Abordagem do Doente Com Hiponatremia


  • Marina Gomes Serviço de Endocrinologia, Hospital de Braga, Braga, Portuga
  • Ana Catarina Matos Serviço de Endocrinologia, Hospital de Braga, Braga, Portugal.




Hiponatremia/diagnóstico; Hiponatremia/epidemiologia; Hiponatremia/tratamento


A hiponatremia é o distúrbio de eletrólitos mais comum na prática clínica. Habitualmente, traduz um ou mais processos patológicos intercorrentes, e encontra-se associada a elevada mortalidade e morbilidade caso não se proceda ao diagnóstico e tratamento apropriados. O primeiro passo na abordagem do doente com hiponatremia é a classificação da gravidade dos sintomas que determina a urgência da intervenção terapêutica. Por um lado, na hiponatremia gravemente sintomática deve ser administrada, imediatamente, solução salina hipertónica. Por outro, nos doentes com hiponatremia assintomática ou moderadamente sintomática devem ser investigadas e removidas/tratadas as possíveis causas associadas, antes de qualquer outra intervenção terapêutica. O objetivo desta revisão é discutir e melhorar a abordagem diagnóstica e terapêutica da hiponatremia, segundo as orientações mais atuais.


Não há dados estatísticos.


Upadhyay A, Jaber BL, Madias NE. Incidence and prevalence of hyponatremia. Am J Med. 2006;119:S30-35.

Spasovski G, Vanholder R, Allolio B, Annane D, Ball S, Bichet D, et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Eur J Endocrinol. 2014;170:G1-47.

Hawkins RC. Age and gender as risk factors for hyponatremia and hypernatremia. Clin Chim Acta. 2003;337:169–72.

Mannesse CK, Vondeling AM, van Marum RJ, van Solinge WW, Egberts TC, Jansen PA. Prevalence of hyponatremia on geriatric wards compared to other settings over four decades: a systematic review. Ageing Res Rev. 2013;12:165–73.

Asadollahi K, Beeching N, Gill G. Hyponatremia as a risk factor for hospital mortality. QJM. 2006;99:877–80.

Hoorn EJ, Lindemans J, Zietse R. Development of severe hyponatraemia in hospitalized patients: treatment-related risk factors and inadequate management. Nephrol Dial Transplant. 2006;21:70–6.

Sherlock M, O’Sullivan E, Agha A, Behan LA, Rawluk D, Brennan P, et al. The incidence and pathophysiology of hyponatraemia after subarachnoid haemorrhage. Clin Endocrinol. 2006;64:250–4.

Saleem S, Yousuf I, Gul A, Gupta S, Verma S. Hyponatremia in stroke. Ann Indian Acad Neurol. 2014;17:55–7.

Gill G, Huda B, Boyd A, Skagen K, Wile D, Watson I, et al. Characteristics and mortality of severe hyponatremia--a hospital-based study. Clin Endocrinol. 2006;65:246–9.

Adrogué HJ. Consequences of inadequate management of hyponatremia. Am J Nephrol. 2005;25:240–9.

Renneboog B, Musch W, Vandemergel X, Manto MU, Decaux G. Mild chronic hyponatremia is associated with falls, unsteadiness, and attention deficits. Am J Med. 2006;119:71.e1-8.

Fujisawa H, Sugimura Y, Takagi H, Mizoguchi H, Takeuchi H, Izumida H, et al. Chronic Hyponatremia Causes Neurologic and Psychologic Impairments. J Am Soc Nephrol. 2016;27:766–80.

Kinsella S, Moran S, Sullivan MO, Molloy MGM, Eustace JA. Hyponatremia independent of osteoporosis is associated with fracture occurrence. Clin J Am Soc Nephrol. 2010;5:275–80.

Verbalis JG, Barsony J, Sugimura Y, Tian Y, Adams DJ, Carter EA, et al. Hyponatremia-induced osteoporosis. J Bone Miner Res. 2010;25:554–63.

Barsony J, Sugimura Y, Verbalis JG. Osteoclast response to low extracellular sodium and the mechanism of hyponatremia-induced bone loss. J Biol Chem. 2011;286:10864–75.

Winzeler B, Jeanloz N, Nigro N, Suter-Widmer I, Schuetz P, Arici B, et al. Long-term outcome of profound hyponatremia: a prospective 12 months follow-up study. Eur J Endocrinol. 2016;175:499–507.

Wald R, Jaber BL, Price LL, Upadhyay A, Madias NE. Impact of hospital-associated hyponatremia on selected outcomes. Arch Intern Med. 2010;170:294–302.

Corona G, Giuliani C, Verbalis JG, Forti G, Maggi M, Peri A. Correction: Hyponatremia Improvement Is Associated with a Reduced Risk of Mortality: Evidence from a Meta-Analysis. PLoS One. 2016;11:e0152846.

Dineen R, Thompson CJ, Sherlock M. Hyponatremia – presentations and management. Clin Med. 2017;17:263–9.

Overgaard-Steensen C, Ring T. Clinical review: practical approach to hyponatraemia and hypernatraemia in critically ill patients. Crit Care. 2013;17:206.

Smith DM, McKenna K, Thompson CJ. Hyponatraemia. Clin Endocrinol. 2000;52:667–78.

Ellis SJ. Severe hyponatremia: complications and treatment. QJM. 1995;88:905–9.

Fraser CL, Arieff AI. Fatal central diabetes mellitus and insipidus resulting from untreated hyponatremia: a new syndrome. Ann Intern Med. 1990;112:113–9.

Rojiani AM, Prineas JW, Cho ES. Electrolyte-induced demyelination in rats. 1. Role of the blood-brain barrier and edema. Acta Neuropathol. 1994;88:287–92.

Sterns RH, Baer J, Ebersol S, Thomas D, Lohr JW, Kamm DE. Organic osmolytes in acute hyponatremia. Am J Physiol. 1993;264:F833-6.

Thompson CJ. Hyponatraemia: new associations and new treatments. Eur J Endocrinol. 2010;162:S1-3.

Hsu Y-J, Chiu J-S, Lu K-C, Chau T, Lin S-H. Biochemical and etiological characteristics of acute hyponatremia in the emergency department. J Emerg Med. 2005;29:369–74.

Achinger SG, Arieff AI, Kalantar-Zadeh K, Ayus JC. Desmopressin acetate (DDAVP)-associated hyponatremia and brain damage: a case series. Nephrol Dial Transplant. 2014;29:2310–5.

Moses AM, Miller M. Drug-induced dilutional hyponatremia. N Engl J Med. 1974;291:1234–9.

Liamis G, Milionis H, Elisaf M. A review of drug-induced hyponatremia. Am J Kidney Dis. 2008;52:144–53.

Agarwal R, Emmett M. The post-transurethral resection of prostate syndrome: therapeutic proposals. Am J Kidney Dis. 1994;24:108–11.

Ayus JC, Arieff AI. Glycine-induced hypo-osmolar hyponatremia. Arch Intern Med. 1997;157:223–6.

Hoorn EJ, Zietse R. Diagnosis and Treatment of Hyponatremia: Compilation of the Guidelines. J Am Soc Nephrol. 2017;28:1340–9.

Ball S, Barth J, Levy M. Society for Endocrinology Endocrine Emergency guidance: Emergency management of severe symptomatic hyponatremia in adult patients. Endocr Connect. 2016;5:G4–6.

Berl T, Verbalis J. Pathophysiology of water metabolism. In: Brenner B, editor. Brenner & Rector’s The kidney. 7th ed. Philadelphia: Saunders; 2004. p. 857–920.

Oster JR, Singer I. Hyponatremia, hyposmolality, and hypotonicity: tables and fables. Arch Intern Med. 1999;159:333–6.

BMJ Best Practice. Assessment of hyponatraemia - Diagnosis Approach [Internet]. BMJ Best Practice. [cited 2021 May 11]. Available from: https://bestpractice.bmj.com/topics/en-gb/57/diagnosis-approach

Overlack A, Niederle N, Klautke G, Stumpe KO, Krück F. Vorgetäuschte Hyponatriämie bei malignen Paraproteinämien. Klin Wochenschr. 1980;58:875–80.

Lawn N, Wijdicks EF, Burritt MF. Intravenous immune globulin and pseudohyponatremia. N Engl J Med. 1998;339:632.

Liamis G, Liberopoulos E, Barkas F, Elisaf M. Spurious electrolyte disorders: a diagnostic challenge for clinicians. Am J Nephrol. 2013;38:50–7.

Theis SR, Khandhar PB. Pseudohyponatremia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 [cited 2021 May 11]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK553207/

Jain A, Subhan I, Joshi M. Comparison of the point-of-care blood gas analyzer versus the laboratory auto-analyzer for the measurement of electrolytes. Int J Emerg Med. 2009;2:117–20.

Hillier TA, Abbott RD, Barrett EJ. Hyponatremia: evaluating the correction factor for hyperglycemia. Am J Med. 1999;106:399–403.

Aviram A, Pfau A, Czaczkes JW, Ullmann TD. Hyperosmolality with hyponatremia, caused by inappropriate administration of mannitol. Am J Med. 1967;42:648–50.

Desmond J. Serum osmolality and plasma electrolytes in patients who develop dilutional hyponatremia during transurethral resection. Can J Surg. 1970;13:116–21.

Carlotti AP, Bohn D, Mallie JP, Halperin ML. Tonicity balance, and not electrolyte-free water calculations, more accurately guides therapy for acute changes in natremia. Intensive Care Med. 2001;27:921–4.

Anderson RJ, Chung HM, Kluge R, Schrier RW. Hyponatremia: a prospective analysis of its epidemiology and the pathogenetic role of vasopressin. Ann Intern Med. 1985;102:164–8.

Chung HM, Kluge R, Schrier RW, Anderson RJ. Clinical assessment of extracellular fluid volume in hyponatremia. Am J Med. 1987;83:905–8.

Musch W, Thimpont J, Vandervelde D, Verhaeverbeke I, Berghmans T, Decaux G. Combined fractional excretion of sodium and urea better predicts response to saline in hyponatremia than do usual clinical and biochemical parameters. Am J Med. 1995;99:348–55.

Rose BD. New approach to disturbances in the plasma sodium concentration. Am J Med. 1986;81:1033–40.

Liamis G, Filippatos TD, Elisaf MS. Correction of hypovolemia with crystalloid fluids: Individualizing infusion therapy. Postgrad Med. 2015;127:405–12.

Sood L, Sterns RH, Hix JK, Silver SM, Chen L. Hypertonic saline and desmopressin: a simple strategy for safe correction of severe hyponatremia. Am J Kidney Dis. 2013;61:571–8.

Sterns RH, Hix JK, Silver S. Treatment of hyponatremia. Curr Opin Nephrol Hypertens. 2010;19:493–8.

Nigro N, Winzeler B, Suter-Widmer I, Schuetz P, Arici B, Bally M, et al. Evaluation of copeptin and commonly used laboratory parameters for the differential diagnosis of profound hyponatraemia in hospitalized patients: “The Co-MED Study.” Clin Endocrinol. 2017;86:456–62.

Liamis G, Filippatos TD, Elisaf MS. Thiazide-associated hyponatremia in the elderly: what the clinician needs to know. J Geriatr Cardiol. 2016;13:175–82.

Sharabi Y, Illan R, Kamari Y, Cohen H, Nadler M, Messerli FH, et al. Diuretic induced hyponatraemia in elderly hypertensive women. J Hum Hypertens. 2002;16:631–5.

Sonnenblick M, Friedlander Y, Rosin AJ. Diuretic-induced severe hyponatremia. Review and analysis of 129 reported patients. Chest. 1993;103:601–6.

Hwang KS, Kim G-H. Thiazide-induced hyponatremia. Electrolyte Blood Press. 2010;8:51–7.

Cui H, He G, Yang S, Lv Y, Jiang Z, Gang X, et al. Inappropriate Antidiuretic Hormone Secretion and Cerebral Salt-Wasting Syndromes in Neurological Patients. Front Neurosci. 2019;13:1170.

Berendes E, Walter M, Cullen P, Prien T, Van Aken H, Horsthemke J, et al. Secretion of brain natriuretic peptide in patients with aneurysmal subarachnoid haemorrhage. Lancet. 1997;349:245–9.

Sherlock M, O’Sullivan E, Agha A, Behan LA, Owens D, Finucane F, et al. Incidence and pathophysiology of severe hyponatraemia in neurosurgical patients. Postgrad Med J. 2009;85:171–5.

Maesaka JK, Imbriano L, Mattana J, Gallagher D, Bade N, Sharif S. Differentiating SIADH from Cerebral/Renal Salt Wasting: Failure of the Volume Approach and Need for a New Approach to Hyponatremia. J Clin Med. 2014;3(4):1373–85.

Warner MH, Holding S, Kilpatrick ES. The effect of newly diagnosed hypothyroidism on serum sodium concentrations: a retrospective study. Clin Endocrinol (Oxf). 2006;64(5):598–9.

Liamis G, Filippatos TD, Liontos A, Elisaf MS. MANAGEMENT OF ENDOCRINE DISEASE: Hypothyroidism-associated hyponatremia: mechanisms, implications and treatment. Eur J Endocrinol. 2017;176:R15–20.

Curtis RH. Hyponatremia in primary myxedema. Ann Intern Med. 1956;44(2):376–85.

Filippatos TD, Makri A, Elisaf MS, Liamis G. Hyponatremia in the elderly: challenges and solutions. Clin Interv Aging. 2017;12:1957–65.

Baylis PH. The syndrome of inappropriate antidiuretic hormone secretion. Int J Biochem Cell Biol. 2003;35:1495–9.

Feldman BJ, Rosenthal SM, Vargas GA, Fenwick RG, Huang EA, Matsuda-Abedini M, et al. Nephrogenic Syndrome of Inappropriate Antidiuresis. New England Journal of Medicine. 2005;352:1884–90.

Tian W, Fu Y, Garcia-Elias A, Fernández-Fernández JM, Vicente R, Kramer PL, et al. A loss-of-function nonsynonymous polymorphism in the osmoregulatory TRPV4 gene is associated with human hyponatremia. Proc Natl Acad Sci U S A. 2009;106:14034–9.

Thaler SM, Teitelbaum I, Berl T. “Beer potomania” in non-beer drinkers: effect of low dietary solute intake. Am J Kidney Dis. 1998;31:1028–31.

Lodhi MU, Saleem TS, Kuzel AR, Khan D, Syed IA, Rahim U, et al. “Beer Potomania” – A Syndrome of Severe Hyponatremia with Unique Pathophysiology: Case Studies and Literature Review. Cureus. 2017;9:e2000

Sailer C, Winzeler B, Christ-Crain M. Primary polydipsia in the medical and psychiatric patient: characteristics, complications and therapy. Swiss Med Wkly. 2017;147:w14514.

Schrier RW, Fassett RG. Pathogenesis of sodium and water retention in cardiac failure. Renal Failure. 1998;20:773–81.

Oren RM. Hyponatremia in congestive heart failure. The American journal of cardiology. 2005;95:2–7.

Gheorghiade M, Abraham WT, Albert NM, Gattis Stough W, Greenberg BH, O’Connor CM, et al. Relationship between admission serum sodium concentration and clinical outcomes in patients hospitalized for heart failure: an analysis from the OPTIMIZE-HF registry. Eur Heart J. 2007;28:980–8.

Goldberg A, Hammerman H, Petcherski S, Nassar M, Zdorovyak A, Yalonetsky S, et al. Hyponatremia and long-term mortality in survivors of acute ST-elevation myocardial infarction. Arch Intern Med. 2006;166:781–6.

Fortune B, Cardenas A. Ascites, refractory ascites and hyponatremia in cirrhosis. Gastroenterol Rep. 2017;5:104–12.

Grant P, Ayuk J, Bouloux P, Cohen M, Cranston I, Murray RD, et al. The diagnosis and management of inpatient hyponatraemia and SIADH. Eur J Clin Invest. 2015;45:888–94.

Mount DB. The brain in hyponatremia: both culprit and victim. Amsterdam: Elsevier; 2009.

Schrier RW, Bansal S. Diagnosis and management of hyponatremia in acute illness. Curr Opin Critical Care. 2008;14:627.

Verbalis JG, Goldsmith SR, Greenberg A, Korzelius C, Schrier RW, Sterns RH, et al. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. Am J Med. 2013;126:S1–42.

Lohr JW. Osmotic demyelination syndrome following correction of hyponatremia: association with hypokalemia. Am J Med. 1994;96:408–13.

Ellison DH, Berl T. The syndrome of inappropriate antidiuresis. New Engl J Med. 2007;356:2064–72.

Winzeler B, Lengsfeld S, Nigro N, Suter‐Widmer I, Schütz P, Arici B, et al. Predictors of nonresponse to fluid restriction in hyponatraemia due to the syndrome of inappropriate antidiuresis. J Intern Med. 2016;280:609–17.

Soupart A, Penninckx R, Stenuit A, Decaux G. Azotemia (48 h) decreases the risk of brain damage in rats after correction of chronic hyponatremia. Brain Res. 2000;852:167–72.

Soupart A, Coffernils M, Couturier B, Gankam-Kengne F, Decaux G. Efficacy and tolerance of urea compared with vaptans for long-term treatment of patients with SIADH. Clin J Am Soc Nephrol. 2012;7:742–7.

Schrier RW, Gross P, Gheorghiade M, Berl T, Verbalis JG, Czerwiec FS, et al. Tolvaptan, a selective oral vasopressin V2-receptor antagonist, for hyponatremia. New Engl J Med. 2006;355:2099–112.

Berl T, Quittnat-Pelletier F, Verbalis JG, Schrier RW, Bichet DG, Ouyang J, et al. Oral tolvaptan is safe and effective in chronic hyponatremia. J Am Soc Nephrol. 2010;21:705–12.

Rozen-Zvi B, Yahav D, Gheorghiade M, Korzets A, Leibovici L, Gafter U. Vasopressin receptor antagonists for the treatment of hyponatremia: systematic review and meta-analysis. Am J Kidney Dis. 2010;56:325–37.

Torres VE, Higashihara E, Devuyst O, Chapman AB, Gansevoort RT, Grantham JJ, et al. Effect of tolvaptan in autosomal dominant polycystic kidney disease by CKD stage: results from the TEMPO 3: 4 trial. Clin J Am Soc Nephrol. 2016;11:803–11.




Como Citar

Gomes M, Matos AC. Abordagem do Doente Com Hiponatremia. RPMI [Internet]. 23 de Dezembro de 2021 [citado 18 de Janeiro de 2022];28(4):378-8. Disponível em: https://revista.spmi.pt/index.php/rpmi/article/view/278



Artigos de Revisão