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Fractional Excretion of Bicarbonate

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121. 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

122. Uric Acid Stones (Treatment)

, Children, and Adults [ ] Neonates* Children Adults 29-33 wk 34-37 wk 38-40 wk 3-4 y 5-9 y 10-14 y 40-44 y Male Female Male Female Male Female Male Female Serum uric acid (mg/dL) 7.71±2.65 6.04±2.19 5.19±1.57 3.45±1.01 3.44±0.8 3.63±1.04 3.71±0.92 4.28±1.19 4.09±1.2 5.134±1.25 4.25±1.1 Uric acid excretion (mg/dL GFR † ) 4.8±2.23 2.81±0.93 1.69±0.84 0.34±0.11 0.403±0.095 Uric acid excretion (mg/kg/d) N/A N/A 19.6 13.5±3.75 (3 y) 11.5±3.75 (7 y) 9±3.75 (12 y) 10 Fractional excretion of uric acid (%) 61.24 (...) Stones Treatment & Management Updated: Jun 11, 2018 Author: Sahar Fathallah-Shaykh, MD; Chief Editor: Craig B Langman, MD Share Email Print Feedback Close Sections Sections Uric Acid Stones Treatment Medical Care The primary treatments are to alkalinize (citrate or bicarbonate) and dilute (large water intake) the urine. Sodium urate is 15 times more soluble than uric acid. At a urine pH level of 6.8, 10 times as much sodium urate as uric acid is present. At a urine pH level of 7.8, 100 times as much

2014 eMedicine Pediatrics

123. Acute Tubular Necrosis (Follow-up)

. 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

124. Toxicity, Mushrooms - Muscarine (Treatment)

), 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 Pediatrics

125. Toxicity, Mushrooms - Muscarine (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 Pediatrics

126. 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

127. 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

128. 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

129. Perioperative Management of the Female Patient

% of the time. Although it is most commonly observed in women with small-cell carcinoma of the lung, SIADH is also observed in women with gynecologic and bladder cancers. The management of this disorder may be difficult. SIADH occurs in a state of euvolemic hyponatremia. The hyponatremia is caused by over-secretion of ADH. Because free water cannot be excreted normally, persistent ADH secretion causes water retention, hyponatremia, and progressive expansion of intracellular and extracellular fluid

2014 eMedicine.com

130. 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

131. Toxicity, Antidysrhythmic (Diagnosis)

, flecainide, propafenone, amiodarone Hemodialysis: Procainamide, mexiletine, sotalol Sodium bicarbonate: Class Ia and Ic antidysrhythmics (quinidine, procainamide, disopyramide, lidocaine, mexiletine, flecainide, propafenone) Magnesium: Class III agents, Ibutilide, dofetilide, sotalol, quinidine, procainamide, disopyramide Intravenous lipid emulsion: Verapamil; less evidence for lidocaine, flecainide, amiodarone Seizure control (benzodiazepines): Quinidine, procainamide, lidocaine, mexiletine, flecainide (...) Disopyramide In addition to sodium and potassium channel blockade, disopyramide is a muscarinic antagonist. See the following: Indications: Documented ventricular dyshythmias, atrial dysrhythmias in patients with hypertrophic cardiomyopathy (unlabeled use) Dosages: Dose adjustment is gradual; 100-200 mg orally every 6 hours; reduced dosage frequency recommended in renally impaired patients Metabolism: Metabolized by the liver (CYP3A4), 40-60% excreted by the kidneys Therapeutic concentrations: Atrial

2014 eMedicine Emergency Medicine

132. Toxicity, Mushrooms (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 Emergency Medicine

133. Rhabdomyolysis (Follow-up)

Dehydration (hematocrit >50, serum sodium level >150 mEq/L, orthostasis, pulmonary wedge pressure < 5 mm Hg, urinary fractional excretion of sodium < 1%) Sepsis Hyperkalemia or hyperphosphatemia on admission Hypoalbuminemia AKI has occasionally developed in severely dehydrated patients with peak CK levels as low as 2000 IU/L. To prevent renal failure, many authorities advocate urinary alkalization, mannitol, and loop diuretics. Alkalization of urine is believed to be helpful and is based (...) . These invasive studies can assist in the assessment of the intravascular volume.) Repeat the CK assay every 6-12 hours to determine the peak CK level. Aggressive and early hydration with isotonic sodium chloride solution is important for the prevention of pigment-associated renal failure. The composition of repletion fluid is controversial and may also include sodium bicarbonate. Initial fluid use in young children has been recommended to be 20 mL/kg; in adolescents, 1-2 L/h has been recommended. Subsequent

2014 eMedicine Emergency Medicine

134. Renal Failure, Acute (Follow-up)

that suggest prerenal ARF include the following: Urine specific gravity >1.018 Urine osmolality (mOsm/kg water) >500 Urine sodium (mEq/L) < 15-20 Plasma BUN-creatinine ratio >20 Urine-plasma creatinine ratio >40 Urine indices that suggest ATN include the following: Urine specific gravity < 1.012 Urine osmolality (mOsm/kg water) < 500 Urine sodium (mEq/L) >40 Plasma BUN/creatinine ratio < 10-15 Urine-plasma creatinine ratio < 20 Previous Next: Calculation of Fractional Excretion of Sodium The calculation (...) of fractional excretion of sodium (FeNa) is as follows: FeNa = (urine Na/plasma Na)/(urine creatinine/plasma creatinine) If FeNa is less than 1%, this suggests prerenal acute renal failure (ARF). If FeNa is greater than 1%, this suggests ATN. The advantages of FeNa compared with other indices include the following: Physiologic measure of sodium reabsorption Measured creatinine and sodium clearances, accounting for filtration and reabsorption of sodium FeNa increased before oliguric phase established

2014 eMedicine Emergency Medicine

135. Hypocalcemia (Overview)

: 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 Emergency Medicine

136. Altitude Illness - Pulmonary Syndromes (Overview)

, triggered by oxygen-sensing cells in the carotid body. Increased ventilation produces a higher alveolar PO 2. Concurrently, a lowered alveolar PCO 2 results in a respiratory alkalosis and so acts as to limit the increase in ventilation. Renal compensation, through excretion of bicarbonate ion, gradually brings the blood pH back toward normal and allows further increase in ventilation. This process, termed ventilatory acclimatization, requires approximately 4 days at a given altitude and is greatly (...) Hypoxia is the primary physiological insult on ascent to high altitude. The fraction of oxygen in the atmosphere remains constant (0.21), but the partial pressure of oxygen decreases along with barometric pressure on ascent to altitude. The inspired partial pressure of oxygen (PiO 2 ) is lower still because of water vapor pressure in the airways. At the altitude of La Paz, Bolivia (4000 m; 13,200 ft), PiO 2 is 86.4 mm Hg, which is equivalent to breathing 12% oxygen at sea level. The response

2014 eMedicine Emergency Medicine

137. Altitude Illness - Cerebral Syndromes (Overview)

important immediate response of the body to hypoxia is an increase in minute ventilation, called the hypoxic ventilatory response (HVR), and is triggered by oxygen sensing cells in the carotid bodies. Increased ventilation produces a higher alveolar PO 2. Concurrently, a lowered alveolar PCO 2 produces a respiratory alkalosis, acting as a brake on the respiratory center of the brain and subsequently limiting further increases in ventilation. Renal compensation, through excretion of bicarbonate ions (...) physiological insult on ascent to high altitude. The fraction of oxygen in the atmosphere remains constant (0.21) at all altitudes, but the partial pressure of oxygen decreases along with barometric pressure on ascent to altitude. The inspired partial pressure of oxygen (PiO 2 ) is lower still because of water vapor pressure in the airways. At the altitude of International Airport at La Paz, Bolivia (4062 m; 13,327 ft), PiO 2 is 98.18 mm Hg, which is equivalent to breathing 12.8% oxygen at sea level. See

2014 eMedicine Emergency Medicine

138. Renal Failure, Acute (Diagnosis)

that suggest prerenal ARF include the following: Urine specific gravity >1.018 Urine osmolality (mOsm/kg water) >500 Urine sodium (mEq/L) < 15-20 Plasma BUN-creatinine ratio >20 Urine-plasma creatinine ratio >40 Urine indices that suggest ATN include the following: Urine specific gravity < 1.012 Urine osmolality (mOsm/kg water) < 500 Urine sodium (mEq/L) >40 Plasma BUN/creatinine ratio < 10-15 Urine-plasma creatinine ratio < 20 Previous Next: Calculation of Fractional Excretion of Sodium The calculation (...) of fractional excretion of sodium (FeNa) is as follows: FeNa = (urine Na/plasma Na)/(urine creatinine/plasma creatinine) If FeNa is less than 1%, this suggests prerenal acute renal failure (ARF). If FeNa is greater than 1%, this suggests ATN. The advantages of FeNa compared with other indices include the following: Physiologic measure of sodium reabsorption Measured creatinine and sodium clearances, accounting for filtration and reabsorption of sodium FeNa increased before oliguric phase established

2014 eMedicine Emergency Medicine

139. Syndrome of Inappropriate Secretion of Antidiuretic Hormone (Diagnosis)

, the nonphysiological secretion of AVP results in enhanced water reabsorption, leading to dilutional hyponatremia. While a large fraction of this water is intracellular, the extracellular fraction causes volume expansion. Volume receptors are activated and natriuretic peptides are secreted, which causes natriuresis and some degree of accompanying potassium excretion (kaliuresis). Eventually, a steady state is reached and the amount of Na + excreted in the urine matches Na intake. Ingestion of water is an essential (...) of the antidiuretic hormone arginine vasopressin (AVP) despite normal or increased plasma volume, which results in impaired water excretion. [ ] The key to understanding the pathophysiology, signs, symptoms, and treatment of SIADH is the awareness that the results from an excess of water rather than a deficiency of sodium. Signs and symptoms Depending on the magnitude and rate of development, hyponatremia may or may not cause symptoms. The history should take into account the following considerations: In general

2014 eMedicine.com

140. 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

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