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Water, Sodium and Potassium Imbalance in Peritoneal Dialysis Pediatric Patients

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Water, Sodium and Potassium Imbalance in Peritoneal Dialysis Pediatric Patients Central Annals of Pediatrics & Child Health Review Article *Corresponding author Carlos G. Musso, Adult Nephrology & Internal Millieu Divisions, Hospital Italiano de Buenos Aires, Argentina, Water, Sodium and Potassium Email: Submitted: 09 July 2016 Accepted: 28 August 2016 Imbalance in Peritoneal Published: 02 September 2016 Copyright Dialysis Pediatric Patients © 2016 Musso et al. OPEN ACCESS Carlos G. Musso¹*, Maritza Contreras², and Paula Coccia² 1Adult Nephrology & Internal Millieu Divisions, Hospital Italiano de Buenos Aires, Keywords • Water Argentina • Sodium 2 Pediatric Nephrology & Internal Millieu Divisions, Hospital Italiano de Buenos Aires, • Potassium Argentina • Peritoneal dialysis • Pediatrics Abstract Water, sodium and potassium regulation is usually altered in end-stage renal disease patients, particularly in frail individuals such as pediatric and elderly people. In this review article, pathophysiology of water, sodium, and potassium imbalance in peritoneal dialysis pediatric patients is in detail described. Understanding the etiological mechanisms of dysnatremia and dyskalemia in this group is crucial for their proper diagnosis and treatment. INTRODUCTION other diseases: neurological, pulmonary, or paraneoplastic. (c) Excessive water intake: A water income which overcomes renal One of the main renal functions consists of regulation of water, free water excretion capability can induce hyponatremia even sodium and potassium metabolisms. Therefore serum sodium in a context of fully suppressed vasopressin secretion. This type and potassium levels can be seriously affected, resulting in the of hyponatremia has been documented in patients who suffered appearance of dysnatremias or dyskalemias, respectively, in end- from primary polydipsia. (D) Low intracelular phosphate content: stage renal disease patients, particularly in pediatric patients Low cellular phosphate can lead to intracellular hypo-osmolarity on dialysis [1-3]. In the present article, the pathophysiology of and consequently to water shift into extracellular compartment. water, sodium, and potassium imbalance in peritoneal dialysis (E) Reset osmostat: Reset osmostat hyponatremia is induced by pediatric patients is analyzed in detail, in order to facilitate its a change in the set point for serum sodium tonicity. This sort of understanding, and consequently the implementation of an hyponatremia is usually found in malnourished chronically-ill adequate therapeutic approach. patients, and it should be a diagnosis of exclusion. Regarding Salt & water imbalance: its pathophysiology Serum sodium level usually results from the relation between (Tablehyponatremia, 2). it is classically classified depending on patient´s salt and water (Na:H2O) body content, thus a low Na:H2O ratio plasma tonicity and patient´s extracellular fluid (ECF) status can induce hyponatremia (serum sodium < 135 mmol/L), and Altered serum sodium in peritoneal dialysis a high Na:H2O ratio can induce hypernatremia (serum sodium Hyponatremia is a prevalent electrolyte problem in > 145 mmol/L) (Table 1). Additionally, there are other factors peritoneal dialysis patients; and this disturbance is mainly which can modify Na:H2O ratio, and induce hyponatremia, such as induced in anuric peritoneal dialysis patients by different [4-12]: (A) Low body potassium content: Potassium intracellular mechanisms [1,12-14]: (A) Low sodium / water ratio secondary depletion induces hyponatremia at least by two mechanisms: inducing inadequate vasopressin release. Edelman summarized Table 1: Salt & water imbalance characteristics. this• by conceptinducing in sodiumthe following shift into equation the intracellular [1]: Serum space,sodium •by = volume contraction volume overload body (exchangeable) sodium + body (exchangeable) potassium imbalance negative positive / total body water (B) Excessive free water retention: Free magnitude mild to severe mild to severe water retention induced by inadequate vasopressin secretion axillary dryness secondary to drugs (opioids, psychotropic medications), hypertension, peripheral clinical manifestation orthostatism, edema, lung congestion endocrinopathies (hypothyroidism, hypoaldosteronism), and hypotension, Cite this article: Musso CG, Contreras M, Coccia P (2016) Water, Sodium and Potassium Imbalance in Peritoneal Dialysis Pediatric Patients. Ann Pediatr Child Health 4(4): 1110. Musso et al. (2016) Email: Central Table 2: Hypotonic Hyponatremia Normotonic Hyponatremia Hypertonic Hyponatremia Hyponatremia clinical classification. PO: <280 PO: 280-300 PO: >300 mOsm/L mOsm/L mOsm/L normal free water body content increased free water body content increased free water intravascular content eg: important paraproteinemia eg: classical hyponatremia eg: hyperglicemia or dyslipidemia Hypotonic Hypotonic Hypotonic Hyponatremia Hyponatremia Hyponatremia axillary dryness, orthostatism hypotension normal clinical exam hypertension, peripheral edema, lung congestion low ECF normal ECF high ECF Abbreviations: PO: Plasma Osmolarity; ECF: Extracellular Fluid to a high oral water intake (water in excess of sodium), and/or volume is low: salt supply should be delivered (orally or intravenously, depending on the acuity of the situation); and if occurs with an increase in body weight, as well as clinical signs of volumelow water overload. excretion (B) (insufficientLow sodium ultrafiltration)./ water ratio secondary This situation to an function: consideration should be given to antidiuretic hormone extracellular volume is normal with significant residual renal residual renal function, it could be interpreted as an osmostat Lowextracellular potassium fluid bodysodium content deficit due due to tolow a low potassium intake (low intake sodium [low reset- driven [13]. renal Hypernatremia water retention; is usually in associated those without with intermittent significant potassiumdiet), and/or diet], excess and/or sodium excessive loss (excessive potassium ultrafiltration). loss (diarrhea). (C) peritoneal dialysis which consists of a dialytic schedule based Intracellular potassium depletion induces sodium to shift from on frequent exchanges at 30-60 minutes intervals. This sort the extracellular compartment to the intracellular one, in order to of dysnatremia occurs more commonly when high dialysate least three mechanisms for the development of hypernatremia leadskeep bodyto extracellular compartments volume electrically contraction. neutral. This The scenario flux of presents sodium glucose concentration is used to achieve ultra filtration [14]. A withfrom athe reduction extracellular in body fluid weight to theand intracellularthere may be compartment, clinical signs of hypovolemia, but not always hypokalemia. (D) Intracellular hyperglycemiahave been proposed which causes[14-16]: osmotic • Dialysate diuresis hypertonicity, (if residual diuresis which isinduces preserved) salt and and water consequently loss in excess increases of water. the •Dialysis serum inducedsodium water into the intravascular compartment. This mechanism of dilutionalphosphate hyponatremia deficit due to presents malnutrition itself with which reduced induces body shift weight of concentration and because of that are more likely associated with (lean mass reduction) but without signs of volume contraction. hypernatremia.level. •Shorter exchanges have a lower outflow dialysate sodium residual renal function (RRF): GFR: 15-20 ml/min/1.73 m², such Salt & water imbalance in peritoneal dialysis asRegarding those who peritoneal start peritoneal dialysis dialysispatients earlier who have due toa significantrefractory pediatrics patients hyperkalemia or concomitant cardiac failure (incremental Fluid and electrolyte requirements in children vary dialysis), they can also suffer from hyponatremia induced by according to their primary kidney disease, degree of residual free water retention due to an inadequate vasopressin secretion. kidney function, and method of kidney replacement therapy. This hyponatremia presents itself without edema or body weight should rule out the presence of non hypotonic hyponatremia, outputSupplementation and the ability or restriction to concentrate of fluid, urine, sodium, hydration and status,potassium and change. When evaluating hyponatremic patients, first of all you either normotonic hyponatremia (pseudohyponatremia), theintake presence is individualized or absence andof hypertension influenced by or thehyperkalemia. volume of urineBody as it is documented in cases of severe paraproteinemia or composition also differs considerably in children as compared to dyslipidemia; or hypertonic hyponatremia, as it is documented in adults. Total body water is 75 % in newborns, 60 % in infants hyperglycemia, or icodextrin use. Secondly, evaluate the serum and adolescents and 50 % in elderly men [17,18]. The primary potassium level, and nutritional status. If the patient presents cause of chronic kidney disease needs to be considered. Although hypokalemia, or intracellular potassium depletion is strongly suspected, potassium should be administered cautiously and with chronic nephropathy associated with sodium and water with close monitoring of the serum potassium level. If the patient retention,restriction the of mostsodium common and/or causes fluids ofis renalappropriate disease inin children is malnourished, adequate nourishment should be provided, but are associated with excessive loss of sodium and chloride. Infants not before assuring the normal serum potassium and phosphorus and children with obstructive
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