Korean Society of Nephrology 2022 Recommendations on controversial issues in diagnosis and management of hyponatremia

Abstract

The Korean Society for Electrolyte and Blood Pressure Research, in collaboration with the Korean Society of Nephrology, has published a clinical practice guideline (CPG) document for hyponatremia treatment. The document is based on an extensive evidence-based review of the diagnosis, evaluation, and treatment of hyponatremia with the multidisciplinary participation of representative experts in hyponatremia with methodologist support for guideline development. This CPG consists of 12 recommendations (two for diagnosis, eight for treatment, and two for special situations) based on eight detailed topics and nine key questions. Each recommendation begins with statements graded by the strength of the recommendations and the quality of the evidence. Each statement is followed by rationale supporting the recommendations. The committee issued conditional recommendations in favor of rapid intermittent bolus administration of hypertonic saline in severe hyponatremia, the use of vasopressin receptor antagonists in heart failure with hypervolemic hyponatremia, and syndrome of inappropriate antidiuresis with moderate to severe hyponatremia, the individualization of desmopressin use, and strong recommendation on the administration of isotonic fluids as maintenance fluid therapy in hospitalized pediatric patients. We hope that this CPG will provide useful recommendations in practice, with the aim of providing clinical support for shared decision-making to improve patient outcomes.

Correspondence on Letter regarding “Evidence-based hyponatremia management in liver disease”

“…8,9 Hyponatremia and overly rapid correction of hyponatremia have been well-known as potent causative factors of ODS. 4,[10][11][12] The only recommendation of ODS till date is conservative treatment. The best approach is focused on prevention strategies with two aspects: identifying patients at risk and implementing proper correction, especially with a strict maximum of 8 mmol/L per day for individuals at risk of ODS.…”

“…The best approach is focused on prevention strategies with two aspects: identifying patients at risk and implementing proper correction, especially with a strict maximum of 8 mmol/L per day for individuals at risk of ODS. [10][11][12] However, it should be noted that ODS can occur even in the absence of hyponatremia or overcorrection of hyponatremia in patients with high risk of ODS. Patients with chronic alcohol consumption (the most common) or liver cirrhosis/liver transplantation (third largest group) are more susceptible to ODS because of reduced ability of astrocytes to synthesize new intracellular osmolytes in response to osmotic changes.…”

Evidence-based hyponatremia management in liver disease

“…Evaluate the severity of clinical hyponatremia symptoms Symptomatic moderate or severe/profound hyponatremia should be treated promptly with hypertonic saline to improve symptoms, and this should be prioritized over further diagnostic testing. 1,55 If acute management has been initiated or there is asymptomatic or mild hyponatremia, step 3 should be followed.…”

“…For contracted ECF volume (hypovolemia), diuretics or renal sodium loss including renal or cerebral salt wasting should be considered, while for normal ECF volume (euvolemia), SIAD, secondary adrenal insufficiency, or hypothyroidism should be ruled out. 1,27,55 The clinical assessment to determine the volume status is difficult as both the sensitivity (0.5-0.8) and specificity (0.3-0.5) are low. 1 Therefore, additional modalities such as fractional excretion of sodium (with a cutoff of 1) or urea (with a cutoff of 35) or point-of-care ultrasound (POCUS) can be helpful for assessing volume status.…”

Hypertonic Saline Infusion for Hyponatremia: Limitations of the Adrogué-Madias and Other Formulas

“…[6][7][8] Guidelines for treating severe symptomatic hyponatremia advocate hypertonic saline infusion. [9][10][11][12] Hypertonic saline infusion risks include overcorrection and undercorrection of [Na], which have severe consequences and must be avoided. 8,13 A vital element of the efforts to prevent correction issues is calculating the volume of the infused hypertonic saline (V Inf ) accurately.…”