The Effectiveness of Sequential Intravenous Saline and Oral Water Loading Tests and Barsoum-Levine Formula for Managing Hyponatremic Patients: 2 Case Reports / 대한신장학회지

In hyponatremic patients, the assessment of extracellular fluid volume plays an essential step in diagnosing the etiology of hyponatremia and deciding how to manage it. Although various laboratory tests and diagnostic procedures have been developed for differential diagnosis of hyponatremia, there still are limits to the evaluation of the status of extracellular fluid volume due to the data that overlaps each other, leading to the difficulty in diagnosing between euvolemia and hypovolemia. Also, there is no consensus about how to guide the type and amount of fluid therapy despite many formulas including Adrogue-Madias and Barsoum-Levine formulas have been suggested. Hereby, we are reporting two hyponatremic patients (102 and 105 mEq/L) admitted simultaneously with indistinct volume status on initial clinical and laboratory examinations, but were clarified as euvolemic hyponatremia (syndrome of inappropriate antidiuretic hormone secretion) in one and hypovolemic hyponatremia in the other case after sequential intravenous saline (2 L over 24 hrs) and oral water (20 mL/kg) loading tests. When serum sodium values calculated by the above-mentioned two formulas were compared with actually measured ones during saline loading test in these cases, the Barsoum-Levine formula revealed almost no discrepancy between both the values while the Adrogue-Madias formula underestimated the measured value.

Varying Dialysate Bicarbonate Concentrations in Maintenance Hemodialysis Patients Affect Post-dialysis Alkalosis but not Pre-dialysis Acidosis

This study aimed to assess the effects of different dialysate bicarbonate concentrations in correcting acid-base imbalance in 53 stable hemodialysis patients in a university-hemodialysis unit. Three different bicarbonate concentrations were assigned, i.e. 25 mEq/L in 10, 30 mEq/L in 30, and 35 mEq/L in 13 patients. Blood gas analyses from arterial line blood samples before and after dialysis in the mid-week were performed for the determination of pH and serum bicarbonate concentration ([HCO3-]). The mean values of predialysis arterial [HCO3-] were mildly acidotic in all 3 groups, but not significantly different among them, whereas those of post-dialysis arterial [HCO3-] were alkalotic, especially in the group of 35 mEq/L as compared with the other two groups. The mean blood pH was not significantly different among the 3 groups. As expected, there was a positive correlation between pre-dialysis pH and post-dialysis pH (r=0.45, p=0.001), and pre-dialysis [HCO3-] and post-dialysis [HCO3-] (r=0.58, p=0.000), but with a negative correlation between pre-dialysis [HCO3-] and the increment of intradialytic [HCO3-] following hemodialysis (r=-0.46, p=0.001). In conclusion, this study shows that the impact of conventional dialysate bicarbonate concentrations ranging from 25 to 35 mEq/L is not quite different on the mild degree of predialysis acidemia, but the degree of postdialysis alkalemia is more prominent in higher bicarbonate concentrations. Base supply by hemodialysis alone does not seem to be the main factor to determine the predialysis acidosis in end-stage renal disease patients on chronic maintenance hemodialysis.

A Case of Paraneoplastic Limbic Encephalitis Associated with Primary Adenocarcinoma of Lung / 결핵및호흡기질환

Paraneoplastic limbic encephalitis is a rare disorder that is characterized by personality changes, irritability, depression, seizures, memory loss and dementia, and is commonly associated with small cell lung cancer. The cause is unknown but it is believed to be an autoimmune disorder that develops secondary to a carcinomatous process. We report a patient with the clinical feature consistent with limbic encephalitis. A 64-year-old women developed disorientation, memory loss and general weakness. She was diagnosed with NSCLC (adenocarcinoma) with a brain metastasis 1 year earlier and was treated with radiation and chemotherapy. Although the lung mass and brain metastatic lesions had improved, the brain T2-weighted MRI showed high signal intensity in the right temporal region. This lesion consisted of with limbic encephalitis and was negative to the other viral and immune markers. The patient's symptoms did not improve after steroid treatment. Our case demonstrated that a NSCLC (adenocarcinoma) also can be associated with paraneoplastic limbic encephalitis.