Hypervolemic Hypoosmolar Hyponatremia

Aka: Hypervolemic Hypoosmolar Hyponatremia

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II. Pathophysiology

  1. Edematous State reduces effective circulating volume
    1. Decreased flow to nephron diluting segment stimulates hormonal response
  2. Stimulates Antidiuretic Hormone (ADH) release
    1. Results in water retention
  3. Stimulates Renin-Angiotensin-Aldosterone system
    1. Increases thirst drive and free water intake (outweighs any increased Sodium retention)

III. Causes

  1. Urine Sodium < 10-15 meq/L (if no Diuretic use)
    1. Urine Osmolality >350 mOsm/kg water
    2. Edematous States
      1. Cirrhosis
      2. Congestive Heart Failure
      3. Nephrotic Syndrome
      4. Hypoalbuminemia
  2. Urine Sodium > 20 meq/L
    1. Advanced Renal Insufficiency
      1. Acute Kidney Injury
      2. Chronic Kidney Disease

IV. Diagnostics (consider)

  1. Chest XRay
  2. Electrocardiogram
  3. Echocardiogram
  4. IVC Ultrasound for Volume Status
    1. Ultrasound may also demonstrate Ascites in Cirrhosis

V. Labs

  1. Urinalysis
  2. Urine Protein to Creatinine Ratio
  3. Comprehensive metabolic panel (Renal Function tests, Liver Function Tests)
  4. Brain Natriuretic Peptide (BNP)

VI. Management

  1. See Hyponatremia Management
  2. Congestive Heart Failure
    1. Salt Restriction <2 to 3 grams/day
    2. Water restriction <1 Liter per day
    3. Decrease contributing Diuretics
    4. Optimize Cardiac Output
  3. Cirrhosis
    1. Water restriction <750 ml per day
    2. Loop Diuretics may be used cautiously in mild Hyponatremia (avoid in moderate to severe Hyponatremia)
  4. Severe Renal Insufficiency
    1. Consider Hemodialysis

VII. References

  1. Edwards, Yang and Mehta (2025) Crit Dec Emerg Med 39(9): 25-33
  2. Kone in Tisher (1993) Nephrology, p. 87-100
  3. Levinsky in Wilson (1991) Harrison's IM, p. 281-84
  4. Rose (1989) Acid-Base and Electrolytes, p. 601-38
  5. Braun (2015) Am Fam Physician 91(5): 299-307 [PubMed]
  6. Miller (2023) Am Fam Physician 108(5): 476-86 [PubMed]

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