Kidney Week

Abstract: FR-PO0889

Sequential Nephron Blockade for the Management of Hypervolemic Hypernatremia: A Case Report and Systematic Review

Session Information

• Fluid, Electrolyte, and Acid-Base Disorders: Case Reports - 1
  October 23, 2026 | Location: Exhibit Hall A, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Fluid, Electrolytes, and Acid-Base Disorders

• 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

• Kouyate, Gnama, SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Gnama Kouyate, MD

• Delp, Crystal, SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Crystal Delp, MD, MBBS

• Akatibo, Emmanuel, SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Emmanuel Akatibo, MBChB

• Syed, Jahanghir, SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Jahanghir Syed, MD

• Safi, Adnan, SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Adnan Safi, MBBS

• Nenwani, Hari Vishal, SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Hari Vishal Nenwani, MBBS

• Lwin, Yone Mee Mee, SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Yone Mee Mee Lwin, MD, MBBS

• Salifu, Moro O., SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Moro O. Salifu, MD, MBA, MPH

• Saggi, Subodh J., SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Subodh J. Saggi, MD, MPH

Introduction

Hypervolemic hypernatremia is a complex electrolyte disorder encountered in critically ill patients, characterized by concurrent sodium excess and fluid overload. Management is challenging, as it requires removal of excess volume and correction of hypertonicity. Loop diuretics, commonly used for volume control, may paradoxically worsen hypernatremia by increasing free water loss disproportionate to sodium excretion. Sequential nephron blockade has emerged as a potential strategy to enhance natriuresis while facilitating safe correction of serum sodium levels.

Case Description

We report the case of an 85-year-old female with multiple comorbidities, including morbid obesity, chronic obstructive pulmonary disease, hypertension, and recent acute ischemic stroke complicated by thrombus formation. Her hospital course included acute kidney injury, compartment syndrome requiring fasciotomy, and persistent volume overload. During her intensive care unit stay, she developed hypervolemic hypernatremia, with worsening of hypernatremia on loop diuretic monotherapy (furosemide).
Sequential nephron blockade was initiated using a combination of furosemide, metolazone, and spironolactone. This multi-site diuretic approach led to improved urine output, progressive reduction in serum sodium levels [Figure 1], and marked improvement in volume status. The patient achieved a significant net negative fluid balance of approximately 12.8 liters, which correlated with clinical improvement in respiratory function, edema, and wound healing. No major complications were observed with close electrolyte and renal function monitoring.

Discussion

This case highlights the limitations of loop diuretic monotherapy in hypervolemic hypernatremia and demonstrates the effectiveness of sequential nephron blockade in achieving enhanced natriuresis and controlled correction of hypernatremia. This strategy may represent a valuable therapeutic approach in critically ill patients with combined fluid overload and hypernatremia, provided that careful monitoring is ensured.