The Forgotten Killers: Life-threatening electrolyte...
Transcript of The Forgotten Killers: Life-threatening electrolyte...
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The Forgotten Killers: Life-threatening electrolyte disbalances (Part I)
Abigail Guija de Arespacochaga, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Bucharest, 16th March 2012
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Water homeostasis
Maintenance of pH
Why are electrolytes to important for the body function?
Function
K+
Na+
Cl-
Ca2+
Mg2+
HCO3-
H2PO4- SO4
2-
Proper heart/muscle function
Oxidation-reduction reactions
Cofactors for enzymes
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
How is electrolyte concentration regulated in the body?
K+
Intake
Skin
Renal
Feces
Na+
Na+Cl-
Cl-K+Na+
EC
IC
Na+
Na+
IntakeFeces
AirwaysK+K+
Cl-
Na+
K+Na+ IC
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Potassium: one of the most important electrolytes in the body
EC
Intake Renal 95%IC
K+ 4mEq/L
AldosteroneNa+ K+Intake
Feces 5%IC
Na+140mEq/L
95% cells
75% muscle cells
anorexia
vomiting
oliguria/anuria/PU
diarrhea
K+Na+
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
The membrane potential: the most important function of Potassium
Action potential
mV
50 Cl- 9
Na+ 15
K+ 150
Prot 107
125
150
5.5IC
EC Na +
K +
-
+
Resting potential
-50
-60
-100
Threshold
Prot 107-
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Hyperkalemia and hypokalemia are life-threatening
Normal values: 3.5 - 5.5 mEq/L (mmol/L)
Danger values:
N <2.5 mEq/LN <2.5 mEq/L
N >7.5 mEq/L
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Prolonged anorexia the most common cause of hypokalemia
EC
↓Intake ↑Renal 95%IC
K+
K+
K+
K+
K+
Electrolyteconcentration (mEq/L)
Lactated Ringer‘s
Ringer‘s
Normal Saline
Na
130
147
154
K
4
4
-
Cl
109
156
154↓Intake
↑Feces 5%IC K+
K+
K+
K+
anorexia
vomiting
iatrogenic!!
chronic renal failure
diuretics
diarrhea
H+
shift EC → IC
Insulin therapy
Normal Saline 154 - 154
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Increase of membrane resting potential due hypokalemia
Action potential
mV
50
IC
EC
K +
-
+
Resting potential
-50
-60
-100
Threshold
-
HYPOKALEMIA
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Cardiac dysrhytmias: most important consequence of hypokalemia
Cardiac arrhythmias
Ø Depressed T-wave amplitude
Ø Depressed ST segment
Ø Prolonged QT interval
Ø Prominent U waveØ Prominent U wave
Ø Arrhythmias: supraventricular and ventricular
Qualitative relationship between plasma potassium leves and QT interval in beagle dogs. G. Haton et al . Laboratory animals (2007) 41, 204-217
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Cats are more susceptible to the effects of hypokalemia
Hypokalemic Polymyopathy
Ø Potassium < 3.5mEq/L
Ø CK 10-30x
Hypokalemic NephropathyHypokalemic Nephropathy
Ø Azotemia
Ø Impaired renal function
Ø Tubulointerstitial nephritis
Picture : http://medical-dictionary.thefreedictionary.com/feline+hypokalemic+polymyopathy
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
•Klinische ChemieWhat would happen with „Tiger“ if we forget to measure Potassium concentration
• 5y, ♂ neutered, ESH cat
• Polidypsia since 10 days
• Lethargy since 5 days
Clinical Signs
• Generalized weakness, lethargy
• Temperature 36.1°C
• Treatment with infusion during 2 days by local veterinary
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Parameter Patient Reference interval Unit
Hematocrit 47.1 27-47 %
Glucose 17 55-100 md/dlß-Hydroxybutyrat 1.19 <1 mmol/LCreatinine 4.1 <1.6 mg/dlTP 8.42 6-7.5 g/dl
Whithout the Potassium measurement we would treat „Tiger“ just like a hypoglykemic patient
TP 8.42 6-7.5 g/dlAlbumin 3.77 g/dlALT 319 <100 U/lCK 3161 <200 U/lSodium 140 142-164 mmol/lPotassium 1.6 3.5-5.0 mmol/lChloride 104 111-130 mmol/lCalcium 1.23 1.1-1.4 mmol/lPhosphate 0.52 0.8-1.6 mmol/l
Hemolytic plasma ++
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Many possible diagnosis in the case of „Tiger“
1. Treatment Diabetic Ketoacidosis
2. Feline Kaliopenic Nephropathy-Polymyopathy Syndrome
• Predisposing factors: low dietary K, dietary acidification, CRF
• Clinical signs: cervical ventroflexion, generalized muscle weakness, signs of renal failure• Clinical signs: cervical ventroflexion, generalized muscle weakness, signs of renal failure
• Diagnosis: hypokalemia, azotemia, metabolic acidosis
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Potassium supplementation in hypokalemic patients
Serum K+ mEq KCL to add Max fluid infusion rate (mEq/L) to 250mL fluid (mL/kg/hr)
<2.0
2.1 – 2.5
20
15
6
8
2.6 – 3.0
3.1 – 3.5
3.6 – 5.0
10
7
5
12
18
25
In: Fluid, electrolyte, and acid-base disorders in small animal practice, (pp107) S.P DiBartola
Rate of IV Potassium administration: max 0.5mEq/kg/h
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Decreased urinary potassium excretion most important cause of hyperkalemia
Intake Renal 95%
EC
IC
K+K+
K+K+
K+
Rule out pseudohyperkalemia!!!!
Intake IC
K+ K+
K+
H+
K+
iatrogenic!! anuria/oliguria
↓renal excretion
Shift IC → EC
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Don‘t panic: first rule out pseudohyperkalemia
anamnesis lab resultsclinical signs+ +
thrombocytosis
leukocytosis
Akita, english springer spaniel,
neonates
asymptomatic
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
• Test • Urea 27• Crea 0.9• AP 111
EDTA anticoagulant most common preanalytical error in themeasurement of potassium concentration
• Reference interval• 20-40 mg/dl• bis 1.2 mg/dl• bis 190 U/L
• Heparin• 28• 1.0• 364• AP 111
• ALT 50• Lipase 254• Ca 0.2• K 29• Na 148• Cl 113
• bis 190 U/L• bis 40 U/L
• bis 250 U/L• 2.4-3.0 mmol/L• 3.6-5.6 mmol/L
• 140-152 mmol/L• 98-120 mmol/L
• 364• 39 • 258• 2.6 • 4.1 • 152• 116
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Decrease of membrane resting potential due hyperkalemia
Action potential
mV
50
IC
EC
K +-K +
K +
K +K +
K +K +
K +
K +
K +
K +
K +K +
K +
Resting potential
-50
-60
-100
Threshold
-
HYPERKALEMIA
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Progressive ECG changes develops with worsening hyperkalemia
5 6 121110987 mEq
In: Cardiovascular System Disorders in Small Animal Internal Medicine, RW Nelson, CG Couto
↑ rate of repolarization → peaked, tented T wave, shortened Q-T interval
Slowed conduction in atria → flattened P wave
Conduction through atria fails → P wave disappears
Progressive slowing of intraventricualr conduction → QRS widens
Activation of ectopic pacemakers → irregular ventricular rhythm
Ventricular fibrillation or asystole
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Poor correlation between ECG changes and potassium concentration
Feline arrhythmias: an update. E. Coté (2010) Vet Clin Small Anim 40, 643-650
> 5.5 - 7 mEq/L peaking T wave, shortening QT interval
7.1 – 8.5 mEq/L widening QRS complex, prolongation PR interval, loss P wave, atrial standstill
8.6 – 12 mEq/L severe indistinctly fusion of QRS complexes and T waves into a sine-wave
> 12 mEq/L critical ventricular fibrillation and/or asystole
Cat A & B (urethral obstruction) and hyperkalemia (10.5mEq/L)
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
•Klinische ChemieWhat would happen with „Simba“ if we forget to measure Potassium concentration
• 5y, ♀ spayed, mix breed
• Vomitous since 3 weeks
• Decrease food and water ingestion sometimes
• Increased serum urea and creatinine concentration• Increased serum urea and creatinine concentration
Clinical Signs:
• Lethargy
• Heart rate 60bpm, weak heart sounds
• Muscle atrophy: hind limbs and head
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Unremarkable hematological results
Parameter Patient Reference interval
Unit
RBC 7.56 5.5-8 106/µlHCT 45 37-55 %HGB 19.5 12-18 g/dlMCV 59.5 60-77 flMCH 21 19-24.5 pgMCH 21 19-24.5 pgMCHC 35.3 31-34 %WBC 11.68 6-15 103/µlNeut. Gran. 7.65 3.3-11.25 103/µlLymphozyten 2.71 0.78-4.5 103/µlMonozyten 0.61 0.5 103/µlEos. Gran. 0.65 0.8 103/µl
Microscopic examination: unremarkable
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Parameter Patient Reference interval
Unit
Glucose 103 55-90 mg/dlFruktosamin 259 < 370 µmol/lUrea 267 20-40 mg/dlCreatinine 6.6 0.4-1.2 mg/dlTP 7.25 6-7.5 g/dl
Whithout the Potassium measurement we would treat „Simba “ just like a renal patient
Azotemia
Prerenal
Renal
Postrenal
History + Clinical Signs + Urinalysis (SG)TP 7.25 6-7.5 g/dl
Albumin 3.37 2.6-4.7 g/dlAP 53 <190 U/lALT 78 <80 U/lTriglycerids 44 50-100 mg/dlCholesterol 179 125-250 mg/dlAmylase 2104 <1650 U/lLipase 22 <125 U/lCK 164 <250 U/lSodium 121 140-152 mmol/lPotassium 7.6 3.6-5.6 mmol/lChloride 94 95-113 mmol/lCalcium 3.32 2.4-3 mmol/lPhosphate 4.02 0.9-1.6 mmol/l
Na:K Ratio = 15.9
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Na:K < 27: most common causes
Na:K < 27; N=39
26% urinary disease
16% parasitism
1 case hypoadrenocorticism Na:K15,75
Evaluation of low sodium:potassium ratio in dogs, L. Roth & R.D. Thyler (1999) J Vet Diagn Invest 11:60-64 (left)
The clinical implication of sodium-potassium rtios in dogs. Son-Il Pak (2000) J. Vet. Sci, 1(1), 61-65
Na:K < 24; N=34
41% urinary tract/renal disease
24% hypoadrenocorticism
Na:K < 15
100% hypoadrenocorticism
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
95% of dogs with hypoadrenocorticism have hyperkalemia
Parameter Reference Interval
Unit
ACTH 2420 < 20 pg/mlCortisol basal < 1.0 1-4 µg/dlCortisol 90 Min. < 1.0 … µg/dl
HypoadrenocorticismHypoadrenocorticism
Hyperkalemia 95%; range 4.1-10.8mEq/L (7mEq/L)
Hyponatremia 86%; range 106-155mEq/L (128mEq/L)
Na:K Ratio Normal 27:1 – 40:1
1° hypoadrenocorticism 95% < 27:1, ratio < 15:1
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
What would happen with „Isis“ if we forget to measure Potassium concentration
• 11y, ♀ spayed, B. Sennenhund
• Since 2 months polakisuria and dysuria
• Reddish urine
Clinical findings
• Lethargy
• Abdomen: undulation
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Slight changes in the hematological results of „Isis“
Parameter Patient Reference interval
Unit
RBC 6.13 5.5-8 106/µlHCT 42.6 37-55 %HGB 16.5 12-18 g/dlMCV 69.5 60-77 flMCH 26.9 19-24.5 pgMCH 26.9 19-24.5 pgMCHC 38.7 31-34 %WBC 15.9 6-15 103/µlNeutrophils 12.58 3.3-11.25 103/µlLymphocytes 1.81 0.78-4.5 103/µlMonocytes 1.27 0.5 103/µlEosinophils 0.31 0.8 103/µl
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Parameter Patient Reference interval
Unit
Glucose 107 55-90 mg/dlUrea 169.7 20-40 mg/dlCreatinine 4.8 0.4-1.2 mg/dlTP 8.22 6-7.5 g/dlAlbumin 4.29 2.6-4.7 g/dl
Azotemia
Prerenal
Renal
Postrenal
History + Clinical Signs + Urinalysis (SG)
Trying to find out origin of Azotemia
Albumin 4.29 2.6-4.7 g/dlALT 68 <80 U/lSodium 148 140-152 mmol/lPotassium 5.9 3.6-5.6 mmol/lChloride 110 95-113 mmol/lCalcium 2.58 2.4-3 mmol/lPhosphate 4.18 0.9-1.6 mmol/l
Na:K Ratio = 25
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Cooperation between laboratory findings
Peritoneal Fluid Analysis:
Color: brown-reddish
Total cell count: 890/µl
Total Protein: 0.3g/dl
Cytological Examination: Cytological Examination:
low cell content, with 90% degenerated
neutrophils and 10% mononuclear cells
Parameter Serum Effusion Unit
Urea 169 273.3 mg/dlCreatinine 4.8 16.3 mg/dl
Uroperitoneum
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology
Treatment of hyperkalemia: step by step
Acute increase (> 6.5mEq/L)
Asymptomatic animals (5.5-6.5mEq/L)
Ø Discontinue Potassium intake and drugs that promote hyperkalemia
Ø Treatment of underlying diseasesØ Treatment of underlying diseases
Ø Fluid therapy e.g. 0.9% NaCl
Ø Treatment of hyperkalemia:
Ø Calcium gluconate (2-10ml of a 10% solution IV)
Ø Glucose (1-2ml/kg 50% dextrose IV)
Ø Dialysis
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Abigail Guija, DVM, Dipl. ECVCPSpecialist for Clinical Pathology