Abstract
BackgroundHyponatremia is a common electrolyte disorder. Multiple organizations have published guidance documents to assist clinicians in managing hyponatremia. We aimed to explore the scope, content, and consistency of these documents.MethodsWe searched MEDLINE, EMBASE, and websites of guideline organizations and professional societies to September 2014 without language restriction for Clinical Practice Guidelines (defined as any document providing guidance informed by systematic literature review) and Consensus Statements (any other guidance document) developed specifically to guide differential diagnosis or treatment of hyponatremia. Four reviewers appraised guideline quality using the 23-item AGREE II instrument, which rates reporting of the guidance development process across six domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Total scores were calculated as standardized averages by domain.ResultsWe found ten guidance documents; five clinical practice guidelines and five consensus statements. Overall, quality was mixed: two clinical practice guidelines attained an average score of >50% for all of the domains, three rated the evidence in a systematic way and two graded strength of the recommendations. All five consensus statements received AGREE scores below 60% for each of the specific domains.The guidance documents varied widely in scope. All dealt with therapy and seven included recommendations on diagnosis, using serum osmolality to confirm hypotonic hyponatremia, and volume status, urinary sodium concentration, and urinary osmolality for further classification of the hyponatremia. They differed, however, in classification thresholds, what additional tests to consider, and when to initiate diagnostic work-up. Eight guidance documents advocated hypertonic NaCl in severely symptomatic, acute onset (<48 h) hyponatremia. In chronic (>48 h) or asymptomatic cases, recommended treatments were NaCl 0.9%, fluid restriction, and cause-specific therapy for hypovolemic, euvolemic, and hypervolemic hyponatremia, respectively. Eight guidance documents recommended limits for speed of increase of sodium concentration, but these varied between 8 and 12 mmol/L per 24 h. Inconsistencies also existed in the recommended dose of NaCl, its initial infusion speed, and which second line interventions to consider.ConclusionsCurrent guidance documents on the assessment and treatment of hyponatremia vary in methodological rigor and recommendations are not always consistent.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-014-0231-1) contains supplementary material, which is available to authorized users.
Highlights
Hyponatremia is the most common electrolyte disorder in clinical medicine; it represents an excess of water relative to total body solute [1]
Hyponatremia usually results from the intake and subsequent retention of electrolyte-free water in response to true hypovolemia due to gastrointestinal solute loss or malnutrition; decreased effective circulating volume due to heart failure or liver cirrhosis; or non-osmotic vasopressin activity due to malignancies, infections, medications, pain, or stress [2]
Even when comorbid conditions are taken into account, people with a mildly decreased serum sodium concentration have a 30% higher risk of death and are hospitalized 14% longer relative to those without hyponatremia [2,4]
Summary
Hyponatremia is the most common electrolyte disorder in clinical medicine; it represents an excess of water relative to total body solute [1]. When defined as a serum sodium concentration below 135 mmol/L, hyponatremia occurs in up to 8% of the general population and in up to 60% of hospitalized patients [2,3]. Even when comorbid conditions are taken into account, people with a mildly decreased serum sodium concentration have a 30% higher risk of death and are hospitalized 14% longer relative to those without hyponatremia [2,4]. It may take days before the electrolyte disorder is investigated, potentially allowing a further decrease in serum sodium concentration and exposing patients to the dangers of profound hyponatremia. When efforts are made to explore the underlying cause, clinicians use widely different strategies for differential diagnosis, testing is often inadequate and misclassification of the hyponatremia frequently occurs [6,7]
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