Postgraduate Medicine

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Ten pitfalls in the proper management of patients

with hyponatremia

Theodosios D. Filippatos, George Liamis & Moses S. Elisaf

To cite this article: Theodosios D. Filippatos, George Liamis & Moses S. Elisaf (2016) Ten pitfalls
in the proper management of patients with hyponatremia, Postgraduate Medicine, 128:5,
516-522, DOI: 10.1080/00325481.2016.1186488

To link to this article: http://dx.doi.org/10.1080/00325481.2016.1186488

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POSTGRADUATE MEDICINE, 2016
VOL. 128, NO. 5, 516–522
http://dx.doi.org/10.1080/00325481.2016.1186488

CLINICAL FEATURE
REVIEW

Ten pitfalls in the proper management of patients with hyponatremia

Theodosios D. Filippatos , George Liamis and Moses S. Elisaf
Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece

ABSTRACT ARTICLE HISTORY

Hyponatremia (serum sodium <135 mEq/L) is a common electrolyte disorder in community or hospi- Received 23 February 2016
talized patients. Serum sodium levels should be corrected at a proper rate in patients with hypona- Accepted 3 May 2016
tremia, since overcorrection of serum sodium levels is related to devastating neurologic consequences, Published online 23 May 2016
such as the osmotic demyelination syndrome (ODS). However, a number of pitfalls, which could lead to KEYWORDS
undercorrection or overcorrection of hyponatremia, are common during the treatment of hyponatremic Sodium; hyponatremia;
patients. Hereby, we describe ten common pitfalls that are observed during the correction of serum syndrome of inappropriate
sodium concentration in hyponatremic patients. These refer to pitfalls in the goals and limits of the antidiuretic hormone
correction rate of serum sodium, pitfalls in the means (e.g. solutions but also drugs) and formulas used secretion; vaptans; formulas;
for achieving the desired correction rate and pitfalls associated with inadequate management or treatment; overcorrection
overcorrection. The knowledge of these common-in-clinical-practice pitfalls could assist clinicians in
the proper management of patients with hyponatremia.

1. Introduction It should be mentioned that patients with intracranial dis-

eases, postoperative patients (especially premenopausal
Hyponatremia (serum sodium <135 mEq/L) is a common elec-
women), and patients with acute water intoxication (observed
trolyte disorder both in community and in hospitalized
in primary polydipsia, psychiatric disorders, and ecstasy use)
patients.[1,2] Decreased sodium concentration (especially
have very high risk for developing the devastating conse-
acute, <48 h) may produce nausea, vomiting, headache, sei-
quences of acute hyponatremia.[13–15]
zures, coma, or death from cerebral edema and herniation,
In cases of acute symptomatic hyponatremia, an acute
whereas chronic hyponatremia (even mild) may cause fatigue,
increase of serum sodium levels by 4–6 mEq/L within the first
cognition impairment, gait deficits, falls and fractures, and
4–6 h is strongly recommended in published guidelines in order
even increased mortality.[3–7] The proper correction rate of
to reverse the symptoms, which is the primary goal of treat-
serum sodium levels in patients with hyponatremia is of spe-
ment.[11] Additionally, if symptoms do not improve in the first
cial importance since overcorrection of serum sodium levels
hour after correction of serum sodium levels by 5 mEq/L in
may result in devastating neurologic consequences, such as
patients with acute significant reduction of serum sodium levels
the osmotic demyelination syndrome (ODS).[8–10] On the
associated with severe neurologic symptoms, a goal of 1 mEq/
other hand, undercorrection can also lead to permanent dis-
L/h increase in serum sodium levels (without a specific limit of
ability or even death, especially in patients with severe neu-
correction) is recommended until the symptoms subside.[12,16]
rologic symptoms. According to current guidelines, serum
In both oligosymptomatic acute hyponatremia and mainly
sodium levels should be corrected at a proper rate.[11,12]
in chronic hyponatremia, even symptomatic, the rate of the
However, a number of pitfalls are common during the treat-
increase in serum sodium levels should be limited at <10 mEq/
ment of hyponatremic patients, which could lead to under-
L/24 h and preferably <6–8 mEq/L/24 h.[12,17]
correction or overcorrection of hyponatremia. Hereby, we
describe 10 common pitfalls that are observed during the
correction of serum sodium concentration (Table 1). 3. No knowledge of the groups of patients in whom
a rather rapid increase in serum sodium is
anticipated
2. No knowledge of the proper correction rate of
serum sodium The removal of the underlying cause of hyponatremia in
certain patient groups with chronic hyponatremia is followed
The proper correction rate of hyponatremia depends on the
by a brisk water diuresis and a rather rapid and considerable
severity of neurological symptoms, the rapidity of the
increase in serum sodium levels. Specifically, the restoration of
decrease in serum sodium levels (acute hyponatremia vs.
the extracellular volume in hypovolemic patients, the admin-
chronic hyponatremia >48 h), and the underlying causes.[12]
istration of hydrocortisone in patients with primary or

CONTACT Theodosios D. Filippatos [email protected] Department of Internal Medicine, School of Medicine, University of Ioannina, 451 10 Ioannina,
Greece
© 2016 Informa UK Limited, trading as Taylor & Francis Group
 POSTGRADUATE MEDICINE 517

Table 1. Common pitfalls in the management of patients with hyponatremia.

Pitfall Tips to avoid
No knowledge of the proper correction rate of serum sodium ● Acute symptomatic hyponatremia: increase in serum sodium levels by 4–6 mEq/L
within the first 4–6 h, by <10 mEq/L within the first 24 h, and by <8 mEq/L/day
thereafter.
● Oligosymptomatic acute hyponatremia and chronic hyponatremia: rate of increase
of serum sodium levels <6–8 mEq/L/24 h

No knowledge of the groups of patients in whom a rather rapid increase in serum High-risk conditions:
sodium is anticipated ● Restoration of the extracellular volume in hypovolemic patients
● Administration of hydrocortisone in patients with primary or secondary adrenal
insufficiency
● Discontinuation of the offending drugs
● Increased intake of salt and proteins in patients with decreased solute intake

Ignorance of the underlying conditions that place patients at high risk of developing High-risk conditions
the osmotic demyelination syndrome (ODS) ● Hypokalemia
● Malnutrition
● Advanced liver disease
● Alcoholic individuals
● Patients with serum sodium ≤105 mEq/L

Inadequate use and evaluation of formulas to predict the serum sodium changes and ● Adrogue and Madias equation: projects the effect of gaining 1 L of any infusate
to calculate the rate of infusates used for the safe correction of hyponatremia on the patients’ serum sodium.
● Formula of sodium deficit is useful.
● Tonicity balance approach is also useful.
● Calculation of the rate of the hypertonic saline solution needed to increase serum
sodium by 6–8 mEq/L is mandatory.

Inappropriate approach to patients with hypovolemic hyponatremia ● Restoration of euvolemia with isotonic saline is indicated.
● Avoid fluid restriction.
● Overcorrection of sodium levels after the restoration of volume is anticipated and
needs special attention.

Inappropriate management of patients with hyponatremia due to SIADH ● Acute symptomatic hyponatremia: hypertonic 3% saline solution in a dose of
2 mL/kg of body weight over 10 min. The dose can be repeated after 20 min (no
more than three doses).
● Moderately severe symptoms: normal saline should be avoided. Careful adminis-
tration of hypertonic (3%) saline solution (0.5–2 mL/kg/h) is advised. Furosemide
can be carefully used to increase water losses and to treat volume overload.
● Asymptomatic patients with SIADH and chronic hyponatremia: water restriction
(500 mL below the 24-h urine volume). Calculation of the electrolyte-free water
clearance or urine/serum electrolyte ratio is mandatory.
● Chronic hyponatremia not responding to water restriction: increase in solute
intake (with salt- and protein-rich diet), urea, demeclocycline, and tolvaptan.
● Frequent determination of serum and urine electrolytes in all cases.

Inability to adjust the patients’ treatment with the use of fluid loss formula Fluid loss formula:
● Projects the effect of losing 1 L of any fluid (mainly urine) on the patients’ serum
sodium.
● Mandatory when ongoing fluid losses (mainly renal losses) are >1 L/day.

Inappropriate use of furosemide during treatment of symptomatic patients with SIADH ● Furosemide can significantly contribute to the increase in serum sodium.
concentration by increasing free water excretion. Frequent determination of
serum sodium is mandatory.

Inappropriate use of vaptans ● Vaptans can be used in patients with euvolemic hyponatremia (mainly in
patients with SIADH), patients with congestive heart failure, or patients with
cirrhosis and ascites.
● Short-term use with frequent determination of serum sodium is advised.
● Long-term use in patients with irreversible euvolemic hyponatremia with distur-
bances associated with the decreased sodium level (gait disturbance and frequent
falls) not responding to fluid restriction.

Inadequate management of patients in whom overcorrection of hyponatremia is ● In patients with high risk of ODS in whom overcorrection of serum sodium
observed concentration is observed, a careful reduction of serum sodium levels (using
hypotonic saline solutions or desmopressin) should be attempted aiming to a
final increase of <6 mEq/L/day in serum sodium concentration.
SIADH: syndrome of inappropriate antidiuretic hormone secretion.
518 T. D. FILIPPATOS ET AL.

secondary adrenal insufficiency, the discontinuation of diure- (approximately 10 mEq/L/24 h) is rather large for most
tics, the abrupt decrease in water intake in patients with patients. Thus, the use of this equation should be tailored to
polydipsia, or the increased intake of salt and proteins com- each patient.
bined with water restriction in patients with decreased solute The Adrogue and Madias equation [28] can project the effect
intake (e.g. in patients with the beer-potomania syndrome or of gaining 1 L of any infusate on the patients’ serum sodium:
in elderly patients with tea and toast diet) may be followed by
½ðNaþ þKþ Þof the infusateðserum Naþ Þ
an abrupt increase in serum sodium levels.[13,14,18–20] ΔNaþ ¼ (2)
Hence, careful monitoring of these patients with repeated Total body water þ 1
(every few hours) determination of serum sodium levels is The administration of 1 L of hypertonic saline (513 mEq Na+/L)
mandatory. It should be mentioned that large-volume polyuria in the previous patient is anticipated to increase serum sodium
is an alarming sign indicating inappropriate correction of levels by 9.6 mEq/L. Thus, a 10-mEq/L/day increase in serum
hyponatremia. sodium levels can be achieved by administering 1070 mL of
the hypertonic saline solution (44 mEq/h). As it is clearly depicted
in the Adrogue–Madias equation, the potassium content of the
4. Ignorance of the underlying conditions that place infusate should be taken into account in the calculation of the
patients at high risk of developing the ODS projected serum sodium change. This means that the adminis-
Rapid correction of hyponatremia, especially in patients with tered potassium can increase serum sodium levels and that
chronic (>48 h) or oligosymptomatic hyponatremia with correction of coexistent potassium depletion aids to the correc-
serum sodium concentration <120 mEq/L, puts patients at tion of hyponatremia.[29]
risk for developing ODS with its devastating consequences. Finally, other authors suggested a simpler strategy to cal-
Additionally, patients with hypokalemia, malnutrition, and culate the rate of the administration of hypertonic saline
advanced liver disease, as well as alcoholic individuals; and solution. This approach estimates an expected correction of
patients with serum sodium concentration ≤105 mEq/L, are 1 mEq/L/h for each mL/kg/h of 3% saline.[30,31]
reported in literature as having high risk for developing the Thus, in the previous case, the rate of infusion needed to
ODS.[21–23] A more frequent monitoring strategy (e.g. deter- increase serum sodium levels by 1 mEq/L/h is as follows:
mination of serum sodium concentration every 4–6 h) and Infusion rateðmL=hÞ ¼ goal rate  body weightðkgÞ
appropriate tailoring of the correction rate is strongly recom-
¼ 1mEq=L=h  70kg ¼ 70mL=h (3)
mended for patients with high risk of developing the ODS.
It should be mentioned that frequent and repeated mea-
surement of serum sodium levels are required during the
5. Inadequate use and evaluation of formulas to administration of hypertonic saline.
predict the serum sodium changes and to calculate The tonicity balance approach is a useful approach for the
the rate of infusates used for the safe correction of understanding of sodium changes. It is based on the following
hyponatremia equation:
A number of formulas have been used to predict the change total cation content
of serum sodium levels during treatment and to calculate the Naþ concentration ¼ (4)
total body water
initial infusion rates. These formulas are useful as starting
points, but it should be mentioned that they underestimate First, the patient’s total cation content is calculated with
the rate of correction, probably because they do not take into the conversion of Equation (4):
account the concurrent water losses (the patient is considered
Total cation content ¼ Serum sodium
as a closed system).[24,25] Hence, frequent adjustments of
 total body water (5)
therapy may be needed in order to avoid overcorrection.
According to the traditional procedure, the sodium The total cation content in the previous case is 4620 mEq
required to increased serum sodium levels by approximately (42 L × 110 mEq/L). Next, the loss of total cations in the urine
10 mEq/L within 24 h can be estimated by the formula of is estimated. Ideally, 24-h urine measurements should be used
sodium deficit [26]: for this estimation, but a spot urine sample along with urine
volume (Vurine) produced during the administration of a cer-
Required Naþ ¼ Total body waterΔNaþ (1)
tain solution can provide a rough estimate of total cation loss.
The estimated total body water (TBW) is calculated as a For example, the administration of 1 L NaCl 3% provides
fraction of body weight; the fraction 0.6 in nonelderly men, 0.5 513 mEq Na+. Let us suppose that during the administration
in elderly men and nonelderly women, and 0.45 in elderly of this solution, a urine volume of 1 L is produced and urine
women has been used.[27] Thus, the amount of Na+ required sodium and potassium concentrations of 80 and 40 mEq/L,
to increase serum sodium by 10 mEq/L/day in a patient with respectively, are measured in a spot urine sample. This means
serum sodium 110 mEq/L and TBW 42 L is 420 mEq loss of 120 mEq of total cations during the administration of
(42 L × 10 mEq/L). Thus, if administration of 3% saline solution this hypertonic solution. Thus, the new total cation content is
(513 mEq Na+/L) has been chosen, the needed volume of this (4620 + 513 − 120) = 5013 mEq, while no significant change in
solution is 420 mEq/513 mEq/L = 818 mL (34 mL/h). It should TBW was observed (1 L − 1 L = 0). Accordingly, the new
be mentioned that the increase estimated by the Equation (1) sodium concentration will be as follows:
 POSTGRADUATE MEDICINE 519

new total cation content 5013 details). Frequent determination of serum and urine
New Naþ concentration ¼ ¼
new total body water 42 electrolytes is necessary during treatment to avoid inap-
¼ 119:3mEq=L: propriate increase in serum sodium levels.
(iii) In asymptomatic patients with SIADH and chronic
So, tonicity balance studies can explain the sodium hyponatremia, water restriction (500 mL below the
changes observed with the administration of certain solutions. 24-h urine volume) is recommended.[35] However,
This approach is very helpful for understanding the pathophy- the effectiveness of water restriction is quite variable;
siology of sodium changes in serum, but it is not helpful for the calculation of the electrolyte-free water clearance
the prediction of serum changes. (Ce H2 O ) is mandatory since it can easily calculate the
ability of the kidneys to excrete water.[36] The Ce H2 O
6. Inappropriate approach to patients with can be easily estimated by the following equation:
hypovolemic hyponatremia  
Urine ðNaþ þ Kþ Þ
Ce H2 O ¼ Vurine  1  (6)
Restoration of plasma volume with isotonic saline solution is Serum Naþ
the treatment of choice in patients with hypovolemic hypona-
A negative value indicates inability of the kidneys to
tremia. Additionally, stopping of thiazides and restoration of
excrete free water and suggests that water restriction
the underlying volume depletion and potassium deficit can
alone is inadequate for the patient’s management.
lead to normonatremia in patients with diuretic-induced hypo-
Alternatively, the urine/serum electrolyte ratio (in a
volemic hyponatremia.[32] Special emphasis should be given
urine sample) is a useful marker of the ability to
in patients with hypovolemic hyponatremia to the possibility
excrete water [37]:
of an overly rapid increase in serum sodium levels when
volume depletion is restored. In this case, an abrupt decrease Urine ðNaþ þ Kþ Þ
in antidiuretic hormone (ADH) secretion and subsequently a Urine=serum electrolyte ratio ¼ (7)
Serum Naþ
rapid increase in diuresis is observed.[25,29,33,34]
A value of >1 suggests that fluid restriction is not able
to increase serum sodium and is not advised. In con-
7. Inappropriate management of patients with trast, a value of <0.5 is indicative of a good response
hyponatremia due to SIADH to fluid restriction.
(i) In patients with acute symptomatic hyponatremia (iv) In patients with chronic hyponatremia due to SIADH in
(especially in patients with severe neurologic symp- whom water restriction is inadequate, the increase in
toms such as vomiting, seizures, or coma), which is solute intake (with salt- and protein-rich diet), com-
a medical emergency, hypertonic 3% saline solution bined with low-dose loop diuretics, could assist to an
(513 mEq Na+/L) in a dose of 100 mL over 10 min increase in serum sodium levels. Alternatively, urea
should be used to gradually increase serum sodium (doses of 0.25–0.50 g/kg/day) may be a useful adjunct
levels; if there is no clinical improvement, this dose if it is available.[12,38,39] Additionally, demeclocycline
can be repeated after 20 min (no more than three (600–1200 mg/day in divided doses; 3 to 4 days to
doses).[11] The urgent correction by 4–6 mmol/L is achieve maximal diuretic effects are needed) or a
usually associated with clinical improvement. In vasopressin receptor antagonist (vaptan) can be used
case that the severe symptoms do not subside to increase serum sodium levels [11,40–42]; however,
despite the correction of serum sodium concentra- other investigators recommend against the use of
tion by 5 mEq/L in the first hour, a correction rate these drugs.[12] Monitoring of serum sodium concen-
of 1 mEq/L/h of serum sodium levels with contin- tration is advised during use of the above treatments
uous infusion of hypertonic saline until symptom in order to follow the appropriate rate of correction.
improvement has been suggested.[12] Frequent
determinations of serum sodium concentration are
advised. Even in patients with symptomatic hypo-
natremia, overcorrection of hyponatremia (increase 8. Inability to adjust the patients’ treatment with
of >10 mEq/L/d) should be avoided. the use of fluid loss formula
(ii) In patients with chronic hyponatremia with moderately
severe symptoms (nausea without vomiting, confusion, In the setting of substantial ongoing fluid losses (>1 L/day;
and headache [12]), normal saline should not be admi- mainly renal losses), the fluid loss formula should be used,
nistered since it can lead to even further decrease in which can project the effect of losing 1 L of any fluid (mainly
serum sodium levels (especially in patients with urine) on the patients’ serum sodium [43,44]:
increased urine osmolality >500 mOsm/kg). In these
Serum Naþ  urine ðNaþ þ Kþ Þ
patients, careful administration of hypertonic (3%) saline ΔNaþ ¼ (8)
TBW þ 1
solution (1 to 2 mL/kg/h) is advised in order to achieve
the desired rate of correction,[30] while furosemide can In the previous case, the ΔNa+ for urinary volume of 1 L
also be used to avoid volume overload and to increase with the above mentioned urine sodium and potassium con-
water losses (decrease in urine osmolality; see below for centration (80 and 40 mEq/L, respectively) is:
520 T. D. FILIPPATOS ET AL.

110  ð80 þ 40Þ to 3.4 L associated with approximately 100 mEq additional
ΔNaþ ¼ ¼ <1meq=L
42 þ 1 Na+ + K+ urine losses, and the Uosm will be reduced to
approximately 300 mOsm/kg. Thus, the new predicted sodium
Thus, in this case, urine losses do not significantly contri-
concentration is as follows:
bute to the change in serum sodium levels. However, in a
patient with body weight 60 kg, serum Na+ 120 mEq/L, urine New total cation content
New sodium concentration ¼
(sodium + potassium) 40 mEq/L and urine volume 2.5 L, the New TBW
ΔNa+ would be 2.5 × 2.6 mEq/L = + 6.5 mEq/L. Thus, a rather 110 mEq  42L
¼ L
 114:4mEq=L
inappropriate sodium correction rate is anticipated if the clin- 42 þ 1  3:4L
ician does not take into account the ongoing urine losses.
So, the administration of furosemide can induce a further
It has been proposed that the Adrogue–Madias formula
increase in serum sodium levels. Consequently, in some cases,
(Equation (2)) should be used to calculate the initial saline
an inappropriate increase in serum sodium concentration
infusion rate in patients with hyponatremia. When ongoing
might be observed, and this change should be taken into
renal losses are substantial (urine volume >1 L), the fluid loss
account during management of patients with hyponatremia.
formula should be used to properly adjust treatment.[45]
The inability of isotonic saline solution to increase serum
It should be mentioned that some authors propose an
sodium levels in patients with SIADH is easily explained with
alternative treatment algorithm for SIADH-associated hypona-
the above calculations. Using the above equations, since the
tremia. In this approach, hypertonic saline is administered
Uosm is relatively constant at 500 mOsm/kg, the anticipated
concurrently with desmopressin (1 to 2 μg parenterally every
urine volume with the use of 1 L of isotonic saline solution
6–8 h). The amount of hypertonic saline projected to increase
(154 mEq/L) will be as follows:
the serum sodium concentration by 6 mEq/L/24 h is calculated
based on Adrogue–Madias formula (Equation (2)). The concur- Solute load 308
rent administration of desmopressin aims to prevent the over- Vurine ðLÞ¼ ¼  0:6L
Uosm 500
correction that may be seen when the cause of hyponatremia
Thus, administration of 1 L of isotonic saline will result in
has been removed.[46] However, this ‘proactive’ approach
retention of 400 mL of water. The projected new serum
should be limited to experienced clinicians because the
sodium concentration is as follows:
administration of desmopressin needs much attention in
order to avoid undercorrection. New total cation content
New sodium concentration ¼
New TBW
L 42L
110 mEq
9. Inappropriate use of furosemide during ¼  109mEq=L
42 þ 0:4L
treatment of symptomatic patients with SIADH
Hence, a decrease in serum sodium concentration is
Hypertonic saline solution (3%) is commonly used in sympto- anticipated.
matic patients with SIADH. In these cases, furosemide (20–40 mg
intravenously) can also be administered to avoid circulatory over-
load. However, furosemide can contribute to the increase in
10. Inappropriate use of vaptans
serum sodium concentration by increasing free water excretion.
For example, 1 L of hypertonic saline solution is adminis- Vaptans (vasopressin receptor antagonists) are a new class of
tered in a male patient (body weight 70 kg) with serum drugs for the management of hyponatremia and are considered
sodium 110 mEq/L and urine osmolality (Uosm) 500 mOsm/ by some authors as first choice drugs, especially in patients with
kg. It should be mentioned that Uosm is relatively stable in SIADH.[48] These drugs selectively antagonize the antidiuretic
SIADH patients despite any changes in water and solutes effect of vasopressin leading to increased water diuresis (aquar-
intake.[47] Hence, since the patient exhibited extracellular esis).[49] These drugs can be used in patients with chronic
volume expansion due to ADH-mediated water retention, symptomatic euvolemic hyponatremia (mainly in patients with
this amount of infusate will be rapidly excreted with urine. SIADH) and in some countries in patients with hypervolemic
Thus, the anticipated Vurine is estimated as follows: hyponatremia (mainly in patients with congestive heart failure
but also in patients with cirrhosis and ascites).[40–42,49–54]
Solute load 1026
Vurine ¼ ¼  2L (9) Vaptans should be initiated in hospital environment, and gen-
Uosm 500
erally, short-term use along with monitoring of serum sodium
Consequently, the anticipated new sodium concentration will and urine output is usually advised to avoid an undesirable
be (according to the previously mentioned tonicity balance increase in serum sodium levels.
study and Equation (4)) as follows: Treatment with tolvaptan should be initiated at a dose of 15 mg
once daily.[55,56] The dose of the drug can be increased to 30 or
New total cation content
New sodium concentration ¼ 60 mg/day if a <5 mEq/L increase in plasma sodium is not observed
New TBW
in the previous 24 h.[11] Additionally, tolvaptan can be carefully
110 mEq  42L
¼ L
 112:7mEq=L given for longer periods in selected patients with irreversible
42 þ 1  2L
euvolemic hyponatremia who cannot be managed with fluid
So, an increase in serum sodium is anticipated. If furose- restriction and having disturbances that could be attributed to
mide is administered, the Vurine will be increased, for example, the decreased sodium concentration (gait disturbance and
 POSTGRADUATE MEDICINE 521

frequent falls). Drug-induced liver injury has been observed in The awareness for these common pitfalls may lead to better
clinical trials investigating the role of long-term tolvaptan (at and safer management of patients with hyponatremia.
higher doses than approved) in autosomal dominant polycystic
kidney disease.[57,58] Determination of liver enzymes should be
promptly performed in patients with symptoms indicating liver
Declaration of interests
injury, and the drug should be discontinued if liver injury is sus-
pected or liver enzymes are elevated more than three times the The authors have no relevant affiliations or financial involvement with any
upper limit of normal levels.[55,56,59] organization or entity with a financial interest in or financial conflict with
the subject matter or materials discussed in the manuscript. This includes
Conivaptan is indicated to raise serum sodium in hospita- employment, consultancies, honoraria, stock ownership or options, expert
lized patients with euvolemic and hypervolemic hyponatre- testimony, grants or patents received or pending, or royalties.
mia.[60,61] Conivaptan is given intravenously as a loading
dose of 20 mg administered over 30 min, followed by contin-
uous infusion at a rate of 20 mg/24 h (which may be increased ORCID
up to 40 mg/24 h) for 2–4 days.[62] Conivaptan has not been Theodosios D. Filippatos http://orcid.org/0000-0002-1713-0923
specifically associated with elevation of liver enzymes. George Liamis http://orcid.org/0000-0003-1522-8318
It should be pointed out that vaptans are contraindicated Moses S. Elisaf http://orcid.org/0000-0003-0505-078X
in hypovolemic hyponatremia.[49]

11. Inadequate management of patients in whom References

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2016;29:22–25..
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