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Diagnosis and management of

Hyponatraemia in Cancer Patients

Fahad A Saadi
F1 Medical Oncology, Belfast City Hospital
fsaadi01@qub.ac.uk
Outline

• Why should we care

• Classification

• True vs False Hyponatraemia

• Hypo-, Hyper- and Euvolaemic hyponatraemia

• SIADH in Cancer Patients

• Treatment Algorithms
Why we should care

• Most common electrolyte disorder


• Multiple aetiologies in cancer patients
• Potential for substantial morbidity and mortality
• Economic burden
Classification

• Acute (< 48 hours) Vs Chronic (> 48 hours)

• Mild Moderate Severe


Hyponatraemia

• Na < 130 mmol/L

• True Vs False Hyponatraemia


False Hyponatraemia

• Low Serum Na conc. associated with:

• —> Normal or High Osmolality

• Does NOT causes the water to move into the cells

1. Water does not move at all = Pseudohyponatraemia (lab error, protein/lipids)

2. Water moves out of the cells = Factitious Hyponatraemia (hyperglycaemia)


True Hyponatraemia

• Low Serum Na conc. associated with:

• —> Low Osmolality

• In other wards Hypoosmolar hyponatraemia

• Causes the water to move into the cells - Osmosis


True Hyponatraemia

• True Hyponatraemia can be:

1. Hypovolumic

2. Euvolumic

3. Hypervolumic

• All of the above are ADH dependent


• Requires volume status assessment
Physiologic stimuli for ADH

1. Increased serum osmolality - not revenant here

2. Decreased perfusion

1. Volume depletion

2. Hypotension
Hypovolaemic Hyponatraemia

VOLUME DEPLETION

• GI loss - diarrhoea/vomiting

• Renal loss - diuretics


Hypervolaemic Hyponatraemia

HYPOTENSION

• heart failure

• cirrhosis

• nephrotic syndrome
Euvolaemic Hyponatraemia

• Fixed ADH release: Not due to hypotension or volume


depletion
Differentiation
• How do you differentiate Euvolaemic
hyponatraemia

• from

• Hyper- and Hypovolaemic hyponatraemia


Overview
Overview

• SIADH: most common aetiology in Cancer


SIADH diagnostic criteria

R. Berardi et al. / Critical Reviews in


Oncology/Hematology 102 (2016) 15–25

• Diagnosis of exclusion, rule out other causes of


hypoosmolar euvolemic hyponatraemia:

• hypothyroidism (severe)

• hypocortisolism (glucocorticoid insufficiency)

• Also absence of diuretic use and normal renal function


Causes of SIADH in Cancer

R. Berardi et al. / Critical Reviews in Oncology/Hematology


102 (2016) 15–25
Treatment of Hyponatraemia

• Acute symptomatic: A medical emergency

• Chronic asymptomatic: Depends on fluid status


• 

Acute Symptomatic Hyponatraemia

• 3% Hypertonic saline
• Goal: Na+ level does not rise by
more than 6 mmol/L in the first
six hours or 10 mmol/L in the
first 24 hours.
• Rapid overcorrection: osmotic
demyelination syndrome.


• Low risk once the serum [Na] has


reached 125 mmol/L 


Copyright © 2015 The Authors European Journal of Clinical Investigation published by John Wiley & Sons Ltd on
behalf of Stichting European Society for Clinical Investigation Journal Foundation.
Asymptomatic Hyponatraemia

Copyright © 2015 The Authors European Journal of Clinical Investigation published by John Wiley & Sons Ltd on behalf of Stichting European Society for
Clinical Investigation Journal Foundation.
Asymptomatic Hyponatraemia

i-e SIADH:

Fluid restrict (500-1000 ml/day for adults).

If fluid restriction ineffective:


Demeclocycline: licensed to treat SIADH due to
malignant disease

Vaptans (vasopressin receptor antagonists - eg,


tolvaptan) may be useful;
• expensive
• potentially may increase sodium levels too rapidly

Copyright © 2015 The Authors European Journal of Clinical Investigation published by John Wiley & Sons Ltd on behalf of Stichting European Society for
Clinical Investigation Journal Foundation.
Conslusion

1. Hyponatraemia Na < 130 mmol/L

2. Determine serum osmolality

• True hyponatraemia is: Hypoosmolar Hypovolaemic

3. Determine Volume status (Hypo-, Hyper-, Euvolaemic)

4. Determine urine sodium to differentiate Hypo-, Hyper-,


Euvolaemic hyponatraemia

5. Treat based on aetiology and acuteness of development


References

Verbalis, Joseph G., Steven R. Goldsmith, Arthur Greenberg, Cynthia Korzelius,


Robert W. Schrier, Richard H. Sterns, and Christopher J. Thompson. "Diagnosis,
Evaluation, and Treatment of Hyponatremia: Expert Panel Recommendations." The
American Journal of Medicine 126.10 (2013): n. pag.

Berardi, Rossana, Silvia Rinaldi, Miriam Caramanti, Christian Grohè, Matteo


Santoni, Francesca Morgese, Mariangela Torniai, Agnese Savini, Ilaria Fiordoliva, and
Stefano Cascinu. "Hyponatremia in Cancer Patients: Time for a New Approach."
Critical Reviews in Oncology/Hematology 102 (2016): 15-25.

Newson, Dr Louise. "Hyponatraemia. Abnormally Low Sodium Levels Information."


Patient. Patient.info, n.d. Web. 19 May 2017

Grant P, Ayuk J, Bouloux PM, et al; The diagnosis and management of inpatient
hyponatraemia and SIADH. Eur J Clin Invest. 2015 Aug 45(8):888-94. doi: 10.1111/
eci.12465. Epub 2015 Jun 28.

Hyponatraemia; NICE CKS, March 2015 (UK access only)


Questions

Thank you!
Vaptans to Treat Hyponatremia
Expert Panel Recommendations: Cautions for Using Vap- tans to Treat Hyponatremia
-  Exclude hypovolemic hyponatremia. 


-  Do not use in conjunction with other treatments for 



hyponatremia. 


-  Do not use immediately after cessation of other treat- 



ments for hyponatremia, particularly 3% NaCl. 


-  Monitor serum [Naþ] closely (every 6-8 hours) for the 



first 24-48 hours after initiating treatment. 


-  Maintain ad libitum fluid intake during the first 24-48 hours of treatment; hyponatremia can correct too quickly with coincidental fluid
restriction; in patients with a defective or impaired thirst mechanism (eg, intubated or unconscious patients), provide sufficient fluid to
prevent overly rapid correction due to unop- 

posed aquaresis. 


-  Increase the frequency of serum [Naþ] monitoring and 



consider stopping the vaptan if there is a change or deterioration in the patient’s condition (eg, NPO [nothing by mouth] status,
intubation) that limits the ability to request, access, or ingest fluid. 


-  Severe, symptomatic hyponatremia should be treated with 3% NaCl, as this provides a quicker and more certain correction of serum
[Naþ] than vaptans. 


-  Currently, there are insufficient data for use of vaptans in severe asymptomatic hyponatremia (ie, serum [Naþ] <120 mmol/L)—use
vaptans with caution and with more frequent monitoring in these patients. 


-  If overcorrection occurs, consider re-lowering the serum [Naþ] to safe limits 

Treatment of SIADH

Copyright © 2015 The Authors European Journal of Clinical Investigation published by John Wiley & Sons Ltd on behalf of Stichting European Society for
Clinical Investigation Journal Foundation.
Hyponatraemia recap

1. Hyponatraemia Na < 130 mmol/L

2. Determine serum osmolality

• True hyponatraemia is: Hypoosmolar Hypovolaemic

3. Determine Volume status (Hypo-, Hyper-, Euvolaemic)

4. Determine urine sodium to differentiate Hypo-, Hyper-,


Euvolaemic hyponatraemia

5. Treat based on aetiology and acuteness of development