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Abstract: PO1180

Acute Metabolic Alkalosis due to Citrate-Containing Oral Rehydration Solution

Session Information

Category: Fluid, Electrolyte, and Acid-Base Disorders

  • 902 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

  • Chalupsky, Megan, University of California Davis Department of Internal Medicine, Sacramento, California, United States
  • Espiritu, Sydnie, University of California Davis Department of Internal Medicine, Sacramento, California, United States
  • Ananthakrishnan, Shubha, UC Davis Department of Nephrology, Sacramento, California, United States
  • Roshanravan, Baback, UC Davis Department of Nephrology, Sacramento, California, United States
  • Young, Brian Y., UC Davis Department of Nephrology, Sacramento, California, United States
Introduction

Patients with ileostomies have high obligatory gastrointestinal (GI) losses, predisposing to volume depletion and electrolyte derangements. Over-the-counter oral rehydration solutions (ORS) are advertised for dehydration. We present a case of acute metabolic alkalosis associated with an ORS containing citrate.

Case Description

66 year old man with Crohn’s disease, status post small bowel excision, sigmoid colectomy with Hartman’s pouch, and ileostomy presented with weight loss and hypotension. He had high output ileostomy loss of > 3 L per day. Initial lab work showed acute kidney injury (AKI), hyponatremia, hypokalemia, and metabolic alkalosis. Nephrology obtained history that for several months he consumed about 8-10 ORS packets daily (Figure). The patient was treated with IV 0.9% sodium chloride, potassium repletion, and cessation of ORS, which resulted in complete resolution of his metabolic disturbances.

Discussion

We present a novel case of acquired acute metabolic alkalosis due to consumption of citrate containing ORS. In the body, 1 citrate is converted by liver, kidney, and muscles to 3 bicarbonate equivalents. Our patient’s volume contraction and pre-renal AKI due to high GI output resulted in elevation of aldosterone leading to increased urine potassium excretion, and alkalosis secondary to augmented ammonia excretion. This was compounded by the high citrate load and low GFR. The ORS distributor would not disclose the full amount of citrate per packet despite several contact attempts. Each standard size ORS contains 330 mg of sodium. Presuming similarity to prescription sodium citrate-citric acid solutions, which are 1:1 equimolar sodium and bicarbonate equivalent, we estimate a minimum bicarbonate equivalent of 14.3 mmol per ORS packet, or 143 mmol daily for our patient. This is before accounting for contributions of potassium and magnesium citrate components, thus potentially higher. We recommend cautious use of citrate-containing ORS, particularly in patients with risk for severe volume depletion and AKI.