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Abstract: FR-PO584

Hyponatremia in a Hemodialysis Patient: A Common Problem with an Uncommon Cause

Session Information

Category: Trainee Case Report

  • 902 Fluid and Electrolytes: Clinical

Authors

  • Gayle, Latoya N., Englewood Health, Bogota, New Jersey, United States
  • Sittol, Rani D., Englewood Health, Bogota, New Jersey, United States
  • Fein, Deborah A., Pattner Grodstein & Fein MD, PA, Englewood, New Jersey, United States
Introduction

Hyponatremia is a common electrolyte disturbance in hospitalized patients and is associated with increased mortality and morbidity.It occurs in ~9-29% of hemodialysis patients.The importance of this finding in pre dialysis labs is often overlooked and assumed to be due to excessive free water intake and diminished kidney dilution capacity in the setting of ESRD.We present a case of hyponatremia in a hemodialysis patient secondary to adrenal insufficiency

Case Description

A 66-year-old Korean male presented after a flight from Korea with headache and abdominal pain.Last hemodialysis(HD) was 3 days prior.Pain resolved spontaneously,but hospitalization prolonged to establish outpatient HD.PMH of ESRD due to HTN,renal transplant(Korea 2007),that failed 6 months prior with return to HD.Admission creatinine8.5mg/dL and sodium140.Over 1 week,his sodium declined.By day 6,pre dialysis sodium was 125 and he developed malaise,anorexia,chest and abdominal pain.Fluid restriction to <750cc/day instituted but sodium further declined,with dialysis complicated by hypotension and fever.Blood cultures,QuantiFERON Gold were negative.Serum calcium increased to 10.7(8.4-10.2mg/dL) and CBC differential noted eosinophilia 0.64(0-0.5).8 am cortisol sent was 1.2mcg/dL and ACTH stimulation test showed poor adrenal reserve indicative of adrenal insufficiency.Repeated questioning done on medication and Methylprednisone found in examined pill bottles,which was absent in admission list.After restarting steroids,he clinically improved to baseline,with sodium improved to 130 at discharge

Discussion

Hyponatremia has been associated with increased mortality in numerous patient populations.In ESRD patients,it is commonly seen and attributed to poor compliance with fluid restriction,hence may not be investigated.Potentially life-threatening causes such as AI,as in our patient, can be missed.Arreggar et al,noted in their study that 6 of 15 ESRD-H patients with sustained hypotension on dialysis had secondary AI,and BP normalized with steroid administration.Our patient was found,with more careful history,to have secondary AI from long term corticosteroid use.Our case suggests that a higher index of suspicion is appropriate in hyponatremic hemodialysis patients,especially if dialysis is complicated with other signs such as intra-dialytic hypotension,as diagnosis and treatment may have benefits in mortality reduction