Sodium, 24-Hour Urine

Overview:

Work up volume depletion, acute renal failure, acute oliguria, and differential diagnosis of hyponatremia.1 Division of hyponatremia into hypervolemia or not, edema or not, and urinary Na+ less than or greater than 10 mmol/L provides a classification of hyponatremia.2 History of diuretics, other drug intake, setting of osmotic diuresis or not, serum or plasma electrolytes and other factors are needed.

In cases of hyponatremia, urine sodium <10 mmol/L may indicate extrarenal depletion: dehydration (gastrointestinal or sweat loss), congestive heart failure, liver disease or nephrotic syndromes.

Urine sodium >10 mmol/L may indicate diuretics, emesis, intrinsic renal diseases, Addison disease, hypothyroidism, or syndrome of inappropriate antidiuretic hormone (SIADH).2 In hypothyroidism and in SIADH, Na+ and Cl- may be >40 mmol/L.3 (Depending on intake, such results also can be found in normal individuals.) In SIADH, urinary sodium is usually >20 mmol/L. Inappropriate secretion of antidiuretic hormone (SIADH) was found in 7% of 250 patients with small cell lung cancer.4 Such patients have hyponatremia, often severe, with hypo-osmolar serum, high urinary sodium excretion with urine osmolality greater than that of serum. Acute and subacute diseases of the CNS, TB and other chronic pulmonary diseases may also cause SIADH. SIADH may also be caused by acute intermittent porphyria, LE, occasional malignant neoplasms other than small cell carcinoma of lung, and a number of drugs.5

The classification as presented here is overly abbreviated for clinical application. Pitfalls exist (eg, increase of Na+ necessary to balance excretion of penicillin).3

Urine Na+ >40 mmol/L in oliguria suggests acute tubular necrosis.3,6 (However, spot urine sodiums without other data have been criticized for their applicability to this diagnosis.)

Low Na+ excretion may be found with early obstructive uropathy and with the oliguria of acute glomerulonephritis3 and in some patients with x-ray contrast acute renal failure.

Silver et al recommend measurement of urinary Na+ excretion in patients with nephrolithiasis and hypercalciuria.7

It is important to know the urinary sodium level in patients with unexplained hyperchloremic metabolic acidosis when the diagnosis of distal renal tubular acidosis is being considered.8

1. Harrington JT, Cohen JJ. Measurement of urinary electrolytes—indications and limitations. N Engl J Med. 1975 Dec 11; 293(24):1241-1243. PubMed 1186803

2. Epstein M, Oster JR. Disorders of hyponatremia and hypernatremia. In: Halsted JA, Halsted CH, eds.The Laboratory in Clinical Medicine: Interpretation and Application. 2nd ed. Philadelphia, Pa: WB Saunders Co;1981:289-295.

3. Sherman RA, Eisinger RP. The use (and misuse) of urinary sodium and chloride measurements. JAMA. 1982 Jun 11; 247(22):3121-3124. PubMed 7077808

4. Hainsworth JD, Workman R, Greco FA. Management of the syndrome of inappropriate antidiuretic hormone secretion in small cell lung cancer. Cancer. 1983 Jan 1; 51(1):161-165. PubMed 6295592

5. Streeten DH, Moses AM, Miller M. Disorders of the neurohypophysis. In: Braunwald E, Isselbacher KJ, Petersdorf RG, et al, eds. Harrison's Principles of Internal Medicine. New York, NY: McGraw-Hill Information Services Co;1987:1722-1732.

6. Schrier RW. Acute renal failure. JAMA. 1982 May 14; 247(18):2518-2522, 2524. PubMed 7069917

7. Silver J, Rubinger D, Friedlaender MM, Popovtzer MM. Sodium-dependent idiopathic hypercalciuria in renal-stone formers. Lancet. 1983 Aug 27; 2(8348):484-486. PubMed 6136646

8. Batlle DC, von Riotte A, Schlueter W. Urinary sodium in the evaluation of hyperchloremic metabolic acidosis. N Engl J Med. 1987 Jan 15; 316(3):140-144. PubMed 3796685