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Inc K
Renal failure
Drugs - ACEi, K or K sparing diuretics
Addisons, Metabolic acidosis - DM
Artefact - haemolysis

Dec K
Fluid loss - diuretics, laxatives, d&v, villous adenoma / fistula, 
Cushings / xs steroids, Conn's

Inc Na
Fluid loss - D&V, burns, diabetes insipidus
Conn's

Dec Na
Fluid loss - diuretics, laxatives, d&v, villous adenoma / fistula
Addisons, CF, SIADH, Hypothyroid, Cirrhosis


''Sanjeev theory ...''
Usually problem with H2O not with Na
Look for problem drugs and stop
Check fluid status and if ...
hypovolaemic - drop in BP (? postural drop) - give fluids (fluid loss - d/v kidney  diuretic)
hypervolaemic  - raised JVP - give IV frusemide (nephrotic, CCF ascites) even if BP low - cardiogenic shock - poor outcome
 
Note pseudo hypo Na - Glc, or protein or TG xs displacing Na - correct the first and Na will resolve
 
Euvolaemia - less common - check for steroids, cortisol deficiency, thyroid status
THEN think SIADH - urine Na, paired osmolality (urine > serum), causes - Carbamazpine, CNS infection or lung ca
 


HIGH Sodium
may reflect lack of access to drinking water or renal tubular problem
Diabetes Insipidus - dec ADH leads to polyuria with water loss and high Na
Lithium, hypokalaemia and hypercalcaemia - impair ADH - can cause nephrogenic DI with high Na
 
LOW Sodium - common finding associated with diuretic use and heart failure, but also in chronic disease
SIADH - rapidly evolving low Na that needs urgent treatment - high urine osmolality and Na so low serum osmolality and Na (hyponatraemic and hypervolaemic)
As Na drops - neuro complications ? coma
loop diuretics unlikely to cause rapid (over days) drop in Na - don't give Na supplements - admit
ADH secreting tumours esp small cell lung cancer, neuro disorders, TB or lung abscess
drugs - carbamazepine, phenothiazines, tricyclics, SSRI,
Mx - fluid restrict ? with tolvaptan or domeclocycline
 
Addisons
low Na but hypovolaemic
 
Potassium
intracellular ion crucial to muscle function (cardiac smooth and skeletal)
eliminated by kidneys so may accumulate in renal insufficiency
controlled by Na/K pump - sensitive to adrenaline and blocked by BB (so they cause a rise in K)
changes in acid-base (eg DKA) may cause problems
Note Lo-salt contains lots of KCl
 
Low K - flattened T waves and U wave on ECG
Loop diuretics cause K and Mg loss leading to myalgia, muscle weakness and arrythmias
low Mg effects PTH which leads to low Ca
low K leads to polyuria
Conn's - usually low K - needs aldosterone / renin ratio and consider adrenal mass
ectopic ACTH - massive levels of steroid exert mineralocorticoid action and so low K
Mx - beware K supplements if aSx esp if on ACE due to dangerous hyperK
 
High K
check genuiness of result if normal renal function (?EDTA bottle used, refrigeration of sample, old sample, blood dyscrasias or clots)
 
Extreme values of K (>7.0 or <2.6) or rapidly changing need admission
beware artefact when renal function is normal
unexplained high or low values needs investigation