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Les deux ennemis > Nephro : Acid-Base and E+ > Flashcards

Nephro : Acid-Base and E+ Flashcards

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1
Q

ECK and hyperkaliemia, how’s :
The t wave
The ps
The PR
The QRS
The rythm

A

Peaker T waves
Flattened Ps
Prolonged PR
Brady - arrythmias
Prolonged QRS

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2
Q

Ethanol : AGMA or N - AGMA ?

A

NAGMA

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3
Q

How are HCO3 in RTA ?

A

Type 1 : may be < 10
Type 2 : 12 - 20
Type 4 : > 17

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4
Q

How can you differentiate Barter and Gitleman’s syndrome?

A

Barter : HIGH calcium in urine + low calcium in plama
Gitleman : LOW calcium in urine

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5
Q

How do you adjust the anion gap ?

A

Every decrease in albumin by 10, add 2.5 mEq/L to the AG

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6
Q

How do you calculate TBW?

A

0.5 x Kg for female
0.6 x Kg for male

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7
Q

How do you correct hypernatremia ?

A

PO WATER or D5 petit débit
If TNG, water flushed
Large volumes of D5 : hyperglycemia : glucosuria and a solute diuresis, worsening polyuria and hypernatremia

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8
Q

How do you diagnose diabetes insipidus ?

A

Hypernatremia with inappropriately LOW urine osmolality (Uosm < Sosm)
** serum Osm > 295 and Na > 145 **
Water deprivation test : urine osm does not rise appropriately despite rising serum osmolality / serum Na (usually not needed)

Then use DDAVP (2-4 mg IV/SC) test to differentiate between central and nephrogenic

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9
Q

How do you interpret delta delta gap ?

A

∆AG&raquo_space;∆HCO3 : >2, bicarb doesn’t change enough, meaning a secondary alkalosis is opposing the acidosis Concurrent Metabolic alkalosis (HCO3 higher than expected) with anion gap metabolic acidosis

∆HCO3 ≈∆AG : 0.8-2, Pure AG acidosis

∆AG &laquo_space;∆HCO3 : <0.8, Bicarb changes more than expected, meaning a secondary acidosis is present
Concurrent non AG metabolic acidosis (with HCO3 lower than expected) with high AG acidosis

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10
Q

How do you use urinary anion gap in NAGMA ?

A

UAG &laquo_space;0 : NH4 excretion high : GI HCO3 loss (diarrhea), pancreatic fistula, NJ tube
UAG > 0 : RTA

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11
Q

How does K change depending on high / low insuline ?

A

Low insuline : hyperkaliemia
High insuline : hypokaliemia

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12
Q

How is renin / aldo in Barrter, Gitleman, Liddle ?

A

High renin and high aldo in Barrter and Gitleman
Low renin and low aldo in Liddle

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13
Q

How is the K in acidosis metabolic ?

A

Hyperkaliemia

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14
Q

How is the K in metabolic alcalosis ?

A

Hypokaliemia

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15
Q

How is the urine pH in RTA ?

A

Type I : > 5.5, calcium phosphate stones
Type II : low, can still acidify urine
Type IV : variable

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16
Q

How is water deprivation test used in hypernatremia ?

A

To diagnose diabetes insipidus but usually not needed
Urine osm does not rise appripriately despite rising serum osmolality / serum Na

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17
Q

How much Na in hypertonic saline 3% ?

A

513

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18
Q

How much Na in LR ?

A

130

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19
Q

How much Na in NS ?

A

154

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20
Q

How to avoid over correction of hyponatremia ?

A

If urine output exceeds 150 ml/h page MD
If overcorrected : DDAVP, D5W

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21
Q

Hypernatremia : how do you calculate water deficit ?

A

Water deficit : % change in (Na) x TBW
% change in Na : (serum Na - 140) / 140

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22
Q

If hyponatremia severe and symptomatic, how much would you increase your Na immediately ?

A

By 4-5 mmol/L immediately

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23
Q

In organic alcohol intoxications, how can the osmolar gap and anion gap exist at different times ?

A

Early on : osmolar gap without anion gap
Later : anion gap without osmolar gap

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24
Q

Isopropyl alcohol, AGMA or NAGMA ?

A

NAGMA

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25
Mangement of a hypovolemic patient presenting with hyponatremia?
NS or LR 1ml/kg/hr Ex: pt onco avec Vo +++ 50 cc/LR avec contrôle dans 4h
26
Mannitol and sorbitol, AGMA or NAGMA ?
NAGMA
27
Metabolic alcalosis : how do you do the DDX ?
With urine Cl <25 or > 25 If < 25 will be chloride/NS responsive If > 25 will not be chloride/NS responsive
28
Metabolic alcalosis and urine Cl < 25, DDX ?
Will be chloride/NS responsive - GI loss (NG tube, villous adenoma, chloride diarrhea) - Renal loss (diuretics) - Sweating (cystic fibrosis)
29
What are causes of acute hypokalemia caused by shifting ?
Endocrine : +++ insulin, thyrotoxic periodic paralysis Stress : ++ catecholamines Metabolic alcalosis ROH withdrawal Hypothermia Amphetamines
30
What are drugs that cause hyperkalemia ?
NSAIDS, ACEi/ARB, MRAs
31
What are precautions to consider when prescribing kayexalate ? What about the electrolytes?
Caution if GI obstruction, risk of hypoCa and hypoMg also Associated with cases of colonic necrosis, bleeding, ischemic colitis, perforation
32
What are some unusual causes of hyperkaliemia ?
Hypoaldosteronism : adrenal insufficiency, RTA type 4 Cell lysis (TLS, acidosis, low insuline) Metabolic acidosis, low insulin Hyperosmolarity (glucose, mannitol)
33
What are the causes of a NAGMA with UAG << 0 ?
GI HCO3 loss (diarrhea) Pancreatic fistula NJ tube NEGUTIVE : the gut
34
What are the causes of anion gap metabolic acidosis ?
GOLDMARK Glycols Oxoproline (organic acid) (consider if unexplained AGMA in setting of chronic acetaminophen use 3-4g/d even, causes excess oxoproline) Lactate D Lactates Methanol ASA Renal failure Ketones Also : pregnancy, vegan, malnutrition
35
What are the causes of chronic hypokalemia with low urine K < 20 ?
Diarrhea, laxatives, villous adenoma
36
What are the causes of hypertonic hyponatremia ?
Hyperglycemia Mannitol Immunoglobulins IvIg sOSM > 295
37
What are the causes of increased osmolar gap ?
AGMA : Organic alcohol poisoning (methanol, ethylene glycol) Paraldehyde Ketoacidosis (EtOH + db) Lactic acidosis Severe CKD No metabolic acidosis : Ethanol Isopropyl alcohol Mannitol Sorbitol * pseudohypoNa * early toxic alcohol
38
What are the causes of nephrogenic DI ?
Lithium, hypercalcemia, hereditary, resolution of obstructive nephropathy
39
What are the causes of SIADH ? What are the typical rx?
No/Vo, pain, pneumonia / lung infections, adrenal insufficiency, CNS disorders DRUGS : SSRIs, carbamazepine, thiazides, TCAs
40
What are the ECG changes seen in hypokaliemia ?
PR prolongation TWI ST depressions U waves
41
What are the situations where you can correct quickly hypernatremia ?
Rare, acute setting : post op central DI, nephrogenic DI for exemple
42
What are the specific labs and how do you treat hyponatremia in case of pancreatitis ?
Uosm > 300 and Una < 25 Fluid resuscitation NS/LR 1ml/kg/hr
43
What are the three potassium binders ?
1) Lokelma / ZS 9 ($$$, exchanges Na and H+ for K in GI tract, drop of K within 2-4 hours, stop if K around 4, safe in CKD) 2) Patiromer (bind K in the colon) 3) Kayexalate (exchange Na in stomach for H which is then exchanged in colon for K)
44
What are the typical labs of a Barter ? How will be the electrolytes ?
Metabolic alkalosis with urine Cl > 25 and low BP Mimics loops : low K and low Mg
45
What are the typical labs of a Gittleman ? How will be the electrolytes ?
Metabolic alcalosis with urine Cl > 25 and low BP Mimics thiazides : low K, low Na, HIGH!! Ca
46
What causes pseudohyponatremia ?
ISOTONIC hyponatremia 280-295 Hypertriglyceridemia Paraproteinemia (MM) Obstruction jaundice vs hypertonic hyponatremia: hyperglycemia, mannitol, immunoglobulins
47
What is a high urine osmolality in context of hyponatremia?
> 300
48
What is a low urine osmolality in context of hyponatremia?
< 200
49
What is the acceptable change in Na per day for chronic hyponatremia?
Target 6, max 8 If any risk factor : target 4, max 6
50
What is the anion gap formula ?
Na - Cl - HCO3 Adjust for albumin (every decrease in albumin by 10, add 2.5 mEa/L to the AG) NACHOS
51
What is the compensation for metabolic acid/base disorders ?
Metabolic acidosis 1:~1 (↓HCO3:↓CO2) Metabolic alkalosis 1:0.7 (↑ HCO3 : ↑ CO2)
52
What is the compensation for respiratory acid/base disorders ?
-Respiratory Alkalosis (↓ CO2 : ↓ HCO3). Chronic (10:4-5) / Acute (10:2) -Respiratory Acidosis (↑ CO2 : ↑ HCO3). Chronic (10: 3-4)/ Acute (10:1)
53
What is the compensation in case of respiratory acidosis ?
-Respiratory Acidosis (↑ CO2 : ↑ HCO3). Chronic (10: 3-4)/ Acute (10:1)
54
What is the compensation in case of respiratory alkalosis ?
-Respiratory Alkalosis (↓ CO2 : ↓ HCO3). Chronic (10:4-5) / Acute (10:2)
55
What is the DDX of chronic hypokalemia with Urine K > 20 + metabolic alcalosis + HTA ?
Low renin / Low aldo : cushing, liddle, florinefm steroids, licorice High Renin / High aldo : RAS / reninoma Low Renin / high Aldo : adrenal problem such as Conns
56
What is the DDX of chronic hypokalemia with Urine K > 20 + metabolic alcalosis + low or normal BP ?
Check URINE CL If < 20 : vomiting or intermittent diuretic use If > 20 : Barrter or Gitelman or recent diuretic use
57
What is the DDX of chronic hypokaliemia with urine K > 20 ?
1) URINE lytes : renal loss if urine K > 20 2) Met acidosis or Met alkalosis If met acidosis : type 1 or 2 RTA If met alcalosis : step 3 Low/normal BP : check URINE CHLORIDE HTA : check RENIN AND ALDOSTERONE
58
What is the DDX of hyponatremia with high Uosm = ADH on ?
If Una < 25 : appropriate ADH secretion - True hypovolemia - Decreased effective circulating volume (CHF, cirrhosis, hypoalbuminemia) If Una > 40 : inappropriate ADH secretion - SIADH
59
What is the DDX of hyponatrmia and U osm < 200 ?
ADH is appropriately off - Polydipsia (typicalle Uosm < 100) - Beer potomania / tea and toaster : low solute diet (Uosm 100-300) - Iatrogenic : IV D5
60
What is the DDX of metabolic alcalosis with urine Cl > 25 ?
Will not be chloride/NS responsive - HIGH BP : Hyperaldosterone (HTN, hypoK, alkalosis, HIGH aldo) Liddle’s (htn, hypoK, alkalosis, LOW aldo) Cushings - LOW BP Barter’s (mimics loops : low k and low Mg) Gittleman’s (mimics thiazides : low K, low Na, low Ca) - Excess bicarb ingestion
61
What is the DDX of metabolic alcalosis with Urine Cl > 25 and high BP ?
• Hyperaldosterone (htn, hypoK, alkalosis, high aldo) • Liddle’s (htn, hypoK, alkalosis, low aldo) • Cushings
62
What is the DDX of metabolic alcalosis with Urine Cl > 25 and low BP ?
• Barter’s (mimics Loops – low K, low Mg) • Gittleman’s (mimics thiazides – low K, low Na, high Ca)
63
What is the definition of acute hyponatremia ?
Acute < 48hours (documented sodium)
64
What is the formula of urinary anion gap ?
Urine Na + Urine K - Urine Cl
65
What is the hyponatremia correction formula ?
Volume infusate to give : TBW x (desired Na - serum Na) / Na infusate TBW : kg x 0.5 if female / 0.6 if male Infusate : Hypertonic saline 3% : 513 mmol/L Na Normal saline 0.9% : 154 Ringers Lactates : 130
66
What is the pathophysio and causes of RTA type I ?
DISTAL : decrease in H+ excretion CTD (Sjogren +++, RA, SLE), hypercalciuria, drugs
67
What is the pathophysio and causes of RTA type II ?
PROXIMAL : decrease in bicarb reabsorption Fanconi’s, myeloma, acetazolamide, tenofovir
68
What is the pathophysio and causes of RTA type IV ?
Hypoaldo state + impaired urinary ammonium excretion Drugs (aldosterone antag, RAAs blockers, calcineurin inh) Adrenal insufficiency, diabetes
69
What is the rate of Na correction in case of chronic hypernatremia ?
max 0.5 mmol/L per hour or 12 over 24 h to avoid cerebral edema
70
What is the response to DDAVP in context of DI ?
If central DI : responds, Uosm will increase by 50 % and urine output will decrease If complete nephro DI : no change (polydipsia with hypoNa : no change either or < 10 %)
71
What is the risk of correction too rapidly hyponatremia ?
Osmotic demyelination RF : hypoK, malnutrition, ROH, liver disease, low starting Na
72
What is the treatment of Barrter and Gitleman’s syndrome ?
K, Mg replacement K sparing diuretics RASi NSAIDS
73
What is the treatment of hyponatremia in the dialysis population ?
FLUID restriction They’re drinking too much water
74
What is the treatment of hyponatremia with low urine Osm ?
Fluid restrict, salt/urea tabs
75
What is the treatment of Liddle’s ?
Amiloride
76
What is the treatment of RTA type I and type II ?
NaHCO3 K citrate (for type 1, only if K low)
77
What is the treatment of RTA type IV ?
Low BP : florinef HTN : thiazide
78
What is the treatment of SIADH ?
Fluid restriction Salt tablets 1g BID / TID Urea 15 mmol BID
79
What is toxic in antifreeze ?
Ethylene glycol
80
What labs should you ask for in case of hyponatremia ?
Obtain Uosm, Sosm, Una. Stop thiazides
81
What RTA have a low serum potassium ?
Type 1 severely low Type 2 low Type 4 high or high normal
82
What should be considered as a cause of unexplained AGMA in setting of chronic acetaminophen use ?
Can deplete glutathione = lose –ve feedback on cycle = excess Oxoproline (pyroglutamic acid) Exacerbated by renal failure
83
What will be the Urine Osm in case of hyponatremia caused by beer potomania ?
Usom 100-300, appropriately low
84
What will be the Urine Osm in case of hyponatremia caused by polydipsia ?
typically < 100, appropriately off
85
What will be the Urine Osm in case of hyponatremia caused by tea and toast ?
100-300, appropriately low
86
What’s a normal osmolar gap ?
10
87
What’s an isotonic plama osmolality ?
280-295
88
What’s the delta delta formula?
ΔAG (12-AG):Δbicarb(24-bicarb)
89
What’s the osmol gap formula?
[calculated osm: 2xNa + Gluc + BUN] – [serum measured osm] 2 SALTS AND A STICKY BUN
90
When is hypokaliema an emergency ?
Respiratory muscle weakness Arrythmias
91
When should you think of adrenal problem such as Conns in case of chronic hypokaliemia ?
Urine K > 20 Metabolic alcalosis HTA Low renin / high aldo
92
When should you think of Barrter in case of chronic hypokaliemia ?
Urine K > 20 Met alcalosis Normal or low BP Urine Cl > 20
93
When should you think of Cushing in case of chronic hypokaliemia ?
Urine K > 20 Met alcalosis HTA Low renin / low aldo
94
When should you think of Gitelman in case of chronic hypokaliemia ?
Renal K > 20 Met alcalosis Normal or low BP Urine Cl > 20
95
When should you think of Liddles in case of chronic hypokaliemia ?
Urine K > 20 Met alcalosis HTA Low renin / low aldo
96
When should you think of RAS/reninoma in case of chronic hypokaliemia ?
Urine K > 20 Metabolic alcalosis HTA High renin / high aldo
97
When should you think of villous adenoma in case of chronic hypokaliemia ?
Low urine K 20 : extra renal
98
When should you think of vomiting in case of chronic hypokaliemia ?
URINE K > 20 Met alcalosis Normal or low BP Urine Cl < 20-25 Caused by diarrhea, laxatives or villous adenoma if UK < 20
99
Where is the defect in Barrter syndrome ?
Autosomal recessive Like lasix : ascending hoop of Henle
100
Where is the defect in Gitleman’s Syndrome ?
Autosomal recessive Distal tubule Na/Cl cotransporter Like TZD
101
Where is the defect in Liddle’s?
Autosomal dominant eNac nutation in collecting duct, reasborb too much Na
102
Which genetic channelopathies (chronic hypokaliemia) is associated with aminoglycoside use ?
Barrter syndrome
103
Which genetic channelopathies seen in chronic hypokaliemia have strong family history ?
Liddle’s, autosomal dominant
104
Which RTA is associated with heparin ?
Type IV
105
Which RTA is associated with myeloma ?
RTA type II
106
Which RTA is associated with Sjogren or other CTD ?
RTA Type I
107
Which RTA si associated with diabetes ?
RTA type IV
108
How can you differentiate type 1 and type 2 RTA?
Type 1 : severely low K, calcium phosphate stones, pH U > 5.5, HCO3 < 10 Type 2 : low K, glycosuria, low PO4, low urine pH, HCO3 12-20

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