1. Interesting Electrolyte Cases Joel M. Topf, M.D. Nephrology 248.470.8163 http://PBFluids.blogspot.com

2. 58 y.o. female with weakness and muscle aches 7.34 / 87 / 33 / 17 139 115 3.1 17 16 1.0

16. Anion gap =

17. Anion gap =

18. Anion gap =

19. Anion gap =

27. Plasma Bile Pancreas Small intestines Large intestines 140 102 4.4 24 135 100 5.0 35 135 50 5.0 90 135 50 5.0 90 110 90 35 40

29. Urine pH=5.5 Serum pH=7.4 100 fold difference

30. Ureterosigmoidostomy Urine pH=5.5 Serum pH=7.4 100 fold difference

31. Ureterosigmoidostomy Ureteroileostomy Urine pH=5.5 Serum pH=7.4 100 fold difference

35. Proximal tubule: reabsorption of filtered bicarbonate

36. Proximal tubule: reabsorption of filtered bicarbonate

37. Proximal tubule: reabsorption of filtered bicarbonate

38. Distal tubule, completion of reabsorption and replacing bicarbonate lost to the daily acid load.

39. Distal tubule, completion of reabsorption and replacing bicarbonate lost to the daily acid load.

40. Distal tubule, completion of reabsorption and replacing bicarbonate lost to the daily acid load.

41. Fate of excreted hydrogen ion The minimal urine pH is 4.5. This is a H + concentration a 1000 times that of plasma.

42. Fate of excreted hydrogen ion The minimal urine pH is 4.5. This is a H + concentration a 1000 times that of plasma. But It still is only 0.04 mmol/L

43. Fate of excreted hydrogen ion The minimal urine pH is 4.5. This is a H + concentration a 1000 times that of plasma. But It still is only 0.04 mmol/L In order to excrete 50 mmol (to produce enough bicarb-onate to account for the daily acid load) one would need to produce 1250 liters of urine.

44. Fate of excreted hydrogen ion Ammonium Titratable acid

60. Diagnosing the cause of: non-anion gap metabolic acidosis

61. To look for renal H + clearance look for urinary ammonium Ammonium Titratable acid

62. To look for renal H + clearance look for urinary ammonium Ammonium Titratable acid NH 4 +

76. 58 y.o. female with weakness and muscle aches 7.34 / 87 / 33 / 16 U/A pH 6.5 Urine electrolytes 139 115 3.1 17 16 1.0 80 115 45

77. 58 y.o. female with weakness and muscle aches 7.34 / 87 / 33 / 16 U/A pH 6.5 Urine electrolytes Appropriately compensated non-anion gap metabolic acidosis due to distal RTA 139 115 3.1 17 16 1.0 80 115 45

78. 74 y.o. female with 34 year history of DM c/o weakness 7.34 / 87 / 33 / 16 Albumin 1.8 139 123 6.6 17 21 1.2

97. Recent lab history

98. Diagnose the cause of: non-anion gap metabolic acidosis with hyperkalemia

101. A dipstick for aldosterone activity: The trans-tubular potassium gradient The TTKG

117. 58 y.o. female with weakness and muscle aches

118. 58 y.o. female with weakness and muscle aches Both the bicarbonate and potassium were normal at admission. This is hospital acquired RTA (type 1 or 4)

126. Fin