Fluid, Electrolyte, and Acid-Base Disturbances

116 Pages·2011·5.65 MB·English

Volume 10 (cid:129) Number 2 (cid:129) March 2011
NephSAP
®
Nephrology Self-Assessment Program
Fluid, Electrolyte, and
Acid-Base Disturbances
Co-Editors:
Richard H. Sterns, MD,
and Michael Emmett, MD
■
Editor-in-Chief: Stanley Goldfarb, MD
■
Deputy Editor: Raymond R. Townsend, MD
NephSAP®
EDITOR-IN-CHIEF Preface
StanleyGoldfarb,MD
UniversityofPennsylvaniaMedicalSchool
Philadelphia,PA NephSAP®isoneofthethreemajorpublicationsoftheAmericanSocietyofNephrology
(ASN).Itsprimarygoalsareself-assessment,education,andtheprovisionofContinuing
DEPUTY EDITOR Medical Education (CME) credits and Maintenance of Certification (MOC) credits for
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UniversityofPennsylvaniaMedicalSchool
automaticallyreceiveNephSAPwiththeirmonthlyissueofTheJournaloftheAmerican
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MANAGING EDITOR
EDUCATION: Medical and Nephrologic information continually accrues at a rapid pace.
GiselaDeuter,BSN,MSA
Bombardedfromallsideswithdemandsontheirtime,busypractitioners,academicians,and
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traineesatalllevelsareincreasinglychallengedtoreviewandunderstandallthisnewmaterial.
ASSOCIATE EDITORS EachbimonthlyissueofNephSAPisdedicatedtoaspecifictheme,i.e.,toaspecificarea
RajivAgarwal,MD ofclinicalnephrology,hypertension,dialysis,andtransplantation,andconsistsofanEditorial,
IndianaUniversitySchoolofMedicine aSyllabus,aCommentaryontheSyllabus,andself-assessmentquestions.Overthecourseof
Indianapolis,IN 24months,allclinicallyrelevantandkeyelementsofnephrologywillbereviewedandupdated.
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Theauthorsofeachissuedigest,assimilate,andinterpretkeypublicationsfromtheprevious
ColumbiaUniversity
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MichaelJ.Choi,MD SELF-ASSESSMENT:Twenty-fivesingle-best-answerquestionswillfollowthe50to75pages
JohnsHopkinsUniversitySchoolofMedicine ofSyllabustext.Theexaminationisavailableonlinewithimmediatefeedback.Thoseanswer-
Baltimore,MD ing(cid:1)75%correctlywillreceiveCMEcredit,andreceivetheanswerstoallthequestionsalong
MichaelEmmett,MD
withbriefdiscussionsandanupdatedbibliography.Tohelpanswerthequestions,readersmay
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will also contain 5 questions and answers examining core topics in the particular discipline
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UniversityofNorthCarolina
ChapelHill,NC
AldoJ.Peixoto,MD
YaleUniversity
WestHaven,CT
NephSAP®
RichardH.Sterns,MD
©2011byTheAmericanSocietyofNephrology
UniversityofRochesterSchoolofMedicine
andDentistry
Rochester,NY
JohnP.Vella,MD
MaineMedicalCenter
Portland,ME
FOUNDING EDITORS
RichardJ.Glassock,MD,MACP
Editor-in-ChiefEmeritus
RobertG.Narins,MD,MACP
NephSAP®
Volume 10, Number 2, March 2011
Fluid, Electrolyte, and Acid-Base Disturbances
Editorial 91
We Come to Bury “Contraction Alkalosis,” Not to Praise
It—John H. Galla, MD, and Robert G. Luke, MD
Syllabus 96
Fluid, Electrolyte, and Acid-Base Disturbances—Richard H.
Sterns, MD, and Michael Emmett, MD
Acid-Base Disorders ................................96
Physiology ......................................96
Bicarbonate Levels and Chronic Renal Failure ...........96
Acquired Metabolic Acidosis .........................98
Lactic Acidosis and Septic Shock ...................98
Lactic Acidosis and Hematologic Malignancy ...........100
Metformin and Lactic Acidosis ....................100
Anion Gap Composition ............................103
Propofol-Related Infusion Syndrome and Lactic Acidosis .104
Toxic Alcohols ...................................105
Asthma: Complex Interaction of Respiratory Alkalosis,
Metabolic Acidosis, and Respiratory Acidosis .........107
Epidemiology of the Anion Gap in “Normal Populations” .109
Topiramate and Hyperchloremic Metabolic Acidosis .....110
Acquired Forms of Metabolic Alkalosis ...............110
Metabolic Alkalosis: The Milk Alkali Syndrome (Calcium
Alkali Syndrome) .............................110
Pseudo-Bartter (or Bartter-Like) Syndrome ...........112
NephSAP®
Volume 10, Number 2, March 2011
Mixed Metabolic Alkalosis and Respiratory Acidosis: Role
for Acetazolamide? ............................112
Metabolic Alkalosis (Pseudo-Bartter Syndrome) in Cystic
Fibrosis ........................................114
Pendred Syndrome: Pendrin (SLC26A4) Defects ........115
General Principles .................................117
Hypokalemia ...................................117
Inherited Forms of Hypokalemia .....................117
Familial Hypokalemic Periodic Paralysis .............118
Thyrotoxic Hypokalemic Periodic Paralysis ..........120
Acquired Forms of Hypokalemia .....................121
Acetaminophen Poisoning .........................121
High-Dosage Penicillin, Hypokalemia, and Metabolic
Alkalosis ....................................122
Hypokalemia from Intestinal Pseudo-obstruction Ogilvie
Syndrome ....................................122
Thiazides, Hypertension, and Hypokalemia ...........123
Hypokalemia as a Risk Factor in Patients with Chronic
Kidney Disease..............................124
Hypokalemia-Induced Hyponatremia and Correction of
(cid:1)
Hyponatremia with K Replacement.............124
Hyperkalemia .....................................125
Physiology .....................................125
Pseudohyperkalemia .............................126
(cid:1)
Excess K Intake ...............................127
(cid:1)
Internal K Shifts ...............................128
Hyperglycemia ................................128
Octreotide ....................................128
Hyperkalemic Periodic Paralysis ..................128
Succinylcholine................................128
NephSAP®
Volume 10, Number 2, March 2011
Cardiac Glycosides.............................129
(cid:1)
Impaired K Excretion ...........................130
Decreased Mineralocorticoid Levels or Activity......130
Addison Disease ...............................130
Hypoaldosteronism .............................130
Pseudohypoaldosteronism........................130
Drug-Induced Hyperkalemia .......................130
Decreased Aldosterone Levels....................130
Aldosterone Receptor Antagonism.................131
Collecting Tubule Sodium Channel Blockade........132
Consequences of Hyperkalemia ....................133
Muscle Weakness ..............................133
ECG Findings .................................133
Mortality .....................................133
Metabolic Acidosis.............................133
Treatment of Hyperkalemia .......................133
Sodium Polystyrene Sulfonate ....................134
Fludrocortisone and Glycyrrhetinic Acid............136
Nonhypotonic Hyponatremia ........................137
Pseudohyponatremia .............................137
Hyperglycemia ..................................138
Exogenous Solutes ...............................139
Intravenous Mannitol ...........................139
Irrigant Absorption .............................139
Hypotonic Hyponatremia: Pathophysiology .............140
Acute Hypotonic Hyponatremia ......................143
Psychotic Polydipsia .............................144
NephSAP®
Volume 10, Number 2, March 2011
Exercise Hyponatremia ...........................144
Obstetric Hyponatremia ...........................145
Postoperative Hyponatremia .......................145
Neurosurgical Hyponatremia .......................146
Treatment of Acute Hyponatremic Emergencies .......146
Chronic Hypotonic Hyponatremia ....................148
Differential Diagnosis ............................148
Causes of Renal Salt Wasting ......................148
Addison Disease ...............................148
Congenital Adrenal Hyperplasia ..................148
Cisplatin .....................................149
Cerebral Salt Wasting...........................149
Causes of Euvolemic Hyponatremia .................150
Tumor-Associated SIADH .......................150
Hyponatremic Hypertensive Syndrome .............150
Drug-Induced Euvolemic Hyponatremia .............150
Cyclophosphamide .............................150
Carbamazepine ................................151
Selective Serotonin Reuptake Inhibitors ............151
Other Drugs...................................151
Nephrogenic Syndrome of Inappropriate Antidiuresis ...152
Clinical Outcomes of Chronic Hyponatremia ...........153
Mortality ......................................153
Hospital Costs ..................................155
Falls and Fractures ..............................155
Rhabdomyolysis .................................157
Osmotic Demyelination Syndrome ..................157
NephSAP®
Volume 10, Number 2, March 2011
Treatment of Chronic Hyponatremia ..................160
Renal Replacement Therapy .......................161
Vasopressin Antagonists (Vaptans) .................161
Conivaptan ...................................162
Tolvaptan.....................................164
Hypernatremia ....................................166
Physiology .....................................166
Essential Hypernatremia ..........................168
Neurogenic DI ..................................169
Familial Neurogenic DI .........................169
Lymphocytic Hypophysitis.......................169
IgG4 Disease..................................170
Neurosurgical DI...............................170
Congenital Nephrogenic DI .......................170
Secondary NDI ................................170
Acquired NDI ..................................171
Gestational DI ..................................172
Consequences of Hypernatremia ....................172
Mortality .....................................172
Brain Injury from Hypernatremia ...................174
Treatment of Hypernatremia .......................174
Edema and Diuretics ...............................176
Cirrhosis and Ascites .............................176
Heart Failure ...................................179
Nephrotic Syndrome .............................180
CME Self-Assessment Questions .....................182
Questions Linked to UpToDate in Green
NephSAP®
Volume 10, Number 2, March 2011
Core Knowledge Questions..........................190
Upcoming Issues
Acute Kidney Injury and Critical Care Nephrology—
Patrick T. Murray, MD, and Kathleen D. Liu, MD..........May 2011
Renal Pathology—
Glen S. Markowitz, MD, Barry Stokes, MD, Neeraja Kambham, MD, Leal
C. Herlitz, MD, and Vivette D. D’Agati, MD ..............July 2011
Chronic Kidney Disease and Progression—
Linda F. Fried, MD, and Michael J. Choi, MD .......September 2011
Transplantation—
John P. Vella, MD, and David J. Cohen, MD ........November 2011
NephSAP®
Volume 10, Number 2, March 2011
The Editorial Board of NephSAP extends its sincere appreciation to the following reviewers. Their efforts and insights have helped to
improve the quality of this postgraduate education offering.
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