Hypokalemia

45 y/o female Department of Agriculture field inspector Stayed in Baguio 3 months Chronic diarrhea 3 weeks Progressive weakness past 3 days

Laboratory Findings

Diagnostic approach to Hypokalemia

Urinary K+ Excretion < 15mmol/d Assess acid-base status

Arterial Blood Gas Profile:

Urine Potassium: 15 meq/L (NV: usually >15 meq/L)

Metabolic Acidosis

Metabolic Alkalosis

Urine Potassium 15 meq/L

Lower gastrointestinal K+ loss

Remote diuretic use Remote vomiting K+ loss via sweat

Diagnostic approach to Hypokalemia Urinary K+

Excretion > 15 mmol/d

Diagnostic approach to Hypokalemia

Acid base status Metabolic acidosis Metabolic alkalosis

Assess K+ secretion Diabetic ketoacidosis Proximal ( type 2) RTA Distal ( type 1) RTA Amphotericin B Hypertension?

TTKG > 4

TTKG < 2

YES Mineralocorticoid excess Liddles symdrome

NO Vomiting Bartters syndrome Exclude diuretic abuse Hypomagnesemia

Acid base status

Na+ wasting nephropathy Osmotic diuresis Diuretic

Cause of Hypokalemia in this Patient

Lower gastrointestinal loss Chronic diarrhea Metabolic acidosis loss of HCO3 in stool

Signs and Symptoms

Clinical Features Signs & Symptoms

Signs and symptoms manifest when Plasma K < 3 mEq/L Fatigue, myalgia, muscular weakness of the LE
Most common complaints Due to lower (more negative) resting membrane potential

Clinical Features Signs & Symptoms

Palpitations Constipation Abdominal pain Nausea and vomiting Polyuria
Due to decreased ability of the kidney to concentrate urine

Polydipsia

Clinical Features Signs & Symptoms

Hypotension Paralytic ileus Ventricular arrythmias Bradycardia or tachycardia Premature atrial or ventricular beats Glucose intolerance
Impaired insulin secretion or peripheral insulin resistance

Clinical Features Signs & Symptoms

More severe hypoK+
Progressive weakness Hypoventilation, respiratory failure (respiratory muscle involvement) Complete paralysis Lethargy or other mental status changes (due to renal ammoniagenesis) Rhabdomyolysis (impaired muscle metabolism, blunted hyperemic response to exercise -> profound K+ depletion)

Adverse medical implications

Neuromuscular Effects

Adverse medical Implications

- muscle weakness and paralysis (due to more negative membrane potential) - Rhabdomyolysis - Ileus of the gut

Adverse medical implications

Respiratory
Hypoventilation due to respiratory muscle involvement

Adverse medical implications

Cardiac ECG Changes
Due to delayed ventricular repolarization Early changes
Flattening or inversion of the T wave Prominent U wave ST-segment depression Prolonged QU interval

Late changes
Prolonged PR interval Decreased voltage and widening of the QRS complex

Cardiac effects

Adverse medical implications

Adverse medical implications

Cardiac
Increased risk for ventricular arrythmias Potential digitalis toxicity Risk for Hypertension

A: Normal B: flattening of T wave C-F:U wave, ST-depression, prolonged QU interval

Adverse medical implications

Metabolic Effects
Glucose intolerance- Hypokalemia suppresses insulin release. Intracellular acidosis Increased renal ammonia production - may worsen encephalopathy in patients with liver cirrhosis

Adverse medical implications

Renal Effects
Mild Nephrogenic Diabetes Insipidus (NDI) Defective activation of adenylate cyclase = decrease effect of vasopressin Prolonged hypokalemia causes proteinuria, proximal renal tubule vaculization, interstitial fibrosis and possibly decreased renal blood flow and glomerular filtration rate. Hypokalemia stimulates acid secretion by the kidney as well as production of the urinary buffer ammonia thus potentially causing alkalinization of the blood (metabolic alkalosis)

Significance of Urinary K+ Levels

What is the significance of urinary K+ levels?

Renal excretion is the major route of elimination of dietary and other sources of excess potassium. In diarrhea, there is stimulation of colonic secretion of K+ resulting to its depletion.

Urinary Potassium
Normal Value: 25-100 meq/L The appropriate response to K+ depletion is to excrete less than 15 mmol/d of K+ in the urine ( reabsorption, distal secretion) Determining the urinary K+ levels would point out to the possible etiology of the hypokalemia.

Urinary Potassium
< 15 mmol/d Assess acid-base status Metabolic acidosis Metabolic alkalosis

Lower gastrointestinal K+ loss

Remote diuretic use Remote vomiting K+ loss via sweat

Treatment
Therapeutic goals To correct K+ deficit To minimize ongoing losses

Treatment

Treatment
It is safer to correct hypokalemia via oral route in order to prevent rebound hyperkalemia if given IV

Mild or moderate hypokalemia

Potassium of 2.5-3.5 mEq/L Oral potassium replacement therapy If cardiac arrhythmias or significant symptoms are present, then more aggressive therapy is warranted.

The plasma potassium concentration should be monitored frequently when assessing the response to treatment

Severe hypokalemia
Potassium level is less than 2.5 mEq/L IV potassium should be given (KCl) Maximum concentration of administered K+
Peripheral vein: no more than 40 mmol/L Central vein: no more than 60 mmol/L

THANK YOU!!!

Rate of infusion should not exceed 20mmol/h unless paralysis or malignant ventricular arrhythmias are present.