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Les deux ennemis > Nephro : Acid-Base and E+ > Flashcards

Nephro : Acid-Base and E+ Flashcards

1
Q

ECK and hyperkaliemia, how’s :
The t wave
The ps
The PR
The QRS
The rythm

A

Peaker T waves
Flattened Ps
Prolonged PR
Brady - arrythmias
Prolonged QRS

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2
Q

Ethanol : AGMA or N - AGMA ?

A

NAGMA

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3
Q

How are HCO3 in RTA ?

A

Type 1 : may be < 10
Type 2 : 12 - 20
Type 4 : > 17

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4
Q

How can you differentiate Barter and Gitleman’s syndrome?

A

Barter : HIGH calcium in urine + low calcium in plama
Gitleman : LOW calcium in urine

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5
Q

How do you adjust the anion gap ?

A

Every decrease in albumin by 10, add 2.5 mEq/L to the AG

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6
Q

How do you calculate TBW?

A

0.5 x Kg for female
0.6 x Kg for male

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7
Q

How do you correct hypernatremia ?

A

PO WATER or D5 petit débit
If TNG, water flushed
Large volumes of D5 : hyperglycemia : glucosuria and a solute diuresis, worsening polyuria and hypernatremia

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8
Q

How do you diagnose diabetes insipidus ?

A

Hypernatremia with inappropriately LOW urine osmolality (Uosm < Sosm)
** serum Osm > 295 and Na > 145 **
Water deprivation test : urine osm does not rise appropriately despite rising serum osmolality / serum Na (usually not needed)

Then use DDAVP (2-4 mg IV/SC) test to differentiate between central and nephrogenic

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9
Q

How do you interpret delta delta gap ?

A

∆AG&raquo_space;∆HCO3 : >2, bicarb doesn’t change enough, meaning a secondary alkalosis is opposing the acidosis Concurrent Metabolic alkalosis (HCO3 higher than expected) with anion gap metabolic acidosis

∆HCO3 ≈∆AG : 0.8-2, Pure AG acidosis

∆AG &laquo_space;∆HCO3 : <0.8, Bicarb changes more than expected, meaning a secondary acidosis is present
Concurrent non AG metabolic acidosis (with HCO3 lower than expected) with high AG acidosis

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10
Q

How do you use urinary anion gap in NAGMA ?

A

UAG &laquo_space;0 : NH4 excretion high : GI HCO3 loss (diarrhea), pancreatic fistula, NJ tube
UAG > 0 : RTA

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11
Q

How does K change depending on high / low insuline ?

A

Low insuline : hyperkaliemia
High insuline : hypokaliemia

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12
Q

How is renin / aldo in Barrter, Gitleman, Liddle ?

A

High renin and high aldo in Barrter and Gitleman
Low renin and low aldo in Liddle

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13
Q

How is the K in acidosis metabolic ?

A

Hyperkaliemia

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14
Q

How is the K in metabolic alcalosis ?

A

Hypokaliemia

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15
Q

How is the urine pH in RTA ?

A

Type I : > 5.5, calcium phosphate stones
Type II : low, can still acidify urine
Type IV : variable

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16
Q

How is water deprivation test used in hypernatremia ?

A

To diagnose diabetes insipidus but usually not needed
Urine osm does not rise appripriately despite rising serum osmolality / serum Na

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17
Q

How much Na in hypertonic saline 3% ?

A

513

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18
Q

How much Na in LR ?

A

130

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19
Q

How much Na in NS ?

A

154

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20
Q

How to avoid over correction of hyponatremia ?

A

If urine output exceeds 150 ml/h page MD
If overcorrected : DDAVP, D5W

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21
Q

Hypernatremia : how do you calculate water deficit ?

A

Water deficit : % change in (Na) x TBW
% change in Na : (serum Na - 140) / 140

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22
Q

If hyponatremia severe and symptomatic, how much would you increase your Na immediately ?

A

By 4-5 mmol/L immediately

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23
Q

In organic alcohol intoxications, how can the osmolar gap and anion gap exist at different times ?

A

Early on : osmolar gap without anion gap
Later : anion gap without osmolar gap

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24
Q

Isopropyl alcohol, AGMA or NAGMA ?

A

NAGMA

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25
Q

Mangement of a hypovolemic patient presenting with hyponatremia?

A

NS or LR 1ml/kg/hr

Ex: pt onco avec Vo +++
50 cc/LR avec contrôle dans 4h

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26
Q

Mannitol and sorbitol, AGMA or NAGMA ?

A

NAGMA

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27
Q

Metabolic alcalosis : how do you do the DDX ?

A

With urine Cl <25 or > 25
If < 25 will be chloride/NS responsive
If > 25 will not be chloride/NS responsive

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28
Q

Metabolic alcalosis and urine Cl < 25, DDX ?

A

Will be chloride/NS responsive
- GI loss (NG tube, villous adenoma, chloride diarrhea)
- Renal loss (diuretics)
- Sweating (cystic fibrosis)

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29
Q

What are causes of acute hypokalemia caused by shifting ?

A

Endocrine : +++ insulin, thyrotoxic periodic paralysis
Stress : ++ catecholamines
Metabolic alcalosis
ROH withdrawal
Hypothermia
Amphetamines

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30
Q

What are drugs that cause hyperkalemia ?

A

NSAIDS, ACEi/ARB, MRAs

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31
Q

What are precautions to consider when prescribing kayexalate ?
What about the electrolytes?

A

Caution if GI obstruction, risk of hypoCa and hypoMg also
Associated with cases of colonic necrosis, bleeding, ischemic colitis, perforation

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32
Q

What are some unusual causes of hyperkaliemia ?

A

Hypoaldosteronism : adrenal insufficiency, RTA type 4
Cell lysis (TLS, acidosis, low insuline)
Metabolic acidosis, low insulin
Hyperosmolarity (glucose, mannitol)

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33
Q

What are the causes of a NAGMA with UAG &laquo_space;0 ?

A

GI HCO3 loss (diarrhea)
Pancreatic fistula
NJ tube

NEGUTIVE : the gut

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34
Q

What are the causes of anion gap metabolic acidosis ?

A

GOLDMARK
Glycols
Oxoproline (organic acid) (consider if unexplained AGMA in setting of chronic acetaminophen use 3-4g/d even, causes excess oxoproline)
Lactate
D Lactates
Methanol
ASA
Renal failure
Ketones

Also : pregnancy, vegan, malnutrition

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35
Q

What are the causes of chronic hypokalemia with low urine K < 20 ?

A

Diarrhea, laxatives, villous adenoma

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36
Q

What are the causes of hypertonic hyponatremia ?

A

Hyperglycemia
Mannitol
Immunoglobulins IvIg

sOSM > 295

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37
Q

What are the causes of increased osmolar gap ?

A

AGMA :
Organic alcohol poisoning (methanol, ethylene glycol)
Paraldehyde
Ketoacidosis (EtOH + db)
Lactic acidosis
Severe CKD
No metabolic acidosis :
Ethanol
Isopropyl alcohol
Mannitol
Sorbitol
* pseudohypoNa
* early toxic alcohol

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38
Q

What are the causes of nephrogenic DI ?

A

Lithium, hypercalcemia, hereditary, resolution of obstructive nephropathy

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39
Q

What are the causes of SIADH ?
What are the typical rx?

A

No/Vo, pain, pneumonia / lung infections, adrenal insufficiency, CNS disorders
DRUGS : SSRIs, carbamazepine, thiazides, TCAs

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40
Q

What are the ECG changes seen in hypokaliemia ?

A

PR prolongation
TWI
ST depressions
U waves

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41
Q

What are the situations where you can correct quickly hypernatremia ?

A

Rare, acute setting : post op central DI, nephrogenic DI for exemple

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42
Q

What are the specific labs and how do you treat hyponatremia in case of pancreatitis ?

A

Uosm > 300 and Una < 25
Fluid resuscitation NS/LR 1ml/kg/hr

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43
Q

What are the three potassium binders ?

A

1) Lokelma / ZS 9 ($$$, exchanges Na and H+ for K in GI tract, drop of K within 2-4 hours, stop if K around 4, safe in CKD)
2) Patiromer (bind K in the colon)
3) Kayexalate (exchange Na in stomach for H which is then exchanged in colon for K)

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44
Q

What are the typical labs of a Barter ?
How will be the electrolytes ?

A

Metabolic alkalosis with urine Cl > 25 and low BP
Mimics loops : low K and low Mg

45
Q

What are the typical labs of a Gittleman ?
How will be the electrolytes ?

A

Metabolic alcalosis with urine Cl > 25 and low BP
Mimics thiazides : low K, low Na, HIGH!! Ca

46
Q

What causes pseudohyponatremia ?

A

ISOTONIC hyponatremia 280-295
Hypertriglyceridemia
Paraproteinemia (MM)
Obstruction jaundice

vs hypertonic hyponatremia: hyperglycemia, mannitol, immunoglobulins

47
Q

What is a high urine osmolality in context of hyponatremia?

A

> 300

48
Q

What is a low urine osmolality in context of hyponatremia?

A

< 200

49
Q

What is the acceptable change in Na per day for chronic hyponatremia?

A

Target 6, max 8
If any risk factor : target 4, max 6

50
Q

What is the anion gap formula ?

A

Na - Cl - HCO3
Adjust for albumin (every decrease in albumin by 10, add 2.5 mEa/L to the AG)

NACHOS

51
Q

What is the compensation for metabolic acid/base disorders ?

A

Metabolic acidosis 1:~1 (↓HCO3:↓CO2)
Metabolic alkalosis 1:0.7 (↑ HCO3 : ↑ CO2)

52
Q

What is the compensation for respiratory acid/base disorders ?

A

-Respiratory Alkalosis (↓ CO2 : ↓ HCO3). Chronic (10:4-5) / Acute (10:2) -Respiratory Acidosis (↑ CO2 : ↑ HCO3). Chronic (10: 3-4)/ Acute (10:1)

53
Q

What is the compensation in case of respiratory acidosis ?

A

-Respiratory Acidosis (↑ CO2 : ↑ HCO3). Chronic (10: 3-4)/ Acute (10:1)

54
Q

What is the compensation in case of respiratory alkalosis ?

A

-Respiratory Alkalosis (↓ CO2 : ↓ HCO3). Chronic (10:4-5) / Acute (10:2)

55
Q

What is the DDX of chronic hypokalemia with Urine K > 20 + metabolic alcalosis + HTA ?

A

Low renin / Low aldo : cushing, liddle, florinefm steroids, licorice

High Renin / High aldo : RAS / reninoma

Low Renin / high Aldo : adrenal problem such as Conns

56
Q

What is the DDX of chronic hypokalemia with Urine K > 20 + metabolic alcalosis + low or normal BP ?

A

Check URINE CL
If < 20 : vomiting or intermittent diuretic use
If > 20 : Barrter or Gitelman or recent diuretic use

57
Q

What is the DDX of chronic hypokaliemia with urine K > 20 ?

A

1) URINE lytes : renal loss if urine K > 20
2) Met acidosis or Met alkalosis
If met acidosis : type 1 or 2 RTA
If met alcalosis : step 3
Low/normal BP : check URINE CHLORIDE
HTA : check RENIN AND ALDOSTERONE

58
Q

What is the DDX of hyponatremia with high Uosm = ADH on ?

A

If Una < 25 : appropriate ADH secretion
- True hypovolemia
- Decreased effective circulating volume (CHF, cirrhosis, hypoalbuminemia)
If Una > 40 : inappropriate ADH secretion
- SIADH

59
Q

What is the DDX of hyponatrmia and U osm < 200 ?

A

ADH is appropriately off
- Polydipsia (typicalle Uosm < 100)
- Beer potomania / tea and toaster : low solute diet (Uosm 100-300)
- Iatrogenic : IV D5

60
Q

What is the DDX of metabolic alcalosis with urine Cl > 25 ?

A

Will not be chloride/NS responsive
- HIGH BP :
Hyperaldosterone (HTN, hypoK, alkalosis, HIGH aldo)
Liddle’s (htn, hypoK, alkalosis, LOW aldo)
Cushings

  • LOW BP
    Barter’s (mimics loops : low k and low Mg)
    Gittleman’s (mimics thiazides : low K, low Na, low Ca)
  • Excess bicarb ingestion
61
Q

What is the DDX of metabolic alcalosis with Urine Cl > 25 and high BP ?

A

• Hyperaldosterone (htn, hypoK, alkalosis, high aldo)
• Liddle’s (htn, hypoK, alkalosis, low aldo)
• Cushings

62
Q

What is the DDX of metabolic alcalosis with Urine Cl > 25 and low BP ?

A

• Barter’s (mimics Loops – low K, low Mg)
• Gittleman’s (mimics thiazides – low K, low Na, high Ca)

63
Q

What is the definition of acute hyponatremia ?

A

Acute < 48hours (documented sodium)

64
Q

What is the formula of urinary anion gap ?

A

Urine Na + Urine K - Urine Cl

65
Q

What is the hyponatremia correction formula ?

A

Volume infusate to give :
TBW x (desired Na - serum Na) / Na infusate

TBW : kg x 0.5 if female / 0.6 if male
Infusate :
Hypertonic saline 3% : 513 mmol/L Na
Normal saline 0.9% : 154
Ringers Lactates : 130

66
Q

What is the pathophysio and causes of RTA type I ?

A

DISTAL : decrease in H+ excretion
CTD (Sjogren +++, RA, SLE), hypercalciuria, drugs

67
Q

What is the pathophysio and causes of RTA type II ?

A

PROXIMAL : decrease in bicarb reabsorption
Fanconi’s, myeloma, acetazolamide, tenofovir

68
Q

What is the pathophysio and causes of RTA type IV ?

A

Hypoaldo state + impaired urinary ammonium excretion
Drugs (aldosterone antag, RAAs blockers, calcineurin inh)
Adrenal insufficiency, diabetes

69
Q

What is the rate of Na correction in case of chronic hypernatremia ?

A

max 0.5 mmol/L per hour or 12 over 24 h
to avoid cerebral edema

70
Q

What is the response to DDAVP in context of DI ?

A

If central DI : responds, Uosm will increase by 50 % and urine output will decrease
If complete nephro DI : no change

(polydipsia with hypoNa : no change either or < 10 %)

71
Q

What is the risk of correction too rapidly hyponatremia ?

A

Osmotic demyelination
RF : hypoK, malnutrition, ROH, liver disease, low starting Na

72
Q

What is the treatment of Barrter and Gitleman’s syndrome ?

A

K, Mg replacement
K sparing diuretics
RASi
NSAIDS

73
Q

What is the treatment of hyponatremia in the dialysis population ?

A

FLUID restriction
They’re drinking too much water

74
Q

What is the treatment of hyponatremia with low urine Osm ?

A

Fluid restrict, salt/urea tabs

75
Q

What is the treatment of Liddle’s ?

A

Amiloride

76
Q

What is the treatment of RTA type I and type II ?

A

NaHCO3
K citrate (for type 1, only if K low)

77
Q

What is the treatment of RTA type IV ?

A

Low BP : florinef
HTN : thiazide

78
Q

What is the treatment of SIADH ?

A

Fluid restriction
Salt tablets 1g BID / TID
Urea 15 mmol BID

79
Q

What is toxic in antifreeze ?

A

Ethylene glycol

80
Q

What labs should you ask for in case of hyponatremia ?

A

Obtain Uosm, Sosm, Una.
Stop thiazides

81
Q

What RTA have a low serum potassium ?

A

Type 1 severely low
Type 2 low
Type 4 high or high normal

82
Q

What should be considered as a cause of unexplained AGMA in setting of chronic acetaminophen use ?

A

Can deplete glutathione = lose –ve feedback on cycle = excess Oxoproline (pyroglutamic acid)
Exacerbated by renal failure

83
Q

What will be the Urine Osm in case of hyponatremia caused by beer potomania ?

A

Usom 100-300, appropriately low

84
Q

What will be the Urine Osm in case of hyponatremia caused by polydipsia ?

A

typically < 100, appropriately off

85
Q

What will be the Urine Osm in case of hyponatremia caused by tea and toast ?

A

100-300, appropriately low

86
Q

What’s a normal osmolar gap ?

A

10

87
Q

What’s an isotonic plama osmolality ?

A

280-295

88
Q

What’s the delta delta formula?

A

ΔAG (12-AG):Δbicarb(24-bicarb)

89
Q

What’s the osmol gap formula?

A

[calculated osm: 2xNa + Gluc + BUN] –
[serum measured osm]

2 SALTS AND A STICKY BUN

90
Q

When is hypokaliema an emergency ?

A

Respiratory muscle weakness
Arrythmias

91
Q

When should you think of adrenal problem such as Conns in case of chronic hypokaliemia ?

A

Urine K > 20
Metabolic alcalosis
HTA
Low renin / high aldo

92
Q

When should you think of Barrter in case of chronic hypokaliemia ?

A

Urine K > 20
Met alcalosis
Normal or low BP
Urine Cl > 20

93
Q

When should you think of Cushing in case of chronic hypokaliemia ?

A

Urine K > 20
Met alcalosis
HTA
Low renin / low aldo

94
Q

When should you think of Gitelman in case of chronic hypokaliemia ?

A

Renal K > 20
Met alcalosis
Normal or low BP
Urine Cl > 20

95
Q

When should you think of Liddles in case of chronic hypokaliemia ?

A

Urine K > 20
Met alcalosis
HTA
Low renin / low aldo

96
Q

When should you think of RAS/reninoma in case of chronic hypokaliemia ?

A

Urine K > 20
Metabolic alcalosis
HTA
High renin / high aldo

97
Q

When should you think of villous adenoma in case of chronic hypokaliemia ?

A

Low urine K 20 : extra renal

98
Q

When should you think of vomiting in case of chronic hypokaliemia ?

A

URINE K > 20
Met alcalosis
Normal or low BP
Urine Cl < 20-25

Caused by diarrhea, laxatives or villous adenoma if UK < 20

99
Q

Where is the defect in Barrter syndrome ?

A

Autosomal recessive
Like lasix : ascending hoop of Henle

100
Q

Where is the defect in Gitleman’s Syndrome ?

A

Autosomal recessive
Distal tubule Na/Cl cotransporter
Like TZD

101
Q

Where is the defect in Liddle’s?

A

Autosomal dominant
eNac nutation in collecting duct, reasborb too much Na

102
Q

Which genetic channelopathies
(chronic hypokaliemia) is associated with aminoglycoside use ?

A

Barrter syndrome

103
Q

Which genetic channelopathies seen in chronic hypokaliemia have strong family history ?

A

Liddle’s, autosomal dominant

104
Q

Which RTA is associated with heparin ?

A

Type IV

105
Q

Which RTA is associated with myeloma ?

A

RTA type II

106
Q

Which RTA is associated with Sjogren or other CTD ?

A

RTA Type I

107
Q

Which RTA si associated with diabetes ?

A

RTA type IV

108
Q

How can you differentiate type 1 and type 2 RTA?

A

Type 1 : severely low K, calcium phosphate stones, pH U > 5.5, HCO3 < 10
Type 2 : low K, glycosuria, low PO4, low urine pH, HCO3 12-20

Les deux ennemis (7 decks)

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