Nephrology- Adults Flashcards
1
Q
Renal function- pathophysiology
A
Filtration of blood
- removal of waste
- maintain a proper concentration of electrolytes
- acid/base balance
2
Q
Renal function- cause
A
Regulating blood volume and BP
Producing erythropoietin
3
Q
Renal function- epidemiology
A
Nephron- basic functionality unit of kidney
Glomerulus- site of blood filtration
Renal tubule- H20 & salt resorbed
4
Q
Renal function- S/S & PE
A
Proximal Convoluted Tubule (PCT) - reabsorbs 60%
- 65% -> Na, K, Ca
- 80% -> Phosphate, H2O, Bicarbonate
- 100% -> Glucose (>200, will see in urine), Amino Acids
- Secretes drugs/toxins that are too big/protein bound to be filtered
- H2O reabsorbed passively - osmotic gradient
- Ammonia from glutamine (acidifies urine)
5
Q
Renal function- diagnosis
A
Loop of Henle
- 4 segments : thin descending, thin ascending, meduallary thick ascending, cortical thick ascending
- Create concentration gradient and form concentrated urine
6
Q
Renal function- labs & imaging
A
Distal Convoluted Tubule
- Na and Ca reabsorption
- Na - 5-10%
- Ca - 10-15%
- regulated by PTH and VitD
7
Q
Renal function- treatment
A
Collecting Tubule
- NaCl - reabsorbed
- Bicarb - reabsorbed
- H2O - rabsorbed - urine concentration
- K - excretion
- H+ - excertion
- Urea - excreted
- Regulated Urine volume
8
Q
Acute renal failure/acute kidney injury- pathophysiology
A
Rapid worsening of renal function
- quick rising BUN/Cr
- accumulation of nitrogenous wastes in blood
9
Q
Acute renal failure/acute kidney injury- cause
A
Prerenal
Postrenal
Intrarenal
10
Q
Acute renal failure/acute kidney injury- epidemiology
A
No particular race/age
10% of people in hosp
2/3 pt in ICU
1% after surgery
11
Q
Acute renal failure/acute kidney injury- S/S & PE
A
Weakness/lethary general malaise, drowsiness Anorexia, N/V, diarrhea Pruritis Hiccups, SOB Dizziness
Signs - point toward underlying cause - prerenal - tachy, hypotensive - Postrenal - distended bladder, CVA tenderness, enlarged prostate Anuria, oliguria Change in volume/wt Change in Mental statu Edema Weakness
12
Q
Acute renal failure/acute kidney injury- diagnosis
A
Criteria
- Abrubt (48hrs) absolute inc of serum creatinin of >0.3mg/dl above baseline
OR
- Serum Cr inc >50% w/in 7days OR
- Oligura (small amount of urine) <0.5mg/kg/hr for >6hr
13
Q
Acute renal failure/acute kidney injury- labs & imaging
A
BMP - BUN, Cr
UA & urine microscopy - urine culuture
Urine output
Renal U/S - acute vs chronic
- small/shrunken kidney - chronic
Urine spot - osmolality, urine Na, Cr
14
Q
Acute renal failure/acute kidney injury- treatment
A
Depends on cause Dialysis if: - serum Cr >5-10mg/dl - unresponsive acidosis - severe electrolyte disorder - fluid overload - uremic complications
15
Q
Acute renal failure/acute kidney injury- prognosis
A
Complications - Dialysis Immediately
- Hyperkalemia
- Fluid overload
- Signs of uremia - pericarditis, altered mental status
- Severe metabolic acidosis (pH <7.1)
16
Q
Prerenal Failure- pathophysiology
A
Most Common Cause of AKI
Reduced effective blood circulating to kidney
- absolute reduction in fluid volume OR
- Effective volume depletion - CHF, cirrhosis -> just perceived as this:: Respond by reabsorbing Na & others to inc vascular volume -> edema etc is made worse
No actual issue with Kidney
17
Q
Prerenal Failure- cause
A
True intravascular volume depletion: hemorrhage, burns, diuretics, dehydration, GI loss, vomiting, diarrhea, anteric fistula
Dec Effective circulating volume: CHF, Cardiac tamponade, aortic stenosis, cirrhosis w/ ascites, nephrotic syndrome
Impaired renal blood flow: ACEI, NSAIDs, renal artery stenosis, renal vein thrombosis
18
Q
Prerenal Failure- labs & imaging
A
BUN:Cr ratio - >20:1 Urine Na - <20 meq/L - not peeing it out Fractional Excretion of Na (FENa) - <1% - measure % of Na filtered by the kidney & excreted in urine Urine specific gravity - >1.020
Kidney is responding by inc reabsorption!!
19
Q
Prerenal Failure- treatment
A
Correct underlying cause
- CHF - diurese pt
- Dehydration - IVF
- Hemorrhage - Blood + Fluid
20
Q
Postrenal failure- pathophysiology
A
Least Common
Ureters, bladder, urethra
- block here -> renal failure
Acute -> fix it - if don’t, can be permanent
- even then - might never be perfect
21
Q
Postrenal failure- cause
A
Nephrolithiasis BPH Obstructing tumor w/in GU system Bladder outlet obstruction Blood clots w/in urinary tract Meds Neurogenic bladder
22
Q
Postrenal failure- S/S & PE
A
Abdominal or groin pain
Bladder discomfort
Anuria
Rectal exam
Pelvic exam
23
Q
Postrenal failure- diagnosis
A
Post void residual >100mL -> bladder outlet obstruction
- > 300 - more worried
- U/S or Cath
U/S or Intravenous pylegram (IVP) - dilated ureters or renal pelvis
Abdominal CT - eval for mass
24
Q
Postrenal failure- treatment
A
Relieve Obstruction!!
Cath Nephrostomy tube Stenting Lithotripsy Surgery - remove mass
25
Intrinsic Renal Failure- pathophysiology
One or both kidneys damaged and not working properly
Some quick, or develop over time
26
Intrinsic Renal Failure- cause
Acute Tubular necrosis - Most common
Nephrotoxins - NSAIDs, contrast agents, aminoglycosides, cyclosporine A, cisplatin, heme pigments (rhabdo)
Interstitial disease - acute interstitial nephritis, SLE, infection
Glomerrrulonephritis
Vascular dis - polyarteritis nodosa, vasculitis
27
Intrinsic Renal Failure- labs & imaging
BUN:Cr ratio - 10-15:1
Urine Na - >40 meq/L
FENa - >2%
Urine specific gravity - 1.010-1.020
28
Acute tubular necrosis (ATN)- pathophysiology
Most common cause of Intrinsic AKI
29
Acute tubular necrosis (ATN)- cause
Renal ischmia - all severe prerenal disease -> postischemic ATN
Nephrotoxins - aminoglycosides, heme pigmenst, cisplatin, radiocontrast media, pentamindine, mannitol, synthetic cannabinoids, tenofovir, IVIT
Sepsis
30
Acute tubular necrosis (ATN)- diagnosis
Classic UA - Muddy brown granular epithelial cell casts & free renal tubular epithelial cells
May have - hyperkalemia & metabolic acidosis
31
Acute tubular necrosis (ATN)- labs & imaging
BUN:Cr ratio - 10-15:1
Urine Na - >40 meq/L
FENa - >2%
Urine specific gravity - 1.010-1.020
32
Acute tubular necrosis (ATN)- treatment
Hold nephrotoxins
Treat underlying cause
Supportive management
Diuretics - for fluid overload
- not for oliguric
Most will spontaneously recover renal function - better if nonoliguric
33
Acute tubular necrosis (ATN)- prognosis
May never return to baseline
If during hosp -> higher in-hospital and long-term mortality
34
Acute Interstitial Nephritis (AIN)- pathophysiology
Immune mediated process of tubulointerstitial injury
| - inflammatory infiltrate in interstitium
35
Acute Interstitial Nephritis (AIN)- cause
Meds - Cephalosporins, penicillins, allopurinol, diuretics, NSAIDs, sulfonamides
Illness - legionella, CMV, streptococcus, myocobacterium, EBC, vandida, SLE, sarcoidosis, Sjogren syndrome
36
Acute Interstitial Nephritis (AIN)- S/S & PE
Classic - fever, maculopapular rash, eosinophilia
37
Acute Interstitial Nephritis (AIN)- labs & imaging
UA - WBC, white cell casts, eosinophils, protein
38
Acute Interstitial Nephritis (AIN)- treatment
Stop offending med
Treat underlying cause
Glucocorticoids
39
Acute Interstitial Nephritis (AIN)- prognosis
Good
40
Glomerulonephritis- pathophysiology
Renal glomeruli damaged by deposition of inflammatory proteins in glomerular membrane
41
Glomerulonephritis- cause
Focal - Henoch-Scholeinpurpura, postinfectious, IgA nephropathy, hereditary nephritis, SLE
Diffuse - Postinfectious, membranoproliferative, SLE, vasculitis, rapidly progressive GN
42
Glomerulonephritis- S/S & PE
Heamturia
Edema of face/eyes - in morning
Edema Feet/ankles - evening
HTN
43
Glomerulonephritis- diagnosis
Hemeturia - tea or cola colored
UA - RBC, RBC casts, misshapen RBCs, proteins
Ranl biopsy
44
Glomerulonephritis- treatment
Steroids
| Immunosuppressants/chemo meds
45
Chronic Kidney Damage (CKD)- pathophysiology
Kidney damage or dec kidney function for >3m
59% of americans develop CKD 3 or higher during life
50% w/ CKD - occurrence of AKI
46
Chronic Kidney Damage (CKD)- cause
DM
| HTN
47
Chronic Kidney Damage (CKD)- epidemiology
```
>60yo
HTN, DM, CV
Fhx of CKD
Recurrent UTI
Prev AKI
Nephrolithiasis
Transplant
Autoimmune
Smoking
```
48
Chronic Kidney Damage (CKD)- S/S & PE
Urine Microscopy
- Squamous epithelial cell - sample contaminated
- Renal tubular cells/cast - ATN or AIN
- RBC casts - glomerulonephritis, AIN, vaculitis
- WBC casts - interstitial nephritis, pyelo, inflammation
- Fatty casts - nephrotic syndrome
- Hyaline casts - nl
- Muddy Borwn Casts - ATN
49
Chronic Kidney Damage (CKD)- diagnosis
Albuminuria
- specific to CKD
- nl - <30 mg/d
- Mod inc - 30-300 mg/day
- Severe inc - >300 mg/day
- Urine albumin:Cr ratio - prefered, yearly screening
- pathognomonic for kidney damage
- detects early CKD - before renal function change
- Higher -> quicker progression to failure
Early detection of med/sever inc in DM -> treat w/ ACEI or ARB and dec amount of albuminuria
- DM - target A1C 7% - prevent/delay progression CKD
U/S
- nl kidney - 10cm
- Shrunken = CKD
- differentiate b/t actue and chronic
50
Chronic Kidney Damage (CKD)- labs & imaging
Creatinin - product of muscle metabolism, excreted by kidneys
- Nl - 0.6-1.2 mg/dl
GFR - plasma filtration by glomerulus
- nl - >90 ml/min/1.73min2
- inulin clear is gold for meas
- MDRD and Cockcroft-Gault
- MDRD - not used for AKI
- use IBW - obese or fluid overload
Proteinuria - all types of proteins in urine
- nl - <150 mg/d
- gold - 24hr urine -> urine protine:Cr ratio
- causes - Tubular damage, diabetic nephropathy, glomerulonephritis, rhabdo, bence jones proteins
- less concerning - exercise, orthostatic porteinuria, acute sickness
51
Chronic Kidney Damage (CKD)- treatment
Staging - GFR and albuminuria
Meds to avoid - NSAIDs, contrast, Mg, Phophorous (Fleet's enemas), Aluminum (Maalox, Rolaids), antimicrobials, DM meds, decongestants, antihypertensives, opioids, & gaba
RENALLY DOSE
Dialysis
- start w/ GFR 10-15 - or unable to control volume status/hyperkalemia
- ArteryVein Fistula needs 2m to mature
- Hemodialysis - 3x/week
- Peritoneal dialysis
- Continuous ambulatotry PD - 4-5x/day
- Continuous cyclic PD - machine cylces at night while asleep
52
Chronic Kidney Damage (CKD)- prognosis
```
Complications:
HTN
Hyperphophatemia
- Sevelamer - phosphate binders
- foods to avoid - berry, whole grain, dark pop, porgessed foods
Hyperparathryoidism
- give Vit D
Anemia
- Erthropoietin, aranesp, iron sup
- Goal Hgb - 10-11
Hyperkalemia - Can be fatal!!
- low K diet, dialysis
- kayexelate - K binder
Acidosis - Na bicarb
Uremic Encephaolopathy
```
53
Nephrotic Syndrome- pathophysiology
Edema
Proteinuria - foamy urine
Low serum albumin
Hyperlipidemia
54
Nephrotic Syndrome- cause
DM
Minimal change disease
Focal segmental glomerular sclerosis
Membranous nephropathy
55
Nephritic Syndrome- pathophysiology
HTN
Hematuria
Proteinuria - less then nephrotic
56
Nephritic Syndrome- cause
Post-inf glomerulonephritis
IgA nephropathy
Membranoproliferative glomerulonephritis
57
Simple Cysts- pathophysiology
Thin wall without septa, calcifications or solid components
Epithelial cells from renal tubules and collecting ducts
58
Simple Cysts- epidemiology
M>W
| >50yo
59
Simple Cysts- S/S & PE
"1cyst or multiple & bilateral
Asymptomatic
HTN
Rupture - hematuria, flank pain
- trauma or spontaneous
Infected - form renal abscesss
60
Simple Cysts- diagnosis
US or CT - incidental finding
61
Simple Cysts- treatment
Ruptures - IB or Tylenol for pain
62
Complex Cysts- pathophysiology
Septa, calcifications, solid components
Risk of malignancy
Bosniak classification system
63
Complex Cysts- diagnosis
CT w/ contrast
64
Polycystic Kidney Disease- pathophysiology
Inherited disease - cause renal cyst
- progressive renal failure from enlargment of cysts
Autosomal dominant PKD - PKD1 & PKD2
65
Polycystic Kidney Disease- epidemiology
50% ESRD by 60
Renal function decline by 4th ecade -> decline by 4-6ml/min/year
- progressively losing kidney function every year
66
Polycystic Kidney Disease- S/S & PE
HTN
```
Hematuria
Proteinuria
Renal insufficiency found on labs
Flank pain - most common
- due to renal hemorrhage, calculi or UTI
Nephrolithiasis - uric acid stones
- all the rest are Ca Oxalate
Renal Cell Carcinoma
```
```
Extrarenal Manifestations:
Cerebral aneurysm
- SAH or ICH most serious complication
- 5% younger
- 20% >60yo
Hepatic Cysts
Pancreatic cysts
Cardiac valve disease
Colonic divertifcula
Abdominal wal and inguinal hernia
```
67
Polycystic Kidney Disease- labs & imaging
U/S
- large kidneys and extensive bilateral cysts
- Screen for those w/ pos FHx
- US is less reliable in peds -> need genetic testing
CT or MRI - more sensitive
68
Polycystic Kidney Disease- treatment
```
HTN - rigorous control of BP
- ACEI
- prevents progression of renal disease and dec
Dietary Na restriction - <2gm per day
Statin
- treat HLD aggressively
- Consider a coronary heart disease risk equivalent
- May preserve renal functiton
```
Tolvaptan - Ssamsca
- 18-55 w/ GFR >25 at high risk for ESRD
- Select via TKV, CT or MRI
- Slow progression of PKD - disease modifying
- Ensure adequate PO H2O intake
- Contra - liver failure, hypovolemia, hypernatremia, dehydrated
- SE - inc LFTs/liver tox, polyuria, polydipsia, chest pain, HA
- Promotes excretion of free water - not losing electrolytes -> lose fluid, inc urin output, dec urine osmolality, restore serum Na level
- Providerss must be registereed, shipped to pt via special pharm
Inc fluid intake
- supresses ADH levels-> inhibits cyst growth
- 3L/day
Dialysis
Kidney transplant
Pain - surgial aspiration or sclerosis of cysts
69
Polycystic Kidney Disease- prognosis
Die from cardiac issues
| Neuro deaths - ruptured intracranial aneurysm & HTN intracerebral hemorrhage
70
Hypermagnesemia- pathophysiology
Plasma Mg > 2.5 mEq/L
Rare - renal impairment
Mg - is a CCB and block cardiac K channels
71
Hypermagnesemia- cause
Oral ingestion - laxative abuse, accidental overdose of epson salts
Mg enemas
Mg infusion - preeclampsia or eclampsia
Renal insufficiency
- Mg excreted renally -> inc levels w/ CKD worsens
- Antacids or laxatives in regular doses
72
Hypermagnesemia- S/S & PE
Asymptocatic -> <4
Neuromuscluar toxicity
4-6 : nasea, flushing, HA, lethargy, drowsiness, dec DTRs
6-10 : somnolence, hypocalcemia, absent DTRs, hypotension, bradycardia, EKG changes
>10: muscle paralysis -> flaccid quadriplegia, apnea, respiratory failure, complete heart block cardiac arrest
73
Hypermagnesemia- labs & imaging
Mg - order by itself
BMP
EKG - dimished conduction, widened QRS, prolonged PQ interval
74
Hypermagnesemia- treatment
Nl renal function:
- stop offending agent
- add diuretic to inc renal excretion of Mg - if still urinating
Ca gluconate - IV
- inc action potential threshold -> harder to depolarize -> more stable
Severe + renal impairment - hemodialysis
75
Hypomagnesemia- pathophysiology
Plasma mg <1.8 mEq/L
76
Hypomagnesemia- cause
Chronic diuretic therapy - loop, thiazide
Chronic alcoholism
Chronic diarrhea
Hypoparathryoidism
Nutritional deficiencies - prolonged TPN, malnutirtion
Uncontrolled DM
Chronic PPI usage - Cdiff + PPI -> gut flora changes
77
Hypomagnesemia- S/S & PE
Neurologic
- Tetany - Trousseau and Chvostek sign, muscle spasm, muscle cramps
- seizures
- involuntary movement
Cardiovascular - EKGs
- Mod - Wide QRS & peaked T waves
- Severe - Prolonged PR interval, QRS widening, diminished T wave
- Freq PACs and PVCs -> sustained afib
- Ventricular arrhythmias -> death
78
Hypomagnesemia- diagnosis
Hypokalemia & Hypocalcemia!
Clinical - if not -> 24hr urine Mg excretion or fraction excretion of magnesium on random urine
- help diff b/t Gi and renal loss
79
Hypomagnesemia- treatment
Severe - tetany, arrhythmias, seizures
- IV Mg Sulfate
- cont Cardiac monitoring
- Reduce dose if CrCl <30
Asymptomatic/Minimal symptoms
- PO replacement - MG Cl or Mg oxide
- > diarrhea major SE
- intracellular stores take longer to replete -> keep going to 1-2 days after labs normal
Correct underlying disease if possible
80
Hypercalcemia- pathophysiology
Serum Ca >10.5 mEq/L
Mild - 10.5 - 12
Severe/life threatening >14
Nl - 9-10.5
81
Hypercalcemia- cause
Malignancy
- ectopic secretion of PTH by tumor
- MM
- Bone Mets
Endocrine
- Hyperparathroid
- MEN
- hyperthyroid
- Pheo
- Adrenal insufficiency
Granulomatous dis - sarcoidosis, TB, histoplamosis, berryliosis, coccidiomycosis
Drugs - Thiazide, Vit A, Vit D, Estrogen, Milk-alkali syndrome, lithium
Misc - dehydration, porlonged immobilization, latrogenic, rhabdomyolysis, familial, lab error
82
Hypercalcemia- S/S & PE
Asymptomatic till >12
Vague/ nonspcific
non-focal bdominal pain
Constipation, fatigue, diffuse body aches, anorexia, N/V
Intravascular volume depletion - tachy, orthostatic hypotension
Anxiety, depression, confusion, hallucinations
Severe::
- lethargy, altered mental status, seizurres, coma
- Cardiac conduction abnormalities - bradyarrhthmias, sinus arrest, AV blocks, AF, VT, LBBB, RBBB
Painful bones, renal stones, abdominal groans, psychic moans
83
Hypercalcemia- diagnosis
EKG
- ST elevation
- Stort QT - classic - but not always seen
84
Hypercalcemia- labs & imaging
Total Ca
- bound and unbound Ca
Ionized/unbound Ca - better represent
- separate lab test OR
- estimate
24hr Urine
Albumin
- might have ""nl"" Ca if labumin is low or vice versa
- correct Ca for albumin levels, or do an ionized Ca level
- Corrected Ca = total Ca + (0.8 x (4-albumin))
```
1st Serum Ca - Elevated -> repeat ionized or total Ca + corrected albumin - HyperCa confirmed
2nd - Measure PTH
- High - primary hyperparathryoid
- low -> Check Vit D and PTHrP
PTHrP elevated - malignancy
```
85
Hypercalcemia- treatment
Crisis - usually dehydrated
- IV access and CV monitoring
- Infuse NS ""wide open"" until BP and perfusion nl
Furosemide - NO LONGER RECOMMEND
- can worsen hyperCa if not yet volumereplete
- adversely affect hemodynamics and renal status
Osteoclast-inhibiting therapies
- Bisphosphonates - hyperCa due to malignancy
- Calcitonin - >14 and symptomatic -> dec serum Ca levels
- Glucocorticoids - dec vit D
Severe - dialysis
Crisis due to primary hyperparathyroid - urgent parathyroidectomy
86
Hypocalcemia- pathophysiology
Serum <8.5 mg/dL
| Ionized <4.6 mg/dL
87
Hypocalcemia- cause
```
Hypoparathryoidism
- genetic
- postsurgical/radiation damage
- Hungry bone syndrome
- Infiltration of parathryoid gland
- Autoimmune
Drugs
- Bisphosphonates
- Ca chelators - EDTA, citrate, phosphate
- Phenytoin
- Fluoride poisoning
Hypomagnesemia
Vit D def
PTH Resistance
Renal Dis
Loss of Ca from circulation
- Tumor lysis
- Acute pancreatitis
- Osteoblastic mets
- Sepsis or acute severre illness
```
88
Hypocalcemia- S/S & PE
Trosseau sign - carpal tunnel spasm after BP cuff applied for 3 min
Chvostek sign - spasm of facial muscle after tapping facial nerve in front of ear
```
Asymptomatic
Mscule spasm orr muscle cramps
Tetany
Paresthesias
Confusion
Seizures
Dry skin, brittle nails, coarse hair
Anxiety, depression, dementia
Laryngospasm, bronchospasm
EKG - prolonged QT, flatened ST
```
89
Hypocalcemia- labs & imaging
```
Total Ca or Ionized Ca
Serum Phosphate
Vit D
Serum PTH
Mg
BMP
EKG
```
90
Hypocalcemia- treatment
Acute & severe - IV calcium gluconate
- treat emergent CV issues
- Tetany, seizures <7.5
Mild - output
- Oral Ca + VitD - Calcitriol/VitD3
FIRST - Treat any concurrent hypomg -> then treat the hypoCa
- Ca problem won't be fixed until Mg is fixed
91
Hyperphosphatemia- pathophysiology
Serum >4.5 mg/dL
92
Hyperphosphatemia- cause
Acute
Acute Renal Failure
Rhabdo
Tumor Lysis syndrome
Acute phosphate load - excess phosphate in TPN, rapid admin of phosphate rich drugs, phosphate containing laxatives, Vit D tox
Hypoparathryoid - parathroidectomy
- infiltration of parathyroid gland, metal overload
Extracellularr shift of phosphate - lactic acidosis, ketoacidosis, respiratory acidosis, crush injuries
Chronic
CKD!!
Hypoparathryoidsm - autoimmune, gene mutations
Pseudohypoparathryoidism
93
Hyperphosphatemia- S/S & PE
Asymptomatic
Acute/severe -> hypoCa
- tetany, muscle cramps, perioral numbness or tingling, seizures
- Trousseau or Chvostek sign, hyperreflexia, carpopedal spasm, seizure
Uremia
- Fatigue, N/V, pruritis, SOB, sleep distrubances
Painful masses around joints, skin ulcerations, irritated conjunctiva
- ectopic calcifications
94
Hyperphosphatemia- labs & imaging
Serum P
PTH
Serum Ca
Vit D
Renal U/S?
95
Hyperphosphatemia- treatment
Acute w/ nl renal function
- Saline + Loop diuretic -> correct phosphaturia
Hypoparrthroid
- Ca + Vit D -> correct hypoCa
AKI::
Phosphate binders when level >6
- ionized Ca low -> Ca based binder - Ca Carbonate orr Ca acetate
- Ionized Ca high -> non-Ca based binder - sevelamer, aluminum hydroxide, lanthanum carbonate
Severe - P >12 or symptomatic
- Dialysis
CKD
- start tx when levels above nl
- Restrict dietary phosphate to 800-1000mg - dark colas, oysters, cheese, milk, organ meats, ice crem, chocolate, nuts/seeds
- Phosphate binders - dec intestinal phosphate absorption
- Dialysis - remove excess phosphate
96
Hypophosphatemia- pathophysiology
Serum <2.5 mg/dL
97
Hypophosphatemia- cause
```
Resp alkalosis
Sepsis
Refeeding syndrome
Alcohol withdrawl
Renal transplant
HyperCa of malignancy
Hyperparthyroid
Hereditary rickets
Vit D
Inhibition of phosphate absorption
Inadequate intake
```
98
Hypophosphatemia- S/S & PE
```
Asymptomatic - unless <1mg/dL
Metabolic encephalopathy
Proximal myopathy
Impaired myocardial contractility
Dysphagia
Resp failure
Rhabdo
Hemolysis
```
99
Hypophosphatemia- labs & imaging
Serum P
Urine P::
24hr or Random speciem + calculate fractional excretion of filtered phosphate
- Exc <100 mg or FEPO4 <5% -> low renal P excretion
->> internal redistubution or dec intestinal absorption
- Ex >100mg or FEPO4 >5% -> renal P wasting
->> Hyperparathyroid, VitD def, renal tubular defect
100
Hypophosphatemia- treatment
Asymptomatic + P <2
- Oral P
Symptomatic
- 1-1.9 = Oral phosphate - IV if rhabdo, CNS, hemolysis
- <1 = IV phosphate - switch to PO once P >1.5
Urine P wasting - most diff to treat
- Dipyridamole QID - inc P levels
- inc renal P reabsorption
101
Hyperkalemia- pathophysiology
Serum K >5.0 mEq/L
- not whole body K
Dangerous electrolyte abnormality!!
98% of K is intracellular
2% in blood stream
Nl 3.5-5 - tightly regulated by kidney
102
Hyperkalemia- cause
```
Inc intake
- PO supplementation, IV K
Pseudophyerkalemia
- Mechanical trauma from venipuncture - see red serum
- true severe intravascular hemolysis - see red serum
- Exercise - repeat clenching of fits durign venipuncture
- Cooling or deterioration of sample
- Thrombocytosis - Plt>500K
- Severe leukocytosis - CLL - cells fragile
Dec Excretion
Renal Failure - acute or chronic
- kidney ubale to filter and excrete nl
Hypovolemia
- dehydration, CHF, cirrhosis
- low flow to kidneys
Hypoaldosteronism
- RTA4
- Adrenal insufficiency
Intra/extracellular Shifts
Any breakdown of cells
- broken cells release K when they lyses
- crush injury, trauma, rhabdo, TLS
- PseudohyperK
Acidosis - H+ moves from blood into cells exchange for K
Insulin deficiency or resistance
- insulin causes K entry into cells - DM
```
103
Hyperkalemia- epidemiology
Meds
- ACEI
- ARBs
- Spironalactone
- Bactrim
- K supplements
- NSAIDs, BetaBlockerrs, digitalis, Succinycholine, Amiloride
104
Hyperkalemia- S/S & PE
Cardiotoxicity
- inc resting membrane potential of cardiac myocite -> membrane excitability
- high levels - K causes depolarization threshold to rise -> depressed Cardiac function
Vague/varied symptoms
Asymptomatic
N/V, palpitations, lethargy, confusion, parethesias, muscle weakness, paralysis if advanced, arrhythmias/death
105
Hyperkalemia- diagnosis
Emergency??
- S/S - Most serious - muscle weakness/paralysis, arrhythmias
- K >6.5
- Mod >5.5 + sig renal impairment + ongoing tissue breakdown OR ongling K absorption OR signicant acidosis
106
Hyperkalemia- labs & imaging
```
K - repeat if any doubt
Serum K >5
BMP - renal function
EKG
ABG - acidosis?
```
EKG
- 5.5-6.5 - Peaked T wave
- 6.5-7.5 -> flattned P wave w/ prolonged PR or absent P wave
- 7.5-8 -> Wide QRS
- >8 -> sine wave pattern - imminent cardiac arrest
107
Hyperkalemia- treatment
Severe + EKG changes - IV calcium gluconate
Continuous cardiac monitoring
Options to drive K back into cell:
- Insulin + glucose
- Beta-2 adrenergic agonist - inhaled albuterol
- IV Na bicarbonate - temp, not lasting solutions
```
Remove K from body:
GI cation exchanger
- bind K in the GI tract in exchange for other cations -> excreted in feces
- Na polystyrene sulfonate - Kayexalate - poop it out
- Patiromer - Veltassa
Diuretics - only if peeing
- Loop diuretic - Lasix + saline
Hemodiaylsis
- HyperrKpt w/ severe renal impairment
```
Stop K supplements or meds that inc K
108
Hypokalmeia- pathophysiology
Serum K <3.5
109
Hypokalmeia- cause
Inc Loss
- Renal - diuretics, hyperaldostteronism
- GI - V/D
K from blood into intracellular compartment
- Insuline excess - put more into cell
- Beta agonist treatment
- Alkalosis
Hypomagnesemia - fix mg first
- Mg & K lost together - diuretics, vomiting
Renal tubular acidosis
- type 1 (distal) & type 2 (proximal) -> K wasting
Meds
- diuretis - except K sparing
- antipsychotics - risperdal, seroquel
- amphotericin B, barium or chlorquine intoxication
Very low cal diets - 200-800cal
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Hypokalmeia- S/S & PE
NO patho presenting S/S
Muscle fatigue or weakness
- starts in LE -> trunk/UE -> paralysis
Cramps, rhabdo, myoglobinuria
Resp muscle weakness -> resp failure/death
GI muscle invovement - ileus, constipation, n/v
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Hypokalmeia- labs & imaging
```
BMP
Mg
EKG
- Flattened or inverted T wave
- Prominent U waves - V4-V6
- ST depression
- Prolonged QT interval -> QU - fusion of T and U wave
- Arrhythmia
```
112
Hypokalmeia- treatment
Not emergent - unless cardiac menifest or <2.5
- IV K - can cause pain & phlebitis
PO K Cl - perfered for most others
Concurrent hypoMg -> needs to be repleted
Continuous Cardiac monitoring and frequent recheck of K levels
113
Hypernatremia- pathophysiology
Elevated Serum Na >145 mEq/L
Na is main extracellular cation
Na is charged - need pump
H2O is the only that can freely move back and forth
As Na concentration inc and dec - fluid will follow
- Ince - hypervolemia
- Dec - hypovolemia
- unchanged - euvolemia
Looking at Na in a blood draw, not the wholebody
114
Hypernatremia- cause
Elderly patients w/ dec thirst and dec access to fluids - highest risk
Inadequate fluid intake
Excess H2O loss - skin, GI tract
- Urine - osmotoic diuresis, diabetes insipidus, diuretics can waste water and/or Na
Diabetes insipidus
- Central - dec pituitary excretion of ADH
- Nephrogenic - dec kidney sensation to ADH
(ADH inc absorption of H2O)
Hypervolemic hypernatremia
- iatrogenic from hypertonic saline or dialysis
- Hyperaldosteronism - inc aldosterone -> inc Na -> inc H2O -> inc volume
Hypovolemic hypernatremia
- renal losses from renal disease or diuretics
- Extrarenal losses
- pt is dehydrated - look volume depleted
Euvolemic hypernatremia
- hypodipsia - dec H2O intake or thirst - lesions
- Diabetes insipidus
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Hypernatremia- epidemiology
Chronic - >2 days
- less likely to provoke neurologic s/s
- underlying neuro disease -> imparired thirst
- undergo brain adaption to hyernatremia
Acute - hours
- more likely to provoke neurologic s/s
116
Hypernatremia- S/S & PE
Early - anorexia, restlessness, N/V
Next - progressive AMS - lethary/irritabolity 1st -> stupor or comas
Neurologic - twitching, hyperreflexia, ataxia, tremor, seizures
- when Na >160
Dec brain volume
- Acute -> rupture of cerebral veins -> hemorrhaging
- OR Demyalating brain lesion
- Chronic - gets used to dec brain mass
S/S of dehyration - dry MM, tenting/poor skin turgor, lack of tears, dec salivation, tachy, hypotension, oliguira/anuria
- ask pt to stick out tongue - good indication
117
Hypernatremia- diagnosis
Cause - Hx
118
Hypernatremia- labs & imaging
BMP
- Na >145
- if pt is alert, not dementated, has water young, and Na >150 -> check for lesion
If Etiology unclear
- Urine
- Osmolality - solute per kg in solvant
- looking for extrenal cause
- plasma>urine osmolality -> DI
119
Hypernatremia- treatment
Dilute fluids to correct deficit - replace ongoing losses
Chronic:
GO SLOW - if not, rapid fluid movement into brain -> cerebral edema -> seizures and coma
Dilute fluid needed - hypotonic
D5W - 1.34mL/hr x weight in kg
- 50kg pt -> 70ml/hr
- goal - lower serum Na by max of 10 mEq/L per 24hr
Recheck Na & glucose 4-6hrs after tx intitation
- correct if dec too fast/slow
```
Acute:
D5W - 3-6mL/kg per hour
- can also use 1/2 or 1/4 NS
Monitor Na & glucose - Q1-2h until Na <145
- then dec rate to 1 ml/kg per hr -> reach Na of 140
- checking glucose b/c giving dextrose
Goal - reduce Na by 1-2mEq/L each hour
- get back into a nl range w/in 24 hrs
```
120
Hypernatremia- prognosis
High mortality - 40-60%
- w/ underlying disease
Inc M&M
- perioperative 30d mortality
- Perioperative major coronary events
- Pneumonia
- VTE
121
Hyponatremia- pathophysiology
Na <135mEq/L
Most common electrolyte disorder seen in hosp pts
122
Hyponatremia- cause
Hypervolemic
- fluid overload
- H2O is added or retained -> Na in serum is diluted
- CHF, cirrhosis, IVF, nephrotic syndrome
Hypovolemic
- H2O and Na is lost - more Na then H2O
- renal losses - duretics ->>> THIAZIDES
- Extrarenal losses - diarrhea, sweating, blood loss, fluid shifts
Fluid loss can lead to hypo or hyper Na - depends on how much Na is loss
Euvolemic
Adrenal insufficiency
Polydipsia - primary or psychogenic -
- urinating large amounts
Hypothyroidism
Syndrome of inapprepriate Antidiuretic Hormone (SIADH)
- Intracranial patho - tumor, hemorrhage
- Paraneoplastic syndrome - tumor secretes ADH
- Pulm dis - cancer, COPD, interstitial lung dis
- Meds - SSRI, cyclophsophamide
Resest osmostat - Kidney cant dilute urine
- threshold to release ADH is reset downwards
123
Hyponatremia- epidemiology
Hypotonic - low solutes - osmolality <280
- SIADH
- Effective arterila blood volume depletion - CHR, cirrhosis, diuretics
- Endocrine d/o: hypothyroid, adrenal insufficiency
- advanced renal failure - extasy, exercise
Isotonic - nl solutes - osmolality 280-295
- Pseudohyponatremia - inc serum lipids or proteins can lead to an erroneous measurement of Na level -> get a fake low Na
Hypertonic - high solutes - osmolality >295
Significant hyperglycemia - cause a false low Na -> need to correct it
- for every 100mg above nl -> add 2ml to Na
Mannitol, maltose, sucrose retention - pulls H2O out of cells -> dilution
124
Hyponatremia- S/S & PE
Not symptomatic until Na is 125-130
Anorexia, N/V, lethargy, disorientation, HA, seizures
Signs - weakness, agitation, hyporeflexia, orthostatic hypotension, delirium, coma, seizure, respiratory arrest, brainstem herniatiton
125
Hyponatremia- diagnosis
When started:
Acute - w/in 24hr
Subacute - 24-48hr
Chronic - >48hr
Na level:
Severe - <120 - BE WORRIED
Mod - 121-129
Mild - 130-135
126
Hyponatremia- labs & imaging
Find underlying cause!!
1st - BMP + serum osmolality
- osmolality can further direct you -> hypotonic, isotonic, hypertonic cause
Urine osmolality & electrolytes - helpful
```
Further looking::
TSH
Plasma cortisol
ACTH stimulation test
Brain/lung imaging
```
127
Hyponatremia- treatment
Identify and treat underlying cause
Symptomatic - even mild - need emerg therapy
- hypertonic saline - 100mL bolus
- raise Na by 4-6 w/in a couple of hours
- should alleviate symptoms & prevent hernia
- check Na every 2H
Non-emergency - goal to Na up slowly
Over rapid correction -> osmotoic demyelination syndrome - central pontine myeinolysis
Hypovolemic - Isotonic saline
Hypervolemic
- CHF, cirrhosis -> diuresis, fluid restrction, Na restriction -- DO NOT TAKE SALT TABS
- Renal Failure -> fluid restriction, dialysis, Na restrction
Euvolemic - Fluid restriction
- SIADH - may add salt tabs and/or loop diuretic
- Demeclocycline - off label use - if dont respond to salt tabs or loop diuretics - last ditch effort
- SE: renal toxicity (esp cirrhosis), nephrogenic DI, intracranial hypertension
