Hypernatremia Management Guidelines PDF

Guidelines for management of Hypernatremia Children’s Kidney Centre University Hospital of Wales Cardiff CF14 4XW DISCLAIMER: These guidelines were produced in good faith by t...

Guidelines for management of Hypernatremia Children’s Kidney Centre University Hospital of Wales Cardiff CF14 4XW DISCLAIMER: These guidelines were produced in good faith by the authors reviewing available evidence/opinion. They were designed for use by paediatric nephrologists at the University Hospital of Wales, Cardiff for children under their care. They are neither policies nor protocols but are intended to serve only as guidelines. They are not intended to replace clinical judgment or dictate care of individual patients. Responsibility and decision-making (including checking drug doses) for a specific patient lie with the physician and staff caring for that particular patient. Version 1, S. Hegde/Nov 2007  Hypernatremia Hypernatremia (HRN), defined as serum sodium >145 mmol/l, represents hyperosmolality. Although it reflects a deficiency of water relative to sodium, total body sodium may be high, normal or low. HRN is mirror image of hyponatremia. Serum sodium (Na) level (hence osmolality) is tightly controlled within a narrow range despite wide variations in Na and water intake, by regulation of urine concentration (via ADH secretion) and regulation of thirst response (more effective). HRN is extremely rare in an alert patient with intact thirst mechanism and having free access to water. The two mechanisms that result in HRN are loss of water in excess of Na & gain of Na in excess of water. HRN induced osmotic gradient result in water movement out of the cells into ECF (ECF volume relatively well maintained, hence the less evident signs of hypovolemia). This cellular dehydration in brain cells (‘cerebral dehydration’ result in local hyperosmolality and reduced `brain volume`) is responsible for the neurological symptoms seen in HRN. Partial restitution of brain volume occurs by intracellular accumulation of electrolytes (within few hours - ‘rapid adaptation’) and organic osmolytes (over several days-‘slow adaptation’). However they can dissipate only slowly out of the cells when HRN is corrected, hence rapid correction carries the risk of cerebral edema. Table 1. Causes of hypernatremia – (Hypovolemic HRN is the commonest) Hypovolemic :ECF volume contraction Euvolemic : ECF volume normal (Total body water ↓↓, Total body a ↓) (Total body water ↓, total body sodium ↔) GI(diarrhea, vomiting) Unconscious patients/infants Evaporative( high ambient temp/pyrexia) Lack of access to water Diabetes insipidus (central/nephrogenic) Primary adipsia Head trauma/ Sheehan’s syndrome Essential hypernatremia (osmoreceptor Tumours/ histiocytosis destruction/malfunction) Degenerative brain diseases/infections Chronic renal failure Hypervolemic ; ECF volume expansion Hypokalemia/ hypercalcemia (total body water ↑, total body sodium ↑↑) Sickle cell disease Renal medullary damage/papillary necrosis Inappropriate IV fluid therapy (with high Na) Chronic pyelonephritis Salt poisoning /improperly mixed formula Nephronophthisis Seawater/sodium chloride ingestion Ineffective breast feeding Minaralocorticoid excess (Cushing`s/Conn`s synd) Osmotic/loop diuretic therapy Signs & Symptoms: 1. Of underlying problem (e.g. suggestive of DI) 2. Most have symptoms of volume depletion (common cause), but are less symptomatic initially as they have better preservation of intravascular volume. 3. CNS symptoms- Severity of the neurological symptoms is related to both the degree and, more importantly, the rate of rise in the serum Na. Hence patients with chronic HRN may be relatively asymptomatic. The symptoms include high pitched cry, irritability, lethargy, weakness which can progress to twitching, seizures, coma and death in severe cases. Consequences of hypernatremia 1. Brain haemorrhage- Due to tearing of intracerebral veins and bridging blood vessels resulting from decrease in brain volume. This could take the form of subarachnoid, subdural, parenchymal and intraventricular hemorrhage, presenting clinically as seizures and coma. 2. Central pontine and extra pontine myelinolysis 3. Thrombotic complications- stroke, dural sinus thrombosis, peripheral including renal vein thrombosis. 4. Hyperglycemia and hypocalcaemia Table 2. Investigations In addition to the appropriate tests to confirm the underlying disorder, the following investigations are essential (also refer Polyuria for DI) Blood Urine Osmolality Osmolality Sodium, potassium, chloride, bicarbonate Sodium, potassium, chloride Urea, creatinine, glucose, calcium, Ph, Urea, creatinine Glucose Calculate-Fractional excretion of sodium Blood gas if bicarbonate is abnormal (FE a = UNa / PNa x PCr / UCr) -Fractional excretion of water (FEH2O = PCr / UCr) Management of hypernatremia Basic principles- 1. Identify and treat the underlying cause 2. HR should be corrected slowly (particularly if HR is of unknown duration or chronic) as rapid correction can induce cerebral edema, seizures, permanent neurological damage and death (rate of correction of Na should be 3%) Fractional excretion of water (FeH2O) Often 1 % Metabolic Acidosis Non-discriminatory Non-discriminatory Urine sodium concentration Non-discriminatory Non-discriminatory  Approach to a child with Hypernatremia Hypernatremia ECF volume status Decreased ormal/Increased Loss of water in excess of Na Gain of Na in excess of water Urine osmolality Urine osmol-Variable > 600 < 600 Urine Na > 75-100 FeNa > 1% FeNa < 1% FeH2O normal or high Urine sodium Urine sodium Excessive oral ingestion Excessive IV administration Saline enema Mineralocorticoid excess Cushing`s syndrome < 20 Variable Variable > 20 Conn`s syndrome GI loss Inadequate intake Central DI Hyperglycemia Thermal injury Pyrexia Nephrogenic Diuretic therapy Hyperventilation DI Intrinsic renal disease