Diagnosis and Treatment of Hyponatremia: Compilation of the Guidelines

J Am Soc Nephrol. 2017 May;28(5):1340-1349. doi: 10.1681/ASN.2016101139. Epub 2017 Feb 7.


Hyponatremia is a common water balance disorder that often poses a diagnostic or therapeutic challenge. Therefore, guidelines were developed by professional organizations, one from within the United States (2013) and one from within Europe (2014). This review discusses the diagnosis and treatment of hyponatremia, comparing the two guidelines and highlighting recent developments. Diagnostically, the initial step is to differentiate hypotonic from nonhypotonic hyponatremia. Hypotonic hyponatremia is further differentiated on the basis of urine osmolality, urine sodium level, and volume status. Recently identified parameters, including fractional uric acid excretion and plasma copeptin concentration, may further improve the diagnostic approach. The treatment for hyponatremia is chosen on the basis of duration and symptoms. For acute or severely symptomatic hyponatremia, both guidelines adopted the approach of giving a bolus of hypertonic saline. Although fluid restriction remains the first-line treatment for most forms of chronic hyponatremia, therapy to increase renal free water excretion is often necessary. Vasopressin receptor antagonists, urea, and loop diuretics serve this purpose, but received different recommendations in the two guidelines. Such discrepancies may relate to different interpretations of the limited evidence or differences in guideline methodology. Nevertheless, the development of guidelines has been important in advancing this evolving field.

Keywords: cerebral edema; copeptin; osmotic demyelination syndrome; urea; vasopressin; vasopressin receptor antagonist.

Publication types

  • Review

MeSH terms

  • Acute Disease
  • Algorithms
  • Chronic Disease
  • Diagnosis, Differential
  • Glycopeptides / physiology
  • Humans
  • Hyponatremia / diagnosis*
  • Hyponatremia / etiology
  • Hyponatremia / therapy*
  • Practice Guidelines as Topic*
  • Vasopressins / physiology


  • Glycopeptides
  • copeptins
  • Vasopressins