Wikipedia

Hyperkalemia

Hyperkalemiais an elevated level ofpotassium(K+) in theblood.[1]Normal potassium levels are between 3.5 and 5.0mmol/L(3.5 and 5.0mEq/L) with levels above 5.5mmol/L defined as hyperkalemia.[3][4]Typically hyperkalemia does not cause symptoms.[1]Occasionally when severe it can causepalpitations,muscle pain,muscle weakness,ornumbness.[1][2]Hyperkalemia can cause anabnormal heart rhythmwhich can result incardiac arrestand death.[1][3]

Hyperkalemia
Other namesHyperkalaemia
Electrocardiographyshowingprecordial leadsin hyperkalemia.
Pronunciation
SpecialtyCritical care medicine,nephrology
SymptomsPalpitations,muscle pain,muscle weakness,numbness[1][2]
ComplicationsCardiac arrest[1][3]
CausesKidney failure,hypoaldosteronism,rhabdomyolysis,certain medications[1]
Diagnostic methodBlood potassium > 5.5mmol/L,electrocardiogram[3][4]
Differential diagnosisPseudohyperkalemia[1][2]
TreatmentMedications, low potassium diet,hemodialysis[1]
MedicationCalcium gluconate,dextrosewithinsulin,salbutamol,sodium bicarbonate[1][3][5]
Frequency~2% (people in hospital)[2]

Common causes of hyperkalemia includekidney failure,hypoaldosteronism,andrhabdomyolysis.[1]A number of medications can also cause high blood potassium includingspironolactone,NSAIDs,andangiotensin converting enzyme inhibitors.[1]The severity is divided into mild (5.5–5.9mmol/L), moderate (6.0–6.4mmol/L), and severe (>6.5mmol/L).[3]High levels can be detected on anelectrocardiogram(ECG).[3]Pseudohyperkalemia, due to breakdown ofcellsduring or after taking the blood sample, should be ruled out.[1][2]

Initial treatment in those with ECG changes is salts, such ascalcium gluconateorcalcium chloride.[1][3]Other medications used to rapidly reduce blood potassium levels includeinsulinwithdextrose,salbutamol,andsodium bicarbonate.[1][5]Medications that might worsen the condition should be stopped and a low potassium diet should be started.[1]Measures to remove potassium from the body include diuretics such asfurosemide,potassium-binders such aspolystyrene sulfonate(Kayexalate) andsodium zirconium cyclosilicate,andhemodialysis.[1]Hemodialysis is the most effective method.[3]

Hyperkalemia is rare among those who are otherwise healthy.[6]Among those who are hospitalized, rates are between 1% and 2.5%.[2]It is associated with an increased mortality, whether due to hyperkalaemia itself or as a marker of severe illness, especially in those withoutchronic kidney disease.[7][6]The wordhyperkalemiacomes fromhyper-'high' +kalium'potassium' +-emia'blood condition'.[8][9]

Signs and symptoms

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The symptoms of an elevated potassium level are generally few and nonspecific.[10]Nonspecific symptoms may include feeling tired, numbness and weakness.[10]Occasionallypalpitationsand shortness of breath may occur.[10][11][12]Hyperventilation may indicate a compensatory response tometabolic acidosis,which is one of the possible causes of hyperkalemia.[13]Often, however, the problem is detected during screeningblood testsfor a medical disorder, or after hospitalization for complications such ascardiac arrhythmiaorsudden cardiac death.High levels of potassium (> 5.5mmol/L) have been associated with cardiovascular events.[13]

Causes

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Ineffective elimination

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Decreased kidney functionis a major cause of hyperkalemia. This is especially pronounced inacute kidney injurywhere the glomerular filtration rate and tubular flow are markedly decreased, characterized byreduced urine output.[13]This can lead to a dramatically elevated potassium in conditions of increased cell breakdown as the potassium is released from the cells and cannot be eliminated in the kidney. Inchronic kidney disease,hyperkalemia occurs as a result of reduced aldosterone responsiveness and reduced sodium and water delivery in distal tubules.[14]

Medications that interfere with urinary excretion by inhibiting therenin–angiotensin systemis one of the most common causes of hyperkalemia. Examples of medications that can cause hyperkalemia includeACE inhibitors,angiotensin receptor blockers,[13]non-selectivebeta blockers,andcalcineurin inhibitorimmunosuppressants such asciclosporinandtacrolimus.[15]For potassium-sparingdiuretics,such asamilorideandtriamterene;both the drugs block epithelial sodium channels in the collecting tubules, thereby preventing potassium excretion into urine.[14]Spironolactoneacts by competitively inhibiting the action of aldosterone.[13]NSAIDssuch asibuprofen,naproxen,orcelecoxibinhibitprostaglandinsynthesis, leading to reduced production of renin and aldosterone, causing potassium retention.[16]The antibiotictrimethoprimand theantiparasitic medicationpentamidineinhibits potassium excretion, which is similar to mechanism of action by amiloride and triamterene.[17]

Mineralocorticoid(aldosterone) deficiency or resistance can also cause hyperkalemia. Primary adrenal insufficiency are:Addison's disease[18]andcongenital adrenal hyperplasia (CAH)(including enzyme deficiencies such as21α hydroxylase,17α hydroxylase,11β hydroxylase,or3β dehydrogenase).[19]

Excessive release from cells

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Metabolic acidosiscan cause hyperkalemia as the elevated hydrogen ions in the cells can displace potassium, causing the potassium ions to leave the cell and enter the bloodstream. However, inrespiratory acidosisor organic acidosis such aslactic acidosis,the effect on serum potassium are much less significant although the mechanisms are not completely understood.[14]

Insulin deficiency can cause hyperkalemia as thehormoneinsulinincreases the uptake of potassium into the cells. Hyperglycemia can also contribute to hyperkalemia by causinghyperosmolalityin extracellular fluid, increasing water diffusion out of the cells and causes potassium to move alongside water out of the cells also. The co-existence of insulin deficiency, hyperglycemia, and hyperosmolality is often seen in those affected bydiabetic ketoacidosis.Apart from diabetic ketoacidosis, there are other causes that reduce insulin levels such as the use of the medicationoctreotide,and fasting which can also cause hyperkalemia. Increased tissue breakdown such asrhabdomyolysis,burns,or any cause of rapid tissuenecrosis,includingtumor lysis syndromecan cause the release of intracellular potassium into blood, causing hyperkalemia.[13][14]

Beta2-adrenergic agonistsact on beta-2 receptors to drive potassium into the cells. Therefore,beta blockerscan raise potassium levels by blocking beta-2 receptors. However, the rise in potassium levels is not marked unless there are other co-morbidities present. Examples of drugs that can raise the serum potassium are non-selective beta-blockers such aspropranololandlabetalol.Beta-1 selective blockers such asmetoprololdo not increase serum potassium levels.[14][medical citation needed]

Exercise can cause a release of potassium into bloodstream by increasing the number of potassium channels in the cell membrane. The degree of potassium elevation varies with the degree of exercise, which range from 0.3 meq/L in light exercise to 2 meq/L in heavy exercise, with or without accompanying ECG changes or lactic acidosis. However, peak potassium levels can be reduced by prior physical conditioning and potassium levels are usually reversed several minutes after exercise.[14]High levels ofadrenalineandnoradrenalinehave a protective effect on the cardiac electrophysiology because they bind to beta 2 adrenergic receptors, which, when activated, extracellularly decrease potassium concentration.[20]

Hyperkalemic periodic paralysisis anautosomal dominantclinical condition where there is a mutation in gene located at 17q23 that regulates the production of proteinSCN4A.SCN4A is an important component ofsodium channelsin skeletal muscles. During exercise, sodium channels would open to allow influx of sodium into the muscle cells fordepolarizationto occur. But in hyperkalemic periodic paralysis, sodium channels are slow to close after exercise, causing excessive influx of sodium and displacement of potassium out of the cells.[14][21]

Rare causes of hyperkalemia are discussed as follows. Acute digitalis overdose such asdigoxintoxicity may cause hyperkalemia[22]through the inhibition of sodium-potassium-ATPase pump.[14]Massiveblood transfusioncan cause hyperkalemia in infants due to leakage of potassium out of the red blood cells during storage.[14]Givingsuccinylcholineto people with conditions such as burns, trauma, infection, prolonged immobilisation can cause hyperkalemia due to widespread activation of acetylcholine receptors rather than a specific group of muscles.Argininehydrochloride is used to treatrefractorymetabolic alkalosis. The arginine ions can enter cells and displace potassium out of the cells, causing hyperkalemia. Calcineurin inhibitors such ascyclosporine,tacrolimus,diazoxide,andminoxidilcan cause hyperkalemia.[14]Box jellyfishvenom can also cause hyperkalemia.[23]

Excessive intake

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Excessive intake of potassium is not a primary cause of hyperkalemia because the human body usually can adapt to the rise in the potassium levels by increasing the excretion of potassium into urine throughaldosteronehormone secretion and increasing the number of potassium secreting channels in kidney tubules. Acute hyperkalemia in infants is also rare even though their body volume is small, with accidental ingestion of potassium salts or potassium medications. Hyperkalemia usually develops when there are other co-morbidities such ashypoaldosteronismandchronic kidney disease.[14]

Pseudohyperkalemia

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Pseudohyperkalemia occurs when the measured potassium level is falsely elevated.[24]This condition is usually suspected when the patient is clinically well without any ECG changes. Mechanical trauma during blood drawing can cause potassium leakage out of the red blood cells due tohaemolysisof the blood sample.[24]Repeated fist clenching during the blood draw can cause a transient rise in potassium levels.[25]Prolonged length of blood storage can also increase serum potassium levels. Hyperkalemia may become apparent when a person's platelet concentration is more than 500,000/microL in a clotted blood sample (serumblood sample). Potassium leaks out of platelets after clotting has occurred. A high white cell count (greater than 120,000/microL) in people withchronic lymphocytic leukemiaincreases the fragility of red blood cells, thus causing pseudohyperkalemia during blood processing. This problem can be avoided by processing serum samples, because clot formation protects the cells from haemolysis during processing. A familial form of pseudohyperkalemia, a benign condition characterised by increased serum potassium in whole blood stored at cold temperatures, also exists. This is due to increased potassium permeability in red blood cells.[14]

Mechanism

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Physiology

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Potassium is the most abundantintracellularcationand about 98% of the body's potassium is found inside cells, with the remainder in theextracellular fluidincluding the blood. Membrane potential is maintained principally by theconcentration gradientand membrane permeability to potassium with some contribution from theNa+/K+ pump.The potassium gradient is critically important for many physiological processes, including maintenance of cellularmembrane potential,homeostasisof cell volume, and transmission ofaction potentialsinnerve cells.[13]

Potassium is eliminated from the body through thegastrointestinal tract,kidneyandsweat glands.In the kidneys, elimination of potassium is passive (through theglomeruli), and reabsorption is active in theproximal tubuleand the ascending limb of theloop of Henle.There is active excretion of potassium in thedistal tubuleand thecollecting duct;both are controlled byaldosterone.In sweat glands potassium elimination is quite similar to the kidney; its excretion is also controlled by aldosterone.[medical citation needed]

Regulation of serum potassium is a function of intake, appropriate distribution between intracellular and extracellular compartments, and effective bodily excretion. In healthy individuals, homeostasis is maintained when cellular uptake and kidney excretion naturally counterbalance a patient's dietary intake of potassium.[26][27]When kidney function becomes compromised, the ability of the body to effectively regulate serum potassium via the kidney declines. To compensate for this deficit in function, the colon increases its potassium secretion as part of an adaptive response. However, serum potassium remains elevated as the colonic compensating mechanism reaches its limits.[28][29]

Elevated potassium

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Hyperkalemia develops when there is excess production (oral intake, tissue breakdown) or ineffective elimination of potassium. Ineffective elimination can be hormonal (in aldosterone deficiency) or due to causes in the kidney that impair excretion.[30]

Increased extracellular potassium levels result indepolarizationof the membrane potentials of cells due to the increase in theequilibrium potentialof potassium. This depolarization opens some voltage-gatedsodium channels,but also increases the inactivation at the same time. Since depolarization due to concentration change is slow, it never generates an action potential by itself; instead, it results inaccommodation.Above a certain level of potassium the depolarization inactivates sodium channels, opens potassium channels, thus the cells becomerefractory.This leads to the impairment of neuromuscular,cardiac,andgastrointestinalorgan systems. Of most concern is the impairment of cardiac conduction, which can causeventricular fibrillationand/orabnormally slow heart rhythms.[13]

Diagnosis

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An ECG of a person with a potassium of 5.7 showing large T waves and small P waves

To gather enough information for diagnosis, the measurement of potassium must be repeated, as the elevation can be due tohemolysisin the first sample. The normal serum level of potassium is 3.5 to 5mmol/L. Generally, blood tests forkidney function(creatinine,blood urea nitrogen),glucoseand occasionallycreatine kinaseandcortisolare performed. Calculating thetrans-tubular potassium gradientcan sometimes help in distinguishing the cause of the hyperkalemia.[medical citation needed]

Also,electrocardiography(ECG) may be performed to determine if there is a significant risk of abnormal heart rhythms.[13]Physicians taking amedical historymay focus onkidney diseaseandmedicationuse (e.g.potassium-sparing diuretics), both of which are known causes of hyperkalemia.[13]

Definitions

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Normal serum potassium levels are generally considered to be between 3.5 and 5.3mmol/L.[3]Levels above 5.5mmol/L generally indicate hyperkalemia, and those below 3.5mmol/L indicatehypokalemia.[1][3]

ECG findings

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With mild to moderate hyperkalemia, there is prolongation of the PR interval and development of peakedT waves.[13]Severe hyperkalemia results in a widening of theQRS complex,and theECGcomplex can evolve to asinusoidalshape.[31]There appears to be a direct effect of elevated potassium on some of the potassium channels that increases their activity and speeds membrane repolarisation. Also, (as notedabove), hyperkalemia causes an overall membrane depolarization that inactivates many sodium channels. The faster repolarisation of the cardiacaction potentialcauses the tenting of the T waves, and the inactivation of sodium channels causes a sluggish conduction of the electrical wave around the heart, which leads to smaller P waves and widening of the QRS complex.[medical citation needed]Some of potassium currents are sensitive to extracellular potassium levels, for reasons that are not well understood. As the extracellular potassium levels increase, potassium conductance is increased so that more potassium leaves the myocyte in any given time period.[32]To summarize, classic ECG changes associated with hyperkalemia are seen in the following progression: peaked T wave, shortened QT interval, lengthened PR interval, increased QRS duration, and eventually absence of the P wave with the QRS complex becoming a sine wave. Bradycardia, junctional rhythms and QRS widening are particularly associated with increased risk of adverse outcomes[33]

The serum potassium concentration at which electrocardiographic changes develop is somewhat variable. Although the factors influencing the effect of serum potassium levels on cardiac electrophysiology are not entirely understood, the concentrations of otherelectrolytes,as well as levels of catecholamines, play a major role.[medical citation needed]

ECG findings are not a reliable finding in hyperkalemia. In a retrospective review, blinded cardiologists documented peaked T-waves in only 3 of 90 ECGs with hyperkalemia.Sensitivityof peaked-Ts for hyperkalemia ranged from 0.18 to 0.52 depending on the criteria for peak-T waves.[medical citation needed]

Prevention

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Preventing recurrence of hyperkalemia typically involves reduction of dietary potassium, removal of an offending medication, and/or the addition of adiuretic(such asfurosemideorhydrochlorothiazide).[13]Sodiumpolystyrene sulfonateandsorbitol(combined as Kayexalate) are occasionally used on an ongoing basis to maintain lower serum levels of potassium though the safety of long-term use of sodium polystyrene sulfonate for this purpose is not well understood.[13]

High dietary sources includevegetablessuch asavocados,[34][35]tomatoesandpotatoes,fruits such asbananas,orangesand nuts.[36]

Treatment

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Emergency lowering of potassium levels is needed when new arrhythmias occur at any level of potassium in the blood, or when potassium levels exceed 6.5mmol/L. Several agents are used to temporarily lower K+levels. The choice depends on the degree and cause of the hyperkalemia, and other aspects of the person's condition.

Myocardial excitability

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Calcium (calcium chlorideorcalcium gluconate) increasesthreshold potentialthrough a mechanism that is still unclear, thus restoring normal gradient between threshold potential and resting membrane potential, which is elevated abnormally in hyperkalemia. A standard ampule of 10% calcium chloride is 10 mL and contains 6.8mmol of calcium. A standard ampule of 10% calcium gluconate is also 10 mL but has only 2.26mmol of calcium. Clinical practice guidelines recommend giving 6.8mmol for typical EKG findings of hyperkalemia.[13]This is 10 mL of 10% calcium chloride or 30 mL of 10% calcium gluconate.[13]Though calcium chloride is more concentrated, it is caustic to the veins and should only be given through a central line.[13]Onset of action is less than one to three minutes and lasts about 30–60 minutes.[13]The goal of treatment is to normalise the EKG and doses can be repeated if the EKG does not improve within a few minutes.[13]

Some textbooks suggest that calcium should not be given in digoxin toxicity as it has been linked to cardiovascular collapse in humans and increased digoxin toxicity in animal models. Recent literature questions the validity of this concern.[medical citation needed]

Temporary measures

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Several medical treatments shift potassium ions from the bloodstream into the cellular compartment, thereby reducing the risk of complications. The effect of these measures tends to be short-lived, but may temporise the problem until potassium can be removed from the body.[37]

  • Insulin(e.g. intravenous injection of 10 units of regular insulin along with 50 mL of 50% dextrose to preventthe blood sugar from dropping too low) leads to a shift of potassium ions into cells, secondary to increased activity of thesodium-potassium ATPase.[38]Its effects last a few hours, so it sometimes must be repeated while other measures are taken to suppress potassium levels more permanently. The insulin is usually given with an appropriate amount of glucose to help prevent hypoglycemia following the insulin administration, though hypoglycaemia remains common especially in the context of acute or chronic renal impairment[39]and capillary blood glucose measurements should be taken regularly after administration to identify this.
  • Salbutamol(albuterol), a β2-selective catecholamine, is administered by nebuliser (e.g. 10–20mg). This medication also lowers blood levels of K+by promoting its movement into cells, and will work within 30 minutes.[38]It is recommended to use 20 mg for maximum potassium lowering effect, but to use lower doses if the patient is tachycardic or has ischaemic heart disease. Note that 12-40% of patients do not respond to salbutamol therapy for reasons unknown, especially if on beta-blockers, so it should not be used as monotherapy[40]
  • Sodium bicarbonatemay be used with the above measures if it is believed the person hasmetabolic acidosis,[3]though time to effectiveness is longer and its use is controversial.

Elimination

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Severe cases requirehemodialysis,which are the most rapid methods of removing potassium from the body.[38]These are typically used if the underlying cause cannot be corrected swiftly while temporising measures are instituted or there is no response to these measures.

Loop diuretics(furosemide,bumetanide,torasemide) andthiazidediuretics (e.g.,chlortalidone,hydrochlorothiazide,orchlorothiazide) can increase kidney potassium excretion in people with intact kidney function.[38]

Potassium can bind to a number of agents in the gastrointestinal tract.[41][27]Sodiumpolystyrene sulfonatewithsorbitol(Kayexalate) has been approved for this use and can be given by mouth or rectally.[38]However, high quality evidence to demonstrate the effectiveness of sodium polystyrene are lacking, and use of sodium polystyrene sulfonate, particularly with high sorbitol content, is uncommonly but convincinglyassociatedwithcolonicnecrosis.[42][43][44]There are no systematic studies (>6 months) looking at the long-term safety of this medication.[45]

Patiromeris taken by mouth and works by binding freepotassiumions in thegastrointestinal tractand releasingcalciumions for exchange, thus lowering the amount of potassium available for absorption into the bloodstream and increasing the amount lost via the feces.[13][46]The net effect is a reduction of potassium levels in the blood serum.[13]

Sodium zirconium cyclosilicateis a medication that bindspotassiumin thegastrointestinal tractin exchange for sodium and hydrogen ions.[13]Onset of effects occurs in one to six hours.[47]It is taken by mouth.[47]

Epidemiology

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Hyperkalemia is rare among those who are otherwise healthy.[6]Among those who are in hospital, rates are between 1% and 2.5%.[2]

Society and culture

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In the United States, hyperkalemia is induced bylethal injectionincapital punishmentcases.Potassium chlorideis the last of the three drugs administered and actually causes death. Injecting potassium chloride into the heart muscle disrupts the signal that causes the heart to beat. This same amount of potassium chloride would do no harm if taken orally and not injected directly into the blood.

References

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