Abstract: PUB097
Empagliflozin Associated Severe Hypernatremia in the Setting of Subclinical Diabetes Insipidus: A Case Report
Session Information
Category: Diabetic Kidney Disease
- 602 Diabetic Kidney Disease: Clinical
Authors
- Ahmed, Maha, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, United States
- Truong, Tai, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States
- Block, Clay A., Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States
Group or Team Name
- Dartmouth Geisel School of Medicine
Introduction
SGLT2i are an important class of drug in the management of diabetes, diabetic nephropathy, chronic kidney disease and heart failure. We describe a case in which the introduction of empagliflozin resulted in severe hypernatremia by unmasking previously unrecognized chronic lithium induced nephrogenic diabetes insipidus (NDI).
Case Description
A 67-year-old veteran with longstanding hypertension, obesity, chronic kidney disease stage 3A, and bipolar disorder on lithium was admitted for management of a hyperosmolar hyperglycemic state with glucose levels exceeding 900 mg/dL. The corrected sodium concentration was 153 mEq/L. After treatment with insulin and IV fluid, the patient was discharged on metformin and 10mg of empagliflozin. Lithium was discontinued and sodium valproate was initiated. On discharge glucose concentration was 267 mg/dL, serum sodium 148 mEq/L, and creatinine 1.41 mg/dL.
Four days after discharge, the patient returned with worsening fatigue, confusion, polyuria, and polydipsia. Serum chemistries revealed glucose level at 267 mg/dL, serum sodium at 156 mEq/L, serum osmolarity 338 Osm/L, creatinine 2.08 mg/dL, urine sodium 38 mEq/L, urine osmolarity was 500 Osm/L, and urine glucose concentration greater than 500 mg/dL (beyond detected range). Hydration was provided along with insulin; empagliflozin was discontinued. Serum sodium continued to climb to a peak of 161 mEq/L on hospital day 4 and subsequently improved. Glycemic control was achieved with glipizide. Despite resolution of his hyperglycemia, polyuria persisted. Daily urine specific gravity measurements were below 1.005 and urine osmolality was less than 200 mosmol/kg. NDI was inferred related to his history of long standing lithium use. Hydrochlorothiazide and a low salt diet were initiated. On hospital day 10, his serum sodium level remained stable at 144 mEq/L without need of intravenous fluid. Follow up sodium level 1 month later was 142 mEq/L.
Discussion
In this clinical vignette, we described a patient who developed severe hypernatremia in the setting of diabetes mellitus and concurrent diabetes insipidus. To our knowledge, our case report is the first to describe severe hypernatremia with empagliflozin in a patient with diabetes insipidus and uncontrolled diabetes mellitus.