![]() ![]() The proper treatment of dilutional hyponatremia, especially when chronic, must avoid increasing serum sodium too rapidly, which can lead to permanent or fatal neurologic sequelae. Prompt recognition and optimal management of hyponatremia in hospitalized patients may reduce in-hospital mortality and symptom severity, allow for less intensive hospital care, decrease the duration of hospitalization and associated costs, and improve the treatment of underlying comorbid conditions and patients’ quality of life. In patients hospitalized for congestive heart failure, hyponatremia is linked to a poor prognosis and increased length of hospital stay. Chronic hyponatremia often develops in patients with nonrenal diseases and is associated with increased morbidity and mortality. In fact, acute severe hyponatremia is potentially life-threatening and must be treated promptly and aggressively. Serious complications of dilutional hyponatremia most frequently involve the central nervous system. Hyponatremia may be classified as either acute or chronic depending on the rate of decline of serum sodium concentration, and can lead to a wide range of deleterious changes involving almost all body systems. ![]() It represents an excess of water in relation to prevailing sodium stores and is most often associated with a high plasma level of arginine vasopressin, including that found in patients with the syndrome of inappropriate antidiuretic hormone secretion. It should be kept in mind, however, that diuretics can alter the urine sodium concentration and confuse the clinical picture.Dilutional hyponatremia is a commonly observed disorder in hospitalized patients. The urine sodium determination should be used as a guide in noneuvolemic states to determine whether further evaluation for renal failure or pathophysiologic renal sodium loss is required. If BUN and creatinine levels are normal, assessment of the extracellular fluid volume should be conducted. Evidence of renal failure (elevated blood urea nitrogen and creatinine levels) points to primary renal disease as the likely cause of hyponatremia. If the urine osmolality is 100 mOsm per kg or greater, renal function should be evaluated. If the urine osmolality is less than 100 mOsm per kg (100 mmol per kg), evaluation for psychogenic polydipsia should be conducted. 13, 16 The first step is to determine the plasma and urine osmolality and to perform a clinical assessment of volume status. 5 Thus, it would be an unusual day in many family physicians' practices that at least one diagnostic or therapeutic issue related to water metabolism did not arise.įigure 1 shows an algorithm for the evaluation of patients with hyponatremia. 4 Among nursing home patients who require acute hospitalization, the prevalence of hypernatremia has been reported to be more than 30 percent. 3 Similarly, cross-sectional studies suggest a 1 percent prevalence of hypernatremia in nursing home residents. 2 A 12-month longitudinal study showed that more than 50 percent of nursing home residents had at least one episode of hyponatremia. 1 Cross-sectional studies suggest that hyponatremia may be present in 15 to 18 percent of patients in chronic care facilities. It is estimated that nearly 7 percent of healthy elderly persons have serum sodium concentrations of 137 mEq per L or less. Hyponatremia is defined as a serum sodium concentration of less than 137 mEq per L (137 mmol per L). Hyponatremia and hypernatremia are common in the elderly, particularly among those who are hospitalized or living in long-term care facilities. Furthermore, clinicians should have a clear appreciation of the roles that iatrogenic interventions and lapses in nutrition and nursing care frequently play in upsetting the homeostatic balance in elderly patients, particularly those who are in long-term institutional and inpatient settings. Clinicians should use a systematic approach in evaluating water and sodium problems, utilizing a comprehensive history and physical examination, and a few directed laboratory tests to make the clinical diagnosis. The sensation of thirst, renal function, concentrating abilities and hormonal modulators of salt and water balance are often impaired in the elderly, which makes such patients highly susceptible to morbid and iatrogenic events involving salt and water. Because age-related changes and chronic diseases are often associated with impairment of water metabolism in elderly patients, it is absolutely essential for clinicians to be aware of the pathophysiology of hyponatremia and hypernatremia in the elderly. Management of abnormalities in water homeostasis is frequently challenging. ![]()
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