 Hyponatremia may be associated with Hypothyroidism (low thyroid levels/function), especially with severe hypothyroidism and myxedema. Myxedema is a constellation of symptoms associated with severe hypothyroidism including:
•Confusion •Swelling •Hypothermia (low body temperature) •Bradycardia (slow heart rate) •Hypotension (low blood pressure) •Hypoglycemia (low blood sugar) With this being said thyroid function is often checked, with a simple blood test, to be sure this is not the cause of the low sodium level. In those with myxedema, it’s the decrease in cardiac output which leads to the release of ADH (anti diuretic hormone) via carotid sinus baroreceptors. The ADH release is the signal that tells the kidney to reclaim and hold on to water, which ultimately dilutes the sodium level in the blood. Slower kidney function (GFR) may also be contributing via the kidneys inability to excrete excess water properly. It is interesting however, that often these hypothyroid cases mimic SIADH, with high, rather then low urine sodium, despite the low cardiac function. In closing, we want to be sure that thyroid levels are tested as part of the workup for SIADH/Hyponatremia. Useful links and sources: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4470237/#__sec2title https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4450783/ https://www.webmd.com/a-to-z-guides/myxedema-coma#2-3 https://www.aafp.org/afp/2000/1201/p2485.html https://healthjade.net/myxedema-coma/
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INTRODUCTION: HYPONATREMIA SIGNS AND SYPMTOMS. Hyponatremia, low blood sodium level, is a relatively common condition. Hyponatremia is the most common electrolyte disturbance to impact patients in clinical settings1. Most often, Hyponatremia is due to the inability of the body to excrete excess water. This excess water accumulates in the blood, dilutes the sodium level, and leads to low blood sodium levels. The effects of Hyponatremia and low blood sodium levels include:
WHAT CAUSES THE BODY TO HOLD WATER TOO TIGHTLY? There are many possible Hyponatremia causes. The way I like to explain it is to consider our evolution. When we were living in the stone ages and a saber tooth tiger was chasing us, or we were under a great deal of stress due to difficulty finding clean water sources, our body was programmed to hold water tightly, to avoid dehydration. Fast forward to 2020, and we find different ‘stressors’ that may signal the body to hold water to tightly. These 'stressors' include:
The hormone that is secreted in these disease states is called Anti-Diuretic Hormone (ADH). ADH does just what its name implies; it is anti-diuresis (urinate). The urine turns dark and concentrated, and water excretion comes to a near halt. HYPONATREMIA TREATMENT For starters, we must be sure there aren't other reasons for the dilution effect. Examples of this include heart failure and liver disease. Both can cause fluid retention due to different mechanisms. These diseases are often treated with a low sodium diet and diuretics (fluid pills). Hyponatremia may also be caused by excessive water intake relative to solid food intake. This is termed primary polydipsia or tea and toast. These diseases are treated with simple fluid restriction and an increase in food intake. Let's think back to the causes of Hyponatremia. Now that we have talked about the other processes, the term SIADH always gets brought up. This is a syndrome of inappropriate antidiuretic hormone release. A bit confusing, but if you follow the name, it is an improper release of the hormone that does not allow the kidney to release water. This is what occurs in those examples, as mentioned earlier, the lung disease, brain disease, pain, or nausea scenarios. SIADH will therefore cause the kidney to hold water inside and not release it, diluting the sodium level in the blood and lead to some of those ominous symptoms. To treat this SIADH process, we must start with a fluid restriction as a part of a Hyponatremia diet. Usually, this would be about 1 liter (32 oz) or less per day. This does include all liquids and not just water. Often that is not enough, and the patient will require further interventions. In previous days we may have used diuretics and salt tablets for Hyponatremia, however more recent studies have shown this to be somewhat ineffective when compared to fluid restriction alone and have significantly more side effects.3 More recently, Tolvaptan has come to market. Tolvaptan is an oral antagonist (blocker) of the ADH receptor in the kidney. This medication works by blocking the signal and thus allowing the body to expel all that excess water.However, this medication's downsides are high cost at over $300 a tablet and low but severe liver injury potential. There are also side effects, including overcorrection of the sodium level (which can be quite dangerous), urinating excessively at night, and extreme thirst with Tolvaptan. Lastly, there is oral Urea for the treatment of SIADH. Urea works by osmosis. It draws water out naturally through the kidney, ridding the body of excess water without the need for salt tablets or extreme fluid restrictions. Urea is a medical food and is thus allowed to be purchased directly by the patient without a prescription. Medical foods like Urea should be taken only under the supervision of a medical practitioner. Urea has minimal if any side effects. It truly is a natural product, medical food, and not a pharmaceutical agent. Urea has a somewhat intense, slightly salty taste and is thus best made palatable by flavorings. Our company, KidneyAide.com, maker of UreaAide, is an example of this with a natural refreshing mint flavor, dosed in individual packs, and easily purchased online. We will soon be expanding into other flavors and a low-cost plain version that could be mixed with other flavorings at home. This will offer patients lots of options in terms of flavors and lower the cost for everyone. In closing, Hyponatremia or low sodium is a common disorder that may cause multiple vague symptoms which only a blood test can detect. A thorough investigation is necessary to tease out the reason for the disturbance. There are several ways to treat Hyponatremia. With the example of SIADH fluid restriction, urea products such as UreaAide, Tolvaptan, or salt plus water pills may all be options to help rid the body of excess water and get the sodium level back into the normal range. Thus alleviating the symptoms of low sodium and getting back to feeling great again. Citations 1. Upadhyay A, Jaber BL, Madias NE. Incidence and prevalence of hyponatremia. Am J Med. 2006 Jul;119(7 Suppl 1):S30-5. doi: 10.1016/j.amjmed.2006.05.005. PMID: 16843082. 2. Goce Spasovski, Raymond Vanholder, Bruno Allolio, Djillali Annane, Steve Ball, Daniel Bichet, Guy Decaux, Wiebke Fenske, Ewout J. Hoorn, Carole Ichai, Michael Joannidis, Alain Soupart, Robert Zietse, Maria Haller, Sabine van der Veer, Wim Van Biesen, Evi Nagler, on behalf of the Hyponatraemia Guideline Development Group, Clinical practice guideline on diagnosis and treatment of hyponatraemia, Nephrology Dialysis Transplantation, Volume 29, Issue suppl_2, 1 April 2014, Pages i1–i39 3. Efficacy of Furosemide, Oral Sodium Chloride, and Fluid Restriction for Treatment of Syndrome of Inappropriate Antidiuresis (SIAD): An Open-label Randomized Controlled Study (The EFFUSE-FLUID Trial) Krisanapan P., Vongsanim S., Pin-on P., Ruengorn C., Noppakun K. (2020) American Journal of Kidney Diseases, 76 (2) , pp. 203-212.   1. Urea’s molecular formula is CO-(NH2)2. Pubchem.
2. Urea is also known as Carbamide, 57-13-6, Carbonyldiamide, IsoUrea. Pubchem 3. Urea is found naturally in our skin and is one of our body’s natural moisturizers. Many skin care products contain Urea at various percentages, Eucerin 10% Urea is an example of one. 4. Urea has a molecular weight of 60.056 g/mol very similar to Sodium Chloride 58.44 g/mol (that’s why 1 packet of 15 g UreaAide is equal to ~7 salt tablets). 5. Urea is formed naturally in the liver. The liver, via the urea cycle, takes 2 toxic Ammonia molecules from protein breakdown plus Carbon Dioxide to form 1 Urea molecule. Urea May then be excreted safely through the urine. 6. An IV formulation of Urea Ureaphil (40 grams/vial) was available, and first used in the 1960’s for increased intracerebral pressure. Ureaphil was later discontinued in 2006, as other products like mannitol came on to market. 7. Urea 13-C is a radiolabelled urea molecule used in the diagnosis of stomach ulcers by the bacterium Helicobacter Pylori. H. Pylori contains the enzyme Urease which will break down Urea to Ammonia and radioactive C02 where the CO2 can be detected in the breath. C-13 Urea breath test 8. Urea is considered extremely safe and there are no reports, to our knowledge, of Osmotic Demyelination with the us of Urea for Hyponatremia. 9. Urea has been used for SIADH since at least 1980 where G Decaux et al. showed it’s effectiveness and published the data in the American Journal of Medicine. 10. Over 90% of oral Urea is absorbed in the upper GI tract. Urea has a half life of only about 2 hours, and an oral dose of Urea is completely excreted by the kidneys by 12 hours. Blood Purif 2020;49:212–218  Pseudohyponatremia, as the name implies, is not what we consider true hyponatremia. In fact, it is a laboratory error (pseudo-greek derivation meaning false; feigned). When serum sodium is measured with the standard indirect ion-selective electrode (ISE) method it is measured in an aqueous solution, diluted, and there is always an assumption that plasma is precisely 93% water. When the samples are analyzed and something in the sample is "displacing" the plasma water, then the actual amount of sodium detected will be lower. What can displace the plasma water? Lipids, as in a very high triglyceride levels for starters. These elevated triglyceride levels, typically >1500 mg/dl, are often seen in conjunction with pancreatitis. Elevated proteins may also lead to Pseudohyponatremia; typically seen with diseases like Multiple Myeloma with total proteins in excess of 10 g/dL. Lastly, in severe biliary obstruction we may see very high levels of cholesterol and lipoproteins (lipoprotein x) usually with cholesterol levels over 1000 mg/dL.
This error can be avoided if a whole blood sample is drawn and analyzed with direct ion-selective electrode like the arterial blood gas method. Because this is not true hyponatremia, the treatment is directed at the underlying process and not on the low sodium.  CJASN Study showing 12 months of Urea use extremely effective at keeping sodium in normal range. Urea has been used for many years and in many countries for the treatment of SIADH/Hyponatremia. Urea is considered a GRAS (generally recognized as safe) product by the FDA1. In fact, an interesting study took place in Belgium in 2012. They looked at 12 patients with chronic SIADH, with an average sodium of 125 meq/L (low). The first year, they were given the new, very expensive, pharmaceutical drug class Vaptans daily. The average Sodium came up to a normal level of 135 meq/L. 1 patient out of the 12 dropped out due to severe thirst. Next, the patients had an 8 day “holiday” without treatment, and as expected the Sodium went back down (pictured above). Over the next 12 months, the SIADH patients were given oral Urea therapy. The patients now on Urea have a similar normal sodium level of 135 meq/L. However, this time there were no dropouts nor any significant adverse events. The authors, therefore concluded that oral Urea was safe, well tolerated and as effective as the Vaptans at a much lower cost.2 This study impacted the current European best practice guidelines which advocate for Urea over Vaptans for SIADH/Hyponatremia.3 Another study, this time out of Italy, looked back from years 2013-2018 on 36 patients with cancer associated SIADH/Hyponatremia. They were treated with Urea, and had an average sodium 1 point lower at 124 meq/L (low). They noted after only 24 hours of treatment, the sodium improved on average by 5 meq/L. Secondarily, the Italian physician scientists discovered over 90% of patients on 60 days of treatment with Urea, achieved a normal sodium level. The authors, therefore concluded oral Urea was safe, effective beginning first day of treatment, and very well tolerated.4 Urea has been used for many years in multiple countries for SIADH/Hyponatremia. Urea has always shown to be safe and effective even when taken for a year or more. Our version of this miraculous medical food is UreaAide which can be found by clicking here KidneyAide. Links to the FDA, CJASN and Endocrinology studies + European guidelines for Hyponatremia. 1.https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=184.1923 2.https://cjasn.asnjournals.org/content/7/5/742 3. http://www.european-renal-best-practice.org/sites/default/files/u33/short%20version%20hyponatraemia%20English%20FINAL.pdf 4.https://onlinelibrary.wiley.com/doi/full/10.1111/cen.13966  There is a misconception in the medical community regarding Hyponatremia (low sodium) and the benefit of salt tablets. Of course it makes sense on the surface, your sodium (salt) level is low so take more salt right? Wrong! I’m sorry but it’s usually not the ideal strategy, especially in SIADH or Hypervolemic hyponatremia, as in heart failure (CHF). Let’s examine CHF first. CHF by name is congestive heart failure which implies correctly, that the patient is congested with salt and fluid. This is why CHF is usually treated with diuretics (medicines that make you pee salt and water). This decongesting process is actually what rids the body of excess fluid that is diluting the sodium level. Patients with CHF are asked to go on a sodium restriction diet to prevent congestion and this, along with diuretics, most often improves the sodium levels. UreaAide may be of benefit here as it will, salt free, draw off the excess fluid.
Now let’s examine SIADH. The Syndrome of Inappropriate Anti-Diuretic Hormone. Again the name gives it away. A syndrome that is inappropriately releasing a hormone, that inhibits (anti) diuresis (fluid excretion via kidneys). I know it sounds complicated, in essence your body is being signaled to hold water too tightly. The urine is dark and concentrated and you are incapable of releasing water well. Water builds up and dilution of your serum sodium occurs, manifesting as a low sodium on labs. The simplest and safest way to combat this is to excrete the excess water. Their is a chemical pharmaceutical, tolvaptan, that inhibits this directly, however the wholesale cost is $360/pill and tolvaptan harbors a risk of liver toxicity as well as overly rapid correction leading to brain swelling. You can combine diuretics such as furosemide, salt tablets and fluid restriction with varying success, but your still consuming a bunch of salt. The best method that is safe, completely salt free and cost effective is with Urea. Urea, an osmotic diuretic, is like taking 7 salt tablets per dose and will draw the water out safely and effectively via osmosis. You will pee the excess water out and increases your serum sodium without any strong drugs or excess salt. UreaAide (the better Urea) happens to taste great, cost less and dissolve rapidly in just 4oz of water. So yes you can, and probably should, come off all those salt tablets, especially if you’ve been diagnosed with SIADH. So ask your doctor if UreaAide may be right for you! Order UreaAide Here  Na=Sodium (Normal range 134-145 meq/L) Hyponatremia, or low sodium, is quite common affecting estimates of 1.7-2.1% of the US population1. There are many causes of Hyponatremia (low serum sodium). For completeness, there are less common causes of Hyponatremia, such as the type associated with hyperglycemia (very high blood sugar) or seen with extremely high lipids or protein levels termed ‘’pseudohyponatremia’. These types are looked at and treated differently then the more common hypotonic Hyponatremia that most patients have. It’s very important that we recognize something first, nearly all Hyponatremia is caused by the dilution effect of excess water in the blood. This excess water dilutes the sodium level to below 135 meq/L. It’s in this context that we discuss the major causes of Hyponatremia. Lets start with medications. There are many medications that lead to Hyponatremia, thiazides diuretics being the most common culprits. Other drugs commonly implicated are antidepressants and anticonvulsants. Street drugs such as ecstasy, bath salts, and amphetamines are also possible causes. One question that is often brought up is, ‘doctor can I drink too much water?’ Answer, a resounding yes with some caveats. Its relative to the solute or food you consume. Your kidney can usually do a great job of ridding your body of excess water. Even the great kidneys, however, have their limits. The lowest dilution the kidneys can ever get down to is 50. 50 what you ask? 50 milliosmoles/Liter (mOsm/L). This implies that your kidney needs at least 50 mOsm/L of ‘stuff’ to get rid of that Liter of water you drank. The ‘stuff’ is food like protein (Urea), salt and potassium. The average person eats about 900 mOsm per day. So consider that scenario of 50 osm/L. The implication here is 900 mOsm/50 mOsm/L is 18 liters a day of water one could excrete. That’s over 4 gallons! So if your eating normally you’d have to drink an awful lot to dilute your sodium. This is actually termed psychogenic polydypsia when it happens. On the other hand, if your not eating all that well, say only 250 mOsm/day, then it’s 250/50= 5 liters. Often however, as we age the kidney may only get down to 100 osm dilution. Now 250/100 is only 2.5 liters of water before you start diluting. This type of Hyponatremia is called ‘’tea and toast’ or ‘beer potomania’ (when it’s beer as the main liquid). So yes you can drink too much water even if your kidney is doing it’s very best. Now what if your kidney is getting the wrong signal? Syndrome of inappropriate ADH secretion or SIADH is just that, inappropriate signal. ADH is anti-diuretic hormone, meaning when it’s around you anti diurese (make less urine). When ADH is on board the kidney holds water very tight and your urine turns darker and more concentrated. Over several days of drinking water and other liquids, your serum sodium will become diluted. So what causes the ADH to be excreted? Common triggers for ADH are nausea and pain; that’s why we often see SIADH after surgeries. Other triggers are Lung disease including cancer (especially small cell) and brain diseases such as stroke, bleed, or infection. These SIADH scenarios respond best to UreaAide because the Urea induces a nice osmotic diuresis. The osmotic diuresis will counteract the dilution effect and raise the serum sodium level. Another cause of low sodium levels are true volume depletion from vomiting and diarrhea. Here your body will also excrete ADH but this time the signal is appropriate. This is termed effective arterial volume depletion. This type of hypovolemic Hyponatremia usually corrects with iv fluids. Other reasons your sodium could be low include: heart failure, cirrhosis of the liver, hypothyroidism, and adrenal Insufficiency. These tend to be obvious in terms of heart or liver disease, however thyroid or adrenal must be considered and tested for. As you see their are a lot of scenarios in which the sodium may drop and your doctor will work with you to figure out why. The key is making the correct diagnosis and then recommending the best treatment. 1. Am J Med. 2013 Dec; 126(12): 1127–37.e1. doi: 10.1016/j.amjmed.2013.07.021 PMID:24262726  Check out UreaAide here click the label There is no such thing as asymptomatic Hyponatremia. We were all taught this in medical school and residency, but what are the problems of leaving your serum sodium a little on the low side?
Based on many different studies both observational and randomized ie: SALT-1 and SALT-2, below are 5 of the more common and ominous risks associated with Hyponatremia especially, a Sodium <130 meq/L 1. Increased risk of osteoporosis-bone disease 2. Increased risk of falls and hospitalizations 3. Increased risk of kidney stones 4. Increased risk of confusion/lethargy/weakness 5. Increased risk of mortality-dying The good news is there is a simple, safe, and effective way to get your sodium back to normal with UreaAide! Check it out here click the button below  UreaAide works by osmosis. It really is that simple. When you have excess water (SIADH/Hyponatremia) it is that excess water that is diluting your sodium and causing the number to be low. UreaAide works by increasing the osmolarity (concentration) in the urine which will ultimately draw water to flow in the urine out of the body. As this water leaves the body the dilution effect decreases and the sodium rises. It really is that easy.
I’ve often been asked in my years of practicing nephrology, why does it matter if my sodium is low? The short answer is even mild Hyponatremia is linked to several notable negative signs and symptoms. Hyponatremia is associated with an increased death rate, longer hospital stay, falls, Re-admissions to the hospital, osteoporosis (bone disease), and worsening mental state. More severe forms can lead to seizures, coma and even death. Good news is if caught early and treated properly Hyponatremia can be cured, and sodium levels can be maintained in a normal range. UreaAide is one of the safest most effective ways of helping you maintain normal sodium level. A typical dose of 1 scoop twice a day often does the trick, and it tastes good too!
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AuthorDr. Barry is a board certified Nephrologist, Internal Medicine, and certified Hypertension Specialist. Archives
January 2021
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