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DR. Srinivas Murki
Chief NeonatologistParamitha Children Hospital
Kothapet, Hyderabad
M.D. DM
Approach to Dyselectrolytemia
Case Based Discussion
Hypokalemia
Hypokalemia
• Normal K 3.5 to 5.5 meq/l
• Hypokalemia
• Renal Vs. Extrarenal (Urinary K >20 meq/L and TTGK)
• Renal
• Renal Tubular Acidosis vs. Barter Syndrome
• Extra-renal
• Upper GI or Lower GI
Hypokalemia: Renal
• Renal tubular Acidosis (proximal versus distal)
• Urinary Sugar, Protein
• Serum Calcium
• USG Kindeys
• Barter Syndrome and Gittleman Syndrome (Magnesium)
• Liddle Syndrome, Hyperaldosteronism, CAH salt retaining, Renovasular
Acidosis vs. Alkalosis
High BP
Hypokalemia : GI causes
• Upper GI or skin loss
• Alkalosis and Hypochloremia
• Vomiting, GI drainage
• Cystic Fibrosis, Excessive Sweating
• Lower GI Loss
• Acidosis : Stoma loss, Diarrhea
Case
• 4months/boy
• Failure to thrive (Birth weight 3kg, at present 2.7kg)
• No vomiting/diarrhea/constipation/seizures
• H/o polyuria (antenatal polyhydramnios)
• Examination
• Weight : 2.7 kg (Expected 6 kg)
• BP : 80/40 (MAP 65mm of Hg)
• Dehydrated and malnourished
• No abdominal mass and other exam normal
Investigations
• Hb 9.2g/dl, TLC 8300/mm3 Platelet Adequate
• Electrolytes : 138/2.1/97 Magnesium: 2.4mg/dl
• Urea 48, creatinine 0.8mg/dl Urine K : 58meq/L
• ABG : 7.92/65/40/ HCO3 53meq/l Serum Calcium: 7.2mg/dl
• USG Abdomen : Mild hyperechoic Kidneys
Hypokalemia
Renal Loss: History of Polyhydramnios: Urinary K + (>20meq/L)
Alkalosis : Barters, Gittlemen Syndrome, CAH, Liddle Syndrome
BP Normal : Barter or Gittleman
Magnesium Normal: Barter Syndrome
Case
• Baby L, 2.5month, girl child
• Failure to gain weight
• Vomiting after feeds for 2 weeks
• SVD/Primi/Birth weight: 2.75kg, NICU for 2days for RD
• No loose stools/cough/cold/RD/seizures/Altered sensorium
• H/o Polyuria (increased frequency of urine)
• Non consanguinous parents
Examination
• Weight 3kg, appears malnourished
• Pallor ++
• HR 130/min, RR 38/min, No retractions
• Euthermic, peripheries warm
• CVS, RS and PA : NAD
• CNS: Active, accepting breast feeds, tone decreased, reflexes fair
• No palpable masses per abdomen
Investigations
• Hb 11.2g/dl, PCV 34%, TLC 13,300/mm3
• DLC 55/40/2/3, Platelets 3.8lakh /mm3
• CUE: Normal And RBS is 108gm/dl
• CRP : Negative
• Na 138meq/l, K+ 3.1meq/l, Urea 24mg/dl, creatinine: 0.4mg/dl, Urine K+: 48meq/L
• X-ray chest/wrist: Normal
• USG Abdomen: Increased echogenicity of kidneys with echogenic cortex,medulla
ABG: 7.2/25.2/100/-13.4
Hypokalemia
Renal Loss: Urine K increased
Acidosis: Renal Tubular Acidosis
CUE : No Protein, No sugar, Hyperechoic kidneys: Distal RTA
Hyperkalemia
Hyperkalemia
Spurious Redistribution Excess cell lysis Renal Cause
HemolysisLuecocytosisThrombocytosis
AcidosisB-blockersDigoxin toxicityPeriodic Paralysis
Tumor lysisRhabdomyolysisOld Blood Tx
Renal Failure(acute or Chronic)
Aldosterone deficiencyAddison'sCAHPseuodhypoaldosetonismDrugsSpironolactoneK-sparing Diuretic
Hyperkalemia
• Renal failure Azotemia
• Addison’s Disease Hyperpigmentation, Hypoglycemia
• CAH Hyperpigmentation, 17 OHP
• Pseuohypoaldosteronism Normal 17 OHP
History
• A male infant presents on day 15, weight of 2.14 kg
• Vomiting, Poor feeding for 3 days
• Dull activity for 2 days
• Fast breathing for 1 day
• Vomiting : multiple episodes per day , non projectile, non – bilious
• Dull activity in the form of poor feeding and lethargic
History
• Born to a mother of 28 years and G4P0A3
• 2* consanguineous
• Abortions were between 8 to 12 weeks of gestation
• Antenatal period uneventful and amniotic fluids was normal
• There is no family history of neonatal death or early infant deaths
• At birth : Term, born by LSCS, 2.5 kg, Vigorous, discharged home on day 4
• Is on exclusive breast feeds and there is no polyuria
At admission
• Admission weight 2.14 kg, HC:30 cm, Length: 48 cm, Temperature 36 C
• HR: 164/min, RR: 42/min, SPO2: 92% on Right arm, BP:80/56/65 mmHg
• CRT< 3 sec, Pulse is low volume
• Severe dehydration ++, skin turgor increased,
• No pallor/ organomegaly/lymphadenopathy/cyanosis
• No dysmorphism/midline defect
• Hyperpimentation ++
Investigation
DOA-1 DOA-3
pH 7.27 7.38
Pco2 33.5 32.1
HCO3 14.9 18.4
B.E -10.8 -5.2
Hb: 20.2 gm/dl, PCV: 60%,
WBC: 19,300/mm3,
Platelet:9.3lac/mm3
CRP: 1.0 mg/L
Calcium : 9.2 mg/dl
CUE: normal
RBS: 120mg/dl
USG s/o Left Bulky
Adrenal
Electrolytes and Renal Function
10/11 10/11 10/11 11/11 11/11 11/11 12/11 13/11 13/11 15/11
Nammol/L
121 127 127 127 130 132 136 135 138 138
K+mmol/L
11 7.1 8.9 8.2 6.0 4.7 4.4 7.0 5.9 5.3
Cl-Mmol/L
102 102 103 95 96 94 97 100 101 99
Day 1 of Admission Day 3 of Admission
Blood Urea 97mg/dl 20mg/dl
Serum Creatinine 1.6mg/dl 0.5mg/dl
Electrolytes and Renal Function
Database
• Male Infant presents at Day 15
• Vomiting
• Severe Dehydration
• Hyperpigmentation
• Metabolic Acidosis
• Hyponatremia and Hyperkalemia
Course
• Improved and started to gain weight on
• Hydrocortisone 5mg/day
• Fludrocortisone 200 mcg
• 3% NS supplementation 2 ml every feed
• Breastfeeds
Differentials
• Acute or Chronic Renal Failure
• Addison Disease
• Congenital Adrenal Hyperplasia
• PSeuodhypoaldosteronism
Azotemia but Improved
17 OHP >200ng/ml
Cortisol 12.16mcg/dL
Hyponatremia
Hyponatremia
• Euvolemia : SIADH, Hypothyroidism, Addison
• Hypervolemia : Renal, Cardiac, Liver dysfunction
• Hypovolemia
• Renal : RTA, Barter, Gittleman, Hypoaldosteronism, Liddle
• Extrarenal : Vomiting, Diarrhea, Third space lossUrine Na 20meq/LOr FeNa
Hypernatremia
Hypernatremia
• Hypervolemia
• Saline Infusion, Saline Enema, Hyperaldosteronism (Cohn’s)
• Hypovolemia
• Increased Urine Osmolality : GI Losses, Hyperpyrexia, Hyperventilation
• Reduced Urine Osmolality : Nephrogenic DI, Central DI, Hyperglycemia
Case
• 35 weeks, 2.5kg at birth, female infant, delivery by CS
• Perinatal Period uncomplicated
• On Breastfeeds and Formula from birth, no polyuria
• Mother is known case of hypothyroidism
• Presents of Day 12
• Reduced activity, poor feeding, no vomits or loose stools
• Weight of 1.6 kg and Fast breathing
Examination
- Admission weight 1.64 kg, weight loss of 860 grams from birth
- 33% weight loss from birth
- Sunken eyes, AF sunken, No pallor
- Pulses well felt, HR 164/min, RR 50/min, BP 70/50mm of Hg
- No organomegaly
- No murmur
- Seizure at admission (uprolling of eyes, tonic posture)
- Sensorium depressed, tone increased
InvestigationsAdm 6hrs 24hrs 48hrs 72hrs 96hrs
Na 180 178 172 157 156 151
K 4.1 3.5 3.5 3.5 3.8 3.4
Cl 125 122 121 118 106 98
Urea 193/1.7 119/1.0 56 .0.8
Feeds NPO 5ml 10ml 25ml full feeds full feeds
IVF 180/k/d Same Same 1ml/hr 1ml/hr
TV/kg/day 180 210 240
Na/day 23meq/day same same
(13.5/kg/day)
Weight 1.64 1.90 2.2
Urine Specific Gravity 1020
Database
• Hypernatremia
• Severe Dehydration (Hypovolemia)
• No fever
• No GI Losses
• No Renal Losses
• No Polyuria
Poor Feeding relatedHigh Urine Osmolality
Hypernatremia Dehydration in newborn
Hypercalcemia
Hypercalcemia
• Primary Hyperparathyroidism
• Vitamin D excess
• Bone accretion reduced (immobility)
• Bone resorption (tumor)
• Increased renal absorption (thiazides, hypocalciuric hypercalcemia)
• Endocrine (Addison and thyrotoxicosis)
Hypocalcemia
Hypocalcemia
• Vitamin D deficiency
• D3 or 1,25 D deficiency
• Hypoparathyroidism
• Primary (Di-george) or pseudohypoparathyroidism
• Hypomagnesemia
• Chronic Kidney disease
Case
A 26 days female infant admitted with cold, seizure like activity
involving left upper limb and lower limb- intermittent multiple episodes
for 1 day
Present Illness
• Seizures
• intermittent ,multiple, left upper limb and lower limb
• Episodes with excessive crying but no loss of consciousness
• No fever/ lethargy/ vomiting's /diarrhea
• Perinatal period uncomplicated
• Birth weight 3.15 kg and current weight : 4.12 kg
• Breastfed from birth
Family History
• No family h/o seizures
• No h/o early infant death, neonatal deaths
• No family history of any recent illness
Examination at admission
• Dull or lethargic but irritable
• Heart rate : 150/min
• Respiratory rate : 45 breaths /min
• CFT : 2seconds
• NIBP: normal
• Temperature : 99F
• SpO2 >90% on room air
General Examination
• Mild pallor
• No icterus or cyanosis or edema
• No dysmorphism (Di-george features)
• No midline defects
• Genitals normal
• No neurocutaneous marker
Systemic Examination
CVS : S1 S2 heard, no murmur
RS : Air entry good, mild retractions and grunt
P/a : Soft, liver palpable 3cms under RCM, soft consistency
CNS :Depressed sensorium, irritable
Tone- decreased in all limbs
Reflexes normal
Investigations
• Hb-13g/dl, WBC-7400 cells/mm3; N-55%, L-40%, Platelet-3.0lakh/mm3
• CRP-1.6mg/L
• Na+ -137mmol/L, K-4.8 mmol/L, Cl-98mmol/L
• Sr. Calcium-5.1mg/dl, Phosphorus -13.1mg/dl, ALP- 419 U/L
• Sr.Magnesium-2.1mg/dl
• Ionized Calcium- 0.54mmol/L
• Sr. Creatinine -0.7mg/dl
Investigations
• LFT : Protein -4.9g/dl, Albumin 2.8g/dl, SGOT/SGPT- 33/14 U/L
• 2D echo : Moderate LV dysfunction, dilated chambers
• X-ray : Thymus normal with infiltrates
• Thyroid profile normal
• EEG : multifocal IED’s in bursts with electrographic seizures in left central region
• USG KUB : Normal with no nephrocalcinosis
• NSG was normal
Database
• Term, C-section, on BF and Formula
• Seizure focal
• LV dysfunction
• Hepatomegaly
• Calcium low, phosphorus high, ALP Normal
Diagnosis?
Differential diagnosis
• Vitamin D deficiency
• Hypoparathyroidism
• Hypomagnesemia
• Renal failure
• Diuretics
Further Tests
• VIT D(25-hydroxy ). : 17.3ng/ml ( >20 ng/ml)
• Intact PTH : 2.88pg/ml (10- 65pg/ml)
• Magnesium : 2.2 mg/dl
• Maternal investigations
• Vit D - 13.8ng/ml ( >20ng/ml)
• Sr Calcium-9.6 mg/dl (9-11mg/dl)
• Sr Phosphorus -5.1mg /dl (4-11 mg/dl)
• Repeat vitamin D3 after 3 days 44 ng/ml
Management and Course
• IV calcium Gluconate
• Vitamin D : Calcirol sachet 50,000 units
• Calcitriol 3 capsule per day for 5 days
• Responded to high dose calcitriol, vitamin D3 and calcium infusion
Persistent Hypocalcemia
• Hypocalcemia with hyperphosphatemia
• Vitamin D deficiency or Hypoparathyroidism
• Normal Vitamin D levels after 3 days
• Low PTH, Low Ca and High Ph
• No di-George features, Normal Mg, Creatinine N
• Response to calcitriol, Vitamin D and Calcium
Primary Hypoparathyroidism
Take Home message
• Refractory Hypokalemia and Hypocalcemia: Hypomagnesemia
• Hypokalemia : Urine K and TTGK, ABG and BP
• Hyperkalemia: Kidney function, 17OHP, Cortisol, Renin aldosterone
• Hypernatremia: Water Loss from Renal or Extra-renal
• Hypocalcemia: Vitamin D, PTH or Urinary Calcium
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