Hyponatremia in peritoneal dialysis patients





hyponatremia, peritoneal dialysis, overhydration, extracellular volume, osmolality


Hyponatremia is the most common disorder of body fluid and electrolyte balance encountered in clinical practice, and also in peritoneal dialysis (PD) population. Depending on the severity and the speed of drop in sodium concentration, the symptoms can vary from asymptomatic hyponatremia to mild and non-specific symptoms or severe and life-threatening situations. Hyponatremia is associated with high morbidity and mortality. Its pathophysiology is complex, specifically in patients undergoing PD. The etiological workup can be cumbersome but is of paramount importance for early and appropriate treatment. In this article, we review the clinical manifestations as well as the pathophysiology and the specific etiologies of hyponatremia in peritoneal dialysis patients, and we propose a diagnostic algorithm. 



Rohrscheib M, Rondon-Berrios H, Argyropoulos C, Glew RH, Murata GH, Tzamaloukas AH. Indices of serum tonicity in clinical practice. Am J Med Sci. juin 2015;349(6):537‑44.

Sterns RH. Disorders of plasma sodium--causes, consequences, and correction. N Engl J Med. 1 janv 2015;372(1):55‑65.

Spasovski G, Vanholder R, Allolio B, Annane D, Ball S, Bichet D, et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Nephrol Dial Transplant. avr 2014;29 Suppl 2:i1‑39.

Rondon-Berrios H, Agaba EI, Tzamaloukas AH. Hyponatremia: pathophysiology, classification, manifestations and management. Int Urol Nephrol.nov 2014;46(11):2153‑65.

Beukhof CM, Hoorn EJ, Lindemans J, Zietse R. Novel risk factors for hospital-acquired hyponatraemia: a matched case-control study. Clin Endocrinol (Oxf). mars 2007;66(3):367‑72.

Arzhan S, Lew SQ, Ing TS, Tzamaloukas AH, Unruh ML. Dysnatremias in Chronic Kidney Disease: Pathophysiology, Manifestations, and Treatment. Front Med (Lausanne). 2021;8:769287.

Ravel VA, Streja E, Mehrotra R, Sim JJ, Harley K, Ayus JC, et al. Serum sodium and mortality in a national peritoneal dialysis cohort. Nephrol Dial Transplant. 1 juill 2017;32(7):1224‑33.

Bravo González-Blas L, García-Gago L, Astudillo-Jarrín D, Rodríguez-Magariños C, López-Iglesias A, García Falcón T, et al. Analysis of Factors Influencing the Prognostic Significance of Hyponatremia in Peritoneal Dialysis Patients. Am J Nephrol. 2020;51(1):54‑64.

Mandai S, Kuwahara M, Kasagi Y, Kusaka K, Tanaka T, Shikuma S, et al. Lower serum sodium level predicts higher risk of infection-related hospitalization in maintenance hemodialysis patients: an observational cohort study. BMC Nephrol. 19 déc 2013;14:276.

Poulikakos D, Marks V, Lelos N, Banerjee D. Low serum sodium is associated with protein energy wasting and increased interdialytic weight gain in haemodialysis patients. Clin Kidney J. avr 2014;7(2):156‑60.

Tseng MH, Cheng CJ, Sung CC, Chou YC, Chu P, Chen GS, et al. Hyponatremia is a surrogate marker of poor outcome in peritoneal dialysis-related peritonitis. BMC Nephrol. 10 juill 2014;15:113.

Kim HW, Ryu GW, Park CH, Kang EW, Park JT, Han SH, et al. Hyponatremia Predicts New-Onset Cardiovascular Events in Peritoneal Dialysis Patients. PLoS One. 2015;10(6):e0129480.

Rose BD, Post TW. Clinical Physiology of Acid-Base and Electrolyte Disorders, 5th ed, McGraw-Hill, New York 2001. p.716, 761.

Renneboog B, Musch W, Vandemergel X, Manto MU, Decaux G. Mild chronic hyponatremia is associated with falls, unsteadiness, and attention deficits. Am J Med. janv 2006;119(1):71.e1-8.

Xu R, Pi H chen, Xiong Z ying, Liao J lan, Hao L, Liu G ling, et al. Hyponatremia and Cognitive Impairment in Patients Treated with Peritoneal Dialysis. Clin J Am Soc Nephrol. 7 oct 2015;10(10):1806‑13.

Verbalis JG, Barsony J, Sugimura Y, Tian Y, Adams DJ, Carter EA, et al. Hyponatremia-induced osteoporosis. J Bone Miner Res. mars 2010;25(3):554‑63.

Hoorn EJ, Rivadeneira F, van Meurs JBJ, Ziere G, Stricker BHC, Hofman A, et al. Mild hyponatremia as a risk factor for fractures: the Rotterdam Study. J Bone Miner Res. août 2011;26(8):1822‑8.

Rhee CM, Ayus JC, Kalantar-Zadeh K. Hyponatremia in the Dialysis Population. Kidney Int Rep. juin 2019;4(6):769‑80.

Wu C, Yosef N, Thalhamer T, Zhu C, Xiao S, Kishi Y, et al. Induction of pathogenic TH17 cells by inducible salt-sensing kinase SGK1. Nature. 25 avr 2013;496(7446):513‑7.

Tannen RL, Regal EM, Dunn MJ, Schrier RW. Vasopressin-resistant hyposthenuria in advanced chronic renal disease. N Engl J Med. 22 mai 1969;280(21):1135‑41.

Arteaga J de. Hyponatremia in peritoneal dialysis : free water overload, hyperosmolarity or malnutrition ? Bulletin de la Dialyse à Domicile. 8 déc 2019;2(4):201‑6. https://doi.org/10.25796/bdd.v2i4.21303

Dimitriadis C, Sekercioglu N, Pipili C, Oreopoulos D, Bargman JM. Hyponatremia in peritoneal dialysis: epidemiology in a single center and correlation with clinical and biochemical parameters. Perit Dial Int. mai 2014;34(3):260‑70.

Hoorn EJ, Zietse R. Hyponatremia revisited: translating physiology to practice. Nephron Physiol. 2008;108(3):p46-59.

Alexandrou ME, Balafa O, Sarafidis P. Assessment of Hydration Status in Peritoneal Dialysis Patients: Validity, Prognostic Value, Strengths, and Limitations of Available Techniques. Am J Nephrol. 2020;51(8):589‑612.

Cherney DZ, Zevallos G, Oreopoulos D, Halperin ML. A physiological analysis of hyponatremia: implications for patients on peritoneal dialysis. Perit Dial Int. févr 2001;21(1):7‑13.

Ing TS, Ganta K, Bhave G, Lew SQ, Agaba EI, Argyropoulos C, et al. The Corrected Serum Sodium Concentration in Hyperglycemic Crises: Computation and Clinical Applications. Front Med (Lausanne). 2020;7:477.

Khan SF, Ronco C, Rosner MH. Counteracting the Metabolic Effects of Glucose Load in Peritoneal Dialysis Patients; an Exercise-Based Approach. Blood Purif. 2019;48(1):25‑31.

Musso CG, Bargman JM. Asymptomatic hyponatremia in peritoneal dialysis patients: an algorithmic approach. Int Urol Nephrol. nov 2014;46(11):2239‑41.



How to Cite

Taghavi M, Jacobs L, Dratwa M, Nortier J. Hyponatremia in peritoneal dialysis patients. Bull Dial Domic [Internet]. 2022 Dec. 28 [cited 2023 Mar. 29];5(4):23-31. Available from: https://www.bdd.rdplf.org/index.php/bdd/article/view/73443