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Hamsho S, Alhussen AHD, Alabdullah H, Sleiay B, Kasem N, Hassan Q. Hypokalemia in a young man…think Bartter syndrome type 3. Ann Med Surg (Lond) 2024; 86:3636-3640. [PMID: 38846905 PMCID: PMC11152808 DOI: 10.1097/ms9.0000000000001994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 03/13/2024] [Indexed: 06/09/2024] Open
Abstract
Background Bartter syndrome is an autosomal recessive salt reabsorption disorder that results in decreased extracellular fluid volume with low/normal blood pressure. Case presentation A 17-year-old boy with polydipsia, polyuria, weakness in the lower limbs, and ataxic gait. His Laboratory test shows hypokalemia; hypochloremia, hypomagnesemia and metabolic alkalosis. The authors' patient was managed by fluid and electrolyte replacement, which is essential in emergency management. Conclusion Bartter syndrome is difficult to treat, and currently, there is no complete cure. The overall prognosis depends on the extent of receptor dysfunction, and despite these facts, most patients can live a normal life if they strictly follow their treatment plan.
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Affiliation(s)
| | | | | | - Bilal Sleiay
- Faculty of Medicine, Hama University, Hama, Syria
| | - Noor Kasem
- Department of Nephrology, Al Assad and Al Mouwasat University Hospital
| | - Qussai Hassan
- Department of Nephrology, Al Assad University Hospital, Faculty of Medicine, Damascus University, Damascus
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2
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Stewart GW. Pyroglutamate acidosis 2023. A review of 100 cases. Clin Med (Lond) 2024; 24:100030. [PMID: 38431210 PMCID: PMC11091441 DOI: 10.1016/j.clinme.2024.100030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
This review concerns the rare, acquired, usually iatrogenic, high-anion-gap metabolic acidosis, pyroglutamic acidosis. Pyroglutamate is a derivative of the amino acid glutamate, and is an intermediate in the 'glutathione cycle', by which glutathione is continuously synthesized and broken down. The vast majority of pyroglutamic acidosis cases occur in patients on regular, therapeutic doses of paracetamol. In about a third of cases, flucloxacillin is co-prescribed. In addition, the patients are almost always seriously unwell in other ways, typically with under-nourishment of some form. Paracetamol, with underlying disorders, conspires to divert the glutathione cycle, leading to the overproduction of pyroglutamate. Hypokalaemia is seen in about a third of cases. Once the diagnosis is suspected, it is simple to stop the paracetamol and change the antibiotic (if flucloxacillin is present), pending biochemistry. N-acetyl-cysteine can be given, but while the biochemical justification is compelling, the clinical evidence base is anecdotal.
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Affiliation(s)
- Gordon W Stewart
- Emeritus Professor of Experimental Medicine, UCL, Division of Medicine, University College London, London WC1E 6JJ, UK.
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3
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Alkhatib EH, Bartlett D, Kanakatti Shankar R, Regier D, Merchant N. Case report: Early molecular confirmation and sodium polystyrene sulfonate management of systemic pseudohypoaldosteronism type I. Front Endocrinol (Lausanne) 2024; 14:1297335. [PMID: 38288475 PMCID: PMC10822876 DOI: 10.3389/fendo.2023.1297335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/15/2023] [Indexed: 02/01/2024] Open
Abstract
Introduction Type 1 pseudohypoaldosteronism (PHA) consists of resistance to aldosterone. Neonatal presentation is characterized by salt wasting, hyperkalemia, and metabolic acidosis with high risk of mortality. Type 1 PHA can be autosomal dominant (renal type 1) or autosomal recessive (systemic type 1). Renal PHA type 1 can be feasibly managed with salt supplementation; however, systemic PHA type 1 tends to have more severe electrolyte imbalance and can be more refractory to treatment. Case Presentation We present a case of a 3-year-old girl with systemic PHA type 1, diagnosed and confirmed molecularly in infancy, who has been successfully managed with sodium polystyrene sulfonate decanted into feeds along with sodium supplementation. On day 5 of life, a full-term female infant presented to the ED for 2 days of non-bloody, non-bilious emesis, along with hypothermia to 94°F. Laboratory results were notable for hyponatremia (Na) of 127, hyperkalemia (K) of 7.9, and acidosis with bicarbonate level of 11.2. Genetic testing ordered within a week of life confirmed PHA type 1 with a homozygous pathogenic frameshift variant in SCNN1A c.575delA (p.Arg192GlyfsX57). Sodium polystyrene sulfonate and feeds were decanted until the age of 16 months, and she was also continued on NaCl supplementation. She was gradually transitioned to directly administered sodium polystyrene sulfonate without any electrolyte issues. She has overall done well after gastrostomy-tube (G-tube) placement without severe hyperkalemia even with several hospitalizations for gastrointestinal or respiratory illnesses. Discussion/Conclusion A treatment approach to systemic PHA and sodium polystyrene sulfonate administration in neonates and infants is described.
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Affiliation(s)
- Einas H. Alkhatib
- Department of Endocrinology, Children’s National Hospital, Washington, D.C., United States
| | - Deirdre Bartlett
- Department of Nephrology, Lurie Children’s Hospital, Chicago, IL, United States
| | - Roopa Kanakatti Shankar
- Department of Endocrinology, Children’s National Hospital, Washington, D.C., United States
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, D.C., United States
| | - Debra Regier
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, D.C., United States
- Department of Genetics and Metabolism, Children’s National Hospital, Washington, D.C., United States
| | - Nadia Merchant
- Department of Endocrinology, Children’s National Hospital, Washington, D.C., United States
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, D.C., United States
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4
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Kettritz R, Loffing J. Potassium homeostasis - Physiology and pharmacology in a clinical context. Pharmacol Ther 2023; 249:108489. [PMID: 37454737 DOI: 10.1016/j.pharmthera.2023.108489] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
Membrane voltage controls the function of excitable cells and is mainly a consequence of the ratio between the extra- and intracellular potassium concentration. Potassium homeostasis is safeguarded by balancing the extra-/intracellular distribution and systemic elimination of potassium to the dietary potassium intake. These processes adjust the plasma potassium concentration between 3.5 and 4.5 mmol/L. Several genetic and acquired diseases but also pharmacological interventions cause dyskalemias that are associated with increased morbidity and mortality. The thresholds at which serum K+ not only associates but also causes increased mortality are hotly debated. We discuss physiologic, pathophysiologic, and pharmacologic aspects of potassium regulation and provide informative case vignettes. Our aim is to help clinicians, epidemiologists, and pharmacologists to understand the complexity of the potassium homeostasis in health and disease and to initiate appropriate treatment strategies in dyskalemic patients.
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Affiliation(s)
- Ralph Kettritz
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité Universitätsmedizin Berlin, Germany.
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5
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Abstract
PURPOSE OF REVIEW We recently localized a new K-Cl cotransporters-3 (KCC3) transporter to the apical membrane of type-B intercalated cells. This gives us an opportunity to revisit the roles of the KCC3 in kidney and integrate the new findings to our current knowledge of the biology of the bicarbonate secreting cells. RECENT FINDINGS Here, we review the basic properties of the K-Cl cotransporter with a particular attention to the responsiveness of the transporter to cell swelling. We summarize what is already known about KCC3b and discuss new information gained from our localizing of KCC3a in type-B intercalated cells. We integrate the physiology of KCC3a with the main function of the type-B cell, that is, bicarbonate secretion through the well characterized apical Cl-/HCO3- exchanger and the basolateral Na-HCO3 cotransporter. SUMMARY Both KCC3b and KCC3a seem to be needed for maintaining cell volume during enhanced inward cotransport of Na-glucose in proximal tubule and Na-HCO3 in intercalated cells. In addition, apical KCC3a might couple to pendrin function to recycle Cl-, particularly in conditions of low salt diet and therefore low Cl- delivery to the distal tubule. This function is critical in alkalemia, and KCC3a function in the pendrin-expressing cells may contribute to the K+ loss which is observed in alkalemia.
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Affiliation(s)
- Mohammed Z Ferdaus
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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6
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Milne A, Radhakrishnan A. Biochemical disturbance in damage control resuscitation: mechanisms, management and prognostic utility. Curr Opin Anaesthesiol 2023; 36:176-182. [PMID: 36728975 DOI: 10.1097/aco.0000000000001226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW With advances in resuscitative techniques, trauma patients are surviving increasingly severe injuries and physiological insult. Timely recognition of futility remains important in terms of patient dignity and resource preservation yet is increasingly challenging in the face of these advances. The understanding of biochemical derangement from pathophysiological processes of trauma and iatrogenic effects of resuscitation has expanded recently. RECENT FINDINGS Acidosis and hypocalcaemia have been recognized as important contributors to mortality among trauma patients. Although less well recognized and studied, critical injury and high blood product volume resuscitation render patients vulnerable to life-threatening hyperkalaemia. The methods of correcting disruptions to acid-base and electrolyte homeostasis during damage control resuscitation have changed little recently and often rely on evidence from undifferentiated populations. Biochemical disturbances have value as ancillary predictors of futility in trauma resuscitation. SUMMARY These findings will contribute to a greater understanding among anaesthesiologists of the causative mechanisms and effects of biochemical derangement after severe injury and aid them in the delivery of well tolerated and effective damage control resuscitation. Gaps in the evidence base are highlighted to encourage future work.
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Affiliation(s)
- Andrew Milne
- Trauma Anaesthesia Group, Barts Health NHS Trust, Royal London Hospital, London, UK
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7
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Johnston JG, Welch AK, Cain BD, Sayeski PP, Gumz ML, Wingo CS. Aldosterone: Renal Action and Physiological Effects. Compr Physiol 2023; 13:4409-4491. [PMID: 36994769 DOI: 10.1002/cphy.c190043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Aldosterone exerts profound effects on renal and cardiovascular physiology. In the kidney, aldosterone acts to preserve electrolyte and acid-base balance in response to changes in dietary sodium (Na+ ) or potassium (K+ ) intake. These physiological actions, principally through activation of mineralocorticoid receptors (MRs), have important effects particularly in patients with renal and cardiovascular disease as demonstrated by multiple clinical trials. Multiple factors, be they genetic, humoral, dietary, or otherwise, can play a role in influencing the rate of aldosterone synthesis and secretion from the adrenal cortex. Normally, aldosterone secretion and action respond to dietary Na+ intake. In the kidney, the distal nephron and collecting duct are the main targets of aldosterone and MR action, which stimulates Na+ absorption in part via the epithelial Na+ channel (ENaC), the principal channel responsible for the fine-tuning of Na+ balance. Our understanding of the regulatory factors that allow aldosterone, via multiple signaling pathways, to function properly clearly implicates this hormone as central to many pathophysiological effects that become dysfunctional in disease states. Numerous pathologies that affect blood pressure (BP), electrolyte balance, and overall cardiovascular health are due to abnormal secretion of aldosterone, mutations in MR, ENaC, or effectors and modulators of their action. Study of the mechanisms of these pathologies has allowed researchers and clinicians to create novel dietary and pharmacological targets to improve human health. This article covers the regulation of aldosterone synthesis and secretion, receptors, effector molecules, and signaling pathways that modulate its action in the kidney. We also consider the role of aldosterone in disease and the benefit of mineralocorticoid antagonists. © 2023 American Physiological Society. Compr Physiol 13:4409-4491, 2023.
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Affiliation(s)
- Jermaine G Johnston
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida, USA
- Nephrology Section, Veteran Administration Medical Center, North Florida/South Georgia Malcom Randall Department of Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - Amanda K Welch
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
- Nephrology Section, Veteran Administration Medical Center, North Florida/South Georgia Malcom Randall Department of Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - Brian D Cain
- Department of Biochemistry and Molecular Biology, University of Florida, Gainesville, Florida, USA
| | - Peter P Sayeski
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida, USA
| | - Michelle L Gumz
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida, USA
- Department of Biochemistry and Molecular Biology, University of Florida, Gainesville, Florida, USA
- Nephrology Section, Veteran Administration Medical Center, North Florida/South Georgia Malcom Randall Department of Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - Charles S Wingo
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida, USA
- Nephrology Section, Veteran Administration Medical Center, North Florida/South Georgia Malcom Randall Department of Veterans Affairs Medical Center, Gainesville, Florida, USA
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8
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Prediction of Acid-Base and Potassium Imbalances in Intensive Care Patients Using Machine Learning Techniques. Diagnostics (Basel) 2023; 13:diagnostics13061171. [PMID: 36980479 PMCID: PMC10047445 DOI: 10.3390/diagnostics13061171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 03/22/2023] Open
Abstract
Acid–base disorders occur when the body’s normal pH is out of balance. They can be caused by problems with kidney or respiratory function or by an excess of acids or bases that the body cannot properly eliminate. Acid–base and potassium imbalances are mechanistically linked because acid–base imbalances can alter the transport of potassium. Both acid–base and potassium imbalances are common in critically ill patients. This study investigated machine learning models for predicting the occurrence of acid–base and potassium imbalances in intensive care patients. We used an institutional dataset of 1089 patients with 87 variables, including vital signs, general appearance, and laboratory results. Gradient boosting (GB) was able to predict nine clinical conditions related to acid–base and potassium imbalances: mortality (AUROC = 0.9822), hypocapnia (AUROC = 0.7524), hypercapnia (AUROC = 0.8228), hypokalemia (AUROC = 0.9191), hyperkalemia (AUROC = 0.9565), respiratory acidosis (AUROC = 0.8125), respiratory alkalosis (AUROC = 0.7685), metabolic acidosis (AUROC = 0.8682), and metabolic alkalosis (AUROC = 0.8284). Some predictions remained relatively robust even when the prediction window was increased. Additionally, the decision-making process was made more interpretable and transparent through the use of SHAP analysis. Overall, the results suggest that machine learning could be a useful tool to gain insight into the condition of intensive care patients and assist in the management of acid–base and potassium imbalances.
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9
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Wu H, Wahane A, Alhamadani F, Zhang K, Parikh R, Lee S, McCabe EM, Rasmussen TP, Bahal R, Zhong XB, Manautou JE. Nephrotoxicity of marketed antisense oligonucleotide drugs. CURRENT OPINION IN TOXICOLOGY 2022; 32:100373. [PMID: 37193356 PMCID: PMC10174585 DOI: 10.1016/j.cotox.2022.100373] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The field of antisense oligonucleotide (ASO)-based therapies have been making strides in precision medicine due to their potent therapeutic application. Early successes in treating some genetic diseases are now attributed to an emerging class of antisense drugs. After two decades, the US Food and Drug Administration (FDA) has approved a considerable number of ASO drugs, primarily to treat rare diseases with optimal therapeutic outcomes. However, safety is one of the biggest challenges to the therapeutic utility of ASO drugs. Due to patients' and health care practitioners' urgent demands for medicines for untreatable conditions, many ASO drugs have been approved. However, a complete understanding of the mechanisms of adverse drug reactions (ADRs) and toxicities of ASOs still need to be resolved. The range of ADRs is unique to a specific drug, while few ADRs are common to a section of drugs as a whole. Nephrotoxicity is an important concern that needs to be addressed considering the clinical translation of any drug candidates ranging from small molecules to ASO-based drugs. This article encompasses what is known about the nephrotoxicity of ASO drugs, the potential mechanisms of action(s), and recommendations for future investigations on the safety of ASO drugs.
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Affiliation(s)
- Hangyu Wu
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, Connecticut 06269, USA
| | - Aniket Wahane
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, Connecticut 06269, USA
| | - Feryal Alhamadani
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, Connecticut 06269, USA
| | - Kristy Zhang
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, Connecticut 06269, USA
| | - Rajvi Parikh
- Department of Physiology and Neurobiology, University of Connecticut, Storrs, Connecticut 06269, USA
| | - SooWan Lee
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, Connecticut 06269, USA
| | - Evan M McCabe
- Department of Molecular and Cell Biology, University of Connecticut, Storrs, Connecticut 06269, USA
| | - Theodore P Rasmussen
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, Connecticut 06269, USA
- Department of Molecular and Cell Biology, University of Connecticut, Storrs, Connecticut 06269, USA
| | - Raman Bahal
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, Connecticut 06269, USA
| | - Xiao-Bo Zhong
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, Connecticut 06269, USA
| | - José E Manautou
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, Connecticut 06269, USA
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10
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Age-related effects of Feeder Space availability on welfare of broilers reared to 56 days of age part 1: biochemical, enzymatical, and electrolyte variables. J APPL POULTRY RES 2022. [DOI: 10.1016/j.japr.2022.100281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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11
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KAYA B, PAYDAS S, KUZU T, DEMİROGLU O, YÜCEL KARAKAYA SP, BALAL M, TAŞOVA Y. Effects of hypokalemia on clinical outcomes in hospitalized patients with Covid-19 pneumonia. CUKUROVA MEDICAL JOURNAL 2021. [DOI: 10.17826/cumj.989230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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12
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Gupta AA, Self M, Mueller M, Wardi G, Tainter C. Dispelling myths and misconceptions about the treatment of acute hyperkalemia. Am J Emerg Med 2021; 52:85-91. [PMID: 34890894 DOI: 10.1016/j.ajem.2021.11.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/14/2021] [Accepted: 11/18/2021] [Indexed: 10/19/2022] Open
Abstract
Hyperkalemia represents a widespread and potentially lethal condition that affects millions of people across their lives. Despite the prevalence and severity of the condition, there are no consensus guidelines on the treatment of hyperkalemia or even a standard definition. Herein, we provide a succinct review of what we believe to be the most significant misconceptions encountered in the emergency care of hyperkalemia, examine current available literature, and discuss practical points on several modalities of hyperkalemia treatment. Additionally, we review the pathophysiology of the electrocardiographic effects of hyperkalemia and how intravenous calcium preparations can antagonize these effects. We conclude each section with recommendations to aid emergency physicians in making safe and efficacious choices for the treatment of acute hyperkalemia.
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Affiliation(s)
- Arnav A Gupta
- Department of Emergency Medicine, University of California at San Diego, 200 W. Arbor Drive, San Diego, CA 92013, USA.
| | - Michael Self
- Department of Emergency Medicine, University of California at San Diego, 200 W. Arbor Drive, San Diego, CA 92013, USA; Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, University of California at San Diego, 200 W. Arbor Drive, San Diego, CA 92013, USA
| | - Matthew Mueller
- Department of Emergency Medicine, University of California at San Diego, 200 W. Arbor Drive, San Diego, CA 92013, USA; Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, University of California at San Diego, 200 W. Arbor Drive, San Diego, CA 92013, USA
| | - Gabriel Wardi
- Department of Emergency Medicine, University of California at San Diego, 200 W. Arbor Drive, San Diego, CA 92013, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California at San Diego, 200 W. Arbor Drive, San Diego, CA 92013, USA
| | - Christopher Tainter
- Department of Emergency Medicine, University of California at San Diego, 200 W. Arbor Drive, San Diego, CA 92013, USA; Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, University of California at San Diego, 200 W. Arbor Drive, San Diego, CA 92013, USA
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13
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Krump L, Sayers RG, Kennedy E, O'Mahony J, Sayers GP. Evaluation of the optimal strong ion difference concentration of an oral electrolyte and buffering solution for the treatment of neonatal calf diarrhea. J Vet Med Sci 2021; 83:1715-1721. [PMID: 34544938 PMCID: PMC8636875 DOI: 10.1292/jvms.21-0391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
An observational study was conducted to comparatively assess the efficacy of three different oral rehydration and buffering solutions, differentiated by their strong ion difference (SID)
concentration, for treatment of neonatal calves with naturally acquired diarrhea. The SID concentrations tested were 100 mM, 170 mM and 230 mM for treatments SID100,
SID170 and SID230, respectively. Clinical assessment and blood gas analysis were completed for 18 diarrheic calves once pre- and twice post- (6 and 24 hr after) oral
administration with one of the three treatments. A repeated measure mixed model approach was used to analyze (a) the within-group efficacy of each treatment over time and (b) the
between-group comparison at each timepoint. SID230 treatment resulted in a significant increase in blood pH, HCO3−, BE, SID and Na+ at 6 and 24 hr
after treatment, and a significant decrease in AG and K+ by 24 hr after treatment. There were no significant changes in any of the blood gas parameters after treatment with
SID100 and SID170. SID230 treatment also resulted in blood gas parameter changes that were significantly different to the other two groups. These results
suggest that the optimum SID concentration for the treatment of calves with diarrhea is likely to be higher than current recommendations.
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Affiliation(s)
- Lea Krump
- Department of Biological and Pharmaceutical Sciences, Munster Technological University, Tralee, Co. Kerry, V92 CX88, Ireland
| | - Ríona G Sayers
- Animal and Grassland Research and Innovation Centre, Teagasc, Moorepark, Fermoy, Co. Cork, P61 C996, Ireland
| | - Emer Kennedy
- Animal and Grassland Research and Innovation Centre, Teagasc, Moorepark, Fermoy, Co. Cork, P61 C996, Ireland
| | - Jim O'Mahony
- Department of Biological Sciences, Munster Technological University, Cork, Co. Cork, T12 P928, Ireland
| | - Gearóid P Sayers
- Department of Biological and Pharmaceutical Sciences, Munster Technological University, Tralee, Co. Kerry, V92 CX88, Ireland
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14
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Benterud BP, Lindenskov PHH, Rosseland LA. No change in plasma potassium concentration during 10 minutes of apnoea: An observational study on potential organ donors. Acta Anaesthesiol Scand 2021; 65:1300-1304. [PMID: 34137462 DOI: 10.1111/aas.13940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/31/2021] [Accepted: 06/05/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute acidosis can increase the plasma potassium concentration. However, data on the effects of acute respiratory acidosis on plasma potassium concentration are conflicting. This study aimed to determine whether acute respiratory acidosis induces an immediate increase in plasma potassium concentration. METHODS This observational study was conducted on participants undergoing apnoea testing prior to final radiological examination, registered in an internal quality registry at Oslo University Hospital between 25 April 2013 and 1 May 2020. A total of 124 donors were assessed for inclusion. Sixteen donors with blood glucose concentrations exceeding 10 mmol L-1 were excluded; finally, data from 108 donors were included in the study. The apnoea test, which is a standard neurological test performed in potential organ donors prior to radiological confirmation of ceased brain circulation, induces respiratory acidosis. The arterial plasma potassium concentration, pH and PaCO2 before and after the apnoea test were compared. Statistical analysis was conducted using the paired t test. RESULTS The pre-apnoea and post-apnoea mean plasma potassium concentrations were 3.79 (95% confidence intervals [CI] 3.70-3.87) and 3.79 mmol L-1 (95% CI 3.70-3.88), respectively. The mean difference was -0.002 mmol L-1 (95% CI -0.04 to 0.04); the difference was not significant. The pre-apnoea and post-apnoea mean pH were 7.39 and 7.21, respectively, and the mean difference was 0.175 (P < .01). The pre-apnoea and post-apnoea mean PaCO2 were 5.66 and 9.48 kPa, respectively, and the mean difference was -3.83 (P < .01). CONCLUSIONS Acute respiratory acidosis does not lead to rapid changes in plasma potassium concentration during apnoea testing in potential organ donors.
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Affiliation(s)
- Bjørn P. Benterud
- Department of Anesthesiology Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
| | - Paal H. H. Lindenskov
- Department of Anesthesiology Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
| | - Leiv A. Rosseland
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Research and Development Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
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15
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Usman A, Mustafa N, Iqbal SP, Hasan MZ, Shaikh MF, Dujaili JA, Gan SH. Mapping the role of pH-adjusted potassium in diabetic ketoacidosis: Hypokalemia and the patient outcomes. Int J Clin Pract 2021; 75:e14315. [PMID: 33934480 DOI: 10.1111/ijcp.14315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/26/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Incidence of hypokalemia during the management of diabetic ketoacidosis (DKA) is high despite detailed potassium replacement guidelines in its treatment. AIM We aimed to find the role of pH-adjusted potassium (pHK ) in the development of hypokalemia, and their mutual impact on patient outcomes during DKA management. METHODOLOGY Adult DKA patient's admission data of preceding 3 years (2015-2017) were retrospectively clerked. Outcomes of interest were time to develop hypokalemia and to terminate emergency department (ED) care (hours), severity of hypokalemia and hospitalisation length (days). Linear regression was used to determine significant associations/predictors. RESULTS The study was concluded on 85 patients. Hypokalemia was observed in nearly 3/4th of all admissions and occurred by the time of ED care termination. Each 1 mmol/L increase in pHK significantly (a) reduced the degree of hypokalemia by 0.07 mmol/L, (b) delayed time to develop hypokalemia by 4.58 hours, (c) and reduced the ED care time by 1.28 hours. Arterial pH was the other factor significantly delaying time to develop hypokalemia (36.25 hours) and facilitating early discharge from ED (13.86 hours). Moreover, each 1 mmol/L reduction in the degree of hypokalemia increased hospitalisation length by 1.86 days. Though significant, acute kidney injury negligibly increased hospitalisation length by 0.01 days. CONCLUSION pH-adjusted potassium shall be used as a marker for hypokalemia and to initiate potassium replacement instead of measured serum potassium in DKA. Utilising pHK will help to avoid hypokalemia, reduce its severity and shorten ED care which will subsequently reduce hospitalisation length. We expect pHK to improve pharmacoeconomics in the future.
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Affiliation(s)
- Atif Usman
- School of Pharmacy, Monash University Malaysia, Selangor, Malaysia
| | - Norlaila Mustafa
- Department of Endocrinology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Saleem Perwaiz Iqbal
- Department of Community Medicine, Shalamar Institute of Health Sciences, Lahore, Pakistan
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Selangor, Malaysia
| | - Md Zobaer Hasan
- School of Science, Monash University Malaysia, Selangor, Malaysia
| | - Mohd Farooq Shaikh
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Selangor, Malaysia
| | | | - Siew Hua Gan
- School of Pharmacy, Monash University Malaysia, Selangor, Malaysia
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16
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Li H, Wu G, Weng Z, Sun H, Nistala R, Zhang Y. Microneedle-Based Potentiometric Sensing System for Continuous Monitoring of Multiple Electrolytes in Skin Interstitial Fluids. ACS Sens 2021; 6:2181-2190. [PMID: 34038108 DOI: 10.1021/acssensors.0c02330] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Electrolytes play a pivotal role in regulating cardiovascular functions, hydration, and muscle activation. The current standards for monitoring electrolytes involve periodic sampling of blood and measurements using laboratory techniques, which are often uncomfortable/inconvenient to the subjects and add considerable expense to the management of their underlying disease conditions. The wide range of electrolytes in skin interstitial fluids (ISFs) and their correlations with those in plasma create exciting opportunities for applications such as electrolyte and circadian metabolism monitoring. However, it has been challenging to monitor these electrolytes in the skin ISFs. In this study, we report a minimally invasive microneedle-based potentiometric sensing system for multiplexed and continuous monitoring of Na+ and K+ in the skin ISFs. The potentiometric sensing system consists of a miniaturized stainless-steel hollow microneedle to prevent sensor delamination and a set of modified microneedle electrodes for multiplex monitoring. We demonstrate the measurement of Na+ and K+ in artificial ISFs with a fast response time, excellent reversibility and repeatability, adequate selectivity, and negligible potential interferences upon the addition of a physiologically relevant concentration of metabolites, dietary biomarkers, and nutrients. In addition, the sensor maintains the sensitivity after multiple insertions into the chicken skin model. Furthermore, the measurements in artificial ISFs using calibrated sensors confirm the accurate measurements of physiological electrolytes in artificial ISFs. Finally, the skin-mimicking phantom gel and chicken skin model experiments demonstrate the sensor's potential for minimally invasive monitoring of electrolytes in skin ISFs. The developed sensor platform can be adapted for a wide range of other applications, including real-time monitoring of nutrients, metabolites, and proteins.
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Affiliation(s)
- Huijie Li
- Department of Biomedical Engineering, Institute of Materials Science, University of Connecticut, Storrs, Connecticut 06269, United States
| | - Guangfu Wu
- Department of Biomedical Engineering, Institute of Materials Science, University of Connecticut, Storrs, Connecticut 06269, United States
| | - Zhengyan Weng
- Department of Biomedical Engineering, Institute of Materials Science, University of Connecticut, Storrs, Connecticut 06269, United States
| | - He Sun
- Department of Biomedical Engineering, Institute of Materials Science, University of Connecticut, Storrs, Connecticut 06269, United States
| | - Ravi Nistala
- Division of Nephrology, Department of Medicine, University of Missouri-Columbia, Columbia, Missouri 65212, United States
| | - Yi Zhang
- Department of Biomedical Engineering, Institute of Materials Science, University of Connecticut, Storrs, Connecticut 06269, United States
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17
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Usman A, Shaikh MF, Dujaili JA, Mustafa N, Gan SH. Re-visiting pH-adjusted potassium to avoid hypokalemic crisis during management of diabetic ketoacidosis: A conceptual framework. Diabetes Metab Syndr 2021; 15:573-580. [PMID: 33706189 DOI: 10.1016/j.dsx.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/01/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Diabetic ketoacidosis (DKA) treatment guidelines recommend to initiate potassium-replacement when serum potassium (SK) drops within normal range, and to withhold insulin if SK is below normal. Despite strict recommendations, hypokalemia is frequently observed in DKA. METHODS Scientific literature was thoroughly searched to find 1) DKA treatment guidelines, 2) studies reporting hypokalemia in DKA, 3) and literature elaborating mechanisms involved in hypokalemia. RESULTS Acidosis affects SK and its regulators including insulin, catecholamines and aldosterone. Current conceptual framework is an argument to gauge the degree of hypokalemia before it strikes DKA patients utilizing SK level after adjusting it with pH. Suggested approach will reduce hypokalemia risk and its associated complications. The nomogram calculates pH-adjusted potassium and expected potassium loss. It also ranks hypokalemia associated risk, and proposes the potassium-replacement rate over given time period. The differences between current DKA treatment guidelines and proposed strategy are also discussed. Moreover, reasons and risk of hyperkalemia due to early initiation of potassium replacement and remedial actions are debated. CONCLUSION In light of proposed strategy, utilizing the nomogram ensures reduced incidence of hypokalemia in DKA resulting in improved clinical and patient outcomes. Pharmacoeconomic benefits can also be expected when avoiding hypokalemia ensures early discharge.
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Affiliation(s)
- Atif Usman
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia.
| | - Mohd Farooq Shaikh
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
| | | | - Norlaila Mustafa
- Department of Endocrinology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia.
| | - Siew Hua Gan
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia.
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18
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Palmer BF, Carrero JJ, Clegg DJ, Colbert GB, Emmett M, Fishbane S, Hain DJ, Lerma E, Onuigbo M, Rastogi A, Roger SD, Spinowitz BS, Weir MR. Clinical Management of Hyperkalemia. Mayo Clin Proc 2021; 96:744-762. [PMID: 33160639 DOI: 10.1016/j.mayocp.2020.06.014] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/18/2020] [Accepted: 06/10/2020] [Indexed: 12/26/2022]
Abstract
Hyperkalemia is an electrolyte abnormality with potentially life-threatening consequences. Despite various guidelines, no universally accepted consensus exists on best practices for hyperkalemia monitoring, with variations in precise potassium (K+) concentration thresholds or for the management of acute or chronic hyperkalemia. Based on the available evidence, this review identifies several critical issues and unmet needs with regard to the management of hyperkalemia. Real-world studies are needed for a better understanding of the prevalence of hyperkalemia outside the clinical trial setting. There is a need to improve effective management of hyperkalemia, including classification and K+ monitoring, when to reinitiate previously discontinued renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, and when to use oral K+-binding agents. Monitoring serum K+ should be individualized; however, increased frequency of monitoring should be considered for patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia and for those receiving RAASi therapy. Recent clinical studies suggest that the newer K+ binders (patiromer sorbitex calcium and sodium zirconium cyclosilicate) may facilitate optimization of RAASi therapy. Enhancing the knowledge of primary care physicians and internists with respect to the safety profiles of these newer K+ binders may increase confidence in managing patients with hyperkalemia. Lastly, the availability of newer K+-binding agents requires further study to establish whether stringent dietary K+ restrictions are needed in patients receiving K+-binder therapy. Individualized monitoring of serum K+ among patients with an increased risk of hyperkalemia and the use of newer K+-binding agents may allow for optimization of RAASi therapy and more effective management of hyperkalemia.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Deborah J Clegg
- Drexel University College of Nursing and Health Professions, Philadelphia, PA
| | | | | | - Steven Fishbane
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Debra J Hain
- Christine E. Lynn College of Nursing, Florida Atlantic University, and Cleveland Clinic Florida, Weston, FL
| | - Edgar Lerma
- Department of Medicine, University of Illinois at Chicago/Advocate Christ Medical Center, Oak Lawn
| | - Macaulay Onuigbo
- Robert Larner College of Medicine, University of Vermont Medical Center, Burlington
| | - Anjay Rastogi
- David Geffen School of Medicine, University of California, Los Angeles
| | - Simon D Roger
- Renal Research, Gosford Hospital, Gosford, Australia
| | | | - Matthew R Weir
- Department of Medicine, University of Maryland School of Medicine, Baltimore
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19
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Brandenburg V, Bauersachs J, Böhm M, Fliser D, Frantz S, Frey N, Hasenfuß G, Kielstein JT. [Symptom control in heart failure patients - how to handle GFR decrease and hyperkalaemia]. Dtsch Med Wochenschr 2021; 146:e47-e55. [PMID: 33482670 PMCID: PMC7972821 DOI: 10.1055/a-1307-8652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Bei Patienten mit Herzinsuffizienz und reduzierter Ejektionsfraktion wird durch eine optimierte medikamentöse Therapie sowohl die Symptomkontrolle verbessert als auch die Mortalität gesenkt. Eckpfeiler der Herzinsuffizienztherapie sind dabei Medikamente mit Einfluss auf das Renin-Angiotensin-Aldosteron-System, sogenannte RAAS-Inhibitoren. Dieser Artikel stellt einen kardiologisch-nephrologischen Konsens zur praxisorientierten Hilfestellung bei abnehmender glomerulärer Filtrationsrate oder Anstieg des Serum-Kaliumspiegels vor. Dies sind die 2 häufigsten Gründe für eine Dosisreduktion oder das Absetzen von prognoseverbessernden Medikamenten bei Herzinsuffizienzpatienten.
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Affiliation(s)
- Vincent Brandenburg
- Klinik für Kardiologie, Nephrologie und Internistische Intensivmedizin, Rhein-Maas-Klinikum, Würselen
| | - Johann Bauersachs
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover
| | - Michael Böhm
- Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Danilo Fliser
- Innere Medizin IV - Nieren- und Hochdruckkrankheiten, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Stefan Frantz
- Medizinische Klinik und Poliklinik I (Kardiologie, Endokrinologie, Nephrologie, Pneumologie, Intensiv- und Notfallmedizin) Universitätsklinikum Würzburg
| | - Norbert Frey
- Klinik für Innere Medizin III (Schwerpunkt Kardiologie, Angiologie und Intensivmedizin), Universitätsklinikum Schleswig-Holstein, Kiel
| | - Gerd Hasenfuß
- Herzzentrum, Abt. Kardiologie und Pneumologie, Universitätsmedizin Göttingen
| | - Jan T Kielstein
- Klinik für Nephrologie, Blutreinigung und Rheumatologie, Klinikum Braunschweig
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20
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Schnaubelt S, Niederdoeckl J, Schoergenhofer C, Cacioppo F, Schuetz N, Spiel AO, Hecking M, Domanovits H. Hyperkalemia: A persisting risk. A case report and update on current management. Clin Case Rep 2020; 8:1748-1753. [PMID: 32983489 PMCID: PMC7495804 DOI: 10.1002/ccr3.2974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/03/2020] [Accepted: 05/07/2020] [Indexed: 12/28/2022] Open
Abstract
We report a case of hemodynamic instability due to bradycardia on the basis of severe hyperkalemia. Diabetic ketoacidosis and acute kidney injury together with polypharmacy triggered the acute onset. Potentially life-threatening hyperkalemia is often induced by drug interactions. ECG features may be crucial for diagnosis, and treatment depends on setting and resources.
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Affiliation(s)
| | - Jan Niederdoeckl
- Department of Emergency MedicineMedical University of ViennaViennaAustria
| | | | - Filippo Cacioppo
- Department of Emergency MedicineMedical University of ViennaViennaAustria
| | - Nikola Schuetz
- Department of Emergency MedicineMedical University of ViennaViennaAustria
| | - Alexander O. Spiel
- Department of Emergency MedicineMedical University of ViennaViennaAustria
- Department of Emergency MedicineWilheminenspital ViennaViennaAustria
| | - Manfred Hecking
- Division of Nephrology and DialysisDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Hans Domanovits
- Department of Emergency MedicineMedical University of ViennaViennaAustria
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21
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Louro LF, Raszplewicz J, Alderson B. Hyperkalaemia during general anaesthesia: six cases. VETERINARY RECORD CASE REPORTS 2020. [DOI: 10.1136/vetreccr-2020-001075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Luís Filipe Louro
- Small Animal Clinical ScienceUniversity of Liverpool Institute of Veterinary ScienceNestonUK
| | - Joanna Raszplewicz
- Small Animal Clinical ScienceUniversity of Liverpool Institute of Veterinary ScienceNestonUK
| | - Briony Alderson
- Small Animal Clinical ScienceUniversity of Liverpool Institute of Veterinary ScienceNestonUK
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22
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Abstract
Acid-base balance is critical for normal life. Acute and chronic disturbances impact cellular energy metabolism, endocrine signaling, ion channel activity, neuronal activity, and cardiovascular functions such as cardiac contractility and vascular blood flow. Maintenance and adaptation of acid-base homeostasis are mostly controlled by respiration and kidney. The kidney contributes to acid-base balance by reabsorbing filtered bicarbonate, regenerating bicarbonate through ammoniagenesis and generation of protons, and by excreting acid. This review focuses on acid-base disorders caused by renal processes, both inherited and acquired. Distinct rare inherited monogenic diseases affecting acid-base handling in the proximal tubule and collecting duct have been identified. In the proximal tubule, mutations of solute carrier 4A4 (SLC4A4) (electrogenic Na+/HCO3--cotransporter Na+/bicarbonate cotransporter e1 [NBCe1]) and other genes such as CLCN5 (Cl-/H+-antiporter), SLC2A2 (GLUT2 glucose transporter), or EHHADH (enoyl-CoA, hydratase/3-hydroxyacyl CoA dehydrogenase) causing more generalized proximal tubule dysfunction can cause proximal renal tubular acidosis resulting from bicarbonate wasting and reduced ammoniagenesis. Mutations in adenosine triphosphate ATP6V1 (B1 H+-ATPase subunit), ATPV0A4 (a4 H+-ATPase subunit), SLC4A1 (anion exchanger 1), and FOXI1 (forkhead transcription factor) cause distal renal tubular acidosis type I. Carbonic anhydrase II mutations affect several nephron segments and give rise to a mixed proximal and distal phenotype. Finally, mutations in genes affecting aldosterone synthesis, signaling, or downstream targets can lead to hyperkalemic variants of renal tubular acidosis (type IV). More common forms of renal acidosis are found in patients with advanced stages of chronic kidney disease and are owing, at least in part, to a reduced capacity for ammoniagenesis.
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Affiliation(s)
- Carsten A Wagner
- Institute of Physiology, University of Zurich, Zurich, Switzerland; National Center for Competence in Research Kidney, Switzerland.
| | - Pedro H Imenez Silva
- Institute of Physiology, University of Zurich, Zurich, Switzerland; National Center for Competence in Research Kidney, Switzerland
| | - Soline Bourgeois
- Institute of Physiology, University of Zurich, Zurich, Switzerland; National Center for Competence in Research Kidney, Switzerland
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23
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Burbridge MA, Jaffe RA. Paradoxical Critical Hyperkalemia After Acetazolamide for Cerebrovascular Reactivity Study: A Case Report. A A Pract 2020; 14:69-71. [PMID: 31770135 DOI: 10.1213/xaa.0000000000001148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We present the case of a 42-year-old man with moyamoya disease presenting for cerebral revascularization surgery who developed critical hyperkalemia following a single intravenous (iv) dose of 1000 mg of acetazolamide 1 day preoperatively for a cerebrovascular reactivity study. His potassium increased from 5.1 to 6.7 mmol/L. Prompt treatment of this abnormality allowed this patient to undergo surgery the next day uneventfully. A paradoxical, critical increase in potassium can result from a single 1000-mg iv dose of acetazolamide.
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Affiliation(s)
- Mark A Burbridge
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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24
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Abstract
Intravenous fluid therapy is the most common intervention received by acutely ill patients. Historically, saline (0.9% sodium chloride) has been the most frequently administered intravenous fluid, especially in North America. Balanced crystalloid solutions (e.g., lactated Ringer's, Plasma-Lyte) are an increasingly used alternative to saline. Balanced crystalloids have a sodium, potassium, and chloride content closer to that of extracellular fluid and, when given intravenously, have fewer adverse effects on acid-base balance. Preclinical research has demonstrated that saline may cause hyperchloremic metabolic acidosis, inflammation, hypotension, acute kidney injury, and death. Studies of patients and healthy human volunteers suggest that even relatively small volumes of saline may exert physiological effects. Randomized trials in the operating room have demonstrated that using balanced crystalloids rather than saline prevents the development of hyperchloremic metabolic acidosis and may reduce the need for vasopressors. Observational studies among critically ill adults have associated receipt of balanced crystalloids with lower rates of complications, including acute kidney injury and death. Most recently, large randomized trials among critically ill adults have examined whether balanced crystalloids result in less death or severe renal dysfunction than saline. Although some of these trials are still ongoing, a growing body of evidence raises fundamental concerns regarding saline as the primary intravenous crystalloid for critically ill adults and highlights fundamental unanswered questions for future research about fluid therapy in critical illness.
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Affiliation(s)
- Matthew W Semler
- 1 Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - John A Kellum
- 2 The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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25
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Successful correction of metabolic acidosis is difficult to achieve in chronic kidney disease. Nefrologia 2019; 40:328-335. [PMID: 31862183 DOI: 10.1016/j.nefro.2019.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/13/2019] [Accepted: 09/16/2019] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Metabolic acidosis (MA) is a common complication of chronic kidney disease (CKD) and is associated with numerous adverse effects, which is why its correction is highly recommended. Oral sodium bicarbonate is the current treatment of choice. OBJECTIVES To describe the prevalence of MA in advanced CKD patients and to determine the clinical and biochemical characteristics associated with its successful correction. MATERIAL AND METHODS Retrospective, observational cohort study in adult patients with CKD stage 4-5. The inclusion criteria were: not being treated with alkali therapy at the time of inclusion, and to have at least three consecutive glomerular filtration rate (GFR) measurements and biochemical parameters during a minimum follow-up period of 3 months. Incident patients with serum bicarbonate<22 mEq/l were included in the follow-up study and treated with oral sodium bicarbonate. Correction was considered successful when more than half of the samples and the mean bicarbonate levels during individual follow-up were≥22 mEq/l. RESULTS The study group consisted of 969 patients (age 65±14 years, 507 males) with a mean GFR of 14.8±4.5ml/min/1.73 m2. At baseline, 530 patients (55%) had serum bicarbonate<22mEq/l. They were treated with sodium bicarbonate and followed for 15 months. Satisfactory correction of MA was only achieved in 133 patients (25%). By multivariate logistic regression analysis, the main characteristics of patients with adequate control of MA were: age (OR=1.03; 95% CI 1.01 - 1.05), baseline GFR (OR=1.07; 1.02 - 1.12), and treatment with proton-pump inhibitors (OR=1.61; 95% CI 1.06 - 2.44). Patients who achieved successful correction of MA showed slower CKD progression (-1.67±3.71 vs -4.36±4.56ml/min/1.73 m2/year, P<.0001), and lower average serum potassium concentration (5.1±0.5 vs 5.3±0.5, P<.0001) than those who did not. However, there were no differences in the hospitalisation or mortality rate. CONCLUSION MA is a common complication of advanced CKD but difficult to manage with current therapies. Due to the significant potential benefit of controlling MA, new, more effective therapies should be further researched.
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26
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Keppner A, Maric D, Sergi C, Ansermet C, De Bellis D, Kratschmar DV, Canonica J, Klusonova P, Fenton RA, Odermatt A, Crambert G, Hoogewijs D, Hummler E. Deletion of the serine protease CAP2/Tmprss4 leads to dysregulated renal water handling upon dietary potassium depletion. Sci Rep 2019; 9:19540. [PMID: 31863073 PMCID: PMC6925205 DOI: 10.1038/s41598-019-55995-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 12/04/2019] [Indexed: 01/09/2023] Open
Abstract
The kidney needs to adapt daily to variable dietary K+ contents via various mechanisms including diuretic, acid-base and hormonal changes that are still not fully understood. In this study, we demonstrate that following a K+-deficient diet in wildtype mice, the serine protease CAP2/Tmprss4 is upregulated in connecting tubule and cortical collecting duct and also localizes to the medulla and transitional epithelium of the papilla and minor calyx. Male CAP2/Tmprss4 knockout mice display altered water handling and urine osmolality, enhanced vasopressin response leading to upregulated adenylate cyclase 6 expression and cAMP overproduction, and subsequently greater aquaporin 2 (AQP2) and Na+-K+-2Cl− cotransporter 2 (NKCC2) expression following K+-deficient diet. Urinary acidification coincides with significantly increased H+,K+-ATPase type 2 (HKA2) mRNA and protein expression, and decreased calcium and phosphate excretion. This is accompanied by increased glucocorticoid receptor (GR) protein levels and reduced 11β-hydroxysteroid dehydrogenase 2 activity in knockout mice. Strikingly, genetic nephron-specific deletion of GR leads to the mirrored phenotype of CAP2/Tmprss4 knockouts, including increased water intake and urine output, urinary alkalinisation, downregulation of HKA2, AQP2 and NKCC2. Collectively, our data unveil a novel role of the serine protease CAP2/Tmprss4 and GR on renal water handling upon dietary K+ depletion.
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Affiliation(s)
- Anna Keppner
- Department of Pharmacology and Toxicology, University of Lausanne, Lausanne, Switzerland.,Department of Medicine/Physiology, University of Fribourg, Fribourg, Switzerland.,National Center of Competence in Research Kidney Control of Homeostasis (NCCR Kidney.CH), University of Lausanne, Lausanne, Switzerland
| | - Darko Maric
- Department of Pharmacology and Toxicology, University of Lausanne, Lausanne, Switzerland.,Department of Medicine/Physiology, University of Fribourg, Fribourg, Switzerland.,National Center of Competence in Research Kidney Control of Homeostasis (NCCR Kidney.CH), University of Lausanne, Lausanne, Switzerland
| | - Chloé Sergi
- Department of Pharmacology and Toxicology, University of Lausanne, Lausanne, Switzerland
| | - Camille Ansermet
- Department of Pharmacology and Toxicology, University of Lausanne, Lausanne, Switzerland
| | - Damien De Bellis
- Department of Pharmacology and Toxicology, University of Lausanne, Lausanne, Switzerland.,Electron Microscopy Facility, University of Lausanne, Lausanne, Switzerland.,Department of Plant Molecular Biology, University of Lausanne, Lausanne, Switzerland
| | - Denise V Kratschmar
- Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland.,National Center of Competence in Research Kidney Control of Homeostasis (NCCR Kidney.CH), University of Lausanne, Lausanne, Switzerland
| | - Jérémie Canonica
- Department of Pharmacology and Toxicology, University of Lausanne, Lausanne, Switzerland.,National Center of Competence in Research Kidney Control of Homeostasis (NCCR Kidney.CH), University of Lausanne, Lausanne, Switzerland.,Ophthalmic Hospital Jules Gonin, University of Lausanne, Lausanne, Switzerland
| | - Petra Klusonova
- Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland.,National Center of Competence in Research Kidney Control of Homeostasis (NCCR Kidney.CH), University of Lausanne, Lausanne, Switzerland
| | - Robert A Fenton
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Alex Odermatt
- Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland.,National Center of Competence in Research Kidney Control of Homeostasis (NCCR Kidney.CH), University of Lausanne, Lausanne, Switzerland
| | | | - David Hoogewijs
- Department of Medicine/Physiology, University of Fribourg, Fribourg, Switzerland.,National Center of Competence in Research Kidney Control of Homeostasis (NCCR Kidney.CH), University of Lausanne, Lausanne, Switzerland
| | - Edith Hummler
- Department of Pharmacology and Toxicology, University of Lausanne, Lausanne, Switzerland. .,National Center of Competence in Research Kidney Control of Homeostasis (NCCR Kidney.CH), University of Lausanne, Lausanne, Switzerland.
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27
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Sidler M, Mohebbi N, Hoorn EJ, Wagner CA. Gut It Out: Laxative Abuse Mimicking Distal Renal Tubular Acidosis. Kidney Blood Press Res 2019; 44:1294-1299. [PMID: 31480048 DOI: 10.1159/000501855] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/01/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Distal renal tubular acidosis (dRTA) can be inherited or acquired. CASE PRESENTATION Here, we describe the case of a 45-year-old female patient with non-anion gap metabolic acidosis, hypokalemia, and alkaline urine. She had a history of rheumatoid arthritis and kidney stones and failed to acidify urine upon the fludrocortisone and furosemide test. Therefore, the diagnosis of dRTA secondary to an autoimmune disease was made. A kidney biopsy was examined for markers of acid-secretory intercalated cells. Surprisingly, no obvious difference in the relative number of acid-secretory intercalated cells or in the distribution of major proteins involved in acid secretion was found. Furthermore, increasing doses of potassium citrate failed to correct the hypokalemia and acidosis. Since these findings were rather atypical for autoimmune dRTA, alternative causes of her hypokalemia and metabolic acidosis were sought. The patient was found to chronically consume laxatives, which can also cause kidney stones and may result in a false-positive urinary acidification test. CONCLUSION Chronic laxative abuse may mimic dRTA and should therefore be considered in unexplained hypokalemia with non-anion gap metabolic acidosis.
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Affiliation(s)
- Marius Sidler
- Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Nilufar Mohebbi
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Ewout J Hoorn
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Carsten A Wagner
- Institute of Physiology, University of Zurich, Zurich, Switzerland,
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Caravaca-Fontán F, Valladares J, Díaz-Campillejo R, Barroso S, Luna E, Caravaca F. Renal potassium handling in chronic kidney disease: Differences between patients with or wihtout hyperkalemia. Nefrologia 2019; 40:152-159. [PMID: 31353054 DOI: 10.1016/j.nefro.2019.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 03/09/2019] [Accepted: 04/11/2019] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Hyperkalemia (HK) is a common electrolyte disorder in chronic kidney disease (CKD), mainly in the advanced stages. A positive potassium balance due to reduced renal excretory capacity is likely the main pathogenic mechanism of HK. Research into the relative role of each pathogenic element in the development of HK in CKD may help to implement more suitable therapies. OBJECTIVE To investigate renal potassium handling in advanced CKD patients, and to determine the differences between patients with or without HK. MATERIAL AND METHODS Cross-sectional observational study in adult patients with stage 4-5 CKD pre-dialysis. Selection criteria included clinically stable patients and the ability to collect a 24hour urine sample correctly. Blood and urinary biochemical parameters were analysed including sodium and potassium (K). Fractional excretion of K (FEK) and K load relative to glomerular filtration (Ku/GFR) were calculated. HK was defined as a serum K concentration ≥5.5mmol/l. RESULTS The study group consisted of 212 patients (mean age 65±14 years, 92 females) with a mean GFR of 15.0±4.2ml/min/1.73m2. 63 patients (30%) had HK. Patients with HK had lower mean bicarbonate levels with respect to patients with normal K levels (NK) (20.3±3.1 vs. 22.8±3.2 mEq/l, P<.0001), but no differences were noted in total urinary sodium and K excretion. While mean FEK values were lower in patients with HK (32.1±12.1% vs. 36.4±14.3%, P=.038), Ku/GFR values were significantly greater with respect to the NK subgroup (4.2±1.5 vs. 3.7±1.4 mmol/ml/min, P=0,049). FEK showed a strong linear correlation with Ku/GFR (R2=0.74), and partial linear regressions demonstrated that at a similar Ku/GFR level, the FEK of patients with HK was lower than that of NK patients. By multivariate linear and logistic regression analyses, both FEK and Ku/GFR were shown to be the main determinants of K serum levels and HK. CONCLUSIONS Although the K load relative to glomerular filtration (Ku/GFR) is an important determinant of HK in advanced CKD, the most noteworthy characteristic associated with HK in these patients was the limitation of compensatory urinary K excretion, as indicated by lower FEK.
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Affiliation(s)
| | | | | | - Sergio Barroso
- Servicio Nefrología, Hospital Infanta Cristina, Badajoz, España
| | - Enrique Luna
- Servicio Nefrología, Hospital Infanta Cristina, Badajoz, España
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Caravaca-Fontán F, Valladares J, Díaz-Campillejo R, Barroso S, Luna E, Caravaca F. Association of hyperkalemia with clinical outcomes in advanced chronic kidney disease. Nefrologia 2019; 39:513-522. [PMID: 31027897 DOI: 10.1016/j.nefro.2019.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 11/13/2018] [Accepted: 01/14/2019] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION Patients with advanced chronic kidney disease (CKD) are at greatest risk of hyperkalemia (HK). The relationship between HK and negative outcomes (mortality or progression of renal insufficiency) in non-dialysis dependent CKD patients is controversial. AIMS To determine the incidence, prevalence, and factors related with HK in a cohort of CKD patients, and its relationship with mortality, hospitalization rate, CKD progression, and dialysis initiation. MATERIAL AND METHODS A retrospective, observational study in an incident cohort of adult patients with stage 4 or 5 CKD not on dialysis. Inclusion criteria were: having at least three consecutive estimated glomerular filtration rate (eGFR) measurements in a follow-up period >3 months. Decline in renal function was estimated as the slope of the individual linear regression line of eGFR over follow-up time. HK was defined as serum K levels ≥5.5 meq/l. Associations of HK with outcomes were adjusted for major confounding variables in the multivariate analysis. RESULTS The study group consisted of 1079 patients (574 males, mean age: 65±14 years) with mean baseline eGFR 14.8±4.5 ml/min/1,73 m2. Mean follow-up time was 15 months with a median of 7 serum sample determinations per patient. HK was observed at baseline in 26% of patients; in at least one serum sample during the individual follow-up period in 68%; or chronically (>50% of samples) in 33% of patients. By multivariate logistic regression, the best determinants of chronic HK were: male sex (OR = 1.529; 95% CI [1.154-2.025], p = .003), serum bicarbonate (OR = 0.863 [0.829-0.900], p <.0001), diuretic treatment (OR = 0.743 [0.556-0.992], p = .044), and angiotensin converting enzyme inhibitor and/or angiotensin receptor blockers (OR = 4.412 [2.915-6.678], p <.0001). Patients whose serum K levels were in the upper quartile showed a significantly faster CKD progression (-4.05±5.22 vs. -2.69±5.61 ml/min/1.73 m2/year, p <.0001), and more frequent dialysis initiation (63% vs. 57%, p = .115), though lower mortality (9% vs. 17%, p = .003) and hospitalization rates (2.68±5.94 vs. 3.16±6.77 days per year, p = .301) than the other study patients. However, in the multivariate analysis, average serum K levels were not independently associated with the clinical outcomes investigated. CONCLUSION HK is a common biochemical finding in non-dialysis dependent CKD patients, mainly associated with prescribed medication. However, HK was not independently associated with major negative clinical outcomes.
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Affiliation(s)
| | | | | | - Sergio Barroso
- Servicio de Nefrología. Hospital Infanta Cristina, Badajoz, España
| | - Enrique Luna
- Servicio de Nefrología. Hospital Infanta Cristina, Badajoz, España
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30
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Berend K, Duits AJ. The role of the clinical laboratory in diagnosing acid-base disorders. Crit Rev Clin Lab Sci 2019; 56:147-169. [PMID: 30917291 DOI: 10.1080/10408363.2019.1568965] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acid-base homeostasis is fundamental for life. The body is exceptionally sensitive to changes in pH, and as a result, potent mechanisms exist to regulate the body's acid-base balance to maintain it in a very narrow range. Accurate and timely interpretation of an acid-base disorder can be lifesaving but establishing a correct diagnosis may be challenging. The underlying cause of the acid-base disorder is generally responsible for a patient's signs and symptoms, but laboratory results and their integration into the clinical picture is crucial. Important acid-base parameters are often available within minutes in the acute hospital care setting, and with basic knowledge it should be easy to establish the diagnosis with a stepwise approach. Unfortunately, many caveats exist, beginning in the pre-analytical phase. In the post-analytical phase, studies on the arterial reference pH are scarce and therefore many different reference values are used in the literature without any solid evidence. The prediction models that are currently used to assess the acid-base status are approximations that are mostly based on older studies with several limitations. The two most commonly used methods are the physiological method and the base excess method, both easy to use. The secondary response equations in the base excess method are the most convenient. Evaluation of acid-base disorders should always include the assessment of electrolytes and the anion gap. A major limitation of the current acid-base laboratory tests available is the lack of rapid point-of-care laboratory tests to diagnose intoxications with toxic alcohols. These intoxications can be fatal if not recognized and treated within minutes to hours. The surrogate use of the osmolal gap is often an inadequate substitute in this respect. This article reviews the role of the clinical laboratory to evaluate acid-base disorders.
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Affiliation(s)
- K Berend
- a St. Elisabeth Hospital , Willemstad , Curaçao
| | - A J Duits
- b Red Cross Blood Bank Foundation , Willemstad , Curaçao
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Dépret F, Peacock WF, Liu KD, Rafique Z, Rossignol P, Legrand M. Management of hyperkalemia in the acutely ill patient. Ann Intensive Care 2019; 9:32. [PMID: 30820692 PMCID: PMC6395464 DOI: 10.1186/s13613-019-0509-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/22/2019] [Indexed: 02/07/2023] Open
Abstract
Purpose To review the mechanisms of action, expected efficacy and side effects of strategies to control hyperkalemia in acutely ill patients. Methods We searched MEDLINE and EMBASE for relevant papers published in English between Jan 1, 1938, and July 1, 2018, in accordance with the PRISMA Statement using the following terms: “hyperkalemia,” “intensive care,” “acute kidney injury,” “acute kidney failure,” “hyperkalemia treatment,” “renal replacement therapy,” “dialysis,” “sodium bicarbonate,” “emergency,” “acute.” Reports from within the past 10 years were selected preferentially, together with highly relevant older publications. Results Hyperkalemia is a potentially life-threatening electrolyte abnormality and may cause cardiac electrophysiological disturbances in the acutely ill patient. Frequently used therapies for hyperkalemia may, however, also be associated with morbidity. Therapeutics may include the simultaneous administration of insulin and glucose (associated with frequent dysglycemic complications), β-2 agonists (associated with potential cardiac ischemia and arrhythmias), hypertonic sodium bicarbonate infusion in the acidotic patient (representing a large hypertonic sodium load) and renal replacement therapy (effective but invasive). Potassium-lowering drugs can cause rapid decrease in serum potassium level leading to cardiac hyperexcitability and rhythm disorders. Conclusions Treatment of hyperkalemia should not only focus on the ability of specific therapies to lower serum potassium level but also on their potential side effects. Tailoring treatment to the patient condition and situation may limit the risks. Electronic supplementary material The online version of this article (10.1186/s13613-019-0509-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- François Dépret
- GH St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, St-Louis Hospital, Assistance Publique-Hopitaux de Paris, Paris, France.,University Paris Diderot, Paris, France.,UMR INSERM 942, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - W Frank Peacock
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Kathleen D Liu
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Zubaid Rafique
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Patrick Rossignol
- F-CRIN INI-CRCT Network, Vandœuvre-lès-Nancy, France.,CHRU-Nancy, INSERM 1116, Université de Lorraine, CIC Plurithématique 1433, 54000, Nancy, France
| | - Matthieu Legrand
- GH St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, St-Louis Hospital, Assistance Publique-Hopitaux de Paris, Paris, France. .,University Paris Diderot, Paris, France. .,UMR INSERM 942, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France. .,F-CRIN INI-CRCT Network, Vandœuvre-lès-Nancy, France.
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Kamel KS, Schreiber M, Halperin ML. Renal potassium physiology: integration of the renal response to dietary potassium depletion. Kidney Int 2018; 93:41-53. [PMID: 29102372 DOI: 10.1016/j.kint.2017.08.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/31/2017] [Accepted: 08/03/2017] [Indexed: 01/30/2023]
Abstract
We summarize the current understanding of the physiology of the renal handling of potassium (K+), and present an integrative view of the renal response to K+ depletion caused by dietary K+ restriction. This renal response involves contributions from different nephron segments, and aims to diminish the rate of excretion of K+ as a result of: decreasing the rate of electrogenic (and increasing the rate of electroneutral) reabsorption of sodium in the aldosterone-sensitive distal nephron (ASDN), decreasing the abundance of renal outer medullary K+ channels in the luminal membrane of principal cells in the ASDN, decreasing the flow rate in the ASDN, and increasing the reabsorption of K+ in the cortical and medullary collecting ducts. The implications of this physiology for the association between K+ depletion and hypertension, and K+ depletion and formation of calcium kidney stones are discussed.
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Affiliation(s)
- Kamel S Kamel
- Renal Division, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
| | - Martin Schreiber
- Renal Division, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mitchell L Halperin
- Renal Division, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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Zhang HY, Tan XX, Kang K, Wang W, Lian KQ, Kang WJ. Simultaneous determination of lactic acid and pyruvic acid in tissue and cell culture media by gas chromatography after in situ derivatization-ultrasound-assisted emulsification microextraction. Anal Bioanal Chem 2018; 411:787-795. [DOI: 10.1007/s00216-018-1502-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 11/12/2018] [Accepted: 11/16/2018] [Indexed: 02/06/2023]
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34
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Wang Y, Saelao P, Chanthavixay K, Gallardo R, Bunn D, Lamont SJ, Dekkers JM, Kelly T, Zhou H. Physiological responses to heat stress in two genetically distinct chicken inbred lines. Poult Sci 2018; 97:770-780. [PMID: 29267901 DOI: 10.3382/ps/pex363] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 11/01/2017] [Indexed: 12/19/2022] Open
Abstract
High ambient temperature is one of the most important environmental factors negatively impacting poultry production and health. Genetics is an important contributor in mitigating the stress response to heat. Two genetically distinct highly inbred lines of similar body size (Leghorn and Fayoumi) were characterized for phenotypic differences in response to heat. At 14 days of age, birds were exposed to 38°C with 50% humidity for 4 hours, then 35°C until the conclusion of the experiment. Non-treated individuals were kept at 29.4°C for the first week and then 25°C throughout the experiment. Birds in the heat-stress group were inoculated at day (d) 21 with Newcastle disease virus (NDV) La Sota strain to investigate the effects of heat stress and NDV infection. Thirteen blood parameters were measured using the iSTAT blood analyzer at three stages: 4 h, 6 d, and 9 d post heat-stress treatment, representing acute heat (AH) exposure, chronic heat (CH1) exposure, and chronic heat exposure after virus infection (CH2), respectively. Most blood parameters were significantly changed with heat stress in Leghorns at AH and in Fayoumis at CH1 and CH2. The Leghorn line had significant acute responses with disrupted acid-base balance and metabolic disorders. The heat-resilient Fayoumis maintained a relatively well-balanced acid-base balance. The current study provides the comprehensive profile of biomarker signatures in blood associated with heat tolerance and suggests that PO2, TCO2, HCO3, and base excess can be served as potential biomarkers that can be used to genetically improve heat tolerance in poultry.
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Affiliation(s)
- Y Wang
- Department of Animal Science, University of California, Davis, CA 95616
| | - P Saelao
- Department of Animal Science, University of California, Davis, CA 95616
| | - K Chanthavixay
- Department of Animal Science, University of California, Davis, CA 95616
| | - R Gallardo
- Department of Population Health and Reproduction, School of Veterinary Medicine, University of California, Davis, CA 95616
| | - D Bunn
- Department of Animal Science, University of California, Davis, CA 95616
| | - S J Lamont
- Department of Animal Science, Iowa State University, Ames, IA 50011, USA
| | - J M Dekkers
- Department of Animal Science, Iowa State University, Ames, IA 50011, USA
| | - T Kelly
- One Health Institute, University of California, Davis, CA 95616
| | - H Zhou
- Department of Animal Science, University of California, Davis, CA 95616
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Filippatos TD, Rizos CV, Tzavella E, Elisaf MS. Gitelman syndrome: an analysis of the underlying pathophysiologic mechanisms of acid-base and electrolyte abnormalities. Int Urol Nephrol 2017; 50:91-96. [PMID: 28744758 DOI: 10.1007/s11255-017-1653-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 07/05/2017] [Indexed: 01/25/2023]
Abstract
Gitelman syndrome is the most common inherited tubular disease resulting from mutations of the SLC12A3 gene that encodes the thiazide-sensitive sodium-chloride cotransporter in the early distal convoluted tubules. The review presents the underlying pathophysiologic mechanisms of acid-base and electrolyte abnormalities observed in patients with Gitelman syndrome. The syndrome is usually characterized by hypokalemic metabolic alkalosis in combination with hypomagnesemia and hypocalciuria. Additionally, increased chloride excretion and renin/aldosterone levels, hypophosphatemia (occasionally), hyponatremia (rarely) and glucose intolerance/insulin resistance have been reported. The knowledge of the pathophysiologic mechanisms is useful for the treatment of patients with Gitelman syndrome as well as for the understanding of other tubular diseases.
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Affiliation(s)
- T D Filippatos
- Department of Internal Medicine, Medical School, University of Ioannina, 45110, Ioannina, Greece.
| | - C V Rizos
- Department of Internal Medicine, Medical School, University of Ioannina, 45110, Ioannina, Greece
| | - E Tzavella
- Department of Internal Medicine, Medical School, University of Ioannina, 45110, Ioannina, Greece
| | - M S Elisaf
- Department of Internal Medicine, Medical School, University of Ioannina, 45110, Ioannina, Greece
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Olanrewaju H, Purswell J, Collier S, Branton S. Effects of Light Ingress through Ventilation Fan Apertures on Selected Blood Variables of Male Broilers. ACTA ACUST UNITED AC 2017. [DOI: 10.3923/ijps.2017.288.295] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Wu KL, Cheng CJ, Sung CC, Tseng MH, Hsu YJ, Yang SS, Chau T, Lin SH. Identification of the Causes for Chronic Hypokalemia: Importance of Urinary Sodium and Chloride Excretion. Am J Med 2017; 130:846-855. [PMID: 28213045 DOI: 10.1016/j.amjmed.2017.01.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 01/13/2017] [Accepted: 01/14/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Uncovering the correct diagnosis of chronic hypokalemia with potassium (K+) wasting from the kidneys or gut can be fraught with challenges. We identified clinical and laboratory parameters helpful for differentiating the causes of chronic hypokalemia. METHODS Normotensive patients referred to our tertiary academic medical center for the evaluation of chronic hypokalemia were prospectively enrolled over 5 years. Clinical features, laboratory examinations-including blood and spot urine electrolytes, acid-base status, biochemistries, and hormones-as well as genetic analysis, were determined. RESULTS Ninety-nine patients with chronic normotensive hypokalemia (serum K+ 2.8 ± 0.4 mmol/L, duration 4.1 ± 0.9 years) were enrolled. Neuromuscular symptoms were the most common complaints. Although Gitelman syndrome (n = 33), Bartter syndrome (n = 10), and distal renal tubular acidosis (n = 12) were the predominant renal tubular disorders, 44 patients (44%) were diagnosed with anorexia/bulimia nervosa (n = 21), surreptitious use of laxatives (n = 11), or diuretics (n = 12). Patients with gastrointestinal causes and surreptitious diuretics use exhibited a female predominance, lower body mass index, and less K+ supplementation. High urine K+ excretion (transtubular potassium gradient >3, urine K+/Cr >2 mmol/mmol) was universally present in patients with renal tubular disorders, but also found in >50% patients with gastrointestinal causes. Of interest, while urine sodium (Na+) and chloride (Cl-) excretions were high and coupled (urine Na+/Cl- ratio ∼1) in renal tubular disorders and "on" diuretics use, skewed or uncoupled urine Na+ and Cl- excretions were found in anorexia/bulimia nervosa and laxatives abuse (urine Na+/Cl- ratio: 5.0 ± 2.2, 0.4 ± 0.2, respectively) and low urine Na+ and Cl- excretions with fixed Na+/Cl- ratios (0.9 ± 0.2) when "off" diuretics. CONCLUSION Besides body mass index, sex, and blood acid-base status, integrated interpretation of the urine Na+:Cl- excretion and their ratio is important to make an accurate diagnosis and treatment plan for patients with chronic normotensive hypokalemia.
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Affiliation(s)
- Kun-Lin Wu
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Department of Medicine, Armed Forces Taoyuan General Hospital, Taoyuan, Taiwan
| | - Chih-Jen Cheng
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Chen Sung
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan
| | - Ming-Hua Tseng
- Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan; Division of Pediatric Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Juei Hsu
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan
| | - Sung-Sen Yang
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan
| | - Tom Chau
- Department of Medicine, Providence St. Vincent Medical Center, Portland, Ore
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan.
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Hine J, Schwell A, Kairys N. An Unlikely Cause of Hypokalemia. J Emerg Med 2017; 52:e187-e191. [DOI: 10.1016/j.jemermed.2016.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 12/05/2016] [Accepted: 12/16/2016] [Indexed: 12/25/2022]
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Guo YM, Liu Y, Liu M, Wang JL, Xie ZD, Chen KJ, Wang DK, Occhipinti R, Boron WF, Chen LM. Na +/HCO 3- Cotransporter NBCn2 Mediates HCO 3- Reclamation in the Apical Membrane of Renal Proximal Tubules. J Am Soc Nephrol 2017; 28:2409-2419. [PMID: 28280139 DOI: 10.1681/asn.2016080930] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 01/23/2017] [Indexed: 12/31/2022] Open
Abstract
The kidney maintains systemic acid-base balance by reclaiming from the renal tubule lumen virtually all HCO3- filtered in glomeruli and by secreting additional H+ to titrate luminal buffers. For proximal tubules, which are responsible for about 80% of this activity, it is believed that HCO3- reclamation depends solely on H+ secretion, mediated by the apical Na+/H+ exchanger NHE3 and the vacuolar proton pump. However, NHE3 and the proton pump cannot account for all HCO3- reclamation. Here, we investigated the potential contribution of two variants of the electroneutral Na+/HCO3- cotransporter NBCn2, the amino termini of which start with the amino acids MCDL (MCDL-NBCn2) and MEIK (MEIK-NBCn2). Western blot analysis and immunocytochemistry revealed that MEIK-NBCn2 predominantly localizes at the basolateral membrane of medullary thick ascending limbs in the rat kidney, whereas MCDL-NBCn2 localizes at the apical membrane of proximal tubules. Notably, NH4Cl-induced systemic metabolic acidosis or hypokalemic alkalosis downregulated the abundance of MCDL-NBCn2 and reciprocally upregulated NHE3 Conversely, NaHCO3-induced metabolic alkalosis upregulated MCDL-NBCn2 and reciprocally downregulated NHE3 We propose that the apical membrane of the proximal tubules has two distinct strategies for HCO3- reclamation: the conventional indirect pathway, in which NHE3 and the proton pump secrete H+ to titrate luminal HCO3-, and the novel direct pathway, in which NBCn2 removes HCO3- from the lumen. The reciprocal regulation of NBCn2 and NHE3 under different physiologic conditions is consistent with our mathematical simulations, which suggest that HCO3- uptake and H+ secretion have reciprocal efficiencies for HCO3- reclamation versus titration of luminal buffers.
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Affiliation(s)
- Yi-Min Guo
- Department of Biophysics and Molecular Physiology, Key Laboratory of Molecular Biophysics of Ministry of Education, Huazhong University of Science and Technology School of Life Science and Technology, Wuhan, Hubei, China; and
| | - Ying Liu
- Department of Biophysics and Molecular Physiology, Key Laboratory of Molecular Biophysics of Ministry of Education, Huazhong University of Science and Technology School of Life Science and Technology, Wuhan, Hubei, China; and
| | - Mei Liu
- Department of Biophysics and Molecular Physiology, Key Laboratory of Molecular Biophysics of Ministry of Education, Huazhong University of Science and Technology School of Life Science and Technology, Wuhan, Hubei, China; and
| | - Jin-Lin Wang
- Department of Biophysics and Molecular Physiology, Key Laboratory of Molecular Biophysics of Ministry of Education, Huazhong University of Science and Technology School of Life Science and Technology, Wuhan, Hubei, China; and
| | - Zhang-Dong Xie
- Department of Biophysics and Molecular Physiology, Key Laboratory of Molecular Biophysics of Ministry of Education, Huazhong University of Science and Technology School of Life Science and Technology, Wuhan, Hubei, China; and
| | - Kang-Jing Chen
- Department of Biophysics and Molecular Physiology, Key Laboratory of Molecular Biophysics of Ministry of Education, Huazhong University of Science and Technology School of Life Science and Technology, Wuhan, Hubei, China; and
| | - Deng-Ke Wang
- Department of Biophysics and Molecular Physiology, Key Laboratory of Molecular Biophysics of Ministry of Education, Huazhong University of Science and Technology School of Life Science and Technology, Wuhan, Hubei, China; and.,Department of Physiology and Biophysics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Rossana Occhipinti
- Department of Physiology and Biophysics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Walter F Boron
- Department of Physiology and Biophysics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Li-Ming Chen
- Department of Biophysics and Molecular Physiology, Key Laboratory of Molecular Biophysics of Ministry of Education, Huazhong University of Science and Technology School of Life Science and Technology, Wuhan, Hubei, China; and
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40
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LASHEEN NN, MOHAMED GF. Possible Mechanisms of Cardiac Contractile Dysfunction and Electrical Changes in Ammonium Chloride Induced Chronic Metabolic Acidosis in Wistar Rats. Physiol Res 2016; 65:927-940. [DOI: 10.33549/physiolres.933171] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Metabolic acidosis could occur due to either endogenous acids accumulation or bicarbonate loss from the gastrointestinal tract or commonly from the kidney. This study aimed to investigate the possible underlying mechanism(s) of chronic acidosis-induced cardiac contractile and electrical changes in rats. Twenty four adult Wistar rats, of both sexes, were randomly divided into control group and chronic metabolic acidosis group, which received orally 0.28 M NH4Cl in the drinking water for 2 weeks. At the end of experimental period, systolic and diastolic blood pressure values were measured. On the day of sacrifice, rats were anesthetized by i.p. pentobarbitone (40 mg/kg b.w.), transthoracic echocardiography and ECG were performed. Blood samples were obtained from abdominal aorta for complete blood count and determination of pH, bicarbonate, chloride, sodium, potassium, troponin I, CK-MB, IL-6, renin and aldosterone levels. Hearts from both groups were studied for cardiac tissue IL-6 and aldosterone in addition to histopathological examination. Compared to control group, chronic metabolic acidosis group showed anemia, significant systolic and diastolic hypotension accompanied by significant reduction of ejection fraction and fraction of shortening, significant bradycardia, prolonged QTc interval and higher widened T wave as well as significantly elevated plasma levels of renin, aldosterone, troponin I, CK-MB and IL-6, and cardiac tissue aldosterone and IL-6. The left ventricular wall of the acidosis group showed degenerated myocytes with fibrosis and apoptosis. Thus, chronic metabolic acidosis induced negative inotropic and chronotropic effects and cardiomyopathy, possibly by elevated aldosterone and IL-6 levels released from the cardiac tissue.
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Affiliation(s)
- N. N. LASHEEN
- Department of Physiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Zieg J, Gonsorcikova L, Landau D. Current views on the diagnosis and management of hypokalaemia in children. Acta Paediatr 2016; 105:762-72. [PMID: 26972906 DOI: 10.1111/apa.13398] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 02/13/2016] [Accepted: 03/08/2016] [Indexed: 12/20/2022]
Abstract
UNLABELLED Hypokalaemia is a common electrolyte disorder in children, caused by decreased potassium intake, increased gastrointestinal and urinary losses or transcellular shift. Patients with severe hypokalaemia may suffer from symptoms such as life-threatening cardiac arrhythmias. The aim of our study was to review the aetiology of hypokalaemia, suggest a diagnostic algorithm and discuss the management of patients with various aetiologies of hypokalaemia. CONCLUSION Understanding the pathophysiology of hypokalaemic states, along with a detailed medical history, physical examination and specific laboratory tests are required for proper diagnosis and appropriate treatment.
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Affiliation(s)
- Jakub Zieg
- Department of Paediatrics; 2 Faculty of Medicine; Motol University Hospital; Charles University in Prague; Praha Czech Republic
| | - Lucie Gonsorcikova
- Department of Paediatrics; 2 Faculty of Medicine; Motol University Hospital; Charles University in Prague; Praha Czech Republic
| | - Daniel Landau
- Paediatrics Department B; Faculty of Health Sciences; Schneider Children's Medical Center of Israel; Ben-Gurion University; Beer Sheva Israel
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Cornelius RJ, Wang B, Wang-France J, Sansom SC. Maintaining K + balance on the low-Na +, high-K + diet. Am J Physiol Renal Physiol 2016; 310:F581-F595. [PMID: 26739887 DOI: 10.1152/ajprenal.00330.2015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 12/29/2015] [Indexed: 02/07/2023] Open
Abstract
A low-Na+, high-K+ diet (LNaHK) is considered a healthier alternative to the "Western" high-Na+ diet. Because the mechanism for K+ secretion involves Na+ reabsorptive exchange for secreted K+ in the distal nephron, it is not understood how K+ is eliminated with such low Na+ intake. Animals on a LNaHK diet produce an alkaline load, high urinary flows, and markedly elevated plasma ANG II and aldosterone levels to maintain their K+ balance. Recent studies have revealed a potential mechanism involving the actions of alkalosis, urinary flow, elevated ANG II, and aldosterone on two types of K+ channels, renal outer medullary K+ and large-conductance K+ channels, located in principal and intercalated cells. Here, we review these recent advances.
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Affiliation(s)
- Ryan J Cornelius
- Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University, Portland, Oregon; and
| | - Bangchen Wang
- Department of Cellular/Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jun Wang-France
- Department of Cellular/Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Steven C Sansom
- Department of Cellular/Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
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43
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Izumi Y, Nakayama Y, Onoue T, Inoue H, Mukoyama M. Renal tubular acidosis complicated with hyponatremia due to cortisol insufficiency. Oxf Med Case Reports 2015; 2015:360-3. [PMID: 26609420 PMCID: PMC4652059 DOI: 10.1093/omcr/omv063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 09/04/2015] [Accepted: 10/06/2015] [Indexed: 11/14/2022] Open
Abstract
Adrenocortical insufficiency such as occurs in Addison's disease causes hyponatremia and renal tubular acidosis (RTA). Hyponatremia results from both aldosterone and cortisol insufficiency. RTA is due to aldosterone insufficiency. The involvement of cortisol in RTA is unclear. Here, we report a woman in her 70s who was admitted to our hospital with severe hyponatremia (106 mEq/l) and RTA. The patient exhibited low plasma cortisol levels with little response to rapid adrenocorticotropic hormone loading. In contrast, the plasma aldosterone concentration was maintained at or above the normal range. Hydrocortisone replacement greatly improved both the hyponatremia and RTA. This case suggests that both aldosterone and cortisol are involved in acid secretion from the kidney.
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Affiliation(s)
- Yuichiro Izumi
- Department of Nephrology , Kumamoto University Graduate School of Medical Sciences , Kumamoto, Kumamoto , Japan
| | - Yushi Nakayama
- Department of Nephrology , Kumamoto University Graduate School of Medical Sciences , Kumamoto, Kumamoto , Japan
| | - Tomoaki Onoue
- Department of Nephrology , Kumamoto University Graduate School of Medical Sciences , Kumamoto, Kumamoto , Japan
| | - Hideki Inoue
- Department of Nephrology , Kumamoto University Graduate School of Medical Sciences , Kumamoto, Kumamoto , Japan
| | - Masashi Mukoyama
- Department of Nephrology , Kumamoto University Graduate School of Medical Sciences , Kumamoto, Kumamoto , Japan
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Abstract
Lactic acidosis occurs when lactate production exceeds its metabolism. There are many possible causes of lactic acidosis, and in any given patient, several causes may coexist. This Attending Rounds presents a case in point. Metformin's role in the pathogenesis of lactic acidosis in patients with diabetes mellitus is complex, as the present case illustrates. The treatment of lactic acidosis is controversial, except for the imperative to remedy its underlying cause. The use of sodium bicarbonate to treat the often alarming metabolic derangements may be quite efficacious in that regard but is of questionable benefit to patients. Renal replacement therapies (RRTs) have particular appeal in this setting for a variety of reasons, but their effect on clinical outcomes is untested.
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Affiliation(s)
- Lawrence S Weisberg
- Division of Nephrology, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, New Jersey
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45
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Olanrewaju H, Purswell J, Collier S, Branton S. Effects of color temperatures (Kelvin) of LED bulbs on blood physiological variables of broilers grown to heavy weights. Poult Sci 2015; 94:1721-8. [DOI: 10.3382/ps/pev139] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2015] [Indexed: 11/20/2022] Open
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Tapper EB, Jiang ZG, Patwardhan VR. Refining the ammonia hypothesis: a physiology-driven approach to the treatment of hepatic encephalopathy. Mayo Clin Proc 2015; 90:646-58. [PMID: 25865476 DOI: 10.1016/j.mayocp.2015.03.003] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Revised: 02/27/2015] [Accepted: 03/03/2015] [Indexed: 12/12/2022]
Abstract
Hepatic encephalopathy (HE) is one of the most important complications of cirrhosis and portal hypertension. Although the etiology is incompletely understood, it has been linked to ammonia directly and indirectly. Our goal is to review for the clinician the mechanisms behind hyperammonemia and the pathogenesis of HE to explain the rationale for its therapy. We reviewed articles collected through a search of MEDLINE/PubMed, Cochrane Database of Systematic Reviews, and Google Scholar between October 1, 1948, and December 8, 2014, and by a manual search of citations within retrieved articles. Search terms included hepatic encephalopathy, ammonia hypothesis, brain and ammonia, liver failure and ammonia, acute-on-chronic liver failure and ammonia, cirrhosis and ammonia, portosytemic shunt, ammonia and lactulose, rifaximin, zinc, and nutrition. Ammonia homeostatsis is a multiorgan process involving the liver, brain, kidneys, and muscle as well as the gastrointestinal tract. Indeed, hyperammonemia may be the first clue to poor functional reserves, malnutrition, and impending multiorgan dysfunction. Furthermore, the neuropathology of ammonia is critically linked to states of systemic inflammation and endotoxemia. Given the complex interplay among ammonia, inflammation, and other factors, ammonia levels have questionable utility in the staging of HE. The use of nonabsorbable disaccharides, antibiotics, and probiotics reduces gut ammoniagenesis and, in the case of antibiotics and probiotics, systemic inflammation. Nutritional support preserves urea cycle function and prevents wasting of skeletal muscle, a significant site of ammonia metabolism. Correction of hypokalemia, hypovolemia, and acidosis further assists in the reduction of ammonia production in the kidney. Finally, early and aggressive treatment of infection, avoidance of sedatives, and modification of portosystemic shunts are also helpful in reducing the neurocognitive effects of hyperammonemia. Refining the ammonia hypothesis to account for these other factors instructs a solid foundation for the effective treatment and prevention of hepatic encephalopathy.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Z Gordon Jiang
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Vilas R Patwardhan
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
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47
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Grimm PR, Lazo-Fernandez Y, Delpire E, Wall SM, Dorsey SG, Weinman EJ, Coleman R, Wade JB, Welling PA. Integrated compensatory network is activated in the absence of NCC phosphorylation. J Clin Invest 2015; 125:2136-50. [PMID: 25893600 DOI: 10.1172/jci78558] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 02/09/2015] [Indexed: 12/11/2022] Open
Abstract
Thiazide diuretics are used to treat hypertension; however, compensatory processes in the kidney can limit antihypertensive responses to this class of drugs. Here, we evaluated compensatory pathways in SPAK kinase-deficient mice, which are unable to activate the thiazide-sensitive sodium chloride cotransporter NCC (encoded by Slc12a3). Global transcriptional profiling, combined with biochemical, cell biological, and physiological phenotyping, identified the gene expression signature of the response and revealed how it establishes an adaptive physiology. Salt reabsorption pathways were created by the coordinate induction of a multigene transport system, involving solute carriers (encoded by Slc26a4, Slc4a8, and Slc4a9), carbonic anhydrase isoforms, and V-type H⁺-ATPase subunits in pendrin-positive intercalated cells (PP-ICs) and ENaC subunits in principal cells (PCs). A distal nephron remodeling process and induction of jagged 1/NOTCH signaling, which expands the cortical connecting tubule with PCs and replaces acid-secreting α-ICs with PP-ICs, were partly responsible for the compensation. Salt reabsorption was also activated by induction of an α-ketoglutarate (α-KG) paracrine signaling system. Coordinate regulation of a multigene α-KG synthesis and transport pathway resulted in α-KG secretion into pro-urine, as the α-KG-activated GPCR (Oxgr1) increased on the PP-IC apical surface, allowing paracrine delivery of α-KG to stimulate salt transport. Identification of the integrated compensatory NaCl reabsorption mechanisms provides insight into thiazide diuretic efficacy.
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48
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Ayach T, Nappo RW, Paugh-Miller JL, Ross EA. Postoperative hyperkalemia. Eur J Intern Med 2015; 26:106-11. [PMID: 25698564 DOI: 10.1016/j.ejim.2015.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/08/2015] [Accepted: 01/23/2015] [Indexed: 01/30/2023]
Abstract
Hyperkalemia occurs frequently in hospitalized patients and is of particular concern for those who have undergone surgery, with postoperative care provided by clinicians of many disciplines. This review describes the normal physiology and how multiple perioperative factors can disrupt potassium homeostasis and lead to severe elevations in plasma potassium concentration. The pathophysiologic basis of diverse causes of hyperkalemia was used to broadly classify etiologies into those with altered potassium distribution (e.g. increased potassium release from cells or other transcellular shifts), reduced urinary excretion (e.g. reduced sodium delivery, volume depletion, and hypoaldosteronism), or an exogenous potassium load (e.g. blood transfusions). Surgical conditions of particular concern involve: rhabdomyolysis from malpositioning, trauma or medications; bariatric surgery; vascular procedures with tissue ischemia; acidosis; hypovolemia; and volume or blood product resuscitation. Certain acute conditions and chronic co-morbidities present particular risk. These include chronic kidney disease, diabetes mellitus, many outpatient preoperative medications (e.g. beta blockers, salt substitutes), and inpatient agents (e.g. succinylcholine, hyperosmolar volume expanders). Clinicians need to be aware of these pathophysiologic mechanisms for developing perioperative hyperkalemia as many of the risks can be minimized or avoided.
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Affiliation(s)
- Taha Ayach
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, USA
| | - Robert W Nappo
- University of Florida Shands Hospital, Gainesville, FL, USA
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49
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Al-Jaghbeer M, Kellum JA. Acid-base disturbances in intensive care patients: etiology, pathophysiology and treatment. Nephrol Dial Transplant 2014; 30:1104-11. [PMID: 25213433 DOI: 10.1093/ndt/gfu289] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 08/05/2014] [Indexed: 12/16/2022] Open
Abstract
Acid-base disturbances are very common in critically ill and injured patients as well as contribute significantly to morbidity and mortality. An understanding of the pathophysiology of these disorders is vital to their proper management. This review will discuss the etiology, pathophysiology and treatment of acid-base disturbances in intensive care patients--with particular attention to evidence from recent studies examining the effects of fluid resuscitation on acid-base and its consequences.
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Affiliation(s)
- Mohammed Al-Jaghbeer
- Center for Critical Care Nephrology, CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - John A Kellum
- Center for Critical Care Nephrology, CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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50
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Cure E, Kirbas A, Tumkaya L, Cure MC, Sahin OZ, Kalkan Y, Yuce S, Altuner D. Effect of infliximab against cisplatin-induced nephrotoxicity. Saudi Med J 2014; 35:953-8. [PMID: 25228176 PMCID: PMC4362156 DOI: pmid/25228176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To investigate whether infliximab (Ib), an inhibitor of tumor necrosis factor alpha (TNF-α), prevents cisplatin (Cis)-induced nephrotoxicity. METHODS The study was performed in the Department of Internal Medicine, Recep Tayyip Erdogan University, Rize, Turkey, between November 2012 and May 2013. Thirty male Wistar albino rats were divided into 3 groups, a control group, a Cis group, and a Cis+Ib group. The animals of the Cis group were injected with a single dose (7 mg/kg) of Cis intraperitoneally. The animals of the Cis+Ib group were injected with a single dose (7 mg/kg) of Ib 72 hours prior to Cis injection. RESULTS The TNF-α, interleukin-1 beta (IL-1b), nitric oxide (NO) and adenosine deaminase (ADA) levels of the Cis group were higher than both the control group TNF-α (p<0.001), IL-1α (p<0.001), NO (p<0.001) and ADA (p<0.001), and the Cis+Ib group TNF-α (p<0.001), IL-1b (p<0.001), NO (p<0.001), and ADA (p=0.003). Histopathological examination revealed extensive damage in the Cis group, while the damage in the Cis+Ib group was lower. While the carbonic anhydrase II (CA-II) level of the Cis group was lower than both groups, it was similar in the Cis+Ib and the control groups. CONCLUSION Infliximab acts against Cis-induced nephrotoxicity by a strong inhibition of TNF-α. Additionally, the combination of these 2 drugs does not obviously change the level of CA-II.
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Affiliation(s)
- Erkan Cure
- Department of Internal Medicine, School of Medicine, Recep Tayyip Erdogan University, Rize 53100, Turkey. Tel. +90 (464) 2130491 Ext. 1859. Fax. +90 (464) 2170364. E-mail.
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