Intravenous albumin infusion is an effective therapy for hyponatremia in patient with malignant ascites
A 58-year-old African American female was referred to renal service with hyponatremia and a 2-day history of weakness, anorexia and headache. The patient had a medical history significant for metastatic breast cancer and ascites requiring frequent therapeutic paracentesis. On physical exam, the patient was noted to have marked ascites with a prominent fluid wave and bulging flanks, bilateral pitting edema below the knees. Her vitals were significant for a pulse of 78 beats/min, blood pressure of 102/68 mm/Hg. Significant laboratory studies included a white blood cell count of 4.3 × 109/L, aspartate transaminase of 111 U/L, alanine transaminase of 49 U/L, albumin of 2.4 g/dl, serum sodium concentration of 121 mEq/L, and serum osmolality of 260 mosm/kg. Patient's serum sodium was 130-131 mEq/L at baseline. However, in the past 3 days, she was given dextrose 5% in 0.45% normal saline (D5 ½ NS) infusion because of her poor oral intake. Urine electrolytes showed urine sodium concentration of <10 mmol/L, and the urine osmolality was 412 mos/kg. Computed tomography scan of the abdomen and pelvis showed innumerable metastasis throughout the liver. A liver sonogram ruled out Budd Chiari's syndrome. The low urinary sodium is consistent with low effective circulating volume depletion, in this case, secondary to large amount of ascites and cirrhotic state. The urine osmolality of 412 mos/kg indicated an inability to normally excrete free water, likely because of persistent secretion of ADH (SIADH). Therefore, a diagnosis of hypervolemic hyponatremia in the setting of liver metastasis was made. SIADH was excluded based on the volume status of the patient (not euvolemic).\nThe patient was treated with 100 ml 25% albumin intravenous infusion every 8 h for 2 days for her symptomatic hyponatremia. She was on fluid restriction to <1200 cc/day and appropriately with sodium restriction to less than 2300 mg/day. Her serum sodium concentration increased to 134 mEq/L over 48 h [] and her weakness, anorexia, and headache significantly improved. She was discharged from the hospital with recommendations for fluid restriction. Her serum sodium concentration maintained in the range of 134-140 mEq/L in the next 2 months after her discharge.