1. Hypokalemia and Hyperkalemia
Dr Madhukar Mittal
Medical Endocrinology

2. Hypokalemia Spurious Extreme leukocytosis
(WBC uptake of K+ in the test tube)

3. Decreased Total Body K+
Transcellular shift
Stress induced catecholamine release
Asthma, COPD exacerbation, CHF, MI/Angina, Drug withdrawal syndrome
Drugs
Insulin
Theophylline, β2 agonists
Anabolic state
Vit B12 or Folate treatment
GM-CSF
TPN
Hypokalemic periodic paralysis
Decreased Total Body K+

4. 3. Decreased Total Body K+
Renal Loss
(urinary K+>20meq/l)
Extra-renal Loss
(urinary K+<20meq/l)
Metabolic alkalosis
Mineralocorticoid excess
Primary aldosteronism
Secondary aldosteronism
↑ mineralocorticoid (Non-aldosterone) action
Normal/↓ BP, No edema, Secondary aldosteronism
Bartter syndrome
Gitelman syndrome
Diuretic abuse
Chronic vomiting
Hypomagnesemia
Metabolic acidosis
DKA
RTA type 1 & 2
Ureterosigmoidostomy
Amphotericin B
Acetozolamide
Normal pH
Decreased intake
GI losses
Metaboic acidosis
Lower GI losses
Diarrhea
Laxative abuse
Metabolic alkalosis
Villous adenoma
Congenital Cl- losing diarrhea
Remote vomiting
Remote diuretic use
Variable pH
Postobstructive diuresis
Drugs
Aminoglycosides
Cisplatin

5. (urinary K+>20meq/l)
Renal Loss
(urinary K+>20meq/l)
Metabolic alkalosis
Mineralocorticoid excess
Primary aldosteronism
Secondary aldosteronism
↑ mineralocorticoid (Non-aldosterone) action
Normal/↓ BP, No edema, Secondary aldosteronism
Bartter syndrome
Gitelman syndrome
Diuretic abuse
Chronic vomiting
Hypomagnesemia
Metabolic acidosis
DKA
RTA type 1 & 2
Ureterosigmoidostomy
Amphotericin B
Acetozolamide
Normal pH
Decreased intake
GI losses

6. (urinary K+<20meq/l)
Extra-renal Loss
(urinary K+<20meq/l)
Metaboic acidosis
Lower GI losses
Diarrhea
Laxative abuse
Metabolic alkalosis
Villous adenoma
Congenital Cl- losing diarrhea
Remote vomiting
Remote diuretic use
Variable pH
Postobstructive diuresis
Drugs
Aminoglycosides
Cisplatin

7. ↑Aldosterone, ↓PRA (Primary Aldosteronism)
Adrenal adenoma (Conn syndrome)
Idiopathic hyperplasia
Adrenal carcinoma
Glucocorticoid remediable aldosteronism (GRA)

8. Hypermineralocorticolism/Aldosteronism (Metabolic alkalosis, Hypokalemia, ↑BP)
↑↑Aldosterone, ↑PRA (Secondary Aldosteronism)
Edema states (Cirrhosis, CHF, Nephrosis)
Pregnancy (Normal physiologic response)
↑Renin d/t ↓Renal blood flow
Renal artery stenosis
Accelerated Hypertension (renal vasoconstriction)
Malignant hypertension (arteriolar nephrosclerosis)
Primary reninism
Renin producing tumors
↓/N BP, No edema
Bartter syndrome
Gitelman syndrome
Chronic vomiting
Diuretic abuse
Hypomagnesemia
Hypertensive States
BCD GH

9. Hypermineralocorticolism/Aldosteronism (Metabolic alkalosis, Hypokalemia, ↑BP)
↓/N Aldosterone, ↓PRA (↑ Mineralocorticoid action)
Liddle syndrome
Cushing syndrome
AME (apparent mineralocorticoid excess syndrome)
Licorice/Carbenoxolone ingestion
(Glycyrrhizinic acid Ɵ 11-βHSD II enzyme)
CAH – 11β hydroxylase deficiency
DOC (deoxycorticosterone) secreting tumour
LAL CD

10. Hypermineralocorticolism/Aldosteronism (Metabolic alkalosis, ↓ K+, ↓/N BP)
Bartter syndrome
Hypercalciuria
Gitelman syndrome
↓Urinary Ca, ↓ serum Mg
Diuretic abuse
Hypomagnesemia
Chronic vomiting
Urine Cl- <10meq/l
Urine Cl- >20meq/l

11. CVS - ECG Flattening or inversion of T wave with ST depression
Prominent U waves
Prolonged QT (QU) interval
+ prolonged PR interval, wide QRS complex
Atrial and ventricular arrhythmias
Predisposition to digitalis toxicity

12. Clinical NeuroMs Endocrine Renal Weakness, flaccid paralysis
Cramps, tetany, rhabdomyolysis
Ileus, constipation, urinary retention
Endocrine
Glucose intolerance
Growth retardation, ↓ aldosterone
Renal
↓ renal blood flow, ↓ GFR
Nephrogenic diabetes insipidus
Increased ammoniagenesis (hepatic encephalopathy)
Chloride wasting/metabolic alkalosis

13. Treatment Agent Max concentration Infusing solution Rate of infusion
KCl
Pot bicarbonate and citrate for hypokalemia associated with chronic diarrhea, RTA
Max concentration
<40 mmol/l via peripheral vein
<60 mmol/l via central vein
Infusing solution NS
Mannitol
Rate of infusion
<20mmol/hr unless paralysis, malignant ventr arrhythmias

14. Treatment Montoring Hypokalemic periodic paralysis Clinical – NeuroMs
ECG
Plasma K conc.
Hypokalemic periodic paralysis
Ca channel disorder
Oral KCl mmol/Kg every min
IV KCL in mannitol
Long term – Actazolamide mg/d, Triamterene mg/d, Spironolactone mg/d, Dichlorphenamide mg/d

16. Hyperkalemia Spurious (Pseudo) Prolonged use of tourniquet
Ischemic blood draws
RBC hemolysis in test tubes
Marked thrombocytosis or leukocytosis

17. Transcellular shift Chronic Hyperkalemia Metabolic acidosis Drugs
Insulin deficiency and hypertonicity
β blockers
Tissue breakdown
Rhabdomyolysis
Tumor lysis syndrome
Intravascular hemolysis
Hyperkalemic periodic paralysis
Drug toxicity
Digitalis
succinylchloline
Chronic Hyperkalemia

18. 3. Chronic Hyperkalemia (Metabolic acidosis, Hypokalemia)
↓Aldosterone, ↑PRA (Hypoaldosteronism)
Primary adrenal insufficiency
Aldosterone bisynthetic defect
Mutation in aldosterone synthase gene (cyp 11B2)
CAH – Lipoid, 3β-HSD def, 21-OH-lase deficiency
Heparin
ACE Ɵ, ARBs (selective unresposivensess to angiotensin II)
↓Aldosterone, ↓PRA (Hyporeninemic Hypoaldosteronism)
NSAIDS
Chronic TIN, Diabetic Nephropathy, Mild renal failure

19. 3. Chronic Hyperkalemia
↓Aldosterone, ↓PRA, ↑BP, (Cl- shunt/reabsorption in distal tubule)
PHA-II (Gordon’s syndrome)
Cyclosporine
Distal Type 4 RTA
↑Aldo, ↑PRA, ↓BP (Mineralocorticoid Resistant Hyperkalemia), Impaired distal Na+ reabsorption
PHA-I
Potassium sparing diuretics - Spironolactone, Eplerenone, Triamterene, Amiloride
Trimethoprim
Pentamidine

20. ↓Aldosterone, ↓PRA (Hypoaldosteronism)
NSAIDS
Chronic TIN
Mild renal failure
Cl- shunt/reabsorption in distal tubule (↑BP)
Cyclosporine
Type 4 RTA
Gordon syndrome (PHA-II)

21. ↑Aldosterone, ↑PRA (Mineralocorticoid Resistant Hyperkalemia)
PHA-I
Potassium sparing diuretics
Spironolactone, Eplerenone
Triamterene, Amiloride
Trimethoprim
Pentamidine
↓BP
Impaired distal Na+ reabsorption

22. CVS - ECG Tall peaked (tented) T waves (earliest change)
Short QT interval
Wide QRS, PR interval prolongs → 20 or 30 AV block
↓ P wave amplitude → complete loss of P waves with associated junctional rhythm
QRS widens → sine wave (ventr. flutter-like) pattern
Eventual asystole

23. Treatment Restrict K intake to <40 mmol/day Stop K supplements
Stop K sparing diuretics

24. Treatment Ca gluconate (10%)
10 ml over 1 -3 min IV
Repeat if no change in ECG after 5-10 min
10-20 U regular insulin g glucose IVI
NaHCO3 3 amp (50-150mmol) in 1L of 5%D
Nebulized β2agonist (albuterol 20mg in 4ml NS)

25. Treatment Diuretics – furosemide 60-80 mg/day
Resins (sodium polysterene sulfonate)
25-50g in 100ml of 20% sorbitol
Retention enema 50g in 50ml of 70% sorbitol in 150ml tap water
Dialysis
For patients with renal failure
Severe life-threatening hyperkalemia unresponsive to conservative treatment
Hemodialysis – most rapid and effective way
Peritoneal dialysis – only 15-20% as effective as hemodialysis

27. Thank You