electrolyte disorder for internist
TRANSCRIPT
Electrolyte disorders for internist
Contents
• Water and sodium metabolism – Hypo- and hyper- osmolarity– Hypo- and hyper- natremia
• Potassium– Hypo- and hyper- kalemia
• Acid-base disorder
Contents
• Water and sodium metabolism – Hypo- and hyper- osmolarity– Hypo- and hyper- natremia
• Potassium– Hypo- and hyper- kalemia
• Acid-base disorder
• Osmotic pressure – A function of the concentration of all the
solutes in a fluid compartment
Osmotic pressure = total solute total water
Osmolarity = total solute ; mOsm/Kg H2O weight of water
Osmolality = total solute ; mOsm / L H2O volume of water
Osmolality
• Measurement
• Calculation
2Na + Glucose + BUN 18 2.8
Total body water Depends on age, gender, body fat
Body water regulation
Water gain Water loss
Intakemetabolism
Insensible loss sweat, lungFeceskidney
HypotonicityHypotonicity
HypothalamusHypothalamusOsmoreceptorsOsmoreceptors
ADHADH
Thirst
OsmoregulationOsmoregulation
Stimulate Stimulate
HypertonicityHypertonicity
ADHADH
Inhibit Inhibit
IsotonicityIsotonicity
Thirst
Water Water intakeintake
Water Water intakeintake
Renal water excretion
Renal water retention
HypothalamusAngiotensin
Baroreceptor
OC = osmoreceptorMnPO = median preoptic nucleiSFO = subfornical organOVLT =organum vasculosum of the lamina terminalis
Osmolality
Arginine vasopressin stimulation
• Osmotic stimuli• Nonosmotic stimuli
– Blood pressure and blood volume– Drinking– Nausea– Angiotensin II– Stress : pain, emotion– Hypoxia– drug
Renal regulation of sodium
Hyponatremia
• Pseudohyponatremia (normal osmolality)– Hyperlipidemia– Hyperproteinemia
• Translocational hyponatremia (hyperosmolality)– Hyperglycemia– Mannitol, sorbital, glycerol
• True hyponatremia ( hypo-osmolality)
Approach Guideline of HypoNa
True HyponatremiaTrue Hyponatremia(exclude hyperglycemia) (exclude hyperglycemia)
Assess ECF volume statusAssess ECF volume status
TBW , TBNaTBW , TBNa++
HypovolemiaHypovolemia
TBW , TBNaTBW , TBNa++
HypervolemiaHypervolemia
TBW , TBNaTBW , TBNa++
NormovolemiaNormovolemia
Renalloss
Extrarenalloss
Renalfailure
Nephrotic syndrome
CirrhosisCardiac failure
SIADHEndocrinopathy
Drugs
UNa >20 <20 > 20 > 20 < 20
• Hypovolemic hyponatremia with UNa >20 (renal loss)– Diuretic use– Mineralocorticoid
deficiency– Salt-losing
nephropathy– Bicarbonaturia– Ketonuria
• Hypovolemic hyponatremia with UNa <20 (extrarenal loss)– Vomiting– Diarrhea– Third space loss
• Burn, pancreatitis
Causes of SIADH
CARCINOMAS PULMONARY DISORDERS
CNS DISORDERS OTHERS
Bronchogenic CA Viral pneumonia Encephalitis AIDS
Small cell lung CA Bacterial pneumonia Meningitis Prolonged exercise
CA duodenum Tuberculosis Head trauma idiopathic
CA pancreas Aspergillosis Brain abscess
CA stomach Lung abscess Delerium tremens
Thymoma Asthma Acute psychosis
Lymphoma Pneumothorax Multiple sclerosis
Ewing sarcoma Mesothelioma CVA
CA bladder Cystic fibrosis Guillain-Barre syndrome
Prostate CA
Oropharyngeal tumor
Positive pressure breathing
Symptoms of hyponatremia
• Depend on – Age– Gender– Magnitude and acuteness
• Gastrointestinal symptoms : nausea, vomiting
• Neurological symptoms: headache, lethargy, muscle weakness, ataxia, psychosis, seizure, coma, brain herniation
Treatment of Hyponatremia
1. Level, duration of hyponatremia
2. Symptoms
3. Volume status
4. Risk of neurological damage
Hyponatremic patients at risk for neurological complications
• Postoperative menstruating female• Elderly women on thiazide• Children• Hypoxemic patients• Psychiatric polydipsic patients• Alcholics• Malnourished patients• Hypokalemic patients
Treatment solution
Depend on volume status(causes of hyponatremia)
Hypovolemia - isotonic saline
Euvolemia (EM) - hypertonic
Hypervolemia - diuretic
hypertonic
Treatment of hyponatremia
• Acute symptomatic hyponatremia– Raise SNa 1-2 meq/L – Not more than 12 meq/L in 24 hours
• Chronic symptomatic hyponatremia– Raise SNa 0.5-1 meq/L – Not more than 10 meq/L in 24 hours
• Asymptomatic hyponatremia– Water restriction– Drug-induced water diuresis : democlocyclin, lithium, V2 antagonist– Increase solute intake : urea
• A 70-Kg man present diagnosed bronchogenic carcinoma. He presents with GTC. BP 130/80 mmHg. JVP 3 cm, lung- clear. His serum Na is 103 meq/L, Cr 0.7 mg/dl, BS 100 mg/dl
• U/A : sp gr 1.020
Euvolemic hyponatremia
Thyroid function test and cortisol level is normal
SIADH
Desired Na= 110 mmol/l
= TBW x (dNa – sNa)
= 0.6 (70) (110 - 103)
= 294 mmol
Na 294 mmol = 3% NaCl 573 ml
Correct Na 1 mmol/l/hr
= 3% NaCl 573/7 = 80 ml/hr iv.drip
Approach guideline for hypernatremia
Assess volume status
Hypovolemia TBW TBNa
EuvolemiaTBW TBNa
Hypervolemia TBW TBNa
UNa >20 <20 variable >20
Renal lossOsmotic or loop diureticsPostobstructive diuresisIntrinsic renal disease
Extrarenal lossExcessive sweatingBurnDiarrheafistula
Renal lossDIhypodipsia
Extrarenal lossInsensible loss
Sodium gainPrimary hyperaldosteronismCushing’s syndromeHypertonic dialysisHypertonic sodium bicarbonate
Patients at risk of severe hypernatremia
• Elderly patients or infants • Patients receiving
– Hypertonic infusion– Osmotic diuresis– Lactulose– Mechanical ventilator
• Third space water loss : rhabdomyolysis• Altered mental status• Uncontrolled diabetes mellitus• Unerlying polyuric disorder
Hypotonic polyuria
Disorders Urine osmolality SNa
Insufficient AVP
Central diabetes insipidus
+ osmoreceptor dysfunction
Diabetes insipidus in pregnancy
Impaired renal response to AVP
Nephrogenic diabetes insipidus
Primary polydipsia
Dipsogenic polydipsia
psychogenic polydipsia
Water deprivation test
• Patients with hypotonic polyuria– Urine > 50 ml/kg/day– UOsm < 300 mOsm/kg– Total osmole <15 mOsm/kg/day, no
glucosuria or other osmoles
Protocol for water deprivation test
• Initiation of the deprivation period• Baseline data
– Body weight, BP– Serum osmolality, electrolyte– Urine osmolality– Serum AVP
• Follow up BW, BP, urine osmolality hourly• Stop deprivation if BW decrease > 3%, orthostatic hypotension
or urine osmolality changes < 10% in 2-3 consecutive measrement
• Serum electrolyte, serum osmolality and serum AVP at the end point
• If SOsm >295, DDAVP 1 ug or AVP 5 ug sc then measure urine output, urine osmolality 1-2 hours after injection
Treatment of hypernatremia
• Reduction of ongoing loss
• Correction of preexisting water deficit– Rate of correction depends on
• Acuteness• Severity• Risk of neurological deficit
• If serum osmolality > 330 (SNa > 165), decrease Sosm to 320-330 mOsm/L in 24 hours then 0.5 meq/L/hour
Water deficit = 0.6 x BW x (SNa – 140) SNa
Treatment of hypernatremia• Specific treatment
– Central DI • DDAVP, vasopressin• Chlorpropamide
– Nephrogenic DI• Correct cause• Low salt diet • Thiazide or amiloride• NSAIDs
– Pregnancy-induced DI – DDAVP– Osmoreceptor dysfunction – schedule– Psychogenic polydipsia – psychotherapy, clozapine
Contents
• Water and sodium metabolism – Hypo- and hyper- osmolarity– Hypo- and hyper- natremia
• Potassium– Hypo- and hyper- kalemia
• Acid-base disorder
Internal and external K balanceInternal and external K balance
IntakeIntake
(RBC, Muscle, Liver, Bone)(RBC, Muscle, Liver, Bone)
ICFICF
ExcretionExcretion
Kidney Kidney 90%90%
Colon Colon 10%10%
K K 60-100 60-100 mEq/daymEq/day
DistributionDistribution
235235 3000 3000 200 200 300 mEq 300 mEq
Sweat <Sweat <10%10%
ECF50-70 meq
Factors - transcellular distribution of Factors - transcellular distribution of KK
NaNa++
KK++KK++
InsulinInsulin
bb22-adrenergic -adrenergic agonistagonist
AldosteroneAldosterone
cAMPcAMP
Na-KNa-K ATPaseATPase
1. 1. HormoneHormone
2. Acid-base status2. Acid-base status
3. Plasma tonicity3. Plasma tonicity
4. Congenital 4. Congenital diseasesdiseases
ThyroidThyroid
Renal regulation of potassium
PosmPosm 300300
mOsmol/kgmOsmol/kg
Serum [K]Serum [K] 4 mEq/L4 mEq/LCCT [K]CCT [K] 40 mEq/L40 mEq/L
CCTCCT
MCDMCD
1 L1 L
0.75 L0.75 L
0.25 L0.25 L
Uosm 1200Uosm 1200
Uosm 300Uosm 300
HH22OO
urine [K]urine [K] 160 mEq/L160 mEq/L
TTKG = CCT[K] = urine[K] / (U/P)osm TTKG = CCT[K] = urine[K] / (U/P)osm Serum [K] Serum [K] Serum [K] Serum [K]
Transtubular K gradientTranstubular K gradient
K CCT = K urine
[K] CCT VCCT = [K]urine Vurine
[K]CCT = [K]urine Vurine
VCCT
V = solute Vurine = K/ Uosm
osmolarity VCCT K/Osm CCT Posm
TTKG = [K]CCT = [K]urine x Posm
[K] P [K]P x Uosm
Symptoms
• Hypokalemia– Skeletal and smooth muscle
weakness– Rhabomyolysis– Nephrogenic DI– EKG; flattened T wave, U
wave• Hyperkalemia
– EKG; peak T wave, flattened P wave, widening QRS complex, sine wave
– Muscle paralysis– Impaired urinary acidification– Stimulate aldosterone
secretion
Approach Guideline of HypoKDecreased serum [K]Decreased serum [K]
excretionexcretionRedistributionRedistribution
- - AlkalosisAlkalosis - Insulin Rx- Insulin Rx - HypoK periodic paralysis- HypoK periodic paralysis - Drugs: - Drugs: -agonists-agonists - Barium poisoning- Barium poisoning
Renal K excretionRenal K excretion: : vary low high (>20 mmol/d)vary low high (>20 mmol/d) lowlow (<20 mmol/d)(<20 mmol/d)
ExtrarenalExtrarenal - Diarrhea- Diarrhea - Cathartics- Cathartics
RenalRenal - Diuretics- Diuretics - HypoMg- HypoMg - Hyperaldosteronism- Hyperaldosteronism - Inherited kidney dis- Inherited kidney dis - Drugs toxicity:- Drugs toxicity: Amphotericin BAmphotericin B Carbenicillin, etc. Carbenicillin, etc.
Low intakeLow intake
Rx of hypokalemia
Rx causes
Potassium deficit,
100-200 mEq if S. [K] = 3-3.5 mEq/L
200-400 mEq if S. [K] < 3 mEq/L
> 600 mEq if S. [K] < 2 mEq/L
Caution in periodic paralysis
Form:
Oral * Elix. KCl (20 mEq/15 ml)
with metabolic alkalosis
* M Pot Cit oral (10 mEq/15 ml)
with metabolic acidosis
IV * [K] < 60 mEq/L in glucose-free sol.
with the rate of < 10 mEq/h
unless ECG is monitored
Causes of hyperkalemia• Pseudohyperkalemia
– hemolysis, thrombocytosis, severe leukocytosis, fist clenching• Decreased renal excretion
Acute and chronic renal failure Aldosterone deficiency: DM, CTIN, obstructive uropathy Addison’s disease Drugs inhibit K+ secretion Kidney diseases that impairdistal tubule function
• Abnormal K+ distribution Insulin defiency -blocker Metabolic acidosis, respiratory acidosis Familial hyperkalemic periodic paralysis
• Abnormal potassium release from cells Rhabdomyolysis Tumor lysis syndrome
Treatment of hyperkalemia
Agents Dosage Action Mechanism
10% calcium gluconate
10 ml IV in 1 min, repeat q 5 min
immedialtely Stabilze myocardium
insulin 5 units + 50% glucose 50 ml
15 min Intracellular K+ shift If BS >300 mg/dl, insulin alone
Aware hypoglycemia
Sodium bicarbonate
50-100 ml Renal K+ excretion
Intracellular shift
Severe metabolic acidosis (<10 meq/L)
B2 agonist 20 mg albuterol NB in 10 min
30 min Intracellular shift
diuretic Furosemide IV 30-60 min Remove K+ For patients with adequate renal function
Exchange resin Kayexalate 50 gm or kallimate
2 hours Remove K+
dialysis Remove K+
Contents
• Water and sodium metabolism – Hypo- and hyper- osmolarity– Hypo- and hyper- natremia
• Potassium– Hypo- and hyper- kalemia
• Acid-base disorder
METABOLIC ACIDOSIS
• Anion gap = [Na+] – { [HCO3-]+[Cl-] }– Normal 9 -12 mEq/L– Each decline in serum albumin by 1 g/dL from
the normal value of 4.5 g/dL, decreases the AG by 2.5 mEq/L
CAUSES OF METABOLIC ACIDOSIS
• High anion gap– Ketoacidosis
• Diabetic • Alcoholic• Starvation
– Lactic acidosis• L-lactic acidosis (type A
and B)• D-lactic acidosis
– Drugs and toxin• Ethanol, Ethylene glycol,
Methanol• Salicylate
– Uremia
• Normal anion gap– GI loss of HCO3
• Diarrhea• Fistula
– Renal loss of HCO3 or failure to excrete NH4+
• Renal tubular acidosis• Acetazolamide
– Miscellaneous• NH4Cl ingestion• Sulfur ingestion
Metabolic acidosisAnion gap ; Na – (Cl + HCO3)
high normal
Osmolol gapMeasured osmolality – calculated osmolality
high normal
EthanolEthylene glycolMethanolIsopropyl alcohol
KetoacidosisLactic acidosisuremic
Serum potassium
Hypo or normokalemia
hyperkalemia
Urine anion gap (Na + K) – Cl
negative positive
GI lossDrugsProximal RTA
Aldosterone resistanceAldosterone deficiency
dRTA type IV
>5.5
Urine pH
<5.5
ACCUMULATION OF LACTATE
Increase lactate productionischemiaseizureextreme exerciseleukemiaalkalosis
Decrease lactate utilizationpoor blood flowdefective active transport of lactate into cellinadequate metabolic conversion of lactate to pyruvate
Liver 70%, kidneys 30%
Muscle, gut, brain, skin, RBC
LACTIC ACIDOSIS
• TYPE A– Poor tissue perfusion– Shock– Hypoxemia– Carbon monoxide
poisoning
• TYPE B– Liver disease– Leukemia, lymphoma,
large tumor– Anemia– Diabetes mellitus– Drugs : metformin, NRTIs,
sorbital, isoniazid, salicylate etc
– Inborn error metabolism– Intravenous fructose
Symptoms
• Respiratory symptoms– Kussmaul respiration– Oxyhemoglobin dissociation curve
• Left shift in chronic acidosis• Right shift in acute acidosis
• Cardiovascular systems– Negative inotropic effect– Peripheral arterial vasodilatation– Central venoconstriction
• Neurological systems– Headache, lethargy, stupor and coma
Treatment of metabolic acidosis
• Get rid of cause– DKA : IV fluid + insulin– Alcoholic ketoacidosis, starvation : IV fluid (5%D)– Shock : IV fluid– Toxin : increase excretion ( kidney, dialysis), antidote
• Bicarbonate replacement– Causes are not corrected in short period
– Ongoing loss of HCO3
– Severe metabolic acidosis