Hamra: Electrolyte Disorders
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| Hyponatremia | Too much water relative to Na
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Na <135 mmole/L
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| Hypernatremia | Too little water relative to Na
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Na >144 mmole/L
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| Osmolality | Concentration of ALL solutes
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| Tonicity | Concentration of solutes that will cause a water shift
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E.g. Na & Cl, not Urea
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| True (absolute) Hypovolemia | Hemorrhage, GI fluid loss, Diuretics, Burns
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| Relative Hypovolemia | Increased capacitance of the compartment : either from vasodilation (drugs, sepsis, NO) or decreased effective arterial blood flow (edema and third spacing)
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| Primary Renal Hypervolemia | Na/water rentention from renal disease
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| Secondary Renal Hypervolemia | Na/water retention from systemic diseases such as cardiac failure and cirrhosis
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| Name the 5 hormonal regulators of Na | (1) Aldosterone (2) ADH (3) ANP (4) Sympathetic Nervous System (5) Angiotensin II
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| Effects of Angiotensin II and NE in the proximal tubule | Tweek (1) the Na/H exchanger on the lumenal side and (2) the Na/K pump on the interstitial side
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| Effects of Aldosterone in the Cortical Collecting Duct Principal Cells | Increases activity of (1) ENaC and (2) Aquaporin channels on the lumenal side and (3) Na/K pump on the interstitial side.
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| Where does ADH work to increase Na reabsorption? | The thick ascending limb and CCD
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| How does ADH effect Urea | It increases Urea transport in the intermedullary collecting duct
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| How does ADH increase water reabsorption? | With the insertion of acquaporin channels in the collecting duct
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| What is the equation associated with Na excretion | Filtered load of Na (GFR X plasma [Na]) - tubular reabsorption of Na
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| What does ANP do (generally) | Increases the excretion of Na and water
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| Name the three controllers of water balance. | Osmolality, Volume, Angiotensin
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| In the presence of competing volume and osmolality signals, which one wins? | Volume always wins
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| Increase/decrease of which factors will increase ADH? | Increase in osmolality, decrease in volume, increase in angiotensis
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| Increase/decrease of which factors will increase thirst? | Increase in osmolality, decrease in volume, increase in angiotensis
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| What do you expect to see with Hypervolemic Hyponatremia in regards to plasma Na, water/Na, osmolality, Una and Uosm? | Plasma Na <136 mm/L : big increase in water, small increase in Na : decrease in plasma osmolality : Una <20 mm/L : Uosm high to isosmotic
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| Name some examples of Hypervolemic Hyponatremia. | CHF, decompensated cirrhosis with ascites, advanced renal failure, nephrotic syndrome (least common)
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| What changes to the Starling forces would cause edema? | increase cap. hydraulic pressure
: decrease cap. oncotic pressure
: increase cap. permeability
: Lymph obstruction
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| Increase in capillary hydraulic pressure can be caused by what? | Increased blood volume or venous obstruction
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| What is the common denominator seen in Hyper. hypo situations? | Decreased EABV
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| What two physiologic responses will increase water retention? | Increased thirst and ADH
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| what two physiologic responses will increase Na retention? | Increased SNS and RAAS
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| Hypovolemic Hyponatremia indicates what? | There is a past or on going Na loss event
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| What do you expect to see with Hypovolemic Hyponatremia in regards to plasma Na, water/Na, osmolality, Una and Uosm? | Plasma Na <136 mm/L
: decreased water with big decrease in Na
: decreased plasma osmolality
: Una depends
: Uosm ranging from low to high
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| Name some examples of Hypovolemic Hyponatremia. | GI loss, bleeding, urine, skin (major sweating or burns)
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| How do you distinguish between Extrarenal and renal hypo hypo? | Extrarenal the Una <20 mm/L
Renal the Una >20 mm/L
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| Examples of Extrarenal causes of hypo hypo. | GI Loss, Excessive sweating, burns, third spacing of fluids
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| Examples of Renal causes of hypo hypo. | Diuretics, salt-wasting neuropathy, mineralocorticoid deficiency, ketonuria, bicarburia
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| What type of urine would you expect to see in a pt with a Renal cause of hypo hypo? | Isosmotic or concentrated urine (high Uosm)
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| What is the "key" with Euvolemic Hyponatremia? | There is neither a volume or osmolar signal to increase ADH.
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| What do you expect to see with Euvolemic Hyponatremia in regards to plasma Na, water/Na, osmolality, Una and Uosm? | Decreased plasma osmolality
: decreased Pna
: very high Una (>40 mm/L)
: Uosm is high
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| What maybe the cause of the really high Una? | SIADH: either lots of ADH or increase renal responce to ADH
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| What kind of conditions can cause SIADH? | Tumor, CNS disorder, thorasic dz, chest wall dz
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| What conditions mimic SIADH | Hypothyroidism and adrenal glucocorticoid deficiency
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| Name 3 examples of euvol. hypo with low Uosm. | Primary polydipsia, beer potomania, and tea and toast diet
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| What can cause Hypernatremia? | Primary Na gain or a primary water deficit
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| What would you expect to see in hypernatremia in respect to Pna and Posm? | Pna > 144 mm/L
: Posm would be high
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| What is the normal response to hypernatremia? | Increase water intake and excrete a maximally concentrated, minimum volume urine
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| What can cause Hypervolemic Hypernatremia? | Over zealous administration of hospital IV fluids
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| What would you expect to see in regards to water, Na, plasma osmolality and Uosm? | Increase in water
: big increase in Na
: high plasma osmolality
: Uosm will depend on the competing signals for ADH
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| What patient populations do you tend to see Euvolemic Hypernatremia in? | Elderly, those in nursing homes, people with no access to water, those with dibetes insipidus, and febrile patients
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| What would you see in regards to water, Na, plasma osmolality, and Uosm? | Decrease in water
: no change in Na
: high plasma osmolality
: Uosm would be very low
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| What is the hallmark seen in euvolemic hypernatremia? | A pure net loss of water with no change in Na
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| What would you expect to see in hypovolemic hypernatremia in respect to water, Na, plasma osmolality and Uosm? | Big decrese in water
: decrease in Na
: increase in plasma osmolality
: Uosm would be high
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| Name some Extrarenal causes of hypo hyper. | GI loss, excessive sweating and burns
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| Nam some Renal causes of hypo hyper. | Loop diuretics and osmotic diuretics (not drugs: urea, glucose, mannitol, glycol)
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