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Kidney
Need:
1. Fluid balance
Acute kidney injury, is it reversible?
2. Restric nephrotoxic drug
3. Electrolyte correction
4. Nutrition
5. Anemia management
Kidney
6. Hypertension management
7. Acid base management
Impact of kidney injury
• Sodium
• Potassium
• Metabolic acidosis
• Metabolic alkalosis
• Water imbalance
Hyponatremia: Serum Na <130 mEq/L
–Any symptoms?
–Acute or chronic?
–Risk factor of neurologic deficit?
Hyponatremia
Adjust the velocity of correction
Symptomatic
Asymptomatic
Intravenous replacement up to
40 mEq/hour Metabolic Metabolic
Continue ECG monitoring acidosis alkalosis
Serial serum K monitoring
Normotensive Hypertensive
K citrate
K bicarbonate
KCL volume
K sparring
replacement
diuretic
Hypokalemia
K parenteral indication:
– Dysrhytmia
– Respiratory muscle paralyze
– Hypokalemia in hepatic encephalopathy
– K+ level very low < 2mEq/L
Hypokalemia
Spurious Transcellular
shift
Impaired
renal
excretion
Hyperkalemia
Spurious: Transcellular shift:
• Hemolysis • Acidosis
• Ischemic blood draw • Non-anion gap
• Leucocytosis (WBC>50.000/mm3) • Respiratory
• Thrombocytosis • Hyperglycemia
(Platelete count > 1.000.000/mm3) • Hypertonicity
• Familial pseudohyperkalemia • β- adrenergic blockade
• Succinylcholine
• Digitalis intoxication
• Fluoride intoxication
• Hyperkalemic periodic paralysis
• Exercise
Hyperkalemia
Serum potassium
Prepare
renal replacement therapy
Hyperkalemia treatment
• Stabilize myocardial membrane:
– Ca gluconas 10%
• Change extracellular to intracellular potassium
– Salbutamol
– Sodium bicarbonate
– Dextrose with insulin
• Release potassium outside the body
– Dialysis
– Resin
Hypernatremia
Treatment:
– Dextrose 5% and NaCL 0.2% during 48 hours
– Target sodium decrease 10 – 15 mEq/L/day
– Continue with maintenance
– Severe hypernatremia (Serum sodium >200
mEq/L) peritoneal dialysis, start with peritoneal
dialysis solution 4.25% glucose, indwelling 1 hour
until Na decrease continue with peritoneal
dialysis solution 1.5%
Acid-bace imbalance
Metabolic acidosis
• Treatment:
• (Ki-Ku)xBWx0.6= mEq NaHCO3
2nd
– Any laboratory error? step
[H+]= pCO2 x 24/HCO3-
Different result >10%laboratory error
3rd
• pH step
– pH > 7.44 alkalemia
– pH < 7.36 asidemia
Determine delta ratio (delta gap) = increase in anion gap / decrease in bicarbonate
0.4 – 0.8 Consider combined high AG and normal AG acidosis ratio often <1 in
acidosis associated kidney failure
1–2 Usual for uncomplicated high AG acidosis
Lactic acidosis: average value 1.6
DKA more likely to have a ratio closer to 1 due to ketone loss
>2 Suggests pre-existing elevated HCO3 level: consider a concurrent
metabolic alkalosis or a pre-existing compensated respiratory
• Common causes of metabolic acidosis with
increased anion gap:
– Methanol intoxication
– End stage renal disease
– Diabetic ketoacidosis
– Paraldehyde intoxication
– Iron overdose
– Alcoholic ketoacidosis
– Lactic acidosis
– Salicylate intoxication
• Common causes of metabolic acidosis with
normal anion gap:
– Mild to moderate kidney disease
– Acute diarrhea
– Type I Renal tubular acidosis
– Type II Renal tubular acidosis
Thank You
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