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Fractional Excretion of Bicarbonate

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101. Acute Renal Failure (Follow-up)

be harmful for the patient. Maintenance of volume homeostasis and correction of biochemical abnormalities remain the primary goals of treatment and may include the following measures: Correction of fluid overload with furosemide Correction of severe acidosis with bicarbonate administration, which can be important as a bridge to dialysis Correction of hyperkalemia Correction of hematologic abnormalities (eg, anemia, uremic platelet dysfunction) with measures such as transfusions and administration (...) agents, nonsteroidal anti-inflammatory drugs [NSAIDs]) should be avoided or used with extreme caution. Similarly, all medications cleared by renal excretion should be avoided, or their doses should be adjusted appropriately. A 2013 study indicated that triple therapy using nonsteroidal anti-inflammatory drugs (NSAIDs) with 2 antihypertensive medications—a diuretic along with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin-receptor blocker (ARB)—significantly increases the risk

2014 eMedicine.com

102. Hypocitraturia (Diagnosis)

filtration rate (GFR) decreases, there is a stepwise decrease in the amount of citrate that is filtered; however, in the early stages of CKD, the increased fractional excretion of citrate prevents an abrupt decline in urinary citrate, such that overt hypocitraturia is not usually observed until advanced stages of CKD. [ ] Primary Hyperaldosteronism In this disease entity, both hypercalciuria and hypocitraturia occur via Na-dependent volume expansion and chronic hypokalemia. [ ] Previous Next: US (...) . Urol Res . 2006 Aug. 34(4):231-8. . Kessler T, Hesse A. Cross-over study of the influence of bicarbonate-rich mineral water on urinary composition in comparison with sodium potassium citrate in healthy male subjects. Br J Nutr . 2000 Dec. 84(6):865-71. . Pinheiro VB, Baxmann AC, Tiselius HG, Heilberg IP. The effect of sodium bicarbonate upon urinary citrate excretion in calcium stone formers. Urology . 2013 Jul. 82(1):33-7. . Seltzer MA, Low RK, McDonald M. Dietary manipulation with lemonade

2014 eMedicine.com

103. Hypocalcemia (Diagnosis)

: Pathophysiology Ionized calcium is the necessary plasma fraction for normal physiologic processes. In the neuromuscular system, ionized calcium facilitates nerve conduction, muscle contraction, and muscle relaxation. Calcium is necessary for bone mineralization and is an important cofactor for hormonal secretion in endocrine organs. At the cellular level, calcium is an important regulator of ion transport and membrane integrity. Calcium turnover is estimated to be 10-20 mEq/day. Approximately 500 mg (...) of calcium is removed from the bones daily and replaced by an equal amount. Normally, the amount of calcium absorbed by the intestines is matched by urinary calcium excretion. Despite these enormous fluxes of calcium, the levels of ionized calcium remain stable because of the rigid control maintained by parathyroid hormone (PTH), vitamin D, and calcitonin through complex feedback loops. These compounds act primarily at bone, renal, and GI sites. Calcium levels are also affected by magnesium

2014 eMedicine.com

104. Hyperchloremic Acidosis (Diagnosis)

, urinary loss of glucose, amino acids, phosphate, uric acid, and other organic anions, such as citrate, can also occur (Fanconi syndrome). A distinctive feature of type II pRTA is that it is nonprogressing, and when the serum bicarbonate is reduced to approximately 15 mEq/L, a new transport maximum for bicarbonate is established and the proximal tubule is able to reabsorb all of the filtered bicarbonate. A fractional excretion of bicarbonate (FE[HCO 3 - ]) greater than 15% when the plasma bicarbonate (...) is normal after bicarbonate loading is diagnostic of pRTA. In contrast, the fractional excretion of bicarbonate in low and normal bicarbonate levels is always less than 5% in distal RTA (dRTA). Another feature of pRTA is that the urine pH can be lowered to less than 5.5 with acid loading. The pathogenic mechanisms responsible for the tubular defect in persons with pRTA are not completely understood. Defective pump secretion or function, namely aberrations in the function of the proton pump ([H

2014 eMedicine.com

105. Hyperkalemia (Diagnosis)

(eg, increased intake or inhibited excretion) In patients with severe hyperkalemia, treatment is as follows: IV calcium to ameliorate cardiac toxicity, if present Identify and remove sources of potassium intake IV glucose and insulin infusion to enhance potassium uptake by cells Correct severe metabolic acidosis with sodium bicarbonate Consider beta-adrenergic agonist therapy (eg, nebulized albuterol, 10 mg, administered by a respiratory therapist); preferred over alkali therapy in patients (...) delivery to the distal tubule (eg, diuretics) High urine flow (eg, osmotic diuresis) High serum potassium level Delivery of negatively charged ions to the distal tubule (eg, bicarbonate) Renal potassium excretion is decreased by the following: Absence, or very low levels, of aldosterone WNK1 and WNK4 mutations Low sodium delivery to the distal tubule Low urine flow Low serum potassium level Kidneys adapt to acute and chronic alterations in potassium intake. When potassium intake is chronically high

2014 eMedicine.com

106. Hypocitraturia (Follow-up)

filtration rate (GFR) decreases, there is a stepwise decrease in the amount of citrate that is filtered; however, in the early stages of CKD, the increased fractional excretion of citrate prevents an abrupt decline in urinary citrate, such that overt hypocitraturia is not usually observed until advanced stages of CKD. [ ] Primary Hyperaldosteronism In this disease entity, both hypercalciuria and hypocitraturia occur via Na-dependent volume expansion and chronic hypokalemia. [ ] Previous Next: US (...) . Urol Res . 2006 Aug. 34(4):231-8. . Kessler T, Hesse A. Cross-over study of the influence of bicarbonate-rich mineral water on urinary composition in comparison with sodium potassium citrate in healthy male subjects. Br J Nutr . 2000 Dec. 84(6):865-71. . Pinheiro VB, Baxmann AC, Tiselius HG, Heilberg IP. The effect of sodium bicarbonate upon urinary citrate excretion in calcium stone formers. Urology . 2013 Jul. 82(1):33-7. . Seltzer MA, Low RK, McDonald M. Dietary manipulation with lemonade

2014 eMedicine.com

107. Hypertension (Follow-up)

[ , ] : (1) elevated BP, with a systolic pressure (SBP) between 120 and 129 mm Hg and diastolic pressure (DBP) less than 80 mm Hg, and (2) stage 1 hypertension, with an SBP of 130 to 139 mm Hg or a DBP of 80 to 89 mm Hg. In adults at increased risk of heart failure (HF), the optimal BP in those with hypertension should be less than 130/80 mm Hg. Adults with HFrEF (HF with reduced ejection fraction) and hypertension should be prescribed GDMT (guideline-directed management and therapy) titrated to attain

2014 eMedicine.com

108. Cystinuria (Follow-up)

range of 7-7.5. Acetazolamide inhibits the brush-border carbonic anhydrase of the proximal convoluted tubule, thereby increasing urinary bicarbonate excretion. Acetazolamide is not widely used as a first-line drug and is of questionable efficacy. Sodium bicarbonate was used in the past for alkalinizatoinbut is no longer recommended as a first-line agent. The sodium ion may actually increase the amount of cystine excreted. Chelating agents Cystine-binding and cystine-reducing agents share the ability (...) is important for decision-making processes, and stone site and size also influence further management. See the treatment algorithm image below. Treatment algorithm for cystinuria. Hydration The average homozygous patient with cystinuria excretes 600-1400 mg of cystine per day. The solubility of cystine at a pH level of 7 is 250-300 mg/L. Therefore, one of the oldest and most effective cystine stone–prevention techniques is hyperdiuresis to decrease urinary cystine concentration. Early studies by Dent et al

2014 eMedicine.com

109. Toxicity, Mushroom (Follow-up)

), Boletus edulis (king boletus), Leccinium versipelle (brown birch boletus), and Albatrellus ovinus (sheep polypore). Many of these are identified in field guides as edible. Treatment is with aggressive IV fluid resuscitation and consideration for IV sodium bicarbonate to alkalinize the urine. In rare cases, dialysis may be needed if renal failure occurs. Agitation, commonly observed with hallucinogenic mushrooms, is treated with benzodiazepines; phenothiazines are best avoided in this setting. Other (...) of them demonstrate an important decrease in hepatic necrosis histologically. [ ] A large human case series found an association between both silibinin and NAC and higher survival rates. [ ] Corticosteroids, vitamin C, kutkin, aucubin, and thioctic acid have been used in the past but have no proven benefit and are no longer recommended. Charcoal hemoperfusion and hemodialysis are also ineffective in removing toxins because once the toxin is formed, it is rapidly excreted by the kidneys. Plasma

2014 eMedicine.com

110. Metabolic Acidosis (Follow-up)

and well tolerated, and was associated with improvements in bone quality, suggesting a beneficial effect of both alkali treatment and restoration of acid/base balance. The researchers concluded that potassium citrate may be superior to sodium bicarbonate, because it lacks volume effects and the obligatory calcium excretion associated with sodium administration. [ ] Go to and for complete information on these topics. Next: Type 1 Renal Tubular Acidosis Administration of an alkali is the mainstay (...) with placebo followed by escalating doses of oral sodium bicarbonate at 2-week intervals (0.3, 0.6, and 1.0 mEq/d per kg ideal body weight). [ ] Sodium bicarbonate was well tolerated, even at high doses; produced a dose-dependent increase in serum bicarbonate; and was associated with an improvement in lower extremity muscle strength and reduced urinary nitrogen excretion. The authors caution, however, that the results require further study and confirmation from a large randomized placebo-controlled study

2014 eMedicine.com

111. Acute Tubular Necrosis (Treatment)

(red arrow). Finally, intratubular obstruction due to the denuded epithelium and cellular debris is evident (green arrow); note that the denuded tubular epithelial cells clump together because of rearrangement of intercellular adhesion molecules. of 2 Tables Table. Laboratory Findings Used to Differentiate Prerenal Azotemia From ATN Finding Prerenal Azotemia ATN and/or Intrinsic Renal Disease Urine osmolarity (mOsm/kg) >500 < 350 Urine sodium (mmol/d) < 20 >40 Fractional excretion of sodium (FENa (...) ) (%) < 1 >2 Fractional excretion of urea (%) < 35 >50 Urine sediment Bland and/or nonspecific May show muddy brown granular casts Contributor Information and Disclosures Author Nikhil A Shah, MBBS, DNB(Neph) Clinical Research Fellow in Home Dialysis, Nephrologist, University of Alberta Faculty of Medicine and Dentistry, Canada Nikhil A Shah, MBBS, DNB(Neph) is a member of the following medical societies: , , , Canadian Society of Nephrology, , Disclosure: Nothing to disclose. Coauthor(s) Mahendra

2014 eMedicine.com

112. Acute Renal Failure (Treatment)

be harmful for the patient. Maintenance of volume homeostasis and correction of biochemical abnormalities remain the primary goals of treatment and may include the following measures: Correction of fluid overload with furosemide Correction of severe acidosis with bicarbonate administration, which can be important as a bridge to dialysis Correction of hyperkalemia Correction of hematologic abnormalities (eg, anemia, uremic platelet dysfunction) with measures such as transfusions and administration (...) agents, nonsteroidal anti-inflammatory drugs [NSAIDs]) should be avoided or used with extreme caution. Similarly, all medications cleared by renal excretion should be avoided, or their doses should be adjusted appropriately. A 2013 study indicated that triple therapy using nonsteroidal anti-inflammatory drugs (NSAIDs) with 2 antihypertensive medications—a diuretic along with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin-receptor blocker (ARB)—significantly increases the risk

2014 eMedicine.com

113. Azotemia (Treatment)

in developing countries: analysis of 2405 cases in 26 years from eastern India. Clin Kidney J . 2013 Apr. 6 (2):150-5. . . Carvounis CP, Nisar S, Guro-Razuman S. Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure. Kidney Int . 2002 Dec. 62(6):2223-9. . . Faubel S, Patel NU, Lockhart ME, Cadnapaphornchai MA. Renal relevant radiology: use of ultrasonography in patients with AKI. Clin J Am Soc Nephrol . 2014 Feb. 9(2):382-94. . . Holmquist F, Hansson K (...) , Mele C, et al. Transvenous transjugular renal core biopsy with a redesigned biopsy set including a blunt-tipped needle. Cardiovasc Intervent Radiol . 2002 Mar-Apr. 25(2):155-7. . Fenske W, Stork S, Koschker AC, et al. Value of fractional uric acid excretion in differential diagnosis of hyponatremic patients on diuretics. J Clin Endocrinol Metab . 2008 Aug. 93(8):2991-7. . Liu KD, Matthay MA, Chertow GM. Evolving practices in critical care and potential implications for management of acute kidney

2014 eMedicine.com

114. Oliguria (Treatment)

, and an estimation of fluid status is a prerequisite for initial and ongoing therapy. This is accomplished by determination of input and output, body weights, vital signs, skin turgor, capillary refill, peripheral edema, cardiopulmonary examination, serum sodium, and fractional excretion of sodium (FENa). Children with intravascular volume depletion require prompt and vigorous fluid resuscitation. Initial therapy includes isotonic sodium chloride or lactated Ringer solution at 20mL/kg over 30 minutes, which can (...) < 7.2), especially in the presence of hyperkalemia, requires IV bicarbonate therapy. Recognize that bicarbonate therapy requires adequate ventilation (to excrete the carbon dioxide produced) to be effective, and it may precipitate hypocalcemia and hypernatremia. Patients who cannot tolerate a large sodium load (eg, those with congestive heart failure) may be treated in an ICU setting with IV tromethamine (THAM), with provision of adequate ventilatory support pending institution of dialysis. Previous

2014 eMedicine Pediatrics

115. Acute Tubular Necrosis (Treatment)

. This is accomplished by measuring input and output, serial body weights, vital signs, skin turgor, capillary refill, serum sodium, and fractional excretion of sodium (FENa). Children with intravascular volume depletion require prompt and vigorous fluid resuscitation. Initial therapy includes normal saline or lactated Ringer solution at 20 mL/kg over 30 minutes. It can be repeated twice if necessary, after careful monitoring to avoid possible fluid overload. Potassium administration is contraindicated until urine (...) is indicated. In addition to Kayexalate, administer intravenous sodium bicarbonate, which causes a rapid shift of potassium into cells. The magnitude of the potassium intracellular shift is variable, and thus, bicarbonate is not reliable in lowering the potassium level. Such therapy should be used with caution because it can precipitate hypocalcemia and sodium overload. Sodium bicarbonate uptake of potassium by cells can also be stimulated by infusion of glucose and insulin or by beta agonists (albuterol

2014 eMedicine Pediatrics

116. Oliguria (Follow-up)

, and an estimation of fluid status is a prerequisite for initial and ongoing therapy. This is accomplished by determination of input and output, body weights, vital signs, skin turgor, capillary refill, peripheral edema, cardiopulmonary examination, serum sodium, and fractional excretion of sodium (FENa). Children with intravascular volume depletion require prompt and vigorous fluid resuscitation. Initial therapy includes isotonic sodium chloride or lactated Ringer solution at 20mL/kg over 30 minutes, which can (...) < 7.2), especially in the presence of hyperkalemia, requires IV bicarbonate therapy. Recognize that bicarbonate therapy requires adequate ventilation (to excrete the carbon dioxide produced) to be effective, and it may precipitate hypocalcemia and hypernatremia. Patients who cannot tolerate a large sodium load (eg, those with congestive heart failure) may be treated in an ICU setting with IV tromethamine (THAM), with provision of adequate ventilatory support pending institution of dialysis. Previous

2014 eMedicine Pediatrics

117. Fluid, Electrolyte, and Nutrition Management of the Newborn (Overview)

output and a serum creatinine that does not decline postnatally or increases may have acute kidney injury (AKI). Urine electrolyte levels and specific gravity may be assessed. If the infant is being treated with diuretics, such as furosemide, results of these tests are difficult to interpret. Calculation of the fractional urinary excretion of sodium in relation to creatinine (FENa) and blood gas analysis may be indicated; metabolic acidosis may be a marker of inadequate tissue perfusion. Previous (...) + excretion and loss of bicarbonate. [ ] During the active growth period after the first week, the need for potassium may increase to 2-3mEq/kg/day, and the need for sodium and chloride may increase to 3-5mEq/kg/day. Some of the smallest preterm infants have sodium requirements of as much as 6-8mEq/kg/day because of the decreased capacity of the kidneys to retain sodium. Previous Next: Fluids and Electrolytes in Common Neonatal Conditions Infants with respiratory distress syndrome need appropriate fluid

2014 eMedicine Pediatrics

118. Acidosis, Respiratory (Overview)

, bicarbonate, and protein bound. It diffuses freely across cell membranes, and this diffusion allows it to be efficiently transported from peripheral tissues to the lungs for excretion. When hypercapnia is present, this same property causes excess carbon dioxide to shift intracellularly and decrease intracellular pH. Carbon dioxide (CO 2 ) normally combines with water (H 2 O) to form carbonic acid (H 2 CO 3 ), which then dissociates to release hydrogen ion (H + ) and bicarbonate (HCO 3 (...) substantial changes in pH, and approximately 10% of carbon dioxide is bound to hemoglobin to form carbaminohemoglobin. Cellular buffering elevates plasma bicarbonate (HCO 3 – ) only slightly and causes plasma HCO 3 – to increase by 1 mEq/L for every 10-mm Hg increase in P a CO 2 . Renal compensation for sustained hypercapnia begins in 6-12 hours, but 3-5 days pass before maximal compensation occurs. The kidneys increase excretion of hydrogen ions (predominantly in the form of ammonium [NH 4

2014 eMedicine Pediatrics

119. Fluid, Electrolyte, and Nutrition Management of the Newborn (Treatment)

output and a serum creatinine that does not decline postnatally or increases may have acute kidney injury (AKI). Urine electrolyte levels and specific gravity may be assessed. If the infant is being treated with diuretics, such as furosemide, results of these tests are difficult to interpret. Calculation of the fractional urinary excretion of sodium in relation to creatinine (FENa) and blood gas analysis may be indicated; metabolic acidosis may be a marker of inadequate tissue perfusion. Previous (...) + excretion and loss of bicarbonate. [ ] During the active growth period after the first week, the need for potassium may increase to 2-3mEq/kg/day, and the need for sodium and chloride may increase to 3-5mEq/kg/day. Some of the smallest preterm infants have sodium requirements of as much as 6-8mEq/kg/day because of the decreased capacity of the kidneys to retain sodium. Previous Next: Fluids and Electrolytes in Common Neonatal Conditions Infants with respiratory distress syndrome need appropriate fluid

2014 eMedicine Pediatrics

120. Acute Tubular Necrosis (Diagnosis)

From ATN Finding Prerenal Azotemia ATN and/or Intrinsic Renal Disease Urine osmolarity (mOsm/kg) >500 < 350 Urine sodium (mmol/d) < 20 >40 Fractional excretion of sodium (FENa) (%) < 1 >2 Fractional excretion of urea (%) < 35 >50 Urine sediment Bland and/or nonspecific May show muddy brown granular casts Contributor Information and Disclosures Author Nikhil A Shah, MBBS, DNB(Neph) Clinical Research Fellow in Home Dialysis, Nephrologist, University of Alberta Faculty of Medicine and Dentistry (...) , but it also helps in the excretion of these toxins by glomerular filtration and tubular secretion. Exogenous nephrotoxins that cause ATN Aminoglycoside-related toxicity occurs in 10-30% of patients receiving aminoglycosides, even when blood levels are in apparently therapeutic ranges. Risk factors for ATN in these patients include the following: Preexisting liver or renal disease Concomitant use of other nephrotoxins (eg, amphotericin B, radiocontrast media, cisplatin) Shock Advanced age Female sex Higher

2014 eMedicine.com

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