Diagnosis and treatment of hyponatremia: a systematic review of clinical practice guidelines and consensus statements

BMC Medicine

Raymond Vanholder⁵  Angela C Webster¹  Wim Van Biesen⁵  Ionut Nistor⁴  Sabine N van der Veer³  Jill Vanmassenhove⁵  Evi V Nagler² 

[1] Centre for Transplant and Renal Research, The University of Sydney at Westmead Hospital, Westmead 2145, NSW, Australia;Centre for Kidney Research, The Children’s Hospital at Westmead, Locked Bag 4001, Westmead 2145, NSW, Australia;Department of Medical Informatics, Academic Medical Center, Amsterdam 1100, DD, the Netherlands;Nephrology Department, Gr. T. Popa University of Medicine and Pharmacy, Strada Universitãtii 16, Iasi 700115, Romania;Renal Division, Department of Internal Medicine, Ghent University Hospital, De Pintelaan 185, Ghent 9000, Belgium

关键词: Systematic review;    Hyponatremia;    Clinical practice guideline;   

Others  :  1118051
DOI  :  10.1186/s12916-014-0231-1

 received in 2014-04-20, accepted in 2014-11-07,  发布年份 2014

【 摘 要 】

Background

Hyponatremia 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.

Methods

We 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.

Results

We 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.

Conclusions

Current guidance documents on the assessment and treatment of hyponatremia vary in methodological rigor and recommendations are not always consistent.

【 授权许可】

   
2014 Nagler et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 1.

【 参考文献 】

• [1]Ellison DH, Berl T: Clinical practice. The syndrome of inappropriate antidiuresis. N Engl J Med 2007, 356:2064-2072.
• [2]Upadhyay A, Jaber BL, Madias NE: Epidemiology of hyponatremia. Semin Nephrol 2009, 29:227-238.
• [3]Liamis G, Rodenburg EM, Hofman A, Zietse R, Stricker BH, Hoorn EJ: Electrolyte disorders in community subjects: prevalence and risk factors. Am J Med 2013, 126:256-263.
• [4]Wald R, Jaber BL, Price LL, Upadhyay A, Madias NE: Impact of hospital-associated hyponatremia on selected outcomes. Arch Intern Med 2010, 170:294-302.
• [5]Hoorn EJ, Lindemans J, Zietse R: Development of severe hyponatremia in hospitalized patients: treatment-related risk factors and inadequate management. Nephrol Dial Transplant 2006, 21:70-76.
• [6]Huda MSB, Boyd A, Skagen K, Wile D, van Heyningen C, Watson I, Wong S, Gill G: Investigation and management of severe hyponatremia in a hospital setting. Postgrad Med 2006, 82:216-219.
• [7]Fenske W, Maier SKG, Blechschmidt A, Allolio B, Stork S: Utility and limitations of the traditional diagnostic approach to hyponatremia: a diagnostic study. Am J Med 2010, 123:652-657.
• [8]Sterns RH, Nigwekar SU, Hix JK: The treatment of hyponatremia. Semin Nephrol 2009, 29:282-299.
• [9]Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, Board on Health Care Services, Institute of Medicine: Graham R, Mancher M, Wolman DM, Greenfield S, Steinberg E (Eds): ᅟ In Clinical Practice Guidelines We Can Trust. The National Academies Press, US; 2011.
• [10]Glujovsky D, Bardach A, García Martí S, Comandé D, Ciapponi A: EROS: a new software for early stage of systematic reviews. Value Health 2011, 14:A564.
• [11]Brouwers M, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L: AGREE Next Steps Consortium: AGREE II: Advancing guideline development, reporting and evaluation in healthcare. Can Med Ass J 2010, 182:E839-E842.
• [12]Collaboration AGREE: Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project. Qual Saf Health Care 2003, 12:18-23.
• [13]Tong A, Chapman JR, Wong G, de Bruijn J, Craig JC: Screening and follow-up of living kidney donors: a systematic review of clinical practice guidelines. Transplantation 2011, 92:962-972.
• [14]Lopez-Olivo MA, Kallen MA, Ortiz Z, Skidmore B, Suarez-Almazor ME: Quality appraisal of clinical practice guidelines and consensus statements on the use of biologic agents in rheumatoid arthritis: a systematic review. Arthritis Rheum 2008, 59:1625-1638.
• [15]AGREE: Advancing the science of practice guidelines. [http://www.agreetrust.org/resource-centre/agree-ii-training-tools/]
• [16]Geers ABM, Tuut MK, Hoorntje SJ, van Saase JLCM, Zietse R: Electrolytstoornissen. Hoorn EJ, NIV; 2012.
• [17]Clinical Knowledge Summaries: Prodigy Topic on Hyponatremia. 2011, [http://www.cks.nhs.uk/hyponatremia]. Accessed 02 January 2013.
• [18]Rahman M, Friedman WA: Hyponatremia in neurosurgical patients: clinical guidelines development. Neurosurgery 2009, 65:925-935.
• [19]Verbalis JG, Goldsmith SR, Greenberg A, Korzelius C, Schrier RW, Sterns RH, Thompson CJ: Diagnosis, evaluation, and treatment of hyponatremia: Expert panel recommendations. Am J Med 2013, 126:S1-S42.
• [20]Spasovski G, Vanholder R, Allolio B, Annane D, Ball S, Bichet D, Decaux G, Fenske W, Hoorn E, Ichai C, Joannidis M, Soupart A, Zietse R, Haller M, van der Veer S, Van Biesen W, Nagler E: Hyponatraemia Guideline Development Group: Clinical practice guideline on diagnosis and treatment of hyponatremia. Nephrol Dial Transplant 2014, 29:i1-i39.
• [21]Royal Children's Hospital Melbourne Australia: Clinical Practice Guideline on Hyponatremia. [http://www.rch.org.au/clinicalguide/index.cfm]. Accessed 02 January 2013.
• [22]Hyponatremia in Adults (On or after 16th Birthday). [http://www.gain-ni.org]. Accessed 03 January 2013.
• [23]Gines P, Cabrera J, Guevara M, Morillas R, Ruiz del Arbol L, Solae R, Soriano G: Consensus document on the treatment of ascites, dilutional hyponatremia and hepatorenal syndrome in liver cirrhosis. Gastroenterol Hepatol 2004, 27:535-544.
• [24]Hew-Butler T, Ayus JC, Kipps C, Maughan RJ, Mettler S, Meeuwisse WH, Page AJ, Reid SA, Rehrer NJ, Roberts WO, Rogers IR, Rosner MH, Siegel AJ, Speedy DB, Stuempfle KJ, Verbalis JG, Weschler LB, Wharam P: Statement of the Second International Exercise-Associated Hyponatremia Consensus Development Conference, New Zealand, 2007. Clin J Sport Med 2008, 18:111-121.
• [25]Runkle I, Villabona C, Navarro A, Pose A, Formiga F, Tejedor A, Poch E, European Hyponatremia N: The treatment of hyponatremia secondary to the syndrome of inappropriate antidiuretic hormone secretion. Medicina Clínica 2013, 141:e501-e510.
• [26]Alonso-Coello P, Irfan A, Solà I, Gich I, Delgado-Noguera M, Rigau D, Tort S, Bonfill X, Burgers J, Schunemann H: The quality of clinical practice guidelines over the last two decades: a systematic review of guideline appraisal studies. Qual Saf Health Care 2010, 19:e58.
• [27]Committee on Standards for Systematic Reviews of Comparative Effectiveness Research, Board on Health Care Services, Institute of Medicine: Eden J, Levit L, Berg A, Morton S (Eds): ᅟ In Finding What Works in Health Care: Standards for Systematic Reviews. The National Academies Press, US; 2011.
• [28]Treweek S, Oxman A, Alderson P, Bossuyt P, Brandt L, Brozek J, Davoli M, Flottorp S, Harbour R, Hill S, Liberati A, Liira H, Schünemann HJ, Rosenbaum S, Thornton J, Vandvik PO, Alonso-Coello P: DECIDE Consortium: Developing and evaluating communication strategies to support informed decisions and practice based on evidence (DECIDE): protocol and preliminary results. Implementation Science 2013, 8:6. BioMed Central Full Text
• [29]Moher D, Liberati A, Tetzlaff J, Altman DG: Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 2009, 6:e1000097. doi:10.1371/journal.pmed1000097
• [30]Irani S, Rashidian A, Yousefi-Nooraie R, Soltani A: Evaluating clinical practice guidelines developed for the management of thyroid nodules and thyroid cancers and assessing the reliability and validity of the AGREE instrument. J Eval Clin Pract 2011, 17:729-736.