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El Nov 21, 2003 6:26 pm, Text-Conference November 20 dijo:
Start of #cin buffer: Thu Nov 20 23:24:22 2003
[22:17] (Pedro> I think we can start with the conference if the speaker is ready, does not it?
[22:17] (DrMusso> Yes it does.
[22:19] POTASSIUM METABOLISM IN CHRONIC RENAL FAILURE
[22:19] Carlos G. Musso MD., and Dimitrios G. Oreopoulos MD., PhD.
[22:23] __________ introduction is over_____________-
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[22:24] (MJesus> thank you very much !
[22:24] (Pedro> thanks
[22:24] (Pedro> it is time for questions
[22:25] (DrOreopou> I presume that you mention Carlos that whereas Hyperkalemia is frequent in HD is a rare complication of PD where one sees Hypokalemia more often the conference is here: http://www.uninet.edu/cin2003/conf/musso/oreopoulos.html
[22:25] (DrOreopou> I would add despite the slow removal of K with PD
[22:26] (DrMusso> Yes, hyperkalemia is very infrequent in pd patients while it is incidence in HD is around 10 %
[22:27] (Pedro> would you explain us which are the reasons to explain this observation?
[22:27] (DrMusso> The most frequent plasma potassium disorder is in fact hypokalemia with an incedence of around 30%
[22:28] (DrOreopou> I would be interested to know what is the experience of the others in this regard and whether there are any questions about its pathogenesis and management
[22:29] (MJesus> How many potassium removed during dialysis is lost from the intracellular compartment ?
[22:30] (DrMusso> When we analyzed the excretion of potassium in PD , it did not explain the hypokalemia, so we especulated that the potassium could be enter into the cell by the insulin action secondary to the glocose infussion by the peritoneum
[22:30] (Pedro> we have the impresion that nowedays it is a problem mainly of diabetic patients,
[22:31] (DrOreopou> but I would add Carlos that this is particular to PD
[22:31] (DrMusso> In hemodialisis approximatelly 60% of the potassium removed is from the intracellular compartment
[22:31] (DrOreopou> Pedro do you mean that Hypo or Hyper kalemia is particular to teh Diabetic patients ?
[22:32] (Pedro> hyper, dr Oreopou
[22:33] (DrOreopou> Thisd does not seem to be the case with the Diabetic on PD who have the same problems with Hypokalemia
[22:33] (DrMusso> Diabetic patients are a real risk for hyperkalemia specially in the pre-dialysis period
[22:34] (gtorres> has seen you at the moment a greater incidence of toxic hiperkalemia since IECA are used?
[22:34] (DrMusso> Because the usually have a tubular resistance to aldosterone action, that it is the main regulator of the external balance of k
[22:35] (DrMusso> Yes, but more during the assotiation of losartan and IECA, specially during the treatment of proteinuria
[22:35] (gtorres> thanks
[22:36] (DrOreopou> I should emphasize however that in the predialysis diabetic it is better to control Hyperkalemia with either diuretics or resins rather than dicontinuing th etreatment
[22:37] (Pedro> we usually see this problem in clinical pratice
[22:37] (DrMusso> Yes, we have to treat the proteinuria and the trend to hyperkalemia simultaneously
[22:37] (DrOreopou> You are right ,.It si not infrequent and it is equally common with ACEs and ARBs
[22:37] (Pedro> in such a way that, for instance, this yera we have made several urgent dialysis
[22:38] (DrMusso> resins of interchange is a very good ally in this objective because it join the colon in order to help the kidney
[22:39] (Pedro> in patients under treatment with ACE or Espirolactone or angiotensin blockers
[22:39] (DrOreopou> It is not that severe especially if you are prepared and looking for it . Most of the times it can be managed with potassium restriction or Diuretics or Diet.
[22:40] (DrMusso> Perhaps the secret is to prepare the patient before to combine both drugs using furosemide or resins, and start with low dosis
[22:40] (DrOreopou> Spironolactone is also possible to cause Hyperkalemia and should be used very carefully in the patient with renal failure and in small doses
[22:40] (Pedro> but it is dificult that the patient was compliant with diet and with resisns
[22:41] (Pedro> the patients came from cardiology and from Internal medicine
[22:41] (DrMusso> Yes, specially because the aldosterone levels are higher in this group because they adapted to the renal failure situation
[22:42] (DrOreopou> In that case you try diuretics and if that does not work you may have to accept that this patient can not continue, but in my experience if I explain to the patient why the treatment is important they really try to comply
[22:42] (Pedro> and cardiologist are not enough alert to this hipthetical problem
[22:43] (DrOreopou> I agree. Potassium should be checked within 1-2 weeks after starting treatment wioth ACE along with creatinine
[22:44] (DrMusso> A new drug propose in order to increase potassium colonic excretion is bisacodil, that it is more tolerated that the resines
[22:44] (Pedro> and we worried about how many patients will died without arriving to the hospital
[22:45] (Pedro> it is a resin?
[22:45] (DrOreopou> I do not understand . Why are you worried?
[22:46] (Pedro> because we tink that many patients are at risk of cardiac arrithmia because of
[22:46] (Pedro> aldosterone+ACE+diabetic+slight crhonic renal failure
[22:46] (DrMusso> No it doesnot it is not act trapping potassium in the colonic lumen, it acts increasing potassium colonic secretion locally.
[22:46] (DrOreopou> But Hyperkalemia does not develop suddenly.
[22:47] (Pedro> true, but the controls of patients are quit infrequent
[22:47] (DrOreopou> It is a matter of awareness on behalf of the treating physician
[22:48] (DrOreopou> Afetr the initial check of K you do not have to check it that frequent . Every 2-3 months would be adequate
[22:49] (DrOreopou> Is it usual that only few of the "audience" participate in the discussion?
[22:50] (DrMusso> I think that if you prepare the patient before starting the combination of losartan and IECA, an then you check periodically the plasma potassium levels there will be no problem
[22:50] (Pedro> we try to explain this problem in a Hospital meeting, but caridologist were "very ocuped"
[22:51] (MJesus> the universal declaration of cardiologist !
[22:52] (MJesus> the question from a pathologist... Why peritoneal dialysis has lower efficiency for potassium removal than HD?.
[22:52] (MJesus> What about managing potasium in hihg efficiency hemodialsis?
[22:52] (DrMusso> Talking about how to aviod hyperkalemia, Another important point it is to avoid the use of tiazides in patients with moderate-severe renal failure
[22:53] (Pedro> why tiazides?
[22:53] (DrOreopou> The maximum ammount that a PD can remove assuming equilibration of the PD fluid with serum can not exceed 40 meQper day
[22:54] (DrOreopou> carlos, why do you suggest avoidance of Thiazides in renal failure? I do not follow you
[22:56] (DrMusso> Because now aday thiazides are very recommended, and sometimes non-nephrologyst use it in order to avoid hyperkalemia during the assotiation of losartan and IECA , with out taking into acount the renal function of the patient
[22:57] (DrMusso> I am talking about patients with renal function below 30 ml-min.
[22:57] (Pedro> but the problem is that tiazides havent diuretic efficacy with renal failure
[22:58] (DrMusso> In these patients they can reduce they renal clearance and even generate hyponatremia.
[22:58] (Pedro> we have seen hyperk with amiloride
[22:59] (DrOreopou> I am afraid that I have to go for rounds. I amsure that Carlos can handle any questions and I want to thank you all . I really enjoyed it and hope to join you againGoodBy
[22:59] (MJesus> as I talk before, this discussion was logged.
[22:59] (MJesus> The text will be sligh edited, and placed at the discussion board of the conference
[22:59] (MJesus> (linked to http://www.uninet.edu/cin2003/conf/musso/oreopoulos.html)
[22:59] (Pedro> thank very
[22:59] (Pedro> much to DR Musso
[22:59] (DrMusso> The only tiazide that is usable is metolazone , but in fact it is not a tiazude, in fact it is a tiazide-like drug
[23:00] (Pedro> and dr Oreopou
[23:00] (MJesus> tomorrw morning... because here, at Spain, are almos midnight
[23:00] (gtorres> I am happy and thank for to the professors and all the participants his attendance
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[23:00] (DrMusso> Thanks
[23:00] (EMPEROR> very good..!
[23:00] (MJesus> thank you very much !!
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