PT renal 1-8

Diagnosis
Evaluating
Monitoring
Screening
Research

Within 2 standard deviations from the mean.

Extent to which the mean measurement is close to the true value.

Reproducibility

Looking at the values
Assessing trends (if any)
Building the clinical picture
Scrutinize medications

False

Electrolytes
Calcium
Kidney Function Tests
Blood Glucose

135-145 mEq/L
Electrolyte

3.5-5.0 mEq/L
Electrolyte

95-105 mEq/L
Electrolyte

22-26 mEq/L
Electrolyte

< 12 mEq/L
Electrolyte

8-20 mg/dL
Renal Function

0.5-1.0 mg/dL
Renal Function

60-100 mg/dL
Metabolic

8.4-10.2 mg/dL
Metabolic

Seizures,
Coma,
Death

Fatal Arrhythmias

Protein Metabolism

SCr (Serum Creatinine)

Elevated

False

K+ and HCO3-

Seizures or Coma

Diabetic ketoacidosis

Stones, Bones, Groans, and Moans

High levels of BUN without symptoms

High level of BUN with symptoms

CMP tests for liver, whereas the BMP does not.

3.7-5g/dL

6-8g/dL

44-147 U/L
Liver and Bone Enzyme

<1.2 mg/dL
Byproduct of RBCs

<32 U/L
Liver Function Test

<40 U/L
Liver Function Test

Total Protein

Maintain oncotic pressure

False

AST and ALT (increased with injury and ETOH injury)

LFTs (Liver Function Tests)
Bilirubin
INR

Liver Disease and Malnutrition

P and Mg2+

2.6-4.5 mg/dL

Increases

1.5-2.2mg/dL

Potassium Balance

RBCs, WBCs, Hb/Hematocrit, and Platelets

4-10 K/mm3
Immune

Men: 14-18 g/dL
Women: 13-16 g/dL

Oxygen carrying capacity of blood

Men: 40-54%
Women: 38-48%

RBC Mass

120-400 K/mm3

Clotting

Most of WBC

>1500

Neutropenia

3-5%

Peripheral Leukocytes

0-1

Granulocytes (Hypersensitivity Rxn)

0-3

Mature Granulocytes

22-44

NK Cells, T Cells, B Cells

3-6

Mononuclear Phagocytes

Anemia

HgB

The volume of RBCs in a unit volume of whole blood (generally 3x the Hgb)

>1000

<100

Determining anemia type.

80-100

Iron deficiency anemia or due to chronic disease.

Folate/B12 deficiency

Blood Loss, Chronic Disease, Bone Marrow Failure

Prothrombin Time and INR

A test used to monitor the coagulation factors made in the liver.

12 seconds

International Normalized Ratio. Measures coagulation.

INR

Liver Disease

Men: 66-180 mcg/dL
Female: 50-170mcg/dL

The major iron storage protein.

20-300 ng/mL

Drops (<100ng/dL)

Pus in urine = UTI

Suggests bacterial presence

Suggests kidney damage.

Elevated resulting from many diseases, such as DM, Medicines, Kidney Problems

Fat Metabolism

Damage to kidney, bladder or UT

Damage to Kidney

Gout, Kidney Stones, Toxic Ingestion

Contaminated Sample

The average blood glucose levels over the last three months.

5.7-6.4%

Someone is diabetic

0.5-4.5

0.7-0.9ng/dL

2.0-4.4 pg/mL

Early in the morning.

>15mcg/dL

Adrenal insufficiency (check ACTH levels)

Cushings

Men: 60%
Women: 50%

60% total body water
40% = Intracellular
20% = Extracellular

275-290mOsm/L

Dry mucous membranes, tachycardia, hypotension, Syncope, Increasing lab values

Elevated jugular pressure, Edema, HTN

Heart Failure
Cirrhosis
CKD

Crystalloids and Colloids

Crystalloids

Colloids

Colloids

Crystalloids

Hypotonic

Hypertonic

Isotonic, it becomes hypotonic (free water) in the environment.

320mOsm/L

273mOsm/L

295mOsm/L

NS, LR, Plasmalyte

LR

D5W

3% NaCl

3% NaCl

No

Distributes into the ECF

66% (free water) enters the cell. 33% remains in the ECF.

High oncotic pressure.

1:1 increase

1:5 increase

5%

Cirrhosis

Isotonic Crystalloid

100ml/Kg/Day

1000mL/Day (<10Kg) +
50mL/Kg/Day

1000mL/Day +
500mL/Day +
20mL/Kg/Day

10Kg * 100mL/Kg/Day = 1000mL/Day
10Kg * 50mL/Kg/Day = 500mL/Day
60Kg * 20ml/Kg/Day = 1200mL/Day

Total = 2700mL/Day

4mL/Kg/hr (first 10Kg)
2mL/Kg/hr (next 10Kg)
1mL/Kg/hr (eacg Kg > 20Kg)

4mL/Kg/hr * 10Kg = 40mL/hr
2mL/Kg/hr * 10Kg = 20mL/hr
1mL/Kg/Hr * 60Kg = 60mL/hr

Total = 120mL/hr

30mL/Kg

1L-2L/hr

500-1000mL/hr

100-125mL/hr

Indication
Efficacy
Safety
Adherence/Compliance

3.5-5.5 mEq/L

Level < 3mEq/L

< 3 mEq/L

1. Renal Losses
2. Stool/GI Losses
3. Intracellular Shifts

1st resolve the underlying causes/discontinue offending med

Then give potassium orally

0.1mEq/L

0.1mEq/L

Klor-Con

60mEq

10mEq/hr

Mg binds to the channel that maintains potassium flow.

More K+ is secreted; K+ Wasting

IV MgSO4 1-2g IV over 2 hours

MgO 400mg PO BID

Diarrhea

1.5-2.2mg/dL

CKD and AKI

Cardiac Arrhythmias

Peaked T Waves

5.5mEq/L

AKI/CKD (Renal Disease)
Hyperglycemic Crisis
Acidosis
Medication-Induced
Tumor-Lysis Syndrome

ACEs/ARBs
Spironolactone
Bactrim

Stabilize the myocardium with CaGluconate (1g) via IV

Shifters and Excreters

Shifters used to treat hyperkalemia by moving K+ intracellularly.

Excreters used to treat hyperkalemia by causing K+ to be excreted via renal or fecal matters.

5-10 units regular insulin with 50mL 50% dextrose (25g)

10-20mg in 4mL by nebulizer over 10 min

10g PO TID

135-145 mEq/L

ADH Mechanism

Hypothalamus

ADH levels are decreased to increase the secretion of free water, thereby increasing Na+ concentration.

Hyponatremia

Na+ decreases within 48hr

>= 48hr or when duration is unknown

Loop Diuretics and Thiazide Diuretics

Glucose levels

Hyperglycemia causes osmotic shifts of water from intracellular to extracellular space causing dilutional hyponatremia

Measured Sodium + 0.016 (serum glucose - 100)

Measured Sodium + 0.024 (serum glucose - 100)

1. Stop and reassess

2. Evaluate patient

3. Refer to Nephrology

Decreased total body water and sodium levels.

Isotonic Saline (given that the person has hypotonic hyponatremia)

Increased total body water and normal sodium levels

Fluid restriction, adjust other underlying problems.

Increased total body water level.

<20 = Diuretic and fluid/sodium restriction

>20= Fluid/sodium restriction and dialysis

3% NaCl (50mL/hr via peripheral line)

VERY SLOW

Osmotic Demylination Syndrome

Excess renal water reabsorption.

SIADH, Tumors, CNS disorders, etc...

Excess free water intake.

Polydipsia

-Stop Medications Causing
-Urea (increases solute excretion)
-Salt Tablets (enhances water excretion)

3% NaCl. DO NOT GIVE NS. THIS IS BAD

Decreased water intake.

Seizures, Coma, Death

Increased free water loss, decreased free water intake, Increased sodium intake.

Diabetes Insipidus (ADH Loss)

Environment

GI Problems

Sweating

Hypodipsia

Physical/Cognitive Problems

Replace ADH via Desmopressin

0.6 body weight [(serum Na+ /140)-1] = Calculated Free Water Deficit (L)

PO or IV as Free Water or D5W; Given Slowly

7.35-7.45

Bicarb System

7.4

80-100mmHg

95%

35-45mmHg

22-26mEq/L

Acidemia
Alkalemia

Metabolic Acidosis;
Respiratory Alkalosis

Hyperventilation (brings down PCO2 levels) raising pH

Respiratory Acidosis;
Metabolic Alkalosis

Retain HCO3- in the kidney. This raises the pH.

Respiratory Alkalosis;
Metabolic Acidosis

Excrete more bicarbonate from the kidneys.

Metabolic Alkalosis;
Respiratory Acidosis

Hypoventilation (increases the PCO2, lowering the pH).

1. Determine Acidemia or Alkalemia
2. Change in PCO2 or HCO3-
3. Calculate Anion Gap
4. What is the compensatory response?

Decreased HCO3-

Too much HCO3-

Hypoventilation (Increased CO2)

Hyperventilation (Decreased CO2)

8-12

Na+ - (Cl- + HCO3-)

AG decreases 2.5 per g/dL decreased albumin from 4 g/dL

Non-anion gap metabolic acidosis

Anion gap metabolic acidosis

Methanol/Meformin
Uremia
Diabetic Ketoacidosis
Poisoning
Intoxication
Lactic Acidosis
Ethylene Glycol
Renal Failure/Rhabdomyolysis
Salicylates

Determining if another acid-base disorder exists

= Change in Anion Gap / Change in HCO3-

1 mEq/L

Uncomplicated AGMA

Mixed AGMA and NAGMA

AGMA and Metabolic Alkalosis

Simple Disorder

Mixed Disorder

A method to calculate the expected PCO2 for compensation.

Expected PCO2 = [(1.5 * HCO3-) + 8] +/-2

NaHCO3- Therapy

Hypernatremia and Hyperosmolarity

Hyperchloremia
Acetazolamide
Renal Tubular Acidosis
Diarrhea
Uretero Fistula
Post
Spironolactone

CNS Depression
Airway Obstruction
Neuromuscular Disorders
Severe pneumonia or other problems

pH > 7.40 and HCO3- > 24mEq/L

Decreased HCO3- excretion, loss of H+, too much bicarbonate ingested

PCO2 increases to compensate.

PCO2 increase = 0.7 * HCO3-

OR

PCO2 increase by 6-7mmHg for every 10 mEq/L HCO3-

Sodium Chloride Responsive or Resistant

False

True

CNS Stimulation
Hypoxia
Anxiety
Mechanical Ventilation
Progesterone
Slicylates

pCO2 < 40mmHg where the lungs are removing too much CO2

SCr. This is used to calculate the eGFR.

In men = 127mL/min
in women = 118mL/min

Cystatin C

CrCl (mL/min) = [((140-age) weight)/(72Scr)] * 0.85 (female only)

BMI < 18.5: Use actual BW
BMI 18.5-24.9: Use Ideal BW
BMI >=25: Adjusted BW w/ correction factor 0.4

CrCl > 130mL/min

This could indicate that the patient is rapidly eliminating medications, therefore leading to subtherapeutic concentrations and poor clinical outcomes.

If trauma or sepsis has occured.

False; Based on SCr, Urine Output, Structural Damage

1. Increased SCr >= 0.3mg/dL in 2 days

2. Decreased UOP <0.5 mL/Kg/Hr for 6 hours

3. Increased SCr >= 150% from baseline within 7 days

Leaking protein in the urine

Leaking blood in the urine

White cells in the urine

No change or SCr < 0.3mg/dL, normal UOP. Damage biomarker is present.

SCr increased above 0.3mg/dL for =< 48hrs or >=150% for =<7 days AND/OR UOP <0.5ml/Kg/hr for >6hrs (no biomarker)

SCr increased above 0.3mg/dL for =< 48hrs or >=150% for =<7 days AND/OR UOP <0.5ml/Kg/hr for >6hrs (biomarker present)

SCr increased >200% AND/OR <0.5mL/Kg/hr UOP for >12hr (no biomarker)

SCr increased >200% AND/OR <0.5mL/Kg/hr UOP for >12hr (biomarker present)

↑ SCr >300% (>=4.0 mg/dL with an acute increase of >=0.5mg/dL
And/or UOP <0.3 ml/kg/hr for >24 hrs or anuria >12 hours and/or acute renal replacement
therapy (no biomarker)

↑ SCr >300% (>=4.0 mg/dL with an acute increase of >=0.5mg/dL
And/or UOP <0.3 ml/kg/hr for >24 hrs or anuria >12 hours and/or acute renal replacement
therapy (biomarker present)

Pre-Renal
Intrinsic
Post-Renal

Prerenal

ACEs
ARBs
NSAIDs
Diuretics

Volume Depletion
Hypotension
Volume Overload

Dilate the afferant and constrict the efferent

Ischemic acute tubular necrosis (ATN)

Renal Ischemia, Sepsis, Surgery, Medications, Contrast Dye

Acute Tubular Necrosis and Acute Interstitial Nephritis

Aminoglycosides and Amphotericin B

Acyclovir
Cephalosporins/Penicillins
Fluoroquinolones
NSAIDs
PPIs/H2RAs

Obstruction at bladder or ureter

BPH (Benign Prostatic Hyperplasia)

Acyclovir
Indinavir
Methotrexate
Sulfonamides
Triamterene

Prerenal AKI due to cirrhosis

Vasopressor Therapy + Albumin

Intrinsic AKI

The breakdown of muscle leading to the buildup of byproducts causing renal damage.

SCr and Creatinine Kinase

Aggressive fluid resuscitated

Dehydration/Infection

HF, Cirrhosis, CDK

Medications, Post-Renal

1. Pitting Edema
2. Ascities
3. Elevated Jugular Venous Pressure

Patient at 45 degree angle, turn head to left, distance from sternal angle to highest level of pulsation.

6-8cm, >10 = overload

<20mEq/L

>30-40mEq/L

Acute = <20mEq/L
Chronic = >40mEq/L over a few days

<1%

>1%