Electrolyte Vignette

Fluid and Electrolyte Conference Joel topf, MD Nephrology Faculty Providence Hospital Friday, February 27, 2009

Friday, February 27, 2009

CC: weakness Social Hx: bum physical exam: starving Friday, February 27, 2009

presentation CC: weakness 12 128 92 128 2.8 22 Social Hx: bum 0.6 EtOH 44 physical exam: starving Friday, February 27, 2009

least sick patient you admitted Friday, February 27, 2009

problem list Friday, February 27, 2009

problem list weakness hyponatremia hypokalemia Friday, February 27, 2009

Hypokalemia: differential diagnosis Friday, February 27, 2009

Hypokalemia: differential diagnosis Decreased intake Alcoholism Starvation Friday, February 27, 2009

Hypokalemia: differential diagnosis Decreased intake Alcoholism Starvation Renal losses Diuretics Vomiting RTA Hyperaldo Friday, February 27, 2009

Hypokalemia: differential diagnosis Decreased intake Alcoholism Starvation Renal losses Diuretics Vomiting RTA Hyperaldo GI Losses Diarrhea Friday, February 27, 2009

Decreased intake 945 outpatients with eating disorders Serum Potassium anorexia, bulemia, or both 2% ALL of the hypokalemic 3% patients were abusing cathartics or inducing vomiting NONE of the hypokalemia was due to restricted caloric intake alone 95% The restricted calorie subgroup was the most nutritionally deprived of >3.5 3.0-3.5 <3.0 all the subgroups. Greenfeld, D., Et Al. Am. J. Psychiatry 152, 60-63 (1995). Friday, February 27, 2009

Serum K with dietary restriction Intake does matter in 4.00 experimental settings but clinical Serum K (mEq/dL) 3.25 relevance is questionable 2.50 A compilation of 7 1.75 separate metabolic balance studies 1.00 reveals the 0 200 400 600 800 following graph K defecit (mEq) Friday, February 27, 2009

Alcoholism 61 patients with weekly alcohol ingestion greater than 600g/wk. No cirrhosis of hepatitis, renal disease or, acute medical condition. Admitted for inpatient detoxiﬁcation for 4 weeks De Marchi, S. et al. N Engl J Med 1993;329:1927-1934 Friday, February 27, 2009

admission 28-days 3.8 4.4 potassium 1.4 1.7 magnesium Friday, February 27, 2009

Vomiting induced hypokalemia is not due to GI losses Friday, February 27, 2009

Vomiting induced hypokalemia is not due to GI losses potassium content of stomach ﬂuid is 15 mEq/L Friday, February 27, 2009

Vomiting induced hypokalemia is not due to GI losses potassium content of stomach ﬂuid is 15 mEq/L How much vomit to get a 120 mEq potassium deﬁcit? Friday, February 27, 2009

Distal convoluted tubule Glomerulus Vomiting induced Proximal tubule hypokalemia is Collecting tubule due to renal losses Loop of Henle Friday, February 27, 2009

Vomiting induced hypokalemia is due to renal losses Friday, February 27, 2009

Vomiting induced hypokalemia is due to renal losses Vomiting causes metabolic alkalosis Increased serum bicarbonate is dumped into the urine urine potassium can rise to 80-120 mEq/L Friday, February 27, 2009

Hypokalemia: Treatment Potassium is 2.8 How much poassium will you give: 100 x (4–k) Friday, February 27, 2009

Orders: Friday, February 27, 2009

Orders: banana bag Friday, February 27, 2009

Orders: banana bag D5LR at 80 an hour Friday, February 27, 2009

Orders: banana bag D5LR at 80 an hour KCL 40 mEq IVPB Friday, February 27, 2009

Orders: banana bag D5LR at 80 an hour KCL 40 mEq IVPB KCL 80mEq orally split over two doses q4 hours Friday, February 27, 2009

Initial Labs 12 128 92 128 2.8 22 0.6 Friday, February 27, 2009

Initial Labs Next morning 12 10 128 92 128 132 100 94 2.8 22 3.2 24 0.6 0.6 Friday, February 27, 2009

120 mEq and he’s still low 10 132 100 94 3.2 24 0.6 Friday, February 27, 2009

120 mEq and he’s still low 10 132 100 94 3.2 24 0.6 repeat treatment check magnesium Friday, February 27, 2009

120 mEq and he’s still low 10 132 100 94 3.2 24 0.6 repeat treatment Ca check magnesium Mg Phos Friday, February 27, 2009

120 mEq and he’s still low 10 132 100 94 3.2 24 0.6 repeat treatment Ca check magnesium Mg Phos 8.8 1.2 2.2 Friday, February 27, 2009

Problem list hypokalemia hypomagnesemia hypophosphatemia hyponatremia Friday, February 27, 2009

Na, 2Cl - + + K ++ Ca + + + + + K + + + + + + Ca, Na, Mg Friday, February 27, 2009

Na, 2Cl - + + K + + + + + K + + + + + + Ca, Na, Mg Friday, February 27, 2009

Na, 2Cl - + + K ATP + ATP + + + + K ATP + + + + + + Ca, Na, Mg Friday, February 27, 2009

Na, 2Cl - + + K Mg ATP + ATP Mg + + + + Mg K ATP + + + + + + Ca, Na, Mg Friday, February 27, 2009

Na, 2Cl - + + K ATP + K + ATP + + + + K + ATP K + + + K + + + + Ca, Na, Mg Friday, February 27, 2009

Na, 2Cl - + + K + ATP + + ATP + + + + + + + K ATP + + + + + + + + + Ca, Na, Mg Ca, Na, Mg+ + + Friday, February 27, 2009

FIX THE MAGNESIUM SAVE THE POTASSIUM Friday, February 27, 2009

magnesium Friday, February 27, 2009

magnesium 2 grams of Magnesium Sulfate IVPB over an hour or so Friday, February 27, 2009

magnesium doesn’t really work the next day it’s still low Most of the IV magnesium is immediately dumped in the urine you need to drip it in over as long as possible i like 6g (48.6 mEq) over 24 hours Friday, February 27, 2009

day one labs 12 128 92 128 2.8 22 3.0 0.6 Friday, February 27, 2009

day two labs 12 128 92 128 2.8 22 3.0 0.6 8.8 10 132 100 94 1.2 2.2 3.2 24 0.6 Friday, February 27, 2009

day three labs 12 128 92 128 2.8 22 3.0 0.6 8.8 10 132 100 94 1.2 2.2 3.2 24 0.6 10 8.9 133 98 94 3.9 24 2.3 1.4 0.6 Friday, February 27, 2009

problem list hyponatremia hypophosphatemia muscle weakness Friday, February 27, 2009

problem list 4 hyponatremia 3 Phos (mg/dL) hypophosphatemia 2 muscle weakness 1 0 Day 1 Day 2 Day 3 Friday, February 27, 2009

weakness hypokalemia corrected magnesium a little high not enough to cause muscle weakness Friday, February 27, 2009

hypermagnesemia the most tolerated electrolyte abnormality Upper limit of magnesium 1.8 pre-eclampsia magnesium 6-8 Lethal magnesium 14 Friday, February 27, 2009

Weakness Hypophosphatemia Friday, February 27, 2009

differential dx Decreased phosphorous absorption Intracellular shift Increased renal excretion Friday, February 27, 2009

differential dx Intracellular shift Decreased phosphorous absorption Calcitonin Dietary insufﬁciency Catecholamines Malabsorption Epinephrine Phosphate binders Dopamine Calcium Terbutaline Magnesium Albuterol Aluminum Insulin Sevelamer Carbohydrate infusions Lanthium refeeding Vitamin D deﬁciency Respiratory alkalosis Steatorrhea Rapid cell proliferation Vitamin D resistant rickets Treatment of anemia Glucocorticoids CML in blast crisis AML Friday, February 27, 2009

differential dx Increased renal excretion Fanconi syndrome Volume expansion/ Alcoholism natriuretic states Multiple myeloma IV Bicarbonate Amoniglycosides Bicarbonaturia Heavy metal toxicity Glucosuria Chinese herbs Diuretics Congenital Acetazolamide is the Ifosfamide most phosphaturic Cisplatin High salt diet or Cystinosis saline infusion Wilson’s Disease Hyperaldosteronism Hereditary fructose SIADH intolerance Paraneoplastic syndrome Glucocorticoids PTHrp Hyperparathyroidism Tumor induced Hypercalcemia osteomalacia Metabolic acidosis Renal transplantation Acute malaria (falciparum) X-linked hypophosphatemic rickets Friday, February 27, 2009

differential dx 3.0 8.8 1.2 2.2 8.9 2.3 1.4 Friday, February 27, 2009

differential dx alcoholism 3.0 refeeding syndrome 8.8 malabsorption 1.2 2.2 respiratory alkalosis 8.9 Saline infusion 2.3 1.4 Friday, February 27, 2009

differential dx 3.0 refeeding syndrome 8.8 1.2 2.2 8.9 2.3 1.4 Friday, February 27, 2009

Transcellular redistribution is movement of phosphorous into cells. This is usually transient and, in the face of normal total body phosphourous is harmless. However, in the face of pre-existing phosphorous depletion, this transcellular movement can provoke serious symptoms including death. The most severe cases are found with refeeding syndrome. Weinsier and Krumdieck, 1981, Am J Clin Nutr, 34, 393-9 Friday, February 27, 2009

Starvation decreases total body phosphorous. However, serum phos remains normal due to movement of phosphorous out of cells. With refeeding, insulin moves phosphorous into cells, in order to phosphorylate carbs as part of glycolysis. This unmasks the previous phosphorous depletion. Friday, February 27, 2009

this is worse with fructose conversion of fructose to fructose-P is unregulated causes rapid consumption of Phos and ATP the loss of ATP is thought to be the cause of fructose toxicity Friday, February 27, 2009

give phos stop carbs Friday, February 27, 2009

Stop the D5LR Started 8 ounces of milk four times a day Used a packet of KPhos Friday, February 27, 2009

IV sodium phosphorous 8mmol q6 hours target 32 mmol in a day careful in renal failure Friday, February 27, 2009

day four and ﬁve labs Day Na K P Mg 1 128 2.8 3.0 2 132 3.2 2.2 1.2 3 133 3.9 1.4 2.3 4 131 3.8 1.8 2.2 5 130 4.2 2.8 1.8 Friday, February 27, 2009

problem list hyponatremia Friday, February 27, 2009

Speciﬁc gravity on admission: 1.005 What’s the speciﬁc gravity in: hypervolemic hyponatremia: heart failure? Cirrhosis? Nephrotic syndrome? Euvolemic hyponatremia: SIADH? Hypovolemic hyponatremia: diuretics? GI losses? Friday, February 27, 2009

What regulates speciﬁc gravity? Friday, February 27, 2009

What regulates speciﬁc gravity? ADH Friday, February 27, 2009

What regulates speciﬁc gravity? ADH We start with an increase in the plasma osmolality Friday, February 27, 2009

What regulates speciﬁc gravity? ADH This is detected increase in We start with an by the brainthe plasma osmolality Friday, February 27, 2009

What regulates speciﬁc gravity? ADH The is detected increase Thisbrain releases the in We start with an by ADHbrainthe plasma osmolality Friday, February 27, 2009

What regulates speciﬁc gravity? ADH ADH acts releases the The is detected kidney Thisbrain on an increase in We start withthe by ADHbrainthe plasma osmolality Friday, February 27, 2009

What regulates speciﬁc gravity? ADH The retained water goes here not here The kidney reacts by retaining water and producing a small amount of kidney The is detected concentrated Thisbrain on an increase in urine. ADH acts releases the We start withthe by ADHbrainthe plasma osmolality Friday, February 27, 2009

What regulates speciﬁc gravity? ADH What do all of the etiologies of hyponatremia have in common? Friday, February 27, 2009

What regulates speciﬁc gravity? ADH What do all of the etiologies of hyponatremia have in common? ADH Friday, February 27, 2009

Hyponatrmia Occurs When Water Intake Exceeds Excretion Friday, February 27, 2009

ADH Decreases Urine Volume Friday, February 27, 2009

Our patient has a low speciﬁc gravity. Friday, February 27, 2009

Our patient has a low speciﬁc gravity. ADH independent hyponatremia Friday, February 27, 2009

Our patient has a low speciﬁc gravity. ADH independent hyponatremia psychogenic polydipsia Friday, February 27, 2009

Our patient has a low speciﬁc gravity. ADH independent hyponatremia psychogenic polydipsia tea and toast or beer drinkers potomania Friday, February 27, 2009

psychogenic polydipsia Friday, February 27, 2009

psychogenic polydipsia 18 liters Friday, February 27, 2009

The kidney is able to concentrate urine to 1200 mOsm/L The kidney is able to dilute urine to 50 mOsm/L If a patient has a daily solute load of 600 mOsms. What is: The minimal amount of urine he can produce (maximum ADH) The maximum amount of urine he can make (minimal ADH) Friday, February 27, 2009

The kidney is able to concentrate urine to 1200 mOsm/L The kidney is able to dilute urine to 50 mOsm/L If a patient has a daily solute load of 600 mOsms. What is: The minimal amount of urine he can produce (maximum ADH) 500 mL The maximum amount of urine he can make (minimal ADH) Friday, February 27, 2009

The kidney is able to concentrate urine to 1200 mOsm/L The kidney is able to dilute urine to 50 mOsm/L If a patient has a daily solute load of 600 mOsms. What is: The minimal amount of urine he can produce (maximum ADH) 500 mL The maximum amount of urine he can make (minimal ADH) 12,000 mL Friday, February 27, 2009

600 mOsms is the typical daily solute load so a patient requires a minimum of 500 mL of urine to remove the daily solute load A patient making less than that is unable to clear the daily solute load what is the deﬁnition of oliguria Friday, February 27, 2009

What if the daily solute load is 100 mOsms? What is the most urine they can make? Friday, February 27, 2009

What if the daily solute load is 100 mOsms? What is the most urine they can make? 2,000 mL Friday, February 27, 2009

What if the daily solute load is 100 mOsms? What is the most urine they can make? 2,000 mL What happens if they are getting IV ﬂuids at 100 mL/hour? Friday, February 27, 2009

An alcoholic gets much of his daily calories from alcohol. Alcohol is metabolized to CO2 and water no solute for the kidney to excrete Low daily solute load Friday, February 27, 2009

A tea and toast diet refers to a carbohydrate rich diet free of proteins Friday, February 27, 2009

Both beer drinker’s and Tea and Toast respond to increased protein intake Usually get a brisk response to crystalloids Friday, February 27, 2009

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Electrolyte Vignette

by Joel Topf on Feb 27, 2009

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Electrolyte Vignette — Presentation Transcript