What is the safe rate of sodium correction in patients with hyponatremia?

From the Guidelines

The safe rate of sodium correction in patients with hyponatremia is 4-6 mEq/L per 24-hour period, not to exceed 8 mEq/L per 24-hour period, as recommended by the American Association for the Study of Liver Diseases in 2021 1.

Key Considerations

• The goal of sodium correction is to ameliorate the risk of osmotic demyelination syndrome (ODS), a potentially devastating neurological complication.
• Patients with chronic hyponatremia, severe hyponatremia (<120 mEq/L), liver disease, or other underlying conditions require more cautious correction.
• Serum sodium measurements should be monitored every 4-6 hours during active correction to avoid overly rapid correction.
• If correction occurs too rapidly, consider administering hypotonic fluids or desmopressin (DDAVP) to slow or reverse the correction.

Management Strategies

• Mild hyponatremia (Na 126-135 mEq/L) in cirrhosis without symptoms may not require specific management apart from monitoring and water restriction 1.
• Water restriction and cessation of diuretics are recommended for moderate hyponatremia (120-125 mEq/L), while severe hyponatremia (<120 mEq/L) may require more severe restriction of water intake with albumin infusion 1.
• Hypertonic saline is reserved for short-term treatment of patients with symptomatic or severe hyponatremia or those with imminent liver transplant (LT) 1.

Risks and Complications

• Overly rapid correction of sodium levels can cause ODS, particularly in patients with chronic hyponatremia, alcoholism, malnutrition, liver disease, or severe hyponatremia (sodium <120 mEq/L) 1.
• Severe hyponatremia at the time of LT increases the risk of ODS, which can be mitigated with multidisciplinary coordinated care 1.

From the Research

Safe Rate of Sodium Correction in Hyponatremia

The safe rate of sodium correction in patients with hyponatremia is a critical aspect of treatment to avoid complications such as osmotic demyelination syndrome. Key points to consider include:

• The rate of correction should not exceed 10 mEq/L in 24 hours to prevent osmotic demyelination syndrome, as recommended by European guidelines 2.
• For patients with severe hyponatremia (serum sodium <115 mEq/L), limiting correction to <8 mEq/L in 24 hours is advisable to minimize the risk of osmotic demyelination syndrome 2.
• Rapid correction (≥8-10 mEq/L per 24 hours) may be associated with lower mortality compared to slow or very slow correction, according to a systematic review and meta-analysis 3.
• The use of desmopressin (DDAVP) can help prevent overcorrection of plasma sodium in hyponatremia, and a reactive strategy for its administration may be beneficial 4.
• General guidelines suggest that the correction rate should not exceed 10 mmol/L during the first 24 hours and 18 mmol/L during the first 48 hours in chronic and profound hyponatremia 5.

Considerations for Correction Rates

When determining the safe rate of sodium correction, consider the following factors:

• Severity of hyponatremia: More severe cases may require slower correction rates to avoid complications.
• Presence of high-risk features: Patients with certain conditions, such as alcohol use disorder, hypokalemia, liver disease, or malnutrition, may be at increased risk for osmotic demyelination syndrome and may require slower correction rates 2.
• Underlying cause of hyponatremia: Treatment should address the underlying cause, and correction rates may need to be adjusted accordingly.
• Clinical symptoms and signs: Patients with severe symptoms, such as seizures or coma, may require more rapid correction, while those with mild symptoms may be corrected more slowly.

Clinical Implications

The safe rate of sodium correction in hyponatremia has significant clinical implications, including:

• Prevention of osmotic demyelination syndrome: A rare but severe neurological condition that can result from overly rapid correction of hyponatremia 6, 2.
• Reduction of mortality: Rapid correction may be associated with lower mortality compared to slow or very slow correction, according to some studies 3.
• Improvement of clinical outcomes: Appropriate correction rates can help improve hospital length of stay and reduce the risk of complications 3, 4.