Primary Metabolic Alkalosis - Differential Diagnosis Algorithm Volume Depleted - 2° hyperaldosteronism • Low Urine Cl-: Vomiting, NGT suction, Low Cl intake, Diuretics (late) • High Urine Cl-: Diuretics, Bartter Syndrome, Gitelman Syndrome Euvolemic* - 1°/2° hyperaldosteronism • High PRA: Renal artery stenosis, Renin-secreting tumor • Low PRA: Adenoma, BAH, AME, GRA, Cushing's syndrome, Liddle syndrome PRA: plasma renin activity; AME: apparent mineralocorticoid excess; GRA: glucocorticoid remediable aldosteronism *Due to aldosterone escape #Metabolic #Alkalosis #Differential #Diagnosis #Algorithm #Nephrology #Causes

Citrate Anticoagulation Toxicity Hypernatremia (HyperNa): - Citrate solutions may have ↑ sodium content and should be paired with a lower sodium dialysate/replacement fluid Hypomagnesemia (HypoMg): - Citrate binds Mg: this complex is removed via CKRT from circulation → ↓Mg Hypocalcemia (HypoCa): - Citrate can bind free, ionized Ca (iCa) - If the [Total Ca: iCa] Ratio is > 2.5: think citrate toxicity - Remember to convert the units: Multiply the Total Ca (mg/dL) by 0.25 to convert to mmol/L Anion-Gap Metabolic Acidosis: - Citrate is a weak, "unmeasured" anion - Liver dysfunction or low mean arterial pressure may increase citrate accumulation by impairing citrate metabolism Metabolic alkalosis: - Bicarbonate may accumulate as: - 1 Citrate → 3 HCO3- #Citrate #Anticoagulation #Toxicity #toxicology #nephrology #diagnosis

Polyuria - Differential Diagnosis Algorithm Polyuria = >3L Urine output / 24 hours Urine osmolality = 2 (Na meq/L + K meq/L] + [BUN mg/dL]/2.8 + [glucose mg/dL]/18 HIGH urine osmolality > 300 mosm/kg • Solute Diuresis: Hyperglycemia, High solute intake (e.g. IV fluids, nutrition), Azotemia LOW urine osmolality < 100 mosm/kg • Diabetes Insipidus • Primary Polydipsia #Polyuria #Differential #Diagnosis #Algorithm #nephrology

Primary Metabolic Alkalosis - Differential Diagnosis Algorithm Volume Depleted 2° hyperaldosteronism • Low Urine Cl-: Vomiting, NGT suction, Low Cl intake, Diuretics (late) • High Urine Cl-: Diuretics, Bartter Syndrome, Gitelman Syndrome Volume Expanded 1° / 2° hyperaldosteronism • High PRA: Renal artery stenosis, Renin-secreting tumor • Low PRA: Adenoma, BAH, AME, GRA, Cushing's syndrome, Liddle syndrome #Primary #Metabolic #Alkalosis #Differential #Diagnosis #Algorithm #nephrology

How-to Calculate the Filtration Fraction (FF) in CKRT FF = Fluid removed from the filter / Fluid entering the filter - The FF is the ratio of fluid being REMOVED from the fluid to the fluid ENTERING the filter - The target FF to reduce the risk of filter clotting is < 20-25% - Dialysate (in CVVHD or CVVHDF) does NOT affect the FF https://nephsim.com/calculators/#Filtration #Filtration #Fraction #FF #CKRT #nephrology #calculation

Membranoproliferative Glomerulonephritis (MPGN) AKA: Mesangiocapillary GN • Active Urine Sediment (dysmorphic RBC, RBC casts, +/- proteinuria) - Mesangial hypercelluIarity - Endocapillary proliferation • Double contour formation along glomerular capillary walls Immune-Complex Mediated • "Full house" IF staining (lg + complement) • Ex: HCV, HBV, Sjogren's, rheumatoid arthritis, monoclonal gammopathy Complement-Mediated MGPN • Complement deposition without lg on IF • Dysregulation and activation of alternative complement pathway • C3 glomerulopathy (Dense deposit disease, C3GN, CFHR5 neph) MPGN without complement of lg deposition • Minimal immune deposits on EM, negative IF • Ex: Thrombotic microangiopathy (TMA), anti-phospholipid syndrome, post-bone marrow transplantation, transplant glomerulopathy, radiation nephritis, malignant HTN #Membranoproliferative #Glomerulonephritis #MPGN #nephrology #diagnosis #renal

GOLDMARK - Mnemonic for Anion Gap Metabolic Acidosis G - Glycols O - Oxoproline L - L-Lactate D - D-Lactate M - Methanol A - Aspirin R - Renal Failure K - Ketoacidosis #GOLDMARK #Mnemonic #AnionGap #Metabolic #Acidosis #diagnosis #differential #causes

How-to Calculate the Filtration Fraction (FF) in CKRT • The FF is the ratio of fluid being REMOVED from the filter to the fluid ENTERING the filter • The target FF to reduce the risk of filter clotting is < 20-25% • Dialysate (in CVVHD or CVVHDF) does NOT affect the FF FF = Fluid removed from the filter / Fluid entering the filter = Ultrafiltration (ml/hr) / (Pre-Filter RF+ Plasma Flow Rate (ml/hr)) Calculator Here: https://nephsim.com/calculators/ #FF #FiltrationFraction #CKRT #nephrology #renal #calculation #diagnosis #calculate

Choose Your Fluid: Crystalloid Comparison Chart: Plasma vs Plasma-Lyte, Saline (.45%, 0.9%, 2%, 3%), D5W, Ringer's Lactate, D5W + 150 mEq NaHCO3 #IVFluids #crystalloids #composition #contents #comparison #table #LR #LactatedRingers #Plasmalyte

What's in a Fibril? Amyloid 8-12 nm Congo Red + Randomly arranged Fibrillary GN 12-20 nm Congo Red - Randomly arranged Immunotactoid GN > 30 nm Congo Red - Bundles Collagenofibrotic GN 80 -100 nm Congo Red - Bundles #fibrils #nephrology #diagnosis #amyloid #differential #fibrillary