Disorder of Fluid Regulation in Geriatric

Disorder of Fluid Regulation in
Geriatric
Lita Septina
Internist - Endocrine Metabolic and Diabetes
List of Topic
•
Aging and Kidney Disease
•
Electrolyte Homeostasis
•
Osmoregulation
Wang Deshun
Renal Plasma Flow Decrease with Age
Age specific glomerulosclerosis
Urinary Creatinin Excretion as a function of Age
Rosner Mitchel H, Geriatric Nephrology, 2018
Proposed Mechanism fo Aging Associated Kidney
Disease
Rosner Mitchel H, Geriatric Nephrology, 2018
Sodium Balance
•
Aging is associated with impaired excretion of a salt load and defective conservation in the
setting of sodium restriction.
•
Proximal sodium reabsorption is increased in aging, whereas distal sodium reabsorption may be
reduced.
•
Because the diet of most individuals in developed countries contains excess sodium (8 to 10 g of
salt daily), there is a tendency in the elderly population for total body sodium excess : predisposing
factors for of hypertension
•
Loss of vascular compliance lead to endothelial dysfunction, perhaps mediated by oxidative
stress.
•
Aging- associated renal and vascular changes may explain why correction of secondary forms of
hypertension (e.g., primary aldosteronism, Cushing syndrome, and renovascular hypertension) is
less effective at curing hypertension in older patients.
Rosner Mitchel H, Geriatric Nephrology, 2018
Sodium Homeostasis
• Hypo and hypernatremia are disorders of water balance
Hyponatremia usually suggests too much water in the ECF relative to Na+ content
Hypernatremia usually suggests too little water in the ECF relative to Na+ content
• Solutes (such as Na+, K+, glucose) that cannot freely traverse the plasma membrane
contribute to effective osmolality and induce transcellular shifts of water
water moves out of cells in response to increased ECF osmolality
water moves into cells in response to decreased ECF osmolality
• ECF volume is determined by Na+ content rather than concentration
Na+ deficiency leads to ECF volume contraction
Na+ excess leads to ECF volume expansion
• Clinical signs and symptoms of hyponatremia and hypernatremia are secondary to cells
(especially in the brain) shrinking (hypernatremia) or swelling (hyponatremia)
ECF = Extra cellular fluid
Endocrine Subspeciality Consult 3rd Ed, 2013
Clinical Assessment of ECF Volume (Total Body Na+)
Toronto Notes 2016
Hyponatraemia
Approach to hyponatremia
Toronto Notes 2016
Endocrine, Therapuetic Guidelines 2014
Shah Beejal, Conn’s Curent Therapy 2016
Signsand Symptoms
• Hyponatremia = swollen cells
• Acute hyponatremia (<24-48 h) more likely to be symptomatic
• Chronic hyponatremia (>24-48 h) less likely to be symptomatic due to adaptation
adaptation: normalization of brain volume through loss of cellular electrolytes
(within hours) and organic osmolytes (within days)
adaptation is responsible for the risks associated with overly rapid correction
• Neurologic symptoms predominate (secondary to cerebral edema): headache,
nausea, malaise, lethargy, weakness, muscle cramps, anorexia, somnolence,
disorientation, personality changes, depressed reflexes, decreased LOC (loss of
consciousness)
Endocrine, Therapuetic Guidelines 2014
Complication of Hyponatremia
•
Seizures,
coma,
respiratory
arrest,
permanent
brain
damage, brainstem herniation, death
• Risk of brain cell shrinkage with rapid correction of
hyponatremia
can
develop
osmotic
demyelination
of
pontine
and
extrapontine neurons; may be irreversible (e.g. central
pontine myelinolysis: cranial nerve palsies, quadriplegia,
decreased LOC)
Toronto Notes 2016
Endocrine, Therapuetic Guidelines 2014
Endocrine Subspeciality Consult 3rd Ed, 2013
Investigation
• ECF volume status assessment
• Serum electrolytes, glucose, Cr
• Serum osmolality, urine osmolality
• Urine Na+ (urine Na+ <10-20 mmol/L suggests volume depletion as the cause of hyponatremia)
• assess for causes of SIADH
• TSH, free T4, and cortisol levels
•Consider CXR andpossibly CT chest if suspect pulmonary cause of SIADH (e.g.small cell lung cancer)
• Consider CT head if suspect CNS cause of SIADH
Toronto Notes 2016
Endocrine, Therapuetic Guidelines 2014
Treatment
General measures for all patients
1) treat underlying cause (e.g. restore ECF volume if volume depleted, remove o ending drug, treat pain, nausea, etc.)
2) restrict free water intake
3) promote free water loss
4) carefully monitor serum Na+ , urine volume, and urine tonicity
5) ensure frequently that correction is not occurring too rapidly
Monitor urine output frequently: high output of dilute urine is the first sign of dangerously rapid correction of hyponatremia
Rapid correcting may produced permanent central nervous system injury due to osmotic demyelination.
Toronto Notes 2016
Endocrine, Therapuetic Guidelines 2014
Impact of IV Solution on Serum [Na+]
TBW = Total Body Water
LR : lactate Ringer
Toronto Notes 2016
Endocrine, Therapuetic Guidelines 2014
Pccket Medicine 6Ed, 2017
Reference, medcape .com
Hypernatraemia
Approach to hypernatremia
Marx J et al [eds]: Rosen's emergency medicine: concepts and clinical practice, ed 6, St Louis, 2006, Mosby
Toronto Notes 2016
Endocrine, Therapuetic Guidelines 2014
Signs and Symptoms
• With acute hypernatremia no time for adaptation,
therefore
more
likely
to
be
symptomatic
• Adaptive response: cells import and generate new
osmotically active particles to normalize size
• Due to brain cell shrinkage: altered mental status,
weakness, neuromuscular irritability, focal
neurologic
deficits, seizures, coma, death
• ± polyuria, thirst, signs of hypovolemia
Toronto Notes 2016
Endocrine, Therapuetic Guidelines 2014
Endocrine Subspeciality Consult 3rd Ed, 2013
Complication Hypernatremia
• Increased risk of vascular rupture resulting in
intracranial
hemorrhage
• Rapid correction may lead to cerebral edema due to
ongoing brain hyperosmolality
Endocrine Subspeciality Consult 3rd Ed, 2013
Treatment Hypernatremia
• General measures for all patients give free water (oral or IV) treat underlying cause
monitor serum Na+ frequently to ensure correction is not occurring too rapidly
• If evidence of hemodynamic instability, must first correct volume depletion with NS bolus
•
Loss of water is o en accompanied by loss of Na+, but a proportionately larger water loss
•
Use formula to calculate free water H2O deficit and replace
•
Encourage patient to drink pure water, as oral route is preferred for fluid administration
• If unable to replace PO or NG, correct H2O deficit with hypotonic IV solution (IV D5W,
0.45% NS [half normal saline], or 3.3% dextrose with 0.3% NaCl [“2/3 and 1/3”])
• Aim to lower [Na+] by no more than 12 mmol/L in 24 h (0.5 mmol/L/h)
•
Must also provide maintenance fluids and replace ongoing losses
•
General rule: give 2 cc/kg/h of free water to correct serum [Na+] by about 0.5 mmol/L/h
or 12 mmol/L/d
Toronto Notes 2016
Endocrine, Therapuetic Guidelines 2014
Hypokalemia
Na+ reabsorption and K+ excretion
• metabolic alkalosis (increases K+ secretion)
• hypomagnesemia
• increased non-reabsorbable anions in tubule lumen: HCO3-, penicillin, salic
tubular ow rate increases K+ secretion)
Hy p o k alem
ia Sympt ms
Signs
and
• serum [K+] <3.5 mEq/L
Depressed ST segment
Prolongation of Q-T interval
1
Normal
2
U wave
3
U wave progression
4
© Andrea Cormier
Signs and Symptoms
• usually asymptomatic, particularly when mild (3.0-3.5 mmol/L)
• N/V, fatigue, generalized weakness, myalgia, muscle cramps, and constipati
• Usually asymptomatic, particularly when mild
(3.0-3.5
mEq/L) muscle necrosis, and rarely paralysis with eventual re
• if severe:
arrhythmias,
• Fatigue, generalized weakness, myalgia, muscle
cramps, and constipation
impairment
arrhythmias
occur
at variable
levels
of K+; more
likely if digoxin use, hypom
• If severe: arrhythmias, muscle necrosis, and•rarely
paralysis
with
eventual
respiratory
impairment
+ [K+]
• ECG changes are more predictive of clinical picture than serum
• Arrhythmias occur at variable levels of K ; more U
likely
ifmost
digoxin
use, hypomagnesemia,
CAD •aECG
waves
important
(low amplitude waveor
following
T wave)
+]
T waves
changes are more predictive of clinical picture than attened
serum or
[Kinverted
depressed ST segment
U waves most important (low amplitude wave
following
a Tinterval
wave)
prolongation
of Q-T
with severe hypokalemia: P-R prolongation, wide QRS, arrhythmias; inc
Flattened or inverted T waves
digitalis toxicity
Figure 6. ECG changes in hypokalemia
With severe hypokalemia: P-R prolongation, wide QRS, arrhythmias; increases risk of digitalis
toxicity
Endocrine Subspeciality Consult 3rd Ed, 2013
The diagnostic approach
to hypokalemia
Abbreviations: ACEI = angiotensin converting enzyme inhibitor; ARB = angiotensin receptor
blocker; ENAC = epithelial sodium channel; GFR = glomerular filtration rate; NSAIDS = nonsteroidal anti-inflammatory drugs; RTA = renal tubular acidosis; TTKG = transtubular K
Tang Jie,Hypokalemia and Hypekalemia, Conn Current Teraphy, 2016
gradient.
Approach to
hypokalemia
BP, Blood pressure; GI, gastrointestinal; GRA, glucose
remediable aldosteronism; RTA, renal tubular acidosis.
Feehally J, Floege J, Johnson RJ: Comprehensive clinical
• Treat underlying cause
Treatment
• If true K+ deficit, potassium repletion (decrease in serum [K+] of 1 mEq is roughly
100-200 mEq of total body loss)
oral sources – food, tablets (KSR, Aspar K), KCl liquid solutions (preferable route if the patient tolerates PO
medications)
IV – usually KCl in saline solutions, avoid dextrose solutions (may exacerbate hypokalemia via insulin release)
max 40 mmol/L via peripheral vein, 60 mmol/L via central vein, max infusion 20 mmol/h
• K+-sparing diuretics (triamterene, spironolactone, amiloride) can prevent renal K+ loss
• Restore Mg2+ if necessary
• If urine output and renal function are impaired, correct with extreme caution
• Risk of hyperkalemia with potassium replacement especially high in elderly, diabetics, and patients with decreased renal
function
• Beware of excessive potassium repletion, especially if transcellular shi caused hypokalemia
Toronto Notes 2016
Endocrine, Therapuetic Guidelines 2014
Hyperkalemia
Signs and Symptoms
• Usually asymptomatic but may develop nausea, palpitations, muscle weakness, muscle stiffness,
paresthesias, areflexia, ascending paralysis, and hypoventilation
• Impaird renal ammoniagenesis and metabolic acidosis
• ECG changes and cardiotoxicity (do not correlate well with serum [K+])
peaked and narrow T waves
decreased amplitude and eventual loss of P waves
prolonged PR interval
widening of QRS and eventual merging with T wave (sine-wave pattern)
AV block
ventricular fibrillation, asystole
Endocrine Subspeciality Consult 3rd Ed, 2013
Clinical Assessment of Hyperkalamia
Causes of Hyperkalemia
Causes of Hyperkalemia with normal GFR
Toronto Notes 2016
Endocrine, Therapuetic Guidelines 2014
The diagnostic approach to
hyperkalemia
*Hyperkalemia may occur with higher GFR if K load is excessive.
Abbreviations: ACEI = angiotensin converting enzyme inhibitor; ARB = angiotensin receptor
blocker; ENAC = epithelial sodium channel; GFR = glomerular filtration rate; NSAIDS = nonsteroidal anti-inflammatory drugs; RTA = renal tubular acidosis; TTKG = transtubular K
gradient.
Tang Jie,Hypokalemia and Hypekalemia, Conn Current Teraphy, 2016
Treatment
• Acute therapy is warranted if ECG changes are present or if patient is symptomatic
• Tailor therapy to severity of increase in [K+] and ECG changes
[K+] <6.5 and normal ECG
• Treat underlying cause, stop K+ intake, increase the loss of K+ via urine and/or GI tract
[K+] between 6.5 and 7.0, no ECG changes: add insulin to above regimen
[K+] >7.0 and/or ECG changes: first priority is to protect the heart, add calcium gluconate to
above
1. Protect the heart
2. Shift K into Cells
+
3. Enhance K Removal from Body
+
Toronto Notes 2016
Endocrine, Therapuetic Guidelines 2014
Endocrine Subspeciality Consult 3rd Ed, 2013
Clinical Consideration in the Assessment of
Emergency Geriatric Patient
Barnett SR. Manual of Geriatric Anesthesia. New York: Springer; 2013.
Prevention
Acute Kidney
Injury in ICU
Chronopoulos A, et al. Intensive
Hope of Asian
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