Hyponatremia resident survival guide

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Hyponatremia
Resident Survival Guide
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Iqra Qamar M.D.[2] Priyamvada Singh, M.D. [3]Vidit Bhargava, M.B.B.S [4] Saeedeh Kowsarnia M.D.[5]

Overview

Hyponatremia is defined as a serum sodium concentration < 135 mEq/L.[1]

Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Severe hyponatremia ( <115 mEq/L) is by itself life threatening and should be treated as such irrespective of the cause.[2]

Common Causes

Hypovolemic hyponatremia:

Euvolemic hyponatremia:

Hypervolemic hyponatremia:

Causes of Hyponatremia based upon Serum Osmolality:

Serum Osmolality Etiology
Hypertonic Hyponatremia Hyperglycemia
Mannitol
Glycerol
Sorbitol
Isotonic Hyponatremia Lab/blood draw error
Hyperparaproteinemia
Hyperlipidemia
Post TURP (bladder irrigation with osmotic solutions)
Hypotonic Hyponatremia Etiology depends upon volume status (Hypervolemic/ Euvolemic/ Hypovolemic

Classification

Hyponatremia is defined as serum sodium less than 135 mEq/L (mmol/L).There are different classifications for hyponatremia based on duration, severity, volume status and ADH level.

Hyponatremia is classified based on serum sodium level to :

  • Mild : Serum sodium 130– 135 mmol/L
  • Moderate:  Serum sodium ≤125–129 mmol/L
  • Severe: Serum sodium <124 mmol/L

Classification based on duration[7] :

  • Hyperacute: Develops in a few hours, excess water intake, impaired water excretion, runners, users of the recreational drug (Ecstasy)
  • Acute: Rapid onset <48 hours, surgeries, colonoscopy preparation, polydipsia, diuretics
  • Chronic: Gradual onset >48 hours, caused by chronic disease ( including cardiac, renal, hepatic and other conditions)

Classification based on ADH level :

  • ↑ ADH: Volume depletion (GI loss, Renal loss) , decreased perfusion ( CHF, Cirrhosis), increased ADH secretion, reset osmostat
  • ↓ ADH: Primary polydipsia, ↓ dietary solute intake, advanced renal failure

According to volume status :

Volume status Sodium status
  • True volume depletion : GI loss, Renal loss, Insensible loss
Hypovolemic

Hyponatremia

  • total body water ↓
  • total body sodium ↓↓
Hypervolemic

Hyponatremia

  • total body water ↑↑
  • total body sodium ↑
  • Decreased effective arterial volume : Cirrhosis, Renal disease, CHF
Euvolemic

Hyponatremia

  • total body water ↑
  • total body sodium ↔
  • Drugs ,Increased ADH level, Reset osmostat, Low dietary salt intake

FIRE


 
 
 
 
 
 
 
 
Serum Na ≤ 135 meq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check for:
Serum osmolality
Urine osmolality
Urea
• Glucose
Urine chloride
Urine Na
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normotonicity
275–295 mOsm/kg
Hyperlipidemia
Hyperproteinemia
•Glycine
 
 
 
 
Hypertonicity
> 295 mOsm/kg
• Glucose
• Mannitol
• Glycine
 
 
 
 
Hypotonicity
<275 mOsm/kg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
UOsm < 100mOsm/kg
 
UOsm > 200mOsm/kg
 
 
UOsm 100–200mOsm/kg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Conditions
Polydipsia
•↓ solute excertion
(Beer potomania
,Tea & toast diet)
 
 
 
 
 
 
 
Conditions
Polydipsia
•↓ solute excertion
(Beer potomania
,Tea & toast diet)
•Rule out SIAD
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypovolemia
Based on history & physical exam
 
 
 
 
 
 
 
Hypervolemia
 
 
 
 
 
 
 
 
 
 
Euvolemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
UNa < 30 mEq/L
 
Variable UNa
 
UNa > 30 mEq/L
 
UNa < 30 mEq/L
 
UNa > 30 mEq/L
 
Variable UNa
 
UNa < 20 mEq/L
 
> 20 UNa < 40 mEq/L
 
UNa > 40 mEq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Extrarenal losses
Vomiting (Ucl ↓)
Diarrhea
Pancreatitis
Sweating
Small bowel obstruction
 
Variable UNa
Diuretic use
Discontinue diuretics if UNa is still abnormal
 
Renal losses
Osmotic diuresis (glucose, urea,bicarbonaturia)
Salt-Iosing nephropathy
Addison disease
CSW
 
Conditions
Heart failure
Liver disease
Nephrotic syndrome
 
Conditions
Chronic kidney disease
Diuretic use in:
Heart failure
Liver disease
Nephrotic syndrome
 
Discontinue diuretics if PNa normalize it's not SIAD if it's not normalized
 
Probable hypovolemia
 
Hypovolemia or euvolemia
 
•Probable euvolemia
SIAD
Cortisol deficiency
Hypothyroidism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer 0.9% saline
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normalize PNa
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer 1–2 L 0.9% saline
 
 
 
 
 
 
 
 
 
 
 
 
Failure to normalize PNa
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypovolemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PNa decreases or no change
 
 
 
 
 
 
 
 
 
 
 
 
PNa increases
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Decreasing UOsm
 
No change in UOsm but UNa increases
 
 
 
 
 
 
 
 
 
 
SIAD
 
 
 
 
 
 
No change in UOsm but UNa increases
 
 
Decreased UNa
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypovolemia
 
Salt-depleted SIAD
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypovolemia
 
 
Decreasing Uosm
 
 
Administer additional saline
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No change in UOsm
but UNa increases
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Salt-depleted SIAD

Management

Diagnostic Approach

Shown below is an algorithm depicting the diagnostic management of hyponatremia based on Diagnosis, Evaluation, and Treatment of Hyponatremia: Expert Panel Recommendations (2013).[8]

 
 
 
 
 
 
 
 
Characterize the symptoms:
❑ Nausea and vomiting
❑ Headache
Confusion
❑ Lethargy, fatigue, loss of appetite
Restlessness and irritability
❑ Muscle weakness, spasms, cramps
Seizures
❑ Decreased consciousness or coma[9]

Hyponatremic encephalopathy: (sodium < 115 meq/L)

❑ Altered thirst, hunger, dilated pupils (suggestive of brain stem compression)
Decorticate or decerebrate posturing
Respiratory arrest
Non-cardiogenic pulmonary edema
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
Orthostatic vital signs
Mental status examination (low score)
Jugular venous pressure ↑/↓
Peripheral edema
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check labs:
Plasma osmolality
Urine osmolality
❑ Urinary sodium concentration
Serum uric acid/creatinine
Thyroid stimulating hormone (TSH)
Serum cortisol level
❑ Serum proteins
Triglyceride
Random blood sugar
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnosis:
Adrenal crisis
Alcoholism
Hypothyroidism
Pulmonary/cardiogenic edema
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Check serum osmolality
Serum osmolality (mmol/kg) = (2 x serum sodium concentration) + (serum glucose concentration/18) + (blood urea nitrogen/2.8)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Isotonic hyponatremia
(Serum osmolality 280-295 mOsm/kg)
 
 
 
Hypotonic hyponatremia
(Serum osmolality < 280 mOsm/kg)
 
 
 
Hypertonic hypernatremia
(Serum osmolality > 295 mOsm/kg)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pseudohyponatremia
 
 
 
Assess volume status
 
 
 
Hyperglycemia
Mannitol infusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypovolemia
 
 
 
Euvolemia
 
 
 
Hypervolemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine sodium levels
 
 
 
Urine sodium levels
 
 
 
Urine sodium levels
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
>20 mEq/L
 
≤ 20 mEq/L
 
>20 mEq/L
 
>20 mEq/L
 
≤ 20 mEq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Vomiting & diarrhea treated with free water replacement
 
SIADH
Primary polydipsia
❑ Exercise associated hyponatremia
Nephrogenic syndrome of inappropriate antidiuresis
Glucocorticoid deficiency
Hypothyroidism
❑ Low solute intake
 
 


Therapeutic Approach

Initial Management

Shown below is an algorithm depicting the initial management of symptomatic hyponatremia based on Diagnosis, Evaluation, and Treatment of Hyponatremia: Expert Panel Recommendations (2013).[8]

 
 
 
 
 
 
 
 
Symptomatic hyponatremia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute hyponatremia (< 48 hours)
 
 
 
 
 
Chronic hyponatremia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Goals of treatment:
❑ Target sodium levels = 125-130 mEq/L[10]
❑ Daily ↑ in sodium levels by 4-6 mmol/L
 
 
 
 
 
Goals of treatment:
❑ Target sodium levels = 125-130 mEq/L
❑ Daily ↑ in sodium levels by 4-8 mmol/L if low risk of ODS
❑ Daily ↑ in sodium levels by 4-6 mmol/L if high risk of ODS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild to moderate symptoms
 
Severe symptoms
 
Mild to moderate symptoms
 
Severe symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Administer 0.9% NaCl to achieve target sodium levels, or
❑ Administer vaptans
 
❑ Administer 3% NaCl (100 ml infused over 10 minutes and repeated once if needed)
❑ Shift to 0.9% NaCl/vaptans at sodium levels > 125 mEq/L
 
❑ Administer 0.9% NaCl to achieve target sodium levels, or
❑ Administer vaptans
 
❑ Administer 3% NaCl (100 ml infused over 10 minutes and repeated once if needed)
❑ Achieve 1st day target in 1st 6 hours and withhold any more fluids for the day
❑ Shift to 0.9% NaCl/vaptans at sodium levels > 125 mEq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer vaptans (contraindicated for hypovolemic hyponatremia)

Conivaptan:

❑ Administer IV 20 mg loading dose over 30 minutes, followed by a continuous infusion of 20 mg/day
❑ Maintain a maximal infusion rate 40 mg/day
❑ Treat for 4 days or until the target sodium level is reached
❑ Monitor with sodium levels every 6-8 hours


OR
Tolvaptan: (Use only if sodium < 125 mEq/L or pt. symptomatic)

❑ Administer PO 15 mg on the first day
❑ Titrate to 30 mg/60 mg at 24-hour intervals if:
Sodium level < 135 mmol/L, or
Increase in sodium <5 mmol/L in the last 24 hours
❑ Monitor with sodium levels every 6-8 hours
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Additional Management

Shown below is an algorithm depicting the management of symptomatic and asymptomatic hyponatremia based on underlying etiology based on Diagnosis, Evaluation, and Treatment of Hyponatremia: Expert Panel Recommendations (2013).[8]

 
 
 
 
 
 
 
 
Etiology based management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypovolemia
 
 
 
Euvolemia
 
 
 
Hypervolemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine sodium level > 20 mEq/L
 
Urine sodium level ≤ 20 mEq/L
 
Urine sodium level > 20 mEq/L
 
Urine sodium level > 20 mEq/L
 
Urine sodium level ≤ 20 mEq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cerebral salt wasting syndrome:
❑ Fluid restriction is not advised

Adrenal failure:
❑ Monitor Na+ level frequently
❑ Perform co-syntropin testing
❑ Treat empirically with high dose hyrdocortisone
❑ Administer fludrocortisone once the diagnosis is confirmed


Thiazide like diuretics:
❑ Stop thiazide diuretics
❑ Monitor the rate of rise of Na+
❑ Monitor urine osmolality & volume to detect hypercorrection
❑ Follow K+ levels, as they may drop with therapy
 
Gastrointestinal losses:
❑ Correct K+ levels as appropriate
❑ Administer bicarbonate if acidosis develops
❑ Start antiemetics and specific therapy as indicated
 
SIADH:
❑ Restrict water
❑ Do not restrict water if the patient is on vaptans
❑ Use enteral water or D5W to prevent over correction
❑ Consider chronic pharmacotherapy depending on the etiology of SIADH

Nephrogenic syndrome of inappropriate antidiuresis:
❑ Similar to SIADH


Hypothyroidism:
❑ Treat hyponatremia only when severe
❑ Treat primary etiology


Glucocorticoid def.:
❑ Replace glucocorticoids
❑ Monitor sodium levels and urine volume to prevent over correction


Exercise associated hyponatremia:
❑ Treat with free water restriction and observation


Low solute intake:
❑ Provide proper nutrition of electrolytes and proteins


Primary polydipsia:
❑ Restrict water
 
Acute kidney injury:
❑ Restrict water
 
Heart failure:
❑ Initiate treatment with fluid restriction
❑ Administer loop diuretics
❑ Consider vaptans
Liver cirrhosis:
❑ Use tolvaptan restrictively based on LFT's
 
 
 
 
 
 
 

ADH: Anti diuretic hormone; SIADH: Syndrome of inappropriate antidiuretic hormone secretion; NaCl: Sodium chloride; LFT: Liver function test;IV: Intravenous; PO: Per oral; ECF:Extra cellular fluid; HPE:History and physical examination; ODS: Osmotic demyelination syndrome

Do's

  • Do the following to prevent over correction of sodium levels:
  • Replace water losses or administer desmopressin after correction by 6-8 mmol/L during the first 24 hours of therapy.
  • Withhold the next dose of vaptans if the correction is >8 mmol/L.
  • Consider therapeutic lowering of serum sodium if correction exceeds therapeutic limits.
  • Consider administration of high-dose glucocorticoids (eg, dexamethasone, 4 mg every 6 hours) for 24-48 hours following the excessive correction.
  • Follow these steps to lower serum sodium, if correction exceeds therapeutic limits:
  • Administer desmopressin to prevent further water losses: 2-4 mg every 8 hours parenterally.
  • Replace water orally or as 5% dextrose in water intravenously at the rate of 3 mL/kg/h.
  • Recheck serum sodium hourly and continue therapy infusion until serum sodium is reduced to goal.
  • Initiate vaptans treatment only in hospital setting, so as to regularly monitor serum sodium levels.
  • Fluid restrictions:
  • Restrict all intake that is consumed by drinking, not just water.
  • Aim for a fluid restriction that is 500 mL/d below the 24-hour urine volume.
  • Do not restrict sodium or protein intake unless indicated.
  • Gastrointestinal losses:
  • Measure urine chloride, if vomiting is present to confirm the presence of solute and volume depletion.
  • Treat typically as a chronic hyponatremia.
  • Thiazide diuretic induced:
  • Treat typically as chronic hyponatremia.
  • Be vary of rapid correction.
  • Serially follow changes in urine osmolality together with urine volume.
  • Measure serum sodium every 6 hours to begin with.
  • Adjust potassium levels in fluids as needed.

Dont's

  • Do not use to treat hypovolemic hyponatremia.
  • Do not use in conjunction with other treatments for hyponatremia.
  • Do not use immediately after cessation of other treatments for hyponatremia, particularly 3% NaCl.
  • Do not use for severe, symptomatic hyponatremia, as 3% NaCl provides a quicker and more certain correction of serum sodium than vaptans.
  • Do not use isotonic normal saline as primary therapy for SIADH.

References

  1. Laczi, F. (2008). "[Etiology, diagnostics and therapy of hyponatremias]". Orv Hetil. 149 (29): 1347–54. doi:10.1556/OH.2008.28409. PMID 18617466. Unknown parameter |month= ignored (help)
  2. Clayton, JA.; Le Jeune, IR.; Hall, IP. (2006). "Severe hyponatraemia in medical in-patients: aetiology, assessment and outcome". QJM. 99 (8): 505–11. doi:10.1093/qjmed/hcl071. PMID 16861720. Unknown parameter |month= ignored (help)
  3. Schmitz, PH.; de Meijer, PH.; Meinders, AE. (2001). "Hyponatremia due to hypothyroidism: a pure renal mechanism". Neth J Med. 58 (3): 143–9. PMID 11246114. Unknown parameter |month= ignored (help)
  4. Macaron, C.; Famuyiwa, O. (1978). "Hyponatremia of hypothyroidism. Appropriate suppression of antidiuretic hormone levels". Arch Intern Med. 138 (5): 820–2. PMID 417689. Unknown parameter |month= ignored (help)
  5. Leung, AA.; Wright, A.; Pazo, V.; Karson, A.; Bates, DW. (2011). "Risk of thiazide-induced hyponatremia in patients with hypertension". Am J Med. 124 (11): 1064–72. doi:10.1016/j.amjmed.2011.06.031. PMID 22017784. Unknown parameter |month= ignored (help)
  6. Oren, RM. (2005). "Hyponatremia in congestive heart failure". Am J Cardiol. 95 (9A): 2B–7B. doi:10.1016/j.amjcard.2005.03.002. PMID 15847851. Unknown parameter |month= ignored (help)
  7. Sterns, Richard H.; Ingelfinger, Julie R. (2015). "Disorders of Plasma Sodium — Causes, Consequences, and Correction". New England Journal of Medicine. 372 (1): 55–65. doi:10.1056/NEJMra1404489. ISSN 0028-4793.
  8. 8.0 8.1 8.2 Verbalis, JG.; Goldsmith, SR.; Greenberg, A.; Korzelius, C.; Schrier, RW.; Sterns, RH.; Thompson, CJ. (2013). "Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations". Am J Med. 126 (10 Suppl 1): S1–42. doi:10.1016/j.amjmed.2013.07.006. PMID 24074529. Unknown parameter |month= ignored (help)
  9. "Sign In" (PDF). Retrieved 28 January 2014.
  10. Gross, P.; Reimann, D.; Neidel, J.; Döke, C.; Prospert, F.; Decaux, G.; Verbalis, J.; Schrier, RW. (1998). "The treatment of severe hyponatremia". Kidney Int Suppl. 64: S6–11. PMID 9475480. Unknown parameter |month= ignored (help)

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