The Curbsiders Internal Medicine Podcast REBOOT #48 Hyponatremia Deconstructed
Tea and Toast Syndrome
- A low-solute diet (tea and toast) limits urine production, even with maximally diluted urine.
- This increases the risk of hyponatremia if water intake exceeds the kidney's capacity.
Volume Status Assessment
- Assess volume status primarily through history, orthostatic vital signs, and neck veins.
- Differentiating heart failure from hypovolemia is crucial as saline can worsen heart failure.
Nephrologists' Accuracy in Volume Assessment
- Experienced nephrologists only correctly assessed volume status in hyponatremia 47% of the time in a 1987 study.
- This highlights the difficulty of relying solely on physical exam findings.
Take your salt game to the next-next level. We brushed off this fan favorite episode and rebooted #48 hyponatremia deconstructed with our Chief of Nephrology, Dr. Joel Topf aka @kidney_boy aka The Salt Whisperer for your CME earning pleasure. Learn the correct steps to diagnose and manage this common and dangerous condition. Topics covered include: true versus false hyponatremia, SIADH, tea and toast hyponatremia, beer potomania, safe rates of sodium correction, IV fluid choice, vaptans and more.
Listeners can claim Free CE credit through VCU Health at http://curbsiders.vcuhealth.org/ (CME goes live at 0900 ET on the episode’s release date).
Show Notes | Subscribe | Spotify | Swag! | Top Picks | Mailing List | thecurbsiders@gmail.com | Free CME!
Credits
- Original episode written and produced by: Matthew Watto MD, FACP
- Show Notes and CME questions by: Deb Gorth ScM
- Cover Art and Infographic by: Edison Jyang
- Hosts: Stuart Brigham MD; Matthew Watto MD, FACP; Paul Williams MD, FACP
- Editor: Molly Heublein (written materials); Matthew Watto MD (audio)
- Guest: Joel Topf MD
Sponsors
POCUS Fellowship at University of Pennsylvania
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Interview season is in full swing and they’re actively accepting applications. Please go to pennultrasound.org or contact nathaniel.reisinger@pennmedicine.upenn for information. You can apply for fellowship using the eusfellowships.com portal.
VCU Health CE
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. Note: A free VCU Health CloudCME account is required in order to seek credit.
Time Stamps
- 00:00 Intro
- 03:30 Guest interview
- 07:15 Pick of the week w/Dr. Topf
- 16:20 Clinical case of hyponatremia
- 17:48 False hyponatremia normal osmolality
- 19:34 False hyponatremia high osmolality
- 20:36 Understanding why osmolality matters
- 23:28 Workup false hyponatremia
- 24:45 Recap of discussion so far
- 25:40 ADH dependent vs independent hyponatremia
- 27:00 Psychogenic polydipsia
- 289:15 Renal failure and hyponatremia
- 30:03 Tea and toast, and Beer Drinker’s potomania
- 35:22 ADH dependent hyponatremia
- 38:15 Volume versus osmolality
- 40:00 Volume status exam
- 45:14 Additional testing with urine lytes and uric acid
- 47:30 Treatment for SIADH
- 52:42 Discussion of the vaptans
- 58:21 Additional testing in SIADH
- 62:50 When to admit patient for hyponatremia
- 63:59 Clinical case of hyponatremia complications
- 68:56 Fluids and rate of correction
- 73:36 DDAVP clamp
- 76:30 Moderate hyponatremia
- 78:35 Diuretic dosing DOES matter!
- 81:59 Loop diuretics for SIADH
- 84:25 Take home points
- 87:25 Outro
Links*
- Dr. Joel Topf’s Textbook
- Dr. Joel Topf’s Blog
- Dungeons and Dragons
- Tartine (cookbook) by Elizabeth M. Prueitt
- I Hate You, Don’t Leave Me by Hall Strauss
- Intentional Parenting by Sissy Goff
- Mindset by Carol Dweck
- Nintendo Switch
- 8.0 Bit Techno- The Curbsiders Theme Song by Stuart Kent Brigham
- Ure-Na
- European Society of Endocrinology Clinical Practice Guidelines.
- Don’t miss Dr. Topf on twitter aka @kidney_boy.
*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.
Goal
Listeners will recall the pathophysiology of hyponatremia and develop a systematized approach to identifying the type and cause of hyponatremia, as well as how to safely manage hyponatremia.
Learning objectives
After listening to this episode listeners will…
- Differentiate true and false hyponatremia
- Recall the pathophysiology of true and false hyponatremia
- Interpret blood and urine tests to identify the cause of hyponatremia
- Recall the limitations of the volume status exam
- List ADH dependent causes of hyponatremia
- List ADH independent causes of hyponatremia
- Explain the pathophysiology of beer drinker’s potomania and “tea and toast” hyponatremia
- Use uric acid to differentiate SIADH from other causes of hyponatremia
- Basic therapy for SIADH
- Recall safe rates of correction for hyponatremia
Disclosures
Dr. Topf has received honoraria from AstraZeneca and Cara Therapeutics. He is joint venture partner in Davita Dialysis centers receiving dividends. The Curbsiders report no relevant financial disclosures.
Citation
Topf J, Gorth DJ, Williams PN, Brigham SK, Heublein M, Jyang E, Watto MF. “REBOOT #48 Hyponatremia Deconstructed”. The Curbsiders Internal Medicine Podcast. https://thecurbsiders.com/episode-list Original air date: July 17, 2017; Updated September 7, 2020.