Eletroneutralidade e gamblegram no equilíbrio ácido-base em grandes animais / Electroneutrality and gamblegram in the acid balance based on large animals

As alterações do equilíbrio ácido-base são usualmente observadas por meio da hemogasometria, sendo esse exame fundamental para tratamento do paciente. O objetivo desta revisão é apresentar a importância da compreensão da teoria de eletroneutralidade e da sua representação gráfica (gamblegram), demonstrando sua aplicabilidade na rotina clínica. Para isso, dois casos clínicos em grandes animais são demonstrados. O primeiro caso é de um potro neonato com diarreia há seis dias, apresentando hiponatremia, hipocalemia e hipocloremia, com redução de SIDs, determinando acidose metabólica por fons fortes com redução de HCO3-. O gamblegram nos primeiros dias de internamento apresentou a influência da hiponatremia e hipercloremia relativa sobre a concentração de HCO3-. Inicialmente, fez-se a reposição de HCO3-, Ca," e K. O segundo caso é de um bovino adulto com refluxo abomasal, que apresentou hipocloremia, hipocalemia e normonatremia; as alterações em questão resultaram em alcalose metabólica iônica. O gamblegram foi eficaz na representação gráfica dessas alterações e da sua repercussão sobre o equilíbrio ácido-base de maneira sucinta. As alterações nas concentrações de eletrólitos merecem atenção e a reposição deve ser imediata e constante. O gamblegram é uma ferramenta útil para os clínicos, sendo capaz de representar alterações complexas de maneira prática.

Changes in the acid-base balance are usually observed using blood gas analysis, and this test is essential for the treatment of the patient. The aim of this review is to present the importance of understanding the theory of electroneutrality and its graphical representation (gamblegram), demonstrating its applicability in clinical routine. For this, two clinical cases in large animals are discussed. The first case, a neonate foal with diarrhea during six days, presenting hyponatremia, hypokalemia and hypochloremia, with a reduction in SID, determining metabolic acidosis by strong ions with a reduction in HCO3-. The gamblegram in the first days of hospitalization showed the influence of hyponatremia and relative hyperchloremia on the concentration of HCO3-. Initially, HCO3-, Ca²** and K' were corrected. The second case, adult cattle with abomasal reflux presented hypochloremia, hypokalemia and normonatremia, the alterations in question resulting in ionic metabolic alkalosis. The gamblegram was effective in representing these changes and their impact on the acid-base balance. Changes in electrolyte concentrations deserve attention and replacement must be immediate and constant. The gamblegram is a useful tool for clinicians, being able to represent complex changes in a practical way.

Hyperchloremia Is Associated With Acute Kidney Injury in Patients With Subarachnoid Hemorrhage.

OBJECTIVE: To assess the prevalence of acute kidney injury in patients with subarachnoid hemorrhage patients. DESIGN: Retrospective analysis of all subarachnoid hemorrhage admissions. SETTINGS: Neurocritical care unit. PATIENTS: All patients with a diagnosis of subarachnoid hemorrhage between 2009 and 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 1,267 patients included in this cohort, 16.7% developed acute kidney injury, as defined by Kidney Disease Improving Global Outcome criteria (changes in creatinine only). Compared to patients without acute kidney injury, patients with acute kidney injury had a higher prevalence of diabetes mellitus (21.2% vs 9.8%; p < 0.001) and hypertension (70.3% vs 50.5%; p < 0.001) and presented with higher admission creatinine concentrations (1.21 ± 0.09 vs 0.81 ± 0.01 mg/dL [mean ± SD], respectively; p < 0.001). Patients with acute kidney injury also had higher mean serum chloride and sodium concentrations during their ICU stay (113.4 ± 0.6 vs 107.1 ± 0.2 mmol/L and 143.3 ± 0.4 vs 138.8 ± 0.1 mmol/L, respectively; p < 0.001 for both), but similar chloride exposure. The mortality rate was also significantly higher in patients with acute kidney injury (28.3% vs 6.1% in the non-acute kidney injury group [p < 0.001]). Logistic regression analysis revealed that only male gender (odds ratio, 1.82; 95% CI, 1.28-2.59), hypertension (odds ratio, 1.64; 95% CI, 1.11-2.43), diabetes mellitus (odds ratio, 1.88; 95% CI, 1.19-2.99), abnormal baseline creatinine (odds ratio, 2.48; 95% CI, 1.59-3.88), and increase in mean serum chloride concentration (per 10 mmol/L; odds ratio, 7.39; 95% CI, 3.44-18.23), but not sodium, were associated with development of acute kidney injury. Kidney recovery was noted in 78.8% of the cases. Recovery reduced mortality compared to non-recovering subgroup (18.6% and 64.4%, respectively; p < 0.001). CONCLUSIONS: Critically ill patients with subarachnoid hemorrhage show a strong association between hyperchloremia and acute kidney injury as well as acute kidney injury and mortality.

Is hyperchloremia associated with mortality in critically ill patients? A prospective cohort study.

PURPOSE: The aim of the study was to determine if acid-base variables are associated with hospital mortality. MATERIALS AND METHODS: This prospective cohort study took place in a university-affiliated hospital intensive care unit (ICU). One hundred seventy-five patients admitted to the ICU during the period of February to May 2007 were included in the study. We recorded clinical data and acid-base variables from all patients at ICU admission. A logistic regression model was constructed using Sepsis-related Organ Failure Assessment (SOFA) score, age, and the acid-base variables. RESULTS: Individually, none of the variables appear to be good predictors of hospital mortality. However, using the multivariate stepwise logistic regression, we had a model with good discrimination containing SOFA score, age, chloride, and albumin (area under receiver operating characteristic curve, 0.80; 95% confidence interval, 0.73-0.87). CONCLUSIONS: Hypoalbuminemia and hyperchloremia were associated with mortality. This result involving chloride is something new and should be tested in future studies.

Fractional excretion of K, Na and Cl following furosemide infusion in healthy, young and very old people.

UNLABELLED: Furosemide test is a simple and useful test of renal physiology used to evaluate the capability of the collecting ducts to secrete potassium under the effect of serum aldosterone. Its behaviour pattern has been established in children and young adults but not described in very old healthy people, which we explored in this study. MATERIAL AND METHODS: Twenty-six healthy volunteers on a standard Western diet (50 mmol of K/day) were studied: 20 of them were young (between 17 and 40 years old) and the rest were very old (between 75 and 85 years old). They suffered from no diseases and were not on any medication. Before, during the test and 180 min after a single dose of intravenous furosemide (1 mg/kg), urine and blood samples were obtained for creatinine and electrolytes levels. From these data we calculated fractional excretion (FE) of electrolytes; serum aldosterone was measured pre and post furosemide infusion. Statistical analysis was performed by applying Student's t-test. RESULTS: There was no significant difference regarding pre-furosemide (basal) FE of potassium between the very old and young group. Post-furosemide average FE of potassium was significantly lower in the very old group (27.4 +/- 2%) compared with the young group (35.4 +/- 9%) (P = 0.04). Even though there was no significant difference in post-furosemide peak FE of potassium value, it was reached later in the very old (120 min) compared with the young (30 min). Serum aldosterone levels were significantly higher post furosemide in both groups: 18.3 +/- 12.2 ng/dl (pre) versus 32.5 +/- 18.6 ng/dl (post) in the young (P = 0.007) and 69.8 +/- 13.7 ng/dl (pre) versus 113.3 +/- 54.8 ng/dl (post) in the very old (P = 0.04). Furthermore, all serum aldosterone values (pre and post furosemide) were significantly higher in very old people compared with young people (P < 0.001). Basal fractional excretion of sodium and chloride were slightly higher in the very old group compared with the young group (P = 0.05). Average post-furosemide FE of sodium and chloride were slightly and significantly lower in the very old (P = 0.05 and P = 0.03), respectively. However, there was no significant difference in peak post-furosemide FE of sodium and chloride values, which were reached later in the very old (120 min) compared with the young (30 min). CONCLUSION: Furosemide test showed a significantly lower average post-furosemide FE of potassium value, delayed post-furosemide peak FE of Na, K and Cl and a hormonal pattern of aldosterone resistance in very old people.

Cl- concentrations of bovine, porcine and ovine aqueous humor are higher than in plasma.

Aqueous humor (AH) Cl- levels were measured from live cows and pigs to confirm the Cl(-)-secretory activities found across the ciliary bodies of these species in in vitro experiments. The values obtained were compared to those of the electrolyte in plasma (PL). In addition, Na+ and K+ concentrations were also measured in AH and PL. For analogy, the same measurements were made in sheep and rabbit. The results indicate that the Cl- AH-to-PL ratios of the bovine, porcine and ovine species, but not that of rabbit, are comparable to published values for humans. Thus, the transport activities of the ciliary epithelia of the former animals may be more adequate as a representative model for human than the commonly used rabbit, which exhibits strikingly different transport properties with a ciliary epithelium that is primarily a bicarbonate-transporting tissue.

Comportamiento endocrino-metabólico de las fracturas de tercio medio facial / Endocrine and metabolic behavior of the fractures of the medial facial third

Se valoran los resultados del comportamiento endocrino-metabólico en 40 pacientes con fracturas del tercio medio facial: 10 nasales, 20 maxilomalares, 2 Lefort I, 4 Lefort II y 4 Lefort III. Según el sexo, 34 pacientes correspondieron al sexo masculino y 6 al femenino. Cuantificamos en orina (muestras de 24 horas): cloruro, sodio, potasio, urea y creatinina; en el ionograma en sangre: cloro, sodio, y potasio; en la química sanguínea: glucosa, clacio, fósforo, urea y creatinina y hemograma con diferencial. Estas muestras se cuantificaron al llegar el paciente, a las 72 horas y a las 24 horas del posoperatorio inmediato. En todos los pacientes estudiados se mantuvo la estabilidad endocrino-metabólica, con excepción de aquéllos portadores de Lefort I, II y III, los cuales en la última muestra tomada presentaron alteraciones del sodio y potasio en el ionograma de orina y sangre (AU)

Comportamiento endocrino-metabólico de las fracturas de tercio medio facial / Endocrine and metabolic behavior of the fractures of the medial facial third

Se valoran los resultados del comportamiento endocrino-metabólico en 40 pacientes con fracturas del tercio medio facial: 10 nasales, 20 maxilomalares, 2 Lefort I, 4 Lefort II y 4 Lefort III. Según el sexo, 34 pacientes correspondieron al sexo masculino y 6 al femenino. Cuantificamos en orina (muestras de 24 horas): cloruro, sodio, potasio, urea y creatinina; en el ionograma en sangre: cloro, sodio, y potasio; en la química sanguínea: glucosa, clacio, fósforo, urea y creatinina y hemograma con diferencial. Estas muestras se cuantificaron al llegar el paciente, a las 72 horas y a las 24 horas del posoperatorio inmediato. En todos los pacientes estudiados se mantuvo la estabilidad endocrino-metabólica, con excepción de aquéllos portadores de Lefort I, II y III, los cuales en la última muestra tomada presentaron alteraciones del sodio y potasio en el ionograma de orina y sangre

Trastornos de los mecanismos renales de acidificacion en pacientes osteoporóticos / Renal acidification mechanism disorders in patients with osteoporosis

Se apresentaron 8 pacientes (6 mujeres y 2 varones de entre 40 y 67 años) con osteoporosis probablemente secundaria a, o agravada por, defectos tubulares renales. TrÛs de las mujeres eran premenopáusicas; las restantes tenían 9,20 y 22 años de postmenopausia y 2 de ellas recibían terapia de reemplazo hormonal. Dos pacientes tenían nefrolitiasis (un varón con cálculos fosfocálcicos recurrentes y coraliforme izquierdo actual, y una mujer con nefrocalcionosis por riñon en esponja e hipercalciuria). En los restantes enfermos, la sospecha clínica se fundó en: a) Fractura de cadera a los 44 años en mujer premenopáusica sin factores de riesgo aparentes; b) múltiples aplastamientos vertebrales en varón de 45 años sin hipogonadismo ni otros factores presiponentes; c) falta de respuesta favorable a regímines terapéuticos anti-osteoporóticos bien cumplidos en 3 mujeres. Se determinó el nível de bicarbonato sérico en todos los pacientes y se practicó además una prueba de acidificación urinaria aguda con CINH4 o con furosemida oral. Tres pacientes tenían un defecto proximal, cuatro un defecto distal, y uno mixto. Las densidades minerales óseas expresadas en puntaje Z(x ñ e.s) fueron, en columna lumbar, -1,75 ñ 0,08 (n=8), y en cuello femoral -1,57 ñ 0,09 (n=4). Luego de un año de terapia con álcali por vía oral 5 enfermos tuvieron incrementos del calcio esquelético total que oscilaron entre 3 y 10 por ciento. Se concluye que seria conveniente incorporar el bicarbonato sérico a la bateía de pruebas de laboratorio en la evaluación inicial de pacientes osteopénicos, y que deberia sospecharse acidosis tubular renal en pacientes nefrolitiásicos osteopénicos, tengan o no hipercalciuria, y en enfermos osteoporóticos que no respondan a tratamientos probadamente efectivos (AU)

Trastornos de los mecanismos renales de acidificacion en pacientes osteoporóticos / Renal acidification mechanism disorders in patients with osteoporosis

Se apresentaron 8 pacientes (6 mujeres y 2 varones de entre 40 y 67 años) con osteoporosis probablemente secundaria a, o agravada por, defectos tubulares renales. Três de las mujeres eran premenopáusicas; las restantes tenían 9,20 y 22 años de postmenopausia y 2 de ellas recibían terapia de reemplazo hormonal. Dos pacientes tenían nefrolitiasis (un varón con cálculos fosfocálcicos recurrentes y coraliforme izquierdo actual, y una mujer con nefrocalcionosis por riñon en esponja e hipercalciuria). En los restantes enfermos, la sospecha clínica se fundó en: a) Fractura de cadera a los 44 años en mujer premenopáusica sin factores de riesgo aparentes; b) múltiples aplastamientos vertebrales en varón de 45 años sin hipogonadismo ni otros factores presiponentes; c) falta de respuesta favorable a regímines terapéuticos anti-osteoporóticos bien cumplidos en 3 mujeres. Se determinó el nível de bicarbonato sérico en todos los pacientes y se practicó además una prueba de acidificación urinaria aguda con CINH4 o con furosemida oral. Tres pacientes tenían un defecto proximal, cuatro un defecto distal, y uno mixto. Las densidades minerales óseas expresadas en puntaje Z(x ñ e.s) fueron, en columna lumbar, -1,75 ñ 0,08 (n=8), y en cuello femoral -1,57 ñ 0,09 (n=4). Luego de un año de terapia con álcali por vía oral 5 enfermos tuvieron incrementos del calcio esquelético total que oscilaron entre 3 y 10 por ciento. Se concluye que seria conveniente incorporar el bicarbonato sérico a la bateía de pruebas de laboratorio en la evaluación inicial de pacientes osteopénicos, y que deberia sospecharse acidosis tubular renal en pacientes nefrolitiásicos osteopénicos, tengan o no hipercalciuria, y en enfermos osteoporóticos que no respondan a tratamientos probadamente efectivos

[Renal acidification mechanism disorders in patients with osteoporosis]. / Trastornos de los mecanismos renales de acidificación en pacientes osteoporóticos.

Eight patients (6 women and 2 men) with osteoporosis caused or aggravated by renal acidification defects are presented. Three of the female patients were premenopausal; the others were 9, 20 and 22 years postmenopausal, and two of them were on hormonal replacement therapy. Two patients had nephrolithiasis: one male with recurrent calcium phosphate stones and a left sided staghorn calculus, and one female with nephrocalcinosis due to medullary sponge kidney and hypercalciuria (patients No. 1 and 2, respectively, Table 1). In the remaining subjects, clinical suspicion was based on: a) Hip fracture in a 44-yr-old premenopausal female without any risk factor (No. 3, Table 2). b) Several vertebral compression fractures in a 45-yr-old male without hypogonadism or other predisposing factors (No. 7, Table 2). c) Lack of response to antiosteoporotic therapy in 3 women (patients No. 4, 6 and 8, Table 2). Serum bicarbonate levels and urine acidification capacity were studied in all patients. Three had low serum bicarbonate (two of whom showed high fractional excretion of bicarbonate), four had a distal defect, and one had a mixed form. Serum creatinine and potassium, and venous blood pH were normal in all cases, suggesting incomplete renal tubular acidosis. Bone mineral density in Z-score (means +/- s.e.m.) was - 1.75 +/- 0.08 in the lumbar spine (n = 8), and - 1.57 +/- 0.09 in the femoral neck (n = 4) [Tables 1 and 2; Figs 1 and 2]. Following one year treatment with oral sodium bicarbonate and potassium citrate, total skeletal calcium increased by 3-10% in five of the patients. Whereas the high prevalence of renal acidification defects among renal stone formers with or without hypercalciuria is well acknowledged, renal tubular acidosis is not included in the list of entities causing secondary osteoporosis. As shown in 6 patients of this series, incomplete RTA should be considered as another disease capable of causing osteoporosis or worsening involutional bone loss.

Principales elementos inorgánicos en el suero de niños diabéticos en relación con el grado de control metabólico / Main inorganic eleents in serum from children in relation to the degree of metabolic contrl

En este trabajo estudiamos las concentraciones de magnesio, zinc, cobre, calcio, sodio, potasio y cloro en el suero de un grupo de niños diabéticos insulinodependientes y su relación con diversos factores como el tiempo de evolución de la enfermedad y su grado de control metabólico. No encontramos diferencias significativas en las concentraciones de los minerales por lo que inferimos que existen otros factores que son los responsables de las variaciones en las concentraciones de estos minerales y no el tiempo de evolución de la enfermedad

Principales elementos inorgánicos en el suero de niños diabéticos en relación con el grado de control metabólico / Main inorganic elements in serum from children in relation to the degree of metabolic contrl

En este trabajo estudiamos las concentraciones de magnesio, zinc, cobre, calcio, sodio, potasio y cloro en el suero de un grupo de niños diabéticos insulinodependientes y su relación con diversos factores como el tiempo de evolución de la enfermedad y su grado de control metabólico. No encontramos diferencias significativas en las concentraciones de los minerales por lo que inferimos que existen otros factores que son los responsables de las variaciones en las concentraciones de estos minerales y no el tiempo de evolución de la enfermedad

Neuroendocrine regulation of osmotic and ionic concentrations in the hemolymph of the freshwater shrimp Macrobrachium olfersii (Wiegmann) (Crustacea, Decapoda).

Putative neuroendocrine mediation of osmotic and ionic responses to acute exposure to high salinity medium was investigated in the freshwater shrimp Macrobrachium olfersii (Wiegmann). Homogenates of supra-esophageal or thoracic ganglia, prepared from shrimps exposed to seawater of 21% S for 6 hr, were injected into the abdominal musculature of shrimps previously exposed to freshwater and subsequently exposed to either freshwater or seawater (21% S). Osmotic, sodium, chloride, potassium, magnesium, and calcium concentrations were determined in hemolymph samples removed by intracardiac puncture at time = 0, 1, 3, or 6 hr after homogenate application. Control shrimps were injected with filtered seawater, isosmotic to the hemolymph, and treated similarly. In control shrimps, the osmotic, Na+, Cl-, K+, Mg2+, and Ca2+ concentrations in the hemolymph increased (P less than or equal to 0.05) after 1-hr exposure to seawater. In shrimps injected with homogenates of supra-esophageal ganglion and exposed to seawater, osmotic and ionic concentrations in the hemolymph did not vary with exposure time; in injected shrimps exposed to freshwater, Na+, Cl-, K+, and Mg2+ concentrations decreased (P less than or equal to 0.05) with time. In shrimps injected with homogenates of thoracic ganglion and exposed to seawater, hemolymph osmotic, K+, and Mg2+ concentrations increased (P less than or equal to 0.05); Na+, Cl-, and Ca2+ concentrations remained unchanged. In injected shrimps exposed to freshwater, hemolymph osmotic concentration alone increased (P less than or equal to 0.05) after 1 hr, all other ionic concentrations remaining unchanged. These data suggest that neurofactors apparently located within the ganglia of the central nervous system of M. olfersii may alter the apparent ionic permeabilities of this shrimp, depending on the salinity characteristics of the external medium. The data support the notion that invasion of the freshwater biotope by estuarine crustaceans has necessitated the evolution of specific physiological mechanisms capable of compensating for the osmotic dilution and ion loss typically encountered by such organisms.

Diagnóstico do hiperparatireoidismo primário / Diagnosis of primary hyperparathyroidism

O hiperparatireoidismo primário é uma afecçäo freqüente que pode incidir em todas as idades, mas que aparece com maior freqüência nos indivíduos com mais de 40 anos e do sexo feminino. Seu diagnóstico se baseia num sinal laboratorial chave, que é hipercalcemia. Esta situaçäo pode produzir uma infinidade de sinais e sintomas de graus e intensidades variáveis, indo desde uma simples, astenia até as formas graves com comprometimento ósseo intenso ou litíases urinárias de repetiçäo. Devido a esse grande polimorfismo de apresentaçäo e sendo a única forma de diagnosticar-se as formas leves e moderadas do hiperparatireoidismo, a determinaçäo sistemática da calcemia em todo consultante parece-nos justificável

Hiperparatiroidismo primario: informe de 12 casos de adenomas hiperfuncionantes; pruebas diagnósticas / Priary hyperthyroidism: report of 12 cases of hyperfunctioning adenomas; diagnostic tests

Se presenta la metodología y se discuten los resultados de un conjunto de pruebas bioquímicas para el diagnóstico de hiperparatiroidismo primario, utilizado en una serie de 12 pacientes atendidos en el Instituto Nacional de Endocrinología. Como principales alteraciones de la homeostasis calciofosfórica se encontró: hipercalcemia con hipofosforemia, hipercalciuria, aumento del aclaramiento renal de fósforo, disminución de la reabsorción tubular de fósforo aumento del cloro plasmático con reserva alcalina normal o baja a pesar de la hipercalcemia; baja densidad urinaria resistente al pitresin exógeno y elevación de la fosfatasa alcalina plasmática. Las alteraciones en el control paratiroideo de la secreción de parathormona se comprobaron por las irregularidades en los resultados de la prueba de frenaje paratiroideo con sobrecarga de calcio y las pruebas de estimulación paratiroidea con EDTA-Na2 y prednisona

Hiperparatiroidismo primario: informe de 12 casos de adenomas hiperfuncionantes; pruebas diagnósticas / Primary hyperthyroidism: report of 12 cases of hyperfunctioning adenomas; diagnostic tests

Se presenta la metodología y se discuten los resultados de un conjunto de pruebas bioquímicas para el diagnóstico de hiperparatiroidismo primario, utilizado en una serie de 12 pacientes atendidos en el Instituto Nacional de Endocrinología. Como principales alteraciones de la homeostasis calciofosfórica se encontró: hipercalcemia con hipofosforemia, hipercalciuria, aumento del aclaramiento renal de fósforo, disminución de la reabsorción tubular de fósforo aumento del cloro plasmático con reserva alcalina normal o baja a pesar de la hipercalcemia; baja densidad urinaria resistente al pitresin exógeno y elevación de la fosfatasa alcalina plasmática. Las alteraciones en el control paratiroideo de la secreción de parathormona se comprobaron por las irregularidades en los resultados de la prueba de frenaje paratiroideo con sobrecarga de calcio y las pruebas de estimulación paratiroidea con EDTA-Na2 y prednisona