Spectrum Health Lakeland Saint Joseph, MI, United States
Audrey Coventry, MD, Joshua Steele, DO Lakeland HealthCare, Saint Joseph, MI
Introduction: Hyponatremia and volume overload are two common complications of cirrhosis. Several studies have evaluated the efficacy of high-dose furosemide plus hypertonic saline in treating diuretic-resistant congestive heart failure as well as refractory ascites in cirrhosis. However, it has not been studied in patients with cirrhosis without ascites. This regimen was applied to a patient with cirrhosis without ascites or congestive heart failure who was admitted for hyponatremia and anasarca.
Case Description/Methods: A 53 year old female with a past medical history of alcohol abuse presented with edema. She had anasarca with pitting edema through the thighs, abdomen, and arms. Lab work showed a sodium of 117. She was admitted for hyponatremia and anasarca. Further inpatient workup revealed cirrhosis without evidence of ascites or congestive heart failure. Urine studies were consistent with hyponatremia from cirrhosis. Sodium initially improved with normal saline, salt tablets, and albumin, however the anasarca worsened. Furosemide and spironolactone were started which improved the edema, however hyponatremia worsened to 114. Nephrology was then consulted. The patient was started on a regimen studied in heart failure: high-dose intravenous furosemide drip at 750mg daily, 150cc 3% saline twice daily, 1 liter fluid restriction, and potassium supplementation. The anasarca did not improve, but the sodium corrected to 131. The patient was then switched to furosemide 80mg q6h, acetazolamide, and chlorthalidone. Sodium remained stable but anasarca still did not improve. At this time the patient was transferred to a tertiary care center where Hepatology confirmed the diagnosis of alcoholic cirrhosis. The sodium remained stable. The patient was ultimately discharged home with Lasix 40mg BID and a 1500cc fluid restriction.
Discussion: Hypovolemic hyponatremia in cirrhosis can be challenging. Hyponatremia is typically treated with albumin, fluid restriction, and potassium replacement. Standard diuresis regimens include a combination of oral furosemide and spironolactone. In this patient, standard diuresis was not tolerated due to worsening hyponatremia. A regimen of high-dose furosemide plus hypertonic saline, previously studied in patients with congestive heart failure or ascites, corrected the sodium at an appropriate rate. This case demonstrates the possibility of using this regimen for treatment of resistant hyponatremia in cirrhosis.
Audrey Coventry indicated no relevant financial relationships.
Joshua Steele indicated no relevant financial relationships.
Audrey Coventry, MD, Joshua Steele, DO. P2934 - High-Dose Furosemide and Hypertonic Saline: A Novel Regimen to Treat Resistant Hyponatremia in a Patient With Cirrhosis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.