Dysnatremia in COVID-19 Patients: An In-depth Analysis of its Prevalence and Impact on Hospitalization


The ongoing COVID-19 pandemic has posed unprecedented challenges to the global healthcare system, with severe respiratory complications being a hallmark of the infection.

However, emerging evidence suggests that disturbances in serum sodium levels, specifically hyponatremia and hypernatremia, may play a critical role in shaping the clinical course and outcomes of COVID-19 patients. This article delves into the intricate relationship between dysnatremia and COVID-19, drawing on numerous studies that underscore the independent association of both hyponatremia and hypernatremia with mortality.

The Hyponatremia-Hypernatremia Spectrum in COVID-19:

Hyponatremia, defined as serum sodium levels below 135 mEq/L, has been identified as a recurring phenomenon in patients admitted with community-acquired pneumonia. Studies indicate that it not only prolongs hospital stays but also correlates with poor survival rates. In the context of COVID-19, where severe pneumonia can prove fatal, the prevalence of hyponatremia in affected individuals ranges from 25% to 45%.

Furthermore, the mortality rate in COVID-19 patients with severe life-threatening pneumonia can reach alarming levels of 20.3% to 27.9%.

The alarming aspect of dysnatremia in COVID-19 is not limited to hyponatremia. Hypernatremia, characterized by serum sodium levels exceeding 145 mEq/L, has also emerged as a noteworthy concern. Recent studies have reported cases of severe treatment-resistant hypernatremia in COVID-19 patients, surpassing >150 mEq/L, posing a significant challenge for correction. This novel finding raises questions about the underlying mechanisms and potential implications for patient outcomes.

Association with Mortality and Clinical Outcomes:

A comprehensive review underscores the high prevalence of hyponatremia in hospitalized COVID-19 patients, linking it to severe disease, intensive care unit (ICU) admission, invasive ventilation, and ultimately, mortality. Longitudinal data are, however, scarce, necessitating further research to establish a conclusive association between dysnatremia and mortality in COVID-19 cases.

Prospective observational studies have shown that both hyponatremia and hypernatremia contribute to longer hospitalization periods and an increased likelihood of requiring mechanical ventilation.

The Need for Longitudinal Data and Future Research:

While existing evidence points to a strong association between dysnatremia and adverse outcomes in COVID-19 patients, the lack of comprehensive longitudinal data is a notable limitation. The dynamics of serum sodium levels throughout different stages of hospital admission remain poorly understood, necessitating further investigation. Addressing this gap was the primary objective of our study, aiming to determine the frequency of hyponatremia and hypernatremia at various stages of hospital admission in patients with COVID-19 infection.


The retrospective study of 574 patients with COVID-19 provides a comprehensive exploration of the intricate relationship between serum sodium levels, dysnatremia, and clinical outcomes. The primary findings of our investigation underscore the significance of dysnatremia, especially hypernatremia, as a potential prognostic indicator in COVID-19 patients.

Dysnatremia Patterns and Mortality:

The study reveals a notable difference in serum sodium levels between survivors and non-survivors, with a significant increase in hypernatremia during hospitalization, particularly among those who did not survive. Hypernatremia escalated from 4.7% to 18.6%, while hyponatremia decreased from 39% to 5.4%. This observation aligns with other studies reporting a rise in hypernatremia among COVID-19 patients, with a considerable presence in fatal cases.

Comparisons with existing literature, such as the study by Tzoulis et al., demonstrate consistency in the prevalence of dysnatremia on admission, predominantly characterized by hyponatremia. However, our study emphasizes the dynamic nature of dysnatremia during hospitalization, shedding light on the substantial increase in hypernatremia, potentially contributing to adverse outcomes.

Factors Influencing Hypernatremia:

The increased development of hypernatremia in COVID-19 patients is attributed to multifactorial causes. Reduced water intake due to loss of taste, anorexia, and nausea, compounded by increased insensible losses from continuous fever, may contribute. Additionally, the proposed increased sodium absorption by renal tubules, triggered by activation of the renin–angiotensin–aldosterone system in COVID-19, adds a layer of complexity to fluid management. The conservative approach to hydration, necessitated by lung involvement, and intermittent furosemide administration further predispose or exacerbate hypernatremia. The intriguing demonstration of improved oxygenation with intravenous furosemide in pulmonary edema patients, as illustrated by Santos et al., advocates for a nuanced fluid balance approach in COVID-19 treatment.

Dysnatremia and Clinical Outcomes:

Our findings strengthen the association between dysnatremia and mortality, particularly highlighting the three-fold increased risk of death in patients with hypernatremia compared to those with hyponatremia. The odds of death in hypernatremic patients, as per Hirsch et al., exceed those with moderate to severe hyponatremia, reinforcing hypernatremia as a critical predictor of poor outcomes.

Acute Kidney Injury (AKI) and Sodium Levels:

The observed frequent occurrence of AKI in our COVID-19 patient cohort aligns with reported rates from other regions. However, the relationship between AKI and hypernatremia remains unclear, with conflicting evidence from different studies. While some studies posit hypernatremia as an independent predictor of mortality, others find no significant association. Our subgroup analysis failed to establish hypernatremia or hyponatremia as independent predictors of AKI, emphasizing the complexity of the interplay between renal function and dysnatremia in COVID-19 patients.

Age, Gender, and Treatment Patterns:

The study corroborates existing evidence on age and COVID-19 outcomes, indicating an increased mortality risk with advancing age. Our findings, though not statistically significant in multivariate analysis, align with the general trend observed in global studies.

The male predilection for COVID-19 infection, as demonstrated in our study, aligns with a meta-analysis, highlighting potential lifestyle, immune system, and receptor-level explanations. The low use of remdesivir among deceased patients raises questions about its effectiveness in critical cases, emphasizing the need for clearer guidelines on its usage.

Strengths and Limitations:

The longitudinal design of our study, tracking dynamic serum sodium levels throughout hospitalization, stands as a notable strength. However, the single-center nature limits generalizability. The absence of detailed data on fluid resuscitation and dosing information for furosemide presents limitations. Furthermore, the observational and retrospective nature of the study prevents establishing causal relationships.


In conclusion, dysnatremia, encompassing both hyponatremia and hypernatremia, has emerged as a significant factor influencing the clinical trajectory and outcomes of COVID-19 patients. The prevalence of these disturbances in serum sodium levels, coupled with their association with prolonged hospitalization, mechanical ventilation, and increased mortality, underscores the need for a nuanced understanding of the intricate interplay between dysnatremia and COVID-19. Our ongoing study seeks to contribute valuable longitudinal data that can illuminate the evolving landscape of dysnatremia in COVID-19 patients, paving the way for more targeted and effective therapeutic interventions.

Dysnatremia is a medical condition in which the sodium concentration in the blood is either too high or too low. Sodium is an electrolyte that plays a vital role in regulating fluid balance and nerve function in the body. Normal sodium levels in the blood range from 135 to 145 milliequivalents per liter (mEq/L).

Hyponatremia is defined as a sodium level below 135 mEq/L. It is the most common type of dysnatremia, accounting for about 80% of cases. Hyponatremia can be caused by a variety of factors, including:

  • Excessive fluid intake
  • Diuretic use
  • Kidney disease
  • Addison’s disease
  • Heart failure
  • Liver disease
  • Certain medications

Hypernatremia is defined as a sodium level above 145 mEq/L. It is less common than hyponatremia, but it can be more serious. Hypernatremia can be caused by:

  • Dehydration
  • Salt overdose
  • Diarrhea
  • Vomiting
  • Diabetes insipidus
  • Certain medications

Symptoms of dysnatremia vary depending on the severity of the condition and the underlying cause. Common symptoms of hyponatremia include:

  • Headache
  • Nausea
  • Vomiting
  • Fatigue
  • Confusion
  • Muscle weakness
  • Seizures
  • Coma

Common symptoms of hypernatremia include:

  • Thirst
  • Dry mouth
  • Headache
  • Fatigue
  • Confusion
  • Muscle weakness
  • Seizures
  • Coma

Treatment for dysnatremia depends on the underlying cause and the severity of the condition. Hyponatremia is typically treated with fluid restriction and medications to help the kidneys excrete more sodium. Hypernatremia is typically treated with intravenous fluids to rehydrate the body and lower the sodium level.

If you have any of the symptoms of dysnatremia, it is important to seek medical attention immediately. Early diagnosis and treatment are essential to prevent serious complications.

reference link :https://journals.sagepub.com/doi/full/10.1177/03000605231202180


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