ELECTROLYTE HOMEOSTASIS DISORDERS

✓ Electrolyte- An electrolyte is a substance that conducts electricity when dissolved in water. Electrolytes are essential for a
number of functions in the body.

o Ex. Sodium and water, calcium, phosphorus, potassium and magnesium

Electrolytes plays a vital role for human survival. Many autonomic processes in the body rely in small electric current to function, and
electrolytes provides this charge. This electrical molecule interacts with the cells in tissues, nerves, and muscles; thus, a balance of
different electrolytes is crucial to the body.

Electrolytes help to regulate myocardial and neurological functions, fluid balance, oxygen delivery, and acid–base balance in the body.
An example is during we do an exercise, every time we excrete sweat, we lose electrolytes that sometimes results to fatigue.

✓ Electrolyte Homeostasis- Steady and balanced or stable equilibrium state of electrolyte activities and functions.

Electrolyte homeostasis is maintained by feedback mechanisms, hormones, and many organ systems, and is necessary for the body’s
normal physiologic functions. Stable equilibrium of electrolytes helps regulate nerve and muscle function, hydrate the body, balance
blood acidity and pressure, and help rebuild damaged tissue

✓ Electrolyte Homeostasis Disorders- occurs when the levels of electrolytes in your body are either too high or too low that
affects the body vital systems.

Causes: Loss of bodily fluids due to vomiting, sweating, diarrhea and small water intake.

Electrolyte Disorders

• Disorders of Sodium and Water Homeostasis

• Disorders of Calcium Homeostasis
• Disorders of Phosphorus Homeostasis
• Disorders of Potassium Homeostasis
• Disorders of Magnesium Homeostasis

EPIDEMIOLOGY

- In a study conducted by Balci et al. (2013) entitled “General characteristics of patients with electrolyte imbalance
admitted to emergency department” In 996 patients, incidence of homeostasis was more common in male accounting
with 55%

- Most cases were identified in patient with dyspnea (shortness of breath) (14.7%), fever (13.7%), and systemic
deterioration (11.9%);

- Moreover, a study by Lindner et al. (2014) entitled “Age-related variety in electrolyte levels and prevalence of
dysnatremias and dyskalemias in patients presenting to the emergency department” In 20,667 patients, the prevalence
rates of hyponatremia and hyperkalemia. It increased from 2.3% for hyponatremia in patients aged 16-21 years to 16.9%
in patients aged >80 years and from 0.8% for hyperkalemia to 10.4% respectivey.

ETIOLOGY

- Biological Factors: Age, Genetics, Chronic Diseases (esp. kidney damage caused by diabetes and high blood pressure,
congestive heart failure, digestive problems)

- Lifestyle (water intake and diet, eating habits)

- Medications (diuretics and laxatives which induces hypokalemia)

- Trauma, such as severe burns

Aldosterone- produced by adrenal gland, responsible for the regulation blood pressure, sodium levels, and potassium levels.
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TYPES OF DISEASES AND PATHOPHYSIOLOGY

DISORDER OF SODIUM AND WATER HOMEOSTASIS (NORMAL ADULT RANGE 135-145 mEq/L)

- Sodium is the most abundant electrolyte in the blood and is highly dependent un fluids

What is the relationship between sodium electrolyte and water?

Total body water is divided into two compartments (ECF and ICF). Sodium’s activity within the body follows to the movement of water
that passes through the cells. Because cell membranes are permeable to water but not sodium, the movement of water across
membranes affects the concentration of sodium in the blood. Sodium acts as a force that pulls water across membranes, and water
moves from places causing lower sodium concentration to places with higher sodium concentration. When evaluating sodium
imbalances, both total body water and total body sodium must be considered.

1. Hyponatremia (SERUM SODIUM 135 mEq/L [<135 mmol/L])

- Results from an excess of extracellular water relative to sodium because of impaired water excretion.

- Causes of nonosmotic release of arginine vasopressin (AVP), commonly known as antidiuretic hormone

Arginine vasopressin is a hormone that helps blood vessels constrict and helps the kidneys control the amount of water and salt in the
body. Vasopressin decreases water excretion by the kidneys. As a result, more water is retained in the body, which dilutes the level of
sodium in the body.

Osmosis- Osmosis is a process by which the molecules of a solvent pass from a solution of low concentration to a solution of high
concentration through a semi-permeable membrane

Depending on serum osmolality, hyponatremia is classified as isotonic, hypertonic, or hypotonic, mOsm or milliosmole is the unit used
to determine serum osmolality

o Isotonic- serum osmolality at 280 mOsm

o Hypertonic- serum osmolality of more than 280 mOsm

o Hypotonic- serum osmolality of less than 280 mOsm

Hypotonic hyponatremia can be classified to three:

- Hypotonic hyponatremia, the most common form of hyponatremia, can be further classified as hypovolemic, euvolemic,
or hypervolemic

o Hypovelmic- Hypovolemic hypotonic hyponatremia is associated with a loss of ECF volume and sodium, with the
loss of more sodium than water

o Euvovelmic- Euvolemic hyponatremia is associated with a normal or slightly decreased ECF sodium content and
increased TBW (total body water) and ECF volume

o Hypervolemic- Hypervolemic hyponatremia is associated with an increase in ECF volume in conditions with impaired
renal sodium and water excretion.

Most patients with hyponatremia are asymptomatic.

Presence and severity of symptoms are related to the magnitude and rapidity of onset of hyponatremia. Symptoms progress from
nausea to headache and lethargy and, eventually, to seizures, coma, and death if hyponatremia is severe or develops rapidly.

2. Hypernatremia (SERUM SODIUM >145 mEq/L [>145 mmol/L])

- Hypernatremia results from water loss due to either diabetes insipidus or from sodium ingestion
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Diabetes insipidus- an uncommon disorder that causes an imbalance of fluids in the body. This imbalance leads you to produce large
amounts of urine. Serum sodium is elevated due to excess free water loss.

Most patients with hyponatremia are asymptomatic.

Symptoms include weakness, lethargy, restlessness, irritability, and confusion. Symptoms of a more rapidly developing hypernatremia
include twitching( muscles tightening up ("contracting") involuntarily), seizures, coma, and death.

DISORDERS OF CALCIUM HOMEOSTASIS (NORMAL ADULT RANGE 8.5-10.5 mg/dL)

Caused by excessive and deficit vitamin D (promotes calcium absorption), high or low parathyroid gland function (regulates calcium in
the blood), and kidney disease

1. Hypercalcemia (TOTAL SERUM CALCIUM >10.5 mg/dL [>2.62 mmol/L])

- Cancer and hyperparathyroidism are the most common causes of hypercalcemia. Primary mechanisms include increased
bone resorption, increased GI absorption, increased tubular reabsorption by the kidneys.

Resorption is the absorption into the circulatory system of cells or tissue

Hypercalcemia develops quickly and is associated with anorexia, nausea and vomiting, and constipation. Hypercalcemia is
characterized by acute elevation of serum calcium to greater than 15 mg/dL (>3.75 mmol/ which leads to acute renal insufficiency.
Untreated hypercalcemic crisis can progress to oliguric renal failure, coma, and life-threatening ventricular arrhythmias

2. Hypocalcemia ((TOTAL SERUM CALCIUM <8.5 mg/dL [<2.13 mmol/L])

- Hypocalcemia results from altered effects of parathyroid hormone and vitamin D on the bone, and kidney. Primary causes
are postoperative hypoparathyroidism and vitamin D deficiency.

Symptomatic hypocalcemia commonly occurs because of parathyroid gland dysfunction, secondary to surgical procedures involving
the thyroid, parathyroid, and neck

Clinical manifestations are variable and depend on the onset of hypocalcemia. Tetany (or the involuntary movement of muscles) is the
hallmark sign of acute hypocalcemia, which manifests as paresthesia (burning sensation in hand, feet) around the mouth and in the
extremities; muscle spasms and cramps; carpopedal spasms (frequent and involuntary muscle contractions in the hands and feet);
and, rarely, laryngospasm and bronchospasm.

DISORDERS OF PHOSPHORUS HOMEOSTASIS (NORMAL ADULT RANGE 2-4.5 mg/dL)

1. Hyperphosphatemia (SERUM PHOSPHORUS >4.5 mg/dL [>1.45 mmol/L]

- Most commonly caused by decreased phosphorus excretion, secondary to decreased glomerular filtration rate (GFR).

- Acute symptoms include gastrointestinal (GI) disturbances, lethargy, obstruction of the urinary tract, and, rarely, seizures.
Calcium phosphate crystals are likely to form when the product of the serum calcium and phosphate concentrations
exceeds 50 to 60 mg2/dL2 (4–4.8 mmol2/L2)

Glomerular Filtration Rate- A glomerular filtration rate (GFR) is a blood test that checks how well your kidneys are working. Your kidneys
have tiny filters called glomeruli which is responsible for the filtration of fluids that passes through it. These filters help remove waste
and excess fluid from the blood. A GFR test estimates how much blood passes through these filters each minute

When the GFR activity decreases, metabolism and excretion of phosphorus cannot be immediate. Decrease phosphorus excretion that
means phosphorus molecules stays in the system, causing the electrolyte imbalance

Calcium aids phosphorus concentrations to form crystals.

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2. Hypophosphatemia (SERUM PHOSPHORUS <2 mg/dL [<0.65 mmol/L])

- Results from decreased GI absorption, reduced tubular reabsorption, or extracellular to intracellular redistribution.

Tubular reabsorption is the process that moves solutes and water out of the filtrate and back into your bloodstream. This process is the
second time that these are being absorbed; the first time being when they were absorbed into the bloodstream from the digestive tract
after a meal.

So in the process of tubular reabsorption, since it will be reduces, less phosphorus obtained will be absorbed to the blood stream, not
enough to achieve the normal serum conc.

Severe hypophosphatemia (serum phosphorus <1 mg/dL [<0.32 mmol/L]) has diverse clinical manifestations that affect many organ
systems, including the following:

Neurologic manifestations: Progressive syndrome of irritability, apprehension, weakness, numbness, confusion, seizures, and coma.

Skeletal muscle dysfunction: Myalgia, bone pain, weakness

Respiratory muscle: weakness and diaphragmatic contractile dysfunction resulting in acute respiratory failure.

Congestive cardiomyopathy: (disease of the heart muscle that makes it harder for your heart to pump blood), arrhythmias, and
increased risk of infection can also occur.

DISORDERS OF POTASSIUM HOMEOSTASIS (NORMAL ADULT RANGE 3.5-5 mEq/dL)

1. Hypokalemia (SERUM POTASSIUM <3.5 mEq/L [<3.5 mmol/L])

- Results from a total body potassium deficit

Many drugs can induce or cause hypokalemia such as Thiazides for enhanced renal excretion, and Sorbitol for enhances fecal
elimination. (Common side effects of Thiazides and Sorbitol is dehydration, diarrhea, resulting to excessive water loss in the body.
Remember that every time that the body loses water and is not supplemented immediately, the body loses essential electrolytes)

- Other causes of hypokalemia include diarrhea, and vomiting.

Signs and symptoms are nonspecific and variable and depend on the degree of hypokalemia and rapidity of onset. Mild hypokalemia
is often asymptomatic, and also usually causes cardiovascular manifestations such cardiac arrhythmias.

Moderate hypokalemia is associated with muscle weakness, cramping, and myalgias.

2. Hyperkalemia (SERUM POTASSIUM >5 mEq/L [>5 mmol/L])

- Hyperkalemia develops when potassium intake exceeds excretion.

- Primary causes of true hyperkalemia include increased potassium intake, decreased potassium excretion, tubular
unresponsiveness to aldosterone

- Hyperkalemia is frequently asymptomatic; patients might complain of heart palpitations or skipped heartbeats.

Primary adrenal insufficiency or tubular unresponsiveness to aldosterone causes low levels of aldosterone that may increase potassium
level.

DISORDERS OF MAGNESIUM HOMEOSTASIS (NORMAL ADULT RANGE 1.5-2.5 mEq/L)

1. Hypomagnesemia (SERUM MAGNESIUM <1.4 mEq/L [<0.70 mmol/L])

- Hypomagnesemia is usually associated with disorders of the intestinal tract or kidneys.

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- Drugs such as cyclosporine’s and diuretics and or conditions that interfere with intestinal absorption, or increase renal
excretion of magnesium can cause hypomagnesemia.

- Commonly associated with alcoholism

Although typically asymptomatic, the dominant organ systems involved when symptoms are the neuromuscular and cardiovascular
systems such as heart palpitations, tetany, and generalized convulsions.

2. Hypermagnesemia (SERUM MAGNESIUM >2 mEq/L [>1 mmol/L])

- Result from magnesium-containing antacids in patients with renal insufficiency, enteral or parenteral nutrition in patients
with multiorgan system failure, magnesium for treatment of eclampsia that results to serizures, lithium therapy,
hypothyroidism

- Excessive magnesium concentration

- Symptoms includes sedation, , coma, muscular paralysis, and, ultimately, respiratory depression

SYMPTOMS

Discussed earlier are the diseases relating to electrolyte imbalance that deteriorate the systemic function; Neurologic, cardiac, and
respiration, and skeletal muscle functions. Here are the general symptoms of electrolyte imbalance

- Muscle aches
- Spasms, Weakness
- Restlessness
- Anxiety
- Frequent Headaches
- Insomnia
- Thirst
- Fever
- Dizziness
- Heart palpitations and irregular heartbeats
- Digestives Issues
- Cramps
- Constipations and Diarrhea
- Confusion/Trouble Concentrating
- Bone Disorders
- Blood Pressure changes
- Change in appetite
- Chronic fatigue
- Numbness and joint pains

DIAGNOSIS

Panel Test (Blood)

- Blood helps to determine the serum concentration of an electrolyte. An electrolyte panel, also known as a serum electrolyte
test, is a blood test that measures levels of the body's main electrolytes.
- Itest, these tests can tell you whether you have an electrolyte imbalance in a specifically.
-

Urine Test

- Urine contains the electrolyte’s salts such as sodium, calcium, potassium, and chloride that has been excreted in the body
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ECG (Electrocardiogram)

- Can be considered as a secondary test to determine electrolyte imbalance, and is usually done to patient with severe cases
of symptoms. This is to check the heart rhythm that is connected on the electrolyte activity in the systemic circulation.

MANAGEMENT AND TREATMENT

- Most treatment for electrolyte disorders are IV and orally administrated, which they call replacement therapy. Most oral
drugs are drugs that suppress or promote organ functions to deplete or elevate the electrolytes in the body depending to
the type of electrolyte disorder disease.
- Most treatment are individualized.
- Mild replacement is usually through oral medications. While IV infusions are done when the patients are in moderate and
severe conditions

Electrolyte Depletion Elevation

Calcium 1. IV infusion 1. Oral
- Normal saline solution, furosemide as a - Calcium diet 1000-1500 mg/ day
starter (fumeroside induces electrolyte 2. IV infusion
delivery) - 10-20mL of 10% calcium gluconate over
2. Oral equal or more than 4 hours
- Low calcium diet
- Reduce intake with foods rich in vitamin D
and A (Vitamin D and Vitamin A promotes
calcium absorption)

Sodium 1. Oral 1. Oral

- Low sodium diet - Consider free water restriction (diet limits
- Increase oral fluid intake (Drinking the intake of hypotonic drinks. Hypotonic
excessive amounts of water can cause low drinks are drinks low in sodium)
sodium by overwhelming the kidneys' 2. IV infusion
ability to excrete water) - Normal saline solution
- - 3% sodium chloride (done in moderate and
2. IV infusion sever cases)
- Decrease of discontinue administration of
sodium with replacement of water deficit
Phosphorus 1. Oral 1. Oral
- Low phosphorus diet - Phosphate containing multivitamins,
- Phosphate binders (ferric citrate) (prevent dietary intake
the body from absorbing the phosphorus 2. IV infusion
from the food you eat. Phosphorus - 0.32-0.64 mmol/kg of Trisodium
binders help to pass excess phosphorus phosphate slowly over 6 hours (moderate)
out of the body in the stool, reducing the - 1 mmol/kg trisodium phosphate for 8-12
amount of phosphorus that gets into the hours (severe cases)
blood.)
Dialysis for sever cases
Potassium 1. Oral - Increase dietary intake as well as
- Low potassium diet potassium oral supplementation 40-100
- Remove potassium-sparing medication mEq daily in divided doses
2. IV infusion - In moderate and severe cases IV infusion is
- Sodium bicarbonate (50-100 mEq) and being done, provisions depend on the
dextrose infusion (25-100 g with 5-10 condition of the patient
units’ insulin)- insulin promotes entry of
potassium into the cell
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Magnesium 1. Oral 1. Oral
- 10mL of 10% calcium gluconate solution - Magnesium lactate (Promote magnesium
on sever cases absorption)

MONITORING

1. Guide patients with medications. Medications for these disorders usually don’t have an absolute dosage
2. Patient must maintain a strict food diet especially in moderate cases to prevent progression to a sever one
3. If the electrolyte disorder is caused by medications or underlying conditions, your doctor will adjust your medication and
treat the cause. This will help prevent future electrolyte imbalances.
4. Monitoring of kidney function is important, thus renal function laboratory values should be checked annually
5. Clinical signs and symptoms of dehydration (clinical signs include dryness of tongue, oral mucosa and/or lips, decreased saliva,
dryness of skin and loss of elasticity)
6. Cardiovascular and Neurologic Assessment (blood pressure, pulse and heart rhythm measurements, neurological signs)

CASE STUDY AND FARM NOTES

Mae Wilson, a 28-year-old, female, was brought to the hospital emergency department when she suddenly felt ill while
waiting with them in line for a theme park ride. Her main complaints were sudden onset of stiffness and weakness in her limbs and
lack of sensation and loss of mobility in her left leg. Additionally, she felt short of breath on minimal exertion, was sweating excessively.
Clinical examination was unremarkable, save signs of dehydration (dry mucous membranes); her vital signs were normal, save a
marked increase in heart rate (tachycardia) to 150 bpm.

Apart from a diagnosis of hypothyroidism at age 10, which was being treated with daily thyroxine, she reported being healthy
all her life, although she did mention two previous episodes similar to what she was now suffering during the past 7 months. These
had resolved without medical intervention after 2 hours of rest and hydration

A. FINDINGS
- Name: Mae Wilson
- 28 years old
- Felt sudden onset of stiffness and weakness in her limbs, lack of sensation and loss of mobility on her left leg
- Felt shortness of breath on minimal exertion and was sweating excessively
- Experienced feeling
- Clinical examination confirms dehydration (dry mucous membrane)
- Increase heart rate
- Diagnosed with hypothyroidism, being treated with thyroxin daily. (Hypothyroidism occur when there is deficiency of
sodium in the body) However being treated with thyroxine

B. ASSESSMENT

After laboratory testing, the result shows

- Sodium (Na+) 139 mmol/L (normal)

- Potassium (K+) 2.3 mmol/L (reduced, hypokalemia)
- Magnesium (Mg+) 1.2 mg/dL, 0.49 mmol/L (reduced, hypomagnesemia)
- Calcium (Ca2+) 8.8 mg/dL, 2.2 mmol/L (normal)
- Urinalysis (dipstick testing) – Positive bacteria (3+) Positive white cells (3+) Urine tract infection

C. RESOLUTION
- Adenosine injection with crystalline bolus (0.9% sodium chloride) for liquid replacement
- Replacement therapy of magnesium (Through IV infusion)
- Replacement therapy of Potassium together with an antibiotic (due to severe hypokalemia after the administration of
crystalline bolus and urinary trach infection) (through IV infusion)
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D. MONITORING
- Electrolyte disorder is caused by medications or underlying conditions, your doctor will adjust your medication and treat
the cause. This will help prevent future electrolyte imbalances.
- Monitoring of kidney function, renal function laboratory values should be checked annually
Kidneys are the primary organ that manages electrolytes
- Clinical signs and symptoms of dehydration
- Cardiovascular and Neurologic Assessment
Kidney malfunction causes electrolytes imbalance affecting blood flow as well as transmission of nerve impulses