![]() Initial differentiation between hypotonic and non-hypotonic hyponatremia is recommended because these conditions require different management strategies. Two sets of treatment guidelines for hyponatremia have been developed by professional organizations, one from the United States ( 1) and the other from Europe ( 2). Hyponatremia is one of the most common water balance disorders and is often difficult to diagnose. He was able to restrict his water intake during his hospitalization, and he was discharged on the 23rd hospital day. On the 22nd hospital day, his serum sodium level was 137 mEq/L, his serum creatinine level was 2.94 mg/dL, and his body weight was 70.4 kg ( Fig. He did not suffer any subsequent recurrence of the renal dysfunction despite not undergoing further hemodialysis. On the 13th hospital day, after 3 rounds of intermittent hemodialysis, the patient's serum creatinine level was 10.0 mg/dL, and his urinary volume was 1,199 mL/day ( Fig. His serum creatinine level also rose to 16.9 mg/dL, and intermittent hemodialysis was started on the 6th hospital day ( Fig. Oliguria persisted during this period, and the patient's body weight rose 4 kg ( Fig. On the 6th hospital day, we stopped correcting the patient's serum sodium level because follow-up examinations indicated that his sodium level had reached 130 mEq/L ( Fig. The patient's serum sodium level increased by 1-2 mEq/L after the administration of each bolus ( Fig. We administered a 130-mL bolus of 3% saline 2 to 5 times per day for 5 days while monitoring the patient's serum sodium level to ensure that it did not rise more than 10 mEq/L/day ( Fig. As hyperkalemia, acidemia, and pulmonary congestion were absent, immediate hemodialysis was considered unnecessary. Water restriction and immediate treatment with hypertonic saline (3% NaCl) for severe hyponatremia were initiated on the 1st hospital day. Myeloperoxidase antineutrophil cytoplasmic antibodyĪntiglomerular basement membrane antibody Proteinase 3 antineutrophil cytoplasmic antibody Low density lipoprotein cholesterol (mg/dL) High density lipoprotein cholesterol (mg/dL) The patient had not started taking any new medications in the past few months. Tests for proteinase-3 anti-neutrophil cytoplasmic antibody (ANCA), myeloperoxidase ANCA, and anti-glomerular basement membrane antibody were negative, and the level of antistreptolysin-O was within the normal range. Further investigations of the patient's renal dysfunction were also performed. Further investigations of the hyponatremia produced unremarkable findings, including a normal thyroid function and normal serum cortisol levels. Chest X-ray showed a cardiothoracic ratio of 55.5%. Echography showed normal-sized kidneys, and the diameter of the inferior vena cava was 16 mm and exhibited respiratory fluctuations. His fractional excretion values for sodium and urea nitrogen were 7.02% and 27.8%, respectively. The patient's urinary sodium, potassium, creatinine, and urea nitrogen levels were 79 mEq/L, 15 mEq/L, 93.7 mg/dL, and 85 mg/dL, respectively ( Table). These findings were consistent with hypotonic hyponatremia. His blood glucose and lipid levels were within normal limits, and his serum total protein level was below the normal limit ( Table). His baseline serum creatinine level was 1.0 mg/dL, and his serum sodium level had been 138 mEq/L one year earlier. An initial investigation revealed severe hyponatremia (109 mEq/L) complicated by a decreased renal function, a serum creatinine level of 9.08 mg/dL, a blood urea nitrogen level of 63 mg/dL, and rhabdomyolysis (creatine kinase: 22,615 IU/L) ( Table). He displayed a tremor and bilateral pedal edema. On an examination, his blood pressure was 135/78 mmHg, and his pulse rate was 105 beats/minute. He was 164.5 cm tall and weighed 79.2 kg. His Glasgow coma scale was E3 V5M6, and he was somnolescent when he arrived at our hospital. There were no witnesses to these events because he lived alone. However, he might not have been able to accurately remember the abovementioned time sequence. His symptoms worsened, and he could not walk on the day of his admission. He developed lightheadedness and fell down several times the next day. He had noticed a decreased urinary volume three days before he came to the hospital. He had been drinking 48 glasses of water every day. His medical history included schizophrenia, for which he had been taking levomepromazine, biperiden, haloperidol, distigmine, flunitrazepam, promethazine, phenobarbital, and suvorexant. A 60-year-old man presented to the emergency department with lightheadedness.
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