Background
Methods
Criteria for selection of studies
Search methods for guidelines and consensus statements
Data collection process and data items
Appraisal of guidelines and consensus statements
Synthesis of guideline recommendations
Results
Search results
Developer | Year | Country | Funding source | Target population | Target users | Guideline writers | Guideline review | Guideline update | Methods support | Evidence base |
---|---|---|---|---|---|---|---|---|---|---|
Europe
| ||||||||||
NIV | 2012 | Netherlands | Government funding | Adults with hyponatremia | Clinicians, Internists | Multidisciplinary internists, epidemiologist | Dutch Association of Internists (NIV), expert peer review | In case of breakthrough changes in diagnosis or treatment | PROVA – company specialized in Evidence Based Guideline Development | Systematic literature review |
NHS | 2011 | UK | NS | Adults with hyponatremia in primary care | Primary care professionals within NHS | NS | NS | Planned in 2015 | NS | Systematic literature review |
GAIN* | 2010 | Northern Ireland | Government funding | Adults with hyponatremia | NS | Multidisciplinary anesthetists, clinical chemist, nephrologist | NS | 3 years | NS | NS |
AEEH* | 2003-2004 | Spain | NS | Patients with cirrhosis | NS | Gastroenterologists | NS | NS | NS | NS |
EHN* | 2013 | Spain | NS | Hospitalized patients with SIADH | NS | Multidisciplinary endocrinologists, nephrologists, internists, hospital pharmacist | NS | NS | NS | Consensus statements |
ERBP/ESE/ESICM | 2014 | Europe | Unrestricted grant from participating societies | Adults with hyponatremia | Health care professionals dealing with hyponatremia | Multidisciplinary nephrologists, endocrinologists, general internists, critical care physicians | External review by KHA-CARI, ESA, and members ERA-EDTA | 5 years or earlier in case of new evidence requiring changes | ERBP methods support team | Systematic literature review |
North America
| ||||||||||
UF | 2008-2009 | USA | NS | Neurosurgery patients with hyponatremia | NS | Multidisciplinary neurosurgeons, nurse practitioners, nephrologists, critical care physician, endocrinologist, pharmacist, nurses | NS | NS | NS | Systematic literature review |
HEP | 2013 | USA | Funding Unrestricted educational grant from pharmaceutical company | Patients with hyponatremia | NS | Endocrinologist, nephrologists | NS | NS | NS | Systematic literature review |
Australia
| ||||||||||
RCHM* | 2012 | Australia | NS | Children | NS | NS | External review within the hospital where appropriate’ | 12 to 24 months | NS | NS |
International
| ||||||||||
EAH- ICD* | 2007 | USA, Canada, UK, Switzer-land, Canada, South Africa, New Zealand, Australia | No commercial sponsorship’ | People with exercise-associated hyponatremia | Medical personnel, athletes, greater public | Multidisciplinary endocrinologist, epidemiologist, nephrologists, emergency medicine physician, general practitioner, internist, sports physicians, exercise physiologists | NS | NS | NS | Systematic literature review |
Appraisal of guidelines and consensus statements
Synthesis of recommendations
Approaches to diagnostic strategies for hyponatremia
Guideline Organization/Society | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|
Criteria/Categories
| NIV [16] | NHS [17] | GAIN [22] | AEEH [23] | EHN [25] | ERBP/ESE/ESICM [20] | UF [18] | HEP [19] | RCHM [21] | EAH-ICD [24] |
Threshold workup [Na] | <135 mmol/L | <135 mmol/L | <135 mmol/L | <130 mmol/L | <135 mmol/L | <135 mmol/L | <131 mmol/L | <135 mmol/L | <135 mmol/L | |
Confirming hypotonic hyponatremia | Serum osmolality <275 mOsm/kg | Plasma osmolality <280 mOsm/kg | Serum osmolality <275 mOsm/kg | Plasma osmolality <275 mOsm/kg | Serum osmolality <275 mOsm/kg | Serum osmolality <285 mOsm/kg | Plasma osmolality <280 mOsm/kg | Serum osmolality threshold not stated | ||
How to classify hypotonic hyponatremia to aid identification of underlying cause | ||||||||||
Volume status/hydration state/extracellular fluid status | Clinical evaluation | Physical examination/clinical signs of dehydration or edema | Physical examination/clinical signs of dehydration or edema | Physical examination/clinical signs of low circulating volume | Physical examination/clinical signs of dehydration or edema | Physical examination/laboratory measurements | Physical examination/laboratory measurements | To assess but method not stated | ||
Urinary [Na]/Threshold | 30 mmol/L | Spot urine: 20–30 mmol/L | 15 mmol/L | 40 mmol/L | 30 mmol/L | 25 mmol/L | Spot urine: 20–30 mmol/L | No threshold stated | ||
Urinary osmolality/Threshold | 100 mOsm/kg | 100 mOsm/kg | 100 mOsm/kg | 100 mOsm/kg | 100 mOsm/kg | 100 mOsm/kg | 100 mOsm/kg | No threshold stated | ||
How to identify the underlying disorder | ||||||||||
History | Medications | Medications | Diuretic use | |||||||
Fluid intake | Recently prescribed intravenous fluids | |||||||||
Nocturnal polyuria | Vomiting/diarrhea | |||||||||
Lab tests | ||||||||||
Serum potassium concentration | + | + | + | |||||||
Serum chloride concentration | + | + | ||||||||
Serum urea concentration | +/– | + | +/– | +/– | + | |||||
Serum creatinine concentration | + | + | +/– | +/– | + | |||||
Serum glucose concentration | + | + | +/– | + | + | |||||
Urinary potassium concentration | + | + | ||||||||
Renal tests | + | |||||||||
Liver tests | + | +/– | ||||||||
Urinary protein | +/– | |||||||||
Thyroid function tests | +/– | +/– | +/– | +/– | ||||||
Adrenal function tests | +/– | +/– | +/– | +/– | ||||||
Serum protein electrophoresis | +/– | |||||||||
Urine protein electrophoresis | +/– | |||||||||
Fractional sodium excretion | +/– | |||||||||
Serum uric acid concentration | +/– | +/– | + | +/– | ||||||
Fractional uric acid concentration | +/– | |||||||||
Fractional excretion urea | +/– | |||||||||
Urinary chloride concentration | +/– | + | +/– | |||||||
Molar weight urine | +/– | |||||||||
Serum bicarbonate concentration | +/– | |||||||||
Hematocrit | +/– |
Approaches to treatment for hyponatremia
Guideline Organization/Societies | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|
Criteria/categories
| NIV [16] | NHS [17] | GAIN [22] | AEEH [23] | EHN [25] | ERBP/ESE/ESICM [20] | UF [18] | HEP [19] | RCHM [21] | EAH-ICD [24] |
Symptoms
| ||||||||||
Acute Onset (<48 h) | NaCl >1% Infusion speed may be guided by Adrogué-Madias | NaCl 3% | NaCl 2.7% 200 mL over 30 min | NaCl 3% 100 mL/10 min up to 3× or infused at 0.5–2 mL/kg/h | NaCl 3% 150 mL/20 min up to 4× | NaCl >1% | NaCl 3% 100 mL/10 min up to 3× or infused at 0.5–2 mL/kg/h | NaCl 3% 4 mL/kg over 30 min | NaCl 3% 100 mL bolus | |
Hypovolemia
| NaCl 0.9% until blood pressure restored | |||||||||
Euvolemia
| Fluid restriction | No hypotonic fluids | ||||||||
Stop offending drugs | ||||||||||
Stop hypotonic fluids | ||||||||||
Hypervolemia
| Furosemide | Furosemide | ||||||||
Chronic onset (>48 h) | NaCl >1% Infusion speed calculation may be guided by Adrogué-Madias | NaCl 3% | Only if severe symptoms NaCl 2.7% 200 mL over 30 min infusion speed by may be guided Adrogué-Madias | NaCl 3% 100 mL/10 min up to 3× or infused at 0.5–2 mL/kg/h | NaCl 3% 150 mL/20 min up to 4× | NaCl >1% | NaCl 3% 100 mL/10 min up to 3× or infused at 0.5-2 mL/kg/h | |||
Hypovolemia
| NaCl 0.9% 1 L over 2–4 h infusion speed may be guided by Adrogué-Madias | NaCl 0.9% until blood pressure restored | ||||||||
Euvolemia
| Fluid restriction | |||||||||
Stop offending medications | ||||||||||
Stop hypotonic fluids | ||||||||||
Hypervolemia
| Fluid restriction | Furosemide | ||||||||
Salt restriction | ||||||||||
No symptoms
| ||||||||||
Acute onset (<48 h) | NaCl >1% Infusion speed by Adrogué-Madias | Treat underlying condition | Stop offending fluids and medications, treat underlying condition NaCl 3% 150 mL/20 min | Treat underlying condition | ||||||
Chronic onset (>48 h) | Treat underlying condition | Treat underlying condition | Stop non-essential fluids Stop offending medications Treat underlying condition | Treat underlying condition | ||||||
Hypovolemia
| NaCl 0.9% | NaCl 0.9% until blood pressure restored | NaCl 0.9% infusion speed may be guided by Adrogué-Madias | NaCl 0.9% or balanced crystalloid 0.5–1 mL/kg/h | NaCl 0.9% | NaCl 0.9% until blood pressure restored | Nasogastric rehydration | |||
NaCl tablets | No VPA | NaCl 0.9% | ||||||||
Euvolemia
| Fluid restriction, dose dependent on serum and urinary electrolytes | Fluid restriction, 500–1,000 mL/d | Fluid restriction | Fluid restriction <500–1,000 mL/d | Fluid restriction | Fluid restriction | Fluid restriction 500 mL below average daily urine output | Fluid restriction, no hypotonic fluids | ||
No salt restriction | Salt restriction | Salt 5–8 g/d | No salt restriction | |||||||
Loop diuretics | Furosemide 20–60 mg/d + oral NaCl | Loop diuretics, low dose + oral NaCl | Diuretics | |||||||
Demeclocycline | Demeclocycline | No demeclocycline | Demeclocycline | Demeclocycline, 600–1,200 mg/d | ||||||
Urea | Urea 30 g/d | Urea, 0.25–0.5 g/kg/d | Urea | Urea, 15–60 g/d | ||||||
Vasopressin receptor antagonist | Vasopressin receptor antagonist | Tolvaptan 15–60 mg/d | No vasopressin receptor antagonists | |||||||
Hypervolemia
| Treat underlying condition | |||||||||
Fluid restriction, dose dependent on serum and urinary electrolytes | Fluid restriction | Fluid restriction | Fluid restriction <1,000 mL/d | Fluid restriction | Fluid restriction, <insensible losses + urine output | Fluid restriction | ||||
Loop diuretics | Salt restriction | Salt restriction | No NaCl >0.9% | Salt restriction | ||||||
Demeclocycline | Stop diuretics | No demeclocycline | Possibly vasopressin receptor antagonist | |||||||
Vasopressin receptor antagonist | No vasopressin receptor antagonist |
Targets and limits of speed of correction
Guideline Organization/Societies | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|
Criteria/categories
| NIV | NHS | GAIN | AEEH | EHN | ERBP/ESE/ESICM | UF | HEP | RCHM | EAH-ICD |
[16] | [17] | [22] | [23] | [25] | [20] | [18] | [19] | [21] | [24] | |
Targets [Na] increase
| ||||||||||
Symptoms | Independent of symptoms | If symptoms | If symptoms | If symptoms | If symptoms | If symptoms | Until seizures resolve or [Na] >125 mmol/L | |||
Acute onset (<48 h) | 1–2 mmol/L/h initially | Until [Na] >120 mmol/L independent of onset | 1–2 mmol/L/h first 2–3 h | 1–6 mmol/L first 2 h | 5 mmol/L first h | 4–6 mmol/L urgently | Independent of onset | |||
Chronic onset (>48 h) | 0.5–1 mmol/L/h first 2–3 h | 1–6 mmol/L first 2 h | 5 mmol/L first h | If seizures or coma 4–6 mmol/L urgently, otherwise 4–6 mmol/L per 24 h | ||||||
Limits [Na] increase
| ||||||||||
Symptoms | Independent of symptoms | If no symptoms | Independent of symptoms | Independent of symptoms | Independent of symptoms | Independent of symptoms | If no symptoms | Symptom dependent | ||
Acute onset (<48 h) | If no risk of ODS ≤10 mmol/L per 24 h ≤18 mmol/L per 48 h If risk of ODS <8 mmol/L per 24 h | ≤8–12 mmol/L per 24 h ≤18 mmol/L per 48 h | <12 mmol/L per 24 h | If no risk of ODS ≤10 mmol/L per 24 h ≤18 mmol/L per 48 h If risk of ODS <8 mmol/L per 24 h | ≤10 mmol/L first 24 h ≤8 mmol/L every 24 h thereafter | ≤10 mmol/L per 24 h | No limits | ≤8 mmol/L per 24 h after seizures resolve, Independent of onset | ||
Chronic onset (>48 h) | <8 mmol/L per 24 h | ≤8–12 mmol/L per 24 h ≤18 mmol/L per 48 h | <12 mmol/L per 24 h | <8–12 mmol/L per 24 h <18 mmol/L per 48 h | ≤10 mmol/L first 24 h ≤8 mmol/L every 24 h thereafter | ≤10 mmol/L per 24 h | <8–12 mmol/L per 24 h <18 mmol/L per 48 h |