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Abstract: SA-PO479

Nineteen Liters of Urine Output as a Consequence of Concomitant Use of Extracorporeal Membrane Oxygenation and Tolvaptan

Session Information

Category: Fluid‚ Electrolyte‚ and Acid-Base Disorders

  • 1002 Fluid‚ Electrolyte‚ and Acid-Base Disorders: Clinical

Authors

  • Guntupalli, Sri Vibhavari, Emory University School of Medicine, Atlanta, Georgia, United States
  • Rahbari-Oskoui, Frederic F., Emory University School of Medicine, Atlanta, Georgia, United States
Introduction

Tolvaptan (TVP), an oral vasopressin (V2) receptor antagonist, has been used in heart failure patients to increase aquaresis, without evidence on improved long-term or all-cause mortality. Veno-arterial ECMO (VA-ECMO) is a new modality to improve tissue oxygenation in cardiogenic shock. We present the first reported case of massive polyuria in a patient who was on TVP and then started VA-ECMO.

Case Description

31 YO male was transferred from an outside hospital with new onset heart failure (LVEF=15%), ventricular tachycardia and cardiogenic shock. After high dose furosemide, he received 4 doses of TVP 30 mg/d and an additional 60 mg on the day of transfer. Urine output (UOP) increased from 1-2 to 4-7L/day and serum sodium ([Na]s) from 122-123 to 126-130 mmol/L temporarily.
VA-ECMO was started at [Na]s of 119 mmol/L. UOP increased to 19L over the next 24h with a rise of [Na]s by 12 mmol. His urine Na and osmolality were 75 mmol/L and 150 mOsm/Kg respectively. Desmopressin at 2 mcg/day was administered over 2 days and UOP decreased to 11, 9, 5.5 and 3L/day over the next 4 days. Despite 1:1 replacement of free water losses, [Na]s continued to rise. His mental status was originally unchanged until his heart failure and overall condition started to deteriorate. His urine output was responsive to loop diuretics but [Na]s increased to 147 mmol/L. Unfortunately, he passed away within 2 weeks.

Discussion

TVP was used to improve hyponatremia (due to non-osmotic release of ADH observed in heart failure) and cause aquaresis. UOP on TVP is typically around 6+/-2 L in 24h, as originally seen in this case. ECMO can also cause polyuria by increased perfusion of the renal arteries. Effect of TVP on [Na]s is unpredictable with overcorrection in 40% of patients [1], [Na]s increased with TVP but overcorrected by 12 mmol/day once ECMO was started. His urine Na was elevated with low osmolarity. This rapid [Na]s rise suggests a residual effect of Tolvaptan administered several days ago combined to the ECMO-induced pressure diuresis. The washout period for tolvaptan should be 5 times the half-life of elimination (12h), which may be prolonged in case of passive hepatic congestion or use of CYP43A inducers.
Concomitant use of tolvaptan and VA-ECMO should be avoided under penalty of causing massive polyuria and rapid overcorrection of hyponatremia.