Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Case Reports
. 2023 Apr 12:11:61-65.
doi: 10.5414/CNCS110854. eCollection 2023.

Moderate hyperosmolar hyponatremia caused by excessive off-label use of icodextrin during peritoneal dialysis

Harshad Chaudhari  1 , Smita Mahendrakar  1 , Apokbo Akporotu  1 , Michael Yudd  2
Affiliations
Case Reports

Moderate hyperosmolar hyponatremia caused by excessive off-label use of icodextrin during peritoneal dialysis

Harshad Chaudhari et al. Clin Nephrol Case Stud. .

Abstract

Icodextrin use during the long dwell of a peritoneal dialysis (PD) regimen is commonly used to increase ultrafiltration. Its use may cause a mild and clinically insignificant degree of hyponatremia. We describe a patient who was admitted twice to our medical center on an atypical continuous ambulatory peritoneal dialysis (CAPD) regimen utilizing solely icodextrin with 2 exchanges (12-hour dwells). On both admissions, he had hyperosmolar hyponatremia in the 120-mmol/L range with a large osmolal gap. After icodextrin was stopped and his PD prescription was switched to dextrose solutions, both hyponatremia corrected and the osmolal gap quickly disappeared. The accumulation of osmotically active solute in extracellular fluids results in efflux of water from the cellular compartment and produces both hyponatremia and hypertonicity [1]. This tonic effect occurs most frequently with hyperglycemia, but other substances can also cause this, including mannitol, sorbitol, glycine, and maltose [1, 2]. In this report, we present a patient with end-stage renal disease (ERSD) on an atypical off-label PD regimen utilizing solely icodextrin solutions who developed hyperosmolar hyponatremia in the 120-mmol/L range, with a large osmolal gap. This appeared to be due to absorbed metabolites of icodextrin, mainly maltose.

Keywords: hyponatremia; icodextrin; osmolal gap; peritoneal dialysis.

PubMed Disclaimer

Conflict of interest statement

None of the authors involved writing this paper has any conflict of interest. Table 1.Serum chemistries, osmolalities, and osmolal gap during two admissions. TimeSodium (mmol/L)Glucose (mmol/L)Urea (mmol/L)Measured plasma OSm (mOsm/kg H2O)*Calculated plasma OSm (mOsm/kg H2O)**Osmolal gap (mosm/L)***First admission Day 11265.327.5284 Day 21264.823.93 Day 31314.823.2130729017 Day 9131524.6430629214Second admission Day 11225.329.28 Day 21224.631.4230527827 Day 31246.128.2130828226 Day 71285.124.28Icodextrin stopped 1.5%g dextrose solution Day 11304.321.782942859 Day 61345.218.932922920 Day 81355.318.93Throughout the first admission and the first week of second admission patient received solely icodextrin solutions at peritoneal dialysis. Then icodextrin solution was discontinued and replaced with 1.5% dextrose solutions. *The measured plasma osmolarity (pOsm) was performed utilizing the freezing point depression. **pOsm was calculated by the formula: pOsm = 2 (Na) + glucose (mmol/L) + urea (mmol/L). ***The osmolal gap was calculated as the difference of the osmolalities (measured pOsm – calculated pOsm). Figure 1Linear regression analysis of serum sodium and the plasma osmolal gap (osmolal gap = calculated – measured plasma osmolality). Table 2.Reported decrease in serum Na+ concentration with icodextrin use in peritoneal dialysis. AuthorYearDecrease in serum Na+ level (mEq/L)Dwell timeGradden et al. [5]2001Diabetics: 3.17; nondiabetics: 5.19Long single dwell time (unspecified)Gokal et al. [11]20023.68-hour overnight dwellPlum et al. [12]20023 – 7Mean long dwell time: 13.4 ± 1.2 hoursWolfson et al. [13]20022.8Long dwell (dwell time, 8 to 16 hours)Dimitriadis et al. [14]20143.5Not specifiedOlszowska et al. [10]20192.216-hour dwell

Figures

Figure 1
Figure 1. Linear regression analysis of serum sodium and the plasma osmolal gap (osmolal gap = calculated – measured plasma osmolality).
See this image and copyright information in PMC

Similar articles

See all similar articles

References

    1. Palevsky PM Rendulic D Diven WF Maltose-induced hyponatremia. Ann Intern Med. 1993; 118: 526–528. - PubMed
    1. Rhee CM Ayus JC Kalantar-Zadeh K Hyponatremia in the dialysis population. Kidney Int Rep. 2019; 4: 769–780. - PMC - PubMed
    1. Silver SA Harel Z Perl J Practical considerations when prescribing icodextrin: a narrative review. Am J Nephrol. 2014; 39: 515–527. - PubMed
    1. Uribarri J Prabhakar S Kahn T Hyponatremia in peritoneal dialysis patients. Clin Nephrol. 2004; 61: 54–58. - PubMed
    1. Gradden CW Ahmad R Bell GM Peritoneal dialysis: new developments and new problems. Diabet Med. 2001; 18: 360–363. - PubMed

Publication types

LinkOut - more resources