Can diuresis cause hyponatremia (low sodium levels)?

From the Guidelines

Diuresis can indeed cause hyponatremia, particularly with loop diuretics, as evidenced by the 2021 practice guidance by the American Association for the Study of Liver Diseases 1. This occurs when the use of diuretics leads to an excessive loss of sodium in the urine, resulting in a dilution of the blood sodium concentration. The risk of hyponatremia is higher in patients who excrete approximately 80 mmol of sodium in their urine per day. Some key points to consider when using diuretics include:

• Starting with the lowest effective dose to minimize the risk of hyponatremia
• Monitoring electrolytes regularly, especially during the first few weeks of treatment
• Educating patients on maintaining adequate sodium intake while avoiding excessive water consumption
• Being aware of the potential complications of diuretic therapy, such as renal failure, hepatic encephalopathy, and electrolyte disorders, as highlighted in the 2018 clinical practice guidelines for liver cirrhosis 1 and the 2010 EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis 1. It is essential to weigh the benefits of diuretic therapy against the potential risks and to closely monitor patients for signs of hyponatremia and other complications. In cases where hyponatremia does occur, treatment may involve withdrawal of diuretics, correction of other possible causes of dehydration, and consideration of hypertonic sodium chloride administration, as recommended in the 2018 clinical practice guidelines 1. Overall, a careful and nuanced approach to diuretic therapy is necessary to minimize the risk of hyponatremia and other complications, while also effectively managing the underlying condition.

From the FDA Drug Label

As with any effective diuretic, electrolyte depletion may occur during Furosemide tablets therapy, especially in patients receiving higher doses and a restricted salt intake All patients receiving Furosemide tablets therapy should be observed for these signs or symptoms of fluid or electrolyte imbalance (hyponatremia, hypochloremic alkalosis, hypokalemia, hypomagnesemia or hypocalcemia)

Yes, diuresing can cause Hyponatremia, as it is listed as one of the signs or symptoms of fluid or electrolyte imbalance that can occur during Furosemide tablets therapy 2. Key points to consider:

• Electrolyte depletion may occur, especially with higher doses and restricted salt intake
• Hyponatremia is a potential sign of fluid or electrolyte imbalance
• Patients should be observed for signs or symptoms of fluid or electrolyte imbalance, including hyponatremia 2

From the Research

Diuresis and Hyponatremia

• Diuresis, particularly with thiazide diuretics, can cause hyponatremia as it impairs the ability to dilute urine, leading to water retention and cation depletion 3, 4.
• Thiazide diuretics can stimulate vasopressin release, reduce glomerular filtration, and enhance proximal water reabsorption, all of which contribute to the development of hyponatremia 3.
• Loop diuretics can also lead to hyponatremia, although this is less common than with thiazide diuretics 5.
• The combination of loop and thiazide diuretics can increase the risk of hyponatremia, as well as other complications such as hypokalemia and worsening renal function 6.

Mechanisms and Risk Factors

• The mechanism of diuretic-induced hyponatremia involves impaired water excretion, cation depletion, and water retention 3, 4.
• Risk factors for diuretic-induced hyponatremia include high water intake, frailty, and underlying disorders that affect fluid balance, such as psychogenic polydipsia or heavy beer drinking 3.
• Hypokalemia, which often accompanies diuretic-induced hyponatremia, can increase the susceptibility to osmotic demyelination syndrome and contribute to the correction of hyponatremia 3.

Clinical Implications

• Diuretic-induced hyponatremia can be severe and potentially life-threatening, requiring careful monitoring and management 4, 5.
• The treatment of diuretic-induced hyponatremia involves discontinuing the diuretic, repairing volume deficits, and replacing electrolyte losses 3, 4.
• Preventing diuretic-induced hyponatremia requires careful selection of patients, monitoring of electrolyte levels, and adjustment of diuretic doses 3, 5.