Successful management of severe hyponatremia in CKD-VD: In a cost limited setting

Patients with end stage renal disease (ESRD) and severe hyponatremia always pose a challenge to manage. It is necessary to correct biochemical parameters, advanced azotemia, and fluid overload with conventional haemodialysis (HD) but it may correct serum sodium (Na) rapidly resulting in neurological complications like seizures and osmotic demyelination syndrome. Continuous renal replacement therapy (CRRT) is an ideal modality to manage such patients. However, most of the centers in the developing or underdeveloped nations do not have CRRT facility. We present two cases of ESRD, who had advanced azotemia requiring dialysis, also had persistent vomiting and severe hyponatremia (one with Na 107, another with Na 109 mEq/L), both cases were managed with conventional HD using dialysate Na concentration of 128 mEq/L (lowest permissible level of Na in a traditional HD machine) and keeping the blood flow of 50 mL/min. The serum Na increased by 1 mEq/L/h during first HD session, during the next session blood flow increased to 100 mL/min, and serum Na increased by two mEq/L/h. At the end of 48 hours, we were able to successfully correct serum Na by 18 mEq/L, with complete resolution of uremic manifestations and no neurological deficits. The current reports highlight management of hyponatremia in newly diagnosed ESRD in a cost limited setting.