[
    {
        "page": 1,
        "title": "Trastornos del potasio",
        "body": "<p>\n\n\n<meta http-equiv=\"Content-Type\" content=\"text\/html; charset=utf-8\" \/>\n<meta name=\"ProgId\" content=\"Word.DocumentW\" \/>\n<meta name=\"Generator\" content=\"Microsoft Word 15\" \/>\n<meta name=\"Originator\" content=\"Microsoft Word 15\" \/>\n<link rel=\"File-List\n\" href=\"file:\/\/\/C:\/Users\/rober\/AppData\/Local\/Temp\/msohtmlclip1\/01\/clip_filelist.xml\" \/>\n<link rel=\"Edit-Time-Data\n\" href=\"file:\/\/\/C:\/Users\/rober\/AppData\/Local\/Temp\/msohtmlclip1\/01\/clip_editdata.mso\" \/>\n\n<style>\nv\\:* {behavior:url(#default#VML);}\no\\:* {behavior:url(#default#VML);}\nw\\:* {behavior:url(#default#VML);}\n.shape {behavior:url(#default#VML);}\n<\/style>\n<xml>\n \n  \n \n<\/xml>\n<link rel=\"themeData\n\" href=\"file:\/\/\/C:\/Users\/rober\/AppData\/Local\/Temp\/msohtmlclip1\/01\/clip_themedata.thmx\" \/>\n<link rel=\"colorSchemeMapping\n\" href=\"file:\/\/\/C:\/Users\/rober\/AppData\/Local\/Temp\/msohtmlclip1\/01\/clip_colorschememapping.xml\" \/>\n<xml>\n \n  \n  \n   \n   \n   \n   \n   \n   \n   \n   \n   \n  \n  \n   \n   \n   \n   \n   \n   \n   \n   \n   \n   \n   \n  \n<\/xml><xml>\n \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n  \n \n<\/xml>\n<style>\n\n<\/style>\n\n<style>\n \/* Style Definitions *\/\n table.MsoNormalTable\n\t{mso-style-name:\"Tabla normal\";\n\tmso-tstyle-rowband-size:0;\n\tmso-tstyle-colband-size:0;\n\tmso-style-noshow:yes;\n\tmso-style-priority:99;\n\tmso-style-parent:\"\";\n\tmso-padding-alt:0cm 5.4pt 0cm 5.4pt;\n\tmso-para-margin-top:0cm;\n\tmso-para-margin-right:0cm;\n\tmso-para-margin-bottom:8.0pt;\n\tmso-para-margin-left:0cm;\n\tline-height:115%;\n\tmso-pagination:widow-orphan;\n\tfont-size:12.0pt;\n\tfont-family:\"Aptos\",sans-serif;\n\tmso-ascii-font-family:Aptos;\n\tmso-ascii-theme-font:minor-latin;\n\tmso-hansi-font-family:Aptos;\n\tmso-hansi-theme-font:minor-latin;\n\tmso-font-kerning:1.0pt;\n\tmso-ligatures:standardcontextual;\n\tmso-fareast-language:EN-US;}\n<\/style>\n\n\n\n\n\n\n<p class=\"MsoNormalM\"><br \/><\/p>\n\n<div align=\"center\" style=\"text-align:center\">\n\n<hr size=\"2\" width=\"100%\" align=\"centerc\" \/>\n\n<\/div>\n\n<p class=\"MsoNormalM\"><b>Homeostasis del potasio<\/b><\/p>\n\n<ul type=\"discd\">\n <li>Potasio\n     plasm\u00e1tico normal: 3,5\u20135,0 mM. El 98% se localiza en m\u00fasculo esquel\u00e9tico.<\/li>\n <li>Regulaci\u00f3n:\n     excreci\u00f3n renal (\u224890%) y gastrointestinal (\u224810%).<\/li>\n <li>Ne\u0301frona\n     distal: canales ROMK y BK, cotransportador NCC, ENaC y bomba Na<span style=\"font-family:&quot;Cambria Math&quot;,serif\">\u207a<\/span>\/K<span style=\"font-family:&quot;Cambria Math&quot;,serif\">\u207a<\/span>-ATPasa.<\/li>\n <li>Aldosterona\n     estimula ENaC y la secreci\u00f3n de potasio.<\/li>\n <li>Factores\n     de riesgo de desequilibrio: diur\u00e9ticos, insuficiencia renal,\n     acidosis\/alcalosis, f\u00e1rmacos que act\u00faan en RAAS.<\/li>\n<\/ul>\n\n<div align=\"center\" style=\"text-align:center\">\n\n<hr size=\"2\" width=\"100%\" align=\"centerc\" \/>\n\n<\/div>\n\n<p class=\"MsoNormalM\"><b>Hipopotasemia (preguntado en CONAREM: ECG t\u00edpico,\nreposici\u00f3n urgente, complicaciones musculares)<\/b><\/p>\n\n<ul type=\"discd\">\n <li>Definici\u00f3n:\n     K<span style=\"font-family:&quot;Cambria Math&quot;,serif\">\u207a<\/span>\n     &lt;3,5 mM.<\/li>\n <li>Clasificaci\u00f3n:\n     leve (3,0\u20133,5), moderada (2,5\u20133,0), grave (&lt;2,5 mM).<\/li>\n <li>Epidemiolog\u00eda:\n     hasta 20% de hospitalizados, asociada a \u2191mortalidad.<\/li>\n<\/ul>\n\n<p class=\"MsoNormalM\"><b>Causas principales<\/b><\/p>\n\n<ul type=\"discd\">\n <li>Redistribuci\u00f3n:\n     insulina, agonistas \u03b2, tiroxicosis, alcalosis, t\u00f3xicos (teofilina,\n     cafe\u00edna, bario).<\/li>\n <li>P\u00e9rdidas\n     extrarrenales: v\u00f3mitos, diarrea, sudoraci\u00f3n, adenoma velloso, ileostom\u00eda.<\/li>\n <li>P\u00e9rdidas\n     renales: diur\u00e9ticos (tiazidas &gt; asa), anfotericina, aminogluc\u00f3sidos,\n     cisplatino, ifosfamida.<\/li>\n <li>Endocrinas:\n     hiperaldosteronismo primario\/secundario, Cushing, Liddle, SAME.<\/li>\n <li>Otras:\n     inanici\u00f3n, hipotermia, nutrici\u00f3n parenteral sin potasio.<\/li>\n<\/ul>\n\n<p class=\"MsoNormalM\"><b>Manifestaciones cl\u00ednicas<\/b><\/p>\n\n<ul type=\"discd\">\n <li>Cardiovasculares\n     (preguntado en CONAREM): onda T aplanada, ondas U, depresi\u00f3n ST,\n     prolongaci\u00f3n QT, arritmias auriculares y ventriculares, \u2191toxicidad\n     digit\u00e1lica.<\/li>\n <li>Musculoesquel\u00e9ticas:\n     debilidad, calambres, par\u00e1lisis, rabdomi\u00f3lisis.<\/li>\n <li>Gastrointestinales:\n     \u00edleo paral\u00edtico.<\/li>\n <li>Renales:\n     poliuria, nefritis intersticial, quistes renales, riesgo de ERC terminal.<\/li>\n<\/ul>\n\n<p class=\"MsoNormalM\"><b>Diagn\u00f3stico<\/b><\/p>\n\n<ul type=\"discd\">\n <li>Excreci\u00f3n\n     urinaria K<span style=\"font-family:&quot;Cambria Math&quot;,serif\">\u207a<\/span> &lt;15 mM\/24h <span>\u2192<\/span>\n     origen extrarrenal.<\/li>\n <li>Relaci\u00f3n\n     K<span style=\"font-family:&quot;Cambria Math&quot;,serif\">\u207a<\/span>\/Cr\n     urinaria &gt;13 mM\/g <span>\u2192<\/span> p<span>\u00e9<\/span>rdida\n     renal.<\/li>\n <li>TTKG\n     &lt;3 en hipopotasemia \u2192 secreci\u00f3n renal inapropiadamente baja.<\/li>\n <li>Cloro\n     urinario &lt;10 mM \u2192 v\u00f3mitos; &gt;20 mM \u2192 p\u00e9rdidas renales.<\/li>\n <li>seg\u00fan\n     la bibliograf\u00eda oficial: \"La excreci\u00f3n de K<span style=\"font-family:\n     &quot;Cambria Math&quot;,serif\">\u207a<\/span> en 24 h\n     &lt;15 mM denota origen extrarrenal<span>\u2026<\/span>\n     proporci<span>\u00f3<\/span>n urinaria de K<span style=\"font-family:&quot;Cambria Math&quot;,serif\">\u207a<\/span>\/Cr\n     &gt;13 mM\/g<span>\u2026<\/span> TTKG &lt;3 en\n     hipopotasemia\" (p. 307).<\/li>\n<\/ul>\n\n<p class=\"MsoNormalM\"><b>Tratamiento (preguntado en CONAREM)<\/b><\/p>\n\n<ul type=\"discd\">\n <li>Oral:\n     40\u2013100 mM\/d\u00eda en dosis fraccionadas.<\/li>\n <li>IV:\n     solo en casos graves (&lt;2,5 mM, arritmias o par\u00e1lisis).<\/li>\n <ul type=\"circlec\">\n  <li>Usar\n      siempre en soluci\u00f3n salina, nunca glucosada.<\/li>\n  <li>Velocidad\n      m\u00e1xima: 10\u201320 mM\/h en UCI con monitorizaci\u00f3n card\u00edaca.<\/li>\n <\/ul>\n <li>Estimar\n     d\u00e9ficit: \u21931 mM s\u00e9rico \u2248 p\u00e9rdida 200\u2013400 mM corporal total.<\/li>\n <li>Corregir\n     magnesio: sin esto, la reposici\u00f3n es ineficaz.<\/li>\n <li>Hipopotasemia\n     redistributiva (ej. tirotoxicosis): propranolol IV en dosis altas.<\/li>\n<\/ul>\n\n<div align=\"center\" style=\"text-align:center\">\n\n<hr size=\"2\" width=\"100%\" align=\"centerc\" \/>\n\n<\/div>\n\n<p class=\"MsoNormalM\"><b>Hiperpotasemia (preguntado en CONAREM: f\u00e1rmacos, calcio\nIV, cambios ECG)<\/b><\/p>\n\n<ul type=\"discd\">\n <li>Definici\u00f3n:\n     K<span style=\"font-family:&quot;Cambria Math&quot;,serif\">\u207a<\/span>\n     &gt;5,5 mM. Urgencia m<span>\u00e9<\/span>dica.<\/li>\n <li>Clasificaci\u00f3n:\n     leve (5,5\u20136,0), moderada (6\u20137), grave (&gt;7).<\/li>\n <li>Epidemiolog\u00eda:\n     frecuente en diab\u00e9ticos, ancianos y en IRC.<\/li>\n <li>Fisiopatolog\u00eda:<\/li>\n <ul type=\"circlec\">\n  <li>Redistribuci\u00f3n:\n      acidosis, lisis tumoral, hem\u00f3lisis, \u03b2-bloqueo, d\u00e9ficit insulina.<\/li>\n  <li>\u2193excreci\u00f3n\n      renal: insuficiencia renal, hipoaldosteronismo hiporrenin\u00e9mico, f\u00e1rmacos\n      (IECA, ARA-II, espironolactona, heparina).<\/li>\n <\/ul>\n<\/ul>\n\n<p class=\"MsoNormalM\"><b>Manifestaciones cl\u00ednicas y ECG (preguntado en CONAREM)<\/b><\/p>\n\n<ul type=\"discd\">\n <li>Ondas\n     T picudas \u2192 PR prolongado \u2192 desaparici\u00f3n P \u2192 QRS ancho \u2192 patr\u00f3n senoidal \u2192\n     asistolia\/fibrilaci\u00f3n ventricular.<\/li>\n <li>S\u00edntomas:\n     debilidad, parestesias, par\u00e1lisis.<\/li>\n<\/ul>\n\n<p class=\"MsoNormalM\"><b>Diagn\u00f3stico<\/b><\/p>\n\n<ul type=\"discd\">\n <li>Confirmar\n     descartando pseudohiperpotasemia.<\/li>\n <li>seg\u00fan\n     la bibliograf\u00eda oficial: \"La pseudohiperpotasemia aparece\u2026 en\n     trombocitosis, leucocitosis o hem\u00f3lisis de la muestra\" (p. 308).<\/li>\n<\/ul>\n\n<p class=\"MsoNormalM\"><b>Tratamiento (preguntado en CONAREM)<\/b><\/p>\n\n<ul type=\"discd\">\n <li>Estabilizar\n     membrana: gluconato o cloruro de calcio IV (efecto inmediato, dura 30\u201360\n     min).<\/li>\n <li>Redistribuir\n     K<span style=\"font-family:&quot;Cambria Math&quot;,serif\">\u207a<\/span>:<\/li>\n <ul type=\"circlec\">\n  <li><span>Insulina + glucosa IV (r\u00e1pido,\n      4\u20136 h).<\/span><\/li>\n  <li>\u03b22\n      agonistas inhalados.<\/li>\n  <li>Bicarbonato\n      IV en acidosis metab\u00f3lica.<\/li>\n <\/ul>\n <li>Eliminar\n     K<span style=\"font-family:&quot;Cambria Math&quot;,serif\">\u207a<\/span>:<\/li>\n <ul type=\"circlec\">\n  <li>Resinas\n      de intercambio cati\u00f3nico (acci\u00f3n lenta).<\/li>\n  <li>Diur\u00e9ticos\n      de asa si hay diuresis.<\/li>\n  <li>Hemodi\u00e1lisis\n      en refractarios o IRC avanzada.<\/li>\n <\/ul>\n<\/ul>\n\n<div align=\"center\" style=\"text-align:center\">\n\n<hr size=\"2\" width=\"100%\" align=\"centerc\" \/>\n\n<\/div>\n\n<p class=\"MsoNormalM\"><b>S\u00edndromes hereditarios y endocrinos<\/b><\/p>\n\n<ul type=\"discd\">\n <li><b>Bartter<\/b>:\n     defecto TALH, hipopotasemia + alcalosis + hipercalciuria, \u2191RAAS.<\/li>\n <li><b>Gitelman<\/b>:\n     defecto NCC (DCT), hipopotasemia + alcalosis + hipomagnesemia +\n     hipocalciuria.<\/li>\n <li><b>Liddle<\/b>:\n     ganancia de funci\u00f3n ENaC, hipertensi\u00f3n + hipopotasemia, renina\/aldosterona\n     bajas. No responde a espironolactona, s\u00ed a amilorida.<\/li>\n <li><b>SAME<\/b>:\n     d\u00e9ficit 11\u03b2-HSD2 o inhibici\u00f3n por regaliz \u2192 pseudohiperaldosteronismo\n     (hipertensi\u00f3n + hipopotasemia + renina\/aldosterona bajas).<\/li>\n <li><b>Hiperaldosteronismo\n     primario<\/b>: renina baja, aldosterona alta.<\/li>\n <li><b>Hipoaldosteronismo\n     hiporrenin\u00e9mico<\/b>: t\u00edpico en diab\u00e9ticos ancianos con IRC leve, cursa con\n     hiperpotasemia + acidosis metab\u00f3lica.<\/li>\n<\/ul>\n\n<div align=\"center\" style=\"text-align:center\">\n\n<hr size=\"2\" width=\"100%\" align=\"centerc\" \/>\n\n<\/div>\n\n<p class=\"MsoNormalM\"><b>Complicaciones sist\u00e9micas<\/b><\/p>\n\n<ul type=\"discd\">\n <li>Cardiovasculares:\n     arritmias, muerte s\u00fabita.<\/li>\n <li>Musculoesquel\u00e9ticas:\n     par\u00e1lisis, rabdomi\u00f3lisis.<\/li>\n <li>Gastrointestinales:\n     \u00edleo paral\u00edtico.<\/li>\n <li>Renales:<\/li>\n <ul type=\"circlec\">\n  <li>Hipopotasemia\n      cr\u00f3nica \u2192 nefropat\u00eda intersticial, quistes, ERC terminal.<\/li>\n  <li>Rabdomi\u00f3lisis\n      \u2192 IRA pigmentaria.<\/li>\n  <li>Hiperpotasemia\n      \u2192 acidosis metab\u00f3lica, paro card\u00edaco.<\/li>\n <\/ul>\n<\/ul>\n\n<div align=\"center\" style=\"text-align:center\">\n\n<hr size=\"2\" width=\"100%\" align=\"centerc\" \/>\n\n<\/div>\n\n<p class=\"MsoNormalM\"><b>Algoritmo mental de diagn\u00f3stico diferencial (\u00fatil para\nexamen)<\/b><\/p>\n\n<ul type=\"discd\">\n <li><b>Hipopotasemia\n     + alcalosis<\/b>:<\/li>\n <ul type=\"circlec\">\n  <li>Cloro\n      urinario &lt;10 \u2192 v\u00f3mitos.<\/li>\n  <li>Cloro\n      urinario alto + hipocalciuria + hipomagnesemia \u2192 Gitelman.<\/li>\n  <li>Cloro\n      urinario alto + hipercalciuria \u2192 Bartter.<\/li>\n  <li>HTA\n      + renina\/aldosterona bajas \u2192 Liddle.<\/li>\n  <li>HTA\n      + renina baja\/aldosterona alta \u2192 Hiperaldosteronismo primario.<\/li>\n <\/ul>\n <li><b>Hiperpotasemia<\/b>:<\/li>\n <ul type=\"circlec\">\n  <li>Diab\u00e9tico\n      anciano con acidosis \u2192 hipoaldosteronismo hiporrenin\u00e9mico.<\/li>\n  <li>IRC\n      terminal \u2192 \u2193excreci\u00f3n renal.<\/li>\n  <li>Pseudohiperpotasemia\n      \u2192 leucocitosis\/trombocitosis sin cl\u00ednica ni ECG.<\/li>\n <\/ul>\n<\/ul>\n\n<p class=\"MsoNormalM\">&nbsp;<\/p>\n\n\n<br \/><\/p>",
        "footer": "P\u00e1gina 1"
    }
]