Shakaroun Dania, Nasser Hassan, Munie Semeret, Soman Sandeep
Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA.
Department of Surgery, Henry Ford Hospital, Detroit, MI, USA.
Int J Surg Case Rep. 2019;57:71-73. doi: 10.1016/j.ijscr.2019.03.006. Epub 2019 Mar 19.
Nephrogenic diabetes insipidus occurs in patients on chronic lithium treatment even after lithium discontinuation. Patients affected by this disorder are highly vulnerable to hypernatremia when they cannot respond to their thirst mechanism. We report a rare case of hypernatremia due to undiagnosed nephrogenic diabetes insipidus post esophagectomy in a patient with remote history of lithium use.
A 70-year-old female with past medical history of bipolar disorder, chronic kidney disease and pheochromocytoma underwent an elective esophagectomy for esophageal adenocarcinoma. Lithium was discontinued 10 years prior to her presentation. She was kept nil per os post operatively and subsequently developed altered mental status necessitating intubation. Her sodium level was found to be 156 mmol/L. A water deprivation test and desmopressin trial confirmed nephrogenic diabetes insipidus. Days after dextrose 5% in water infusion, free water flushes through the jejunostomy tube and hydrochlorothiazide, her hypernatremia improved slowly with subsequent improvement in her mental status.
Several mechanisms have been described in literature to explain the persistent damage caused by lithium on the kidneys. When patients lose access to a source of free water and are resuscitated with normal saline post operatively, they are at risk of developing life-threatening hypernatremia. This can be avoided by aggressive hydration with appropriate fluid replacement.
Surgeons should be aware of the persistent renal defects caused by long term lithium use and development of nephrogenic diabetes insipidus even years after medication cessation.
即使停用锂盐，接受慢性锂治疗的患者仍会发生肾性尿崩症。患有这种疾病的患者在无法对口渴机制做出反应时极易发生高钠血症。我们报告了一例罕见的高钠血症病例，该病例发生在一名有锂盐使用史的患者食管切除术后，病因是未被诊断出的肾性尿崩症。
一名70岁女性，有双相情感障碍、慢性肾病和嗜铬细胞瘤病史，因食管腺癌接受择期食管切除术。在她就诊前10年停用了锂盐。术后她禁食禁水，随后出现精神状态改变，需要插管。发现她的钠水平为156 mmol/L。禁水试验和去氨加压素试验证实为肾性尿崩症。在输注5%葡萄糖水、通过空肠造口管进行自由水冲洗并使用氢氯噻嗪几天后，她的高钠血症逐渐改善，精神状态随后也有所改善。
文献中描述了几种机制来解释锂盐对肾脏造成的持续性损害。当患者无法获得自由水源且术后用生理盐水复苏时，他们有发生危及生命的高钠血症的风险。通过积极补液进行适当的液体替代可以避免这种情况。
外科医生应意识到长期使用锂盐导致的持续性肾脏缺陷以及即使在停药数年之后仍可能发生肾性尿崩症。
