Because of the breadth of both guidelines, this review will focus on the salient features. 6– 8 This brief review will compare the two guidelines to discuss the diagnosis and treatment of hyponatremia, while also highlighting recent developments. Both guideline committees were interdisciplinary, and the European guideline was endorsed by the European societies of nephrology, endocrinology, and intensive care. The European guideline did perform systematic reviews of the available evidence using the Grading of Recommendations Assessment Development and Evaluation scoring system. Instead, the guideline was on the basis of expert panel recommendations, which relied on a critical evaluation of relevant literature by the panel members. 6– 8 The United States guideline refrained from using a quality-of-evidence scoring system due to the limited evidence.
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9 The professional organizations involved in the European guideline were the European Renal Association–European Dialysis and Transplantation Association, the European Society of Endocrinology, and the European Society of Intensive Care Medicine. 6– 9 The professional organizations involved in the United States guideline were Tufts University Office of Continuing Education and In 2 MedEd the initiative was also supported by an unrestricted educational grant from Otsuka America Pharmaceutical. To capture the current approach to hyponatremia, two sets of guidelines have been developed, one by professional organizations from within the United States (“United States guideline”) and one from within Europe (“European guideline,” in which the authors of this review participated). Although recent years have seen several developments in the diagnosis and treatment of hyponatremia, the evidence base is still limited. 4, 5 The most common causes of hyponatremia are the syndrome of inappropriate antidiuresis (SIAD), diuretic use, polydipsia, adrenal insufficiency, hypovolemia, heart failure, and liver cirrhosis (the latter two are often collectively referred to as “hypervolemic hyponatremia”). Instead, the underlying disease that is complicated by hyponatremia usually characterizes patients with hyponatremia. This has complicated clinical studies, because “the” patient with hyponatremia does not exist. These classifications illustrate that hyponatremia is a very heterogeneous disorder.
3 Therefore, hyponatremia should be further classified in order to provide directions for diagnosis and treatment ( Table 1). 2 Hyponatremia is not a disease but rather a pathophysiologic process indicating disturbed water homeostasis. 1 This may explain why management of hyponatremia is still suboptimal, as also recently illustrated by a hyponatremia registry. Hyponatremia (serum sodium <136 mmol/L) is a common water balance disorder that often poses a diagnostic or therapeutic challenge. Nevertheless, the development of guidelines has been important in advancing this evolving field. Such discrepancies may relate to different interpretations of the limited evidence or differences in guideline methodology.
Vasopressin receptor antagonists, urea, and loop diuretics serve this purpose, but received different recommendations in the two guidelines.
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Although fluid restriction remains the first-line treatment for most forms of chronic hyponatremia, therapy to increase renal free water excretion is often necessary. For acute or severely symptomatic hyponatremia, both guidelines adopted the approach of giving a bolus of hypertonic saline. The treatment for hyponatremia is chosen on the basis of duration and symptoms. Recently identified parameters, including fractional uric acid excretion and plasma copeptin concentration, may further improve the diagnostic approach. Hypotonic hyponatremia is further differentiated on the basis of urine osmolality, urine sodium level, and volume status. Diagnostically, the initial step is to differentiate hypotonic from nonhypotonic hyponatremia. This review discusses the diagnosis and treatment of hyponatremia, comparing the two guidelines and highlighting recent developments. Therefore, guidelines were developed by professional organizations, one from within the United States (2013) and one from within Europe (2014). Hyponatremia is a common water balance disorder that often poses a diagnostic or therapeutic challenge.
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