Acid/Base/Potassium (ALL BRCU lectures done 7/19) Flashcards by Priya Yenebere

What are 3 things that enhance renal NH3 production and NH4+ excretion?
3 things that inhibit it?
#abk #brcu

Enhancers:
- Acidemia, hypokalemia, gluconeogenesis

Inhibitors:
- Alkalemia, hyperkalemia, angiotensin blockers

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abk #brcu

What are the three main processes for urinary H+ excretion?

Proximal acidification
Distal acidification
Bicarb reabsorption/generation

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Hypokalemia stimulates acidemia/alkalemia?
Hyperkalemia?
#abk #brcu

Hypokalemia –> alkalemia (increased bicarb generation)
Hyperkalemia –> acidemia (decreased bicarb generation)

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abk #brcu

NAGMA: gain of ____ and loss of ____
HAGMA: gain of ____ and loss of ____

(Like what kind of ions)

NAGMA: gain of chloride ion and loss of bicarb
HAGMA: gain of non-chloride anion and loss of bicarb

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DDx for HAGMA:
GOLD MARK
#abk #brcu

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What are the metabolites for the following:
Glycols: ethylene (?), propylene (?)
Oxoproline: (?)
L-lactate
D-lactate
Methanol: (?)
ASA: (?)
Renal failure
Ketoacidosis
#abk #brcu

Glycols: ethylene (oxalic acid), propylene (lactate)
Oxoproline: (pyroglutamic acid)
L-lactate
D-lactate
Methanol: (formic acid)
ASA: (lactate + ketones)
Renal failure
Ketoacidosis

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DDx for HAGMA:
CUTE DIMPLES
#abk #brcu

Cyanide, citrate
Uremia
Toluene
Ethylene glycol
DKA
INH, iron
Methanol, metformin
Pyroglutamic acid, prolylene glycol, paraldehyde, propofol
Lactic acidosis, linezolid
Ethanol ketoacidosis
Salicyclates, starvation ketoacidosis, sodium thiosulfate (?)

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What are the metabolites for the following:
Cyanide, citrate: (?)
Uremia
Toluene: (?)
Ethylene glycol
DKA
INH, iron
Methanol, metformin: (?)
Pyroglutamic acid, prolylene glycol, paraldehyde, propofol: (?)
Lactic acidosis, linezolid: (?)
Ethanol ketoacidosis
Salicyclates, starvation ketoacidosis, sodium thiosulfate
#abk #brcu

Cyanide, citrate: (citric acid)
Uremia
Toluene: (hippuric acid)
Ethylene glycol
DKA
INH, iron
Methanol, metformin: (lactate)
Pyroglutamic acid, prolylene glycol, paraldehyde, propofol: (lactate)
Lactic acidosis, linezolid: (lactate)
Ethanol ketoacidosis
Salicyclates, starvation ketoacidosis, sodium thiosulfate

Toluene leads to an early HAGMA

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What is the difference between diarrhea and RTA in NAGMA?
Which has a positive or negative urinary AG?
#abk #brcu

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When should you determine the delta gap?
What are the steps you take to determine a mixed AB disorder?
#abk #brcu

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What is the Winter’s Formula?
When do you use it?
How do you interpret it?
#abk #brcu

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What is the UCl for diuretics? Hyperaldo? Bartter? Gitelman?
#abk #brcu

UCl > 20

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Hyperaldo –> MetAc or MetAlk?
#abk #brcu

MetAlk

Direct stimulation of H-ATPase
Direct stimulation of Na/K exchange
More open ENaC channels

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When do you typically see pseudohypokalemia?
What is the WBC usually?
#abk #brcu

Seen in AML
Marked leukocytosis

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What does increased B-adrenergic activity do to the K level?
What drugs can have this affect?
#abk #brcu

Cellular shift that causes hypokalemia (ex: stress induced epi)
Drugs: theophylline intoxication, rotodrine and terbutaline, albuterol

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What does treatment of pernicious anemia do to K level? How?
#abk #brcu

Causes hypokalemia
Give back Vit B12, now the new cells take up the K

Also, rapidly growing leukemias and lymphomas
(think anabolism)

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Hypokalemia periodic paralysis:
Inheritance? Mutation?
Other clinical association?
#abk #brcu

AD
Mutation in a-1 subunit of DHP-sensitive Ca channel
Hyperthyroidism

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(Asian) male that has paralysis after large meal or extreme exercise: name the disorder? What other disorder is associated with this?
#abk #brcu

Acquired hypokalemic periodic paralysis (they usually have hyperthryoidism)

Diuretics can cause a hypoK, but you get both extra and intracellular depletion - so they aren’t as symptomatic as someone with paralysis. The paralysis guys have a such a large transgradient because the K is shifting intracellularly - you aren’t losing K like in diuretics

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In GI loss, what do you expect the UK to be?
#abk #bruc

UK < 20

Diarrhea is the most common cause

Vomiting has 5-10 meq in the gastric juice (so hypokalemia is more due to the kidney K loss due to hypovolemia)

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You have hypoK without an AB disorder: what are you thinking?
HyperK?
#abk #brcu

Clay ingestion (also low phos and Fe)
Red clay (hyperK)

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HypoK with NAGMA: what are you thinking?
#abk #brcu

Small intestine disorder

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HypoK with MetAlk: what are you thinking? (3, one of them is a med)
#abk #brcu

Chronic laxative abuse

Congenital chloridorrhea (needs lifelong salt supplementation)
Villous adenoma

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What do you expect the UK in kidney loss for hypoK? Why?
#abk #brcu

UK > 20
Coupling of increased distal Na delivery and increased MC activity

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High renin and High aldo
DDx?
#abk #brcu

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What is the renin and aldo in renal artery stenosis? #abk #brcu

High renin High aldo

What is the renin and aldo in renin secreting tumor? #abk #brcu

High renin High aldo

What is the renin and aldo in malignant HTN? #abk #brcu

High renin High aldo

Low renin and High aldo DDx? #abk #brcu

What is the renin and aldo in Conn's syndrome? #abk #brcu

Low renin High aldo

What is the renin and aldo in BL adrenal cortical hyperplasia? #abk #brcu

Low renin High aldo

What is the renin and aldo in GC suppressible hyperaldo? #abk #brcu

Low renin High aldo

What is GC suppresible hyperaldo? What's the big enzyme you need to know? How do you check? Inheritance pattern? What's the treatment? #abk #brcu

- This is a crossover that results in a chimeric gene, where ACTH from the pituitary is driving the aldosterone production - Increased production of 18-oxocortisol and 18-hydroxycortisol (check in the urine) - AD (FMHx of HTN) - Treat with exogenous GC (decreases the ACTH release, which will decrease aldo production)

Low renin and low aldo DDx? #abk #brcu

Also Liddle Activating mutation of the MC receptor

What is the renin and aldo in SAME? #abk #brcu

Low renin Low aldo

What is the renin and aldo in Cushings? #abk #brcu

Low renin Low aldo

What is the renin and aldo in congenital adrenal hyperplasia? #abk #brcu

Low renin Low aldo

What are some clincal ssx in 11 b-hydroxylase deficiency? 17 a-hydroxylase deficiency? (in congenital adrenal hyperplasia) #abk #brcu

11 beta = virilization 17 alpha = decreased sex hormones

Pathophys for syndrome of apparent mineralocorticoid excess? What is the enzyme issue? How are you labs? What are some acquired causes? #abk #brcu

Cortisol isn't being inactivated into cortisone 11 B-hydroxysteroid dehydrogenase deficiency leads to more cortisol which stimulates the MC receptor Urinary cortisol levels >> urinary cortisone Glycyrrhetinic acid (licorice, chewing tobacco), grapefruit juice, bile acids (hyyperbili patients)

What is the renin and aldo in Liddle? Treatment? #abk #brcu

Low renin Low aldo Amiloride or triamterene

What is the renin and aldo in activating mutation of MC receptor? Inheritance? What's the pathophys? What med is CI in this? #abk #brcu

Low renin Low aldo AD Steroids usually antagonize, but here they activate the receptor Spironolactone is CI (it's now an MCR agonist)

What are things that increase distal Na delivery? #abk #brcu

Name 4 things that decrease proximal reabsorption of Na. #abk #brcu

Carbonic anhydrase inhibitors (acetazolimide) Osmotic diuretics Met Ac Topirimate

Name 3 things that decreases TAL reabsorption of Na. #abk #brcu

Loop diuretics Mg deficiency Bartter syndrome ## Footnote remember that loops are secreted in the proximal tubule

What other electrolyte abnormalities are associated with hypoMg? #abk #brcu

Hypokalemic alkalosis Hypocalcemia | Mg deficiency inhibits TAL Na absorption

Normal BP Hypokalemia MetAlk Name the syndrome #abk #brcu

Bartter syndrome

Bartter syndrome: HTN? K level? AB disorder? Aldo? #abk #brcu

What are the 5 different Bartter mutations? Which ones are clinically associated with other medical conditions? #abk #brcu

## Footnote Know the deafness one and the AD hypocalcemia hypokalemic alkalosis, I can see this in a stem

Bartter: Renin? Aldo? Urinary Ca? #abk #brcu

High renin and aldo Hypercalciuria

Name 2 things that decreases DCT reabsorption of Na #abk #brcu

What do nonreabsorbable anions in the filtrate do to distal Na delivery? How does it affect K excretion? What are some of these anions? #abk #brcu

## Footnote Also, toluene exposure (hippurate)

Kidney K Handling algorithm #abk #brcu

## Footnote if you have MetAc and hypoK, treat the hypoK first (if you give BC, the K will go lower b/c it shifts into the cell)

What are some causes of pseudohyperK? #abk #brcu

Venipuncture Increased WBC or Plt

What are 2 factors that shift K into the cell? 4 factors that shift K out? #abk #brcu

Name 3 drugs that shift K out of the cell? #abk #brcu

Digoxin Chan su (herbal) Succinylcholine (causes depolarization and leads to K accumulation in the NM junction)

What are some meds/conditions that impair renin release? Impair aldo metabolism? (figure) #abk #brcu

What are some other names for Gordon syndrome? #abk #brcu

Familial hyperK HTN Pseudohypoaldo type 2

HTN, hyperK, NAGMA Cl dependent AD Responds to thiazides Name the syndrome #abk #brcu

WNK4 inactivating mutation Name the syndrome What are some associated lab abnormalities? #abk #brcu

## Footnote Associated hyperCalciuria

What is pseudohypoaldo type 1? How is it different than type 2? #abk #brcu

HyperK, MetAc, with hypoTN AR pattern: inactivating ENaC; lots of pulm infections AD pattern: inactivating MC receptor; mild and improves with age Gordon's (type 2) has HTN

What are 3 causes of high sweat Cl? #abk #brcu

CF Congenital hyperchloridia Pseudohypoaldo type 1

Name all the kidney syndromes (figure) #abk #brcu

What are some ways to determine the respiratory compensation for primary MetAc? #abk #brcu

## Footnote First: most accurate Second: easiest

What are some causes of low anion gap? #abk #brcu

Low albumin Severe NAGMA Increased unmeasured cations (but with accompanied Cl or BC) - Increased Ca or Mg, lithum, IgG paraproteinemia, polymyxin B Spurius Cl elevation - Bromide, iodide, salicyclate

What are some causes of a high anion gap? #abk #brcu

Severe volume depletion (increased albumin) Resp and Met alkalosis Increased IgA (anion) Increased TG Severe hyperphos

What are the only 2 things that lower you Cl level? #abk #brcu

MetAlk Chronic RespAc Does what to you Cl level?

Na 150 Cl 100 BC 20 Name the AB disorder #abk #brcu

Na 130 Cl 100 BC 6 Name the AB disorder #abk #brcu

What are the only 2 things that increase you Cl level? #abk #brcu

NAGMA Chronic RespAlk Does what to your Cl level?

What are the 3 different types of lactic acidosis? #abk #brcu

Type A: tissue hypoxia Type B: nothing to do with hypoxia or hypoperfusion Type D: bacterial overgrowth

What are the causes of hyperK in DKA? What is NOT a cause? #abk #brcu

What kind of acidosis do you see in early vs. late DKA? #abk #brcu

NAGMA in early DKA (ECF volume is near normal) Once you have decreased EABV, you get in increased AG ## Footnote NAGMA in the recovery phase of DKA due to indirect loss of NaBC in the urine with kidney retention of NaCl and admin of NaCl

What are the metabolites and their effects of methanol? Ethylene glycol? Treatment? #abk #brcu

In EtOH ketoacidosis, which comes first: thiamine or glucose and why?

Thiamine then glucose to minimize the risk of Wernicke or Korsakoff

Propylene glycol: what kind AB disorder? #abk #brcu

HAGMA

RespAlk and HAGMA: whats the intoxication? #abk #brcu

Salicylate poisoning | Sometimes as NAGMA

What kind of AB disorder do you get with salicylate toxicity? Uric acid level? Glucose level? #abk #brcu

RespAlk + HAGMA Low dose salicylate -> increase uric acid High dose salicylate -> decreases uric acid Hypoglycemia | Sometimes a NAGMA

Steps to do an AB disorder question (figure) #abk #brcu

What are your compensation ratios for bicarb and CO2? (figure) #abk #brcu

## Footnote There are a lot of different ways to do it, but maybe just learn the box?

What are the correction factors of a VBG to ABG for pH and pCO2? #abk #brcu

pH: add 0.05 pCO2: subtract 5

What is the correction factor for albumin when you determining the anion gap? #abk #brcu

Correction for albumin: (4-albumin) x 2.5

What is the equation for a urine anion gap? What's the etiology of a positive UAG? Negative UAG? #abk #brcu

Na+K-Cl Positive - renal cause (low NH4 excretion) Negative - nonrenal cause (appropriate NH4 excretion)

Toluene is associated with what metabolite? #abk #brcu

Hippuric acid is a metabolite of what?

What is the equation for a urine osmolal gap? #abk #brcu

Measured UOsm - [2x(Na+K)+(UUN/2.8)+(Glucose/18)]

Which of the RTAs cause hypoK? #abk #brcu

Proximal RTA (type 2) Classic distal RTA (type 1) Mixed (type 3)

Which of the RTAs cause hyperK? #abk #brcu

Aldo deficiency/resistance (type 4) Non-MC voltage defect

What is the K level and the type of MetAc: progressive CKD? Uremic acidosis? #abk #brcu

Progressive CKD: normal K and NAGMA Uremic acidosis: normal K and HAGMA

What is the K level in the following? Proximal RTA? Distal RTA? Mixed RTA? Aldo deficient/resistance? #abk #brcu

Top three - hypoK Bottom - hyperK

What are the updated names (locations) of the 4 RTAs? #abk #brcu

Urinary bicarb loss - what kind of RTA? #abk #brcu

Type 2 proximal RTA

What is the overall pathophys for a Type 2 RTA? #abk #brcu

Urinary bicarb loss

NaPi-2 mutation, cystinosis (MC), glycogen storage diease, wilson's - what kind of RTA? #abk #brcu

Type 2 proximal RTA

What are some other etiology for generalized proximal RTA dysfunction? #abk #brcu

What is type 2 RTA also known as? What are reasons for an acquired form of Type 2 RTA? #abk #brcu

MM, amyloidosis, heavy metal toxins (Pb, Cd, Hg) - what kind of RTA? #abk #brcu

Type 2 proximal RTA

Carbonic anhydrase (acetazolimide), ifosfamide, cisplatin, tenofovir - what kind of RTA? #abk #brcu

Type 2 proximal

What are some meds that can cause Type 2 RTA? #abk #brcu

UpH < 5.5 Normal UAG Fanconi syndrome Name the RTA #abk #brcu

Proximal RTA UpH? UAG? What other syndrome?

Proximal RTA UpH? UAG? What other syndrome? #abk #brcu

UpH < 5.5 Normal UAG Fanconi syndrome

What medication can give you an isolated proximal RTA? Mixed RTA? #abk #brcu

Carbonic anhydrase (isolated prox RTA) Topirimate (mixed RTA)

Carbonic anhydrase inhibitors give you what type of RTA? #abk #brcu

Isolated proximal RTA (topirimate - mixed RTA)

Poor H+ excretion - what kind of RTA? #abk #brcu

Type 1 distal (classic)

What is the overall pathophy for Type 1 RTA (classical)? #abk #brcu

Poor H+ excretion

Sjogrens, RA, sickle cell, hypercalciuria (medullary sponge, hyperpara, excessive VitD), obstructive uropathy - there are all acquired forms of what kind of RTA? #abk #brcu

Type 1 Distal

What are some acquired forms of distal RTA? #abk #brcu

Ampho B, lithium, isofofamide, topirimate, toluene - what type of RTA? #abk #brcu

Type 1 distal

What are some meds that cause a distal RTA? #abk #brcu

UpH >= 5.5 UAG + Hypocitraturia Hypercalciuria Name the RTA? #abk #brcu

Distal RTA Urine pH? UAG? Findings in urine?

Distal RTA Urine pH? UAG? Findings in urine? #abk #brcu

UpH >= 5.5 UAG + Hypocitraturia Hypercalciuria

Type 4 RTA will have what renin and aldo levels? #abk #brcu

For aldo deficiency: high renin and low aldo But there is hyporenin and hypoaldo type 4 RTA too

Congenital AI, heparin, ACE/ARB - what kind of RTA? #abk #brcu

Type 4 distal low aldo

What are some reasons for hyporenin hypoaldo Type RTA? #abk #brcu

DM nephropathy NSAIDs (decreased PGs) CNIs Obstructive uropathy

DM nephropathy NSAIDs (decreased PGs) CNIs Obstructive uropathy What kind of RTA? Renin and aldo levels? #abk #brcu

Type 4 RTA hyporenin hypoaldo

Spiro, amiloride, triamterene, TMP, pentamidine, CNI - what kind of RTA? #abk #brcu

Type 4 RTA

What are some meds that can cause Type 4 RTA? (figure) #abk #brcu

Obstructive uropathy - what kind of RTA? #abk #brcu

Non-MC voltage defect Type 4 RTA

Interstial nephritis (sickle cell) - what kind of RTA? #abk #brcu

Non-MC voltage defect Type 4 RTA

Lupus nephritis - what kind of RTA? #abk #brcu

Non-MC voltage defect Type 4 RTA

What are some non-MC voltage defect reasons for Type 4 RTA? (figure) #abk #brcu

Pseudohypoaldo type 2 Other names for this? Inheritance? Aldo? BP? K? AB disorder? #abk #brcu

Pseudohypoaldo type 2 Familial hyperK HTN Gordon syndrome AD HTN (volume expansion) Low aldo HyperK MetAc

AD HTN (volume expansion) Low aldo HyperK MetAc Name the syndrome #abk #brcu

Pseudohypoaldo type 2 Familial hyperK HTN Gordon syndrome

Different types of Type 4 RTA Pathophys? Disease? Renin? Aldo? (figure) #abk #brcu

Different RTAs: K? UAG? UpH? Bicarb? (figure) #abk #brcu

Treatments for hypokalemic RTA? #abk #brcu

Treatment for hyperkalemic RTA? #abk #brcu

Treatment for Gordon syndrome? #abk #brcu

Definition of MetAlk What are values in the compensation table? (figure) #abk #brcu

In MetAlk, what is your cut off for Cl sensitive and Cl resistant for UCl levels? Which one is volume "depleted"? "Expanded"? #abk #brcu

UCl < 20 = sensitive (depleted) UCl > 20 = resitant (expanded)

What are some Cl sensitive states for MetAlk? What is the UCl? #abk #brcu

GI: vomiting/NG suction; hereditary Cl losing Drh; laxative use disorder Urinary: diuretics (exception UCl is high in recent med use) UCl < 20

What are some Cl expanded states for MetAlk? What is the UCl? #abk #brcu

Exogenous alkali MC/GC excess Tubular disorders (exception: Bartter and Gitelman are volume depleted) Severe hypoK UCl > 20

Milk alkali syndrome: AB disorder? Urine pH? Chloride resistent or sensitive (UCl)? #abk #brcu

Met Alk Urine pH high Cl resistant (UCl>20) Name the disorder.

Met Alk Urine pH high Cl resistant (UCl>20) Name the disorder. #abk #brcu

Milk alkali syndrome

Which MetAlk etiolgies have a high aldo level? #abk #brcu

Which MetAlk etiology have a high cortisol level? #abk #brcu

Liddle syndrome Inheritance? Pathophys? K level? Renin/Aldo levels? Treatment options? #abk #brcu

Name the disorder #abk #bcru

Liddle

Bartter Inheritance? Acquired etiologies? Renin/aldo? UCl? UCa? Treatment? #abk #brcu

Name types 1-4 of bartter - which channels are affected? #abk #brcu

Name the syndrome #abk #brcu

Bartter

Gitelman Inhertance? Channel defect? Mag level? Renin/aldo? UCl? UCa? Treatment? #abk #brcu

Name the syndrome #abk #brcu

Gitelman

Gitelman vs. Bartter Which one has high UCa vs low UCa? #abk #brcu

Gitelman: low UCa "giteLman = Low" Bartter: high (high-normal) UCa

Bartter, gitelman, liddle: high or low renin? #abk #brcu

Bartter and Gitelman: high renin (therefore high aldo) (normal is 1-6) Liddle: low renin (Liddle = Low)

Severe hypoK: high or low renin? #abk #brcu

Low renin with hypoK

MetAlk summary #abk #brcu

## Footnote Or, delta AG + BC (7+6) = 13 13 < 24 = NAGMA

What are the steps to do a delta gap? What are the cutoffs for a concurrent NAGMA or MetAlk? #abk #brcu

What kind of AB disorders (or clinical scenarios) do you see for the following? Salicylate ingestion? Metformin overdose? Toluene ingestion? Diethylene glycol ingestion (brake fluid?) D-lactic acidosis?

Patient has an instestinal surgery - what kind of AB disorder are you thinking?

D-lactic acidosis

Osmolal gap and cranial nerve palsies - what kind of ingestion?

Diethylene glycol (brake fluid)

What kind of ingestion gives you a respiratory alkalosis?

Salicylate ingestion

HAGMA and NAGMA with no lactic acidosis - what kind of ingestion?

Toluene ingestion

What kind of poisoning give you visual disturbances?

Methanol poisoning

What kind of poisoning gives you calcium oxalate crystals with AKI?

Ethylene glycol

What are the big differences in toxic alcohol poisonings? (figure)

Does RRT remove metformin?

HD removes metformin and treats the acidosis, so you should RRT early and RRT long There will be rebound because the VoD is large (>3L/kg)

Hypokalemia NAGMA DDx (figure)

If you have chronic diarrhea, what do you expect the UpH to be?

Urine pH > 5.5 (< 5.3 is normal) (> 5.5 +/- acidification defect)

Intestinal bypass surgery - what kinda of urinary metabolite findings?

Hyperoxaluria (from fat malabsorption)

How do you calculate the urine osmolal gap? What is the cutoff number and what does it mean?

What are the cutoffs for an acidification defect for D-RTA? Urine pH? UAG? UOG?

Urine pH > 5.3 UAG < (-20) (aka more positive) UOG < 150

Urine pH > 5.3 UAG < (-20) (aka more positive) UOG < 150 What kind of ABDO?

D-RTA

What kind of disorder also comes with D-RTA? Why?

Common causes of D-RTA? Syndromes? Meds?

What's the AB D/O?

HAGMA, NAGMA, RespAc

What are the only 2 things that allow for a high Cl without a high Na?

Chronic RespAlk NAGMA (usually they both move together)

Toluene breaks down into hippurate and causes what kind of disorder?

Overproduction of aciduria (you pee out hippuric acid) Can get a NAGMA (late) or HAGMA (acute when coupled with volume depletion) | Toluene can cause an extra-renal acidosis ## Footnote Urinary AG is normally negative; but if you have extra anions, you can get a positive UAG (looks like an RTA); so you use the UOG (normal is 10-100); if there is a huge UOG there is some type of extra Osm getting voided (aka the kidney is actually normal function - not abnormal like an RTA); UAG can be misleading in the setting of unmeasured anions (B-OH-butyrate and acetoacetate in ketoacidosis, hippurate in toluene exposure)

80kg pt; assuming no additional acid production, how much BC is required to raise the BC from 12 to 20?

(20-12) x (80 x 0.5) = 320mEq

What are complications of bicarbonate therapy? (figure)

What are AE of acidemia? (figure)

IV lorazepam - what's the medication toxicity?

Propylene glycol

Propylene glycol toxicity - what medication do you suspect? What kind of gap do you get?

IV lorazepam (ativan) HAGMA (lactic acid) and OG as well

Malnourished patient with tylenol intoxication - what is the etiology?

Pyroglutamic acid (oxoproline) (HAGMA without a lactate)

Sepsis-like patient with high lactate and HAGMA, but no source of bacterial sepsis?

Propylene glycol induced lactic acidosis (HAGMA + lactate) Usually seen in IV lorazepam (but also other meds)

Antifreeze ingestion - what do you suspect and do you find?

Ethylene glycol AKI Calcium oxalate crystals

AKI Calcium oxalate crystals What kind of ingestion?

Ethylene glycol (antifreeze)

Malnoutrition and chronic tylenol exposure? What's the cause? Whats the ABDO? Gaps?

Oxoproline (pyroglutamic acid) HAGMA + high OG Lack of lactate or ketones (other reasons for HAGMA)

Oxoproline toxicity: what kind of ABDO?

HAGMA and high OG (lactate will be low)

What are causes of Type B, L-lactic acidosis? (figure)

Malignancies, DKA, Mangosteen (fruit), HIV meds, metformin, toxic alcohols, acute liver fulminant failure, severe thiamine deficiency

What are causes of Type B, D-lactic acidosis? (figure)

Gut bacteria overgrowth in short gut (looks "drunk"), DKA, propylene glycol

What's a normal OG? Whats the formula?

Normal OG < 10

Alcohol intoxications: metabolite? complications? treatment? dialyze?

Which of the alcohols is not like the other and why? Methanol, ethylene glycol, isopropyl alcohol (aka isopropranol or rubbing alcohol)?

Isopropyl alcohol does not cause a metabolic acidosis; it gets metabolized into acetone which is not an acid

NAGMA, postive UAG, UOG < 100: name the condition? (figure)

D-RTA

What are the UAGs? Extrarenal? P-RTA? D-RTA? Toluene?

Extrarenal - Negative P-RTA - Positive D-RTA - > 0 Toluene - > 0 (but otherwise doesn't look like RTA)

BC > 15 urine pH < 5.5 Met Ac Hypokalemia Name the condition

P-RTA | Can't reabsorb BC in the prox tubule

P-RTA BC level? urine pH? AB d/o? K level?

BC > 15 urine pH < 5.5 Met Ac Hypokalemia

Etologies of P-RTA (figure)

know the acquired defects: MM, heavy metals, amyloidosis, PNH, cisplatin, ifosfamide, aminoglycosides, imatinib, tenofovir, valproic acid, CA inhibitors (acetazolimide, topirimate, zonisamide (SZ med)) CA inhibitors are known for increased stone risk

How do you dx P-RTA?

Fe of BC

How do you manage P-RTA?

BC replacement K replacement Thiazides

D-RTA BC level? urine pH? Clinical associations? Urine findings?

BC < 15 urine pH > 5.5 (but not always) Growth impairment and polyuria Hypercalciuria, nephrocalcinosis, stones (type 4 D-RTA doesnt have increased risk of nephrocalcinosis because it has a low urine pH)

BC < 15 urine pH > 5.5 (but not always) Growth impairment and polyuria Hypercalciuria, nephrocalcinosis, stones What kind of disorder?

D-RTA | Can't secrete H+

Etiologies of D-RTA (figure)

Know the hypoK and hyperK (Type 4) etiolgoies HypoK: SS, RA, SLE, PBC, Li, ifosfamide (more prox than distal), ampho, bisphosphonates HyperK: aldo deficiency or resistance, DM, tubulointerstitial nephropathy, sickle cell, obstructive uropathy, CNIs, K-sparing diuretics, NSAIDs, RAAS blockers, hepatin

How do you test for D-RTA?

How do you manage D-RTA?

Name a genetic condition that will give you a mixed RTA? Inheritance? Other clinical findings? Genetic mutation?

AR with mixed RTA with osteoporosis (young kids) Name the disease and the mutation

What is the UOG with toluene intoxication? What kind of an ABDO?

Usually > 100-150 NAGMA

Diarrhea causes what kind of ABDO? UAG? UpH? Any other labs values you should think of?

NAGMA UAG < 0 UpH may be high (>5.5) HypoK

What are 3 GI causes of NAGMA?

Diarrhea, ileal conduit, D-lactic acidosis

When should you be really cautious with alkalinzation?

Common causes of Cl sensitive MetAlk? Whats the UCl?

Describe the phases of vomiting (figure)

Severe MetAlk with BC > 45 - whats the cause?

Almost always due to a gastric cause

Met Alk with BC > 45 UCl < 10 Hypokalemia Whats the disorder?

Surreptitious vomiting

What lab findings do you see in surreptitious diuretic use?

Varying MetAlk UNa AND UCl (both very low or very high)

Common causes of Cl-resistant MetAlk (figure)

Goiter, sensorineural deafness, metabolic acidosis: name the condition. Where is the channel mutation? What medication should you be cautious of and why?

Pendred syndrome - rare Cl-Bicarb exchanger mutation in the collecting duct Hypovolemia, MetAlk, HypoK if you use thiazides (because you are inhibiting the NCC channel and the pendrin channel already doesn't work)

What is pendred syndrome? (figure)

How to correct a severe MetAc? (figure)

Common causes of RespAlk and Resp Ac? (figure)

Low serum pH shifts the K how? High pH?

Acidemia: shifts K out Alkalemia: shifts K in

What kind of indices do you use to evaluate K disorders? (figure)

What are some common causes of pseudohyperkalemia? (figure)

CLL - what kind of K disorder?

"reverse" pseudohyperkalemia

Episodic weakness with rest after exercise - condition? K level? (figure)

Sofosbuvir can cause what kind of lab abnormality?

HyperK with MetAc and salt wasting - name the syndrome. Treatment? (figure)

HTN in early adulthood, NAGMA, hyperK, hypercalciuria, osteoporosis, and stones - name the condition. Pathophys/mutation? Treatment? (figure)

Hypokalemic nephropathy: histology? pathogenesis? clinical findings? (figure)

AML or CML - whats the K level?

pseudohypokalemia (may also see hypophosphatemia and pseudohypoglycemia)

Clay ingestion - K level?

Hypokalemia

HypoK, hypoMag, hypoCal with secretory diarrhea - whats the syndrome? (figure)

Paralysis after strenuous exercise - condition? (figure)

Thyroid issue with period paralysis - hyperK or hypoK? What other lab is noteworthy?

Treatment for hypoK periodic paralysis? Food?

BBL, K supplementation, low card diet, k sparing diuretics, CA inhibitors

Which of the periodic paralysis conditions is treated with high carb vs low carb diet?

HyperK - treat with high carb diet HypoK - treat with low carb diet

Barbituate coma therapy (with thiopentone) causes what K value?

Initial hypoK then rebound hyperK Replace slowly during the first 12-24 hours to reduce the rapid and severe rebound

HypoK with Met Alk with gain of function ENaC - name the syndrome

Liddle

DDx/algorithm for HTN, hypoK, MetAlk (figure)

Syndrome of apparent MC excess - what's the ingestion/molecule that mimics this? What ratio do you see?

Abiraterone - what medication is this and what can it cause? (figure)

What is Geller sydnrome? (figure)

Ampho leads to high or low serum K?

MetAc and eletrolyte wasting Low K in serum

Hypercalcemia causes high or low serum K? what kind of AB DO?

HypoK with MetAlk (like a loop)

Normotension, hypoK, MetAlk High renin and High aldo Bartter or gitelman?

Both

Bartter BP? K? ABO DO? Renin? Aldo?

Normotension, hypoK, MetAlk High renin and High aldo

Gitelman BP? K? ABO DO? Renin? Aldo?

Normotension, hypoK, MetAlk High renin and High aldo

What are the differences between Bartter and Gitelmans? (figure)

Inheritance pattern for Bartter; channel mutations? (figure)

Which has more common and more severe hypoMag? Bartter or Gitelmans?

Gitelmans has really bad hypoMag

What urine study is needed to determine Gitelman vs bartter?

Metabolic disturbances for urinary diversions (figure)

List of etiologies for Type B lactic acidosis (figure)

Acid/Base/Potassium (ALL BRCU lectures done 7/19) Flashcards

7/19/2021 Lectures