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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2018  |  Volume : 29  |  Issue : 6  |  Page : 1470-1474
Safe correction of severe hyponatremia in patient with severe renal failure using continuous venovenous hemofiltration with modified sodium content in the replacement fluid


1 Department of Pharmaceutical Care, King Abdul Aziz Medical City, National Guard Health Affairs, Jeddah, Saudi Arabia
2 Department of Pharmaceutical Care, King Abdul Aziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia

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Date of Submission10-Oct-2018
Date of Acceptance11-Oct-2018
Date of Web Publication27-Dec-2018
 

   Abstract 

Optimal treatment of severe hyponatremia in patients requiring dialysis is not known. Rapid correction with the use of different dialysis modalities can lead to osmotic demyelination syndrome. We described a safe correction of severe hyponatremia in a 42-year-old male patient requiring dialysis, who was treated with continuous venovenous hemofiltration using hypotonic replacement fluid which was prepared and adjusted on a daily basis.

How to cite this article:
Alqurashi BY, Gramish JA. Safe correction of severe hyponatremia in patient with severe renal failure using continuous venovenous hemofiltration with modified sodium content in the replacement fluid. Saudi J Kidney Dis Transpl 2018;29:1470-4

How to cite this URL:
Alqurashi BY, Gramish JA. Safe correction of severe hyponatremia in patient with severe renal failure using continuous venovenous hemofiltration with modified sodium content in the replacement fluid. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2019 Jun 27];29:1470-4. Available from: http://www.sjkdt.org/text.asp?2018/29/6/1470/248308

   Introduction Top


Treatment of severe hyponatremia in patients with severe renal failure requiring dialysis presents a special dilemma. The guidelines recommend that the rate of correction should not exceed 8–12 mmol/L/day.[1] However, rapid correction of serum sodium (Na+) may occur with the use of different dialysis modalities due to unavailability of hypotonic dialysate or replacement fluid (with normally available concentration of 130 mmol/L and 140 mmol/L in dialysate and replacement fluid, respectively).

We describe here a case of severe hypo-natremia, and renal failure successfully treated with modulation of Na+ content in the replacement fluid of continuous venovenous hemo-filtration (CVVH) to gradually and safely increase serum Na+ level


   Case Report Top


A 42-year-old male patient presented to emergency department with five days history of shortness of breath at rest, paroxysmal nocturnal dyspnea, orthopnea, nonproductive cough, vomiting, and poor appetite. He had no neurological symptoms.

His medical history was significant for hypertension, diabetes, chronic kidney disease, and hepatitis C which was diagnosed three years back which did not respond to treatment. At present, the blood pressure was 210/109, heart rate 112, respiratory rate 39, and oxygen saturation was 88% at room air.

Physical examination revealed bilateral respiratory crackles. No obvious focal neurological abnormalities were noted. Laboratory values were remarkable for the following: serum Na+ (105 mmol/L), potassium (3.1 mmol/L), chloride (73 mmol/L), bicarbonate (14 mmol/L), blood urea nitrogen (15 mmol/L), creatinine (813 umol/L), adjusted calcium (1.79 mmol/ L), phosphorus (1.89 mmol/L), troponin I (320 μg/mL), B-type natriuretic peptide (797 pmol/ L), hemoglobin (9.3 g/dL), and hematocrit (26%). Venous blood gas analysis showed pH (7.42), pO2 (43.2 mm Hg), pCO2 (27.3 mm Hg), and bicarbonate (17.5 mmol/L). Serum osmolality was 247 mOsm/kg, urine osmo-lality (263 mOsm/kg), and random urine Na+ (32 mmol/L).

The electrocardiogram showed sinus tachycardia with first degree A-V block and non-specific ST, and T was abnormalities. Chest X-ray demonstrated pulmonary edema. Renal ultrasound showed hyperechogenic small kidneys with poor corticomedullary differentiation. Serologic workup was negative except for hepatitis C.

The patient remained oliguric despite treatment with high doses furosemide. He was admitted to the intensive care unit (ICU) for close observation and the commencement of slow low efficiency dialysis aiming for alleviating fluid overload. Blood filtration rate was 80–150 mL/min. Serum Na+after one 24 h of ultrafiltration was 106 mmol/ L.

He was started on CVVH using modified replacement fluid. Standard fluid bag, (Prismasol 4) that contains Na+ 140 mmol/L, was diluted with sterile water for injection to Na+ 118 mmol/L at the start of CVVH, and Na+ 124 mmol/L at 24 h. Blood flow rate was 200 mL/min, replacement rate 1.2 L/h. This hypotonic replacement fluid was used for 48 h. The patient became normotensive and saturating at room air. CVVH was stopped at Na+ 126 mmol/L. [Figure 1] represents Na+ concentration during CVVH over 48 h period. The patient was discharged from the ICU to continue chronic conventional hemodialysis (HD).
Figure 1: Serum sodium concentration at baseline and during CVVH using hypotonic replacement fluid for 48 h

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   Discussion Top


This case describes the successful treatment of severe hyponatremia in fluid overloaded patient with severe renal failure requiring dialysis. Initially, we started CVVH with diluted replacement fluid at Na+ 118 mmol/L by exchanging 800 mL of replacement fluid by 800 mL of sterile water. At 24 h, we diluted the replacement fluid to Na+ of 124 mmol/L by replacing 600 mL of replacement fluid by 600 mL of sterile water. Serum Na+ was corrected safely by 10 mmol in 48 h. We followed replacement fluid exchange suggested by Yessayan et al,[2] that proposed that in those with 24-h Kt/V = 1.2, about 10–12 mEq/L difference between fluid replacement and serum Na+ is required for daily correction of 6–8 mEq/L. We also used the following equation to estimate the amount of fluid to be replaced:[2]



[Table 1] represents the expected change in electrolyte with exchanging different volumes of the replacement fluid. Other electrolyte and bicarbonate content were also affected which required monitoring and supplementation.
Table 1: Effect of exchanging different volumes of a 5-L replacement fluid bag with sterile water.

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The method we utilized for this patient is applicable for CVVH, continuous venovenous HD (CVVHD), or continuous venovenous hemodiafiltration (CVVHDF).[3] To yield hypotonic replacement fluid, sterile water can be either added to or exchanged by replacement fluid.[2]

Treatment of severe hyponatremia in patients requiring dialysis is challenging. The current guidelines did not discuss treatment options in this patient population. Treatment mainly depends on fluid intake restriction.[1],[4] The use of hypertonic saline injection is acceptable in symptomatic patient, or when normal saline or water restriction is unlikely to raise serum Na+ concentration to the desired level. However, the risk of fluid overload and overcorrection may limit its use in patients with progressive renal failure.[5]

Rapid serum Na+ correction can lead to osmotic demyelination syndrome (ODS). Therefore, in patients with chronic hypo-natremia (>48 h), the guidelines recommend not to exceed 8 mmol/L/day in patients with high risk to develop ODS, and not to exceed 12 mmol/L/day in patient with normal risk of ODS.[1] Serum Na+ of 105 mmol/L or less or hypokalemia were some of risk factors that place the patients at higher risk for developing ODS.[1] This was challenging in our case since the lowest Na content in dialysate and replacement fluid is 130 mmol/L and 140 mmol/L, respectively.

ODS has not been reported commonly in dialysis patients. A reasonable explanation is that, the sudden decrease in urea levels from extracellular space with dialysis can lead to brain edema (disequilibrium syndrome) which may prevent cellular dehydration caused by rapid correction of serum Na+.[4],[6] However, a case report described occurrence of ODS in a uremic patient with hyponatremia after 2.5 h of conventional HD which rapidly corrected serum Na+ from 100 mmo/L to 121 mmol/L,[7] suggesting that uremia does not protect against ODS and neurological damage can occur with the use of conventional HD in the setting of severe hyponatremia.

Optimal treatment of severe hyponatremia in this population is not known. However, providing this risk of overcorrection, available options of dialysis that appear to be safe includes: HD at low blood flow,[6] use of CVVH,[8] or the use of CVVH[2] or CVVHD[9],[10],[11] with modulation of Na+ content in replacement fluid.

Using HD with reduced blood or dialysate flow rate might be an option but is suboptimal for the correction of uremia and solute clearance. More importantly, serum Na+ correction would be less predictable in this technique.

Ji et al, reported the use of CVVH for the treatment of hyponatremia in 11 cases which resulted in rapid correction of hyponatremia, where average Na+ increased by >21 mmol/L in the first 8 h of initiating CVVH. Patients did not experience neurological complications. However, all patients in this report had acute hyponatremia that developed in 38–48 h.[8]

We believed that with this severe hypona-tremia, reducing Na+ content in replacement fluid of continuous hemofiltration is the safest and more predictable approach. Similar to our report, Bender reported the use of CVVHD with hypotonic dialysate that increased serum N+ by 11 mmol in 28 h safely.[9] In another two reports by Vassallo et al and Viktorsdottir et al, CVVHD was used with hypotonic dialysate that corrected serum Na+ by 33 mmol in six days, and 39 mmol in nine days, respec-tively.[10],[11] Na+ content in the dialysate was adjusted daily. More recently, Yessayan et al described a case of acute kidney injury and severe hyponatremia where replacement fluid of CVVH was diluted and adjusted on daily bases. That corrected serum Na+ from 96 mmol/L to 126 mmol/L in 72 h safely.[2] Studies used different fluid to dilute the dialysate or replacement fluid that included pure water, dextrose 5%, or hypotonic solution.

This technique of diluting replacement fluid takes effort and time from pharmacy staff and it requires coordination and proper communication between physicians, nurses, and pharmacy staff to avoid errors.

In conclusion, the use of CVVH with low Na+ replacement fluid can gradually correct severe hyponatremia in a predictable manner which makes it an attractive option in patients with severe hyponatremia requiring dialysis. Guidelines need to discuss this population and suggest preferred method to treat them based on available data.

Conflict of interest: None declared.

 
   References Top

1.
Verbalis JG, Goldsmith SR, Greenberg A, et al. Diagnosis, evaluation, and treatment of hyponatremia: Expert panel recommendations. Am J Med 2013;126:S1-42.  Back to cited text no. 1
    
2.
Yessayan L, Yee J, Frinak S, Szamosfalvi B. Treatment of severe hyponatremia in patients with kidney failure: Role of continuous venovenous hemofiltration with low-sodium replacement fluid. Am J Kidney Dis 2014;64: 305-10.  Back to cited text no. 2
    
3.
Ostermann M, Dickie H, Tovey L, Treacher D. Management of sodium disorders during continuous haemofiltration. Crit Care 2010;14: 418.  Back to cited text no. 3
    
4.
Zhang R, Wang S, Zhang M, Cui L. Hyponatremia in patients with chronic kidney disease. Hemodial Int 2017;21:3-10.  Back to cited text no. 4
    
5.
Mohmand HK, Issa D, Ahmad Z, et al. Hypertonic saline for hyponatremia: Risk of inadvertent overcorrection. Clin J Am Soc Nephrol 2007;2:1110-7.  Back to cited text no. 5
    
6.
Wendland EM, Kaplan AA. A proposed approach to the dialysis prescription in severely hyponatremic patients with end-stage renal disease. Semin Dial 2012;25:82-5.  Back to cited text no. 6
    
7.
Huang WY, Weng WC, Peng TI, et al. Central pontine and extrapontine myelinolysis after rapid correction of hyponatremia by hemodialysis in a uremic patient. Ren Fail 2007; 29:635-8.  Back to cited text no. 7
    
8.
Ji DX, Gong DH, Xu B, et al. Continuous veno-venous hemofiltration in the treatment of acute severe hyponatremia: A report of 11 cases. Int J Artif Organs 2007;30:176-80.  Back to cited text no. 8
    
9.
Bender FH. Successful treatment of severe hyponatremia in a patient with renal failure using continuous venovenous hemodialysis. Am J Kidney Dis 1998;32:829-31.  Back to cited text no. 9
    
10.
Vassallo D, Camilleri D, Moxham V, Ostermann M. Successful management of severe hypo-natraemia during continuous renal replacement therapy. Clin Kidney J 2012;5:155-7.  Back to cited text no. 10
    
11.
Viktorsdottir O, Indridason OS, Palsson R. Successful treatment of extreme hyponatremia in an anuric patient using continuous venovenous hemodialysis. Blood Purif 2013;36:274-9.  Back to cited text no. 11
    

Top
Correspondence Address:
Ms. Bashaer Y Alqurashi
Department of Pharmaceutical Care, King Abdul Aziz Medical City, National Guard Health Affairs, Jeddah
Saudi Arabia
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DOI: 10.4103/1319-2442.248308

PMID: 30588980

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