Abstract: TH-PO0762
Point-of-Care Ultrasound-Identified Venous Congestion Guides Hypertonic Saline-Assisted Diuresis in a Patient with Severe Hyponatremia with Cardiorenal Syndrome
Session Information
- AKI: Critical Care, CKRT, Cardiorenal Syndromes, and Clinical Outcomes
October 22, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Acute Kidney Injury
- 102 AKI: Clinical, Outcomes, and Trials
Authors
- Reisinger, Nathaniel, St Louis Kidney Consultants, St Louis, Missouri, United States
- Koratala, Abhilash, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
Introduction
Patients with acute decompensated heart failure with hyponatremia are often misclassified as hypovolemic, particularly in the presence of hypotension and AKI. Oral sodium chloride may worsen venous congestion and delay definitive diuretic therapy. Point-of-care ultrasound (POCUS) assessment of the hemodynamic circuit can differentiate hypervolemic hyponatremia driven by cardiorenal physiology from other causes by objective identification of systemic venous congestion.
Case Description
A 80-year-old woman with hypertension, type 2 diabetes, and chronic kidney disease was admitted with worsening dyspnea and cough. She had new heart failure with reduced ejection fraction of 25%. Hospital course was complicated by acute kidney injury and severe symptomatic hyponatremia with confusion and restlessness. Serum sodium fell from 130 mmol/L on presentation to 113 mmol/L. Creatinine rose from 1.0 mg/dL to 2.7 mg/dL. She was admitted to an ICU level of care where she was managed with oral sodium chloride. However, she had persistent altered mental status. Nephrology was consulted with POCUS revealing a distended and non-collapsing IVC, diffuse bilateral B-lines, jugular venous distention, and portal vein pulsatility greater than 50%, consistent with venous congestion. Urine sodium was less than 25 mmol/L. Serum and urine osmolality were 267 and 356 mOsm/kg respectively. TSH and cortisol were normal. Oral sodium chloride was switched to 3% hypertonic saline with high-dose loop diuretic. Serum sodium and creatinine rapidly improved. Her encephalopathy and volume overload resolved and she was discharged on an oral diuretic regimen.
Discussion
This case is illustrative of misclassification of severe hyponatremia in acute heart failure which often reflects venous congestion and neurohumoral activation rather than hypovolemia, even when hypotension and AKI are present. In this patient, POCUS reclassified the hyponatremia by identifying venous congestion as the dominant physiology leading to a change in therapy preventing further harm. Combined hypertonic saline and loop diuresis led to rapid improvement in serum sodium, kidney function, mental status, and volume status. The teaching point is that multi-organ POCUS of evaluation of the hemodynamic circuit including assessment of the IVC, lungs, and portal venous waveform can meaningfully drive management in hyponatremia.