Amy Yau Profile picture
Jan 12 8 tweets 4 min read
🧵Let's talk hypernatremia

So often we discuss the correction rate of hyponatremia, but what about hypernatremia? #medtwitter #nephtwitter #meded

🧐What is your correction rate for chronic hypernatremia?
Older guidelines recommend a correction of no more than 8-10 mEq/dL in 24 hours borrowed from pediatric literature

“Fast” correction is generally considered to be more than 12 mEq/dL per day

pubmed.ncbi.nlm.nih.gov/20412412/
There are some cases in which you may tolerate permissive hypernatremia, but the evidence behind its benefits we can discuss another day.

Ahem #neurocriticalcare looking at you….
For those with a correction rate in mind, in patients who “overcorrect” to your goal, do you...
The risk of correcting hypernatremia too fast is the development of cerebral edema🧠

However, there was no evidence of cerebral edema in 🐇“fast” (> 0.5 mEq/dL/hr) correction compared to 🐢slow. This analysis included included neuro ICU patients

pubmed.ncbi.nlm.nih.gov/30948456/
Physiologically this makes sense because the loss of ionic osmolytes is the main component to regularly volume decrease, and this happens VERY FAST.



pubmed.ncbi.nlm.nih.gov/7495565/
pubmed.ncbi.nlm.nih.gov/20498228/
But the 🔑key to fixing hypernatremia is to actually fix the hypernatremia.

Often is it “slowly” recorrected…or not corrected at all, and mortality is higher.

Not to mention your patients are 🥤thirsty!!!

pubmed.ncbi.nlm.nih.gov/21358313/
The only times I would consider going slow (<8 mEq/L per day) would be

⭐️if there is another increased osmole (i.e., high BUN or glucose) that I am also lowering

⭐️already existing cerebral edema or an acute large stroke that has the potential to develop cerebral edema

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More from @amyaimei

Sep 13, 2021
⁉️What is the difference between mineral and organic acidosis?
⁉️Why does one cause more hyperkalemia than the other?

Join me on this 🐇🕳️rabbit hole #tweetorial on metabolic acidosis and it's effect on potassium.

📊To start, which type of acidosis causes more hyperkalemia?
Metabolic acidosis is defined as a ⬇️low pH due to a ⬇️decrease in bicarbonate extracellularly

💎Mineral acids (aka inorganic acids) are “synthesized from earth minerals.”

🥬Organic acids are metabolized by the cell and occur naturally.
Both can have a 🩸high anion-gap...just depends on anion accumulated.

💎Mineral acids are often (not always) a hyperchloremic normal anion gap metabolic acidosis

Think of 🥬organic acidosis as high anion gap metabolic acidosis (though not always true)
Read 19 tweets
Feb 6, 2021
The 🎩baron of kidney stone prevention has been citrate supplementation.

📖Let’s quickly review hypocitraturia and its relationship to stones.

Where is most of your citrate reabsorbed?
Which condition is ❌NOT associated with hypocitraturia?
Before we get into the #tweetorialanswers, let’s establish that hypocitraturia is a risk factor.

Previous data show around 📊46-60% of stone formers have hypocitraturia.

In Ca stone formers, hypocitraturia is the 📊sole abnormality in 10%.

pubmed.ncbi.nlm.nih.gov/32715836/
Read 13 tweets
Dec 9, 2020
🤔🔬Why are kidney stones so interesting?
Because the 🔑tubules > glomeruli

Disagree if you like, but it’s true.

A short thread on some mechanisms associated with calcium stones...

#nephtwitter #FOAMed #MedEd #uronephrology #kidneystone #nephrolith Image
Which is a risk factor for calcium oxalate stones?
Correct!

Risk factors for calcium oxalate stones classically include 📌hypercalciuria and 📌hyperoxaluria along with 💧low urine volume.

#Hypercalciuria can stem from a LOT of different causes and clinical settings. The most common in adults is idiopathic. Image
Read 17 tweets
Jul 28, 2020
Which is your favorite hypertension syndrome #eponym?
So a short #VisualMnemonic quiz thread on some of the #HTNsyndromes I can never remember🤔 (list is not all inclusive)

Some are better than others.🤷‍♀️If nothing else, hope it's fun.🎉
#timetostudy #boardprep
A young man comes to you with high blood pressure since teen years.

K is high, Bicarb is low.

What is the mechanism of his HTN?
(MC = mineralocorticoid)
Read 10 tweets
Jun 2, 2020
Is being pregnant magical🌟?
I’m not so sure, but let’s give OB a Nephrology twist. 🍼🐣

#nephtwitter #obtwitter #endotwitter #reallythekidneysarethecoolest #medtwitter #tweetorial

Why do you gain weight when you are pregnant?
The average woman ⬆️gains a plasma volume of 1250 mL (an increase of 45-55%).

Significant lab values changes include
- Plasma Na ⬇️reduced by ~ 5 mmol/L
- Plasma osmolality ⬇️reduces by ~10 mOsm/kg
- Cr ⬇️decreases by 0.3 mg/dL due to increased GFR among other changes ImageImage
There is an entire milieu of hormone changes during pregnancy🤰. Some are natriuretic and some are anti-natriuretic.

Sources: Comprehensive Clinical Nephrology Chapter 42, pubmed.ncbi.nlm.nih.gov/22879432 ImageImage
Read 18 tweets
Dec 16, 2019
The Tale of the Low Chloride

Once there was 34 year old man who used marijuana and was 🤮nauseous, vomitting, and confused. The resident 📞calls and says, "All the electrolytes are abnormal!! Can you help?"

renalfellow.org/2019/12/16/ske…

@TheSkeletonKG #FOAMED #medtwitter #tweetorial Image
You say of course and see the patient. 🥼🩺His BP was 131/87 mmHg with a HR of 142 bpm. He was fatigued, but AOx3. Moist mucous membranes, normal skin turgor, and no LE edema.

💉Labs are shown and reveal a serum osmolality of 263 with ALL normal labs 3 months prior. Image
Loving Nephrology🤓, you ask, "What about the urine?!"

He is making urine with a urine Cl of < 20.

(💭Learn more about FeK and Urine K/Cr ratio with our previous case! renalfellow.org/2019/11/14/the… @hotsaltrocks ) Image
Read 15 tweets

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