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Hyponatremia

Last reviewed: 3 Apr 2025
Last updated: 28 Feb 2024

Summary

Definition

History and exam

Key diagnostic factors

  • high fluid intake
  • fluid losses
  • history of diabetes mellitus
  • history of cirrhosis, nephrosis, congestive heart failure
  • nausea/vomiting
  • mild cognitive symptoms
  • altered mental status, seizures, coma
  • low urine output
  • weight changes
  • orthostatic hypotension
  • abnormal jugular venous pressure
  • poor skin turgor
  • dry mucus membranes
  • absence of axillary sweat
  • edema
  • rales or crackles on lung auscultation
  • polyuria
Full details

Other diagnostic factors

  • history of hyperlipidemia or paraproteinemia
Full details

Risk factors

  • older age
  • hospitalization
  • selective serotonin-reuptake inhibitor (SSRI) use
  • thiazide diuretic use
  • underlying medical conditions
  • severe hypothyroidism
  • adrenal insufficiency
  • malignancy
  • use of other medications
  • MDMA (ecstasy) use
Full details

Diagnostic tests

1st tests to order

  • serum sodium concentration
  • serum electrolytes, BUN, creatinine, and glucose
  • serum osmolality
  • urine sodium concentration
  • urine osmolality
  • urine electrolytes
  • urine flow rate
  • electrolyte-free water excretion
  • fractional excretion of sodium
  • thyroid-stimulating hormone
  • serum cortisol level and/or adrenocorticotropic hormone test
  • serum lipids and serum protein electrophoresis
Full details

Tests to consider

  • CT brain, chest, abdomen/pelvis
  • other tests targeted at evaluating the underlying cause
Full details

Treatment algorithm

ACUTE

acute onset (<48 hours) and/or symptomatic

ONGOING

chronic onset (≥48 hours) or asymptomatic

overcorrection of serum sodium concentration

Contributors

Authors

Judith H. Veis, MD
Judith H. Veis

Section Director

Nephrology

MedStar Washington Hospital Center

Washington

DC

Disclosures

JHV declares that she has no competing interests.

Peer reviewers

Gregor Lindner, MD

Director

Department of Internal & Emergency Medicine

Hirslanden Klinik Im Park

Zurich

Switzerland

Disclosures

GL is an author of a number of references cited in this topic.

Michael E. Ullian, MD

Professor of Medicine

Division of Nephrology

Department of Medicine

Medical University of South Carolina

Charleston

SC

Disclosures

MEU declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Spasovski G, Vanholder R, Allolio B, et al; Hyponatraemia Guideline Development Group. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Eur J Endocrinol. 2014 Feb 25;170(3):G1-47.Full text  Abstract

Adrogué HJ, Tucker BM, Madias NE. Diagnosis and management of hyponatremia: a review. JAMA. 2022 Jul 19;328(3):280-91. Abstract

Verbalis JG, Grossman A, Höybye C, et al. Review and analysis of differing regulatory indications and expert panel guidelines for the treatment of hyponatremia. Curr Med Res Opin. 2014 Jul;30(7):1201-7. Abstract

Hoorn EJ, Zietse R. Diagnosis and treatment of hyponatremia: compilation of the guidelines. J Am Soc Nephrol. 2017 May;28(5):1340-9.Full text  Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
  • Hyponatremia images
  • Differentials

    • Hypertonic hyponatremia
    • Pseudohyponatremia
    • Evaluation of hyponatremia
    More Differentials
  • Guidelines

    • Clinical practice guidelines for the management of exercise-associated hyponatremia: 2019 update
    • Clinical practice guidelines for the management of exercise-associated hyponatremia: 2019 update​
    More Guidelines
  • Patient information

    Hyponatremia (low blood sodium)

    More Patient information
  • Calculators

    Sodium Correction in Hyperglycemia (Hillier 1999)

    Osmolality Estimator (serum)

    More Calculators
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