RENAL SUMMARY DR CENDRELLA HOJEILY
Acute Respitory alkalosis • Without hypoxia: acute hyperventilation • With hypoxia: asthma/PE/chest trauma • With metabolic acidosis:sepsis/ASA/RF • Chronic respitory alkalosis: • Without hypoxia: CNS problem/ LIVER D • ! With hypoxia: !COPD pink puffer (early)
Acute respitory acidosis: • Without hypoxia: sedative use • With hypoxia: resp failure • Chronic respitory acidosis With hypoxia: COPD retainer
HAG: NA-CL-HCO3 6-12 • KETOSIS: DKA/ AKA/ STARVATION • LACTIC ACIDOSIS • ACUTE RENAL FAILURE/ SEPSIS • OSM GAP 10 • Ethylene glycol(ANTIFREEZE) UR OXALATE • Methanol (WOOD ETOH) /VISION • Isopropyl alcohol (RUBBING) NO ACIDOSIS/
NAG • RTA 1 UPH>5.5 UAG+ LOW K UNA HIGH • RTA2 UPH<5.5 OR + NL-LOWK UNA H • RTA4 UPH<5.5 + HIGH K UNA H • DIARRHEA UPH5.5 - NL-LOW UNALOW
Diuretic/ barter/ gitleman High renin aldosterone UNa same Ucl
serum sodium concentration ≤135 meq/L • retention of water • 10 liters per day • water load will, fall in plasma osmolality suppresses the release (ADH).
ADH LEVELS ARE ELEVATED • Appropriate: • True volume depletion • Heart failure and cirrhosis • plasma volume may be markedly increased in these disorders, the pressure sensed at the carotid sinus baroreceptors is reduced due to the fall in cardiac output in heart failure and to peripheral vasodilatation in cirrhosis • Inappropriate:
ADH LEVELS SUPPRESSED • Primary polydipsia • primary stimulation of thirst • anxious, middle-aged women and in patients with psychiatric illnesses, particularly those taking antipsychotic drugs in whom the common side effect of a dry mouth leads to increased water intake
High plasma osmolality: • hyperglycemia; • hypertonic mannitol. • maltose retention when IVIG. • Normal plasma osmolality • isosmotic (or near isosmotic) but non-sodium-containing fluid to the extracellular space • glycine or sorbitol flushing solutions during transurethral resection of the prostate or bladder
Pseudohyponatremia • lipids and proteins, result in a reduction in the fraction of plasma that is water and an artificially low sodium concentration • plasma water is approximately 93% with fats and proteins 7 % • 142 represents a concentration in the plasma water of 154 meq/L (142 ÷ 0.93 = 154). • plasma water fraction may fall below 80 percent in patients with marked hyperlipidemia
hyponatremia in renal failure • plasma osmolality may be normal or high because of the retention of urea • urea is an ineffective osmole • Corrected Posm = Measured Posm - (BUN ÷ 2.8)
DIAGNOSIS: • History and physical • PE • LABS: • Plasma osmolality • Urine osmolality • Urine sodium concentration
Plasma osmolality • Hyponatremia with a normal plasma osmolality may be due to hyperlipidemia or hyperproteinemia • sucrose and maltose-containing IgG formulations or the absorption of isotonic glycine during urological or gynecological procedures.
high plasma osmolality • Hyperglycemia • Mannitol • Renal failure • Low plasma osmolality: • true
Urine osmolality: • ADH or not • The normal response to hyponatremia • suppress ADH secretion, resulting in the excretion of a maximally dilute urine with an osmolality below 100 mosmol/kg • Values above this level indicate an inability to normally excrete free water:ADH
Urine sodium concentration: • below 25 meq/L in hypovolemia • above 40 meq/L in patients with the SIADH • Plasma uric acid and urea concentrations • SIADH is frequently associated with hypouricemia
A low plasma osmolality An inappropriately elevated urine osmolality (above 100 mosmol/kg and usually above 300 mosmol/kg) A urine sodium concentration usually above 40 meq/L Low BUN and serum uric acid concentration A relatively normal plasma creatinine concentration Normal adrenal and thyroid function
SIADH will have a low urine sodium concentration if they are also volume depleted or if their sodium intake is extremely low. In such patients, the diagnosis of SIADH is made by observing the response to a saline load: the urine sodium rises but the urine osmolality remains high.
hypernatremia can occur only when thirst oraccess to water is impaired, the groups at highest risk arepatients with altered mental status, intubated patients, infants,and elderly persons.Hypernatremia in infants usually resultsfrom diarrhea, whereas in elderly persons it is usually associatedwith infirmity or febrile illness.Thirst impairmentalso occurs in elderly patients.Frail nursing home residentsand hospitalized patients are prone to hypernatremia becausethey depend on others for their water requirements.
elderly patientsgenerally have few symptoms until the serum sodium concentrationexceeds 160 mmol per liter. Intense thirst may be presentinitially, but it dissipates as the disorder progresses andis absent in patients with hypodipsia.5 The level of consciousnessis correlated with the severity of the hypernatremia.6 Muscleweakness, confusion, and coma are sometimes manifestations ofcoexisting disorders rather than of the hypernatremia itself.