RE: Persistent hyponatremia in patient taking chronic psychiatric medication 4 hours ago

One (obvious) addendum to the above: As u osm reaches the low levels of beer potomania or "tea and toast" then the treatment surely is to provide o...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 5 hours ago

That all makes great sense to me, and the only quibble I would add is that I try to avoid salt pills, they taste terrible and you need about six pi...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 8 hours ago

I definitely teach the treatment of SIADH as a hierarchy. Obviously, step 1 is remove the inciting agent/pain/nausea is possible but it often isn't...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 18 hours ago

Other psychiatric medications have been tried but we're not effective. She was previously taking 300 mg of trileptal twice dialy. We decreased it t...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 20 hours ago

She seems like a challenging patient. I would offer the following observations: (1) Oxcarbazepine is the most likely culprit drug. Hyponatremia...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 20 hours ago

Thanks. Where are Diet and CRRT in this algorithm.? It suggests that Tolvaptan, Urea and SGLT2 are equivalent in effucacy and safety. Has this been...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 21 hours ago

The EFFUSE fluid trial failed to see benefit in fluid restriction + salt tablets + furosemide alone or in combination (although low dose furosemide...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 21 hours ago

The hierarchical arrangement of diet, water restriction , oral urea, salt tablets/Furosemide , SGLT2i, Tolvaptan (generic or private label ), Hyper...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 22 hours ago

I agree with a trial of SGLT2. I've used it in two patients with acceptable results. Re diet, here in West LA Bev Hills I rec treatment at a spec...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 1 day ago

Thanks for clarifying the exact findings of lower dose Tolvaptan in sIADH disorders.. Rulings by the FDA ate not the nd all of "truth". When in dou...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 1 day ago

I think a better comparison is a Big Mac (or equivalent) which has 25 gms protein and a gram of salt. That alone should prompt quite a bit of free ...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 1 day ago

Nice analysis -thanks. so 3 high-protein "bars" containing about 15 gms. Protein each would add about 250mOSM to the daily osmolal excretion and re...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 1 day ago

nice discussion, lots here all good points the only solution I dont like is fluid restriction, urea works great. 'If the patient ha...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 1 day ago

Thank you all for your recommendations. I'll pursue the urea route, see how palatable it is and vaptan if all else fails (if insurance willing to p...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 1 day ago

This is a perfect case for UreaAide tablets. They are tasteless and currently 2.5 grams each . You could start her on 3 twice a day and that will p...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 1 day ago

Yes, a glucose osmotic diuresis might improve hyponatremia in this case, but will it be any better than increase of protein (and salt) in the diet ...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 1 day ago

If the patient had an extra 15 gram protein bar daily, what are the calculations regarding urea nitrogen generation and how much additional obligat...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 1 day ago

It seems to me that it is chronic hyponatremia (medication induced SIAD). One approach tested both outpatient and inpatient is iSGLT2 inhibitors. ...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 1 day ago

This chronic condition patient will continue his psychiatric medication for long time Because of potential hepatotoxicity, tolvaptan should not be...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 2 days ago

Thank you Dr. Glassock! ------------------------------ Ralph Mohty MD, MPH Fellow Stanford Paradise Valley AZ (602) 509-4310 --------------------...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 2 days ago

I have seen over correction with 7.5 in the hospital, (see attached link my fellow put this together a few years back) but I think we are really ta...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 2 days ago

Dr Hirsch, I have seen rapid correction with 15 mg but so far not with 7.5. Unfortunately the other side of the coin is that anyone can prescribe a...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 2 days ago

I concur with Hirsch and Kirsch (has a nice ring to it). She has isosthenuria and her U Na + K is < P Na, meaning she can excrete free water. T...

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RE: Hypotension In CKD patients With HFrEF or HFpEF 2 days ago

The first questions I have are: is the patient symptomatic; does he have orthostatic hypotension; does he have autonomic dysfunction? If the patien...

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RE: Hypotension In CKD patients With HFrEF or HFpEF 2 days ago

Another perspective on this very thought provoking question - progressive CKD and morality from CVD are "competing risks ". Patients with Non-dialy...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 2 days ago

Thanks- interesting twist. No generics yet in the USA. ------------------------------ Richard Glassock MD, FASN Laguna Woods CA (949) 388-8885 --...

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RE: renal effects of Nivolumab 2 days ago

Dr. Rodby Agree with your assessment. Sometimes it is better care to step back and not push, particularly in the elderly. Id the Bicarb is under,...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 2 days ago

Dr, Balan . Reading many of the discussions, it seems that in India, you have more generics and develop hem more quickly than we do here in the s...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 2 days ago

Gosh I wish we could get talvaptan here in the US, esp for severe hyponatremia with high U osm/ADH levels. In this case, with the Na near 130 and...

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RE: Hypotension In CKD patients With HFrEF or HFpEF 2 days ago

I have found that the BP lowering of the renal and cardio protective agents you have listed to be variable and some better tolerated than others ...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 2 days ago

Multiple generic brands of tolvaptan are available in our country at around 0.5$ for a tablet of 15 mg. We routinely prescribe this for chronic hyp...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 2 days ago

Remember - the prescription should be for Samsca, not Jynarque. Same drug (Tolvaptan) but for different indications. ----------------------------...

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RE: C3 glomerulopathy ? 2 days ago

Definitely. Will post the biopsy results once I get them. ------------------------------ Adi Leiba MD Assuta Ashdod University Hospital Kiryat O...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 2 days ago

Would you use the 1/2 FDA dose of 7.5 to start? or 15? ------------------------------ Ralph Mohty MD, MPH Fellow Stanford Paradise Valley AZ (602...

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RE: Hypotension In CKD patients With HFrEF or HFpEF 2 days ago

I guess my point was "it all depends"- if the patient was a diabetic with HF and CKD with diabetic autonomic neuropathy, I would be content with so...

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RE: Amiloride for lithium nephrotoxicity 2 days ago

Thanks- This is at the upper border of the therapeutic range (0.6- 0.8mmol/L) - as a first step, I would slowly reduce the Lithium dose to obtain...

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RE: Non-resolution of proteinuria of native kidney origin during primary non-function of first kidney transplant and prompt resolution of native proteinuria with immediate graft function of second transplant 2 days ago

This case certainly supports the hypothesis that recovery of uremia reduces compensatory hyperfiltration of the native kidneys. May I ask whether y...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 2 days ago

If the urine osm is 259 mosm/L, then on a standard diet of about 750 mosm, she would have an obligate excretion of about 3 liters daily. She does...

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RE: renal effects of Nivolumab 2 days ago

"His creatinine in October, 2022 was 1.42 correlating with a GFR of 50, then we next checked in January, 2023 as 1.38 correlating with a GFR of 51 ...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 2 days ago

I would at least try to get tolvaptan approved. It occasionally will occur. I would hardly call it "overkill", it is easy to take, no taste issues,...

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RE: Amiloride for lithium nephrotoxicity 3 days ago

Dr Glassock, his lithium dose is 300 mg daily and his level was 0.9 most recently ------------------------------ Raphael Rosen MD, FASN New Roche...

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RE: Hypotension In CKD patients With HFrEF or HFpEF 3 days ago

Fludrocortisone works to raise BP and might help the patient but it is essentially aldosterone, so it will be counterproductive if the goal is just...

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RE: Amiloride for lithium nephrotoxicity 3 days ago

Creatinine trend: 1.8 (2018) -> 1.8 (2021) -> 2.3 ( 1/2023) -> 1.9 (3/2023) -> 2.1 (9/2023). Cystatin is 3. eGFR by CKD epi cr/cys is 22 ml/min. No...

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RE: Hypotension In CKD patients With HFrEF or HFpEF 3 days ago

Thanks Dr. glassock for your input. The question was about how to treat hypotension and increase BP in a way we can initiate or maintain the benefi...

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RE: Hypotension In CKD patients With HFrEF or HFpEF 3 days ago

Both CKD and HF are highly non-specific terms, making sensible answers impossible . To help clarify -are you describing Diabetic patients , Amyloid...

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Hypotension In CKD patients With HFrEF or HFpEF 3 days ago

General question. We routinely encountered patients with CKD with HFpEF or HFrEF who were hypotensive (in a range of 70-90/40-60 mmHg) and we can’t...

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RE: Persistent hyponatremia in patient taking chronic psychiatric medication 3 days ago

Some thoughts/opinions: --Her u osm is on the low side, she is drinking a lot of water, that's a big part of the problem here. Her urinary diluti...

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RE: C3 glomerulopathy ? 3 days ago

Could you post the deidentified kidney biopsy report , including IF (and EM when available)? ------------------------------ Richard Glassock MD, ...

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Persistent hyponatremia in patient taking chronic psychiatric medication 3 days ago

Good morning ASN community. Your advice would be greatly appreciated. I am taking care of 64 yo woman w/ bipolar disorder and is otherwise health...

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RE: PGNMID Diagnosis & Treatment 3 days ago

I would give rituximab a try before SCT. The dara VCD ruled out a plasma cell clone in this case. I would hit the B-cell clone now. I generally giv...

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