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Common electrolyte disorders in primary care

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Title: Common electrolyte disorders in primary care


1
Common electrolyte disorders in primary care
  • Steve Hyer

2
  • ELECTROLYTES

3
Approach
  • History including drugs
  • Examination including fluid status, blood
    pressure
  • Screening tests
  • Confirmatory tests

4
Thinking about electrolytes
Excess/reduced intake
Redistribution
Excess/reduced Loss
5
Is hyponatraemia important?
  • 3 reasons
  • The wrong treatment can be disastrous
  • Rapid correction can be disastrous
  • Acute severe hypoNa associated with increased
    mortality

T1 Low density T2 High density
6
Scope
  • Sodium
  • Potassium
  • Calcium

7
Case 1
  • 69y F Na 121
  • Previously Na 139
  • Started bendro 10d previously
  • Stopped bendro Na 134 10d later.

Diagnosis Thiazide-induced hyponatraemia
8
Case 2
  • 88y M
  • Acutely unwell with sodium 120 mmol/l and signs
    of pleural effusion.
  • Chest CT scan showed extensive inoperable
    bronchial carcinoma. .

Diagnosis SIADH associated with carcinoma
bronchus
9
Case 3
  • 83y F
  • Na 126129 mmol/l following AP resection and
    ileostomy.
  • Urine maximal sodium conservation.
  • Na normalised by reversal of ileostomy .

Diagnosis Salt and water loss through high flow
stoma
10
Case 4
  • 56y M
  • 10d diarrhoea and vomiting.
  • Na 108 mmol/l K 5.5
  • Subsequent investigations confirmed Addisons
    disease. .

Diagnosis Hyponatraemia due to adrenal
insufficiency
11
  • 2 important hormones.

12
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13
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14
No aldosterone! (Adrenal
insufficiency)
ACE-inhibitors effectively lead to low
aldosterone can cause hypoNa
15
Diagnosis adrenal insufficiency
SYNACTHEN TEST
16
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17
Enhanced ADH release
  • Tumours releasing ADH eg Ca bronchus
  • CNS disorders affecting hypothalamus eg SAH
  • Pain especially thoracic
  • Nausea
  • Opiates, SSRIs, CBZP
  • Atypical pneumonia

V2 receptors
Dilutional hyponatramia
18
  • One important bit of the kidney.

19
Distal convoluted tubule
  • This is where the aldosterone works
  • Drugs
  • Renal tubular acidosis
  • Chronic pyelonephritis

20
  • Excess water intake with low solutes

21
Low solute intake Fun runners
  • Drinking fluids every mile
  • Gain weight after run!
  • Drink 3 litres in a run of 1-2 hrs
  • Severe hyponatraemia and even death

Non elite runner
22
Low solute intake Beer potomania
  • Beer
  • Very low sodium/ potassium
  • Maximum 4-5 litres of electrolye free water
    excretable per day
  • In absence of solute, gt5L beer severe hypoNa

Tea toast old ladies
23
Primary polydipsia
  • Low osmotic threshold to feel thirsty
  • Unable to suppress thirst
  • Exaggerated thirst
  • Hyponatraemia polydipsia polyuria

24
  • Diagnosis

25
Clinical symptoms
Plasma Na Symptoms Mortality ()
gt125 Usually none. Occasional headache, nausea Not reported
120 -125 Headache, nausea, cramps, confusion 23
115-120 Agitation, drowsy, stupor 30
lt115 Seizures, coma 40
26
Step 1 Assess Volume status
  • Mucosal membranes, tongue, skin turgor, urine
    output

27
Step 2 CLASSIFY
  • Hyper-volaemic
  • Normo-volaemic
  • Hypo-volaemic

Weight Down OK Up
28
Step 3 Evaluate Clinical
29
Step 4 Evaluate Laboratory
Conserving sodium
Losing sodium in urine
30
Management SIADH
  • Underlying cause
  • Fluid restrict (0.5-1L/d)
  • May take days to come down
  • Maintain Na intake
  • (Demeclocycline-causes NDI)
  • VAPTANS (e.g.Tolvaptan)

V2 blocker
31
Tolvaptan
  • Oral agent
  • Currently only in secondary care for chronic
    SIADH
  • Expensive but could reduce hospital stay
  • Especially where fluid restriction poorly
    tolerated
  • C/I Hypovolaemic hypoNa
  • ?long term

32
Secondary care
  • Special tests
  • Hypertonic saline test
  • Water loading tests
  • Measurement of AVP
  • Hypertonic saline infusions Na rise not
    gt10mmol/d
  • Scans, etc

DDI Dipsogenic DI
33
Summary Hyponatramia
  • Multitude of causes
  • Many patients with chronic mild hyponatraemia
    have adapted and apparently very well- may
    decompensate in acute illness
  • First do no harm!

34
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35
Hypernatraemia Nagt145
  • History
  • Thirst/ Polyuria
  • No symptoms
  • Drugs
  • Examination
  • Dehydrated
  • Excessive water loss

Think diabetes insipidus
36
Algorithm Na
Loss of water
Loss of water
37
Hypokalaemia
  • History
  • Diarrhoea, vomiting
  • No symptoms
  • Drugs eg Ventolin, diuretics, insulin
  • Examination
  • Fluid status
  • Blood pressure

Think diuretics
38
Cola drink hypokalaemia
  • Sugar
  • Caffeine
  • At least 2 litres/day

39
Hypertension low K
  • Think Conn
  • (Hyper-aldosteronism)
  • Think Cushing
  • Think renal artery stenosis

Renin Aldo ratio
40
Algorithm K
Gut loss
Renal loss
41
Hyperkalaemia Kgt5.0
  • History
  • Renal
  • No symptoms
  • Drugs eg ACE-I, spiro, amiloride
  • Examination
  • Addisons
  • Renal

Think renal failure
Dont forget haemolysed samples, old samples
42
Algorithm
Output
Input
Dont forget Addison
43
Hypercalcaemia Cagt2.6
  • Mild hypercalcaemia (Ca lt3mmol)
  • Mostly due to primary hyperparathyroidism
  • Usually asymptomatic
  • Diagnosis Ca blood/ urine PTH

44
Recommending PTH-ectomy


  • Patient fit for surgery
  • Significantly reduced BMD on DEXA scan
  • Reduced renal function (eGFR)
  • Cagt2.85
  • History of stones
  • Increased Ca excretion

Frail elderly consider bisphosphonate infusion
45
Moderate-severe Ca
  • Consider malignancy esp older patient
  • Myeloma
  • Sarcoidosis
  • Thyrotoxicosis
  • FHH
  • Drugs

Bisphosphonates
46
Malignant hypercalcaemia
Tumour mets
Non-metastatic (PTH-RP)
47
Algorithm
48
Low calcium Ca lt2.2mmol
  • Usually Vitamin D deficiency (30 elderly, 90
    Asians?)
  • May be Chronic renal failure
  • HypoPTH
  • PseudohypoPTH
  • (Low Mg)

Lack of sun
Phytate in chipatis
Housebound
49
High Ca High PTH
Low Ca High PTH

High Ca Low PTH
Low Ca Low PTH
50
Assessment Ca
  • History
  • Diet/ diarrhoea/ mal-absorption
  • Thyroid surgery
  • Drugs eg phenytoin
  • Examination
  • Tetany, Chvostek
  • Renal
  • Investigations
  • Ca/P/ Alk Pase/ Vit D/ PTH

51
Treatment Vit D deficiency
  • Calciferol (D2)
  • Ex Calcium Vit D 400u bd
  • Colecalciferol (D3)
  • Ex Adcal-D3 (400) bd
  • Ergocalciferol
  • 10,000 u (mal-absorption)
  • Analogues
  • Ex One Alpha 0.25mcg (renal failure)

Pure vitamin D (Boots, Tesco, Holland
Barrets 25mcg (1000u) od (treat)
10 mcg (400u) od (maintain)
52
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