Outpatient Dietary Management of Electrolyte Disorders During COVID-19

Abstract

What should I eat?" is one of most common questions patients ask in the clinical setting. Patients with diabetes are asked to adhere to a low-carbohydrate diet, while patients with hypertension should consume a lowsalt diet. But truthfully, the process of calculating the milliequivalents (mEq) of each food element is tedious and often not feasible. In this essay we describe a 97-yearold patient who learned to titrate condensed chicken soup like a medicine during the coronavirus 2019 (COVID-19) pandemic. Without a doubt, this nonagenarian is a woman of great courage and wit. She first presented to the University of California, San Francisco, Nephrology and Hypertension clinic 2 years ago seeking guidance for hyponatremia management. At the age of 87 years, she had undergone a 3-vessel coronary artery bypass graft with residual reduced ejection fraction congestive heart failure. At the age of 94 years, she underwent a partial colectomy and en bloc resection of a 9-cm recurrent gastrointestinal stromal tumor. Unfortunately, for some time thereafter, she was hospitalized almost once every 2 months for heart failure exacerbations followed by hypovolemia-related hyponatremia. Eventually, her hospitalizations decreased from 6 per year to 2 per year, as she was prescribed sodium citrate-citric acid for the mild metabolic acidosis she experienced from chronic kidney disease. This both treated her acidosis and provided additional sodium content for her hyponatremia. To manage her narrow window of euvolemia, she took furosemide whenever she was above a specific weight threshold, and her laboratory tests were checked at least once a month. However, even a minor episode of gastric reflux could tip her over into hypovolemic hyponatremia despite withholding diuretics. During one of her most recent hospitalizations, her intravenous catheter had infiltrated, leading to compartment syndrome requiring surgery. Consequently, she developed a healthy fear of the hospital, which was further exacerbated by the COVID-19 shelter-in-place order implemented in the spring of 2020. In mid-April, her family called regarding her poor appetite. She was otherwise asymptomatic during her video visits, and they reported stable vital signs. Laboratory tests showed a decrease in her sodium level from 128 mEq/L to 123 mEq/L, while her creatinine level had risen from 0.92 mg/dL to 1.02 mg/dL. Her daily weights were drifting down. To better examine her volume status, we asked her to come to the clinic. Citing fears of contracting COVID-19, she refused the in-person visit. However, she reminded us that she still had cans of condensed chicken soup, which we had recommended she consume if her appetite was poor.