By Farahnak Assadi
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Extra info for Clinical decisions in pediatric nephrology: a problem-solving approach to clinical cases
Urine sodium is 10 mEq/l and urine osmolality is 410 mOsml/kg. What orders would you like to write (select all that apply)? A. B. C. D. E. 9% saline, 3 liters/24 hours Administer ADH Intravenous 3% saline, 3 liters/24 hours The correct answers are A, B, and C. It appears that the hyponatremia is due to a combination of reduced intake and antidiuretic hormone (ADH) secretion in response to extra cellular fluid (ECF) volume contraction, pain, and medications. Treatment therefore include restoration of ECF volume with isotonic saline, restriction of free water intakes until the other issues are resolve, and drainage of the abscess.
Because this patient has an almost isotonic urine, what will his free water clearance (CH2 0) be, assuming the patient is ingesting 600 mosm/day? Will he develop hyponatremia? A. B. C. D. E. 017 liter/day Not enough data to calculate the CH2 0 1 Fluid and Electrolyte Disorders 33 The correct answer is A. 17 liter/day It would appear that, with the condition of the patient, he is unable to generate free water. Thus, on a liter of water intake, he should develop hyponatremia. But actually, he does not.
B. C. D. E. Genetic testing Measurement of the ratio of cortisol to cortisone in a 24-hr urine Measurement of urinary 17 (OH) steroid Measurement of plasma aldosterone level Measurement of plasma renin level The correct answers are A and B. Genetic testing can confirm the defect in Liddle’s syndrome. At that point, family members should be evaluated so that any of them with hypertension can receive appropriate treatment. Diagnosis of apparent mineralocorticoid excess syndrome is usually done by demonstration of an excess of free urinary cortisol over free urinary cortisone in a 24-hour urine collection, although genetic testing can identify the congenital defect.