Hypernatremia Hypercalcemia Case Vignette

Electrolyte Vignettes Joel Topf, MD nephrology 248.470.8163 http://pbﬂuids.com

38 yr old presents for elective lap chole 158 106 40 routine pre-op labs 3.4 22 1.6

38 yr old presents for elective lap chole 158 106 40 routine pre-op labs 3.4 22 1.6 Patient had labs two- weeks prior

38 yr old presents for elective lap chole 158 106 40 routine pre-op labs 3.4 22 1.6 Patient had labs two- 143 106 28 weeks prior 3.3 23 1.2

HYPERNATREMIA the lack of water that looks like excess sodium

Patient reports she had been NPO since midnight as instructed She normally drinks 3-4 glasses of water a night She usually urinates 6 times a night

Dx: Diabetes Insipidus Central Nephrogenic

COMMON After day 5 roughly 20-25% of ICU patients are hypernatremic (Na>145)

ICU Mortality Hospital Mortality Lethal 75% 50% Mortality Hospital acquired, ICU 25% associated dysnatremia 125 130 135 140 145 150 155 160 160+

immediate treatment of hypernatremia

Replace water deﬁcit Assumes no gain of sodium The change in sodium is entirely due to loss of water The % body water lost equals delta Na divided by the ideal (or prior) Na To calculate the water deﬁcit take % water lost and multiply total body water Na now – Na ideal x Kg x 0.5* Na ideal

Calculate free water deﬁcit Na now – Na ideal x Kg x 0.5* Na ideal The kg x 0.5 is an estimate of total body water The asterisk is because you need to estimate the multiplier

The older and fatter you are the less water you are. We use 50% as standard because most people with hypernatremia are older and fatter than the 60% estimated for men.

Ideal weight: Females: 45 kg + 2.3 kg for every inch over 5 feet Males: 50 kg Adjusted weight: ideal weight + 0.4 (actual body weight – ideal weight)

Calculate free water deﬁcit Na now – Na ideal x Kg x 0.5* Na ideal 1. Na 165; Prior Na 144; Body Wt 70 kg; %H2O 60% 2. Na 185; Prior Na 138; Body Wt 23 kg; %H2O 70% 3. Na 155; Prior Na 142; Body Wt 76 kg; %H2O 50% 4. Na 152; Prior Na 140; Body Wt 65 kg; %H2O 40%

Calculate free water deﬁcit Na now – Na ideal x Kg x 0.5* Na ideal Na 165 Prior Na 144 Body Wt 70 kg %H2O 60%

Calculate free water deﬁcit Na now – Na ideal x Kg x 0.5* Na ideal Na 165 Prior Na 144 H2O deﬁcit = 6.1 liters Body Wt 70 kg %H2O 60%

CAUSES OF HYPERNATREMIA

GENERATION CAUSES OF HYPERNATREMIA

GENERATION MAINTENANCE CAUSES OF HYPERNATREMIA

Hypernatremia Generation Maintenance

Hypernatremia Generation gain of sodium loss of water Maintenance

Hypernatremia Generation hypertonic saline hypertonic dialysate gain of sodium bicarbonate tube feedings or TPN loss of water salt tablets primary hyperaldosteronism Maintenance Cushing’s syndrome congenital adrenal hyperplasia

Hypernatremia Generation sweating, burns osmotic diarrhea gain of sodium central diabetes insipidus nephrogenic diabetes insipidus loss of water congenital ATN, CKD Maintenance lithium hypercalcemia hypokalemia osmotic diuresis

Hypernatremia Generation gain of sodium loss of water Maintenance

Hypernatremia Generation Generation increases water demand. As long as increased gain of sodium demand is met the sodium remains normal loss of water Maintenance

Hypernatremia Generation Generation increases water demand. As long as increased gain of sodium demand is met the sodium remains normal loss of water Maintenance Patient had labs 2-wks prior: 143 106 28 3.3 23 1.2

Hypernatremia Generation gain of sodium loss of water Maintenance lack of water

Lack of water Absence of water desert No access to water infants mental status changes patients tied to the bed

In this case, the patient was made NPO

Maintenance: the patient was made NPO

but what about generation?

How about some more history... Lap chole was being done for gall stones and increased in abdominal pain The polydipsia had been ongoing for 3-6 months ROS revealed increased DOE and cough No history of lithium use

Generation? Gain of Sodium Loss of water hypertonic saline sweating, burns hypertonic dialysate osmotic diarrhea bicarbonate central diabetes insipidis tube feedings or TPN nephrogenic diabetes insipidis salt tablets congential primary hyperaldosteronism ATN, CKD Cushing’s syndrome hypercalcemia, hypokalemia congenital adrenal hyperplasia osmotic diuresis lithium

Generation? Loss of water sweating, burns 158 106 40 osmotic diarrhea 92 3.4 22 1.6 central diabetes insipidis nephrogenic diabetes insipidis congential ATN, CKD hypercalcemia, hypokalemia osmotic diuresis lithium

Generation? Loss of water sweating, burns 158 106 40 osmotic diarrhea 92 3.4 22 1.6 central diabetes insipidis nephrogenic diabetes insipidis congential Calcium 13.2 ATN, CKD Phos 5.8 hypercalcemia, hypokalemia Albumin 3.6 osmotic diuresis lithium

Nephrogenic diabetes insipidus: hypercalcemia

Na, 2Cl - + + K ++ Ca + + + + + K + + + + + + Ca, Na, Mg TUBULE PLASMA THICK ASCENDING LOOP OF HENLE HYPERCALCEMIA RESULTS IN POLYDIPSIA

Hypercalcemia decreases paracellular calcium reabsorption Increased tubular calcium binds CaS receptors in the collecting duct and attenuates ADH activity

Nephrogenic diabetes insipidus: hypokalemia Hypokalemia (K < 3 mmol/L) induced NDI Rare May decrease the expression of aquaporin-2

Calcium 13.5 What caused this? Increased intake Mobilization from bone Decreased renal excretion

Increased intake Milk-alkali syndrome Granulomatous diseases TB, histo, sarcoidosis, wegener’s, berylliosis, talc granulomatosis, disseminated candidiasis Lymphoma Vitamin D intoxication

Mobilization of bone ๏ Hypercalcemia of malignancy ๏ Humoral hypercalcemia (PTHrp) ๏ Direct invasion of bone (OAF) ๏ Breast Cancer ๏ Multiple Myeloma ๏ Lung cancer ๏ Primary and Tertiary Hyperparathyroidism

Decreased renal excretion Primary hyperparathyroidism Acute renal failure Hypocalciuric hypercalcemia

Additional data Calcium 13.5 Ionized Calcium 1.6 PTH 12 25-OH vitamin-D 23 1,25-OH Vitamin-D 116

SARCOIDOSIS Stage-2 bilateral hilar adenopathy, ﬁne Biopsy of cervical node revealed linear reticular opacities noncaseating granulomas

Patient was started on oral prednisone Alternatives include ketoconzole and plaquinil Rarely requires bisphosphonates The case occurred in July 2008

A week after the patient’s calcium was 10 mg/dL The patient still had polydipsia and polyuria When surgical team made her NPO to take her to the OR she again became hypernatremic NA NA NPO 142 158

water deprivation test is it central, nephrogenic or psychogenic polydipsia

Patient started on intranasal ddAVP

160 158 Sodium (mmol/L) 150 149 140 144 138 130 132 120 day 1 day 2 day 3 day 4 day 5 7,000 Urine output (mL) 6,050 5,000 3,900 3,000 3,200 2,200 2,400 1,000 day 1 day 2 day 3 day 4 day 5

Head MRI: Pituitary lesion

Head MRI: Pituitary lesion Neurosarcoidosis

Notes on treatment central diabetes insipidus responds to ddAVP Unlike vasopressin, ddAVP does not cause vasoconstriction

Notes on treatment central diabetes insipidus responds to ddAVP Unlike vasopressin, ddAVP does not cause vasoconstriction Patient had labs two- 143 106 28 weeks prior 3.3 23 1.2

Notes on treatment central diabetes insipidus responds to ddAVP Unlike vasopressin, ddAVP does not cause vasoconstriction Patient had labs two- 143 106 28 weeks prior 3.3 23 1.2 It is a cosmetic drug

that was the ﬁrst time I slept through the night in months

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Hypernatremia Hypercalcemia Case Vignette

by Joel Topf on Jan 25, 2009

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Hypernatremia Hypercalcemia Case Vignette — Presentation Transcript