Evaluation of low sodium : potassium ratios in dogs

J Vet Diagn Invest 11:60 64 (1999) Evaluation of low sodium : potassium ratios in dogs Lois Roth, Ronald D. Tyler Abstract. The results of general chemistry profiles of canine patients from Angell Memorial Animal Hospital, Boston, Massachusetts, during 1993 were reviewed for low ( 24) serum sodium : potassium (Na:K) ratios. Thirty-seven dogs had low Na:K ratios. The medical records for 34 these patients were available and sufficiently complete to identify conditions that were associated with low Na:K ratios. Of these 34 dogs, 8 (24%) had, and 14 had renal disease. Twenty-two of the 34 (65%) had Na:K ratios between 24 and 20. Of these 22 dogs, 9 (41%) had renal or urinary tract disease, and 2 (9%) had. Other diagnoses in this group included pancreatic disease (3), disseminated neoplasia (3), circulatory disturbance (2), pyometra (1), mushroom poisoning (1), and behavior problem (1). Eight of 34 dogs had Na:K ratios between 19.9 and 15. Of these 8 dogs, 4 (50%) had urinary tract disease, 2 had, 1 had pancreatic disease, and 1 had severe anemia and hypoproteinemia due to severe parasitism. All of the 4 dogs with Na:K ratios 15 had, and 1 of these 4 had concurrent. In all dogs, serum potassium concentration was above the laboratory s reference range, but sodium was below the laboratory s reference range in only 18 dogs (53%). Two of the 8 (25%) dogs with had serum sodium concentrations within the laboratory s reference range. In this population, low Na:K ratios were invariably associated with hyperkalemia but not always with hyponatremia. Although numerous conditions were associated with a low Na:K ratio, renal disease was the most common. Hypoadrenocorticism was present in only 13% of dogs with Na:K ratios between 24 and 15 but was present in all dogs with Na:K ratios 15. Diagnosis of in canine patients is difficult. Clinical signs (weakness, dehydration, bradycardia, and hypotension) are nonspecific. 9,11 The adrenocorticotropin stimulation test (ACTH-st) is recommended for confirmation of the diagnosis. Unfortunately, the ACTH-st is expensive, time consuming, and not always diagnostic. Therefore, suspicion of is necessary to merit performance of an ACTH-st, and other clinical and clinicopathological findings must be considered in its interpretation. Evaluation of serum electrolyte concentrations is important in identifying patients that might have. Decreased ( 24) sodium : potassium (Na:K) ratios is a common finding in patients with, and is considered among the more likely diagnoses in dogs with an Na:K ratio 25. 6 However, other disorders, particularly renal and gastrointestinal disease, may cause similar electrolyte imbalances and signs consistent with. 3,4,8 In an effort to determine the most frequent causes of decreased Na:K ratios, the 1993 medical records of canine patients at Angell Memorial Animal Hospital, Boston, Massachusetts, were examined. From the Department of Pathology, Angell Memorial Animal Hospital, 350 South Huntington Avenue, Boston, MA 02130 (Roth), and Glaxo Research Institute, 5 Moore Drive, Research Triangle Park, NC 27709 (Tyler). Received for publication December 5, 1997. Materials and methods The daily result logs of Angell Memorial Animal Hospital s Clinical Laboratory were reviewed, and the number of hospital patients having Na:K ratios 24 was recorded. Subsequently, the medical records were reviewed and the primary diagnoses were recorded. In all cases of, a combination of clinical signs, clinical chemistry values, and the results of an ACTH-st were used to establish the diagnosis. In each case, the serum sodium concentration and the serum potassium concentration were compared with their respective Na:K ratio using a standard method for calculation of the coeffiecient of correlation (r). 2 Results Thirty-seven dogs had Na:K ratios 24. The medical records of 34 of these dogs were sufficiently complete for inclusion in this study. Table 1 lists the serum sodium and potassium values, the Na:K ratios and the primary diagnosis for each case in order of decreasing Na:K ratio. The diagnosis of was established clinically in 8 dogs by the lack of response to an ACTH-st. The ACTH-st was done for the dogs with the mammary tumor, behavior disorder, thyroid carcinoma, heart failure, and pancreatitis. All but 1 dog with pancreatitis had a normal result. This dog had an ACTH-st result within the equivocal range. Renal disease was established by biopsy in 7 dogs and at necropsy in 5. Severe parasitism (Trichuris vulpis, Toxacara canis) was established by fecal examination in 1 dog, and diarrhea and electrolyte imbalance resolved following treatment for parasitism. The diagnoses of 60

Low sodium : potassium ratios in dogs 61 Table 1. Serum sodium, potassium, and Na : K ratio values and diagnoses listed in descending order of ratio values. Sodium (meq/ liter)* 143 152 147 147 140 149 149 139 127 133 145 145 143 126 136 121 119 123 130 142 134 129 129 128 Potassium (meq/ liter) 6.3 5.5 6.7 6.8 6.1 5.9 7.0 7.0 7.8 7.3 8.0 8.7 9.3 Na : K ratio 23.87 23.87 23.83 23.75 23.7 23.33 23.33 23.28 23.28 23.17 23.09 23.00 22.81 22.17 21.97 21.97 21.79 21.45 21.03 20.66 20.66 20.51 19.71 19.71 19.19 18.72 17.82 17.81 17.25 16.32 14.89 14.33 14.33 13.76 Primary diagnosis mammary tumor behavioral disorder thyroid adenocarcinoma heart failure hemagiosarcoma pyometra ketoacidosis, diabetes pancreatitis heart failure mushroom poisoning ruptured bladder pancreatitis parasitism * Reference range 141 153 meq/liter. Reference range 4.1 5.3 meq/liter. ketoacidosis, diabetes perineal hernia, incarcerated bladder, bladder incarceration and bladder rupture were established at surgery. Both dogs were euthanized, and necropsies were not done. Pyometra was determined in 1 dog at surgery, and recovery was uneventful following hysterectomy. Electrolyte concentrations returned to normal without further treatment. Ketoacidosis was determined in 2 dogs by urine and serum chemistry values. The dog with mushroom poisoning died shortly after admission. No adrenal lesions were detected either grossly or histologically. Twenty-two dogs had Na:K ratios between 24 and 20. Only 2 of these dogs had, and 9 had renal or urinary tract disease. Disseminated neoplasia was present in 3 dogs, 2 dogs had pancreatitis, and 1 dog had ketoacidosis associated with diabetes. The remaining 4 dogs in this group had miscellaneous diagnoses that included pyometra, heart failure, mushroom poisoning, and a behavioral disorder. Eight dogs had Na:K ratios between 15 and 20. Only 2 had, and 4 had renal or urinary tract disease. Intestinal parasitism (trichuriasis and ascariasis) was present in 1 dog, and 1 dog in this group had ketoacidosis associated with diabetes. All 4 dogs with Na:K ratios 15 had. 1 dog had concurrent. Figures 1 and 2 show the relationship between serum Na:K ratios and serum sodium and potassium concentrations, respectively. Serum Na:K ratios were more closely related to serum potassium concentration (r 0.908) than to serum sodium concentration (r 0.548). 2 The closer the absolute r value is to 1, the greater the correlation between 2 values. Given the guidelines for interpreting r values, the correlation between serum potassium concentration and the Na:K ratio was interpreted as excellent and the correlation between serum sodium concentration and the Na:K ratio was interpreted as fair. Discussion In this study, or urinary tract disease leading to decreased urine excretion was a more common cause of low Na:K ratios than was (Table 1). Only 24% of dogs with Na:K ratios 24 had, whereas 41% had urinary tract or renal disease. Hypoadrenocorticism was uncommon among dogs with Na:K ratios between 24 and 15, affecting only 13% of this group, but was present in all 4 dogs with Na:K ratios 15. Comparison of the Na:K ratio to serum sodium concentration and to serum potassium concentration (Figs. 1, 2, respectively) revealed that low Na:K ratios were more strongly correlated with increased serum potassium concentrations than with decreased serum sodium concentration. All dogs with Na:K ratios 24 were hyperkalemic, but some were not hyponatremic. Two dogs with had serum sodium concentrations within the laboratory s reference range. Other workers have reported hyponatremia with normokalemia as a more frequent cause of low Na:K ratios. 10 Some dogs determined to have based on clinical signs and a lack of response to an ACTH-st test have serum sodium and potassium concentrations within reference range. 9 11 Although adrenal cortical function may be diminished, mineralocorticoid secretion can remain adequate for maintenance of normal electrolyte concentrations. This would be the case if hypostimulation or atrophy only affected steroid secreting cells of the zona fasiculata and zona recticularis. 7 These dogs would have been excluded from this study because all Na:K ratio 24 was a requirement for inclusion.

62 Roth, Tyler Figure 1. Serum sodium concentration versus Na:K ratio. The correlation is fair (r 0.548). R/U renal or urinary tract disease. Normal plasma sodium and potassium concentrations are maintained by balanced intake and excretion, intracellular and extracellular osmotic pressure, and ph. 1,3 Because most dogs are fed commercial diets with appropriate amounts of these nutrients, impairment of normal excretory pathways, excessive loss of sodium, potassium, or water, and acid base imbalance are more common causes of altered Na:K ratios. Physiological mechanisms that adjust osmolar balance between the intracellular and extracellular fluid compartments may mask changes in total body concentrations of potassium and sodium. Two of the dogs in this series were diabetic with associated ketoacidosis. Hyperglycemia with associated hyperosmolality may have contributed to decreased serum sodium concentrations by causing water to shift from the intracellular to the extracellular space. Hyperkalemia has been associated with insulin deficiency. Renal excretion is responsible for maintenance of balanced intake and secretion of both sodium and potassium. 1,3 After filtration by the glomerulus, sodium is reabsorbed by the proximal and distal convoluted Figure 2. disease. Serum potassium concentration versus Na:K ratio. The correlation is excellent (r 0.948). R/U renal or urinary tract

Low sodium : potassium ratios in dogs 63 tubules. Potassium also passes through the glomerular filter, but it is almost totally reabsorbed by proximal tubular epithelial cells. The extent of potassium excretion by the distal convoluted tubules and collecting ducts is determined by the potassium concentration in these cells. The sodium potassium pump normally maintains intracellular potassium concentration in these cells at 140 150 meq/liter. Aldosterone, secreted by the zona glomerulosa/arcuata of the adrenal cortex, enhances the permeability of distal tubular cell membranes to potassium, promoting its excretion. Low aldosterone concentration, as would occur in, promotes retention of potassium. The rate of tubular flow also influences ion concentrations, with higher rates of flow maintaining potassium concentration gradients that favor potassium excretion. 1,3 Electrolyte imbalances due to diarrheal fluid loss and extracellular translocation of potassium associated with it is the purported pathogenesis for hyperkalemia and hyponatremia associated with Trichuris vulpis infection in dogs. 8 One dog in this series had trichuriasis involving the cecum and colon with severe diarrhea, and its low Na:K ratio most likely occurred by this mechanism. One dog with pyometra and 1 with pancreatitis had marked polydipsia and polyuria. Hyponatremia was more severe than hyperkalemia in both cases. Renal sodium loss and dilutional hyponatremia may have contributed to the hyponatremia and the low Na:K ratio in these dogs. One dog with disseminated mammary adenocarcinoma had a thoracic effusion, and 3 dogs (one each with heart failure, pancreatitis, and hemangiosarcoma) had abdominal effusion. Repeated fluid drainage has been associated with hyperkalemia and hyponatremia in dogs with chylothorax. 12 Fluid drainage was part of the treatment in the dogs with the mammary gland adenocarcinoma and heart failure. Fluid loss into the thoracic or abdominal cavity and fluid drainage most likely contributed to the electrolyte imbalances in these 4 dogs. Sodium : potassium ratios of 21.2 and 23.5 have been previously reported in 1 dog with cardiomyopathy and another with pericardial effusion, respectively, although drainage of fluid was not mentioned. 5 Administration, of potassium-sparing diuretics, such as spironolactone, amiloride, or triamterene, which would result in decreased urinary excretion of potassium, was not included in the medical record of the dog with heart failure. The mechanism for elevated potassium in 2 dogs (mushroom poisoning and behavioral problem) and elevated potassium and decreased sodium (thyroid adenocarcinoma) is unknown because abnormalities related to fluid intake, excretion, or third space accumulation were not detected. The hyperkalemia and hyponatremia in these dogs may have been the result of conditions that were not detected. Angell Memorial Animal Hospital serves as both a primary care and referral hospital. Thus, the distribution of causes of low Na:K ratios in this study may not represent what occurs in a strictly primary care or strictly referral hospital setting. Because is a difficult and complex diagnostic challenge, dogs are often referred for diagnosis, confirmation of diagnosis, or treatment. As a result, might represent a greater proportion of cases with low Na:K ratios at referral hospitals than at primary care hospitals. Although is more common in dogs with Na:K ratios 15, too few dogs were in this category to reliably predict the relative frequency of Na:K ratios 15 in dogs with. Further studies are needed to determine if the relative frequencies of low Na:K ratios differ between primary care and referral hospitals and to determine the relative frequencies of extremely low Na:K ratios. In this study, renal or urinary tract disease was the most common cause of Na:K ratios 24. However, if the ratio was markedly decreased ( 15) was the most common cause. Hyperkalemia was consistently present when the Na:K ratio was low. Hyponatremia was much less consistent, present in only 53% of dogs with low Na:K ratios and only 75% of dogs with low Na:K ratios attributed to. This finding differs from the results of a previous study in which low Na:K ratios were more often associated with hyponatremia and normokalemia. 10 References 1. 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64 Roth, Tyler 9. Rakich PM, Lorenz MD: 1984, Clinical signs and laboratory abnormalities in 23 dogs with spontaneous. J Am Anim Hosp Assoc 20:647 649. 10. Sadek D, Schaer M: 1996, A typical Addison s disease in the dog: a retrospective survey of 14 cases. J Am Anim Hosp Assoc 32:159 163. 11. Schaer M, Chen CL: 1983, A clinical survey of 48 dogs with adrenocortical hypofunction. J Am Anim Hosp Assoc 19:443 452. 12. Willard MD, Fossum TW, Torrance A, Lippert A: 1991, Hyponatremia and hyperkalemia associated with idiopathic or experimentally induced chylothorax in four dogs. J Am Vet Med Assoc 199:353 358.