Electrolytes & Acid-Base Disturbance Workshop - Dr. Gawad

Electrolytes & Acid-Base Disturbance
Workshop
Mohammed Abdel Gawad MD, ESENeph
Lecturer of Nephrology, School of Medicine, NewGiza University
Founder of NephroTube.com
ISN Education SoMe Team Member
Co-chair of AFRAN Web/Media Committee

Cases
• Case #1: Hyponatremia diagnosis
• Case #2: Hyponatremia treatment
• Case #3: Hypernatremia
• Case #4: Potassium disorder
• Case #5: Calcium disorder
• Case #6: Magnesium disorder
• Case #7: Phosphorus disorder
• Case #8: Acid-Base disorder

History
• An 18-year-old man presents with the complaint of nocturia and polyuria. His 24-hour
urine volume is 4.2 L. He has no other medical history.
Physical
examination
• BP of 115/70 mmHg
• heart of 72 beats per minute
• He is afebrile
• The rest of the examination is unremarkable
Blood tests
• sodium, 130 mEq/L
• potassium, 3.9 mEq/L
• chloride, 95 mEq/L
• bicarbonate, 26 mEq/L
• BUN, 10 mg/dl
• creatinine, 0.8 mg/dl
Urine tests
• potassium, 20 mEq/L
• volume, 4.2 L/d
• osmolality, 90 mOsm/L
What is the most likely cause of his hyponatremia?
A. SIADH
B. Occult diuretic use
C. Hypothyroidism
D. Primary polydipsia
Case #1 Electrolytes, Acid-Base Disturbance Workshop
Reference: Modified from NephSap-2013-Fluids 40th ESNT Congress, Dr. Mohammed Abdel Gawad

5
Nephrol Dial Transplant (2014) 29 (Suppl. 2): ii1–ii39

History
• A 75-year-old man with recently diagnosed pancreatic cancer and hypertension (on
lisinopril and chlorthalidone).
Physical
examination
• He is intermittently agitated and disoriented with infrequent seizures
• The BP is 140/85 mmHg, and the pulse rate is 85/min
• The remainder of examination is unremarkable
Blood tests
• sodium of 115 mEq/L
• potassium of 3.9 mEq/L
• BUN of 6 mg/dl
• creatinine of 0.8 mg/dl
• glucose of 106 mg/dl
• calcium of 9.0 mg/dl
• serum osmolality of 236mOsm/kg
Urine tests
• The urine osmolality is 380 mOsm/kg
• The urine sodium is 40 mEq/L, and the urine potassium is 30 mEq/L
In addition to fluid restriction and discontinuing chlorthalidone, what is the MOST next step in management?
A. No additional interventions
B. 3% saline to increase SNa+ 4–6 mEq/L
C. Tolvaptan
D. Furosemide plus intravenous isotonic saline with potassium chloride

Repeat serum Na
Exclude Drugs
4
5

IV infusion of 150
ml 3% hypertonic
(2 ml/kg) in case
of obviously
deviant body
composition
20 min
check
serum Na
Maximum:
Repeat twice
Maximum:
5 mmol/l
increase
A. Improvement of
symptoms
→ Stop 3% infusion
B. No improvement
of symptoms
→ continue infusion
targeting general
rules of raising
serum Na
keep the i.v. line
open by infusing the
smallest feasible
volume of 0.9%
saline until cause-
specific treatment is
started
First-hour management:
Hyponatremia - Management – Severe Symptoms

General rules – 0.9% or 3% NaCl infusion
Maximum correction limit (i.e. Stop infusion when)
10 mmol/l in the
first 24 h
8 mmol/l during
every 24 h
thereafter
130 mmol/l is
reached or
serum sodium
concentration
increases
10 mmol/l in
total
symptoms
improved
If the symptoms still have not improved, it is unlikely that the
symptoms are due to the hyponatremia and alternative
explanations should be sought
Handbook of Critical Care Nephrology. Chapter 19. 2021

History
• A 38-year-old woman entered the emergency department with weakness, frequent
urination (UOP; 8L/d), and increased thirst.
Physical
examination
• Heart rate of 80 beats per minute
• BP of 120/80 mmHg supine and 115/75 mmHg upright
• The rest of the examination was noncontributory.
Blood tests
• chloride, 123.0 mEq/L
• bicarbonate, 24.0 mEq/L
• creatinine, 0.9 mg/dl
• BUN, 22.0 mg/ dl
• glucose, 130 mg/dl
• calcium, 9.1 mg/dl.
Urine tests • Urine osmolality was 88 mmol/kg
Which ONE of the following would MOST likely reveal the cause of her electrolyte disorder?
A. Fluid deprivation test
B. Plasma cortisol assay
C. Serum thyroid-stimulating hormone assay
D. Estimation of urinary osmoles

AJKD. VOLUME 72, ISSUE 5, PA17-A19, NOVEMBER 01, 2018
Polyuria –
Approach 1

urine osmolality ×
urine volume >900
mosmol/day
Am J Kidney Dis. 67(3):507-511, 2016.
Polyuria –
Approach 2

Am J Kidney Dis. 2016 Mar;67(3):507-11

History
• A 38-year-old man presents with a recent history of hypertension.
• He is referred to you for further evaluation. He is currently being treated with a CCB.
Physical
examination
• BP of 165/90 mmHg supine and standing
• Heart rate of 62 beats per minute
• The rest of the examination is unremarkable
Blood tests
• chloride, 100 mEq/L
• metabolic alkalosis
• BUN, 16 mg/dl
• creatinine, 0.9mg/dl.
Urine tests • Urine K/Cr ratio, 35
• Urine chloride, 35 mmol/L
At this point, which ONE of the following should be done?
A. Plasma aldosterone to renin ratio
B. Abdominal CT scan
C. 24-hour urinary aldosterone level
D. Thyroid function test

Acta Med Indones. Jan-Mar 2007;39(1):56-64.

Glucocorticoid remediable aldosteronism
Acta Med Indones. Jan-Mar 2007;39(1):56-64.

Reference: Modified from NephSap-2014-Bone 40th ESNT Congress, Dr. Mohammed Abdel Gawad
History
• A 56-year-old man was diagnosed with colon cancer 3 years ago and had successful
surgery and postoperative chemotherapy.
• He denies weight loss, abdominal pain, jaundice, confusion, constipation, or polyuria.
• The patient drinks three to four “health tonics” rich in calcium and several servings of
milk and calcium-fortified orange juice daily.
CT scan
• He now has a possible metastatic lesion of the liver that was seen on a recent
abdominal computed tomography (CT) scan.
Blood tests
• serum calcium, 12.5 mg/dl
• undetectable serum (PTH)
• serum PTHrP, normal
• serum 25(OH)D 288 ng/ml (N, 25–80 ng/ml),
• serum 1,25(OH)2D 72 pg/ml (N, 25–65 pg/ml)
Which ONE of the following is the MOST likely cause of this patient’s hypercalcemia?
A. Recurrent colon cancer-producing PTHrP
B. Bone metastases
C. Vitamin D intoxication
D. Sarcoidosis
E. Excess calcium intake

History
• A 70-year-old man was admitted to the hospital after he had lost consciousness.
• He had a history of peptic ulcer disease, hypertension, and hyperlipidemia.
• He was treated with lisinopril, atorvastatin, and omeprazole.
ECG • Rapid supraventricular tachycardia
Blood tests
• hypomagnesemia
• hypocalcemia
• hypokalemia
Beside management of his electrolyte disturbances, which ONE of the following should be the next step?
A. Measure PTH.
B. Measure calcitonin.
C. Discontinue omeprazole.
D. Discontinue atorvastatin.
E. Measure the renin/aldosterone ratio.

History
• A 70-year-old man with recently diagnosed monoclonal Ig deposition disease is evaluated
for hyperphosphatemia.
• He began therapy with bortezomib, lenalidomide, and dexamethasone 2 days ago.
• His urine output has been normal, and he complains of fatigue.
Blood tests
• sodium of 136 mEq/L
• potassium of 4.2 mEq/L
• BUN of 25 mg/dl, creatinine of 1.3 mg/dl
• calcium of 9.1 mg/dl
• phosphorus of 6.6 mg/dl
• Normal LDH
• uric acid of 4.2 mg/dl
• leukocyte count of 4700/ml
• hemoglobin 9.6 of g/dl
• The serum IgG is 14,400 mg/dl
(reference range=600–1700 mg/dl)
• Serum free k-light chains, 1288 mg/dl
• serum free l-light chains are 2.16 mg/dl.
Which ONE of the following is the MOST likely cause of this man's hyperphosphatemia?
A. Tumor lysis syndrome
B. Decreased GFR
C. Elevated IgGk monoclonal protein
D. Rhabdomyolysis

History
• A 25-year-old woman with recurrent kidney stones.
• She reports intermittent episodes of constipation
alternating with diarrhea.
Physical
examination
• BP is 106/70 mmHg
• The remainder of the examination is normal
Blood tests
• Na 137 mEq/L
• K 3.1 mEq/L
• Cl 114 mEq/L
• HCO3 11 mEq/L
• BUN 13
mg/dl
• creatinine
1.2 mg/dl
• Venous blood gas
metabolic acidosis
Urine tests • Na 60 mEq/L
• K 50 mEq/L
• Cl 42 mEq/L. • pH 6.5
• specific gravity 1.014
Which ONE of the following is the MOST likely diagnosis?
A. Proximal RTA
B. Barium sulfide toxicity
C. Type I distal RTA
D. Toluene toxicity

Metabolic Acidosis
Calculate Anion Gap
AG
HCO3-
Cl-
Na + K
AG
HCO3-
Cl-
Na + K
Wide anion gap
Normo-cholremic
Acidosis
Na + K
AG
HCO3-
Cl-
Cl-
Normal anion gap
Hyper-cholremic
Acidosis
Corrected Anion Gap: anion gap is decreased by 2.5
mmol/l for each 1 g/dl decrease in the serum albumin
concentration below normal.
AG = (Na + K) – (Cl + HCO3) = 16 ± 4 mmol/l
AG = (Na) – (Cl + HCO3) = 12 ± 4 mmol/l

33
4- uretrosigmoid-
ostomy
Non-Anion Gap Causes
Hypercholeremic

Approved Metabolic Acidosis
Calculate Anion Gap
• a- if high anion gap → calculate delta gap
• b- if normal anion gap → calculate urinary AG

2- b- if normal anion gap → calculate urinary AG
4- uretrosigmoid-ostomy
NH4Cl

2- b- if normal anion gap → calculate urinary AG
4- uretrosigmoid-ostomy
NH4Cl
urine AG = u[Na + K] – u[Cl]
If –ve: so the loss is non renal
If zero or +ve: so the loss is renal

Thank You
drgawad@gmail.com
twitter: @Gawad_Nephro
Facebook: Doctor.Gawad
www.NephroTube.com

Electrolytes & Acid-Base Disturbance Workshop - Dr. Gawad

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