patient was seen by Nephro service. Biopsy was not opted. suggested to initiate RAS for proteinuria.

If I have to start him On RAS , what would you suggest?? ACEI vs ARB???
or ACEI and ARB for this proteinuria ( more than 10 g a day)???

Thanks.

Q22#

A 54-year-old woman comes for a follow-up examination. She was discharged from the hospital 7 days ago after hospitalization for severe shortness of breath. During her hospitalization, a large pleural effusion was found and pleurodesis was performed. At today's visit, she feels tired. She has not had nausea, headache, or irritability and has not vomited. She was diagnosed with metastatic small-cell lung carcinoma 13 months ago and was treated with palliative chemotherapy with a good response. Previous surgeries include two cesarean sections. She also has a 75-pack-year history of cigarette smoking.

On physical examination, her temperature is 36.8 °C (98.2 °F), pulse rate is 84/min, respiratory rate is 18/min, and blood pressure is 126/84 mm Hg. She appears cachectic. Cardiac examination is normal. On pulmonary examination, there are diminished breath sounds in the right base and the left side is clear to auscultation. There is no pedal edema.

Lab: Glucose 6.33 mmol/L, BUN 3.57 mmol/L, Creatinine 53.05 μmol/L,
Sodium 112 mmol/L, Potassium 3.2 mmol/L, Chloride 84 mmol/L, Bicarbonate 21 mmol/L,
Phosphorus 1 mmol/L, Albumin 32 g/L,
Serum osmolality 243 mmol/kg, Urine sodium 120 mmol/L, Urine potassium 24 mmol/L,
Urine osmolality 542 mmol/kg.

Which of the following is the most appropriate therapy at this time? and why???

1)3% saline via infusion pump
2)Demeclocycline
3)Fluid restriction <1 L/d
4)Sodium chloride tablets, 2 g three times daily
5)Hydrochlorothiazide

nnavam wrote:
Q22#


Which of the following is the most appropriate therapy at this time? and why???

1)3% saline via infusion pump
2)Demeclocycline
3)Fluid restriction <1 L/d
4)Sodium chloride tablets, 2 g three times daily
5)Hydrochlorothiazide

This is difficult to answer. The patient has SIADH. Demecocylcine is an ADH antagonist that is used (sparingly) in SIADH. I don't feel it is very reliable. So realistically, fluid restriction might be the most realistic answer.

I might use lasix (to reduce urine osmolality) and replace sodium loss with salt and which will also make the water restriction less as she might now have a net free water loss.

Hi Dr Jordan!!!
Yes, this is a challenging question to me......even though she is asymptomatic,seeing her Na as 112 and only fluid restrict her.. as a poor oncall resident?????

The given answer is Demeclocycline to decrease her urine osmolality to prevent her water-retentive state from worsening.

Agree, as there is no manifestations of hyponatremic encephalopathy, 3% saline in therapy is not appropriate regardless of the degree of hyponatremia.

Other option as you suggested is " useing lasix (to reduce urine osmolality) and replace sodium loss with salt and which will also make the water restriction less as she might now have a net free water loss", which was not given in the question....

They say "fluid restriction would be ineffective at increasing the serum sodium level
as, the urine electrolyte concentration is 144 meq/L (120 + 24), which exceeds the serum electrolyte concentration (111 + 3.6). Therefore, there is no electrolyte-free water clearance occurring.

nnavam wrote:

Agree, as there is no manifestations of hyponatremic encephalopathy, 3% saline in therapy is not appropriate regardless of the degree of hyponatremia.

Actually, there are situaitons where 3% saline could be used in severe SIADH as you have less risk of desalination (the excretion of the sodium and retention of water when IV fluids are administered). So I wouldn't say that 3% saline is never indicated in SIADH