A 58-year-old man presented with confusion following a head injury from a car accident. Tests revealed hyponatremia with low serum osmolality and high urine osmolality, consistent with SIADH (syndrome of inappropriate antidiuretic hormone). SIADH was likely caused by the head injury. The man was placed on fluid restriction and his sodium levels began to rise. He improved with treatment and was discharged when his sodium levels normalized.
This document describes the case of a 28-year-old man with type 1 diabetes who presents with abdominal pain and vomiting. On examination, he is found to have diabetic ketoacidosis (DKA) with metabolic acidosis, hyperglycemia, and ketosis. His diabetes has been poorly controlled for many years, as evidenced by an HbA1c of 9.9%.
The key aspects of initial management include intravenous fluids, insulin, potassium replacement and monitoring, nasogastric intubation due to reduced consciousness, and prophylactic anticoagulation due to dehydration and immobility risks. Further workup shows chronic kidney disease stage 3 likely due to longstanding diabetic nephropathy.
Glomerular diseases in children commonly manifest as nephrotic syndrome. The nephrotic syndrome is characterized by edema, high cholesterol, low albumin, and severe protein in the urine. The most common cause is minimal-change disease, which typically responds well to corticosteroid therapy. Complications can include infections, electrolyte imbalances, and blood clotting issues. Treatment involves dietary changes, diuretics, antibiotics for infections, and corticosteroids as the primary therapy, with cytotoxic drugs used for resistant cases. Prognosis depends on the underlying histology, with minimal-change disease having a good long-term outlook in most cases.
Management of a case of post kidney transplant finalAnil Kumar Majhi
This document discusses the management of patients who have undergone kidney transplantation. It outlines the risks these patients face such as rejection, infection, and toxicity from immunosuppressant drugs. It provides guidance on pre-operative evaluation and optimization, intraoperative considerations like fluid management and choice of anesthetic drugs, and post-operative care including analgesia and monitoring of drug levels and renal function. The goal is to maintain renal perfusion and function while avoiding complications in these high-risk patients.
- A 19-year-old male student presented with pallor, easy fatigability, oliguria and a history of skin rash and joint pain diagnosed as systemic lupus erythematosus 8 years prior.
- His creatinine has gradually increased over the years and is now 11.2 mg/dl. He has been admitted for further investigation and management.
- A kidney biopsy showed lupus nephritis class IV with active lesions and chronic changes, consistent with his long history of lupus nephritis. He is being treated with steroids, immunosuppressants and other medications.
An elderly woman presented with end stage renal failure. She had a history of diabetes and hypertension for over 10 years which likely caused her kidney disease. Her labs showed severe hyperkalemia, elevated urea and creatinine, and acidosis, indicating kidney failure. She was started on hemodialysis and other treatments, but refused further dialysis and left against medical advice. Her condition deteriorated and she ultimately died of cardiac failure.
This document provides an overview of urine analysis techniques and findings related to nephrology. It discusses urine dipstick testing and issues that can affect results. It also describes urine casts, crystals, and cells that may be seen during microscopic urine examination and what different findings indicate in terms of kidney conditions and diseases. Common bacteria that cause urinary tract infections are listed. Radiologic techniques used to evaluate the kidneys are briefly outlined.
A 60-year-old female patient presented with fever, abdominal pain, and burning urination for 3 days. Medical history included diabetes and hypertension. Examination found anemia and pedal edema. Tests showed renal dysfunction and urinary tract infection. Imaging found bilateral hydroureteronephrosis. She was diagnosed with diabetic nephropathy, urinary tract infection, and chronic kidney disease. She was treated with antibiotics and underwent hemodialysis and stent placement. The document discusses renal complications of diabetes including nephropathy, papillary necrosis, and infections. It also covers evaluation and treatment of microalbuminuria.
This document discusses acute renal failure (ARF) and its causes, definitions, and classifications. It describes the key components of the nephron and how ARF results from a reduction in glomerular filtration rate (GFR). ARF can be classified as pre-renal, renal, or post-renal based on its underlying cause and pathophysiology. The most common type of renal ARF is acute tubular necrosis (ATN), which results from intrinsic injury to the renal tubules.
This document describes the case of a 28-year-old man with type 1 diabetes who presents with abdominal pain and vomiting. On examination, he is found to have diabetic ketoacidosis (DKA) with metabolic acidosis, hyperglycemia, and ketosis. His diabetes has been poorly controlled for many years, as evidenced by an HbA1c of 9.9%.
The key aspects of initial management include intravenous fluids, insulin, potassium replacement and monitoring, nasogastric intubation due to reduced consciousness, and prophylactic anticoagulation due to dehydration and immobility risks. Further workup shows chronic kidney disease stage 3 likely due to longstanding diabetic nephropathy.
Glomerular diseases in children commonly manifest as nephrotic syndrome. The nephrotic syndrome is characterized by edema, high cholesterol, low albumin, and severe protein in the urine. The most common cause is minimal-change disease, which typically responds well to corticosteroid therapy. Complications can include infections, electrolyte imbalances, and blood clotting issues. Treatment involves dietary changes, diuretics, antibiotics for infections, and corticosteroids as the primary therapy, with cytotoxic drugs used for resistant cases. Prognosis depends on the underlying histology, with minimal-change disease having a good long-term outlook in most cases.
Management of a case of post kidney transplant finalAnil Kumar Majhi
This document discusses the management of patients who have undergone kidney transplantation. It outlines the risks these patients face such as rejection, infection, and toxicity from immunosuppressant drugs. It provides guidance on pre-operative evaluation and optimization, intraoperative considerations like fluid management and choice of anesthetic drugs, and post-operative care including analgesia and monitoring of drug levels and renal function. The goal is to maintain renal perfusion and function while avoiding complications in these high-risk patients.
- A 19-year-old male student presented with pallor, easy fatigability, oliguria and a history of skin rash and joint pain diagnosed as systemic lupus erythematosus 8 years prior.
- His creatinine has gradually increased over the years and is now 11.2 mg/dl. He has been admitted for further investigation and management.
- A kidney biopsy showed lupus nephritis class IV with active lesions and chronic changes, consistent with his long history of lupus nephritis. He is being treated with steroids, immunosuppressants and other medications.
An elderly woman presented with end stage renal failure. She had a history of diabetes and hypertension for over 10 years which likely caused her kidney disease. Her labs showed severe hyperkalemia, elevated urea and creatinine, and acidosis, indicating kidney failure. She was started on hemodialysis and other treatments, but refused further dialysis and left against medical advice. Her condition deteriorated and she ultimately died of cardiac failure.
This document provides an overview of urine analysis techniques and findings related to nephrology. It discusses urine dipstick testing and issues that can affect results. It also describes urine casts, crystals, and cells that may be seen during microscopic urine examination and what different findings indicate in terms of kidney conditions and diseases. Common bacteria that cause urinary tract infections are listed. Radiologic techniques used to evaluate the kidneys are briefly outlined.
A 60-year-old female patient presented with fever, abdominal pain, and burning urination for 3 days. Medical history included diabetes and hypertension. Examination found anemia and pedal edema. Tests showed renal dysfunction and urinary tract infection. Imaging found bilateral hydroureteronephrosis. She was diagnosed with diabetic nephropathy, urinary tract infection, and chronic kidney disease. She was treated with antibiotics and underwent hemodialysis and stent placement. The document discusses renal complications of diabetes including nephropathy, papillary necrosis, and infections. It also covers evaluation and treatment of microalbuminuria.
This document discusses acute renal failure (ARF) and its causes, definitions, and classifications. It describes the key components of the nephron and how ARF results from a reduction in glomerular filtration rate (GFR). ARF can be classified as pre-renal, renal, or post-renal based on its underlying cause and pathophysiology. The most common type of renal ARF is acute tubular necrosis (ATN), which results from intrinsic injury to the renal tubules.
AKI is defined as an increase in serum creatinine concentration within 48 hours or 1.5 times the baseline within 7 days. It can be prerenal, intrinsic, or postrenal. Prerenal AKI is reversible if renal perfusion is optimized through fluid resuscitation and vasopressors. Intrinsic AKI is commonly caused by sepsis, ischemia, nephrotoxins and has a worse prognosis. Treatment focuses on treating the underlying cause, managing complications like fluid overload, and starting renal replacement therapy for severe cases.
Topics Covered:
Basic kidney physiology (just enumeration).
Manifestations of renal impairment.
AKI vs. CRF , definitions, causes and their classifications (in brief) .
Clinical evaluation of a case of renal failure.
indications for renal replacement therapy.
Approach for real-Life patient with renal impairment: group-case discussion.
This document discusses chronic kidney disease (CKD), including its classification based on glomerular filtration rate (GFR), clinical findings such as lab tests and imaging, complications, and management options. It recommends referring patients with stage 3-5 CKD to a nephrologist and considering admission for those with decompensation of CKD-related problems or those needing initiation of renal replacement therapy when unstable for outpatient care.
Chronic pancreatitis (CP) is irreversible injury to the pancreas caused by chronic inflammation and fibrosis. It commonly results from long-term heavy alcohol use or other causes like genetic mutations or obstruction of the pancreatic duct. CP leads to impairment of exocrine and endocrine pancreatic function over many years, resulting in abdominal pain, steatorrhea from fat maldigestion, diabetes, and nutritional deficiencies. Treatment focuses on pain management, pancreatic enzyme replacement, diabetes control, and nutritional support. Complications include pseudocysts, ascites, biliary or duodenal obstruction, and an increased risk of pancreatic cancer.
This document provides an overview of acute kidney injury (AKI), including definitions, causes, presentations, investigations, and management. It discusses the most common causes of AKI as being acute tubular necrosis, prerenal disease, and acute injury superimposed on chronic kidney disease. It also reviews peritoneal dialysis peritonitis and includes summaries of 6 case examples involving AKI, peritonitis, myeloma, vasculitis, and renal artery stenosis. Key points for managing renal patients are highlighted such as the importance of a baseline creatinine and treating peritonitis in a time-critical manner.
The document discusses renal failure and chronic kidney disease (CKD). It covers the functions of the kidneys, types of renal failure, causes, symptoms, complications, diagnosis and management of CKD including treatment to slow progression, dialysis options, and kidney transplantation. Risk factors, progression, and secondary issues associated with CKD such as bone disease, anemia, and cardiovascular problems are described. Dental considerations for patients with renal disease are also outlined.
This document outlines an approach to renal diseases. It begins by listing common renal syndromes such as hematuria, proteinuria, nephrotic syndrome, nephritic syndrome, and acute/chronic renal failure. It then provides details on evaluating and differentiating each syndrome, including causes, diagnostic criteria, and key laboratory findings. Kidney biopsy indications are also outlined. The document aims to guide practitioners in diagnosing and classifying renal conditions based on presenting signs, symptoms and test results.
This document discusses critical care aspects of chronic hepatic failure. It covers complications like variceal hemorrhage, refractory ascites, spontaneous bacterial peritonitis, and hepatic encephalopathy that often require ICU admission. It describes treatments for these complications including pharmacologic, endoscopic, radiologic, and surgical options. It also discusses management of portal hypertension, variceal bleeding, ascites, hepatic encephalopathy, and other issues related to caring for patients with chronic liver disease in the intensive care setting.
Anaesthesia to patiens with liver disease or a liver transplantscanFOAM
A presentation by Anna Januszkiewicz at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
1) Chronic renal failure results from the progressive deterioration of renal function due to diseases like diabetes and hypertension. It is defined as kidney damage or a glomerular filtration rate less than 60 mL/min/1.73 m2 for more than 3 months.
2) Anesthetic management of chronic renal failure patients requires special considerations due to electrolyte imbalances, unpredictable fluid status, cardiac disease, and slower drug clearance. Induction and maintenance agents must be chosen and dosed carefully to avoid large decreases in blood pressure.
3) Postoperative monitoring is important due to risks of muscle weakness from incomplete drug reversal, cardiac issues from hyperkalemia, and respiratory depression from opioid accumulation in these patients.
Chronic kidney disease is defined as kidney damage or decreased kidney function (GFR <60mL/min/1.73m^2) for more than 3 months. It is staged based on GFR from stage 1 to 5. Major causes include diabetes and hypertension. Patients experience cardiovascular, respiratory, immune, electrolyte, gastrointestinal, endocrine, hematological, neurological and acid-base abnormalities due to decreased kidney function. Anesthesia management focuses on optimizing fluid, acid-base, electrolyte and hemodynamic status as well as modifying dosages based on creatinine clearance. Regional techniques may be used but prolonged bleeding time is a contraindication.
This document discusses colonic ischemia, including its pathophysiology, risk factors, and treatment approaches. It notes that colonic ischemia is caused by reduced blood flow to the colon and can result from arterial occlusion, venous thrombosis, or mesenteric hypoperfusion. Symptoms include lower abdominal pain and bloody diarrhea. Treatment involves supportive care for mild cases, antibiotics and antithrombotics for moderate cases, and abdominal exploration for severe cases involving necrosis or gangrene. Surgical intervention may involve resection of ischemic bowel segments.
This document provides an overview of renal anatomy, physiology, and common renal disorders. It begins with the anatomy and functions of the kidney and nephron. It then discusses disorders such as acute kidney injury, chronic kidney disease, glomerular diseases including nephrotic syndrome and nephritic syndrome, and nephrolithiasis. For each condition, it outlines causes, clinical features, diagnosis, and management approaches. The document thus provides a comprehensive yet concise review of renal health and diseases.
Fulminant hepatic failure is a clinical syndrome resulting from massive liver cell necrosis or impairment. It is characterized by coagulopathy and encephalopathy that develops over less than 8 weeks. The liver loses its synthetic, excretory, and detoxifying functions. Causes include viral hepatitis, drugs like acetaminophen, and metabolic disorders. Presentation includes jaundice, fever, vomiting, and confusion. Treatment focuses on supportive care, treating complications, and sometimes liver transplantation. Prognosis depends on factors like age, etiology, and development of complications.
AKI is characterized by a sudden impairment of kidney function resulting in the retention of waste products normally cleared by the kidneys. It is diagnosed by an increase in BUN/creatinine and/or decrease in urine output. AKI can range from asymptomatic lab abnormalities to life-threatening complications. Common causes include ischemia, nephrotoxins, sepsis, surgery, and obstruction of urine flow. A careful history, physical exam, urine analysis, and consideration of potential causes are used to diagnose the type and severity of AKI.
The document discusses renal failure and chronic kidney disease (CKD). It defines acute and chronic renal failure and how they are diagnosed using estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (ACR). CKD is diagnosed if abnormalities are present for over 3 months. The document outlines management of CKD including treatment of complications like anemia, electrolyte imbalances, mineral metabolism abnormalities, and medication dosing considerations. It emphasizes regularly monitoring kidney function and adjusting medications according to glomerular filtration rate.
The document discusses several nephrology cases and questions. It includes a case of a 64-year-old man with alcoholic cirrhosis and hyponatremia admitted for confusion and lethargy. Labs show hyponatremia and the cause is determined to be hepatorenal syndrome. Another case discusses a 72-year-old man who developed acute renal failure after cardiac catheterization, with findings suggesting cholesterol embolization. The document also reviews acid-base disorders and provides mnemonics for differential diagnoses of anion gap and non-gap acidosis.
This document discusses hyponatremia and hypernatremia. It begins by explaining sodium regulation and the physiological basis of serum sodium concentration. It then defines and describes the types and causes of hyponatremia, including hypovolemic, euvolemic, and hypervolemic hyponatremia as well as pseudo hyponatremia. Specific conditions like SIADH are explained in detail. The clinical features, diagnosis, and treatment of hyponatremia are outlined. Hypernatremia is also defined and its causes such as net water loss or hypertonic sodium gain are summarized. The clinical features of hypernatremia are said to be predominantly neurologic.
AKI is defined as an increase in serum creatinine concentration within 48 hours or 1.5 times the baseline within 7 days. It can be prerenal, intrinsic, or postrenal. Prerenal AKI is reversible if renal perfusion is optimized through fluid resuscitation and vasopressors. Intrinsic AKI is commonly caused by sepsis, ischemia, nephrotoxins and has a worse prognosis. Treatment focuses on treating the underlying cause, managing complications like fluid overload, and starting renal replacement therapy for severe cases.
Topics Covered:
Basic kidney physiology (just enumeration).
Manifestations of renal impairment.
AKI vs. CRF , definitions, causes and their classifications (in brief) .
Clinical evaluation of a case of renal failure.
indications for renal replacement therapy.
Approach for real-Life patient with renal impairment: group-case discussion.
This document discusses chronic kidney disease (CKD), including its classification based on glomerular filtration rate (GFR), clinical findings such as lab tests and imaging, complications, and management options. It recommends referring patients with stage 3-5 CKD to a nephrologist and considering admission for those with decompensation of CKD-related problems or those needing initiation of renal replacement therapy when unstable for outpatient care.
Chronic pancreatitis (CP) is irreversible injury to the pancreas caused by chronic inflammation and fibrosis. It commonly results from long-term heavy alcohol use or other causes like genetic mutations or obstruction of the pancreatic duct. CP leads to impairment of exocrine and endocrine pancreatic function over many years, resulting in abdominal pain, steatorrhea from fat maldigestion, diabetes, and nutritional deficiencies. Treatment focuses on pain management, pancreatic enzyme replacement, diabetes control, and nutritional support. Complications include pseudocysts, ascites, biliary or duodenal obstruction, and an increased risk of pancreatic cancer.
This document provides an overview of acute kidney injury (AKI), including definitions, causes, presentations, investigations, and management. It discusses the most common causes of AKI as being acute tubular necrosis, prerenal disease, and acute injury superimposed on chronic kidney disease. It also reviews peritoneal dialysis peritonitis and includes summaries of 6 case examples involving AKI, peritonitis, myeloma, vasculitis, and renal artery stenosis. Key points for managing renal patients are highlighted such as the importance of a baseline creatinine and treating peritonitis in a time-critical manner.
The document discusses renal failure and chronic kidney disease (CKD). It covers the functions of the kidneys, types of renal failure, causes, symptoms, complications, diagnosis and management of CKD including treatment to slow progression, dialysis options, and kidney transplantation. Risk factors, progression, and secondary issues associated with CKD such as bone disease, anemia, and cardiovascular problems are described. Dental considerations for patients with renal disease are also outlined.
This document outlines an approach to renal diseases. It begins by listing common renal syndromes such as hematuria, proteinuria, nephrotic syndrome, nephritic syndrome, and acute/chronic renal failure. It then provides details on evaluating and differentiating each syndrome, including causes, diagnostic criteria, and key laboratory findings. Kidney biopsy indications are also outlined. The document aims to guide practitioners in diagnosing and classifying renal conditions based on presenting signs, symptoms and test results.
This document discusses critical care aspects of chronic hepatic failure. It covers complications like variceal hemorrhage, refractory ascites, spontaneous bacterial peritonitis, and hepatic encephalopathy that often require ICU admission. It describes treatments for these complications including pharmacologic, endoscopic, radiologic, and surgical options. It also discusses management of portal hypertension, variceal bleeding, ascites, hepatic encephalopathy, and other issues related to caring for patients with chronic liver disease in the intensive care setting.
Anaesthesia to patiens with liver disease or a liver transplantscanFOAM
A presentation by Anna Januszkiewicz at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
1) Chronic renal failure results from the progressive deterioration of renal function due to diseases like diabetes and hypertension. It is defined as kidney damage or a glomerular filtration rate less than 60 mL/min/1.73 m2 for more than 3 months.
2) Anesthetic management of chronic renal failure patients requires special considerations due to electrolyte imbalances, unpredictable fluid status, cardiac disease, and slower drug clearance. Induction and maintenance agents must be chosen and dosed carefully to avoid large decreases in blood pressure.
3) Postoperative monitoring is important due to risks of muscle weakness from incomplete drug reversal, cardiac issues from hyperkalemia, and respiratory depression from opioid accumulation in these patients.
Chronic kidney disease is defined as kidney damage or decreased kidney function (GFR <60mL/min/1.73m^2) for more than 3 months. It is staged based on GFR from stage 1 to 5. Major causes include diabetes and hypertension. Patients experience cardiovascular, respiratory, immune, electrolyte, gastrointestinal, endocrine, hematological, neurological and acid-base abnormalities due to decreased kidney function. Anesthesia management focuses on optimizing fluid, acid-base, electrolyte and hemodynamic status as well as modifying dosages based on creatinine clearance. Regional techniques may be used but prolonged bleeding time is a contraindication.
This document discusses colonic ischemia, including its pathophysiology, risk factors, and treatment approaches. It notes that colonic ischemia is caused by reduced blood flow to the colon and can result from arterial occlusion, venous thrombosis, or mesenteric hypoperfusion. Symptoms include lower abdominal pain and bloody diarrhea. Treatment involves supportive care for mild cases, antibiotics and antithrombotics for moderate cases, and abdominal exploration for severe cases involving necrosis or gangrene. Surgical intervention may involve resection of ischemic bowel segments.
This document provides an overview of renal anatomy, physiology, and common renal disorders. It begins with the anatomy and functions of the kidney and nephron. It then discusses disorders such as acute kidney injury, chronic kidney disease, glomerular diseases including nephrotic syndrome and nephritic syndrome, and nephrolithiasis. For each condition, it outlines causes, clinical features, diagnosis, and management approaches. The document thus provides a comprehensive yet concise review of renal health and diseases.
Fulminant hepatic failure is a clinical syndrome resulting from massive liver cell necrosis or impairment. It is characterized by coagulopathy and encephalopathy that develops over less than 8 weeks. The liver loses its synthetic, excretory, and detoxifying functions. Causes include viral hepatitis, drugs like acetaminophen, and metabolic disorders. Presentation includes jaundice, fever, vomiting, and confusion. Treatment focuses on supportive care, treating complications, and sometimes liver transplantation. Prognosis depends on factors like age, etiology, and development of complications.
AKI is characterized by a sudden impairment of kidney function resulting in the retention of waste products normally cleared by the kidneys. It is diagnosed by an increase in BUN/creatinine and/or decrease in urine output. AKI can range from asymptomatic lab abnormalities to life-threatening complications. Common causes include ischemia, nephrotoxins, sepsis, surgery, and obstruction of urine flow. A careful history, physical exam, urine analysis, and consideration of potential causes are used to diagnose the type and severity of AKI.
The document discusses renal failure and chronic kidney disease (CKD). It defines acute and chronic renal failure and how they are diagnosed using estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (ACR). CKD is diagnosed if abnormalities are present for over 3 months. The document outlines management of CKD including treatment of complications like anemia, electrolyte imbalances, mineral metabolism abnormalities, and medication dosing considerations. It emphasizes regularly monitoring kidney function and adjusting medications according to glomerular filtration rate.
The document discusses several nephrology cases and questions. It includes a case of a 64-year-old man with alcoholic cirrhosis and hyponatremia admitted for confusion and lethargy. Labs show hyponatremia and the cause is determined to be hepatorenal syndrome. Another case discusses a 72-year-old man who developed acute renal failure after cardiac catheterization, with findings suggesting cholesterol embolization. The document also reviews acid-base disorders and provides mnemonics for differential diagnoses of anion gap and non-gap acidosis.
This document discusses hyponatremia and hypernatremia. It begins by explaining sodium regulation and the physiological basis of serum sodium concentration. It then defines and describes the types and causes of hyponatremia, including hypovolemic, euvolemic, and hypervolemic hyponatremia as well as pseudo hyponatremia. Specific conditions like SIADH are explained in detail. The clinical features, diagnosis, and treatment of hyponatremia are outlined. Hypernatremia is also defined and its causes such as net water loss or hypertonic sodium gain are summarized. The clinical features of hypernatremia are said to be predominantly neurologic.
This document discusses hyponatremia and hypernatremia. It begins by explaining sodium regulation and the physiological basis of serum sodium concentration. It then defines and describes the types and causes of hyponatremia, including hypovolemic, euvolemic, and hypervolemic hyponatremia as well as pseudo hyponatremia. Specific conditions like SIADH are explained in detail. The clinical features, diagnosis, and treatment of hyponatremia are outlined. Hypernatremia is also defined and the causes of net water loss and hypertonic sodium gain are listed. The clinical features of hypernatremia are said to be predominantly neurologic.
This document discusses hyponatremia, defined as a plasma sodium concentration less than 135 mEq/L. It describes the etiology and pathogenesis of hyponatremia as being related to the kidney's inability to excrete water or excess water intake. The classification of hyponatremia includes pseudohyponatremia, hyperosmolar hyponatremia, and true hyponatremia. The treatment of hyponatremia depends on whether it is acute or chronic, symptomatic or asymptomatic, and the underlying cause. The rate of sodium correction is an important consideration to avoid complications like central pontine myelinolysis.
This document discusses the approach to hypo- and hypernatremia in neurosurgical patients in the perioperative period. It covers several key points:
1. Hyponatremia is common in neurosurgical patients and is associated with high mortality. It can be categorized based on extracellular fluid volume status. SIADH and cerebral salt wasting require different treatments.
2. Hypernatremia results from a loss of free water and can cause central nervous system dysfunction. Rapid correction poses risks like cerebral edema. The approach involves assessing volume status based on labs and symptoms.
3. Diabetes insipidus is a potential complication after pituitary or brain surgeries/injuries. It involves excessive
This document discusses guidelines for the diagnosis and management of hyponatremia according to NICE. It defines hyponatremia as a sodium level below 135 mEq/L and describes its causes including hypovolemic, hypervolemic, and euvolemic types. It outlines approaches to evaluating volume status and correcting sodium levels, noting the importance of avoiding rapid overcorrection to prevent osmotic demyelination syndrome. Treatment involves fluid restriction, hypertonic saline in severe cases, and addressing underlying causes such as SIADH. Special considerations are given for cirrhosis, adrenal insufficiency, and drug-induced hyponatremia.
A 33-year-old male presented with one week of continuous high fever and vomiting for three days. On examination, he was found to be drowsy but responsive with abdominal tenderness and swelling. Laboratory tests showed elevated pancreatic and liver enzymes indicative of acute pancreatitis. He was treated conservatively but his condition deteriorated and he eventually suffered cardiac arrest due to complications of his illness.
This document discusses a case of a 56-year-old female patient presenting with bilateral lower leg cellulitis and hyponatremia. She has a history of epilepsy, intellectual disability, and is on multiple medications including Moduretic. Initial workup found sodium of 118 mmol/L. She was started on IV saline and diuretics. Carbamazepine was identified as a potential cause of drug-induced hyponatremia and was replaced with levetiracetam. She was discharged on frequent sodium monitoring. The document then reviews hyponatremia causes, presentation, evaluation, and treatment considerations including the risk of rapid correction.
Hyponatremia is the most common electrolyte abnormality seen in hospitalized patients. It is caused by an imbalance of water in the body, resulting in a dilution of sodium concentration. The document discusses the various types of hyponatremia (hypovolemic, euvolemic, hypervolemic) based on extracellular fluid volume status and their underlying causes such as SIADH, heart failure, liver cirrhosis. It also covers the diagnostic evaluation, management principles, and treatment approaches for acute symptomatic and chronic hyponatremia which involves slow correction of sodium levels to avoid osmotic demyelination syndrome.
This document discusses hyponatremia (low sodium levels in blood). It defines hyponatremia as a serum sodium level less than 135 mmol/L. The document outlines the major causes of hyponatremia including syndrome of inappropriate antidiuretic hormone secretion (SIADH), heart failure, liver cirrhosis, and hypothyroidism. It emphasizes the importance of slowly correcting sodium levels in patients with chronic hyponatremia to avoid osmotic demyelination syndrome, a serious neurological complication. The document recommends increasing sodium no more than 12 mmol/L over 24 hours or 18 mmol/L over 48 hours for safe correction.
This document discusses the approach to a patient presenting with hyponatremia. It begins by outlining the clinical scenario of a 74-year-old man with recent gastroenteritis, fatigue, headache and a sodium level of 118. It then provides definitions and discusses evaluating hyponatremia by assessing serum osmolality, urine osmolality and volume status. Based on these factors, the patient's hyponatremia is likely due to volume depletion from gastroenteritis. The document concludes by stating the patient should be treated slowly with isotonic saline given mild symptoms, but more rapid correction with hypertonic saline would be needed if seizures were present.
Sodium homeostasis and the regulation of serum sodium concentration is essential for normal physiological functioning. Hyponatremia occurs when there is a relative excess of water compared to sodium, decreasing the plasma sodium concentration below 135 mmol/L. It can be hypo-osmolar, euvolemic, or hypervolemic depending on water and sodium levels. Treatment involves correcting the underlying cause, restricting water intake, and sometimes using hypertonic saline or vaptans. Rapid correction of sodium levels can have neurological consequences, so changes should be gradual. Hypernatremia is less common but also dangerous, defined as a sodium level over 145 mmol/L.
This document discusses several oncologic emergencies including hypercalcemia, hyponatremia, superior vena cava syndrome, and malignant pericardial effusion. Hypercalcemia is one of the most common oncologic emergencies and can be caused by parathyroid hormone-related peptide or vitamin D overproduction from tumors. Treatment involves intravenous fluids and bisphosphonates. Hyponatremia is also common in cancer patients, often due to inappropriate antidiuretic hormone secretion, and requires fluid restriction or saline infusion depending on symptoms. Superior vena cava syndrome occurs when the superior vena cava is compressed by tumors and causes edema, and stenting or radiation are treatments.
Hyponatremia, defined as a plasma sodium concentration below 135 mM, is a common electrolyte disorder seen in up to 22% of hospitalized patients. It is usually caused by water retention due to increased secretion of antidiuretic hormone (ADH) and/or increased renal sensitivity to ADH combined with free water intake. Hyponatremia can be categorized as hypovolemic, euvolemic, or hypervolemic based on clinical history and volume status. Treatment involves correcting the underlying cause and raising the plasma sodium concentration slowly to avoid complications like osmotic demyelination syndrome which can result from overly rapid correction.
This case report describes a 13-year-old male who presented with severe urosepsis and acute kidney injury requiring acute haemodialysis. Following haemodialysis, the patient experienced dialysis disequilibrium syndrome (DDS), becoming hypotensive with loss of brainstem reflexes. A CT scan showed generalized cerebral edema consistent with DDS. DDS is a neurological complication of haemodialysis caused by a shift of water into the brain due to rapid changes in osmolality. Prevention through gradual urea reduction via low efficiency dialysis is important to manage DDS risk, especially in high risk patients like this pediatric case.
This document provides information on various metabolic emergencies that oncologists may encounter, including tumour lysis syndrome, hyponatremia, hypercalcemia, lactic acidosis, and hyperammonia. It focuses on sodium disorders and discusses hyponatremia and hypernatremia in depth. Hyponatremia is a common condition in cancer patients that can be caused by the disease, medications, or comorbidities. It outlines approaches for screening, diagnosis, classification, and management of hyponatremia depending on the severity and chronicity of the low sodium levels. Rapid correction of sodium is important in acute severe cases to avoid neurological complications.
Hyponatremia is defined as a low serum sodium concentration and can be acute (<48 hours) or chronic (>48 hours). It is clinically important because acute severe hyponatremia can cause morbidity and mortality, and adverse outcomes are higher in hyponatremic patients. Overly rapid correction of chronic hyponatremia can cause severe neurological deficits or death. Hyponatremia can be hypervolemic, hypovolemic, or euvolemic based on water and sodium levels. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a common cause of euvolemic hyponatremia and results from excess vasopressin secretion. Treatment depends on
This document provides an overview of sodium disorders, including definitions, classifications, approaches, etiologies, and treatments. It discusses hyponatremia and hypernatremia. Hyponatremia is classified based on sodium level, onset, volume status, and osmolality. Treatment depends on factors like underlying cause, symptoms, and chronicity. Rapid correction of sodium levels can cause osmotic demyelination syndrome. Hypernatremia treatment involves slow correction based on calculated water deficit to avoid neurological issues. The document also presents three case studies and guidelines for evaluating and managing different sodium disorder presentations.
This document discusses sepsis, acute kidney injury (AKI), and their recommended treatment. It begins with definitions of sepsis, septic shock, and lactic acidosis. It then discusses recommended treatment for severe sepsis patients, including antimicrobial therapy, fluid therapy, vasopressor therapy, corticosteroids, and managing AKI. Specific goals for fluid resuscitation in the first 6 hours are provided. The document also discusses oliguria, RIFLE criteria, and epidemiology of AKI in critically ill patients.
This document discusses fluid and electrolytes in the human body. It provides information on:
- Water content and distribution in the body
- Distribution of electrolytes like sodium, potassium, calcium, and magnesium between intracellular, interstitial, and intravascular fluid compartments
- Daily water requirements
- Causes, signs, and treatments of electrolyte abnormalities like hyponatremia, hypernatremia, hypokalemia, hyperkalemia, hypocalcemia, and hypercalcemia.
Side effects of commonly prescribed drugs:
Diuretics
NSAIDs.
Antiplatelet.
Corticosteroids.
Drug induced Hemolytic Anemia.
Lipid lowering agents.
Anticoagulants
Iron
Bone marrow transplantation involves replacing a patient's damaged or diseased bone marrow with healthy stem cells from bone marrow. It treats conditions such as leukemia, lymphoma, aplastic anemia, and others. The procedure requires a conditioning process using chemotherapy and/or radiation to prepare the body for the transplant, followed by infusion of the donor's stem cells and a recovery period requiring close monitoring for complications like infection and graft-versus-host disease.
1) The document discusses various medical conditions and topics related to integrated medicine including hemarthrosis, sickle cell ulcer, thalassemic facies, differential diagnoses, deep vein thrombosis, and bleeding gums.
2) It also covers strawberry tongue in scarlet fever patients with compromised immunity, jaundice, cyanosis, lymph node groups, Virchow's node, and generalized lymphadenopathy in immune-compromised patients.
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Case 23 A 58-year-old type II diabetic with
confusion and hyponatraemia
Mr Sanjay Singh is a 58-year-old type II diabetic. He is
admitted following a road traffic accident with a head injury
and fractured tibia and fibula. Glasgow Coma Score (GCS)
on admission was 15 and a CT head did not show any
obvious fracture, haematoma or contusion. His lower limb
fractures are fixed in plaster of Paris (POP) and he is
admitted for observation and analgesia.
Bloods on admission are shown below.
Na 135mmol/L, K 4.0mmol/L, Urea 7.3mmol/L, Creatinine
112μmol/L, Glc 6.8mmol/L
Hb 15.8g/dL, WBC 5.7 × 109
/L, Platelets 230 × 109
/L
He is seen on ward round the next day and a plan is made
to discharge him later in the day. Unfortunately, he becomes
increasingly confused during the afternoon. His temperature
is 38o
C, pulse 90bpm, BP 145/85mmHg and JVP is visible.
He has no peripheral oedema. O2 saturations are 93% on air
and there are some crackles at the right base. There are no
focal neurological signs. Repeat bloods are shown below
and Mr Singh’s drug chart is shown in Figure 23.1.
Na 125mmol/L, K 3.8mmol/L, Urea 5.7mmol/L, Creatinine
108μmol/L, Glc 10.6mmol/L
Hb 15.5g/dL, WBC 6.2 × 109
/L, Platelets 353 × 109
/L
What is the most likely cause of
Mr Singh’s hyponatraemia?
The causes of hyponatraemia are summarised in Box
23.1. Mr Singh’s hyponatraemia is acute and he is not
obviously oedematous, fluid overloaded or dehydrated
(thus CCF, nephrosis, cirrhosis and diarrhoea are unlikely
to be the cause of his hyponatraemia). He is not on any
medications, particularly diuretics, which might directly
affect renal salt handling. We are not told anything about
Mr Singh’s fluid replacement regimen, therefore if he has
been given an excess of 5% dextrose in the past 36 hours,
this may have caused hyponatraemia. However, given
all of the above exclusions, the most likely diagnosis is
the syndrome of inappropriate antidiuretic hormone
(SIADH).
Review of Mr Singh’s fluid charts shows that he has had
free oral intake but no intravenous fluids.
What investigations would you
undertake to confirm the diagnosis
of syndrome of inappropriate
antidiuretic hormone?
Serum and urine osmolalities should be measured.
Plasma osmolality is usually kept within a tight range. In
SIADH there is dilute plasma with osmolalities of
<260mmol/kg and inappropriately concentrated urine
with urine osmolalities of >500mmol/kg. Urinary
sodium levels are usually >20mmol/L.
Mr Singh’s urine osmolality is 549mosmol/kg and his serum
osmolality is 258 mosmol/kg, confirming the diagnosis of
SIADH.
What is the likely cause of syndrome of
inappropriate antidiuretic hormone in
Mr Singh’s case?
Syndrome of inappropriate antidiuretic hormone can be
caused by many pathologies, as summarised in Box 23.2.
In this particular case, it is most likely to be due to head
injury. However, there may be other contributory fea-
tures. His examination findings suggest the possibility of
a right basal pneumonia (febrile, crackles at right base).
In addition, he has been given opiates for his pain and is
receiving chlorpropamide (see drug chart in Figure 23.1).
Where is antidiuretic hormone produced
and what are its actions?
Antidiuretic hormone (ADH, also known as vasopressin)
is produced in the hypothalamus, stored in vesicles in the
Nephrology: Clinical Cases Uncovered. By M. Clatworthy.
Published 2010 by Blackwell Publishing.
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SANJAY
MRC BEECH
20/6/50
ASPIRIN
75mg
10mg
250mg
Ti
P0
P0
P0
P0
22/10
22/10
22/10
22/10
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ATORvASTATIN
CHLORPROPAMIDE
COPROXAMOL
22/10 ul
M
A30694
Surname
First names
Consultant
Date of birth Sex
Ward
Weight
Height
Date Drug/substance
Drug sensitivities
Regular prescriptions
Month and date
Tick times or enter other times
1. Drug (approved name)
2. Drug (approved name)
3. Drug (approved name)
4. Drug (approved name)
5. Drug (approved name)
6. Drug (approved name)
Dose Route Start date Stop date
Dose Route Start date Stop date
Dose Route Start date Stop date
Dose Route Start date Stop date
Pharm
6
8
12
14
18
22
6
8
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14
18
22
6
8
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18
22
6
8
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18
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6
8
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6
8
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14
18
22
Pharm
Signature:
Bleep no.:
Signature:
Bleep no.:
Pharm
Signature:
Bleep no.:
Pharm
Signature:
Bleep no.:
Dose Route Start date Stop date
Pharm
Signature:
Bleep no.:
Additional instructions
Additional instructions
Additional instructions
Additional instructions
Additional instructions
Dose Route Start date Stop date
Pharm
Signature:
Bleep no.:
Additional instructions
Doctor must enter this information on FRONT of case folder
Signature
Hospital No.
Prescription chart
Figure 23.1 Mr Singh’s prescription chart.
3. Case 23 161
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Antidiuretic hormone causes a more concentrated
urine to be produced by increasing the permeability to
water of the distal convoluted tubule and collecting
ducts, thus allowing an increase in water reabsorption
down the osmotic gradients set up by the loop of Henle.
This results in the excretion of a smaller volume of more
concentrated urine – antidiuresis.
Antidiuretic hormone increases permeability via the
insertion of additional water channels (aquaporin-2)
into the apical membrane of the tubules/collecting duct
epithelial cells. This is achieved through the action of
ADH on V2 receptors, G protein-coupled receptors on
the basolateral membrane of cells lining the distal con-
voluted tubules and conducting ducts.Following binding,
the G protein triggers the cAMP cascade which triggers
the insertion of aquaporin-2 water pores by exocytosis of
storage vesicles. The aquaporins then allow water to pass
out of the distal convoluted tubules and the conducting
tubules into the interstitium and back into the blood,
increasing the concentration of urine and expanding
blood volume.
Antidiuretic hormone also increases peripheral vascu-
lar resistance and thus mean arterial blood pressure. This
effect appears small in healthy individuals but may be an
important compensatory mechanism for restoring blood
pressure in hypovolaemic shock.
Antidiuretic hormone also has a number of actions
locally in the brain including:
• memory formation
• maintenance of circadian rhythm
• control of aggressive behaviour.
How would you manage
this patient?
The main management of SIADH is to restrict fluid
intake to 0.5–1L per day. This is usually in the form of
normal saline, if IV fluids are used (NB: normal (0.9%)
saline contains approximately 150mmol/L of Na). Occa-
sionally hypertonic saline is given but this requires
careful management to avoid a rapid increase in sodium
levels. The aim is to bring the sodium up by no more
than 5mmol/day. Severe cases may require the use of
demeclocycline, an agent which causes nephrogenic dia-
betes insipidus, i.e. it makes the collecting tubules insen-
sitive to the actions of ADH.
More recently, a new class of drugs has become
available in the form of specific V2 antagonists, for
example tolvaptan and satavaptan, which may be useful
in SIADH.
Box 23.1 Causes of hyponatraemia
• Inappropriate water retention – SIADH. Urine osmolality
is usually >500mosmol/kg (inappropriately concentrated
when compared with serum osmolality which tends to
be <260mosmol/kg)
• Excess water intake
䊊 Psychogenic polydipsia
䊊 Inappropriate IV fluids
• Combined Na + water retention with an excess of water
䊊 Congestive cardiac failure (CCF)
䊊 Nephrotic syndrome
䊊 Cirrhosis
• Salt loss
䊊 Renal: diuretics, Addison’s disease, salt-losing
nephropathy
䊊 GI: diarrhoea, villous adenoma
• Pseudohyponatraemia
䊊 Hypercholesterolaemia
䊊 Hyperproteinaemia
Box 23.2 Causes of SIADH
• Malignancy
䊊 Pancreatic cancer
䊊 Lymphoma
䊊 Small cell carcinoma of the lung
䊊 Prostate cancer
• CNS/neurological disorders
䊊 Abscess
䊊 Meningoencephalitis
䊊 Subarachnoid/subdural haemorrhage
䊊 Head injury
䊊 Guillain–Barré syndrome
• Pulmonary disorders
䊊 TB
䊊 Pneumonia
䊊 Pulmonary abscess/empyema
䊊 Aspergillosis
• Metabolic causes
䊊 Porphyria
• Drugs
䊊 Chlorpropamide
䊊 Opiates
䊊 Cytotoxins
䊊 Chlorpromazine
posterior pituitary and released in response to rising
plasma osmolality or a reduction in plasma volume/pres-
sure. Its main action is on the kidneys, causing water
retention and thus a more concentrated urine to be pro-
duced (as its name suggests).
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Why is important not to correct
hyponatraemia too quickly?
If plasma Na+ is corrected too quickly then central
pontine myelinolysis (CPM) can occur, where neurones
in the pontine region become demyelinated. This is
thought to be due to rapid fluid shifts out of the brain in
response to large increases in plasma sodium. Patients
rapidly develop para- or quadraparesis, dysphagia, dys-
arthria, diplopia and loss of consciousness. Diagnosis
is by clinical features and MRI (showing a high signal in
the pons).
Aim to correct plasma sodium by 5mmol/L/24h.
Maximum correction 8mmol/L/24h. Reports of CPM
have occurred where Na has risen by >10mmol/
L/24h.
Mr Singh is placed on a 1000mL fluid restriction over the
next 4 days. A chest X-ray confirms a likely right basal
Table 23.1 Causes of hypontraemia according to volume
status and urine Na excretion
Hypovolaemia Euvolaemia/
hypervolaemia
Urine Na+
>20mM Diuretics
Hypoadrenalism /
Addison’s
SIADH
Hypothyroidism
Chronic renal failure
Urine Na+
<20 mM Vomiting
Diarrhoea
LVF
Cirrhosis
Nephrotic syndrome
CASE REVIEW
A 58-year-old type II diabetic is admitted following an
accident. Over the next 36 hours he becomes confused.
Investigations show significant hyponatraemia (Na
125mmol/L), reduced serum osmolality and increased
urine osmolality in keeping with a diagnosis of SIADH.
This has probably been caused by the head injury sustained
during the accident. He is fluid restricted to 1L in 24 hours
and his sodium begins to rise. He improves rapidly and is
discharged 5 days later with a sodium of 136mmol/L.
KEY POINTS
• Mild hyponatraemia is common and usually asymptomatic.
If the sodium falls to around 120mmol/L then there is
often restlessness, irritability and confusion. Sodium levels
of <110mmol/L lead to progressive coma and seizures.
• Hyponatraemia occurs if there is too little sodium, too
much water or both.
• When assessing the cause of hyponatraemia, it is
important to establish the volume status of the patient.
• If the patient is hypovolaemic then hyponatraemia may be
caused by diuretics, hypoadrenalism, salt-wasting
nephropathy (see Table 23.1).
• If the patient is euvolaemic or fluid overloaded then
hyponatraemia may be due to SIADH, chronic renal
failure, LVF, cirrhosis or nephrotic syndrome (see
Table 23.1).
• In SIADH, typical findings are:
䊊 Na <125mmol/L
䊊 patient is normovolaemic
䊊 urinary Na >20mmol/L
䊊 plasma osmo <260mosmol/kg
䊊 urinary osmo >500mosmol/kg.
• Syndrome of inappropriate antidiuretic hormone may be
caused by intracranial pathology such as head injury or
infection, pulmonary pathologies including pneumonia,
malignancies and drugs (particularly chlorpropamide and
chlorpromazine).
• Treatment of SIADH is with fluid restriction. The aim
should be to bring the sodium up slowly in order to avoid
central pontine myelinolysis.
pneumonia and he is therefore commenced on appropriate
antibiotic therapy. His sodium rises from 125 to 129mmol/L
on day 1, to 132mmol/L on day 2 and to 136mmol/L by
day 3. He is finally discharged on oral antibiotics on day 6.