kalium - internisten · ace-remmer co-trimoxazol na+ k+ h+ serum k+ ... watson, 2012 . lepage et...
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KaliumBob Zietse,
internist-nefroloog
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Kalium in het Paleo dieet
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Dagelijkse kaliumbalans
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Postprandiale translocatie van Kalium
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Regulatie Renale Kalium Excretie
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Regulatie renale K+ excretie
1. Aldosteron 2. Distale flow
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Wat bepaalt of er K excretie plaatsvindt?
Distal delivery van Natrium en
distal flow
Aantal ENaC kanalen en hun
“open probability”
(mineralocorticoid effect)
Negatief voltage in CNT/CCD
Niet reabsorbeerbare anionen in
het tubulus lumen; b.v. Bicarb
+
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Feedback & feedforward
Greenlee et al., Ann Intern Med 2009
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Relatie
kalium balans
en
volume balans
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Tegengesteld effect van flow en ENaC
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Hypokaliemie
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Symptomen hypokaliëmie
Spier
• Spierzwakte
• Ileus
• Rhabdomyolyse
• Respiratoire insufficiëntie
• Paralyse
Hartgeleiding
• U-golf, ST-depressie, QT
• PAC’s, PVC’s
• Tachycardie
• AV-blok
• Ventrikelfibrilleren
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Oorzaken hypokaliëmie
1. Shift
2. Extrarenaal kaliumverlies
3. Renaal kaliumverlies
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Is er sprake van shift ?
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Differentiatie hypokaliëmie
• Urine kalium
• Aanwezigheid hypertensie
• Wat is de [Mg]
• Zuur-base status
• Urine chloor
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Urine kalium
Lin et al., Arch Intern Med 2004
Spot urine K Spot urine K / kreatinine
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Aanwezigheid hypertensie
Hyperaldosteronisme
• Sporadisch
• Familiair (types I – III)
Pseudohyperaldosteronisme
• Apparent mineralocorticoid excess (11ßHSD)
• Syndroom van Liddle
• Activerende mutatie mineralocorticoïd receptor
Overig
• Nierarteriestenose
• Syndroom van Cushing (ectopisch ACTH)
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Wat is de [Mg]?
Subramanya et al., Clin J Am Soc Nephrol 2014
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K+
Effect zuurbase balans op de K+ secretie in de nier
alkalose
intracellulair
K overschot
+
K+
H+
Hypokaliemie
Hypokaliemie
K+ ↓
H+ ↓
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Hyperkaliemie
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Symptomen hyperkaliëmie
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Hyperkaliëmie
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Oorzaken hyperkaliëmie
1. Shift
2. Minder filtratie
3. Minder secretie
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Differentiatie hyperkaliëmie
• Hemolyse?
• Trombo- of leukocytose?
• Celverval?
• Nierfunctiestoornissen?
• Zuur-base status?
Pseudo!
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Renine
Angiotensine II
Aldosteron
Angiotensine I
Spironolacton
ACE-remmer
Co-trimoxazol
Na+
K+
H+
Serum K+
GFR ↓
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Behandeling hyperkaliëmie: waarom?
• Bedreigt de patiënt acuut (minuten, uren)
• Bedreigt de patiënt chronisch (dagen)
• Wil RAAS-blokker eigenlijk niet stoppen
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Behandeling hyperkaliëmie: hoe?
Renale excretie
• Infuus
• Lisdiuretica
• Fludrocortison
Extracorporeel
• Hemodialyse
• Hemofiltratie
“Oude” binders
• Natriumpolystyreensulfonaat
• Calciumpolystyreensulfonaat
Shift
• Insuline
• Bicarbonaat
• (Salbutamol)
• (Noradrenaline)
Nieuwe binders
• Zirconium
cyclosilicaat 9 (ZS-9)
• Patiromeer
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Effectiviteit behandeling
Blumberg et al., Am J Med 1988
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Orale kaliumbinders ?
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• 123.391 patiënten
• 2194 patiënten SPS
• 82 darmnecrose
• 0.14% vs. 0.07%
• NNH = 1395
Watson, 2012
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Lepage et al., Clin J Am Soc Nephrol 2015
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Patiromeer
Bakris et al., JAMA 2015
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ZS-9: acute effecten
Kosiborod et al., JAMA 2014