Talk:Hyponatremia

Can this be added to Notable Cases?
In Seattle, a radio station held a water drinking contest for a Nintendo Wii console. Jennifer Lea Strange, a 28 year old mother of 3, entered, won, & died from "water intoxication" or Hyponatremia & the staff was fired. Marry Christmas kids, I hope your mom wasn't single. http://seattletimes.nwsource.com/html/nationworld/2003529990_water18.html —Preceding unsigned comment added by 67.160.77.255 (talk) 04:30, 26 November 2008 (UTC)
 * It's already there. Dan Levy (talk) 14:31, 26 November 2008 (UTC)
 * The woman was in Sacramento, not Seattle! —Preceding unsigned comment added by Loflorian (talk • contribs) 06:52, 9 January 2010 (UTC)
 * And it should not be part of the article. Fullness of bladder has no impact on the concentration of sodium in blood or tissues. Her illness and death were caused by drinking too much water, not the fact that she was also trying to not urinate. David notMD (talk) 00:04, 22 September 2017 (UTC)

Lead revision
I am rewriting the Lead and for some reason I am unable to delete a redundant paragraph on treatment, or add any more material (on pathophysiology). The edit fn just doesn't take the changes. I need to contact WP livechat, but I've forgotten how and can't seem to find it by googling. Can anyone help me with how to get there? Thanks. IiKkEe (talk) 15:26, 15 September 2017 (UTC)
 * Have restored it to before.
 * Why have symptoms in the first and 4th paragraph?
 * Why remove information about how common it is?
 * A paper on SIADH belongs in the SIADH article (hyponatremia is more than just SIADH)
 * Why have treatment being the second half of the second paragraph and the third paragraph?
 * The specific and common type of low Na (SIADH) was already discussed after discussing a general management of low NA.
 * Evaluation and diagnosis are synonyms. We do not duplicate this section per MEDMOS. Doc James  (talk · contribs · email) 00:36, 16 September 2017 (UTC)

First, thank you for the restoration. Second, thank you for all the questions. There are six of them. Most of them are due to the fact that I was in the middle of reorganizing the Lead, and all of the sudden the system wouldn't take my edits. I think I have entered 4 edits since you posted this without my knowing the post was here. None has been reverted so I'm assuming your OK with them. Please revert any you disagree with, and we'll discuss them here. If any are related to your other 5 questions, I'll discuss them here, without editing on that subject until I do.

I'll tackle one of your questions now: you asked me about a paper on SIADH. Are you speaking of a reference? If so, which one? Thanks. Regards IiKkEe (talk) 00:21, 17 September 2017 (UTC)

OK I've finished editing the 1st para. Next I'm next going to replace the 3rd paragraph on treatment with a new one - in one edit. If you don't like any part of it, edit each part you don't like one edit at a time, or revert the whole thing, and we can discuss here. Regards IiKkEe (talk) 00:48, 17 September 2017 (UTC)

OK I've finished the revamp of Lead, para 3. I will start a new subject to talk about para. 2 IiKkEe (talk) 06:04, 17 September 2017 (UTC)

First paragraph
The first paragraph should begin with a simple definition in words, not one which includes mmol/L Doc James  (talk · contribs · email) 17:05, 18 September 2017 (UTC)
 * I have only a minor problem with starting with a subjective definition: my main interest is in rearranging the sentences so that all sentences addressing levels come first and symptoms come 2nd - which I have already done, with an invitation to undo if you don't prefer it, and give me your reason for the reversion.  IiKkEe (talk) 21:43, 18 September 2017 (UTC)
 * Okay Doc James  (talk · contribs · email) 03:37, 19 September 2017 (UTC)

@talk Great. IiKkEe (talk) 04:19, 19 September 2017 (UTC)

I am proposing some word economy for paragraph 1 as follows: The current paragraph, with references removed here only for readability:

Hyponatremia is a low sodium level in the blood. Normal serum sodium levels are 135–145 mmol/L (135–145 mEq/L). Hyponatremia is generally defined as a serum sodium level of less than 135 mmol/L and is considered severe when the level is below 120 mmol/L. Symptoms can vary from none to severe. Mild symptoms include a decreased ability to think, headaches, nausea, and poor balance. Severe symptoms include confusion, seizures, and coma.

The proposed paragraph, which I entered as an edit, but was reverted:

Hyponatremia is a serum sodium concentration under 135 meq/L. Mild hyponatremia is 120 - 134 mEq/L; severe hyponatremia is below 120 mEql/L. Symptoms can be absent, mild or severe. Mild symptoms include a decreased ability to think, headaches, nausea, and poor balance. Severe symptoms include confusion, seizures, and coma.

The current paragraph has 70 words, the proposed one has 46 with IMO no loss of meaning, and an increase in clarity and word economy.

Thoughts, anyone? Regards IiKkEe (talk) 06:00, 19 September 2017 (UTC)
 * Support some bits oppose others. The first sentence should be in easy to understand English. In the change we loss the international units in favor of only US units. Doc James  (talk · contribs · email) 16:07, 19 September 2017 (UTC)

@talk Good point. You're right about the units: I put in what I am used to seeing without thinking. I'll go ahead and put "my" version in and leave "your" 1st sentence and units.IiKkEe (talk) 23:43, 19 September 2017 (UTC)
 * The ref does not support "Mild hyponatremia is 120 - 134 mmol/L". I have corrected it  Doc James  (talk · contribs · email) 01:55, 20 September 2017 (UTC)
 * "Generally" is there for a reason specifically that NOT all definitions are less than 135 per Doc James  (talk · contribs · email) 18:26, 20 September 2017 (UTC)

The definition is based on the physiologic fact that 135 is the level at which ADH secretion ceases. This is from Seldin's The Kidney:

CHAPTER 44 Hyponatremia Richard H. Sterns, Stephen M. Silver and J. Kevin Hix

THE PLASMA SODIUM CONCENTRATION AND BODY FLUID TONICITY "Sodium and its accompanying anions are the principle osmotically active solutes in extracellular fluid. When extracellular  osmolality  is  low,  intracellular osmolality is equally low. Therefore, although there are exceptions, hyponatremia is usually associ ated with hypoosmolality and dilution of all body fluids. When (as is usually the case) the concentration of non-permeant extracellular solutes other than sodium is very low, the plasma sodium concentration is a function of three variables, as indicated by the following equation:

It is intuitively obvious that the extracellular sodium concentration should be proportional to the body’s content of water and soluble sodium. The sodium concentration falls when the body retains water (without solute) or when there are net external losses of sodium (without water). The importance of intracellular potassium stores to the plasma sodium concentration is less obvious. In potassium depletion, sodium ions move intracellularly as intracellular potassium is lost, balancing negative charges on intracellular macromolecules. Thus, external loss of exchangeable potassium causes an internal loss of extracellular sodium. Similarly, when intracellular potassium is replaced by hydrogen ions, rather than sodium or when it is lost with phosphate (an intracellular anion), the loss of osmotically active intracellular solute causes a redistribution of water from the intracellular to the extracellular fluid compartments, diluting extracellular sodium ions.

PHYSIOLOGIC CONTROL OF WATER EXCRETION   Osmotic Regulation Controlled by changes in water intake, vasopressin secretion, and water excretion, the plasma sodium concentration is normally prevented from ...falling below 135 mEq/L. (boldface added.) When the plasma sodium concentration changes by as little as 1% (with a corresponding change in plasma osmolality), cell volume receptors (“osmoreceptors”) in the hypothalamus respond, relaying signals to vasopressin-secreting neurons located in the supraoptic and paraventricular nuclei whose axons terminate in secretory bulbs in the neurohypophysis."

IMO this is the universally accepted definition. Please consider deleting "generally". I will add this reference. Regards IiKkEe (talk) 19:42, 20 September 2017 (UTC)
 * Yes 135 is often used but the "Generally" is there as NOT all definitions are less than 135 per
 * Can I also ask you to continue the discussion in the section it is happening in rather than creating new sections for the same discussion. Best Doc James  (talk · contribs · email) 18:26, 20 September 2017 (UTC)
 * It is already supported by the existing references. These additional ones are not needed " "
 * Plus they are unformatted.
 * And the AIM was ALREADY a ref supporting that sentence? Doc James  (talk · contribs · email) 03:27, 21 September 2017 (UTC)

Proposal to trim 2nd paragraph of Lead
The 2nd paragraph includes examples of diseases that fit in these various categories of causes. I propose that the diseases under each category be moved to the body of the article along with the references. That would remove 11 diseases, most of which the general reader has never heard of, and only obscures the big picture of what the categories are. Nothing is omitted - just moved from the introductory "big idea" paragraph - the Lead.

What would be moved is: "Cases in which the urine is dilute include adrenal insufficiency, hypothyroidism, and drinking too much water or too much beer. Cases in which the urine is concentrated include syndrome of inappropriate antidiuretic hormone secretion (SIADH). High volume hyponatremia can occur from heart failure, liver failure, and kidney failure. Conditions that can lead to falsely low sodium measurements include high blood protein levels such as in multiple myeloma, high blood fat levels, and high blood sugar. "

What would remain is: "The causes of hyponatremia are classified by a person's fluid status into low volume, normal volume, and high volume. Normal volume hyponatremia is divided into cases with dilute urine and concentrated urine. There are also conditions that cause a falsely low serum sodium, called factitious hyponatremia."

Thoughts, anyone? IiKkEe (talk) 04:53, 19 September 2017 (UTC)
 * Oppose What the causes of a condition is, is important and IMO belongs in the lead. Doc James  (talk · contribs · email) 16:09, 19 September 2017 (UTC)

Third paragraph
Why did you replace properly formatted references from 2013, 2014, and 2016 with none properly formatted references from 2007?

This is not about SIADH so why did you begin with "Potential treatments of SIADH include restriction of fluid intake"? This article is about hyponatremia which is NOT the same as SIADH. Doc James (talk · contribs · email) 17:04, 18 September 2017 (UTC)
 * That was a one word error in the paragraph: it should say "hyponatremia" not "SIADH" I'll be happy to correct it. I take it you deleted all the new paragraph and replaced it with the old one. I don't find an explanation for that in any of your "please describe your edits". Is there something you object to in the new paragraph other than the one word error? If so, perhaps you could provide an explanation here.
 * The prior version was based on newer references which were about hyponatremia generally. Doc James  (talk · contribs · email) 03:38, 19 September 2017 (UTC)
 * @talk So if I provide current references and correct the one word error, you would consider the new text?
 * What is wrong with the current version? Every sentence of that current section is referenced to a high quality recent secondary source.
 * Why replace it with a much older secondary source from 2007 that is about one type of hyponatremia rather than hyponatremia generally. It makes no sense and is NOT an improvement. Doc James  (talk · contribs · email) 16:14, 19 September 2017 (UTC)

Video
The video is in the section on SIADH within this article. I agree it is not about hyponatremia generally and thus it is not in the lead. Doc James (talk · contribs · email) 17:08, 18 September 2017 (UTC)


 * Here is my reason at the time for deleting it. It's from "View history" which you may have missed:


 * "1) 20:09, 16 September 2017‎ IiKkEe (talk | contribs)‎ . . (26,602 bytes) (-106)‎ . . (Video on SIADH deleted. I deleted this once, with explanation: "it's about SIADH, not hyponatremia". It was restored with explanation "restored". A fuller explanation from me: this video is about one of numerous causes of hyponatremia: if interested in SIADH:click...) (undo)


 * 2) 20:50, 16 September 2017‎ IiKkEe (talk | contribs)‎ . . (26,603 bytes) (+1)‎ ... ((continuing previous explanation for edit) ...the reader can click on SIADH and both read about it and click on the video and view it if they choose. If it is reverted again, please provide rationale this time, so we can discuss at Talk) (undo)"


 * It's not that big a deal if you want it in the ‎Hyponatremia article, IMO it will do no harm, but I personally wouldn't do it because I believe it's a distraction. Have you viewed it? It's pretty detailed, more than a high school kid who just wants to know what hyponatremia is. IiKkEe (talk) 22:57, 18 September 2017 (UTC)
 * SIADH is a fairly common cause. I do not see an issue with the video within the body of the article. Doc James  (talk · contribs · email) 03:41, 19 September 2017 (UTC)
 * @(talk As I said: it's only 2 clicks away - but I yield to you. Might ask for opinions from others at some point IiKkEe (talk) 04:25, 19 September 2017 (UTC)
 * Sure you may. Doc James  (talk · contribs · email) 15:58, 19 September 2017 (UTC)

Once more into the breach. Changed the lead's second paragraph, first sentence. Willing to be reverted if this makes someone's brain swell until their head explodes. By the was, I personally at risk of hyponatremia because I have a SIADH reaction to extended exercise. David notMD (talk) 00:17, 22 September 2017 (UTC)
 * User:David notMD thanks. Grammar is not my strong suit :-) Doc James  (talk · contribs · email) 01:07, 22 September 2017 (UTC)

New approach to categorizing causes of hyponatremia
I have never been a fan of the "low-normal-high volume" approach to categorizing the causes of hyponatremia. This a quote from Chapter 44 Sterns RH of Seldin's and Giebich's The Kidney (which of course can't be used as such: COPYVIO), but I place it here as support for a new approach to categorizing the causes of hyponatremia. I plan to add the new approach to the Body without disturbing the old approach - but there's only room for one in the Lead, so I will only mention the old approach there. This will as usual be fair game for editing, reverting and discussing here once I get it in place The following describes the pitfalls of the old approach better than I can:

HYPOTONIC HYPONATREMIA: CLASSIFICATION AND PATHOGENESIS "Traditionally, patients  with  hyponatremia  are divided into categories according to their body sodium content  and/or  intravascular  volume:  low  body sodium content (volume depletion); high body sodium content  (edematous  conditions)  or  normal  body sodium content (euvolemic hyponatremia or SIADH).

Although this  time-honored  approach  is  often helpful to clinicians, intravascular volume and body sodium content do not always change in parallel (e.g., self-induced water intoxication), and some causes of hyponatremia (e.g., diuretic-induced and cerebral salt- wasting) may be difficult to classify by intravascular volume. Moreover, physiologic responses to extracellu- lar volume expansion and contraction often create ambiguities in volume status. Thus, secondary water retention in response to volume depletion and second- ary natriuresis in response to water overload may ulti- mately yield similar values for total body sodium and water."

I'll get started after some sleep. RegardsIiKkEe (talk) 06:01, 17 September 2017 (UTC)


 * What are you proposing adding exactly? What is the "new approach" they are suggesting? Doc James  (talk · contribs · email) 17:07, 18 September 2017 (UTC)


 * @talk I've already added it, under section Pathophysiology. It's a different approach to categorizing, not management. It replaces "low-normal-high volume" categories with three new categories based on urine volume ("impairment of urine diluting ability"), and ADH levels. The section should probably be titled "Alternate categorization". I'm still working on that section to fine tune it. — Preceding unsigned comment added by IiKkEe (talk • contribs) 22:17, 18 September 2017 (UTC)

Causes section: paucity of references
I have not contributed to the construction of this section or edited it, but I am concerned with how few references it has. It has an introduction and four subsections: the five references for these five parts are distributed 0,0,1,5, and 0. One was used twice.

I'm going to sprinkle the section with "citation needed" flags, but that doesn't help make the Article any better. Anyone interested in editing and referencing?

One thing that definitely needs to be addressed is explaining what "volume" means in this section. I've asked a few high school kids to read the Lead and this section, and then asked what they think is meant by volume, they all said "urine volume". Click on the "low volume" link and at that site ("Hypovolemia") there is an incorrect definition, with no explanation of the various body fluid compartments and subcompartments and their relationships. Just three sentences and three references: one from the dictionary, two from Medterms.com.

Work to do... Regards IiKkEe (talk) 23:40, 18 September 2017 (UTC)
 * Hypovolemia is literally Latin for low volume.. Doc James  (talk · contribs · email) 03:47, 19 September 2017 (UTC)

talk Right, but "hypovolemia" is not used in the Lead. - "low volume" is. And what about CHF, where the arterial volume is low but the venous volume and ECF volume are high?

Any thoughts on how to handle the paucity of references? Looks like this is one to ask for the opinion of others. IiKkEe (talk) 04:29, 19 September 2017 (UTC)
 * Every sentence in the lead is referenced to a high quality recent secondary source. Doc James  (talk · contribs · email) 16:13, 19 September 2017 (UTC)

I am questioning the lack of references in the Causes section, not the Lead. IiKkEe (talk) 23:50, 19 September 2017 (UTC)
 * Yes please go ahead and add further references to support the causes section. Doc James  (talk · contribs · email) 01:47, 20 September 2017 (UTC)

Comment This 2017 review has a nice classification. Will adjust based on that. Doc James (talk · contribs · email) 18:50, 20 September 2017 (UTC)
 * Have updated. Was mostly correct Doc James  (talk · contribs · email) 19:13, 20 September 2017 (UTC)

Moved to the body
Sodium homeostasis does not belong in the WP:LEAD of this article. It is somewhat tangential to the topic in question. So moved to the pathophysiology section:

"There is a hypothalamic-renal feedback system which normally maintains the concentration of of the serum sodium within a narrow range. This system operates as follows: in some of the cells of the hypothalamus, there are osmoreceptors which respond to an elevated serum sodium in body fluids by signalling the posterior pituitary gland to secrete antidiuretic hormone (ADH), (also called vasopressin). ADH then enters the bloodstream and signals the kidney to bring back sufficient solute-free water from the fluid in the kidney tubules to dilute the serum sodium back to normal, and this turns off the osmoreceptors in the hypothalamus. Also, thirst is stimulated. Normally, when mild hyponatremia begins to occur, (the serum sodium begins to fall below 135 mEq/L), there is no secretion of ADH, and the kidney stops returning water to the body from the renal tubule. Also, no thirst is experienced. These two act in concert to raise the serum sodium to the normal range. "

To the body. Doc James (talk · contribs · email) 16:01, 19 September 2017 (UTC)


 * @talk That is a good idea - it is definitely better suited to the body. IiKkEe (talk) 04:48, 21 September 2017 (UTC)


 * "The causes of and treatments for hyponatremia can only be understood by having a grasp of the size of the body fluid compartments and subcompartments and their regulation; how under normal circumstances the body is able to maintain the sodium concentration within a narrow range (homeostasis of body fluid osmolality); conditions can cause that feedback system to malfunction (pathophysiology); and the consequences of the malfunction of that system on the size and solute concentration of the fluid compartments. "
 * No the causes can be understood independent of this. Regardless I do not beleive this is needed in the lead Doc James talk · contribs · email) 03:25, 21 September 2017 (UTC)


 * @talk Just so I am clear with your position on this: you have read the reference and it does not support my statement?; or you have read it and disagree with the author? Or something else? I have placed the statement under Pathophysiology for now: it is compatible with all in that section. IiKkEe (talk) 04:48, 21 September 2017 (UTC)
 * Are you sure that is the right DOI? It gives this http://www.sciencedirect.com/science/article/pii/B9780123814623000379 which is chapter 37.
 * I also do not believe that conclusions and second it is not significant enough for the lead. Doc James  (talk · contribs · email) 05:08, 21 September 2017 (UTC)
 * Okay maybe you actually meant this
 * I have read the pages 1511 and 1512 and do not see what text in the source supports your text. Doc James  (talk · contribs · email) 05:12, 21 September 2017 (UTC)

Why is well referenced prose being removed
Why was this removed?

"There is tentative evidence that vasopressin receptor antagonists (vaptans), such as conivaptan, may be slightly more effective than fluid restriction in those with high volume or normal volume hyponatremia. They should not be used in people with low volume. Their use in SIADH is unclear. "

And replaced with point for content supported by older sources? Doc James (talk · contribs · email) 16:16, 19 September 2017 (UTC)

@talk I can't seem to spot when I took it out and when you put it back in. In what part of what section is it? IiKkEe (talk) 01:47, 20 September 2017 (UTC)

@talk I found it in its current spot, but I can't find in "View history" when I deleted it, don't recall deleting it, and have no problem with it being in the article. IiKkEe (talk) 02:33, 20 September 2017 (UTC)
 * Okay thanks. Doc James  (talk)contribs · email) 16:12, 20 September 2017 (UTC)

@talk I'm going to put the above sentence in bullet format like the rest of that subsection, and place it third, since its uncertain what role it will play in therapy. If there is a reason to leave it where it is, revert and let me know why. Regards IiKkEe (talk) 16:47, 20 September 2017 (UTC)
 * I have removed all bullet points as we should be writing in prose not bullet points. Doc James  (talk · contribs · email) 18:26, 20 September 2017 (UTC)


 * @talk Bullets or no bullets: either way is OK by me - thought it odd that one sentence was "non-bullet", everything else was "bullet", and they should all be one way or the other.

I do have a question for you on this subsection. I know nothing about these meds, but based on what is written here, I conclude that none is really worth a hoot. Do you think an introductory sentence something like "None of the medications discussed here has a significant role to play in the treatment of hyponatremia" or something to that effect? Just a suggestion. IiKkEe (talk) 05:08, 21 September 2017 (UTC)
 * There use is controversial. The source you added concluded that the US and EU guidelines came to different conclusions. Meds have limited use as a second / third line therapy. That is to say they have a small role maybe. We just need to base on the conclusions of the sources. Doc James  (talk · contribs · email) 05:15, 21 September 2017 (UTC)

@ Doc James Your reply here is very helpful to me. Based on your comments, how about an introductory sentence to the drug treatment subsection, something like: "United States and European Union guidelines (2 refs) for the use of agents which raise the serum sodium concentration differ in their conclusions about indication and efficacy. They currently are regarded as having a limited role, and only as second or third line therapy"? IiKkEe (talk) 16:57, 22 September 2017 (UTC)
 * How is this ? The exact wording I used above is not supported by the current source and we would need to find another source. Doc James  (talk · contribs · email) 17:29, 22 September 2017 (UTC)

@ Doc James I am glad you made this addition: I like my wording better, but        we'll go with yours! Regards IiKkEe (talk) 22:17, 22 September 2017 (UTC)

True vs False hyponatraemia?
I would argue that glucose and mannitol caused hyponatremia (hypertonic) shouldn’t be considered ‘pseudo’hyponatraemia. Considering that in those cases the sodium is ''actually'’ low. Compared to hyperlipidaemia when the sodium levels are normal, but the lab test reads low. FreeT (talk) 22:47, 26 March 2018 (UTC)

Spelling
Hyponatremia is also spelled hyponatraemia in British English, Australian English, etc. Please don't edit out '(also: hyponatraemia)' in the article. There is no good reason not to include the alternative spelling. — Preceding unsigned comment added by 2A00:23C5:DA0E:CC00:B9AC:4A00:1777:F2EB (talk) 10:59, 12 March 2020 (UTC)


 * I don't find it suitable that 'hyponatraemia' is merely listed in an info box as an alternative name. It isn't an alternative name. It's an alternative spelling. On the page for sulfur, it doesn't consign the alternative spelling 'sulphur' to an info box as an alternative name. — Preceding unsigned comment added by 2a00:23c5:da0e:cc00:44d8:17f5:419a:6bce (talk) 10:36, 23 March 2020 (UTC)

"Too much water" listed at Redirects for discussion
A discussion is taking place to address the redirect Too much water. The discussion will occur at Redirects for discussion/Log/2021 July 4 until a consensus is reached, and readers of this page are welcome to contribute to the discussion. signed,Rosguill talk 18:54, 4 July 2021 (UTC)

Hyponatremic zombies?
In an anthropology article, I've heard that in areas where zombie making is a real thing (read Haiti as the main area), people who use them for slave labor subject them to various mistreatments designed to keep them in line and keep them apathetic, in particular, food deprivation, and most notably, sodium deprivation. This would of course be a case of chronic hyponatremia. Since the article doesn't say a thing about the chronic effects of sodium deficiency, could somebody explain if this is a superstitious thing, of if that deprivation really does what it is supposed to? Svartalf (talk) 03:42, 29 October 2022 (UTC)