Rethinking Sodium Correction in Severe Hyponatremia: New Study in JAMA Internal Medicine Suggests Faster Correction Times Could Improve Outcomes

A new systematic review and meta-analysis published in JAMA Internal Medicine provides insights into the management of severe hyponatremia in hospitalized patients, insights that challenge the existing treatment guidelines on the rapidity of treatment to correct sodium levels.

Contributing to the study from the Division of Pediatric Nephrology at UPMC Children’s Hospital of Pittsburgh was clinical director, Michael L. Moritz, MD.

“Our team has been studying the question of optimal treatment approaches for correcting severe hyponatremia, including how fast to do it,” says Dr. Moritz. “Our findings from this study suggest that taking too conservative of an approach may actually increase the risk of mortality without improving safety.”

More About the Study

For decades, clinical guidelines have recommended slow correction rates of sodium levels to avoid osmotic demyelination syndrome (ODS), which is a rare but serious complication of overly rapid sodium correction. However, recent evidence suggests that these conservative correction targets may come with unintended risks.

The meta-analysis conducted by Dr. Moritz and colleagues reviewed 16 cohort studies involving data on 11,800 hospitalized adults with severe hyponatremia – defined as serum sodium < 120 mEq/L or <125 mEq/L with severe symptoms.

The research team looked at how different sodium correction rates affected in-hospital and 30-day mortality, hospital length of stay (LOS), and the incidence of ODS.

What the Research Found

Dr. Moritz and colleague’s analysis showed that faster sodium correction (8 to 10 mEq/L per 24 hours) was associated with substantially lower in-hospital and 30-day mortality rates when compared to slower correction methods.

They found that rapid correction was linked to 32 fewer in-hospital deaths per 1,000 patients compared to slow correction, and 221 fewer deaths compared to very slow correction. At 30 days, mortality rates improved even further, with 61 and 134 fewer deaths per 1,000 patients, respectively.

“Perhaps most importantly, we did not find a statistically significant increase in the risk of ODS with faster sodium correction,” says Dr. Moritz.  “The incidence of ODS remained low across all correction rates. While we must remain cognizant of the possibility for ODS, I think we may be overemphasizing the risk of ODS in the current treatment guidelines.”

The study also highlighted that rapid correction decreased the length of hospital stays by an average of 1.2 to 3 days compared to slower correction strategies, a finding which further supports the potential clinical benefits of revising standard treatment protocols around correction rates.

Implications for Clinical Practice

These findings suggest that current guidelines for managing severe hyponatremia may need to be reevaluated. While the risk of ODS has driven conservative treatment recommendations thus far, this new study indicates that slow correction could increase mortality risk without offering additional safety benefits.

“I think this analysis should start a broader conversation in the field about rethinking established treatment protocols for severe hyponatremia,” says Dr. Moritz. “We need to balance the urgency of treatment with patient-specific risk factors, rather than adhering to one-size-fits-all guidelines.”

Study Reference

Ayus JC, Moritz ML, Fuentes NA, Meja JR, Alfonso JM, Shin S, Fralick M, Ciapponi A. Correction Rates and Clinical Outcomes in Hospitalized Adults With Severe Hyponatremia: A Systematic Review and Meta-Analysis. JAMA Intern Med. 2024 November 18. Online ahead of Print.