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Electrolyte Disorders Dom Colao, DO November 2011 Jeff Kaufhold MD 2019

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Page 1: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Electrolyte Disorders

Dom Colao, DO November 2011

Jeff Kaufhold MD 2019

Page 2: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Review of Electrolyte disorders

•  HypoNatremia •  Hypernatremia •  HypoKalemia •  HyperKalemia •  Calcium •  Magnesium •  Phosphorus

Page 3: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Overview of Disorders

•  The differential for any lab abnormality: – Lab error

•  Lab error –  Lab error

–  Polypharmacy –  Iatrogenic –  Real disease

•  In that order!

Page 4: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Always consider the potential for a confounding variable

•  Was the blood drawn above a running IV?

•  Did it sit too long before the test was run?

•  Is it your patients blood? •  Is there a pattern of abnormalities in

numerous patients on the same day?

Page 5: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Over view of Sodium Disorders

•  Pseudo-hyponatremia – Due to high concentrations of other solutes

in the blood - Mannitol in a pt with cerebral edema, Glucose in a diabetic.

•  Then look at the patient’s volume status

•  Hypervolemic/Euvolemic/Hypovolemic

Page 6: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Hyponatremia

•  Hypervolemic:

•  HypOvolemic:

•  Euvolemic:

Page 7: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Hyponatremia

•  Hypervolemic: –  CHF, –  Cirrhosis, –  Pregnancy, –  Nephrotic syndrome –  In these conditions, total body sodium is up, but

total body WATER is up even more. –  Due to reduced Effective Arterial Blood Volume,

(EABV) leading to increased ADH secretion.

Page 8: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Hyponatremia

•  Hypervolemic: –  CHF, Cirrhosis, Pregnancy, Nephrotic syndrome

•  HypOvolemic: –  GI losses (diarrhea, Vomiting, NG suction) –  Renal Losses (diuretics, Salt wasting nephropathy,

recovery phase from ATN or obstruction). –  Due to true depletion of water and sodium, leading

to increased secretion of Aldosterone AND ADH

Page 9: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Hyponatremia

•  Hypervolemic: –  CHF, Cirrhosis, Pregnancy, Nephrotic syndrome

•  HypOvolemic: –  GI losses (diarrhea, Vomiting, NG suction) –  Renal Losses (diuretics, Salt wasting nephropathy,

recovery phase from ATN or obstruction). •  Euvolemic:

–  Medication effects, Endocrine syndromes, Excessive water intake, reset osmostat, SIADH

Page 10: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Hyponatremia •  Euvolemic:

–  Medication effects •  ACE/ ARB/Tekturna/Spironolactone/HCTZ •  Antidepressant and antipsychotic meds •  NSAID’s

–  Endocrine syndromes •  Hyper and Hypo thyroid, •  Adrenal insufficiency and excess (addison’s / Cushings)

–  Excessive water intake, •  Psychogenic polydipsia, beer potomania

–  reset osmostat, •  Seen in conditions which stimulate tonic ADH secretion from

tissues which have Neuroectoderm (brain and Lung) –  SIADH

Page 11: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Hyponatremia •  Euvolemic:

–  reset osmostat, •  Seen in conditions which stimulate tonic ADH secretion from

tissues which have Neuroectoderm (brain and Lung) •  Pneumonia, COPD, stroke, brain hemorrhage. •  These conditions result in a stable low level of sodium, around

which water and sodium regulation are functioning normally, but at a new lower setting.

•  Confirmed by water loading test. –  SIADH - Persistant high production of ADH which does not

suppress in the face of water load, usually due to a tumor such as small cell lung carcinoma or brain tumor.

Page 12: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Case 1, Hyponatremia �6 �0 � �y �. �o �. � �m �a �l �e � �a �l �c �o �h �o �l �i �c � �p �r �e �s �e �n �t �s � �t �o � �E �R � �w �i �t �h � �c �e �l �l �u �l �i �t �i �s �, � � �w �a �l �k �i �n �g � �a �n �d � �t �a �l �k �i �n �g �. � �E �x �a �m � �s �h �o �w �s � BP 104/50, pulse 90, Temp 98, with �s �i �g �n �s � �o �f � �p �o �r �t �a �l � �h �y �p �e �r �t �e �n �s �i �o �n � � �a �n �d � �3 �+ � �p �r �e �t �i �b �i �a �l � �e�d�e�m�a�.� � F �o �u �n �d � �o �n � �r �o �u �t �i �n �e � �l �a �b �s � �t �o � �h �a �v �e � �s �e �r �u �m � �s �o �d �i �u �m � �1 �1 �8 � �m�E�q�/�L�.� �C�L�A�S�S�I�F�I�C�A�T�I�O�N� �O�F� �S�O�D�I�U�M� �D�I�S�O�R�D�E�R�S�: Hypo? Hyper? Euvolemic? �A�D�H� �L�E�V�E�L� �=� �H�I�/�L�O�/�N�O�R�M�?� � �W�H�Y�?� � � � � T�r�e�a�t�m�e�n�t�?�

Page 13: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Case 1b Hyponatremia 60 y.o. female with COPD brought to ER with pneumonia and severe SOB. Exam shows her BP is 150/80, Pulse 110, Resp 40. Breathing is labored, wheezing, no edema. Initial resuscitation with Normal Saline, B-agonist resp treatments and intubation improves her breathing, but she then has a seizure. Lytes on admission show her sodium is 126, CLASSIFICATION? After the seizure her sodium is 118 mg/dl. Why did it drop in spite of using Normal Saline? Is her ADH level low/ normal/ high ? How would you treat her?

Page 14: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Case 1c, Hyponatremia 3 �5 � �y �. �o �. � �f �e �m �a �l �e � �w �i �t �h � �l �o �n �g � �h �i �s �t �o �r �y � �o �f � �m �e �n �t �a �l � �d �i �s �o �r �d �e �r �s � � �a �d �m �i �t �t �e �d � �t �o � �p �s �y �c �h � �s �e �r �v �i �c �e � �a �f �t �e �r � �p �l �a �c �i �n �g � �2 �5 � �s �e �w �i �n �g � �n �e �e �d �l �e �s � � �s �u �b �c �u �t �a �n �e �o �u �s �l �y � �i �n � �b�o�t�h� �f�o�r�e�a�r�m�s�.� �Y �o �u � �a �r �e � �c �o �n �s �u �l �t �e �d � �a �f �t �e �r � � �a �d �m �i �s �s �i �o �n � �l �a �b �s � �s �h �o �w � �s�e�r�u�m� �s�o�d�i�u�m� �=� �1�2�0� �m�E�q�/�L�.� �E �x �a �m � �s �h �o �w �s � �p �l �e �a �s �a �n �t � �f �e �m �a �l �e � �i �n � �n �o � �d �i �s �t �r �e �s �s � �c �o �n �s �i �d �e �r �i �n �g � �t �h �e � �s �c �a �r �r �i �n �g � �o �n � � �f �o �r �e �a �r �m �s � �( �f �r �o �m � �p �r �e �v �i �o �u �s � �s �u �r �g �i �c �a �l � �r �e �m �o �v �a �l � �o �f � �p �r �i �o �r � �n �e �e �d �l �e � �i�n�s�e�r�t�i�o�n�s�)�,� �n�o� �e�d�e�m�a�.� � �C�L�A�S�S�I�F�I�C�A�T�I�O�N�?� � � � A�D�H� �L�E�V�E�L� �=� �H�I�/�L�O�/�N�O�R�M� �?� � �W�H�Y�?� �T�r�e�a�t�m�e�n�t�?�

Page 15: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Pieces of metal in abdominal wall

Page 16: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Can you guess what she swallowed?

Page 17: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Hypernatremia

•  Due to the patient’s inability to respond to thirst despite high ADH level – Fall at home with fracture – can’t get up – ECF/ Hospitalized with dementia –  Intubated on vent in ICU – Heat illness/ heat stroke – OR

Page 18: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Hypernatremia

•  Or Diabetes Insipidus – ADH - Low – Central DI

•  Seen after catastrophic event/ pituitary necrosis •  Sheehan’s Syndrome after peripartum

hemorrhage – ADH present but kidneys are resistant

•  Nephrogenic DI •  Seen in ATN, Lithium toxicity

Page 19: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Hypernatremia

•  Urine osmo will be low due to free water loss in tubules

•  Evaluate patient volume status – Hypervolemic – Euvolemic – Hypovolemic

Page 20: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Hypernatremia

•  volume status – Hypervolemic

•  Usually iatrogenic from sodium bicarb administration or IV’s

– Euvolemic •  The DI syndromes

– Hypovolemic •  Dehydration, heat illness, Immobility

Page 21: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Hypernatremia

•  How does it Kill? – Brain shrinks away from the calverium – Large dural sinuses full of blood – Develop subdural hemorrhage

Page 22: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Hypernatremia

•  Treatment – Hypotonic fluid resuscitation – Free water deficit calculator – deficit:= TBW X [(measured/140)-1] – TBW = 0.4X Wt in Kg – Sodium of 155 = 6 Liter deficit – How much water stays intravascular?

•  Is there a risk of putting patients into CHF?

Page 23: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Only about 9% stays intravascular

Page 24: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Hypernatremia treatment

•  For Hypervolemic patients •  Can give metolazone to hypervolemic patients to

augment natriuresis –  For DI patients/ Euvolemic

•  Use DDAVP/ Vasopressin

Page 25: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Hypernatremia

•  Once you calculate Free water deficit: – Give half the deficit over 24 hours – May shoot for more than that if the etiology

is still ongoing (fever, Diarrhea, osmotic diuresis, etc)

– How much water stays in the intravascular space?

Page 26: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Case 2a Hypernatremia �6 �5 � �Y �. �o �. � �d �i �a �b �e �t �i �c � �a �n �d � �h �y �p �e �r �t �e �n �s �i �v �e �, � �S �/ �P � �C �V �A �, � �b �e �d �r �i �d �d �e �n � �NNursing Home � � �p �a �t �i �e �n �t � �w �i �t �h � �f �e �v �e �r � �a �n �d � �m �e �n �t �a �l � �s �t �a �t �u �s � �c �h �a �n �g �e �s �. � �P �a �t �i �e �n �t � �w �a �s � �o �n � �t �u �b �e � �f�e�e�d�i�n�g�s�,� �h�a�d� �d�i�a�r�r�h�e�a�.� � �E �x �a �m � �r �e �v �e �a �l �s � BP of 140/70, Pulse 98, Resp 20 �d �r �y � �s �k �i �n � �a �n �d � �m �o �u �t �h �, � Chest is clear, no rub, no edema. �S�e�r�u�m� �s�o�d�i�u�m� �=� �1�5�5� �m�E�q�/�l�.� � � �C�L�A�S�S�I�F�I�C�A�T�I�O�N�?� we classify Hypernatremia disorders similar to Hyponatremia disorders, based on volume status. � A�D�H� �L�E�V�E�L� �=� �H�I�/�L�O�/�N�O�R�M� �?� � � T�r�e�a�t�m�e�n�t�?�

Page 27: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Case 2b Hypernatremia �3 �5 � �y �. �o �. � �f �e �m �a �l �e � �s �u �f �f �e �r �s � �a �i �r � �e �m �b �o �l �i �s �m � �d �u �r �i �n �g � �s �a �l �p �i �n �g �o �s �c �o �p �y �, � � �r �e �q �u �i �r �i �n �g � �C �P �R � �f �o �r � �4 �5 � �m �i �n �u �t �e �s �. � �B �l �o �o �d � �p �r �e �s �s �u �r �e � �a �n �d � �p �u �l �s �e � � �s �t �a �b �i �l �i �z �e � �a �f �t �e �r � �p �a �t �i �e �n �t � �i �s � �t �a �k �e �n � �t �o � �h �y �p �e �r �b �a �r �i �c � �c �h �a �m �b �e �r � �f �o �r � �2 � � �h �o �u �r �s �. � �W �h �i �l �e � �i �n � �t �h �e � �c �h �a �m �b �e �r � �s �h �e � �i �s � �n �o �t �e �d � �t �o � �b �e �g �i �n � �l �a �r �g �e � �v �o �l �u �m �e � �d �i �u �r �e �s �i �s � �w �h �i �c �h � �e �v �e �n �t �u �a �l �l �y � �r �e �a �c �h �e �s � �2 �0 � �l�i�t�e�r�s� �i�n� �1�8� �h�o�u�r�s�.� Serum� �s�o�d�i�u�m� �=� �1�6�5�m�E�q�/�l�.� � � D�I�A�G�N�O�S�I�S�?� �A�D�H� �L�E�V�E�L� �=� �H�I�/�L�O�/�N�O�R�M� �?� � �T�r�e�a�t�m�e�n�t�?� �

Page 28: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Case 3a Hypokalemia �2�6 � �y �.�o �.� �f �e�m �a�l�e� �r�e�f �e�r�r �e �d � �f �o�r � �e �v �a�l�u �a�t�i�o�n� �o�f � �" �R�u �l�e� �o �u �t� �B �a �r �t �t �e �r �s � �S �y �n�d�r�o �m �e�" � �d�u�e� �t�o� �p �e�r�s�i�s�t�e�n �t� �h �y �p�o�k�a�l�e�m �i�a�, hypochloremia, �a�n �d � �a �l �k �a �l �o �s �i �s �. � � E�x �a�m � �r �e �v �e �a �l �s � � BP 90/40, pulse 65, �e�m�a �c �i �a �t �e �d� �w �h �i�t�e� �f �e�m �a�l�e� �w �i�t�h � �f �i�n �e� �l�a�n �u �g �o� �h �a�i�r � �o�n � �b �a�c�k �,� �p�o�o �r� �d �e�n �t�i�t�i�o�n �,� �a�n�d� �s �m �a �l�l� �s �c �a �r �s � �o �v �e�r � �k�n �u �c �k �l �e �s � �o�f� �l�e�f �t� �h �a �n �d �. � �U�r �i�n �e � � �K �= �4 �0 �,� �U �r �i�n �e � �C �l �< �1 �0 �. � �s�e�r�u �m � �k �=� �2�. �5 � �m �E�q �/�l�,� �H �C�O �3� �=� �3�2 �, � � �P �O�4� �=� �2 �. �0 �. � ��W�h �a�t� �i�s� �B �a�r �t�t�e�r �' �s � �s�y �n �d�r �o�m �e�? � �W�h �a�t� �i�s � �h �e �r � �d �i�a �g �n �o�s�i�s�? � �

Page 29: Electrolyte Disorders - Nephrologyjeffkaufhold.com/wp-content/...disorders-and-cases.pdf · • HyperKalemia • Calcium • Magnesium • Phosphorus . Overview of Disorders ... Disorders

Case 3a Hypokalemia � ���B�a�r �t�t�e�r �' �s� �s�y �n �d�r�o �m �e� can be thought of as a tubular problem in the kidneys in which the tubules do not resorb chloride normally. The result is chloride wasting, Hypokalemia, a contraction alkalosis, low BP and High aldosterone levels. �It is diagnosed by measuring urine chloride, which should be high. Her labwork: �U�r �i�n �e � � �K �= �4 �0 �,� �U �r �i�n �e � �C �l �< �1 �0 �. � �s�e�r�u �m � �k �=� �2�. �5 � �m �E�q �/�l�,� �H �C�O �3� �=� �3�2 �, � � �P �O�4� �=� �2 �.�0�.� What is her condition? �

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Case 3 b, Hypokalemia �1�6 � �y �.�o �.� �h �i�s �p�a�n�i�c� �m �a �l �e � �a �d �m �i�t�t�e�d� �d �u �e� �t�o� �p �r �o �f�o �u �n�d� �w �e�a�k �n�e�s�s�.� � �N o nf �o�c�a�l� �n �e�u�r�o�l�o �g �i�c� �e�x �a�m � �e�x �c �e �p �t� �f �o �r � �s �y �m �m�e�t�r �i�c� �w �e�a�k �n �e �s s �. � � �N�o�r�m �a�l� �C�T � �a�n �d� �L �P� �a �r �e � �p �e �r �f �o�r�m �e�d � �b �e �f �o�r �e� �e�l�e�c�t�r �o�l�y �t�e�s � �r�e�t�u �r�n � � �r �e �v �e �a �l �i �n �g � �s �e�r �u �m� �p�o�t�a�s �s �i�u �m � �=� �2 �.�0 � �m �E �q �/�l�,� �H �C �O �3 � �= � �1 �2 �. � �H �e � � �s �u �b�s �e�q�u�e�n �t�l�y � � �a �d �m �i�t�s � �t�o� �i�n �h �a�l�i�n �g � �c�o �r �r�e �c �t�i�o �n � �f �l�u �i�d� �w �h �i�c�h � � �c �o �n �t �a �i �n �s � �t�o�l�u �e�n �e �. � � �D�i�a�g �n �o�s�i�s�? �

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Case 3 b, Hypokalemia

�In the Dayton area, a couple of teenage boys die every year from huffing gas in a garage. The same process is operative, an acquired Renal Tubular Acidosis (RTA) from the inhalation of solvent.

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Case 4 Hyperkalemia �2�6 � �y �.�o �.� �f �e�m �a�l�e� �w �i�t�h � �H �I �V � �r �e �f �e�r�r �e�d� �f �o�r � �e�v �a�l�u �a�t�i�o�n � �o�f � � �p �e �r �s�i�s�t�e�n �t � �h �y�p�e�r �k�a�l�e�m �i�a�.� �S �h �e� �h �a�s � �a� �h�i�s �t�o�r �y � �o�f � �m �y�o �t �o �n �i �c � �d �y �s�t�r�o�p �h �y � �(�a�n � �i�n �h �e �r �i �t �e �d � �s�y �n �d�r �o �m �e� �o�f � �i�n �v�o�l�u �n�t�a�r�y � �m�u �s�c�l�e� �f �a�s�c�i�c�u �l�a�t�i�o�n � �a�n �d� �s �p�a�s �m �) �. � � E�x �a�m � �i�s� �n �o�r�m �a�l� �w �i�t�h � �t�h �e� �e�x �c�e�p�t�i�o�n� � �o�f� �h �e�r� �i�n �i�t�i�a�l� �h �a�n �d�s�h �a�k�e� �- � �s�h �e� �w �a�s � �u �n �a �b �l�e � �t�o � �l�e �t� �g �o � �f �o�r� �1�0 � �s �e�c�o �n �d�s�. � �S �e�r �u �m � �p�o�t�a�s�s�i�u �m � �=� �5�. �8� with a range from 5.4 to 6.0 ��D�i�f �f �e�r�e�n�t�i�a�l�? � � �H�o�w � �m �i�g�h �t� �y �o�u � �e�v �a�l�u�a�t�e�? � �M�a�n �a�g�e�m �e�n �t�? �

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Case 4 Hyperkalemia �2�6 � �y �.�o �.� �f �e�m �a�l�e� �w �i�t�h � �H �I �V � �r �e �f �e�r�r �e�d� �f �o�r � �e�v �a�l�u �a�t�i�o�n � �o�f � � �p �e �r �s�i�s�t�e�n �t � �h �y�p�e�r �k�a�l�e�m �i�a�.� �S �h �e� �h �a�s � �a� �h�i�s �t�o�r �y � �o�f � �m �y�o �t �o �n �i �c � �d �y �s�t�r�o�p �h �y � �(�a�n � �i�n �h �e �r �i �t �e �d � �s�y �n �d�r �o �m �e� �o�f � �i�n �v�o�l�u �n�t�a�r�y � �m�u �s�c�l�e� �f �a�s�c�i�c�u �l�a�t�i�o�n � �a�n �d� �s �p�a�s �m �) �. � � ��D�i�f �f �e�r�e�n�t�i�a�l�? � � R habdomyolysis Medication effects Adrenal dysfunction Obstructive uropathy �H�o�w � �m �i�g�h �t� �y �o�u � �e�v �a�l�u�a�t�e�? � C PK 68 S he was not on medications Cortisol level 6, with poor response to ACTH Bladder post void less than 10 cc. �M�a�n �a�g�e�m �e�n �t�? �

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Case 4 Hyperkalemia �2�6 � �y �.�o �.� �f �e�m �a�l�e� �w �i�t�h � �H �I �V � �r �e �f �e�r�r �e�d� �f �o�r � �e�v �a�l�u �a�t�i�o�n � �o�f � � �p �e �r �s�i�s�t�e�n �t � �h �y�p�e�r �k�a�l�e�m �i�a�.� �S �h �e� �h �a�s � �a� �h�i�s �t�o�r �y � �o�f � �m �y�o �t �o �n �i �c � �d �y �s�t�r�o�p �h �y � �(�a�n � �i�n �h �e �r �i �t �e �d � �s�y �n �d�r �o �m �e� �o�f � �i�n �v�o�l�u �n�t�a�r�y � �m�u �s�c�l�e� �f �a�s�c�i�c�u �l�a�t�i�o�n � �a�n �d� �s �p�a�s �m �) �. � � ��Always consider adrenal disorders (Addison’s) and obstructive uropathy in patients with hyperkalemia out of proportion to their renal dysfunction. It turns out that one of the earliest manifestations of HIV disease with respect to Nephrology is hyperkalemia from early adrenal dysfunction. �M �a�n �a�g�e�m �e�n �t�? � Flurinef

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Case 5, Hypercalcemia

�4�6 � �y �.�o �.� �f �e�m �a�l�e� �p�r �e�s �e�n �t�s � �t�o� �c�l�i�n �i�c� �w �i�t�h � �c�o�m �p�l�a�i�n �t � �o �f � � �w �o �r �s �e�n �i�n�g � �c�h �r�o�n �i�c� �c�o �n �s �t�i�p�a�t�i�o�n � �a�n�d� �f �a�t�i�g �u �e�. � �E�x �a�m � �i�s � � �u�n�r�e�m �a �r �k �a �b �l �e �. � � L �a�b� �e�v �a�l�u �a�t�i�o�n� �r �e�v �e�a�l�s � �s �e�r �u �m � �C�a�l�c�i�u �m � �=� �1�1 �. �5 � � �w �i�t�h � �a�l�b�u�m �i�n � �=� �4 �. �0 �. � � � W�h �a�t� �t�e�s�t� �w �o�u �l�d � �y �o�u � �o �r �d�e�r � �n �e�x �t�? � �( �S�u �t�t�o�n �' �s� �L �a�w �) �

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Case 6 Hypocalcemia �6�5 � �y �.�o �.� �d�i�a�b �e �t�i�c � �d �i�a �l�y �s �i�s � �p�a�t�i�e�n �t� �n �o�t�e�d� �o�n� �r �o �u �t�i�n �e � �l �a �b �s � �t �o � � �h �a�v �e� �a�l�b�u�m �i�n � �=� �1 �.�9 �,� �s �e�r �u �m � �c�a�l�c�i�u �m � �=� �6 �.�0 �,� �s �e�r �u �m � �P �O �4� �=� �1�1 �. �9 �. � ��C�o�r �r �e�c�t�e�d � �c�a�l�c�i�u �m � �=�? � �P�T �H � �l�e�v �e�l� �=� �h�i�/�l�o�/�n �o �r �m �? � � E�t�i�o�l�o�g�y �? � � �T �r �e�a�t�m �e�n�t�? �

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Case 6 Hypocalcemia �6�5 � �y �.�o �.� �d�i�a�b �e �t�i�c � �d �i�a �l�y �s �i�s � �p�a�t�i�e�n �t� �n �o�t�e�d� �o�n� �r �o �u �t�i�n �e � �l �a �b �s � �t �o � � �h �a�v �e� �a�l�b�u�m �i�n � �=� �1 �.�9 �,� �s �e�r �u �m � �c�a�l�c�i�u �m � �=� �6 �.�0 �,� �s �e�r �u �m � �P �O �4� �=� �1�1 �. �9 �. � ��C�o�r �r �e�c�t�e�d � �c�a�l�c�i�u �m � �= � 7.6 (each gram of albumin carries 0.8 gm of calcium) so correct for an albumin of 4.0 � �P�T �H � �l�e�v �e�l� �=� �h�i�/�l�o�/�n �o �r �m �? � � HIGH (target in dialysis 150-400), normal is less than 75 E�t�i�o�l�o�g�y �? � � Inadequate production and conversion of Vitamin D �T �r �e�a�t�m �e�n�t�? � Vitamin D supplementation/analogue, Ca l c ium supplementation (sometimes) Phosphate binders to lower Phos.

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Case 7, Hypomagnesemia

�34 �y �.�o �.� �m �a�l�e� �w �i�t�h � �C�r �o�h�n �' �s � �d�i�s �e�a�s �e� �r �e�p�o �r�t�s� �f �l�a �r�e � �o �f � �h �i�s� �s�y �m �p �t �o �m �s � �i�n �c�l�u �d�i�n �g � �d �i�a �r �r �h �e�a �, � �a �r �t �h �r�a�l�g �i�a�,� �f �e�v�e�r� �a�n �d� �f ��a�t�i�g �u �e�. � ��L �a �b �s � �r �e �v �e �a �l� �s �e �r �u �m � �C�a�l�c�i�u �m � �=� �7�. �0�,� �A �l�b�u�m �i�n � �=� �1 �.�9 �,� �M �a �g �n �e�s�i�u �m � �=� �1�.�0�. � � �E �t �i �o �l �o �g �y � �o �f � �h �y�p �o �m �a�g� �c�o�m �b�i�n �e�d� �w �i�t�h � �h �y �p�o �c �a �l�c �e �m �i�a�? �

�U�r �i�n �e� �m �a�g �n �e�s�i�u �m � �e�x �c�r �e�t�i�o�n�? � �h �i�/�l�o�/�n �o�r�m �a �l �

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Case 7, Hypomagnesemia �34 �y �.�o �.� �m �a �l �e � �H �i�s � �C�r �o�h �n �' �s � �r �e �s �p �o �n �d �s � �t �o � �t �r �e �a �t �m �e�n�t� �a�n �d� �h�i�s� �l�y �t�e�s � �a�n �d� �a�l�b�u�m �i�n �

�normalize �.� �H �e� �s �u �b�s �e�q�u�e�n �t�l�y � �i�s� �d �i�a�g �n �o�s�e�d� �w �i�t�h � �t�e�s�t�i�c�u �l �a �r � �carcinoma �(�B �-�h �c�g � �+�,� �n�o�n �s�e�m �i�n �o�m �a�t�o�u �s �) � �a�n �d � �r�e�c�e�i�v �e�s � �chemo�t�h�e�r �a�p�y � �w �i�t�h � �c�i�s �p�l�a�t�i�n �u �m �. �

�N�o�w � �l�a �b �s � �r �e �v �e �a �l� �n �o�r �m �a�l� ��c�o�r �r �e �c �t �e �d � �c �a �l �c �i �u �m�,� �M �a �g �n�e�s�i�u �m � �=� �1�.�0�, �

�p�o �t�a�s�s�i�u �m � �=� �3�.�0�.� � � R�e�p�l�a�c�e�m �e�n �t� �w �i�t�h � �u�p� �t�o� �4�0�0 � �m �E�q �/�d�a�y � �o �f � �p�o �t�a�s�s�i�u �m � �f �a �i �l �s � �t �o �

�improve� �t�h �e� �h �y�p�o�k�a�l�e�m �i�a�.� �E�t�i�o�l�o �g �y � �o �f � �h �y�p�o�m �a�g � �c�o �m �b�i�n �e�d� �w �i�t�h � �hypo �k �a�l�e�m �i�a�? � �U �r �i�n �e� �M�a�g �n �e�s�i�u �m � �e �x �c �r �e �t�i�o �n �? � �h �i�/�l�o�/�n �o�r�m

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Case 8 Hypermagnesemia

•  Hypermagnesemia is seen only in patients with renal failure who are supplemented,

•  or in cases where large amounts of magnesium are infused.

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Case 9, Hypophosphatemia See Case 3 with Anorexia and severe malnutrition. Attempts to force feed her with tube feeds and TPN result in severe muscle fatigue and respiratory failure. She develops renal failure, heart failure and cardiovascular collapse. Urinalysis shows 4+ blood but the microscopic exam of the urine is negative for more than a few RBC’s. PO4 level : 2.0 before the feeding, up to 6 the next day as she gets intubated. Potassium 2.9 before, goes up to 7 the next day. Diagnosis?

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Case 9 Hyperphosphatemia •  Classic presentation of Hypophosphatemic

rhabdomyolysis. •  Prolonged NPO status/starvation •  Resp failure requiring reintubation after

extubation or surgery. Due to resp muscle weakness.

•  Phos goes very low, then suddenly climbs without any supplementation. Associated with high K and Low calcium.

•  Creatinine climbs more than 1.0 mg/dl/day, suggesting increased creatinine production

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Reference

•  Narins. Fluid and Electrolyte Disorders: Am journal of Medicine, 1982