Valproate Monitoring in Patients With Hypoalbuminemia

Abstract

A 50-year-old man with a history of schizoaffective disorder, bipolar type, diabetes mellitus type 2, chronic kidney disease stage 3, and hypertension was brought to the emergency department for swelling of his face and extremities, questionable medication compliance, and recent unusual and threatening behavior. His psychiatric medications included divalproex sodium extended-release (2,000 mg nightly), long-acting injectable risperidone (25 mg every 2 weeks), and trazodone (100 mg nightly). The patient had been stable on this regi-men for many years before the days leading up to his presentation in the emergency department. His total valproic acid level on presentation was 65 µg/ mL. His complete blood count was un-remarkable. His basic metabolic panel was notable for blood urea nitrogen (22 mg/dL), his creatinine level was 2.1 mg/ dL, his estimated glomerular filtration rate was 34, his aspartate aminotrans-ferase level was 65 IU/L, and his alanine aminotransferase level was 97 IU/L. The patient's urine drug screen was negative , and an ECG was unremarkable. He weighed 183 lbs and had a body mass index of 28. His bilateral lower extremities showed edema of 1+, and a neuro-logical examination was unremarkable. Further workup revealed nephrotic syndrome with an albumin level of 2.2 g/dL (normal range, 3.6-4.8 g/dL).