renal treatment/dx Flashcards
dx SIADH
Serum osmolality < 280 mOsm/kg (hypotonic).
■ Urine osmolality > 100 mOsm/kg in the setting of serum hypoosmolarity
without a physiologic reason for ↑ ADH (eg, congestive heart failure, cir-
rhosis, hypovolemia).
■ Urinary sodium level often ≥ 20 mEq/L.
tx SIADH
Explore and address the underlying cause.
■ Best initial treatment: Restrict fluid.
■ Persistent or symptomatic hyponatremia (< 120 mEq/L): IV hypertonic
saline therapy.
■ Severe SIADH: ADH antagonists (eg, tolvaptan, conivaptan).
■ Chronic SIADH: Demeclocycline.
SIADH CAUSING DRUGS
Carbamazepine, Cyclophosphamide, SSRIs
calcium correction for albumin formula
0.8( normal albumin- measured albumin) + measured calcium
normal albumin 4.0
hypo albumin may cause false low ca+ levels
increase pH –> affinity of albumin (negative charge) to bind Ca2+ hypocalcemia acidosis decrease AB-bind H+
every reduction of albumin by 1 reduces ca+ by 0.8
acute hypercalcemia treatment t
0.9% saline + loop diuretic
diarrhea
vomiting
diarrhea - loss of HCO3 and K+
vomiting - loss of HCL and then RAAS compensates worse metabolic alkalosis and causes hypokalemia
hypokalemia ECG
T-wave flattening, U waves (an additional wave after the T wave), and ST-segment depression, leading to AV block and cardiac arrest
hypo K treatment
Treat the underlying disorder. hypomag can cause hypokalemia
■ Oral and/or IV K+ repletion. Oral is the preferred route for safety pur-
poses. If IV is necessary, a continuous rate of K+ as an additive is preferred over an IV K+ bolus. Reserve IV boluses for symptomatic hypokalemia or ECG changes. Do not exceed 20 mEq/L/h.
■ Replace magnesium, as this deficiency makes K+ repletion more difficult.
hypo MG most common in
Alcoholics are the most common patient population with hypomagnesemia.
Mg2+ (low levels can induce PTH resistance)
most accurate test for hypocalcemia
ECG changes
- Most accurate test: Ionized Ca2+ and PTH.
2. prolong QT - 3 phase decrease ca enter
hypo Ca+ treatment
Treat the underlying disorder.
administer oral calcium supplements; give oral
and IV calcium for severe symptoms or signs.
Ensure magnesium repletion.
hyperkalemia tx
C BIG K
Calcium chloride or gluconate (intravenous)
heart > 6.5
Bicarbonate, β2-agonists
Insulin + Glucose
Kayexalate (sodium polystyrene sulfonate)
diuretics
hyperkalemia dx
Diagnosis
■ Confirm hyperkalemia with a repeat blood draw for suspected spurious results. In the setting of extreme leukocytosis or thrombocytosis, check plasma K+.
spurious- blood hemolysis, fist clenching
■ Other work-up: ECG to evaluate for cardiac complications. ECG findings include tall, peaked T waves; a wide QRS; PR prolongation; and loss of P waves (see Figure 2.16-4). Can progress to sine waves, ventricular dys- rhythmias, and cardiac arrest.
If hypokalemia is not responding to K+ repletion
check magnesium levels.
hypo Mg treatment
Tetany, torsades de pointes,
trEatmEnt
■ Generally most causes respond to IV and/or oral supplements, depending on severity.
■ Hypokalemia and hypocalcemia will not correct without magnesium correction.
hypvolemic hypernatremia
if hypovolemic with unstable vital signs, use isotonic 0.9%
Use isotonic 0.9% NaCl until the patient is euvolemic, even with stable vital signs.
normal volume and asymptomatic
If normal volume status and asymptomatic, can treat with D5W, 0.45% NaCl or enteral fluids.
hypervolemic hypernatremia
with a combination of diuretics and D5W to remove excess Na.
hypernatremia determine
determine free water deficits
determine rate of replacement
Determine free water deficit. Water deficit = Total body water × ([serum Na/140] − 1).
■ Total body water (TBW) is ± 60% of lean body weight.
■ Replace with D5W, 0.45% NaCl, or enteral water.
Correction of chronic hypernatremia (> 48 hours) should be accomplished gradually over 48–72 hours (≤ 0.5 mEq/L/h) to prevent neurologic damage secondary to cerebral edema.
hypernatremia determine
determine rate of replacement
Correction of chronic hypernatremia (> 48 hours) should be accomplished gradually over 48–72 hours (≤ 0.5 mEq/L/h) to prevent neurologic damage secondary to cerebral edema.
hypervolemic and euvolemic hyponatremia x
Treat hyponatremia from hypervolemic and euvolemic etiologies with water restriction ± diuretics.
hypovolemic hyponatremia tx
replete with NS
sever hyponatremia range or symptomatic and treatment
If severe hyponatremia (Na < 120 mEq/L), con- sider 3% hypertonic saline, particularly if symptomatic.
chronic hyponatremia def and tx
Correct chronic hyponatremia (> 72 hours’ duration) slowly (< 8−10 mEq/L/day) to prevent osmotic demyelination syndrome (symptoms include paraparesis/quadriparesis, dysarthria, and coma)
indication for urgent dialysis
AEIOU Acidosis Electrolyte abnormalities (hyperkalemia) Ingestions (salicylates, theophylline, methanol, barbiturates, lithium, ethylene glycol) Overload (fluid) Uremic symptoms (pericarditis, encephalopathy, bleeding, nausea, pruritus, myoclonus)
increase anion gap
> 12 MUDPILES: Methanol (formic acid) Uremia- NH4 urine production Diabetic ketoacidosis Propylene glycol Iron tablets or INH Lactic acidosis Ethylene glycol (oxalic acid) Salicylates (late)
normal anion gap
normal 8-12 artificial nutrients
HARDASS: Hyperalimentation( artificial nutrients) Addison disease Renal tubular acidosis Diarrhea Acetazolamide Spironolactone Saline infusion
osmolar gap increase
Both present with ↑ osmolal gap (Measured osmolality-calculated osmolality > 10 mOsmol/L)
chloride resistant metabolic alkalosis
mineral chloride >20 mEq /per day urine
not corrected with saline
ECF expansion
primary hypaldo, batter, gietlamn
chorlide sensitive MA
< 20 cholride urine
corrected with saline, ECF loss
thiazide, loop, vomiting,
