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Abstract: PO1138

Will the Real Sodium Stand Up!

Session Information

Category: Fluid, Electrolyte, and Acid-Base Disorders

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

Authors

  • Flemming, Nia, Englewood Health, Englewood, New Jersey, United States
  • Basir, Michael, Englewood Health, Englewood, New Jersey, United States
  • Simmonds, Ro-Kaye A., Englewood Health, Englewood, New Jersey, United States
  • Gayle, Latoya N., Englewood Health, Englewood, New Jersey, United States
  • Banbury, Zachary, Englewood Health, Englewood, New Jersey, United States
  • Fein, Deborah A., Englewood Health, Englewood, New Jersey, United States
Introduction

Hyponatremia is a common finding as it could be precipitated by multiple factors ranging from medications to simply dehydration. Accurate approach to management depends on assessing serum osmolality in an effort to distinguish cases of true, factitious or pseudohyponatremia. We present a case of hyponatremia secondary to hyperlipidemia.

Case Description

36 year old Asian woman with HTN,Type 2 DM, HLD presented with 1 day of epigastric pain. On exam S1, S2 were heard with vesicular breath sounds throughout, epigastric tenderness and no focal neurological deficits. Initial labs: sodium 114 potassium 3.5 chloride 85 glucose 254, BHB 3.7. Sodium corrected for glucose 116 CO2, BUN, Cr and AG were incalculable. Urinalysis: ph 6.0, ketones > 160, glucose > 1000, protein > 1000. Total cholesterol 1020, HDL 25, Triglycerides >5680, LDL incalculable, serum osmolality 314, lipase 57. Venous blood gas: 7.37/30.1/94.8/17.8, sodium on VBG 132.
Abdominal ultrasound revealed a normal pancreas with hepatic steatosis. She was treated in ICU with normal saline, insulin infusion, icosapent ethyl and gemfibrozil. Abdominal pain resolved and insulin was changed to Glargine. Over three days triglycerides trended down to 1744 and sodium to 132. She was discharged on icosapent ethyl, gemfibrozil, atorvastatin, glargine, metformin and lisinopril, with a sodium of 132.

Discussion

Sodium is most commonly measured by indirect potentiometric (ISE) measurement. By this method serum specimens are diluted based on estimated typical balance of serum to solid blood components. By this method factitious low sodium results are known to occur in patients with significantly elevated lipids and protein. As in this case, direct sodium measured by VBG/ABG are most accurate. Typically markedly elevated serum triglyceride with concentrations> 1500 mg/dl are thought to be responsible for factitious hyponatremia. In our patient the value of serum sodium on admission was unexpectedly low at 114 and severe hypercholesterolemia may have contributed. Applying the following formula to correct for triglycerides = Measured Na+ (Plasma triglycerides (g/L) x 0.002 ); measured serum sodium would have been expected to be 125 meq. Thus in cases of extremely high lipids, one must consider lab techniques for measuring serum sodium, as well as full lipid panel in the evaluation and treatment of factitious hyponatremia.