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Patients with chronic hyponatremia, especially those with a serum sodium level below 120 mEq/l, pose a significant challenge in both acute and chronic HD settings. In cases where the hyponatremia gradually develops over several days or weeks, the brain cells adapt to reduce the risk of cerebral edema by excreting organic osmolytes. However, this adaptation makes brain cells vulnerable to osmotic demyelination syndrome, such as pontine and extrapontine myelinolysis, if the serum sodium level is corrected too rapidly. Therefore, it is necessary to avoid rapid serum sodium correction.
A 41-year-old female with no previous recorded visits to our hospital was brought to the emergency room with a history of deteriorating level of consciousness over the past few days. She is known to have chronic kidney disease with a historical creatinine of 6.2 mg/dL in 2022. At the time of admission, her vital signs were stable with a pulse rate of 98 beats per minute, respiratory rate of 18 breaths per minute, and blood pressure of 120/80 mmHg. However, her labs showed some abnormalities, including a creatinine level of 828 micromol/L, urea level of 42.7mmol/L, potassium level of 5.9 meq/L, bicarbonate level of 9 mmol/L, arterial PH of 7.15, and hemoglobin level of 5.6 G/dL. Furthermore, her sodium level was found to be 104 meq/L. In the emergency room, she received a 100 ml bolus of 3% normal saline. As part of her investigations, her liver enzymes were found to be elevated, and a Pan CT scan revealed an incidental finding of a calcified right subclavian artery aneurysm. Considering her condition, the Nephrology team decided to perform continuous renal replacement therapy (CRRT) in the ICU. Her sodium level was measured on hourly bases, the CRRT continued for 6 hours and then stopped with close monitoring of sodium. The next day she had her first hemodialysis session with machine sodium as low as 127 meq/L and required dextrose with water 5% infusion throughout, low blood pump speed was used and the duration of the session was 180 minutes, . The patient regained her baseline level of consciousness and underwent surgical aneurysmal repair and continued on hemodialysis through left permcath, the latest sodium is 138meq/L.