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Medical Series: Electrolyte Abnormalities Part 1 Dr. Acute Medicineman Trust Grade DoctorSocial Medias Case 1 Question A 40-year-old patient presents to ED with acute chest pain that started two hours ago. He is being managed an an NSTEMI. On taking his blood you notice it is quite viscous. His bloods are in the table. What is the most likely cause of his hyponatraemia? Value Range Hb 151 130-180 WCC 7.0 4-11 A. Hypovolaemic hyponatraemia Platelets 350 150-400 B. Hypervolaemic hyponatraemia Na 125 135-145 C. Euvolaemic hyponatraemia K 3.9 3.5-5 Creatinine 90 <110 D. Pseudohyponatraemia Urea 6.7 <8 Troponin 520 <5 E. Don’t know Serum 310 275-290 Osmolarity Triglycerides15 1.8 Case 1 Answer What is the most likely cause? A. Hypovolaemic hyponatraemia B. Hypervolaemic hyponatraemia C. Euvolaemic hyponatraemia D. Pseudohyponatraemia E. Don’t know Pseudohyponatraemiais a false Cause of pseudohyponatraemia hyponatraemia due to how blood is • •arHypertriglycadaemia MM) ‘indirectly’ analysed but is not a problem with point of care testing. Blood Analysis Hyponatraemia + normal/high plasma osmolarity = pseudohyponatraemia Case 1 Explanation Summary- Value Range 1. Low sodium with a high serum osmolarity Hb 151 130-180 2. Raised troponin with normal renal function WCC 7.0 4-11 3. High triglycerides – likely cause of the Platelets 350 150-400 pseudohyponatraemia Na 125 135-145 K 3.9 3.5-5 Creatinine 90 <110 Urea 6.7 <8 Pseudohyponatraemia = normal or high serum osmolarity + Troponin 520 <5 hyponatraemia Serum 310 275-290 Osmolarity Triglycerides 15 1.8 Case 1 Serum Osmolarity Slightly less 275- solute dissolved within a litre90mmol/L osmolarity of solvent. Osmoles is the osmosis Intravascular Interstitial caused by a mole of Space substance. Space Albumin No protein because of lymphatics Other: Ca, Other: Ca, HCO3, K HCO3, K Cl- Cl- 110mmol/L 110mmol/L Na+ Na + 140mmol/L 140mmol/L Case 1 Hyponatraemia • Sodium < 135 Value Range • Classified according to fluid status/biochemistry Hb 151 130-180 • Important to determine cause as management will WCC 7.0 4-11 differ Platelets 350 150-400 Na 125 135-145 • Severe hyponatraemia = <120 and acute hyponatraemia = rapid change the brain can’t adjust K 3.9 3.5-5 to. Creatinine 90 <110 Urea 6.7 <8 • This is what typically lead to a spectrum of neurological symptoms because of resulting cerebral Troponin 520 <5 Serum 310 275-290 oedema. Osmolarity Triglycerides 15 1.8 • Other symptoms depend on the cause. Case 1 Hyponatraemia Sodium < 135 PseudohyponatrTrue Hyponatraemia Hypovolaemic Euvolaemic Hypervolaemic Case 2 Question A 70-year-old lady was admitted to the acute medical unit with delirium. She has a history of epilepsy and has recently been diagnosed with gastritis. She has no signs of fluid overload or dehydration and has an AMTS of 4. What is the most likely cause of her hyponatraemia? Value Range Hb 151 130-180 WCC 5.0 4-11 A. Vomiting and diarrhoea Platelets 320 150-400 B. Carbamazepine Na 120 135-145 C. Omeprazole K 4.3 3.5-5 Creatinine 90 <110 D. Hypothyroidism Urea 7.0 <8 E. Don’t know Serum 265 275-290 Osmolarity Urinary Na+ 40 10-20 Case 2 Answer What is the most likely cause? A. Vomiting and diarrhoea B. Carbamazepine C. Omeprazole D. Hypothyroidism E. Don’t know From the history the history she has SIADH been taking Carbamazepine likely for Antidiuretic Hormone = concentrated a long time so it is unlikely to be the urine. causative agent. Omeprazole, More reabsorption of water = inappropriately salty urine = high however, was newly started. urine Na+ >20. Case 2 Euvolaemic Hyponatraemia Summary- 1. Low sodium with low serum osmolarity = true hyponatraemia 2. Inappropriately high urinary sodium = either concentrating Value Range of urine OR renal loss sodium Hb 151 130-180 3. Rest of the bloods within normal parameters. WCC 5.0 4-11 Platelets 320 150-400 Na 120 135-145 4.3 K 3.5-5 Creatinine 90 <110 Urea 7.0 <8 Serum 265 275-290 Osmolarity Urinary 40 10-20 Na+ Case 2 Euvolaemic Hyponatraemia • Commonly caused by SIADH. SIADH bloods Serum osmolarity Low • Increased antidiuretic hormone (vasopressin). Urine osmolality High • Increases aquaporin V2 channels in collecting duct. Urinary sodium High • Therefore decreased water excretion compared to sodium. Euvolaemic Causes SIADH • Glucocorticoid insufficiency cause euvolaemic hyponatraemia. Severe Hypothyroidism Psychogenic polydipsia • This is because cortisol has an inhibitory effect on ADH. • Less cortisol/glucocorticoids = more ADH. Beer potomania/weird diets Glucocorticoid insufficiency • Adrenal insufficiency however = low aldosterone SIADH Drugs Antidepressants Antiepileptics PPIs NSAIDS Case 3 Question A 23-year-old gentleman has been admitted to ED with severe malaise, fatigue, vomiting and feeling unwell. His observations: HR 110, BP 80/50, RR 21, Sats 94%, Temp 37.6. What investigation will most likely identify the cause ? Value Range Hb 151 130-180 WCC 5.5 4-11 A. Random Cortisol Platelets 180 150-400 B. TFTs Na 120 135-145 K 5.6 3.5-5 C. Urine dip D. LFTs Creatinine60 <110 Urea 4.0 <8 E. Don’t know Serum 260 275-290 Osmolarity Urinary 35 10-20 Na+ Case 3 Answer What investigation will most likely identify the cause? A. Random Cortisol B. TFTs C. Urine dip D. LFTs E. Don’t know Cortisol is released in a pulsatile Cortisol fashion and there is diurnal A random cortisol can be useful if variation with peaks in the morning cortisol >450 to confidently state and evening. It’s why a 9am test is there is no adrenal insufficiency but anything below will require further preferred* investigation. Case 3 Adrenal Insufficiency Summary- 1. Low sodium with a low serum osmolarity = true hyponatraemia Value Range 2. High potassium with normal renal function + low sodium = ?adrenal function related Hb 151 130-180 WCC 5.5 4-11 3. High urinary Na+ = inappropriate urinary concentrating OR renal loss of sodium Platelets 180 150-400 Na 120 135-145 K 5.6 3.5-5 Creatinine60 <110 Urea 4.0 <8 Serum 260 275-290 Osmolarity Urinary 35 10-20 Na+ Case 3 Hypovolaemic Hypovolaemic hyponatraemia Renal loss Non-renal loss (Urine Na >20) (Urine Na<20) GI Skin Case 3 Adrenal Cortex Cortex Layers (Zona GFR) Cortex Functions- Order Glomerulosa you’d spend the evening in.. Salt- Mineralocorticoids Fasciculata Reticularis Sugar- Glucocorticoids Sex- DHEA/Testosterone Miray Kirollos, The 6PM Series Case 3 Adrenal Insufficiency • Glucocorticoid and mineralocorticoid insufficiency. • cortisol >450 no insufficiency, but if 350 unlikely to be deficient. Low cortisol doesn't necessarily mean deficiency as it is released in a pulsatile manner. • Low Cortisol = shortsynacthen test • increased ADHd Insufficiency = Euvolaemic hyponatraemia– cortisol supress ADH production – decreased cortisol = • sodium via kidneyslaemic hyponatraemia - mineralocorticoid insufficiency – decreased aldosterone = decreased ↓ Glucocorticoids ↓ Mineralocorticoids ↑ ACTH Non-specific symptoms Hyponatraemia Hyperpigmentation Hypotension Hyperkalaemia HypoglycaemiaCase 3 RAASCase 3 Aldosterone Aldosterone & Principal Cells DCT ENaC ACEi Indirect Na+ Aldosterone K+ } Case 4 Question A 30-year-old lady presents to your GP practice because she is concerned her urine is becoming increasingly foamy and she has new ankle swelling. You have bloods. What investigation would be most useful? Value Range Hb 151 130-180 A. BNP WCC 7.0 4-11 Platelets 180 150-400 B. TFTs Na 120 135-145 C. Urine dip K 4.0 3.5-5 D. LFTs Creatinin 70 <110 e E. Don’t know Urea 5.0 <8 Albumin 25 34-54 Case 4 Answer What investigation would be most useful? A. BNP B. TFTs C. Urine dip D. LFTs E. Don’t know The vignette is alluding to nephrotic Dipstick & proteinuria syndrome. Foamyurine is suggestive Very specific test for proteinuria. of proteinuria. Normal kidneys = <150mg/24hours in urine. Nephrotic range proteinuria = 3g/24hours OR PCR > 300mg/mmol. Case 4 Hypervolaemic Summary- 1. Low sodium with hypervolaemia on examination. Value Range 2. Low albumin likely secondary to proteinuria Hb 151 130-180 WCC 7.0 4-11 Platelets 180 150-400 Na 120 135-145 K 4.0 3.5-5 Creatinin 70 <110 e Urea 5.0 <8 Albumin 25 34-54 Case 4 Hypervolaemic Clinically determined and usually requires diuresis. Nephrotic syndrome management = steroidsACEi, statins and anticoagulation to consider Proteinuria Appropriate ADH (Also loss of ATIII)Hypoalbuminaemia Oedema Hyperlipidaemia release leads to hyponatraemia Case 5 Question A 25-year-old lady has been brought to ED having had multiple seizures. She has a background of bipolar depression and GORD. Her bloods are in the table. What is the likely cause of herhypernatraemia? Value Range Hb 151 130-180 A. Psychogenic polydipsia WCC 8.9 4-11 Platelets430 150-400 B. Lithium Na 155 135-145 C. Lansoprazole K 5.1 3.5-5 D. Diarrhoea and vomiting Creatinin60 <110 e E. Don’t know Urea 8.0 <8 Lithium 1.5 0.6-1.2 Case 5 Answer What is the most likely cause? A. Psychogenic polydipsia B. Lithium C. Lansoprazole D. Diarrhoea and vomiting E. Don’t know Lithium toxicity can lead to nephrogenic diabetes insipidus = opposite of ADH – pure water loss. Case 5 Hypernatraemia Salt gain Salt>Water loss Pure water loss/ poor intake Oral Renal (diuresis/diuretics) Diabetes Insipidus Iatrogenic GI Hypodipsia Hyperaldosteronism (rare) Skin Case 5 Diabetes Insipidus • Opposite of SIADH. • Either lack ADH production from posterior pituitary (neurogenic DI). • Or resistance to ADH (nephrogenic DI). • hypercalcaemia & hereditary.e chronic/acute lithium ingestion, • Leads to more pure water excretion. • Treat with ADH analogue. • ADH analogues can also be used to differentiate the two, if no response to analogues likely nephrogenic DI. Case 6 Question During your night shift you are called to see the same patient, her GCS is 5 and she is snoring. Her bloods are as seen below. What complication may she have experienced? Value Range Hb 151 130-180 A. Osmotic demyelination (CPM) WCC 5.0 4-11 Platelets 320 150-400 B. Cerebral bleed Na 120 135-145 C. Cerebral oedema K 4.3 3.5-5 D. Meningitis Creatinin 90 <110 e E. Don’t know Urea 7.0 <8 Case 6 Answer What complication may she have experienced? A. Osmotic demyelination (CPM) B. Cerebral bleed C. Cerebral oedema D. Meningitis E. Don’t know Case 6 Sodium Complications • HYPOnatraemia = cerebral oedema • Overcorrected HYPERnatraemia = cerebral oedema • HYPERnatraemia = Osmotic demylination (CPM) or cerebral bleed • bleedorrected HYPOnatraemia = Osmotic demylination (CPM) or cerebral • Don’t correct more than 8-10mmol/L within 24 hours and repeat sodium bloods often.Case 6 Sodium ComplicationsCase 6 Sodium Complications