Hyponatremia andOther

ElectrolyteDisorders
SharonAnderson,M.D.
Div.ofNephrologyandHypertension
OregonHealth&ScienceUniversity
PortlandVAMedicalCenter
October2012

Disclosures
NothingtoDisclose

Hyponatremia
Mostcommonelectrolytedisorderin
hospitalizedpatients
Chronichyponatremiaiscommoninthe
elderly:thiazides,CHF,cancer,SIADH(drugs)
Consequences:osteoporosis,gaitdisturbance,falls
SNa = 130 mEq/L

SNa = 139 mEq/L

Renneboog B, AJM 119:e71,2006

Risk of Inpatient Hyponatremia by Age

Berl T. CJASN, in press (10/04/12)

* p < 0.05

Preoperative Hyponatremia and Mortality

Leung AA, et al. Arch Intern Med (09/10/12)

Aim:todetermineassociationbetweenpreop
hyponatremiaand30daymortality
ReviewedNSQIPdatabase
Comparedthosewithhyponatremia(<135
mEq/L)vs.135144mEq/L
Preophyponatremiariskof30day
mortality,5.2%vs.1.3%,OR1.44
AlsoCVevents,woundinfec ons,PNA,LOS

Preoperative Hyponatremia and Mortality

Leung AA, et al. Arch Intern Med (09/10/12)

Hyponatremia is a WATER Disorder

Assessment of Hyponatremia
Measure serum osmolality
Normal: isotonic pseudohyponatremia
(hyperlipidemia, hyperproteinemia)
Low: true hypotonic hyponatremia

Assess volume status

Measure urine sodium and osmolality

DiagnosisofSIADH
EllisonDH,BerlT.NEJM356:2064,2007
EssentialFeatures
serumosm<275
mOsm/kgofwater
Urinaryosm>100mg/kgof
waterwhilehypotonic
Clinicaleuvolemia
UrineNa>40mEq/Lwith
normalNaintake
Normalthyroid,adrenalfnx
Norecentdiuretics

SupplementalFeatures
Plasmauricacid<4mg/dl
BUN<10mg/dl
FENa >1%;FEurea >55%
Failuretocorrectafter0.9%
NaClinfusion
Correctionwithfluid
restriction
Abnormalwaterloadtest
ElevatedplasmaAVPlevel

www.clevelandclinicmeded.com

Causes

www.clevelandclinicmeded.com

DrugRelatedSIADH
UpdatedfromEllisonDH,BerlT.NEJM356:2064,2007
Painmeds:opiates,tramadol,NSAIDs
Antidepressants:SSRIs,tricylcics
Protonpumpinhibitors
Chemo:vincristine,cyclophosphamide,cisplatin,
ifosfamide,imatinib
Streetdrugs:MDMA(ecstasy),nicotine
Antiepileptics:carbamezepine
Others:ciprofloxacin,amiodarone,ACEI,clofibrate,
antipsychotics,chlorpropamide

Treatment

Treat
www.clevelandclinicmeded.com

Treatment of Symptomatic Hyponatremia

Hypertonicsaline
Calculation:
mEqneeded=0.6xwt(kg)x(desired actualNa)
Oneliterof3%NaCl=513mEqNaCl
mlof3%NaClneeded=(mEqNaClneededx
1000)/513

Rateofinfusion:adjusttoNaby12.5
mEq/hr
www.clevelandclinicmeded.com

Hypertonicvs.NormalSaline?
Well,sheisprettyhyponatremic.I dont
reallywanttomovehertotheICUfor
hypertonicsaline,soletskeepheronthe
floorandusenormalsaline.
Iftheurineosm >300mOsm/kg,giving
normalsalinewillWORSENhyponatremia

WhataboutConivaptan?
NonselectivevasopressinV1a/V2
receptorantagonist
Intravenous,ICUonly,4daysmax
Veryeffectiveinraisingserumsodium
Druginteractionsarecommon
OVERSHOOT canhappeneasily;monitor
serumandurineNaq2hours

AsymptomaticHyponatremia
Nearlyalwayschronic
Commoncauses(esp.intheelderly):
thiazides,SSRIs,NSAIDs,PNA,subdural
hematoma,cancer/chemotherapy,teaand
toastdiet,idiopathic
HospitalizationisusuallyNOTrequired
Removeoffendingculprit(s);fluidrestriction

AsymptomaticHyponatremia
ALLfluidsaremostlywater!
Fluidrestriction+NaCltabs=oral
hypertonicsaline
Example:1gmNaCltablets3x/daily

Demeclocycline
Urea

SALTWATERTRIAL:Tolvaptan
BerlT,etal.JASN21:705,2010

OralVaptans:Caveats
Hospitalizationrequiredforinitiation;
thenfrequentoutpatientmonitoring
RiskofnephrogenicDIiffluidscannot
bereadilyaccessed
Costisprohibitivetomany
Stopthedrughyponatremiarecurs;
notacure

www.clevelandclinicmeded.com

HYPERKALEMIA

-Too much in
- Too little out
- Redistribution from
cells extracellular fluid

Hyperkalemia:TooMuchIn
Fruitsandvegetables:notallcreatedequal
HighK:bananas,oranges,limabeans,celery
LowK:tangerines,lettuce,greenbeans,carrots
Dietaryconsult/handouts=essential!

AskaboutOTCKsupplements(legcramps)
Ask/counselaboutsaltsubstitutes

SaltSubstitutes BeSpecific!

Ingredients:
Potassium Chloride, Fumaric
Acid, Tricalcium Phosphate and
Monocalcium Phosphate.

Ingredients:
Onion, Spices (Black Pepper, Chili
Pepper, Parsley, Celery Seed, Basil,
Bay, Marjoram, Oregano, Savory . . .

Hyperkalemia:TooLittleOut
100
mEq

90
mEq

10
mEq

RenalPotassiumExcretion
Tubule Lumen
Low GFR
Low urine volume
Amiloride
Triamterene
Trimethoprim

Blood

Na
3 Na

2K

K
Principal Cell

RenalPotassiumExcretion
Tubule Lumen

Blood

Na
3 Na

2K

K
Principal Cell

Digoxin
Spironolactone
ACEI/ARBs
NSAIDs
CyA, FK506
Heparin

HeparininducedHyperkalemia
OsterJR,etal.AmJMed98:575,1995

SomeKin7%ofpa ents,butusuallyneed
otherfactorsforlargeriseinK
Mechanism:inhibitionofaldosteroneproduction
inadrenalzonaglomerulosa,mostlyviadecrease
inAngIIreceptornumberandaffinity
Occurswithinafewdaysoftherapy;isreversible;
isunrelatedtoanticoagulanteffectorrouteof
administration
Canoccurwithlowdoses[5000unitstwicedaily]
andwithlowmolecularweightheparins

RenalPotassiumExcretion
Tubule Lumen

Blood

Na
3 Na

Spironolactone
and other
aldosterone
blockers

2K

K
Principal Cell

EstimationofAldoEffect
Transtubularpotassiumgradient(TTKG)
TTKG=

UK/PK
Uosm/Posm

<6=Hypoaldosteronism >10=Normal
610=Indeterminate

TreatmentofHyperkalemia
Hyperkalemiaisamedicalemergency
YoucanalwaysshoveKintothecells
FASTERthanyoucanremoveitfromthe
body!
Kayexalate=toolittle,toolate

DontletanormalEKGlullyouintoa
falsesenseofsecurity

TreatmentofHyperkalemia:Redistribution
Insulin+glucose=best
Betaagonistsalsowork(butveryhigh
dosesareneeded;riskofarrhythmias)
BicarbonateisoftenNOTveryeffective

ChangesinPlasmaKinESRD
AllonM.JASN6:1134,1995

Change in K (mEq/L)

0.5
0
Bicarbonate
Epinephrine
Insulin
Dialysis

-0.5
-1
-1.5

TIME COURSE (0-60 mins)

Hypokalemia
Etiology:Toolittlein,toomuchout,or
redistribu onfromextracellularfluidcells
Thinkabout:Nadeliverytodistaltubule
(IVF,diuretics);betaagonists;adrenocortical
steroids;aminoglycosides;amphotericin,
cisplatinum
UsetheTTKGtohelpwithdiagnosis
<2=GIloss

>4=renalloss,aldo

Carroll ME, AFP 67:1959, 2003

Carroll ME, AFP 67:1959, 2003

MetabolicBoneDiseaseinCKD
TreatmentofHyperphosphatemia
Calciumcarbonate(TUMS)
Calciumacetate
Sevelamer
Lanthanum

TreatmentofHyperparathyroidism
VitaminD
Calcitriol(andothers)
Cinecalcet

MineralMetabolisminCKD

Vitamin D/calcium/phos/PTH
Restrict dietary phos
Oral phos binders
Vit D or analog supplement

Opinion

MetaAnalysis

Concensusin2012
Calciumandphosphorusarebad
PTHisbad(unlesstoolow)
VitDisgood(probably?)

RCT

Hypomagnesemia
MoeSM.PrimCare35:215,2008

Occursin712%ofhospitalizedpatients;up
to20%ofICUpatients
Oftenassociatedwithotherelectrolyte
abnormalities(hypokalemia,hyponatremia,
hypocalcemia,hypophosphatemia)
Causes:intake,GIabsorp on,GIor
renallosses
DRUGS

RisksofPPITherapy
VakilN.Drugs72:437,2012

PPIsareincreasingassociatedwithriskof:
Pneumonia
Osteoporosisandbonefractures
Infectiousdiarrhea,C.diff
Interac onwithclopidogrelCVevents
SIADH
Acuteinterstitialnephritis
Hypomagnesemia

References

EllisonDH,BerlT.Thesyndromeofinappropriateantidiuresis.NEJM
256:2064,2007
BerlT.Anelderlypatientwithchronichyponatremia.ClinJAmSoc
Nephrol2012(online10/04/12)
BuckleyMS,etal.Electrolytedisturbancesassociatedwithcommonly
prescribedmedicationsintheintensivecareunit.CritCareMed38(Suppl
6):S253,2010
PerazellaMA.Druginducedhyperkalemia:oldculpritsandnewoffenders.
AmJMed109:307,2000
CarrollME,etal.Apracticalapproachtohypercalcemia.AmFam
Physician67:1959,2003
MoeSM.Disordersinvolvingcalcium,phosphorus,andmagnesium.Prim
Care35:215,2008