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Jung Y, Nelson HA, Lin DMH. Use of therapeutic plasma exchange to remove lipoprotein X in a patient with vanishing bile duct syndrome presenting with cholestasis, pseudohyponatremia, and hypercholesterolemia: A case report and review of literature. J Clin Apher 2024; 39:e22105. [PMID: 38334173 DOI: 10.1002/jca.22105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 12/21/2023] [Accepted: 12/26/2023] [Indexed: 02/10/2024]
Abstract
INTRODUCTION Lipoprotein X (Lp-X) is an abnormal lipoprotein found in multiple disease conditions, including liver dysfunction and cholestasis. High Lp-X concentrations can interfere with some laboratory testing that may result in spurious results. The detection of Lp-X can be challenging, and there is currently a lack of consensus regarding the management of Lp-X other than treating the underlying disease. CASE PRESENTATION A 42-year-old female with Hodgkin's lymphoma treated with dexamethasone, high dose cytarabine and cisplatin and vanishing bile duct syndrome confirmed by liver biopsy presented with cholestasis, pseudohyponatremia (sodium, 113 mmol/L; reference range 136-146 mmL/L; serum osmolality, 303 mOsm/kg), and hypercholesterolemia (> 2800 mg/dL, reference range < 200 mg/dL). Lp-X was confirmed by lipoprotein electrophoresis (EP). Although she did not manifest any specific signs or symptoms, therapeutic plasma exchange (TPE) was initiated based on laboratory findings of extreme hypercholesterolemia, spuriously abnormal serum sodium, and HDL values, and the potential for short- and long-term sequelae such as hyperviscosity syndrome, xanthoma, and neuropathy. During the hospitalization, she was treated with four 1.0 plasma volume TPE over 6 days using 5% albumin for replacement fluid. After the first TPE, total cholesterol (TC) decreased to 383 mg/dL and sodium was measured at 131 mmol/L. The patient was transitioned into outpatient maintenance TPE to eliminate the potential of Lp-X reappearance while the underlying disease was treated. Serial follow-up laboratory testing with lipoprotein EP showed the disappearance of Lp-X after nine TPEs over a 10-week period. LITERATURE REVIEW There are seven and four case reports of Lp-X treated with TPE and lipoprotein apheresis (LA), respectively. While all previous case reports showed a reduction in TC levels, none had monitored the disappearance of Lp-X after completing a course of therapeutic apheresis. CONCLUSION Clinicians should have a heightened suspicion for the presence of abnormal Lp-X in patients with cholestasis, hypercholesterolemia, and pseudohyponatremia. Once Lp-X is confirmed by lipoprotein EP, TPE should be initiated to reduce TC level and remove abnormal Lp-X. Most LA techniques are not expected to be beneficial since Lp-X lacks apolipoprotein B. Therefore, we suggest that inpatient course of TPE be performed every other day until serum sodium, TC and HDL levels become normalized. Outpatient maintenance TPE may also be considered to keep Lp-X levels low while the underlying disease is treated. Serum sodium, TC, and HDL levels should be monitored while on maintenance TPE.
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Affiliation(s)
- Yujung Jung
- Bloodworks Northwest, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Heather A Nelson
- Department of Pathology, University of Utah Health, Salt Lake City, Utah, USA
- ARUP Institute for Clinical and Experimental Pathology®, Salt Lake City, Utah, USA
| | - David Ming-Hung Lin
- Bloodworks Northwest, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
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Aziz F, Sam R, Lew SQ, Massie L, Misra M, Roumelioti ME, Argyropoulos CP, Ing TS, Tzamaloukas AH. Pseudohyponatremia: Mechanism, Diagnosis, Clinical Associations and Management. J Clin Med 2023; 12:4076. [PMID: 37373769 DOI: 10.3390/jcm12124076] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/08/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Pseudohyponatremia remains a problem for clinical laboratories. In this study, we analyzed the mechanisms, diagnosis, clinical consequences, and conditions associated with pseudohyponatremia, and future developments for its elimination. The two methods involved assess the serum sodium concentration ([Na]S) using sodium ion-specific electrodes: (a) a direct ion-specific electrode (ISE), and (b) an indirect ISE. A direct ISE does not require dilution of a sample prior to its measurement, whereas an indirect ISE needs pre-measurement sample dilution. [Na]S measurements using an indirect ISE are influenced by abnormal concentrations of serum proteins or lipids. Pseudohyponatremia occurs when the [Na]S is measured with an indirect ISE and the serum solid content concentrations are elevated, resulting in reciprocal depressions in serum water and [Na]S values. Pseudonormonatremia or pseudohypernatremia are encountered in hypoproteinemic patients who have a decreased plasma solids content. Three mechanisms are responsible for pseudohyponatremia: (a) a reduction in the [Na]S due to lower serum water and sodium concentrations, the electrolyte exclusion effect; (b) an increase in the measured sample's water concentration post-dilution to a greater extent when compared to normal serum, lowering the [Na] in this sample; (c) when serum hyperviscosity reduces serum delivery to the device that apportions serum and diluent. Patients with pseudohyponatremia and a normal [Na]S do not develop water movement across cell membranes and clinical manifestations of hypotonic hyponatremia. Pseudohyponatremia does not require treatment to address the [Na]S, making any inadvertent correction treatment potentially detrimental.
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Affiliation(s)
- Fahad Aziz
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA
| | - Ramin Sam
- Department of Medicine, Zuckerberg San Francisco General Hospital, School of Medicine, University of California in San Francisco, San Francisco, CA 94110, USA
| | - Susie Q Lew
- Department of Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC 20052, USA
| | - Larry Massie
- Department of Pathology, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM 87108, USA
| | - Madhukar Misra
- Department of Medicine, Division of Nephrology, University of Missouri, Columbia, MO 65211, USA
| | - Maria-Eleni Roumelioti
- Department of Medicine, Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA
| | - Christos P Argyropoulos
- Department of Medicine, Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA
| | - Todd S Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, USA
| | - Antonios H Tzamaloukas
- Research Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM 87108, USA
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Datta SK, Chopra P. Interference in Ion-Selective Electrodes Due to Proteins and Lipids. J Appl Lab Med 2021; 7:589-595. [PMID: 34751739 DOI: 10.1093/jalm/jfab125] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/13/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Ion-selective electrodes (ISE) have become the mainstay of electrolyte measurements in the clinical laboratory. In most automated analyzers used in large diagnostic laboratories, indirect ISE (iISE) -based electrolyte estimation is done; whereas direct ISE (dISE) -based equipment are mostly used in blood gas analyzers and in the point-of-care (PoC) setting. CONTENT Both the techniques, iISE as well as dISE, are scientifically robust; however, the results are often not interchangeable. Discrepancy happens between the two commonly due to interferences that affect the two measuring principles differently. Over the last decade, several studies have reported discrepancies between dISE and iISE arising due to abnormal protein and lipid contents in the sample. SUMMARY The present review endeavors to consolidate the knowledge accumulated in relation to interferences due to abnormal protein and lipid contents in sample with the principal focus resting on probable solutions thereof.
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Affiliation(s)
- Sudip Kumar Datta
- Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Parul Chopra
- Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India
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Hansen RS, Revsholm J, Motawea M, Folkestad L. Pseudohyponatraemia caused by acute pancreatitis-derived hypertriglyceridaemia. BMJ Case Rep 2021; 14:14/4/e241806. [PMID: 33875511 PMCID: PMC8057565 DOI: 10.1136/bcr-2021-241806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of pseudohyponatraemia due to severe hypertriglyceridaemia-induced acute pancreatitis, stemming from unknown diabetes. A woman in her late 30s was admitted to the local hospital by her general practitioner due to severe hyponatraemia (116 mmol/L) and upper abdominal pain. At admission to the hospital, there was a discrepancy of 19 mmol/L between arterial and venous sodium, along with severe hypertriglyceridaemia and hypercholesterolaemia. Pancreatitis was diagnosed using a CT scan. The patient received plasmapheresis which significantly reduced triglycerides, and venous plasma sodium was normalised indicating pseudohyponatraemia at admission. Finally, a haemoglobin A1c of 83 mmol/mol was found. Diabetes was diagnosed, and insulin was initiated.
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Affiliation(s)
- Rasmus Søgaard Hansen
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Jesper Revsholm
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Mohammad Motawea
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Lars Folkestad
- Department of Endocrinology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Syddanmark, Denmark
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Igbinedion SO, Pandit S, Mavuram MS, Boktor M. Pseudohyponatraemia secondary to hyperlipidaemia in obstructive jaundice. BMJ Case Rep 2017; 2017:bcr-2017-221984. [PMID: 29196308 DOI: 10.1136/bcr-2017-221984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 44-year-old man with uncontrolled diabetes and chronic pancreatitis presented with abdominal pain, jaundice and unintentional weight loss. Laboratory investigations were significant for hyponatraemia, an obstructive pattern of liver enzymes. Imaging was consistent with intrahepatic and extrahepatic biliary obstruction, and endoscopic evaluation revealed a long common bile duct stricture. Intravascular volume depletion, beer potomania and syndrome of inappropriate antidiuretic hormone (with concern for biliary or pancreatic malignancy) were considered in the work-up for the aetiology of the hyponatraemia. After 4 days of conventional treatment, hyponatraemia persisted. Lipid panel obtained revealed very high levels of total cholesterol. The patient underwent a successful biliary diversion and reconstruction surgery. Follow-up after 3 months showed a clinically stable patient with resolution of elevated liver enzymes, hyperlipidaemia and hyponatraemia. We illustrate this rare case of hyponatraemia secondary to hyperlipidaemia in obstructive biliary cholestasis. It is important for physicians to thoroughly investigate the aetiology of hyponatraemia at its onset.
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Affiliation(s)
| | - Sudha Pandit
- Gastroenterology and Hepatology, LSU HSC Shreveport, Shreveport, Louisiana, USA
| | - Meher S Mavuram
- Internal Medicine, LSU HSC Shreveport, Shreveport, Louisiana, USA
| | - Moheb Boktor
- Gastroenterology and Hepatology, LSU HSC Shreveport, Shreveport, Louisiana, USA
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Phatlhane DV, Zemlin AE. Severe hypercholesterolemia mediated by lipoprotein X in a patient with cholestasis. Ann Hepatol 2016; 14:924-8. [PMID: 26436366 DOI: 10.5604/16652681.1171785] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Lipoprotein X (LpX) is an abnormal lipoprotein associated with cholestasis. It is a significant cause of severe hypercholesterolemia and should always be considered in patients with cholestatic liver disease. This case highlights the significance of LpX as a cause of severe hypercholesterolemia in a patient with cholestasis secondary to a granulomatous hepatitis attributed to tuberculosis. Lipoprotein agarose gel electrophoresis and gradient gel electrophoresis were performed for the detection of LpX. The liver function tests, electrolytes, lipid profile and bile acids were also determined. Anti-tuberculous therapy was initiated and the liver functions improved with normalisation of the lipid profile.
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Affiliation(s)
- Dineo V Phatlhane
- Department of Chemical Pathology, National Health Laboratory Service (NHLS) and University of Stellenbosch, Tygerberg Hospital, Cape Town, South Africa
| | - Annalise E Zemlin
- Department of Chemical Pathology, National Health Laboratory Service (NHLS) and University of Stellenbosch, Tygerberg Hospital, Cape Town, South Africa
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Hussain I, Ahmad Z, Garg A. Extreme hypercholesterolemia presenting with pseudohyponatremia - a case report and review of the literature. J Clin Lipidol 2014; 9:260-4. [PMID: 25911084 DOI: 10.1016/j.jacl.2014.11.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 11/10/2014] [Accepted: 11/22/2014] [Indexed: 12/18/2022]
Abstract
Pseudohyponatremia has been reported in association with severe hypertriglyceridemia and hyperparaproteinemia, but its association with severe hypercholesterolemia is not well-known. We report a 43-year-old woman with refractory primary biliary cirrhosis who presented with asymptomatic hyponatremia (121 mmol/L; normal range: 135-145 mmol/L). She was ultimately found to have a total serum cholesterol level of 2415 mg/dL (normal range: 120-199 mg/dL) - secondary to accumulation of lipoprotein-X-causing pseudohyponatremia. The diagnosis was confirmed by measurement of serum osmolality (296 mOsm/kg H2O; normal range: 270-300 mOsm/kg H2O) and serum sodium by direct potentiometry (141 mmol/L). Furthermore, following 16 sessions of plasmapheresis over a 4-month period, there was marked lowering of serum cholesterol to 200 mg/dL and normalization of serum sodium (139 mmol/L) as measured by indirect potentiometry. This case shows that extreme hypercholesterolemia from elevation of lipoprotein-X particles in cholestasis can be a rare cause of pseudohyponatremia. It highlights the need to measure serum sodium with direct potentiometry in the setting of extreme hypercholesterolemia and consider this possibility before initiating treatment of hyponatremia.
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Affiliation(s)
- Iram Hussain
- Division of Nutrition and Metabolic Diseases, Department of Internal Medicine, Center of Human Nutrition, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Zahid Ahmad
- Division of Nutrition and Metabolic Diseases, Department of Internal Medicine, Center of Human Nutrition, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Abhimanyu Garg
- Division of Nutrition and Metabolic Diseases, Department of Internal Medicine, Center of Human Nutrition, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Sivakumar T, Chaidarun S, Lee HK, Cervinski M, Comi R. Multiple lipoprotein and electrolyte laboratory artifacts caused by lipoprotein X in obstructive biliary cholestasis secondary to pancreatic cancer. J Clin Lipidol 2011; 5:324-8. [DOI: 10.1016/j.jacl.2011.04.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 04/07/2011] [Accepted: 04/08/2011] [Indexed: 11/30/2022]
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Abstract
Factitiously low sodium estimations are a hazard in most modern clinical laboratories. Most modern high-throughput analyzers use indirect ion-selective electrodes to estimate electrolyte concentrations in serum samples. This analysis is preceded by a dilution step of the sample. If the water concentration is altered by the presence of increased lipid or protein, the dilution step and the subsequent calculation of concentration by the analyzer results in a falsely low sodium value. This places patients at risk, particularly if the factitious result is acted upon by the physician. In this short review, we highlight this problem and review the methodology and situations where this artifact can occur and discuss strategies to circumvent this problem. When factitious results are suspected, whole blood sodium can be assessed using a direct ion-selective electrode, by measurement of osmolality, or by calculation of the serum water fraction and applying a correction to the reported value.
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Affiliation(s)
- Philip Fortgens
- Division of Chemical Pathology, University of Cape Town and National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
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Kettritz R, Elitok S, Koepke ML, Kuchenbecker J, Schneider W, Luft FC. The case: the eyes have it! Kidney Int 2009; 76:465-6. [PMID: 19644489 DOI: 10.1038/ki.2009.235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Ralph Kettritz
- Franz-Volhard Clinic Nephrology Section, HELIOS Klinkum Berlin, Berlin, Germany.
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Cristol JP, Balint B, Canaud B, Daurés MF. Méthodes de dosage du sodium dans les liquides biologiques. Nephrol Ther 2007; 3 Suppl 2:S104-11. [DOI: 10.1016/s1769-7255(07)80017-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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