To the Editor: The case report and discussion of Al-Absi et al is of interest for demonstrating the development of hypernatremia in one patient in the presence of volume overload and with volume depletion. However, some points in the discussion may be considered.First, in Fig 1 in the article, the closed circles presumably are meant to indicate solute, not sodium; cellular sodium concentration is ~ 10 mEq/L. The bulk of cell cation is potassium.Second, it is not clear that hypernatremia in the presence of volume overload results in cellular dehydration. Insofar as total-body water is high and cells remain isosmolar to plasma, cell volume may be increased. High extracellular volume plus high cellular volume might help explain why antidiuretic hormone may not be maximal, urine osmolality is not maximal, and sodium excretion is maintained (see the first table in).
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