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