UNIVERSTIY OF MALAWI

COLLEGE OF MEDICINE

FACULTY OF MEDICINE
Bsc MEDICAL LAB TECHNOLOGY
YEAR 4

CLINICAL CHEMISTRY CASE REPORT 2

WATER, ELECTROLYTES AND ACID BASE BALANCE

GROUP 2
PATRIC MBULAJE (MC/MLT/06/32)
ENOCH MAULANA (MC/MLT/06/31)
CHIFUNDO SOKO (MC/MLT/06/36)

DATE OF SUBMISSION
19TH June 16, 2009
Clinical presentation
A 56 year old man diagnosed with oat cell carcinoma of the lung develops progressive
lethargy and confusion.

Laboratory findings
Laboratory investigation produced the following results.

ELEMENT RESULT OBTAINED NORMAL RANGE

MEASURED
Sodium 119 mmol/l 135-145 mmol/l

Potassium 4.6 mmol/l 3.6-5.0 mmol/l

Urea 5.0 mmol/l 3.3-6.7 mmol/l

Chloride 77 mmol/l 98-107 mmol/l

Bicarbonate 26 mmol/l 22-30 mmol/l

Glucose 6.2 mmol/l 2.0-6.7 mmol/l

Ur osmolality 857 mOsm/kg 300-900 mOsm/kg

Comment on laboratory findings

Plasma sodium levels are low and urine osmolality is close to upper limit.
This is suggestive of hyponatremia.

Possible causes of the abnormality

In health sodium concentration in the body is controlled by Antideuretic Hormone
secreted by the pituitary gland in the hypothalamus. Increase in plasma osmolality which
is mainly due to sodium concentration in the blood is sensed by osmo-receptors in the
hypothalamus. This induces secretion of Antideuretic hormone (ADH) by the pituitary
gland. The hormone act on the distal convoluted tubule of the kidney. This makes the
kidney to retain water in the blood thus diluting the ECF and bringing plasma osmolality
to normal.

In oatcell carcinoma the cancer cells contain neurosecretory bodies which secrete
Antideuretic Hormone and other hormones like Adenocorticotrophic Hormone (ACTH)
and calcitonin.
This abnormal (ectopic) secretion of ADH causes unnecessary water retention by the
kidney leading to dilution of Extra Cellular Fluid.
Retention of water by the kidneys explains the excretion of urine of high osmolality by
the patient. According to the evidence found the patient has dilutional hyponatremia due
to inappropriate ADH secretion.

Clinical and laboratory evidence

Lethargy and confusion are typical symptoms of hypomatremia. Low concentration of
sodium in the brain ECF result in lethargy. Confusion is due to water intoxication.

Additional laboratory investigation

Sodium is the main determinant of plasma osmolality, in dilutional hyponatremia plasma
osmolality should be low.

Plasma osmolality= 2[Na+]+[urea]+[glucose]

2[119] +5+6.2
=249mOsmo/kg

From the calculations plasma osmolality of the patient is lower than the minimum normal
level. This is 282 mOsmo/kg. This evidence support the fact that water is being retained
thus diluting the ECF.
To be certain that this is dilutional hyponatrenia, the patient should have.
1. Normal renal createnine clearance rate.
2. To confirm the dilution of plasma, albumin concentration should be measured and
should be low.

Relevant information
No clinical evidence of fluid overload (edema) because in dilutional hyponatrenia the
excess of fluid is shared equally between the extra cellular compartment and Intracellular
compartment.

Reference
• Marjorie J. Williams, Robert N. Barnes et al. Hyponatremia, Antidiuretic
Hormone Secretion and Oat Cell Carcinoma of the Lung.
• www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Fluid_retention?OpenD
ocument
• Clinical chemistry WJ Marshall SK Bangert 6th edition (29-31, 149-153)