Hyponatremia
Definition
The normal concentration of sodium in the blood plasma is 136-145 mM. Hyponatremia occurs when sodium falls below 130 mM. Plasma sodium levels of 125 mM or less are dangerous and can result in seizures and coma.
Description
Sodium is an atom, or ion, that carries a single positive charge. The sodium ion may be abbreviated as Na+ or as simply Na. Sodium can occur as a salt in a crystalline solid. Sodium chloride (NaCl), sodium phosphate (Na2HPO4) and sodium bicarbonate (NaHCO3) are commonly occurring salts. These salts can be dissolved in water or in juices of various foods. Dissolving involves the complete separation of ions, such as sodium and chloride in common table salt (NaCl).
About 40% of the body's sodium is contained in bone. Approximately 2-5% occurs within organs and cells and the remaining 55% is in blood plasma and other extracellular fluids. The amount of sodium in blood plasma is typically 140 mM, a much higher amount than is found in intracellular sodium (about 5 mM). This asymmetric distribution of sodium ions is essential for human life. It makes possible proper nerve conduction, the passage of various nutrients into cells, and the maintenance of blood pressure.
The body continually regulates its handling of sodium. When dietary sodium is too high or low, the intestines and kidneys respond to adjust concentrations to normal. During the course of a day, the intestines absorb dietary sodium while the kidneys excrete a nearly equal amount of sodium into the urine. If a low sodium diet is consumed, the intestines increase their efficiency of sodium absorption, and the kidneys reduce its release into urine.
The concentration of sodium in the blood plasma depends on two things: the total amount of sodium and water in arteries, veins, and capillaries (the circulatory system). The body uses separate mechanisms to regulate sodium and water, but they work together to correct blood pressure when it is too high or too low. Too low a concentration of sodium, or hyponatremia, can be corrected either by increasing sodium or by decreasing body water. The existence of separate mechanisms that regulate sodium concentration account for the fact that there are numerous diseases that can cause hyponatremia, including diseases of the kidney, pituitary gland, and hypothalamus.
Causes and symptoms
Hyponatremia can be caused by abnormal consumption or excretion of dietary sodium or water and by diseases that impair the body's ability to regulate them. Maintenance of a low salt diet for many months or excessive sweat loss during a race on a hot day can present a challenge to the body to conserve adequate sodium levels. While these conditions alone are not likely to cause hyponatremia, it can occur under special circumstances. For example, hyponatremia often occurs in patients taking diuretic drugs who maintain a low sodium diet. This is especially of concern in elderly patients, who have a reduced ability to regulate the concentrations of various nutrients in the bloodstream. Diuretic drugs that frequently cause hyponatremia include furosemide (Lasix), bumetanide (Bumex), and most commonly, the thiazides. Diuretics enhance the excretion of sodium into the urine, with the goal of correcting high blood pressure. However, too much sodium excretion can result in hyponatremia. Usually only mild hyponatremia occurs in patients taking diuretics, but when combined with a low sodium diet or with the excessive drinking of water, severe hyponatremia can develop.
Severe and prolonged diarrhea can also cause hyponatremia. Severe diarrhea, causing the daily output of 8-10 liters of fluid from the large intestines, results in the loss of large amounts of water, sodium, and various nutrients. Some diarrheal diseases release particularly large quantities of sodium and are therefore most likely to cause hyponatremia.
Drinking excess water sometimes causes hyponatremia, because the absorption of water into the bloodstream can dilute the sodium in the blood. This cause of hyponatremia is rare, but has been found in psychotic patients who compulsively drink more than 20 liters of water per day. Excessive drinking of beer, which is mainly water and low in sodium, can also produce hyponatremia when combined with a poor diet.
Marathon running, under certain conditions, leads to hyponatremia. Races of 25-50 miles can result in the loss of great quantities (8 to 10 liters) of sweat, which contains both sodium and water. Studies show that about 30% of marathon runners experience mild hyponatremia during a race. But runners who consume only pure water during a race can develop severe hyponatremia because the drinking water dilutes the sodium in the bloodstream. Such runners may experience neurological disorders as a result of the severe hyponatremia and require emergency treatment.
Hyponatremia also develops from disorders in organs that control the body's regulation of sodium or water. The adrenal gland secretes a hormone called aldosterone that travels to the kidney, where it causes the kidney to retain sodium by not excreting it into the urine. Addison's disease causes hyponatremia as a result of low levels of aldosterone due to damage to the adrenal gland. The hypothalamus and pituitary gland are also involved in sodium regulation by making and releasing vasopressin, known as anti-diuretic hormone, into the bloodstream. Like aldosterone, vasopressin acts in the kidney, but it causes it to reduce the amount of water released into urine. With more vasopressin production, the body conserves water, resulting in a lower concentration of plasma sodium. Certain types of cancer cells produce vasopressin, leading to hyponatremia.
Symptoms of moderate hyponatremia include tiredness, disorientation, headache, muscle cramps, and nausea. Severe hyponatremia can lead to seizures and coma. These neurological symptoms are thought to result from the movement of water into brain cells, causing them to swell and disrupt their functioning.
In most cases of hyponatremia, doctors are primarily concerned with discovering the underlying disease causing the decline in plasma sodium levels. Death that occurs during hyponatremia is usually due to other features of the disease rather than to the hyponatremia itself.
