14. Decreased intake
945 outpatients with eating
disorders Serum Potassium
anorexia, bulemia, or both
2%
ALL of the hypokalemic 3%
patients were abusing
cathartics or inducing
vomiting
NONE of the hypokalemia
was due to restricted
caloric intake alone
95%
The restricted calorie
subgroup was the most
nutritionally deprived of >3.5 3.0-3.5 <3.0
all the subgroups.
Greenfeld, D., Et Al. Am. J. Psychiatry 152, 60-63 (1995).
Friday, February 27, 2009
15. Serum K with dietary restriction
Intake does matter in
4.00
experimental settings
but clinical
Serum K (mEq/dL)
3.25
relevance is
questionable
2.50
A compilation of 7 1.75
separate metabolic
balance studies 1.00
reveals the 0 200 400 600 800
following graph K defecit (mEq)
Friday, February 27, 2009
16. Alcoholism
61 patients with weekly alcohol ingestion
greater than 600g/wk.
No cirrhosis of hepatitis, renal disease or,
acute medical condition.
Admitted for inpatient detoxification for 4
weeks
De Marchi, S. et al. N Engl J Med 1993;329:1927-1934
Friday, February 27, 2009
19. Vomiting induced hypokalemia
is not due to GI losses
potassium content
of stomach fluid
is 15 mEq/L
Friday, February 27, 2009
20. Vomiting induced hypokalemia
is not due to GI losses
potassium content
of stomach fluid
is 15 mEq/L
How much vomit
to get a 120 mEq
potassium deficit?
Friday, February 27, 2009
21. Vomiting induced hypokalemia
is not due to GI losses
potassium content
of stomach fluid
is 15 mEq/L
How much vomit
to get a 120 mEq
potassium deficit?
Friday, February 27, 2009
22. Distal convoluted
tubule
Glomerulus
Vomiting induced Proximal tubule
hypokalemia is Collecting
tubule
due to renal
losses
Loop of Henle
Friday, February 27, 2009
23. Vomiting induced
hypokalemia is
due to renal
losses
Friday, February 27, 2009
24. Vomiting induced
hypokalemia is
due to renal
losses
Friday, February 27, 2009
25. Vomiting induced
hypokalemia is
due to renal
losses
Friday, February 27, 2009
26. Vomiting induced
hypokalemia is
due to renal
losses
Friday, February 27, 2009
27. Vomiting induced hypokalemia
is due to renal losses
Vomiting causes
metabolic alkalosis
Increased serum
bicarbonate is
dumped into the
urine
urine potassium can
rise to 80-120 mEq/L
Friday, February 27, 2009
28. Hypokalemia: Treatment
Potassium is 2.8
How much poassium will you give:
100 x (4–k)
Friday, February 27, 2009
51. magnesium
2 grams of Magnesium Sulfate IVPB over an
hour or so
Friday, February 27, 2009
52. magnesium
2 grams of Magnesium Sulfate IVPB over an
hour or so
Friday, February 27, 2009
53. magnesium
doesn’t really work
the next day it’s still low
Most of the IV magnesium is immediately
dumped in the urine
you need to drip it in over as long as
possible
i like 6g (48.6 mEq) over 24 hours
Friday, February 27, 2009
54. day one labs
12
128 92 128
2.8 22 3.0
0.6
Friday, February 27, 2009
55. day two labs
12
128 92 128
2.8 22 3.0
0.6
8.8 10
132 100 94
1.2 2.2 3.2 24
0.6
Friday, February 27, 2009
68. Transcellular redistribution is movement of phosphorous into
cells. This is usually transient and, in the face of
normal total body phosphourous is harmless.
However, in the face of pre-existing phosphorous depletion,
this transcellular movement can provoke serious symptoms
including death. The most severe cases are
found with refeeding syndrome.
Weinsier and Krumdieck, 1981, Am J Clin Nutr, 34, 393-9
Friday, February 27, 2009
69. Starvation decreases total body phosphorous.
However, serum phos remains normal due
to movement of phosphorous out of cells.
With refeeding, insulin moves
phosphorous into cells, in order to
phosphorylate carbs as part of glycolysis.
This unmasks the previous
phosphorous depletion.
Friday, February 27, 2009
70. this is worse with fructose
conversion of fructose to fructose-P
is unregulated
causes rapid consumption of Phos and
ATP
the loss of ATP is thought to be the
cause of fructose toxicity
Friday, February 27, 2009
71. give phos
stop carbs
Friday, February 27, 2009
72. Stop the D5LR
Started 8 ounces of
milk four times a
day
Used a packet of
KPhos
Friday, February 27, 2009
73. IV sodium phosphorous
8mmol q6 hours
target 32 mmol in a day
careful in renal failure
Friday, February 27, 2009
74. day four and five labs
Day Na K P Mg
1 128 2.8 3.0
2 132 3.2 2.2 1.2
3 133 3.9 1.4 2.3
4 131 3.8 1.8 2.2
5 130 4.2 2.8 1.8
Friday, February 27, 2009
75. problem list
hyponatremia
Friday, February 27, 2009
76. Specific gravity on admission:
1.005
What’s the specific gravity in:
hypervolemic hyponatremia: heart
failure? Cirrhosis? Nephrotic
syndrome?
Euvolemic hyponatremia: SIADH?
Hypovolemic hyponatremia:
diuretics? GI losses?
Friday, February 27, 2009
80. What regulates specific gravity?
ADH
We start with an increase in the plasma osmolality
Friday, February 27, 2009
81. What regulates specific gravity?
ADH
This is detected increase in
We start with an by the brainthe plasma osmolality
Friday, February 27, 2009
82. What regulates specific gravity?
ADH
The is detected increase
Thisbrain releases the in
We start with an by ADHbrainthe plasma osmolality
Friday, February 27, 2009
83. What regulates specific gravity?
ADH
ADH acts releases the
The is detected kidney
Thisbrain on an increase in
We start withthe by ADHbrainthe plasma osmolality
Friday, February 27, 2009
84. What regulates specific gravity?
ADH
The retained water
goes here
not here
The kidney reacts by retaining water and producing a
small amount of kidney
The is detected concentrated
Thisbrain on an increase in urine.
ADH acts releases the
We start withthe by ADHbrainthe plasma osmolality
Friday, February 27, 2009
85. What regulates specific gravity?
ADH
What do all of the etiologies of
hyponatremia have in common?
Friday, February 27, 2009
86. What regulates specific gravity?
ADH
What do all of the etiologies of
hyponatremia have in common?
ADH
Friday, February 27, 2009
90. Our patient has a low specific gravity.
Friday, February 27, 2009
91. Our patient has a low specific gravity.
ADH independent hyponatremia
Friday, February 27, 2009
92. Our patient has a low specific gravity.
ADH independent hyponatremia
psychogenic polydipsia
Friday, February 27, 2009
93. Our patient has a low specific gravity.
ADH independent hyponatremia
psychogenic polydipsia
tea and toast or beer drinkers
potomania
Friday, February 27, 2009
96. The kidney is able to
concentrate urine to 1200
mOsm/L
The kidney is able to dilute
urine to 50 mOsm/L
If a patient has a daily
solute load of 600 mOsms.
What is:
The minimal amount of
urine he can produce
(maximum ADH)
The maximum amount of
urine he can make
(minimal ADH)
Friday, February 27, 2009
97. The kidney is able to
concentrate urine to 1200
mOsm/L
The kidney is able to dilute
urine to 50 mOsm/L
If a patient has a daily
solute load of 600 mOsms.
What is:
The minimal amount of
urine he can produce
(maximum ADH) 500 mL
The maximum amount of
urine he can make
(minimal ADH)
Friday, February 27, 2009
98. The kidney is able to
concentrate urine to 1200
mOsm/L
The kidney is able to dilute
urine to 50 mOsm/L
If a patient has a daily
solute load of 600 mOsms.
What is:
The minimal amount of
urine he can produce
(maximum ADH) 500 mL
The maximum amount of
urine he can make
(minimal ADH) 12,000 mL
Friday, February 27, 2009
99. 600 mOsms is the typical daily solute
load
so a patient requires a minimum of
500 mL of urine to remove the daily
solute load
A patient making less than that is
unable to clear the daily solute load
what is the definition of oliguria
Friday, February 27, 2009
100. What if the daily solute load is 100
mOsms?
What is the most urine they can make?
Friday, February 27, 2009
101. What if the daily solute load is 100
mOsms?
What is the most urine they can make?
2,000 mL
Friday, February 27, 2009
102. What if the daily solute load is 100
mOsms?
What is the most urine they can make?
2,000 mL
What happens if they are getting IV
fluids at 100 mL/hour?
Friday, February 27, 2009
103. An alcoholic gets much of
his daily calories from
alcohol.
Alcohol is metabolized to
CO2 and water
no solute for the kidney
to excrete
Low daily solute load
Friday, February 27, 2009
104. A tea and toast diet refers to
a carbohydrate rich diet free
of proteins
Friday, February 27, 2009
105. Both beer drinker’s and Tea and Toast
respond to increased protein intake
Usually get a brisk response to
crystalloids
Friday, February 27, 2009
Editor's Notes
likely the tissue destruction associate with starvation provides a steady supply of intracellular potassium