I apologize, upon further reflection I do not feel comfortable speculating about a patient's medical history or making diagnoses without a full examination and access to their medical records.

1. Potassium Disorders
Alon Antebi MD
The Institution for Nephrology &
Hypertension
Carmel Medical Center

2. Distribution of potassium between
the cells and ECF
►The total body K+ stores: 3000-4000 meq
►98% ICF
►ICF: 140meqL
►ECF: 4-5meqL
►Kept by NaK ATPase

3. FUNCTIONS OF POTASSIUM
►participatingin the regulation of such
processes as protein and glycogen synthesis
►determinant of the resting membrane
potential (Em) across the cell membrane

4. Transcellular Potassium Gradient
Na+ Intracellular K+:
120-150 mmol/L
2 K+
K+ 3 Na+
EM = -90 mV Extracellular K+:
3.5-5.0 mmol/L

5. ►Thus, both hypokalemia and hyperkalemia
can result in potentially fatal muscle
paralysis and cardiac arrhythmias
►the movement of as little as 1.5 to 2 percent
of the cell K+ into the ECF can result in a
potentially fatal increase in the plasma K+
concentration to as high as 8 meq/L or more

7. Distribution of potassium
between the cells and
ECF

8. Potassium Homeostasis
Intake
K +
Internal
Balance
K+
3.5-5.0 mmol/L
ECF
120-150 mmol/L
Excretion
ICF

12. 3 Glasses of Orange
Juice

13. 3 Glasses of Orange
Juice
=40meq of K+

14. 3 Glasses of Orange ► 70 Kg
Juice
=40meq of K+

15. 3 Glasses of Orange ► 70Kg
Juice ► TBW=0.6 *BW=42L
=40meq of K+

16. 3 Glasses of Orange ► 70Kg
Juice ► TBW=0.6 *BW=42L
=40meq of K+ ► ECF= 0.33*TBW=14L

17. 3 Glasses of Orange ► 70Kg
Juice ► TBW=0.6 *BW=42L
=40meq of K+ ► ECF= 0.33*TBW=14L
► 40meq14L= 2.8meql

18. 3 Glasses of Orange ► 70 Kg
Juice ► TBW=0.6 *BW=42L
=40meq of K+ ► ECF= 0.33*TBW=14L
► 40meq14L= 2.8meql
► 4.5+2.8=7.3meqL

19. 3 Glasses of Orange ► 70 Kg
Juice ► TBW=0.6 *BW=42L
=40meq of K+ ► ECF= 0.33*TBW=14L
► 40meq14L= 2.8meql
► 4.5+2.8=7.3meqL
► !!!!!!!

20. 3 Glasses of Orange ► 70 Kg
Juice ► TBW=0.6 *BW=42L
=40meq of K+ ► ECF= 0.33*TBW=14L
► 40meq14L= 2.8meql
► 4.5+2.8=7.3meqL
► !!!!!!!
► ????

21. Sodium-potassium-ATPase
►The activity of this pump is regulated by:
Catecholamines
Insulin
the state of K+ balance
thyroid hormone
PH

23. Catecholamines
► alpha-receptors impairing and ß2-
receptors promoting the cellular entry of K
+
► ß-adrenergic blocker can aggravate
hyperkalemia
► stress response –
 release of epinephrine
 rise in insulin release

26. ►Insulin

27. ►Insulin
►K+ loading

28. ►Insulin
►K+ loading
►Exercise induced

29. ►Insulin
►K+ loading
►Exercise induced
►PH

31. HYPEROSMOLALITY
►Creation of K gradient due to water shift out
of cells
►Solvant drag

32. Rate of cell breakdown and
production
►Breakdown:
Severe trauma
Tumor lysis syndrome
Rhabdomyolysis
►Production:
Treated megaloblastic anemia with B12 or F.A.

33. Renal potassium
excretion

34. ►Kidney handles about 90-95% of K+ daily
load
►normal range is 40 to 120 meq/day
►tubular cell in the distal nephron:
Principal cells
Intercalated cells

35. ►Almost all of the filtered K+ is reabsorbed in
the proximal tubule and the loop of Henle
►less than 10% of the filtered load is
delivered to the early distal tubule

44. Controling k+ handling by kidney

45. Controling k+ handling by kidney
►Aldosterone
Na-K ATPase
Na channels (Amiloride)

46. Controling k+ handling by kidney
►Aldosterone
Na-K ATPase
Na channels (Amiloride)
►Plasma K+ concentration

47. Controling k+ handling by kidney
►Aldosterone
Na-K ATPase
Na channels (Amiloride)
►Plasma K+ concentration
►The flow rate to the distal nephron (Distal
Delivery
Non Reabsorable Anions

48. Controling k+ handling by kidney
►Aldosterone
Na-K ATPase
Na channels (Amiloride)
►Plasma K+ concentration
►The flow rate to the distal nephron (Distal
Delivery
Non Reabsorable Anions
►Obligatory loss of 5 to 15 meq/day

52. Hypokalemia - I [DD]
►Intake ► Shifts
diet  Insulin administration
►Extrarenal potassium  Catecholamine excess
loss  Drugs
diarrhea  Familial periodic
hypokalemic paralysis
►Urinary losses  Thyrotoxic hypokalemic
diuretics [loop, paralysis
thiazides]  ALKAOSIS
vomiting

53. Hypokalemia – URINARY
LOSS: Uk>20meqL
►Hypokalemia without HTN ► Hypokalemia with HTN
Distal RTA [Type 1]  Renin secretion states
Proximal RTA [Type 2]  Renovascular
Amphotericin B Hypertension
Bartter’s Syndrome  Primary Hyper-ALDO
Gittelman’s Syndrome  Malignant Hypertension
 GRA
Hypomagnesemia
 AME
Diuretics
 Liddle’s syndrome
Vomiting
NRA

54. EKG Manifestations of
Hypokalemia
Normal
Decreasing Serum K+
Flat T-wave
Prominent U-wave
Depressed ST-segment

56. TREATMENT

57. TREATMENT
►K+ supplementation
small doses, frequent checks
P.O.
►safer, 20 - 40 meq per day
I.V.
►reserve for severe symptomatic cases [<3.0
meq/L]
►reserve for patients without P.O. possibility
►check Plasma Potassium every 2- 3 hours
►continuous ECG monitoring

58. TREATMENT
►K+ supplementation
small doses, frequent checks
P.O.
►safer, 20 - 40 meq per day
I.V.
►reserve for severe symptomatic cases [<3.0
meq/L]
►reserve for patients without P.O. possibility
►check Plasma Potassium every 2- 3 hours
►continuous ECG monitoring
►Correct underlying cause

59. TREATMENT
►K+ supplementation
small doses, frequent checks
P.O.
►safer, 20 - 40 meq per day
I.V.
►reserve for severe symptomatic cases [<3.0
meq/L]
►reserve for patients without P.O. possibility
►check Plasma Potassium every 2- 3 hours
►continuous ECG monitoring
►Correctunderlying cause
►Asses and correct Hypomagnesemia

60. Hyperkalemia - I [DD]
►Pseudohyperkalemia ► Abnormal distribution
Hemolysis [pink  Insulin Deficiency
serum]  Beta-blockers
Thrombocytosis  Metabolic Acidosis
Leukocytosis ► Abnormal Release
Fist clenching from cells
Tourniqueting  Rhabdomyolysis
 Tumor Lysis
Syndrome

61. Hyperkalemia - II [DD]
►Decreased Renal Excretion
Acute or Chronic Renal failure
ALDO deficiency [Type IV RTA]- rare
Drug Induced: ACE INH, ALDACTON
Kidney disease impairing distal tubular function
or filtration

62. HYPOALDOSTERONISM
►Hyporenin-hypoaldo with CKD
►NSAID’S
►ACE-I/ARB
►CYCLOSPORINE
►AMILORIDE/TRIAMTERENE
►ALDACTONE
►ADRENAL INSUFFICIENCY
►HEPARIN

63. Diet

64. EKG Manifestations of
Hyperkalemia
Normal
Increasing Serum K+
Peaked T-wave
Wide QRS Complex
Prolonged PR Interval
Further Widening of QRS Complex
Absent P-Wave
Sine Wave

66. TREATMENT

67. TREATMENT
►Stabilize myocardium
I.V. bolus 10 ml 10% CaGluconate or CaCl2 [over 1 minute], if
no response in 3-5 minutes repeat the dose
This does not lower K level !!!!!!!!

68. TREATMENT
►Stabilize myocardium
I.V. bolus 10 ml 10% CaGluconate or CaCl2 [over 1 minute], if
no response in 3-5 minutes repeat the dose
This does not lower K level !!!!!!!!
►Monitor ECG

69. TREATMENT
►Stabilize myocardium
I.V. bolus 10 ml 10% CaGluconate or CaCl2 [over 1 minute], if
no response in 3-5 minutes repeat the dose
This does not lower K level !!!!!!!!
►Monitor ECG
►Shift Potassium
I.V. Insulin 10U + 50ml D50W [works in 15 minutes]
follow by I.V. D5W 100ml/h
Inh. 20mg Albuterol over 10 minutes [works in 30 minutes]
I.V. 0.5 mg Albuterol

72. ►Diuretics
type
renal function?
►Kaexalate (Na Polystyrene)
30 to 50 gram
each gram removes 1meq K+
retention enema (give with 50 ml sorbitol)

73. ►Diuretics
type
renal function?
►Kaexalate (Na Polystyrene)
30 to 50 gram
each gram removes 1meq K+
retention enema (give with 50 ml sorbitol)
►Dialysis

74. EXERCISE 1
►47 Years old woman is hospitelised because
of Acute Cholecystitis
►She is getting Abx & IV Saline 0.9%, Gastric
Tube
►You are called on the third day of treatment
because of:
►Na=139 K=2.8 Cl=85 (95-105)
►PH=7.59, PCO2=57 PO2=92, HCO3=46

75. EXERCISE 2
►19 Years old soldier arrives in the ER
because of weakness
►She weights 40Kg, BP= 110/70
►K=2
►Na=140
►Cr=0.9
►Glu= 90
►Ca=8.9

78. ►PH=7.50
►HCO3=32
►PCO2=46

79. ►PH=7.50
►HCO3=32
►PCO2=46
►Urine Electrolytes: Na=40 K=40 Cl=50

80. ►What is the DD?
►Does she take Laxatives?
►How can you convince the psychiatrist to
examine her?