How to manage a patient with hyponatremia, impaired renal function (Chronic Kidney Disease, CKD), and a history of hypertension who presented with a fall?

From the Guidelines

Managing a patient with hyponatremia, CKD, and hypertension who has fallen requires a comprehensive approach addressing all conditions simultaneously, with a focus on correcting hyponatremia, controlling blood pressure, and preventing further falls. The patient's serum sodium level is 127 mEq/L, which is considered moderate hyponatremia. According to the guidelines 1, fluid restriction to 800-1000 mL/day is appropriate for moderate hyponatremia, while avoiding rapid correction (no more than 8-10 mEq/L in 24 hours) to prevent osmotic demyelination syndrome. For hypertension management, ACE inhibitors like lisinopril (5-10 mg daily) or ARBs like losartan (25-50 mg daily) are preferred as they provide renoprotection for CKD patients 1. However, the target systolic blood pressure should be individualized, and the KDIGO-recommended target of <120 mm Hg may not be suitable for all patients, especially those with multimorbidity and frailty 1. Some key points to consider in managing this patient include:

• Evaluating medications that may contribute to hyponatremia, particularly thiazide diuretics, which should be discontinued if possible 1
• Assessing fall risk factors, including orthostatic hypotension, which can be exacerbated by antihypertensives, and considering physical therapy referral
• Monitoring renal function with regular creatinine and eGFR measurements, adjusting medication dosages accordingly
• Implementing dietary sodium restriction (2-3 g/day) to manage both hypertension and hyponatremia, while moderating protein intake based on CKD stage. By taking a comprehensive approach, addressing the interconnected nature of these conditions, and prioritizing the patient's individual needs, we can improve outcomes and reduce the risk of further complications.

From the FDA Drug Label

Midodrine use has not been studied in patients with renal impairment Because desglymidodrine is eliminated via the kidneys, and higher blood levels would be expected in such patients, midodrine should be used with caution in patients with renal impairment, with a starting dose of 2. 5 mg [seeDOSAGE AND ADMINISTRATION]. Renal function should be assessed prior to initial use of midodrine.

The patient has hyponatremia and impaired renal function (CKD). When considering the use of midodrine, caution should be exercised due to the potential for increased blood levels of desglymidodrine in patients with renal impairment.

• Renal function should be assessed prior to initial use of midodrine.
• A starting dose of 2.5 mg is recommended for patients with renal impairment.
• The patient's hyponatremia and CKD should be carefully managed, and midodrine should be used with caution to avoid exacerbating these conditions.
• Blood pressure should be closely monitored when using midodrine, especially in patients with a history of hypertension 2.

From the Research

Patient Management

The patient is a 92-year-old male with a past medical history of hypertension, presenting with hyponatremia (sodium level of 127 mEq/L), impaired renal function (Chronic Kidney Disease, CKD), and a history of falls. The management of this patient should be based on the underlying cause of hyponatremia and the patient's volume status.

• Classification of Hyponatremia: Hyponatremia can be classified as hypovolemic, euvolemic, or hypervolemic based on the patient's volume status 3.
• Treatment Approach: The treatment approach should consist of treating the underlying cause of hyponatremia, and the patient's volume status should be taken into account 4, 5.
• Mild Hyponatremia: Mild hyponatremia (sodium level 130-134 mEq/L) can be managed by restricting free water intake and treating the underlying cause 5.
• Moderate to Severe Hyponatremia: Moderate to severe hyponatremia (sodium level < 130 mEq/L) requires more aggressive treatment, including the use of hypertonic saline and vasopressin antagonists 4, 3.
• Correction Rate: The correction rate of sodium level should be carefully monitored to avoid overly rapid correction, which can cause osmotic demyelination syndrome 4, 6.
• CKD Considerations: In patients with CKD, the management of hyponatremia should take into account the patient's renal function and the potential for worsening renal function with certain treatments 7.

Laboratory Results

The patient's laboratory results show a sodium level of 127 mEq/L, potassium level of 4.4 mEq/L, and a creatinine level of 1.60 mg/dL, indicating impaired renal function.

• Hyponatremia: The patient's hyponatremia is classified as moderate (sodium level 125-129 mEq/L) 5.
• CKD: The patient's CKD is stage 3 (eGFR 40 mL/min/1.73 m^2) 7.
• Electrolyte Imbalance: The patient's electrolyte imbalance should be carefully monitored and managed to avoid further complications.

Fall Risk

The patient's history of falls and current presentation with a fall should be taken into account when managing the patient's hyponatremia and CKD.

• Fall Risk Assessment: A fall risk assessment should be performed to identify potential risk factors and implement strategies to reduce the risk of future falls 4.
• Gait Disturbances: The patient's gait disturbances should be evaluated and managed to reduce the risk of falls 4.