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Restrict dietary potassium and discontinue any medications that may be contributing to the hyperkalemia.
When serum sodium is low or rapidly decreasing, hyponatremia may lead to cerebral edema that may result in seizures, status epilepticus, coma, or even death.
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The kidneys are unresponsive to ADH.
Envision a salty desert.
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Usually indicates that the kidneys are wasting potassium.
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Patients can present in fluid overload from urinary retention.
Euvolemic hyponatremia: If the patient is symptomatic, give hypertonic NS with furosemide.
Consider in patients with pancreatitis, refractory peptic ulcer disease, a personal or family history of kidney stones, or bone pain.
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CHF before giving the bolus!
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D5W, or oral water depending on the patient's volume status.
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Start by administering calcium to stabilize the heart.
Tx: Replace with calcium carbonate orally or with IV calcium gluconate.
Causes of Acute Renal Failure.
Get an ECG, as this may show serious signs of hyperkalemia.
Identify and treat the underlying cause.
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Other findings are specific to the etiology of the renal failure.
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Alkalosis is most commonly associated with Proteus UTIs but may also be seen with some strains of Klebsiella, Pseudomonas, Providencia, and Staphylococcus.
Next, follow the mnemonic C BIG K Drop.
Usually indicates a nonrenal source of hypokalemia.
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Uosm should not respond to DDAVP challenge.
Note that overly rapid correction may result in central pontine myelinolysis (flaccid paralysis, dysarthria, dysphagia, and gait abnormalities).
You call the laboratory, and they state that the specimen was not hemolyzed.
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The pituitary does not make ADH.
Given this patient's worsening cough, you might also consider a CXR, as this may be relevant in the setting of SIADH.
Acidosis with nephrolithiasis suggests uric acid or cystine stones.
You may be able to bump hyponatremia to the bottom of your problem list, but central pontine myelinolysis will go to spot number one!
Postrenal failure: Caused by urinary outflow obstructions in one or both ureters, the bladder neck, the urethra, or the prostate.
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The man has a past medical history of smoking and CAD.
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ARF but should prompt one to test for it.
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Check calcium, phosphate, albumin, ionized calcium, and alkaline phosphatase.
Evaluate the patient for urinary retention, as this is likely the cause of his renal failure.
What are the next steps in diagnosis?
PTHrP secretion from cancer cells (often squamous cell carcinoma) can cause a paraneoplastic hypercalcemia.
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Hemorrhage Drains Skin GI.
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Pyelonephritis or interstitial nephritis.
What do you do next?
Hemodialysis is a last resort.
Bladder neck: Anticholinergics, tumor.
Often asymptomatic, but may present with confusion, lethargy, muscle cramps, and nausea.
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If the patient has a large postvoid residual, he should keep his Foley in place and be referred to urology.
Urine potassium levels can help determine the etiology of the hyperkalemia.
DM, is in the hospital receiving IV antibiotics for pyelonephritis.
Severe or symptomatic hyperkalemia, hyperkalemia refractory to the above management, or patients on chronic hemodialysis may require acute hemodialysis.
Also consider vitamin D levels, SPEP, TSH, and imaging.
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Causes include excessive hydration with hypertonic fluids, dysfunction of central regulation, and mineralocorticoid excess (consider if the patient has hypokalemia and hypertension).
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GI absorption (as found in hypoparathyroidism, pseudohypoparathyroidism, vitamin D deficiency, malabsorption, renal failure, critically ill patients, and hypomagnesemia), acute pancreatitis, rhabdomyolysis, tumor lysis, and diuretics.
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Intrinsic failure: Can be vascular, glomerular, tubular (most common), or interstitial.
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May present with fatigue, muscle weakness or cramps, ileus, hyporeflexia, paresthesias, and flaccid paralysis if severe.
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WBCs is always abnormal except when the sample is contaminated (eg, with epithelial cells).
Examination should include checking BP, daily weights, and assessment of volume status.
Consider ordering a CXR.
Check plasma and urine osmolalities and sodium.
Do not give patients with SIADH NS, as this can paradoxically worsen the hyponatremia.
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What should you do next?
ATN, acute interstitial nephritis, vasculitis, or anything causing renal ischemia.
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Acute interstitial nephritis yields a UA with eosinophils, WBCs, and WBC casts.
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To ensure the patient's safety, order an ECG (may show a short QT interval).
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