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![Urine [ClUrine [Cl--
]]
Chloride-responsive alkalosesChloride-responsive alkaloses Chloride-unresponsive alkalosesChloride-unresponsive alkaloses
Gastric fluid lossGastric fluid loss
Nonreabsorbale anion deliveryNonreabsorbale anion delivery
DiureticsDiuretics
PosthypercapneaPosthypercapnea
Villous adenomaVillous adenoma
Congenital chloridorrheaCongenital chloridorrhea
Urine KUrine K++
Laxative abuseLaxative abuse
Severe KSevere K++
depletiondepletion
HypertensionHypertension
Bartter syndrome orBartter syndrome or
diuretic abusediuretic abuse
Plasma reninPlasma renin
High unilateralHigh unilateral
renal vein reninrenal vein renin
Plasma cortisolPlasma cortisol
Rimary aldosteronismRimary aldosteronism
Licorice abuseLicorice abuse
Renovascular HTNRenovascular HTN
JGA tumorJGA tumor
Malignant orMalignant or
Accelerated HTNAccelerated HTN
Cushing syndromeCushing syndrome
HighHigh
LowLowHighHigh
HighHigh
NormalNormal
NoNoYesYes
Low/normalLow/normal
<30 mEq/d<30 mEq/d >30 mEq/d>30 mEq/d
<20 mEq/L<20 mEq/L >20 mEq/L>20 mEq/L](https://image.slidesharecdn.com/flowchart-150719140237-lva1-app6892/75/Flow-chart-8-2048.jpg)
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- 5. Low PTHLowPTH actionaction High Bone Shift Resistance HypocalcemiaHypocalcemia Low to normal InP GI synthesis Renal loss Vit DVit D Related Unrelated LowLow HighHigh
- 6. Plasma Na <120 mmol/LPlasma Na < 120 mmol/L Yes,Yes, this isthis is acuteacute NO,NO, chronicchronic NoNo YesYes •Usually posteperativeUsually posteperative •Identify source ofIdentify source of EFWEFW •Treat aggressivelyTreat aggressively • Hypertonic NaClHypertonic NaCl untiluntil PPNaNa up to 130up to 130 mmol/Lmmol/L •Go slowlyGo slowly • PPNaNa rise < 8rise < 8 mmol/L/daymmol/L/day • Remove cause forRemove cause for ADHADH • Restrict waterRestrict water • Replace ECF NaReplace ECF Na deficitdeficit • Think ICF KThink ICF K •Danger signsDanger signs •Rapid initial correctionRapid initial correction •Hypertonic NaClHypertonic NaCl • Rise PNa < 5Rise PNa < 5 mmol/Lmmol/L in 2-3 huin 2-3 hu • Symptoms abateSymptoms abate •Total: 8 mmol/L/dayTotal: 8 mmol/L/day Is duration known to be < 48 hr ?Is duration known to be < 48 hr ? Convulsions or coma ?Convulsions or coma ?
- 7. Metabolic alkalosisMetabolic alkalosis Lowurine chlorideLow urine chloride (urine Cl < 10 mEq/L)(urine Cl < 10 mEq/L) High urine chloriedHigh urine chloried (urine Cl > 10 mEq/L)(urine Cl > 10 mEq/L) •NormotensiveNormotensive VomitingVomiting Gastric drainageGastric drainage Diuretic useDiuretic use Post-hypercapneaPost-hypercapnea Cl-losing diarrheaCl-losing diarrhea •NormotensiveNormotensive DiureticsDiuretics Bartter’s syndromeBartter’s syndrome Severe K depletionSevere K depletion Gittelman’s syndromeGittelman’s syndrome •Low reninLow renin PrimaryPrimary hyperaldoseronismhyperaldoseronism AdenomaAdenoma hyperplasiahyperplasia •High reninHigh renin renovascularrenovascular hypertensionhypertension MalignantMalignant hypertensionhypertension Renin secretingRenin secreting tumortumor •Low aldsoterone andLow aldsoterone and low reninlow renin glycyrrhizic acidglycyrrhizic acid CarbenoxoloneCarbenoxolone ExogenousExogenous mineralocoticoidsmineralocoticoids Liddle’s syndromeLiddle’s syndrome ApparentApparent mineralocorticoid exonmineralocorticoid exon High aldosteroneHigh aldosterone HypertensiveHypertensive •Normal aldosteroneNormal aldosterone and normal reninand normal renin Cushings syndromeCushings syndrome
- 8. Urine [ClUrine [Cl-- ]] Chloride-responsivealkalosesChloride-responsive alkaloses Chloride-unresponsive alkalosesChloride-unresponsive alkaloses Gastric fluid lossGastric fluid loss Nonreabsorbale anion deliveryNonreabsorbale anion delivery DiureticsDiuretics PosthypercapneaPosthypercapnea Villous adenomaVillous adenoma Congenital chloridorrheaCongenital chloridorrhea Urine KUrine K++ Laxative abuseLaxative abuse Severe KSevere K++ depletiondepletion HypertensionHypertension Bartter syndrome orBartter syndrome or diuretic abusediuretic abuse Plasma reninPlasma renin High unilateralHigh unilateral renal vein reninrenal vein renin Plasma cortisolPlasma cortisol Rimary aldosteronismRimary aldosteronism Licorice abuseLicorice abuse Renovascular HTNRenovascular HTN JGA tumorJGA tumor Malignant orMalignant or Accelerated HTNAccelerated HTN Cushing syndromeCushing syndrome HighHigh LowLowHighHigh HighHigh NormalNormal NoNoYesYes Low/normalLow/normal <30 mEq/d<30 mEq/d >30 mEq/d>30 mEq/d <20 mEq/L<20 mEq/L >20 mEq/L>20 mEq/L
- 9. Low PTHLowPTH actionaction High Bone Shift Resistance HypocalcemiaHypocalcemia Low to normal InP GI synthesis Renal loss Vit DVit D Related Unrelated LowLow HighHigh
- 10. GIGI BoneBone RenalRenal ShiftShift HighHigh LowLow PTH Decreased PTH secretion • PHP type Ia, Ib, Ic Renal failure Ca+2 -sensing receptor activating (inherited or acquired) PTH resistance HypocalcemiaHypocalcemia Low to normal InP High
- 12. Lin SH. CurrMedicinal Chem 2007
- 13. ECF↑+ Metabolic alkalosis(Fast Na+ or MES) ReninRenin AldoAldo CortisolCortisol ReninRenin AldoAldo ReninRenin AldoAldo ReninRenin AldoAldo NormalNormal LowLow • PAPA CortisolCortisol• MHMH • RVHRVH • RSTRST Ectopic ACTHEctopic ACTH Cushing syndromeCushing syndrome Exogenous HExogenous H LicoriceLicorice Liddle’s SLiddle’s S AMEAME DOCDOC 1111ββ hydroxylase Dhydroxylase D 1717αα hydroxylase Dhydroxylase D HighHigh
- 15. Serum Cortisol and/orUFF High Normal Low ACTH ↓ MRI of pituitary gland Inferior petrosal sinus samping Pituitary ACTH Ectopic ACTH Adrenal Cushing syndrome Exogenous hydrocortisone THF/THE or UFF/UFE Normal Glycyrrhetinic acid- containing substance Chronic licorice ingestion AME Serum DOC DOC secreting tumor Liddle’s syndrome Aldosterone analogue Sex hormone (Testosterone or Estradiol) 11β-hydroxylase deficiency 17α-hydroxylase deficiency ↑ History CT of adrenals Adrenal vein samping ↑ ↑ ↓ ↑ ↓ MES with low Renin and low Aldo + - -+ MES: mineralocorticoid excessive status THF/THE: 5α-tetrahydrocortisol/tetrahydrocortisone UFF/UFE: urinary free cortisol/urinary free cortisone DOC: deoxycorticosterone AME: apparent mineralocorticoid excess
- 16.
- 17. Low PTHLowPTH actionaction High Bone Shift Resistance HypocalcemiaHypocalcemia Low to normal InP GI synthesis Renal loss Vit DVit D Related Unrelated LowLow HighHigh