Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Hyponatremia in patients receiving parenteral nutrition: the importance of correcting serum sodium for total proteins. The role of the composition of parenteral nutrition in the development of hyponatremia



Hyponatremia is the most common electrolyte disorder, and is associated with high-morbimortality rates. The true prevalence of hyponatremia in patients on parenteral nutrition (PN) is unknown, and the relationship between PN composition and development of hyponatremia has yet to be studied. Hypoproteinemia, a common finding in patients receiving PN, induces an overestimation of serum sodium (SNa) levels, when using indirect electrolyte methodology. Thus, SNa should be corrected for serum total protein levels (TP).

The objective was to accurately determine the prevalence of hyponatremia (indirect SNa corrected for PT) and evaluate the relationship between the composition of PN and the development of hyponatremia.


Medical records of 222 hospitalized patients receiving total PN during a 7-month period were reviewed. Composition of PN, indirect SNa-mmol/l-, and SNa corrected for TP (SNa-TP)-mmol/l-, both upon initiation and during PN administration, were analyzed.


Hyponatremia (SNa < 135 mmol/l) was present in 81% of subjects when SNa was corrected for TP, vs. 43% without correction (p = 0.001). In total 64% of patients that were eunatremic upon initiation of PN developed hyponatremia during PN administration, as detected by SNa-TP, vs. 28% as detected by uncorrected SNa (p < 0.001). There were no significant differences in volume, osmolarity, sodium or total osmols administered in PN between patients who developed hyponatremia and those who remained eunatremic.


A majority of patients receiving PN present hyponatremia, when indirect SNa levels are corrected for TP. The development of hyponatremia during PN is not related to the composition of the PN.

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Fig. 1
Fig. 2


  1. 1.

    Hoorn EJ, Lindemans J, Zietse R. Development of severe hyponatremia in hospitalized patients: treatment-related risk factors and inadecuate management. Nephrol Dial Transplant. 2006;21:70–6.

    Article  Google Scholar 

  2. 2.

    Hawkins RC. Age and gender as risk factors for hyponatremia and hypernatremia. Clin Chim Acta. 2003;337:169–72.

    CAS  Article  Google Scholar 

  3. 3.

    Waikar SS, Mount DB, Curhan GC. Mortality after hospitalization with mild, moderate, and severe hyponatremia. Am J Med. 2009;122:857–65.

    CAS  Article  Google Scholar 

  4. 4.

    Wald R, Jaber BL, Price LL. Impact of hospital-associated hyponatremia on selected outcomes. Arch Intern Med. 2010;170:294–302.

    CAS  Article  Google Scholar 

  5. 5.

    Corona G, et al. Moderate hyponatremia is associated with increased risk of mortality: evidence from a meta-analysis. PLoS ONE. 2013;8:e80451

    Article  Google Scholar 

  6. 6.

    Verbalis J, et al. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. Am J Med. 2013;126:S1–S42

    Article  Google Scholar 

  7. 7.

    Verbalis JG. Disorders of body water homeostasis. Best Pract Res Clin Endocrinol Metab. 2003;17:471–503.

    CAS  Article  Google Scholar 

  8. 8.

    Hoorn EJ, Zietse R. Hyponatremia revisited: translating physiology to practice. Nephron Physiol. 2008;108:46–59.

    Article  Google Scholar 

  9. 9.

    Anderson RJ, Chung HM, kluge R, Schrier RW. Hyponatremia: a prospective analysis of its epidemiology and the pathogenetic role of vasopressin. Ann Intern Med. 1985;102:164–8.

    CAS  Article  Google Scholar 

  10. 10.

    American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. Clinical guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr. 2009;33:255–9.

    Article  Google Scholar 

  11. 11.

    Singer P, et al. ESPEN guidelines on parenteral nutrition: intensive care. Clin Nutr.2009;28:387–400

    Article  Google Scholar 

  12. 12.

    Hillier A, Abbot R, Barrett B. Hyponatremia: evaluating the correction factor for hyperglycemia. Am J Med. 1999;106:399–403.

    CAS  Article  Google Scholar 

  13. 13.

    Dimeski G, Morgan TJ, Presneill JJ, Venkatesh B. Disagreement between ion selective electrode direct and indirect sodium measurements: estimation of the problem in a tertiary referral hospital. J Crit Care. 2012;27:326.e9–e16.

    CAS  Article  Google Scholar 

  14. 14.

    Dimeski G, Barnett RJ. Effects of total plasma protein concentration on plasma sodium, potassium and chloride measurements by an indirect ion selective electrode measuring system. Crit Care Ressusc. 2005;7:12–5.

    CAS  Google Scholar 

  15. 15.

    Chow E, Fox N, Gama R. The effect of low serum total protein on sodium and potassium measurement by ion-selective electrodes in critically ill patients. Br J Biomed Sci. 2008;65:128–31.

    CAS  Article  Google Scholar 

  16. 16.

    Liamis G, Liberopoulos E, Barkas F, Elisaf M. Spurious electrolyte disorders: a diagnostic challenge for clinicians. Am J Nephrol. 2013;38:50–7.

    Article  Google Scholar 

  17. 17.

    Berl T. Impact of solute intake on urine flow and water excretion. J Am Soc Nephrol. 2008;19:1076–8.

    CAS  Article  Google Scholar 

  18. 18.

    Crook MA. Hypoalbuminemia: the importance of correct interpretation. Nutrition. 2009;25:1004–5.

    CAS  Article  Google Scholar 

  19. 19.

    Crook MA. Clinical Chemistry and Metabolic Medicine. 7th ed. London: Hodder Arnold; 2006. p. 280–300.

    Google Scholar 

  20. 20.

    Smith G, Weidel SE, Fleck A. Albumin catabolic rate and protein–energy depletion. Nutrition. 1994;10:335–41.

    CAS  PubMed  Google Scholar 

  21. 21.

    Cuesta M, et al. The contribution of undiagnosed adrenal insufficiency to euvolaemic hyponatraemia: results of a large prospective single-centre study. Clin Endocrinol.2016;0:1–9

    Google Scholar 

  22. 22.

    Sorensen JB, Andersen MK, Hansen HH. Syndrome of inappropiate secretion of antidiuretic hormone (SIADH) in malignant disease. J Intern Med. 1995;238:97–110.

    CAS  Article  Google Scholar 

  23. 23.

    Berghmans T, Paesmans M, Body JJ. A prospective study on hyponatraemia in medical cancer patients: epidemiology, aetiology and differential diagnosis. Support Care Cancer. 1999;8:192–7.

    Article  Google Scholar 

  24. 24.

    Yoon J, Hee Ahn S, Yoo Lee Y, Min Kim C. Hyponatremia as on indepent prognostic factor in patients with terminal cancer. Support Care Cancer. 2015;23:1733–40.

    Article  Google Scholar 

  25. 25.

    Choi JS, et al. Prognostic impact of hyponatremia inpatients with colorrectal cancer. Colerectal Dis.2015;15:409–16

    Article  Google Scholar 

  26. 26.

    Raftopoulos H. Diagnosis and management of hyponatremia in cancer patients. Support Care Cancer. 2007;15:1341–7.

    Article  Google Scholar 

  27. 27.

    Gómez Hoyos E., et al. Diagnosis and management of patients presenting hyponatremia while receiving parenteral nutrition. Endocrine Abstract 15th European Congress Endocrinology 2013;32:Abstract no. 457.

  28. 28.

    Cuesta M, Thompson CJ. The syndorme of inappropiate antidiuresis (SIAD). Best Pract Res Clin Endocrinol Metab. 2016;30:175–87.

    CAS  Article  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Emilia Gómez-Hoyos.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interest.

Additional information

Funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Dr. Isabelle Runkle has worked in an advisory capacity for Otuska, and given talks sponsored by Otsuka. Dr. Martin Cuesta has given talks sponsored by Otsuka

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Gómez-Hoyos, E., Fernández-Peña, S., Cuesta, M. et al. Hyponatremia in patients receiving parenteral nutrition: the importance of correcting serum sodium for total proteins. The role of the composition of parenteral nutrition in the development of hyponatremia. Eur J Clin Nutr 72, 446–451 (2018).

Download citation

Further reading


Quick links