ERBP methods support team used two formats for data extraction and collation. It is plausible that overly rapid correction occurs more readily in conditions where treatment of the underlying cause results in restoration of the kidneys' capacity to excrete electrolyte-free water. Consequently, the calculation of an ion level with the use of a degree of dilution that is based on the incorrect fraction of solid-phase particles will lead to an underestimate. 184.108.40.206. Stretch-sensitive receptors in the left atrium, carotid sinus and aortic arch sense circulating volume. At least every 5 years, the ERBP methods support team will update its literature searches. In 96% (52/54), the diagnosis of osmotic demyelination syndrome was based on magnetic resonance imaging. with the remaining studies using NaCl intravenously (19). We know very Everybody who is experienced with the use of tolvaptan knows that it is a powerful, highly effective tool that 220.127.116.11. Both structures organise, regulate and control the scientific and educational activities of the society. Secondary adrenal insufficiency is caused by reduced or absent secretion of adrenocorticotrophic hormone, resulting in hypocortisolism. 18.104.22.168. Nephrol Dial transplant (2014)0:1-39. desmopressin 2 µg, with the understanding that this should not be repeated more frequently than every 8 h (1D). Therefore, Hyponatremia: evaluating the correction factor for hyperglycemia. Mind the gap. Management of severe hyponatremia: rapid or slow correction? Urinary sodium loss can cause volume depletion and, if sufficiently severe, trigger vasopressin release. and collect the experiences and perspectives of experts in different countries and to include them in the guideline. Hyponatraemia is therefore both common and important. 5 Chantzichristos D, Drougge H, Dahm P, Ed?n Engstr?m B, Ekman B, The authors of the guideline may argue that the authors of this letter have received honoraria from the company producing tolvaptan and are therefore not objective. Statutes and detailed standard operating procedures can be found on the ESICM website (www.esicm.org). (ERBP) group has helped stimulate a debate on this important cause of Be aware that sometimes it may not be possible to assess an improvement in symptoms, e.g. We recommend consulting an expert to discuss if it is appropriate to add i.v. Calculated using equation from Hillier TA, Abbott RD & Barrett EJ. In profound hyponatraemia, we recommend against vasopressin receptor antagonists (1C). There is one issue about tolvaptan that has to be taken into account though: its high price. Rapid correction of The first case occurred in a man with hyponatraemia probably due to polydipsia and low solute intake, the second in a woman with hyponatraemia due to thiazides, which were stopped on admission. For identifying the limits for the increase in serum sodium concentration above which the risk of osmotic demyelination starts to rise, we included all observational studies reporting cases of osmotic demyelinating syndrome and corresponding serum sodium concentration correction speeds. We excluded case series that reported on benefit if the number of participants was ≤5 but included even individual case reports if they reported an adverse event. It was designed to provide information and assist in decision-making related to this topic. The rationale contains a brief section on ‘why this question’ with relevant background and justification of the topic, followed by a short narrative review of the evidence in ‘what did we find’ and finally a justification of how the evidence translated in the recommendations made in ‘how did we translate the evidence into the statement’. In the first of these, a retrospective single-arm cohort study, six patients were given desmopressin after a 24-h increase in serum sodium concentration of 12 mmol/l had already been reached. O'Connell R, . Br J Biomed Sci. We have categorised the causes of hyponatraemia in those associated with a reduced, normal or increased extracellular fluid volume. 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