Hindawi Case Reports in Nephrology Volume 2017, Article ID 4521319, 6 pages https://doi.org/10.1155/2017/4521319

Case Report Multiple and Metabolic Emergencies in a Single Patient

Caprice Cadacio,1 Phuong-Thu Pham,2 Ruchika Bhasin,1 Anita Kamarzarian,1 and Phuong-Chi Pham1

1 Olive View-UCLA Medical Center, 14445 Olive View Drive, 2B-182, Sylmar, CA 91342, USA 2Ronald Reagan UCLA Medical Center, 200 Medical Plaza, Los Angeles, CA 90095, USA

Correspondence should be addressed to Phuong-Chi Pham; [email protected]

Received 12 December 2016; Accepted 12 January 2017; Published 31 January 2017

Academic Editor: Yoshihide Fujigaki

Copyright © 2017 Caprice Cadacio et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

While some electrolyte disturbances are immediately life-threatening and must be emergently treated, others may be delayed without immediate adverse consequences. We discuss a patient with and diabetes mellitus type 2 who presented with volume depletion and multiple life-threatening electrolyte and metabolic derangements including severe (serum sodium concentration [SNa] 107 mEq/L), hypophosphatemia (“undetectable,” <1.0 mg/dL), and hypokalemia (2.2 mEq/L), moderate diabetic ketoacidosis ([DKA], pH 7.21, serum anion gap [SAG] 37) and hypocalcemia (ionized calcium 4.0 mg/dL), mild hypomagnesemia (1.6 mg/dL), and electrocardiogram with prolonged QTc. Following two liters of normal saline and associated increase in SNa by 4 mEq/L and serum osmolality by 2.4 mosm/Kg, renal service was consulted. We were challenged with minimizing the correction of SNa (or effective serum osmolality) to avoid the osmotic demyelinating syndrome while replacing volume, potassium, phosphorus, calcium, and and concurrently treating DKA. Our management plan was further complicated by an episode of significant aquaresis. A stepwise approach was strategized to prioritize and correct all disturbances with considerations that the treatment of one condition could affect or directly worsen another. The current case demonstrates that a thorough understanding of electrolyte physiology is required in managing complex electrolyte disturbances to avoid disastrous outcomes.

∘ 1. Introduction Physical Exam.Temperaturewas37.2C, blood pressure 114/85 mmHg, heart rate 109 beats per minute, respiratory Managing various electrolyte and metabolic disturbances is rate 22 per minute, and oxygen saturation 98%. Patient was generally a simple task for nephrologist. However, in complex acutely ill-appearing, slow in verbal responses, alert and cases, one must be vigilant of potentially life-threatening oriented, and free of stigmata of advanced liver disease. Oral interactions among multiple simultaneous treatment plans mucosa was dry. Heart exam was notable for tachycardia. and cautiously formulate a comprehensive treatment algo- Lungs were clear bilaterally. Abdomen had hypoactive bowel rithm to prevent disastrous outcomes. sounds and mild midepigastric tenderness without guarding or rebound. Extremities were significant for a few ecchy- 2. Case Report moses. Neurological exam was nonfocal.

Clinical History. A 33-year old male with known Initial Laboratory Data. Serum chemistries at presentation abuse and diabetes mellitus type 2 presented with a two- andhospitalcoursearepresentedinTable1.Mostnotable day history of nausea, vomiting, watery diarrhea, and light abnormalities included serum sodium (SNa) 107 mEq/L, headedness. Patient denied fevers and chills but endorsed potassium (SK) 2.8 mEq/L, total CO2 12 mEq/L, glucose mild midepigastric dull pain and poor oral intake. 331 mg/dL, and anion gap (SAG)37mEq/L.Others were 2 Case Reports in Nephrology 154 mEq/L 10% solution normal saline 4 g mixed in 250 mL as needed to achieve of fluids administered sodium correction goal 15 mmol mixed in 200 mL Electrolyte concentrations normal saline or free water 4 (9.3 mmol) at presentation 4 g calcium gluconate during hospitalization Total amount replaced 2 liters of normal saline 5.5 240 mmol KPO 4.5 480 mEq KCl 100 mEq/L after admission) Discharge (12 days 1.0 6.8 8.4 2.7 < Not done Not done Table 1: Clinical data. 8 hours afterinsulin hours after admission) administration (30 to 32 1.0 4.0 6.8 < 2.9 to 3.2 12 to 14 hours after admission 1.0 2.2 < Not done 3.1 Not done 1.7 8 g was consulted) After 2normal L saline (renal service 12 11 6 14 25 Corrected with insulin 37 31 30 19 10 Corrected with insulin — 7.2 6.9 4.1 Not done 1.6 2.8 Not done 2 Serum chemistry Admission Sodium (mEq/L)Potassium (mEq/L) 107Total CO (mEq/L) Serum anion gap (mEq/L) Glucose (mg/dL) 111Phosphorus 331(mg/dL) Total calcium(mg/dL) 113 248Magnesium (mg/dL) 117 250 108 132 217 Corrected with insulin — Ionized calcium (mg/dL) [normal 4.6–5.4] Case Reports in Nephrology 3 mild transaminitis, mildly elevated lipase, and hemoglobin all treatable osmotic demyelinating syndrome (ODS) risks, 12 g/dL. correction of DKA to prevent respiratory decompensation Renal service was consulted following the increase in without worsening the life-threatening , and SNa from 107 to 111 mEq/L over one hour (effective serum intermittent infusions of magnesium sulfate and calcium osmolality [Sosm] increase of 2.4 mosm/Kg) with the admin- gluconate while anticipating and managing any significant istration of two liters of normal saline. aquaresis without derailing the planned SNa correction rate. The algorithm for the comprehensive management of current Additional Investigations. Renal service requested STAT patient is summarized in Figure 1. serum phosphorus and magnesium which resulted as Hypokalemia was the most life-threatening and one of <1 mg/dL and 1.6 mg/dL, respectively. Other findings were first abnormalities to be treated emergently. Etiologies likely moderate serum ketones, lactic acid 1 mmol/L, and Sosm included poor dietary intake, renal wasting given recent vom- 255 mosm/Kg (serum osmolality gap 6 mosm/Kg). iting and poorly controlled diabetes, and diarrhea. Imme- diate life-saving interventions included KCl infusion via a Venous Blood Gas at Six Hours following Presentation to central line along with instructions to avoid alkalinization Emergency Department (ED).pHwas7.40,pCO2 17 mmHg, or administration of insulin or glucose-containing fluids, the and HCO3 10 mEq/L (SAG 31 mEq/L), and at thirteen hours, latter because of endogenous insulin secretion, and to prevent + pH was 7.21, pCO2 14 mmHg, and HCO3 6mEq/L (SAG intracellular K -shift and worsening hypokalemia. 30 mEq/L). Urine studies show osmolality 450 mosm/Kg, While aggressive potassium administration was critical, sodium 25 mEq/L, and potassium 25 mEq/L. SNa level had to be closely monitored because potassium effectively increases SNa. Serum sodium concentration has Diagnoses. Diagnoses included volume depletion, diabetic beenshowntobedirectlyproportionaltothesumoftotal + + ketoacidosis (DKA) (with initial concurrent metabolic and exchangeable Na and K content [1]. Mechanisms whereby respiratory alkaloses), severe hyponatremia, hypokalemia, + K administration can raise SNa include the following [2]: hypophosphatemia, mild to moderate hypocalcemia, and + mild hypomagnesemia. (1) intracellular K -uptake induces an equivalent extra- + cellular Na -movement and hence increased SNa, Clinical Follow-Up. Patient received emergent potassium + chloride (KCl) infusion via a central line (200 mL/hr of (2) parallel K -Cl- intracellular uptake leads to increased 100 mEq/L KCl solution [total 480 mEq KCl]) and potas- intracellular osmolality which leads to intracellular sium phosphate (KPO4) (total 240 mmol), magnesium sulfate free water shift and lower extracellular free water (total 8 g), and calcium gluconate (total 4 g) via peripheral volume and hence increased SNa,or lines. Oral thiamine and folate were given daily. All net + (3) intracellular K -uptake induces an equivalent extra- fluid and effective solutes (sodium and potassium) were + cellular H -movement to maintain electrical neutral- closely monitored. Calculations were performed (based on + CurbsideConsultant.com) every six hours to readjust all fluid ity. While H can bind to the extracellular buffer system and not perturb extracellular osmolality, the rates as needed to ensure a goal sodium correction rate of + 4–6 mEq/L/24 hours. Treatment of DKA was intentionally intracellular K -gained increases intracellular osmo- delayed until SK reached 2.9 mEq/L to avoid insulin-driven lality and hence intracellular free water shift. The intracellular potassium uptake, exacerbation of hypokalemia, lower extracellular free water volume increases extra- and precipitation of life-threatening arrhythmias. On hospital cellular SNa. day 3, patient developed significant aquaresis with approx- + imated free water clearance of 230 to 300 mL/hr (urine Given the direct effect of K on SNa, both sources of potas- output of 3140 mL over 8 hour; urine studies: osmolality sium, KCl and KPO4, were accounted for in all calculations 186 mosm/Kg, sodium 13 mEq/L and potassium 16 mEq/L; for expected changes in SNa. Further sodium administra- SNa 122 mEq/L). Two micrograms of desmopressin (DDAVP) tion was withheld because potassium supplement alone and two liters of electrolyte-free water were given intra- was determined to be sufficient to correct hyponatremia. venously to slow urine output and prevent rapid overcorrec- Failure to recognize this fact and unwarranted infusion of tion of SNa, respectively. Over the first four hospital days, SNa sodium-containing solutions could have easily led to rapid corrected at an average of 5 mEq/L/day. Additionally, patient hyponatremia overcorrection. also underwent upper gastroendoscopy for gastrointestinal Hypophosphatemia may be a risk factor for ODS [3]. Our bleed and nausea which revealed diffuse , presumed routine hyponatremia treatment protocol requested a STAT to be induced by his chronic alcohol consumption. His nausea level, which was likely life-saving. Patient’s severe hypophos- resolved with proton pump inhibitor and supportive care. phatemia could arise from poor oral intake, renal wasting, hypomagnesemia-induced skeletal resistance to parathyroid ( ) 3. Discussion hormone (PTH 161 pg/mL, 1,25 OH 2 vitamin D 146 pg/mL), and possibly some degree of intracellular uptake associated The current case was challenged by multiple concurrent with primary respiratory alkalosis at presentation [4]. The problems including the need for continuing volume sup- latter could induce intracellular alkalemia and associated port and substantial administration of both KCl and KPO4 increased glycolysis and intracellular uptake of phosphorus without rapidly correcting hyponatremia, optimization of for ATP production [5]. Phosphorus replacement was given 4 Case Reports in Nephrology

Moderate diabetic Severe ∗ Mild to moderate ∗∗ Initial presentation Severe Marked ketoacidosis hypokalemia hyponatremia hypocalcemia hypovolemia ED bolus 2 Renal consult and Hold insulin, Immediate Determine rate of correction goal based on ODS risks alkalinization, and central line liters of management placement Check serum normal saline glucose-containing Severe magnesium, Mild fluid Replace hypophosphatemia phosphorus hypomagnesemia administration potassium as Replace Replace Supplement (KCl and KPO4) magnesium as phosphorus as thiamine as Diabetic MgSO4 Replace ketoacidosis with KPO4 clinically calcium as increasing indicated calcium respiratory Monitor urine gluconate distress output, sodium, Moderate hypokalemia and potassium; Administer insulin and glucose Continue to replace potassium administer free support cautiously and phosphorus (KPO4) as water & DDAVP once hypokalemia needed; monitor for appropriate and adjust KCl becomes less rise in serum sodium and infusion rate as severe accordingly adjust infusion rates needed

Resolution of diabetic ketoacidosis Normal serum potassium, phosphorus, sodium, and magnesium levels Normocalcemia Euvolemia

Immediate life-threatening conditions Nonimmediate life-threatening, but serious conditions Immediate intervention Other supportive measures Indirect therapy; indirect outcome Direct therapy; direct outcome Outcome per both direct and indirect therapies

∗ Figure 1: Algorithm for the treatment of multiple concurrent life-threatening disturbances. For hyponatremia, correction resulted from both potassium infusion (indirect therapy) and fine adjustment with intermittent free water infusion and single administration of desmopressin ∗∗ (direct therapy) to achieve rate of correction goal during an episode of aquaresis. For volume depletion, patient received two liters of normal saline on presentation to the emergency department (direct therapy) and continuous KCl infusion at 200 mL/hour (indirect therapy, i.e., the main purpose for KCl infusion, was potassium replacement, but patient benefited from the infusion as maintenance intravenous fluid) over the following 2 to 3 days while his oral intake was poor. ODS: osmotic demyelination syndrome; ED: emergency department; DDAVP: desmopressin. emergently to avoid respiratory and cardiac arrest among Patient’s respiratory status, however, was closely monitored. other potential serious complications. Once SK reached 2.9 mEq/L, insulin was cautiously given Volume depletion is typically managed with normal saline to avoid respiratory failure as patient exerted high work of (NS), but not in current case. Patient received predomi- breathing to compensate for the metabolic acidosis. Within + nantly K -containing fluids (200 mL/hour of 100 mEq/L KCl 12 hours of insulin administration, SAG, likely all reflecting solution and 25 to 50 mL/hour of KPO4 solution [15 mmol ketone bodies, decreased from 30 mEq/L to 19 mEq/L with KPO4 mixed in 200 mL of either normal saline or sterile a parallel increase in total CO2 from 6 to 14 mEq/L. The + water as indicated by SNa]). Since K is an effective solute, rapid inverse change in SAG and total CO2 demonstrates + + either K or Na -containing solutions that are relatively iso- perfectly how sufficient fluid resuscitation, not excessive fluid tonic to patient’s effective osmolality will effectively expand administration with resultant urinary loss of serum ketone bodies, can allow for preservation of serum ketone bodies, intravascular volume. With the exception of two liters of NS where rapid hepatic conversion to bicarbonate occurs with given in the ED, patient's total body volume was repleted + insulin administration [6]. Patient’s respiratory status also and maintained with the infusion of K -containing fluids improved significantly with correction of metabolic acidosis. intended for potassium and phosphorus repletion. Failure to Hyponatremia was likely multifactorial and includes con- recognize the volume expansion capacity of relatively isotonic tinuing free water intake in the presence of enhanced secre- KCl-containing fluid and unwarranted infusion of NS for tion of antidiuretic hormone (ADH) with volume depletion the sole purpose of volume support would have complicated and/or inappropriate ADH secretion in the setting of nau- the treatment of hyponatremia. Additionally, high volume sea, “ potomania,” and small degree of hyperglycemia- infusions of multiple fluids would have led to excess urinary induced extracellular free water shift. The major goal in loss of ketone bodies necessary for bicarbonate production hyponatremia correction is ODS prevention. This requires with insulin administration [6]. bothsettinganappropriatecorrectiongoalandrecognizing Hypocalcemia was likely due to poor nutrition, mal- and optimizing any concurrent factors that could potentiate absorption, and hypomagnesemia-induced hypoparathy- theriskofdevelopingODS[3,9].Thecorrectiongoal roidism[7,8].GivenprolongedQTc,patientreceivedlow was determined to be 4 to a maximum of 6 mEq/L/day dose calcium gluconate intravenously following the initiation because of patient’s ODS risks including severe hypona- of KPO4 administration to avoid any potential calcium- tremia, hypokalemia, alcoholism, hypophosphatemia, hypo- induced worsening of severe hypophosphatemia via calcium magnesemia, glucose intolerance, and presumed thiamine phosphate precipitation. deficiency [3, 9]. Routine assessment of reversible ODS risk Diabetic ketoacidosis was potentially life-threatening, but factors is warranted because such as phosphorus not the most serious derangement. Insulin administration and magnesium are not routinely measured at many institu- was intentionally delayed to avoid worsening of hypokalemia. tions, including our own (Table 2). Case Reports in Nephrology 5 to achieve a 4 infusions, the 4 improved from 6 to 14 mEq/L within 8 hours 2 (i) Hypokalemia and hypophosphatemia were theconditions two in most current life-threatening patient. Since thewith treatment insulin of with diabetic or ketoacidosis without (DKA) glucosehypokalemia support and could precipitate cardiac have arrest, exacerbated such thedelayed. treatment severe Aggressive was potassium intentionally replacement with both KCl and KPO (i) While hyponatremia was being corrected with KCl and KPO (i) The substitution of KClgiven for in NaCl cases solution of severe for volume hypokalemia.solution The MUST expansionrate be and adjusted can concentration to only be assure(ii) of a Note KCl the safe that rate a of maximum increase ofthrough in 20 a mEq serum central of sodium venous KCl catheter may be(i) continuously Following infused the per administration hour of insulin,from our a patient’s respiratory respiratory status rate improved up to24 mid-30’s hours breaths per minute down to(ii) mid-20’s Similarly, within patient’s serum total CO (iii) Note, however, close monitoring ofand potassium glucose must be support therapy. done With following the insulin potassium initiation decreased of from insulin a therapy, patient’s serum high of 3.2 mEq/L to 2.7 mEq/L within 7 hours saferserumpotassiumlevelwasdonePRIORtothetreatmentofDKA immediate plan to monitor andhypomagnesemia] correct associated factors with [hypophosphatemia high and ODS riskssevere led and to life-threatening the hypophosphatemia prompt recognition(ii) of In addition to the correctionsupplementation of should concurrent be electrolyte considered disturbances, in thiamine patientsas with thiamine malnutrition deficiency or has alcoholism been implicated(iii) Currentincreasing patient’s in serum sodium the concentration risk improvedpotassium-containing as for ODS fluids planned with only (iv) Aggressive monitoring of both urine(sodium output and and content potassium) of allows effective electrolytes rapid for prompt over intervention correction and of thus hyponatremia prevention of , Table 2: Teaching points box. treatment interactions protocol for the management of hyponatremia: the most to least life-threatening disturbance and treat accordingly. prioritize Additionally, consideration must be made for all possible particularly when the treatment of alife-threatening less condition critical problem can exacerbate a General teaching pointsTreatment of one electrolyte or metabolic abnormality cananother. critically In worsen a patient with multiple disturbances,must a comprehensive management plan Comprehensive (i) Determine osmotic demyelination risks (ODS)(ii) and Assess appropriate rate and of treat correction all correctablehypophosphatemia, ODS altered glucose risks metabolism, (hypokalemia, hypomagnesemia, and clinical(iii) need Understand for that thiamine) potassium can increaseamount serum of sodium sodium exactly is as being if administered (iv) the Monitor same urine output and itsaquaretic content phase of sodium and potassium for any possible KCl is as effective as NaCleven solution required as when potassium volume a is expander critically and deficient may preferred be or Respiratory hyperventilation and metabolic acidosis associatedketoacidosis with alone diabetic may be Comments easily pertinent andinsulin. to promptly Persistent current reversed abnormalities case with should the thus administration promptunderlying an of etiologies evaluation for other 6 Case Reports in Nephrology

In terms of actual hyponatremia correction, the infu- Competing Interests sion of potassium-containing solutions alone was sufficient. Patient’s SNa improved daily at expected rates from the The authors declare that they have no competing interests. predominant infusions of KCl and KPO4 solutions (Table 1). Additionally, as per our routine hyponatremia management References protocol, monitoring of urine output, sodium, and potassium was done at regular intervals. Patient indeed developed [1] I. S. Edelman, J. Leibman, M. P. O’Meara, and L. W. Birkenfeld, a significant aquaretic phase when electrolyte-free water “Interrelations between serum sodium concentration, serum andDDAVPwerepromptlygiventodiverthyponatremia osmolarity and total exchangeable sodium, total exchangeable overcorrection. Significant aquaresis during the treatment of potassium and total body water,” TheJournalofClinicalInvesti- gation,vol.37,no.9,pp.1236–1256,1958. hyponatremia may occur in multiple clinical settings and generally stems from the rapid cessation of ADH secretion [2]B.D.Rose,Ed.,Clinical Physiology of Acid-Base and Electrolyte following the correction of underlying stimuli that induced Disorders,McGraw-Hill,NewYork,NY,USA,4thedition,1994. ADH secretion like correction of volume depletion, nausea, [3]P.-M.T.Pham,P.-A.T.Pham,S.V.Pham,P.-T.T.Pham,P.-T. pain, among others [10]. In current case, the aquaretic phase T. Pham, and P.-C. T. Pham, “Correction of hyponatremia and osmotic demyelinating syndrome: have we neglected to think was likely due to the correction of volume depletion and intracellularly?” Clinical and Experimental Nephrology,vol.19, nausea. no.3,pp.489–495,2015. Hypomagnesemia was likely due to poor oral intake, [4]J.J.Freitag,K.J.Martin,M.B.Conradesetal.,“Evidence gastrointestinal malabsorption, and possibly urinary loss for skeletal resistance to parathyroid hormone in magnesium associated with diabetes mellitus [11]. Patient was monitored deficiency. Studies in isolated perfused bone,” Journal of Clinical closely for hypomagnesemia and treated as needed. Investigation,vol.64,no.5,pp.1238–1244,1979. Thiamine was also supplemented given history of alco- [5] N. Brautbar, H. Leibovici, and S. G. Massry, “On the mecha- holism to minimize ODS risk [4]. nism of hypophosphatemia during acute hyperventilation: evi- Respiratory and metabolic alkalosis on presentation were dence for increased muscle glycolysis,” Mineral and Electrolyte Metabolism,vol.9,no.1,pp.45–50,1983. likely due to pain/anxiety and volume depletion, respectively. Both conditions resolved with comprehensive supportive [6] P. Felig, “Diabetic ketoacidosis,” New England Journal of Medicine,vol.290,no.24,pp.1360–1363,1974. care. [7] L.R.ChaseandE.Slatopolsky,“Secretionandmetabolicefficacy of parathyroid hormone in patients with severe hypomagne- 4. Conclusions semia,” Journal of Clinical Endocrinology and Metabolism,vol. Wepresent a complex case involving multiple life-threatening 38,no.3,pp.363–371,1974. [8] R. K. Rude, S. B. Oldham, and F. R. Singer, “Functional electrolyte and metabolic disturbances which demonstrates − the critical need for prioritization for the treatment of each hypoparathyroidism and parathyroid hormone end organ resistance in human magnesium deficiency,” Clinical abnormality and considerations for all interactions among Endocrinology,vol.5,no.3,pp.209–224,1976. multiple concurrent treatment plans. [9] J. G. Verbalis, S. R. Goldsmith, A. Greenberg et al., “Diagnosis, Aggressive potassium replacement prior to the adminis- evaluation, and treatment of hyponatremia: expert panel rec- tration of insulin for the DKA is vital to prevent worsening of ommendations,” The American Journal of Medicine,vol.126,no. life-threatening hypokalemia. 10, supplement 1, pp. S1–S42, 2013. Both sodium and potassium are equivalent effective [10]P.C.Pham,P.V.Chen,andP.T.Pham,“Overcorrectionof solutes. Hyponatremia can be corrected with the predomi- hyponatremia: where do we go wrong?” American Journal of nant infusion of potassium. Similarly, volume expansion with Diseases,vol.36,no.2,articleno.E12,2000. relatively isotonic KCl solution is as effective as NaCl in [11] P.-C. T. Pham, P.-M. T. Pham, S. V. Pham, J. M. Miller, and P.- current case of severe hypokalemia. T. T. Pham, “Hypomagnesemia in patients with type 2 diabetes,” The treatment of hyponatremia must incorporate correc- Clinical Journal of the American Society of Nephrology,vol.2,no. 2,pp.366–373,2007. tion rate, monitoring, and treatment of all factors (potassium, phosphorus, magnesium, glucose, and thiamine) associated with increased ODS risks. Additionally, during the treatment of hyponatremia, transient aquaresis may arise for various reasons and must be anticipated and immediately treated to avoid rapid overcorrection [11]. Insulin effectively converts ketone bodies to bicarbonate if the former have not been lost in the urine with excessive fluid administration. Despite multiple life-threatening electrolyte and meta- bolic disturbances, patient was discharged within twelve days in good condition and continued to do well at one month follow-up. Teaching points are summarized in Table 2. M EDIATORSof INFLAMMATION

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