fluid and electrolyte metabolism/ renal and urologic disorders ??2017-07-25fluid and electrolyte...

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  • FluidandElectrolyteMetabolism/RenalandUrologicDisorders

    AdamWeinstein,MDAssistantProfessorPediatricNephrology

    ChildrensHospitalatDartmouthHitchcock

  • Disclosures Ihavenorelevantfinancialrelationshipswiththemanufacturers(s)ofanycommercialproducts(s)and/orproviderofcommercialservicesdiscussedinthisCMEactivity.

    Idonotintendtodiscussanunapproved/investigativeuseofacommercialproduct/deviceinmypresentation.

  • Objectives Evaluateandplantreatmentforvariousetiologiesof

    hyponatremiaandtheirassociatedfluidandelectrolyteabnormalities

    Distinguishbetweenthecausesofandinitiateevaluationforglomerularandnonglomerularhematuria

    Interpretwhichmarkersofseverityinthesettingofacuteglomerulonephritiswarrantevaluationandtreatment

    Reviewthecausesofandmanagementapproachesfornephrotic syndromeandasymptomaticproteinuriainchildren

  • MajorConceptsinSodiumHandling Whyisthesodiumlow?**

    Toomuchwater Toolittlesalt

    Whataidsinthisdecision?** Patientvolumestatusclinically

    Weightchanges UrineNa+ [FractionalExcretionofNa+(FENa)] UrineOsmolality

  • MajorConceptsinUrineNa+ Evaluation Kidneypreservescirculatingvolumewithhighestpriority!

    UNa+reflectsrenalperfusion**independentofSerumNa+: LowUNa+(2%)

    RenalPerfusionisnormalorincreased Defectintubulereabsorption**

    IfUNa+ elevatedinclinicalcircumstancewhenrenalbloodflowisexpectedtobedecreased suggestsrenaltubulardysfunction**

  • MajorConceptsinUrineOsm Evaluation

    UOSMreflectsH20removalfromtubulefluid** WhenUOSM ishigh waterretainedbybody WhenUOSMislow waterisbeingexcretedinurine

    NormalUOSM canrangefrom501200mOsm/L SGinurine1.010=UOSM 300mOsm/L

  • MajorConceptsinUrineOsm Evaluation ADHsecretionstimulatedby

    Increaseserumosmolality (SOSM) Decreasecirculatingvolume ADHsecretionresultsinincreasesinUOSM (anyincreasecanbe

    relatedtoADHsecretion) However,whenUOSM>SOSM by>1.5Xormore,theonlywaythat

    canhappenisbyADHactingoncollectingduct IfUOSM isincreasedwithoutincreasedSOSM ordecreased

    intravascularvolume: ADHsecretionisnonphysiologic(SIADH)irrespectiveofurine

    outputorurinevolume**

  • HyponatremiaCaseOne 9 montholdgirl 3daysoffever,nonbilious,nonbloodyvomiting,andwaterydiarrhea

    Decreasingurineoutputoverpast2days,onlyonceinpast24hours

    3lb weightlosssincehealthmaintenancevisit2weeksago.Shehassometachycardiabutisinteractive,crankybutconsolablebymother,goodperipheralperfusion

  • CaseOneLabs** Na127 K3.0 Cl100 HCO316 BUN24 Cr0.3

  • QuestionsCaseOne WhatdoyoususpecttheFENa andUrineOsmolalityare?

  • CaseOneUrineLabs** UrineNa

  • QuestionsCaseOne Whatisthediagnosis?**

    Doesthepatientseemtohavemorevomitingordiarrhea?**

    Explainthehypokalemiaandhowwouldyoutreatit?**

  • HyponatremiaCaseTwo Thesame9montholdgirlisgivenoralrehydration.Overnext24hours,vomitingpersists,intakeispoor,anddiarrheaisincreasing.Nourineoutput.

    Weightisfurtherdecreased.Shehasworsetachycardia.Sheislethargicanddoesntrespondmuchtoexamination.Caprefillisnowprolonged

  • CaseTwoLabs** Na125 K6.5 Cl92 HCO39 BUN45 Cr0.9

  • QuestionsCaseTwo WhatdoyoususpecttheFENa andUrineOsmolalityare?

  • CaseTwoUrineLabs** UrineNa60mEq/L FENa 2.3% UrineOsm 250mosm/L

  • QuestionsCaseTwo Thepatientappearsmorevolumedepletedbutbasedon

    urinesodiumandFENa,thekidneythinksrenalperfusionisadequate.Whatiscausingthisdiscrepancy?**

    Explainthelowbicarbonate?**

    Whatmanagementwouldyouprovideforthehighpotassium?**

    WhatdoyouthinkherGFRis?**

  • HyponatremiaCaseThree Fiveyearoldmalepresentswithperiorbitaledema,abdominaldistension,andankleswelling

    Hehasaweightgainof5lb overthepast4days NotableinhishistoryarearecentURI,anddecreasedurineoutputonly12timesperday.

    HisHRisborderlinetachycardia,BloodPressure92/54

  • CaseThreeLabs** Na128 K4.9 Cl90 HCO326 BUN12 Cr0.5

  • QuestionsCaseThree Whatdoyouthinkthechildsdiagnosisis?** WhatdoyoususpecttheFENa andUrineOsmolalityare?**

    Whyishyponatremiaassociatedwithhiscondition?**

    Howdoyoufixthehyponatremia?**

  • HyponatremiaCaseFour 12montholdmalewithneuroblastomareceivingchemotherapyincludingcyclophosphamide

    Heisprescribed1andMaintenancefluidratewithNSfor3days

    Hehasnoedemabutaslightweightgainoverthistime,normalheartrate,bloodpressure

  • CaseFourLabs** Na128 K3.6 Cl96 HCO322 BUN5 Cr0.3

  • QuestionsCaseFour WhatdoyoususpecttheFENa andUrineOsmolalityare?

  • CaseFourUrineLabs** UrineNa95mEq/L FENa 2.1% UrineOsm 780mosm/L

  • QuestionsCaseFour Whatisthechildsdiagnosisis?** Whatwillyourmanagementbe?**

  • HyponatremiaCaseFive 6 yearoldfemaledevelopspolyuriaandpolydipsia

    Herweightisdecreasedandshehasanincreasedrespiratoryrate

  • CaseFiveLabs** Na128 K5.8 Cl94 HCO310 BUN20 Cr0.7 Glucose450

  • QuestionsCaseFive Whyistheserumsodiumlow?**

  • VariousEtiologiesofHyponatremia**:ClinicalUtilizationofUNa andUosmIncreased Weight UNa UOSM Decreased Weight

    HypoalbuminemiaNephrosis/Cirrhosis

    AGN

    500 Dehydration/Volume DepletionCystic Fibrosis

    Acute Volume expansionWater intoxicationExcess IV Fluids

    >10

  • TakeHomePointsforPractice Theetiologyofhyponatremiacanbedeterminedthrough

    assessmentofclinicalvolumestatus,urinesodiumexcretion(FENa),&urineosmolality

    Iftherenalresponsetoasuggestedclinicalvolumestateappearsinappropriate,considerrenaltubularpathologytubularinjury,tubulardysfunction,orinappropriatehormonesecretion(e.g.SIADH)

    Treatmentoflowvolumestatesrespondwelltovolumeandelectrolyterepletion;treatmentofexcessvolumestatesrespondtomanagementofunderlyingdisorder(e.g.nephroticsyndrome)andthoughtfulsupportiverestrictions(e.g.SIADH)

  • HematuriaCase1 7yearoldmalepresentswithteacoloredurine Otherwisewell,noknowntrauma,URIsymptoms1month

    ago,nowbetter.+Headache,otherwiseROSnegative PMHxwellmanagedType1DMdxd 4yearsprior OnInsulin,acetaminophenasneeded Soc Hx,Fam Hx:noncontributory Exam

    BP150/80,vitalsotherwisenormalforage 95%ht,97%wt (momnotedweightisup5poundsfromaweekago) examotherwisenormal,fundiwnl,noedema,normalabdomenand

    lungs

  • Whatisthenextstep?

  • Whatisthenextstep? First,confirmtruehematuria**

    IsU/A+forblood? IfU/Aneg bloodingestion(beets,med)

    NextconfirmRBCinurine** IsMicroscopy+forRBCs? IfMicroscopyneg forRBCsthenthink:

    Myoglobinuria Hemoglobinuria Oldspecimenorotherfalsepositive

  • DDx GrossHematuriainChildren** Glomerular(Kidney)

    Systemicsigns/sx Brownorblackcolor RBCcasts,dysmorphicRBCs

    Glomerulonephritis PostInfectious MPGN,SLE IgANephropathy,HSP HUS Alports,ThinBMDz

    NonGlomerular Localizedsigns/sx Pink/redurine+/ clots eumorphic RBCs

    Tumors,Trauma Infection,Inflammation Cysticdisease,Congenital

    anomaly,Crystalluria(Calciuria)

    Stones,Sicklecell

  • PatientsUrinalysis

  • AcuteGlomerulonephritis

    Whatnext?

  • Whatareclinicalindicatorsofasevereglomerulonephritis?

    Acutekidneyinjury/elevatedcreatinine Hypertension Severeproteinuria,nephrotic rangeproteinuria,inparticularnephrotic syndrome

    Whyandhowcanglomerulonephritiscausenephrotic syndrome?

  • RecaponPodocytes andGlomerularBasementMembrane

    Podocytes Helpcreatethenegativelychargedslitdiaphragmthatpreventsmanyserumproteins(e.g.albumin)fromfilteringacrosstheglomerulus

    MinimalChange Diseaseisaresultofpodocytes thatarenolongerfunctioning(theyareeffaced) Negativechargeslitdiaphragmisgone Serumproteins(e.g.albumin)filterintotheBowmansSpace

  • SevereGlomerulonephritis Whenthereissevereinvolvementofthebasementmembrane,thenonemightthinkofthepodocytes asinnocentbystanders

    Therefore,Nephrotic Syndromeisamanifestationofsevereproteinuriaandamarkerforasevereglomerulonephritis(GN)

    IfsuchaGNgoesuntreated,ordoesnotresolvespontaneously(e.g.postinfectious),thenthisresultsinapoorlongtermprognosis

  • SerologyInterpretation LetssayyougetC3andC4andASLOtiter Resultsshowa+ASLOtiter,butC3andC4arenormal

    Whatisyourdiagnosticinterpretation?**

  • BacktoPatient

    CBCnormal ANANeg,C3verylow,C4normal,Poststreptiterspositive Pr/Crratio7.2!

    4.2 0.514

    23108140

  • Whatisyourpresumptivediagnosis?**

    A. IgANephropathyB. Alport SyndromeC. Membranoproliferative GND. PostInfectiousGN

  • Howcouldyouconfirmthis?**A. Monitoringforspontaneousresolutionand

    returnofC3tonormalovernext23monthsB. Responsetoempirictreatmentwith

    CorticosteroidsC. RenalBiopsy

  • ButwhatabouthisHypertension?**A. Providereassurance.IfthisispoststrepGN,itwillget

    betteronitsownsoitdoesnotrequiretreatment

    B. Itisseverelyelevatedfora7yo sowarrantstreatmentwithalowsodiumdietandanACEInhibitoruntiltheGNresolves

    C. Itisseverelyelevatedfora7yo,sowarrantstreatmentwithalowsodiumdietandthiazide diureticuntiltheGNresolves

  • Whydidhegainweight?**A. WithhisacuteGNandHTNhewasmoresedentary,

    sothisisincreasedbodyfatB. WithhisacuteGN,hisGFRmaybedecreasedsothis

    islikelyfluidweightfromrenalfailureC. WithhisacuteGN,renin isstimulatedandhis

    nephrons arelikelyreabsorbingsaltandwatersothisisfluidweight

    D. WithhisacuteGNandbeingsick,heprobablyactuallylostweight,sothisismeasurementerror

  • HematuriaCase2 6 yo malepresentswithpinkishredcoloredurine Otherwisewell,noknowntrauma,norecentmedications,inschoolbutnoobviousillness,ROScompletelynegative

    PMHx,Soc Hx,Fam Hx allNonContributory Exam

    normalBPandvitals,50%ht andwt Examotherwisecompletelynormal

  • NextStep