Abstract: SA-PO480
A Surprising Complication Following Immunoglobulin G Therapy: Osmotic Diuresis
Session Information
- Fluid, Electrolyte, and Acid-Base Disorders: Case Reports
November 05, 2022 | Location: Exhibit Hall, Orange County Convention Center‚ West Building
Abstract Time: 10:00 AM - 12:00 PM
Category: Fluid‚ Electrolyte‚ and Acid-Base Disorders
- 1002 Fluid‚ Electrolyte‚ and Acid-Base Disorders: Clinical
Authors
- Vega-Colon, Jesus Daniel, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
- Rivera, Maria Eugenia, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
- Rivera Gonzalez, Alexis, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
- Rivera-Bermudez, Carlos G., University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
- Andujar-Rivera, Krystahl Z., University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
- Ocasio Melendez, Ileana E., University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
Introduction
Polyuria is defined as a urine output greater than 3 liters in 24 hours. The differential diagnosis can be classified into osmotic and water diuresis causes. Osmotic diuresis is characterized by an excess of urinary solute with an osmolar excretion rate more than 1,000 mOsm/Day. Elevated urea, resolving acute tubular necrosis and hyperglycemia must be considered as potential triggers. Few cases on literature described the occurrence of immunoglobulin G induced osmotic diuresis in a patient with Pemphigus Vulgaris exacerbation, thus making the diagnosis challenging.
Case Description
We report a 52-year-old Puerto Rican female with Pemphigus Vulgaris complaining of recurrent painful blisters in the mouth and chest in the past 5 days. During the initial evaluation patient was started on immunoglobulin G IV therapy. Throughout hospital stay, nephrology service was consulted for persistent polyuria of 6.60 liters/24 hours and hypernatremia of 153 meq/L. No history of diuretics use reported. Renal function was stable with serum creatinine levels on baseline (BUN:19 Scr:0.65 mg/dl). Further workup showed elevated urine osmolality results of 391 mOsm/Kg. To differentiate between osmotic and water diuresis, 24-Hour Osmolar Excretion Rate was calculated multiplying urine output times urine osmolality. Results revealed evidence of 2,580 mOsm/Day indicating osmotic diuresis as the cause of severe polyuria. Typical causes of polyuria were absent leaving recent administration of immunoglobulin G containing maltose as the culprit of osmotic diuresis. Following discontinuation of immunoglobulin G therapy urine output reached normal values of 1.0-1.5 liters/Day.
Discussion
This case illustrates a not well-known cause of osmotic diuresis that should be included on the differential diagnosis. Increased awareness of this uncommon side effect will help clinicians recognize and address it early to prevent life-threatening electrolyte disorders. The uniqueness of this case lies on the rarity of this therapy causing osmotic diuresis with only a small percentage of hyperosmolar maltose found on the immunoglobulin G product that led to massive urinary solute loss. Our patient successfully responded after discontinuation of the potential trigger reaching adequate uresis.