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syndrome.hyponatremia.core.v1

Hyponatremia (syndrome aggregator)

nephrologyacutesyndromeadultacuteinpatientoutpatient
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Severe symptomatic Rx delegated to protocol.severe_hyponatremia (registry id) — 3% NaCl 100–150 mL bolus per ESE 2014; aim 4–6 mmol/L acute rise. Tolvaptan RxCUI (358257) and urea (11002) sourced from neph.aki.core.v1 / chronic SIAD axis; both need re-validation via scripts/research/rxnav-validate.ts before final promotion. Hypertonic saline 3% (rxcui 9863), 0.9% NaCl (7407), DDAVP (3992), furosemide (4603), D5W (4850) reuse RxCUIs already validated elsewhere. Calculator gaps to flag to C.4 calc-quality chat: calc.osmolality (calculated serum osmolality 2*Na + glucose/18 + BUN/2.8), calc.osmolal_gap, calc.tbw (Watson — sex-specific), calc.corrected_sodium (Hillier formula for hyperglycemia — +2.4 mmol/L per 100 mg/dL glucose >100; Katz +1.6 is historical) not yet registered in clinical-tools-registry. Adrogué-Madias (calc.na_correction) and free water deficit (calc.fw_deficit) ARE registered. CSW vs SIAD ambiguity now encoded as severity_trigger with FEurate threshold (>11% after correction = CSW; <11% = SIAD; Maesaka 2009). Workup id workup:fractional_excretion_urate referenced but not yet a registered workup id; orchestrator must register if not present. Beer-potomania / low-solute-diet ODS-prone phenotype added 2026-05-12 — high ODS risk requires correction ceiling ≤6 mmol/L/24h with DDAVP-clamp prophylaxis on standby. Exercise-associated hyponatremia trigger added per 2015 International Consensus (PMID 25647058). No targeted disease test file (covered by tests/dossiers/integration/syndrome-hyponatremia-integration.test.ts + dossier-contract).

Entry points (3)

  • lab_abnormality
    Serum Na <135 mmol/L mild / <130 moderate / <125 severe (Spasovski 2014 ESC severity tiers)
    na_low
  • symptom
    Altered mental status / seizure / coma (Spasovski 2014 ESC — severely symptomatic)
    altered_mental_status
  • symptom
    Headache, nausea, vomiting (Spasovski 2014 ESC — moderately symptomatic)
    headache_nausea

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    Elderly + women + premenopausal women at higher ODS risk (Sterns NEJM 2015)
  • sodiumrequired
    lab • used at ENTRY
    Severity tier and correction ceiling calculation (Spasovski 2014 ESC)
  • glucoserequired
    lab • used at CONTEXT
    Pseudohyponatremia from hyperglycemia — Hillier corrected sodium formula in this runtime (Spasovski 2014 ESC)
  • serum_osmrequired
    lab • used at INITIAL_WORKUP
    Tonicity classification: hypotonic <275 vs isotonic vs hypertonic (Spasovski 2014 ESC)
  • urine_osmrequired
    lab • used at INITIAL_WORKUP
    High UOsm → ADH-driven (SIAD/HF/cirrhosis); low → primary polydipsia/low-solute diet (Verbalis AJM 2013; Spasovski 2014 ESC)
  • urine_sodiumrequired
    lab • used at INITIAL_WORKUP
    UNa <20 → hypovolemic; UNa >40 → SIAD/CSW/diuretic (Verbalis AJM 2013; Spasovski 2014 ESC)
  • volume_statusrequired
    vital • used at CONTEXT
    Hypovolemic / euvolemic / hypervolemic branches treatment (Spasovski 2014 ESC — Algorithm 1)
  • current_medsrequired
    medication • used at CONTEXT
    Thiazides, SSRIs, desmopressin, MDMA, NSAIDs as drivers (Verbalis AJM 2013; Spasovski 2014 ESC)
  • cirrhosis
    history • used at CONTEXT
    Hypervolemic subtype; tolvaptan contraindicated (FDA boxed warning; Schrier NEJM 2006 SALT)
  • heart_failure
    history • used at CONTEXT
    Hypervolemic subtype; tolvaptan candidacy (Schrier NEJM 2006 SALT-1/2)
  • tsh
    lab • used at INITIAL_WORKUP
    Hypothyroidism rare cause of euvolemic hyponatremia (Spasovski 2014 ESC — exclude before diagnosing SIAD)
  • cortisol
    lab • used at INITIAL_WORKUP
    Adrenal insufficiency rare but reversible cause (Spasovski 2014 ESC — exclude before diagnosing SIAD)

12-phase flow (12)

  1. 1FRAME
    Confirm hypotonic hyponatremia: tonicity assessment first to rule out pseudo + translocational (Spasovski 2014 ESC — Algorithm 1 step 1)
    inputs: sodium, glucose, serum_osm
    actions: calc.na_correction
    advance: Hypotonic confirmed (Spasovski 2014 ESC)
  2. 2ENTRY
    Stratify severity by symptoms (severe = AMS/seizure) and Na+ level (Spasovski 2014 ESC — symptom-based severity tiers)
    inputs: sodium
    advance: Severity tier assigned (Spasovski 2014 ESC)
  3. 3CONTEXT
    Volume status (hypo/eu/hyper), full med list, HF / cirrhosis / nephrotic / SIAD risk factors (Spasovski 2014 ESC — Algorithm 1; Verbalis AJM 2013)
    inputs: volume_status, current_meds, cirrhosis, heart_failure
    advance: Volume status + risk factors documented (Spasovski 2014 ESC; Verbalis AJM 2013)
  4. 4RED_FLAGS
    Severe symptoms (seizure / coma / herniation) → STAT 3% NaCl 100–150 mL bolus (Spasovski 2014 ESC — recommendation 6.3.1)
    inputs: sodium
    actions: protocol.severe_hyponatremia
    advance: Severe symptoms reversed or protocol active (Spasovski 2014 ESC)
  5. 5INITIAL_WORKUP
    Serum osm, urine osm, urine Na, TSH, cortisol, BMP, glucose, lipid + protein for pseudo (Spasovski 2014 ESC — diagnostic algorithm; Verbalis AJM 2013)
    inputs: serum_osm, urine_osm, urine_sodium, tsh, cortisol
    actions: panel.renal
    advance: Tonicity + volume + ADH state mapped (Spasovski 2014 ESC; Verbalis AJM 2013)
  6. 6BRANCHING_WORKUP
    CSW vs SIAD distinction in CNS injury (Maesaka 2009 — FEurate >11% = CSW); oral free water trial for primary polydipsia; CT head if AMS (Sterns NEJM 2015)
    advance: Subtype localized (Sterns NEJM 2015; Maesaka 2009)
  7. 7DIFFERENTIAL
    Pseudo / translocational / hypovolemic (GI, diuretic, salt-wasting, CSW) / euvolemic (SIAD, hypothyroid, AI, primary polydipsia, beer potomania, exercise, MDMA) / hypervolemic (HF, cirrhosis, nephrotic, advanced CKD) (Spasovski 2014 ESC — Algorithm 1; Verbalis AJM 2013)
    advance: Subtype assigned (Spasovski 2014 ESC; Verbalis AJM 2013)
  8. 8RISK_STRATIFICATION
    ODS risk factors (Na <105, alcoholism, hypokalemia, malnutrition, liver disease) gate correction ceiling ≤8 vs ≤10/24h (Sterns NEJM 2015 — ODS risk factor hierarchy)
    inputs: sodium
    advance: ODS risk + correction ceiling set (Sterns NEJM 2015)
  9. 9TREATMENT
    Severe sx → 3% NaCl bolus (Spasovski 2014 ESC); chronic SIAD → fluid restriction → urea → tolvaptan (Schrier NEJM 2006 SALT) → salt+loop; hypovolemic → isotonic NS; hypervolemic → fluid restriction + loop ± tolvaptan HF only (Spasovski 2014 ESC — treatment algorithm)
    inputs: sodium, volume_status
    actions: protocol.severe_hyponatremia, calc.na_correction
    advance: Plan executed at appropriate rate (Spasovski 2014 ESC; Sterns NEJM 2015)
  10. 10DISPOSITION
    ICU/HDU if 3% NaCl or severe sx; floor with Q4–6h Na monitoring otherwise; outpatient for chronic stable (Spasovski 2014 ESC; Verbalis AJM 2013)
    advance: Disposition set (Spasovski 2014 ESC; Verbalis AJM 2013)
  11. 11MONITORING
    Na q2h while titrating then q4–6h; correction ceiling ≤10 mmol/24h (≤8 if high-risk); DDAVP clamp + D5W if overcorrecting (Spasovski 2014 ESC; Sterns NEJM 2015)
    inputs: sodium
    advance: Stable correction trajectory (Spasovski 2014 ESC; Sterns NEJM 2015)
  12. 12FOLLOWUP
    Address cause (med review, HF/cirrhosis treatment); educate on fluid intake; outpatient BMP (Verbalis AJM 2013; Spasovski 2014 ESC)
    advance: Follow-up scheduled (Verbalis AJM 2013; Spasovski 2014 ESC)