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Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Nephrol. Jan 6, 2017; 6(1): 1-13
Published online Jan 6, 2017. doi: 10.5527/wjn.v6.i1.1
Hypertonicity: Clinical entities, manifestations and treatment
Helbert Rondon-Berrios, Christos Argyropoulos, Todd S Ing, Dominic S Raj, Deepak Malhotra, Emmanuel I Agaba, Mark Rohrscheib, Zeid J Khitan, Glen H Murata, Joseph I Shapiro, Antonios H Tzamaloukas
Helbert Rondon-Berrios, Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, United States
Christos Argyropoulos, Mark Rohrscheib, Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
Todd S Ing, Department of Medicine, Strich School of Medicine, Loyola University Chicago, Maywood, IL 60153, United States
Dominic S Raj, Division of Nephrology, Department of Medicine, George Washington University, Washington, DC 20037, United States
Deepak Malhotra, Division of Nephrology, Department of Medicine, School of Medicine, University of Toledo, Toledo, OH 43614-5809, United States
Emmanuel I Agaba, Division of Nephrology, Department of Medicine, Jos University Teaching Hospital, Jos, Plateau State 930001, Nigeria
Zeid J Khitan, Division of Nephrology, Department of Medicine, School of Medicine, Marshall University Joan C. Edwards, Huntington, WV 25701, United States
Glen H Murata, Informatics Section, Medicine Service, Raymond G. Murphy Veterans Affairs Medical Center, Albuquerque, NM 78108, United States
Glen H Murata, Antonios H Tzamaloukas, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 78108, United States
Joseph I Shapiro, Marshall University Joan C. Edwards School of Medicine, Huntington, WV 25701, United States
Antonios H Tzamaloukas, Section of Nephrology, Medicine Service (111C), Raymond G. Murphy Veterans Affairs Medical Center, Albuquerque, NM 78108, United States
Author contributions: Rondon-Berrios H reviewed the literature and wrote the first draft of the hypernatremia part of the report; Argyropoulos C added critical changes in the report and references; Ing TS made critical changes in the manuscript and added references; Raj DS made critical changes in the manuscript; Malhotra D made critical changes in the manuscript; Agaba EI made important changes in the report; Rohrscheib M made important additions in the manuscript; Khitan ZJ made important changes in the report and added references; Murata GH made important changes in the report; Shapiro JI made important additions, including figures, to the report; Tzamaloukas AH wrote the first draft of the hyperglycemia part of the report.
Conflict-of-interest statement: Helbert Rondon-Berrios is a member of the advisory board of Astute Medical Inc. The rest of the authors declare no conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Antonios H Tzamaloukas, MD, MACP, Section of Nephrology, Medicine Service (111C), Raymond G. Murphy Veterans Affairs Medical Center, 1501 San Pedro, SE, Albuquerque, NM 87108, United States. antonios.tzamaloukas@va.gov
Telephone: +1-505-2651711 Fax: +1-505-2566441
Received: June 13, 2016
Peer-review started: June 16, 2016
First decision: July 27, 2016
Revised: October 17, 2016
Accepted: November 1, 2016
Article in press: November 2, 2016
Published online: January 6, 2017
Processing time: 198 Days and 4.2 Hours
Abstract

Hypertonicity causes severe clinical manifestations and is associated with mortality and severe short-term and long-term neurological sequelae. The main clinical syndromes of hypertonicity are hypernatremia and hyperglycemia. Hypernatremia results from relative excess of body sodium over body water. Loss of water in excess of intake, gain of sodium salts in excess of losses or a combination of the two are the main mechanisms of hypernatremia. Hypernatremia can be hypervolemic, euvolemic or hypovolemic. The management of hypernatremia addresses both a quantitative replacement of water and, if present, sodium deficit, and correction of the underlying pathophysiologic process that led to hypernatremia. Hypertonicity in hyperglycemia has two components, solute gain secondary to glucose accumulation in the extracellular compartment and water loss through hyperglycemic osmotic diuresis in excess of the losses of sodium and potassium. Differentiating between these two components of hypertonicity has major therapeutic implications because the first component will be reversed simply by normalization of serum glucose concentration while the second component will require hypotonic fluid replacement. An estimate of the magnitude of the relative water deficit secondary to osmotic diuresis is obtained by the corrected sodium concentration, which represents a calculated value of the serum sodium concentration that would result from reduction of the serum glucose concentration to a normal level.

Keywords: Hypertonicity; Hypernatremia; Osmotic diuresis; Hyperglycemia; Water diuresis

Core tip: States of hypertonicity cause transfer of fluid from inside the body cells into the fluid compartment surrounding the cells. The shrinking of the brain cells in hypertonicity causes severe manifestations and even death. The management of hypertonicity requires administration of intravenous solutions. The volume and the composition of the administered solutions are calculated by various equations. Close monitoring of the condition of the patient and frequent measurements of appropriate blood chemistries during treatment are critical steps for a favorable outcome. The two major states of hypertonicity are hypernatremia, an elevation of the concentration of sodium in the blood, and hyperglycemia, an elevation of the concentration of glucose in the blood. The management of severe hypertonicity in hypernatremia and hyperglycemia encounters different obstacles and requires different equations for the quantitative replacement of body fluid deficits.