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U&Es Interpretation Dr Dan Taylor FY1.

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Presentation on theme: "U&Es Interpretation Dr Dan Taylor FY1."— Presentation transcript:

1 U&Es Interpretation Dr Dan Taylor FY1

2 Urea & Electrolytes Components
Creatinine Sodium Potassium Calcium Magnesium Phosphate Urea Cycle converts ammonia to urea in the liver A less toxic metabolite Transported to the kidneys where it is excreted

3 Urea & Electrolytes Components Urea Creatinine Sodium Potassium
Calcium Magnesium Phosphate Creatine is produced by the liver and used as part of fast energy stores by binding to phosphate (phosphorylation) Creatine phosphate then broken down to make ATP + creatinine waste product Transported to the kidneys where it is excreted at a steady and constant rate Creatinine concentration a specific marker of renal function but depends on muscle store

4 Urea & Electrolytes Components Main component of extra-cellular fluid
Creatinine Sodium Potassium Calcium Magnesium Phosphate Main component of extra-cellular fluid Na content monitored by aortic/carotid bodies and as reflects fluid status by heart chamber stretch Juxtaglomerular apparatus monitors Na and causes renin release

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6 Urea & Electrolytes Components
Creatinine Sodium Potassium Calcium Magnesium Phosphate Main intracellular electrolyte component Levels controlled by aldosterone at the DCT acting to increase K+ excretion Levels also vary with H+ ion concentration as they compete for transporter in the kidney

7 Urea & Electrolytes Components
Creatinine Sodium Potassium Calcium Magnesium Phosphate Calcium and phosphate both closely related Generally stored within bone Levels controlled by PTH released from the parathyroid gland PTH production affected by Mg2+ levels

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9 Urea & Electrolytes Components
Creatinine Sodium Potassium Calcium Magnesium Phosphate Vital electrolyte used in bone/teeth formation but also nerve conduction and signalling Mostly found intracellular

10 Doctor, can you please review the U&Es??
Urea 22.0 ( ) Creatinine 286 (45-100) Na 142 ( ) K 5.6 ( )

11 Raised Creatinine Problems? Raised Urea Kidney damage
Dehydration GI bleed (urea rise in isolation) Increased protein breakdown (surgery, trauma, infection, malignancy) High protein intake Kidney damage Raised Creatinine Kidney damage Increased lean body mass

12 Acute Kidney Injury (AKI)
Rise in creatinine >50% from baseline or urine output <0.5ml/kg/hr for 6+ hours Investigations Urine dipstick Bloods – FBC, U&Es, CRP, chemistry profile, PTH VBG – acidosis?/hyperkalaemia? Fluid balance chart (catherterise patient) Stop nephrotoxins ?renal screen (if indicated) ?renal tract ultrasound (if severe)

13 AKI Nephritic screen Pre-Renal (70%) ANA
Hypovolaemia, Dehydration, sepsis Low BP, equal rise in urea and creat IV fluid replacement May be complicated by ATN Nephritic screen ANA P-ANCA/c-ANCA Anti-GBM Complement screen RhF Hepatitis serology Anti-phospholipid antibody Renal ultrasound Renal biopsy Myeloma screen FBC, chem/bone profile, LDH Urinary bence-jones protein Serum immunoglobulins Serum electrophoresis and immunofixation Skeletal survey Creatine kinase Intrinsic Renal (20%) ATN (ischaemic/nephrotoxic), nephritis, glomerulonephritis Causative drugs, hypovolaemic episodes, haematuria, proteinuria Dipstick blood +++/protein +++ Urine Protein-creatinine ratio (PCR) to quantify and monitor protein loss Renal screen Treat the underlying cause and give bicarbonate if indicated (protects the kidney) Post-Renal (10%) Urinary tract obstruction (stones/prostate/tumour/stricture) Renal tract ultrasound indicated Relieve the obstruction (catherterise/nephrostomy)

14 Chronic Kidney Disease
Markers of damaged kidney function (proteinuria) or decreased eGFR for >3 months Graded 1-5 based on eGFR Causes Diabetes and hypertension Chronic glomerulonephritidies and inherited disorders/drugs Management Manage underlying cause Fluid restriction/low protein intake/ACE-inhibitor Treat complications Anaemia, hypertension, oedema, renal bone disease, hyperkalaemia Dialysis if eGFR<15/complications Indications for Dialysis Acidosis Electrolyte abnormalities Intoxication Overload Uraemia (symptomatic or >60.0)

15 Hypernatraemia (>155)
Reflects an inability to concentrate urine so more water is lost than salt Concentrated serum Causes Fluid loss without replacement Diarrhoea/vomiting Burns Decreased access to water Incorrect IV fluids Diabetes insipidus (no ADH) Osmotic diuresis Aldosterone increase Conn’s Cushings Signs and Symptoms Dehydration/thirst lethargy/weakness Confusion/coma Seizures Ix U&E ↑Na ↑urea/alb Identify cause Management Increase oral water intake if dehydrated IV fluids (dextrose and saline) Correct use of IV fluids Guide therapy by volume status and bloods

16 Hyponatraemia (<135) Does not necessarily indicate a depletion – depends on fluid state Suggestion of an issue with sodium distribution in water Causes Dehydrated Actual fluid loss Euvolaemic Distribution problem Oedematous Dilution Signs and Symptoms Anorexia/nausea Malaise/weakness Confusion/coma seizures Ix U&E Urine and serum osmolality Urine sodium Management Fluid restriction Corrects distribution and dilution Replace fluids IV Pharmacological Demeclocycline or vaptans

17 Hyponatraemia Euvolaemic High urine osmolality (concentrated) SIADH
Low urine osmolality (dilute) Water overload Hypothyroidism Addison's Too much dextrose Dehydrated High urinary Na (renal loss) Addison’s (low aldosterone) Excess diuretic (thiazide/loop) Non-functioning kidneys Osmolar diuresis Low urinary Na (loss elsewhere) Diarrhoea Vomiting Burns/heat/sweating Small bowel obstruction Overloaded Renal failure Cardiac failure Low protein states Liver failure Nephrotic syndrome

18 Hyperkalaemia (>6.5) Emergency as may lead to myocardial excitability and ventricular fibrillation Be aware of artefactual results: haemolysis, delayed analysis, contamination Causes Impaired renal excretion K+ sparing diuretics AKI/CKD Hypoaldosteronism Addison’s Disease ACE-i/ARBs Release from cells Acidosis Cell lysis/burns Tumour lysis syndrome Rhabdomyolysis Signs and Symptoms Fast irregular pulse Palpitations Chest pain Light headedness Ix U&E ECG Management Check the patient and ECG – repeat 1.) 10mls 10% IV calcium gluconate 2.) 2.5mg salbutamol nebs 3.) Insulin + glucose (10u in 50ml 50% dextrose) 4.) dialysis/haemofiltration

19 Hypokalaemia (<2.5) Very common electrolyte abnormality
Related to Mg concentration if it is also low K+ will not correct Causes Diuretics (thiazide and loop) Alkalosis Vomiting and diarrhoea Renal tubular damage Cushing’s/steroids Conns Villous adenoma Signs and Symptoms Usually asymptomatic Hypotonia/hyporeflexia Palpitations Ix U&E & Mg ECG Management Oral replacement (sando K) IV replacement – slowly & diluted

20 Hypercalcaemia (>2.6)
Calcium involved in cell signalling and muscle function Adjusted calcium values in relation to albumin as calcium bound to albumin readily Causes 1⁰ hyperparathyroidism 3⁰ hyperparathyroidism Malignancy Bony metastases Myeloma PTHrp Vitamin D excess Sarcoidosis Signs and Symptoms Bones, stones, groans & psychic moans Bone pain & path # Abdo pain/ n+v Tiredness/weakness Confusion/depression Polydipsia/polyuria Ix Ca and Po4 Raised together – malignancy High Ca, low Po4 – PTH driven Myeloma screen Identify malignancy Management Correct dehydration aggressively IV bisphosphonate

21 Hypocalcaemia (<2.2) May be artefactual due to low albumin and also if phosphate is high (renal failure) as PO4 chelates calcium rendering it useless Causes Osteomalacia Acute pancreatitis Hypoparathyroidism (iatrogenic) Pseudohypoparathyroidism Hypomagnaesia Vitamin D deficiency Renal failure High phosphate Failure to retain Ca Failure to activate Vit D Signs and Symptoms Cramps Peri-oral paraesthesia spasms Chovsteks/Trousiers Anxiety/irritability Confusion/disorientation seizures Ix Bone profile ECG Management Calcium replacement orally IV calcium gluconate if severe Alfacalcidol in renal failure

22 Case 48 year old gentleman presents with a 4/52 history of increasing fatigue and anorexia He has also noticed he has lost some weight and that his skin, especially around his armpits looks darker than usual He complains of feeling lightheaded on standing and occasionally even when sitting

23 Case BP sitting 110/65, standing 83/45 FBC – Hb 122, WCC 8.4, plt 352
U&Es – Na 130, K 5.9, urea 9.2, creat 112 LFTs – normal TFTs – normal

24 Case What are the investigative abnormalities?
What are the immediate management steps? Patient assessment and ECG Correct hyperkalaemia IV fluids What is the underlying cause? Addisons Disease (autoimmune, infective, infiltrative, metastatic disease) How can this be confirmed? Short synacthen test What is the management? Steroid replacement

25 Any questions?


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