Abstract Case Presentation A 29-year-old woman with a history of asthma and normal body mass index was found unresponsive in her locked apartment after four days without contact. She appeared profoundly dehydrated, with dry mucous membranes, cracked lips, and caked oral secretions. Collateral history revealed she had been on an extreme “dry fast,” abstaining from both food and water as part of a cleansing routine. On admission, laboratory values were remarkable for Na 187 mmol/L, Cl 132 mmol/L, BUN 251 mg/dL, Creatinine 14.5 mg/dL, Hgb 19.2 g/dL, Hct 64.8%, Platelets 97 K/µL, CK 33,000 U/L, AST 142 U/L, ALT 119 U/L, and Glucose 182 mg/dL. Toxicology screening was negative for methanol, ethylene glycol, and recreational drugs. She was encephalopathic and oliguric. Nephrology diagnosed severe oliguric acute kidney injury secondary to rhabdomyolysis and profound volume depletion. Hospital Course Slow low-efficiency dialysis (SLED) was initiated to manage uremia and extreme hypernatremia. Shortly after initiation, the patient developed sudden pulmonary edema and hypoxemia, necessitating intubation and vasopressor support. She was transferred for advanced management and placed on veno-venous extracorporeal membrane oxygenation (VV-ECMO) for inability to oxygenate despite maximal ventilator support. Infectious work-up subsequently revealed Staphylococcus pneumonia and Enterococcus urinary infection. She was managed with continuous renal replacement therapy (CRRT), gradual sodium correction, and broad-spectrum antibiotics. Discussion Although profoundly dehydrated, the patient developed pulmonary edema due to rapid osmotic disequilibrium during dialysis. When solute removal (notably urea) exceeds the rate at which water can equilibrate across cell membranes, intracellular water shifts into tissues such as the lungs and brain, resulting in edema despite systemic hypovolemia. Additional factors including capillary leak from sepsis, endothelial injury from rhabdomyolysis, and transient myocardial dysfunction exacerbated the presentation. This represents an atypical form of dialysis disequilibrium syndrome manifesting with pulmonary rather than neurologic compromise. Conclusion Extreme dry fasting can precipitate life-threatening hypernatremia, rhabdomyolysis, and acute kidney injury. Dialysis in this setting must employ slow, carefully titrated solute correction to prevent osmotic shifts and paradoxical pulmonary edema. Early multidisciplinary involvement is essential to optimize outcomes. This abstract is funded by: None
Philip et al. (Fri,) studied this question.