Criteria for Hyponatremic Overcorrection: Systematic Review and Cohort Study of Emergently Ill Patients



Hyponatremia is the most common electrolyte disturbance amongst hospitalized patients. An overly rapid rate of correction of chronic hyponatremia is believed to increase the risk of poor clinical outcomes including osmotic demyelination syndrome (ODS). There is disagreement in the literature regarding the definition of hyponatremic overcorrection.


We performed a systematic review of all English language studies to identify those that calculated sodium correction rate and classified patients’ overcorrection status. We then identified all patients who presented to our hospital’s emergency department between 2003 and 2015 with a corrected serum sodium ≤ 116 mmol/L. All methods from the systematic review for sodium correction rate calculation and overcorrection status were applied to this cohort.


We identified 24 studies citing 9 distinct sodium correction rate methods and 14 criteria for overcorrection. Six hundred twenty-four patients presenting with severe hyponatremia (median initial value 113 mMol) were identified. Depending on the method used, the median sodium correction rates in our cohort ranged from 0.271 to 1.13 mmol/L per hour. The proportion of patients classified with overcorrection with the different criteria varied almost 11-fold, ranging from 8.5 to 89.9%.


Published methods disagree regarding the calculation of sodium correction rates and the definition of hyponatremic overcorrection. This leads to wide variations in sodium correction rates and the prevalence of overcorrection in patient cohorts. Definitions based on ODS risk are needed.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 99

This is the net price. Taxes to be calculated in checkout.


  1. 1.

    Upadhyay A, Jaber BL, Madias NE. Incidence and Prevalence of Hyponatremia. Am J Med. 2006;119(7, Supplement 1):S30-S35.

  2. 2.

    Peters M, Van der Hoeven J, Hoedemaekers C. Risk factors for poor outcome in patients with osmotic demyelination syndrome. Crit Care. 2012;16(Suppl 1):P143.

  3. 3.

    Lohr JW. Osmotic demyelination syndrome following correction of hyponatremia: Association with hypokalemia. Am J Med. 1994;96(5):408–413.

  4. 4.

    Verbalis JG, Goldsmith SR, Greenberg A, et al. Diagnosis, Evaluation, and Treatment of Hyponatremia: Expert Panel Recommendations. Am J Med. 2013;126(10):S1-S42.

  5. 5.

    Spasovski G, Vanholder R, Allolio B, et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Eur J Endocrinol. 2014;170(3):G1-G47.

  6. 6.

    Cheung K, Kaur MN, Tolliver T, Longo CJ, Naam NH, Thoma A. A Tale of Two Health-Care Systems: Cost-Utility Analysis of Open Carpal Tunnel Release in Canada and the United States. Plast Surg. 2017;25(1):7–13.

  7. 7.

    Katz MA. Hyperglycemia-Induced Hyponatremia — Calculation of Expected Serum Sodium Depression. N Engl J Med. 1973;289(16):843–844.

  8. 8.

    Byrt T, Bishop J, Carlin JB. Bias, prevalence and kappa. J Clin Epidemiol. 1993;46(5):423–429.

  9. 9.

    Ayus JC, Krothapalli RK, Arieff AI. Treatment of Symptomatic Hyponatremia and Its Relation to Brain Damage. N Engl J Med. 1987;317(19):1190–1195.

  10. 10.

    Velez JCQ, Dopson SJ, Sanders DS, Delay TA, Arthur JM. Intravenous conivaptan for the treatment of hyponatraemia caused by the syndrome of inappropriate secretion of antidiuretic hormone in hospitalized patients: a single-centre experience. Nephrol Dial Transplant. 2010;25(5):1524–1531.

  11. 11.

    Jahangiri A, Wagner J, Tran MT, et al. Factors predicting postoperative hyponatremia and efficacy of hyponatremia management strategies after more than 1000 pituitary operations. J Neurosurg. 2013;119(6):1478–1483.

  12. 12.

    Castello LM, Baldrighi M, Panizza A, Bartoli E, Avanzi GC. Efficacy and safety of two different tolvaptan doses in the treatment of hyponatremia in the Emergency Department. Intern Emerg Med. 2017;12(7):993–1001.

  13. 13.

    Morris JH, Bohm NM, Nemecek BD, et al. Rapidity of Correction of Hyponatremia Due to Syndrome of Inappropriate Secretion of Antidiuretic Hormone Following Tolvaptan. Am J Kidney Dis. 2018;71(6):772–782.

  14. 14.

    Verbalis JG, Greenberg A, Burst V, et al. Diagnosing and Treating the Syndrome of Inappropriate Antidiuretic Hormone Secretion. Am J Med. 2016;129(5):537.e9–537.e23.

  15. 15.

    Burst V, Grundmann F, Kubacki T, et al. Euvolemic hyponatremia in cancer patients. Report of the Hyponatremia Registry: an observational multicenter international study. Support Care Cancer. 2017;25(7):2275–2283.

  16. 16.

    Chiong JR, Hauptman PJ, Dunlap ME, Chiodo JA, Chase SL. Hospital Management of Hyponatremia in Patients with Heart Failure: Final Report from the HN Registry. J Card Fail. 2014;20(8):S62-S63.

  17. 17.

    Mohmand HK, Issa D, Ahmad Z, Cappuccio JD, Kouides RW, Sterns RH. Hypertonic Saline for Hyponatremia: Risk of Inadvertent Overcorrection. Clin J Am Soc Nephrol. 2007;2(6):1110–1117.

  18. 18.

    Umbrello M, Mantovani ES, Formenti P, et al. Tolvaptan for hyponatremia with preserved sodium pool in critically ill patients. Ann Intensive Care. 2016;6.

  19. 19.

    Salahudeen AK, Ali N, George M, Lahoti A, Palla S. Tolvaptan in hospitalized cancer patients with hyponatremia: A double-blind, randomized, placebo-controlled clinical trial on efficacy and safety. Cancer. 120(5):744–751.

  20. 20.

    Schrier RW, Gross P, Gheorghiade M, et al. Tolvaptan, a Selective Oral Vasopressin V2-Receptor Antagonist, for Hyponatremia. N Engl J Med. 2006;355(20):2099–2112.

  21. 21.

    Shoaf SE, Bricmont P, Dandurand A. Low-dose tolvaptan PK/PD: comparison of patients with hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion to healthy adults. Eur J Clin Pharmacol. 2017;73(11):1399–1408.

  22. 22.

    George JC, Zafar W, Bucaloiu ID, Chang AR. Risk Factors and Outcomes of Rapid Correction of Severe Hyponatremia. Clin J Am Soc Nephrol CJASN. June 2018.

  23. 23.

    Soupart A, Gross P, Legros J-J, et al. Successful Long-Term Treatment of Hyponatremia in Syndrome of Inappropriate Antidiuretic Hormone Secretion with Satavaptan (SR121463B), an Orally Active Nonpeptide Vasopressin V2-Receptor Antagonist. Clin J Am Soc Nephrol. 2006;1(6):1154–1160.

  24. 24.

    Kim G, Heo B, Oh E, et al. Management of Recipients With Hyponatremia During and After Liver Transplantation; Ten Year Experience of Single Center.: Abstract# D2628. Transplantation. 2014;98:791.

  25. 25.

    Romanovsky A, Azevedo LCP, Meeberg G, Zibdawi R, Bigam D, Bagshaw SM. Serum sodium shift in hyponatremic patients undergoing liver transplantation: a retrospective cohort study. Ren Fail. 2015;37(1):37–44.

  26. 26.

    Crook MA, Velauthar U, Moran L, Griffiths W. Review of Investigation and Management of Severe Hyponatremia in a Hospital Population. Ann Clin Biochem. 1999;36(2):158–162.

  27. 27.

    Sood L, Sterns RH, Hix JK, Silver SM, Chen L. Hypertonic Saline and Desmopressin: A Simple Strategy for Safe Correction of Severe Hyponatremia. Am J Kidney Dis. 2013;61(4):571–578.

  28. 28.

    Winzeler B, Jeanloz N, Nigro N, et al. Long-term outcome of profound hyponatremia: a prospective 12 months follow-up study. Eur J Endocrinol. 2016;175(6):499–507.

  29. 29.

    MacMillan TE, Cavalcanti RB. Outcomes in Severe Hyponatremia Treated With and Without Desmopressin. Am J Med. 2018;131(3):317.e1–317.e10.

  30. 30.

    Burst V, Grundmann F, Kubacki T, et al. Thiazide-Associated Hyponatremia, Report of the Hyponatremia Registry: An Observational Multicenter International Study. Am J Nephrol. 2017;45(5):420–430.

  31. 31.

    Rafat C, Schortgen F, Gaudry S, et al. Use of desmopressin acetate in severe hyponatremia in the intensive care unit. Clin J Am Soc Nephrol CJASN. 2014;9(2):229–237.

  32. 32.

    Ward FL, Tobe SW, Naimark DMJ. The Role of Desmopressin in the Management of Severe, Hypovolemic Hyponatremia: A Single-Center, Comparative Analysis. Can J Kidney Health Dis. 2018;5.

  33. 33.

    Ghali JK, Koren MJ, Taylor JR, et al. Efficacy and Safety of Oral Conivaptan: A V1A/V2 Vasopressin Receptor Antagonist, Assessed in a Randomized, Placebo-Controlled Trial in Patients with Euvolemic or Hypervolemic Hyponatremia. J Clin Endocrinol Metab. 2006;91(6):2145–2152.

  34. 34.

    Abraham WT, Hensen J, Gross PA, et al. Lixivaptan safely and effectively corrects serum sodium concentrations in hospitalized patients with euvolemic hyponatremia. Kidney Int. 2012;82(11):1223–1230.

Download references

Author information

Correspondence to Carl van Walraven MD.

Ethics declarations

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Clinical Significance

• This is the most extensive examination of methods used to calculate hyponatremia correction rates and definitions of overcorrection.

• There is little evidence available to guide definitions of overcorrection.

• This is the first study to directly compare the different definitions of overcorrection in a large cohort study.

• The heterogeneity of overcorrection definitions directly influences the prevalence of overcorrection in a given cohort.

Electronic Supplementary Material


(DOCX 41 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Woodfine, J.D., van Walraven, C. Criteria for Hyponatremic Overcorrection: Systematic Review and Cohort Study of Emergently Ill Patients. J GEN INTERN MED 35, 315–321 (2020).

Download citation


  • hyponatremia
  • osmotic demyelination syndrome
  • outcome measurement
  • methodology