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Abstract: TH-PO179

Mannitol Therapy for Choroidal Hemorrhage: A Nephrological Challenge

Session Information

Category: Trainee Case Report

  • 902 Fluid and Electrolytes: Clinical

Authors

  • Sullivan, Elixabeth Laskurain, University of Rochester Medical Center, Rochester, New York, United States
  • Grewal, Rickinder, University of Rochester Medical Center, Rochester, New York, United States
  • Phan, Tramanh, Nephrology Division, Rochester, New York, United States
Introduction

Mannitol is an osmotic diuretic that reduces intraocular pressure (IOP). Hyponatremia and acute renal failure are complications that can occur in high risk patients. We report a case of hyperosmolar hyponatremia and oliguria necessitating hemodialysis (HD) after mannitol infusion for choroidal hemorrhage.

Case Description

A 91 year old female with chronic kidney disease (CKD) stage 3 on angiotensin II receptor blocker, coronary artery disease, hypertension, and chronic hyponatremia presented to the hospital with left eye pain and redness concerning for choroidal hemorrhage after her ophthalmologist discovered elevated IOP. Laboratory testing revealed a serum sodium concentration [Na] of 128 mg/dL and a serum creatinine concentration [Cr] of 1.21 mg/dL, at her baseline.

She was given 2 g/kg of 20% mannitol. Seven hours later, testing revealed serum [Na] 123 mg/dL, serum [Cr] 1.49 mg/dL, and serum osmolality gap (OG) of 19 mOsm/kg with improvement in IOP. The following morning, serum [Na] remained 123 mg/dL, serum [Cr] increased to 2.03 mg/dL with a serum OG of 19 mOsm/kg. Due to recurrent eye pain, a second dose of 2 g/kg mannitol was given. Three hours later, serum [Na] decreased to 111 mg/dL, serum [Cr] increased to 2.54 mg/dL, with a serum OG of 83 mOsm/kg and serum osmolality of 322 mg/dL. Nephrology was consulted and recommended normal saline 500 ml bolus followed by continuous infusion at 125 mL/hr. However, over the next 12 hours, urine output continued to decline with serum [Na] decreased to as low as 107 mg/dL with serum [Cr] 4.90 mg/dL. Though serum osmolality decreased to 296 mg/dL, serum OG remained 60 mOsm/kg. Given progressive oliguria, azotemia, and hyperkalemia, emergent HD was performed with repeat serum [Na] 117 mg/dL, serum OG 31 mOsm/kg, and improved urine output. After repeat HD, serum [Na] increased to 129 mg/dL with a normal OG. Oliguria resolved and mental status improved.

Discussion

Mannitol can be used to manage elevated IOP but high and frequent dosing can lead to oliguric renal failure with profound hyperosmolar hyponatremia, particularly in elderly patients with CKD. Our case highlights the importance of recognizing hyperosmolar hyponatremia as a distinct clinical entity and emphasizes reversibility of renal failure with early HD. It also raises thoughts regarding alternative therapies for elderly patients with CKD and increased IOP.