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Fractional Excretion of Bicarbonate

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141. 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

142. Respiratory Acidosis (Diagnosis)

elevates plasma bicarbonate values, but only slightly (approximately 1 mEq/L for each 10-mm Hg increase in PaCO 2 ). The second step is renal compensation that occurs over 3-5 days. With renal compensation, renal excretion of carbonic acid is increased, and bicarbonate reabsorption is increased. The expected change in serum bicarbonate concentration in respiratory acidosis can be estimated as follows: Acute respiratory acidosis – Bicarbonate increases by 1 mEq/L for each 10-mm Hg rise in PaCO 2 (...) . [ , ] Alveolar hypoventilation leads to an increased PaCO 2 (ie, hypercapnia). The increase in PaCO 2 , in turn, decreases the bicarbonate (HCO 3 – )/PaCO 2 ratio, thereby decreasing the pH. Hypercapnia and respiratory acidosis ensue when impairment in ventilation occurs and the removal of carbon dioxide by the respiratory system is less than the production of carbon dioxide in the tissues. Lung diseases that cause abnormalities in alveolar gas exchange do not typically result in alveolar hypoventilation

2014 eMedicine.com

143. Respiratory Alkalosis (Diagnosis)

quantity of volatile acid (carbon dioxide) and nonvolatile acid. The metabolism of fats and carbohydrates leads to the formation of a large amount of carbon dioxide. [ ] The carbon dioxide combines with water to form carbonic acid. The lungs excrete the volatile fraction through ventilation, and acid accumulation does not occur. Significant alterations in ventilation can affect the elimination of carbon dioxide and lead to a respiratory acid-base disorder. PaCO 2 is normally maintained in the range (...) : Oct 03, 2018 Author: Ryland P Byrd, Jr, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP Share Email Print Feedback Close Sections Sections Respiratory Alkalosis Overview Background Respiratory alkalosis is a disturbance in acid and base balance due to alveolar hyperventilation. Alveolar hyperventilation leads to a decreased partial pressure of arterial carbon dioxide (PaCO 2 ). In turn, the decrease in PaCO 2 increases the ratio of bicarbonate concentration to PaCO 2 and, thereby, increases the pH

2014 eMedicine.com

144. Toxicity, Mushrooms (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 Emergency Medicine

145. Toxicity, Barbiturate (Treatment)

to be renally excreted. Urinary alkalinization is not recommended for short-acting barbiturates. Enhancement of urinary elimination may be accomplished with an initial sodium bicarbonate bolus of 1 mEq/kg followed by a constant infusion. This infusion may be made by adding 100-150 mEq of sodium bicarbonate to 850 mL of D5 and titrating to maintain a urine pH of greater than 7.5 with an arterial pH of less than 7.50. The goal should be a urine output of 150-250 mL/h. Risks include hypokalemia, fluid overload (...) it was administered at 30 minutes, 60 minutes, and 120 minutes, respectively, current guidelines in overdose management question its benefit. There is no evidence that the administration of activated charcoal improves clinical outcome. Indeed, its use has decreased to less than 5% of all reported ingestions in recent years. [ ] A single dose of activated charcoal may be given within an hour of overdose if the clinician estimates that a clinically significant fraction of the ingested substance remains in the GI

2014 eMedicine Emergency Medicine

146. Rhabdomyolysis (Treatment)

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

147. Renal Failure, Acute (Treatment)

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

148. Syndrome of Inappropriate Antidiuretic Hormone Secretion (Overview)

, 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 Pediatrics

149. Fluid, Electrolyte, and Nutrition Management of the Newborn (Follow-up)

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

150. 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

151. Altitude Illness - Cerebral Syndromes (Diagnosis)

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

152. Altitude Illness - Pulmonary Syndromes (Diagnosis)

, 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

153. Syndrome of Inappropriate Antidiuretic Hormone Secretion (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 Emergency Medicine

154. 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 Emergency Medicine

155. Toxicity, Antidysrhythmic (Overview)

, 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

156. Syndrome of Inappropriate Antidiuretic Hormone Secretion (Overview)

, 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 Emergency Medicine

157. Renal Failure, Acute (Overview)

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

158. Hypocitraturia (Treatment)

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

159. The Diet Pill and the Deadly Acidosis

and serum bicarbonate of 7 mmol/L). She was initially suspected as having diabetic ketoacidosis due to miscalculation of the anion gap by the admitting team who used the corrected serum sodium and not the actual sodium, and as expected, her acidosis did not resolve despite the correction of hyperglycemia with intravenous fluids and insulin. Her urine pH was 6.2, urine anion gap was 12 (no ketonuria) and fractional excretion of bicarbonate was 17% suggesting the possibility of mixed renal tubular (...) fractional excretion of bicarbonate with elevated B2 microglobulinuria suggesting proximal tubular impairment. Besides metabolic acidosis, topimarate use has been associated with 10 fold increased risk of and is largely due to hypocitraturia that develops in these patients with failure of renal acidification. These patients are also at risk for for the same reasons. Non ambulatory patients, ketogenic diets, hypovolemia and higher dosage (400mg/d) is associated with an increased risk of renal

2011 Renal Fellow Network

160. Urine electrolytes in metabolic alkalosis

with passage of concentrated small amount of urine, the concentration of chloride may be high too. The ideal way of eliminating this error is by doing a fractional excretion of chloride!! It probably is the ideal way of assessing volume status. Subscribe to: Interested in Contributing to the Renal Fellow Network? Email Matt or Gearoid NSMC Founding Member Get notified of new RFN posts by email Partner A nice repository of landmark articles and reviews in the field of nephrology at . are also included (...) Urine electrolytes in metabolic alkalosis Renal Fellow Network: Urine electrolytes in metabolic alkalosis | | | | | Tuesday, February 8, 2011 Urine electrolytes in metabolic alkalosis No time like the present for a quick review of urine electrolytes. Is there any such thing as a ‘normal’ urine sodium? Not really – like all great answers in medicine, ‘it depends’. In general, in patients who are euvolaemic, the urine sodium excretion will directly correlate with the degree of dietary sodium

2011 Renal Fellow Network

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