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Hyponatremia has been associated with confusion, lethargy, seizures, coma, and even death. Hyponatremia is related to many conditions. It has been reported that patients receiving diuretics like Indapamide can cause hyponatremia. To describe one patient with severe indapamide-induced hypovolemic hyponatremia and correcting with Fludrocortisone and 1-deamino-8-d-arginine vasopressin; DDAVP.
A 51-year-old man was admitted to the hospital with a seizure and severe hyponatremia (plasma sodium concentrations of 101 mmol/L) and hypokalemia (plasma potassium concentrations of 1.9 mmol/L) 10-12 weeks after they received indapamide 2.5 mg/d therapy for hypertension. An urgent CT scan of the brain was done, and we did not find any acute brain injury or focal seizure.
On examination, he had moist mucous membranes and normal skin turgor without postural hypotension and no signs of overload like raised jugular venous pressure (JVP), peripheral edema or shortness of breath. From the laboratorium, serum osmolality was 244 mmol/kgH2O (NR: 275-295 mmol/kgH2O) correlating with the hypo-osmolar state, and urine osmolality was in the normal range 186 mosm/kgH2O (NR: 150-1150 mosm/kgH2O). Level sodium urine was 192 (NR:60-180) mmol/L, Calcium ion was 0,85 mmol/L and Urine volume was 9890 ml for 24 hours. The treatment was based on the correction of fluid and electrolyte disturbances using isotonic saline, and 3% hypertonic saline via a central line.
On 5th day of hospitalization, treatment with fludrocortisone 200 mcg was initiated, with a marked improvement in hyponatremia. We give fludrocortisone for seven days. To control polyuria, oral DDAVP 2 mcg was administered, which decreased her urine output without causing hyponatremia. DDAVP was continued twice daily for three days with significant improvement in his urine output. We followed up within 7th day of hospital discharge; the plasma sodium was 140 mmol/L. Fludrocortisone was administered to maintain a level of sodium. It exerts its effects by stimulating the reabsorption of sodium and water in the distal tubule, leading to the expansion of the ECFV.
Indapamide can cause both severe hypokalemia and hypovolemia hyponatremia. Rapid correction of natrium and volume status with the combination fludrocortisone and DDAVP can be considered to patient with polyuria and severe hyponatremia.