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APPROACH TO HYPOKALEMIA Dr.M.EDWIN FERNANDO Associate Professor & Head  Department of Nephrology Chengalpattu Medical Coll...
Goals of this talk . . . <ul><li>SESSION OBJECTIVES </li></ul><ul><ul><li>Learn to effectively assess & manage hypokalemia...
<ul><li>Big head - Think big </li></ul><ul><li>Big ears - listen patiently </li></ul><ul><li>Narrow eyes - Watch deeply  <...
POTASSIUM. . .  <ul><li>Most abundant cation in the human body </li></ul><ul><li>Atomic no.:19 </li></ul><ul><li>Molecular...
POTASSIUM. . . <ul><li>Intracellular K +  concentration : 140 meq/l </li></ul><ul><li>Extracellular concentration : 4-5 me...
POTASSIUM METABOLISM
 
 
K HOMEOSTASIS – KEY HORMONES Gennari FJ,NEJM,339:451-458:1998
Na & K transport in P cell in CCD www.uptodate.com
ALDOSTERONE ACTION IN PRINCIPAL CELLS
Hypokalemia Overview <ul><li>Plasma K < 3.5 mEq/L </li></ul><ul><li>Occurs in > 20% of hospitalized patients </li></ul><ul...
HYPOKALEMIA <ul><li>Clinical manifestations determine urgency & magnititude of treatment, not laboratory values </li></ul>...
HYPOKALEMIA – CLINICAL MANIFESTATIONS <ul><li>CVS  : ECG changes,atrial/ventricular arrhythmias,digitoxicity </li></ul><ul...
HYPOKALEMIA – RENAL EFFECTS <ul><li>Impaired concentrating ability – polyuria & polydipsia – Nephrogenic DI </li></ul><ul>...
PSEUDOHYPOKALEMIA <ul><li>Abnormal WBCs – in large numbers(AML) – can take up extracellular K when stored at room temp </l...
HYPOKALEMIA - CAUSES <ul><li>DRUGS </li></ul><ul><li>GI LOSS :  Vomiting,NG suction,diarrohea </li></ul><ul><li>SKIN : Pro...
HYPOKALEMIA – DRUG INDUCED Phenolphthalein Na polystrene sulfonate  Acetazolamide Thiazides Loop diuretics Fludrocortisone...
HYPOKALEMIA - ECG <ul><li>ST depressions with prominent U waves & prolonged repolarization </li></ul>
HYPOKALEMIA - ECG <ul><li>Prominent U wave in V3 & V4 giving the conjoined T- U wave the appearance of &quot;camel's hump&...
HYPOKALEMIA -  STEPWISE APPROACH
TTKG
TTKG
Transtubular Potassium Gradient <ul><li>TTKG =  Uk x Posm     Sk x Uosm   </li></ul><ul><li>During hypokalemia -TTKG shoul...
 
Approach to Hypokalemia <ul><li>Step 1 : Redistribution or depletion? </li></ul><ul><ul><li>Redistribution causes </li></u...
Approach to Hypokalemia <ul><li>Step 1 : Redistribution or depletion? </li></ul><ul><ul><li>Depletion causes (common) </li...
Approach to Hypokalemia <ul><li>Step 2 : Estimate the deficit </li></ul><ul><ul><li>For every 100 mEq below normal, serum ...
 
HYPOKALEMIA & TOTAL K DEFICIT Sterns RH, Medicine 60:339-354:1981 500 -750 300-600 150-400 125 -250 TOTAL K deficit  (mEq/...
Approach to Hypokalemia <ul><li>Step 3: Choose route to replace K + </li></ul><ul><ul><li>In nearly all situations, ORAL r...
Approach to Hypokalemia <ul><li>Step 4:  Choose K +  preparation </li></ul><ul><ul><li>Oral therapy </li></ul></ul><ul><ul...
Approach to Hypokalemia <ul><li>Step 4 (con’t):  Choose K +  prep </li></ul><ul><ul><li>IV therapy </li></ul></ul><ul><ul>...
Approach to Hypokalemia <ul><li>Step 5:  Choose dose/timing </li></ul><ul><ul><li>Mild/moderate hypokalemia </li></ul></ul...
Approach to Hypokalemia <ul><li>Step 5 (con’t):  Choose dose/timing </li></ul><ul><ul><li>Severe hypokalemia (< 3.0 mEq/L)...
Approach to Hypokalemia <ul><li>Step 6:  Monitor/reassess </li></ul><ul><ul><li>Severe hypokalemia, DKA patients </li></ul...
K CONCENTRATION OF IV FLUIDS 4 10 17 20 35 K(mEq/L) RL Iso E Iso G Iso P Iso M IV Fluid
Approach to Hypokalemia <ul><li>Step 7:  Housekeeping/follow up </li></ul><ul><ul><li>BE AGGRESSIVE  in DKA patients & IV ...
Hypokalemia – TAKE CARE . . . <ul><li>Monitor IV K – ECG & S.K levels </li></ul><ul><li>Never give IV push </li></ul><ul><...
K RICH FOOD <ul><li>Fruit juices </li></ul><ul><li>Tender coconut water </li></ul><ul><li>Banana </li></ul><ul><li>Juicy f...
ACID – BASE DISORDERS IN HYPOKALEMIA Liddle, Bartter, Gitelman syndromes Penicillin derivatives Salt-wasing nephropathy Mi...
HYPOKALEMIA & ABG
 
HYPOKALEMIA & CONTRACTION ALKALOSIS
UCl IN METABOLIC ALKALOSIS &    K
 
HYPOKALEMIA,HT,METABOLIC ALKALOSIS - DIFFERENTIALS
 
HYPOKALEMIC METABOLIC ALKALOSIS WITHOUT HT
HYPOKALEMIA & PARALYSIS
Ok, You Think You Got It??? <ul><li>Let’s try it out on some cases </li></ul><ul><ul><li>Real cases from real patients  </...
Case 1 <ul><li>30,F </li></ul><ul><li>Diarrohea,muscle weakness </li></ul><ul><li>ECG – s/o hypokalemia </li></ul><ul><li>...
Case1 - discussion <ul><li>Hypokalemic metabolic acidosis due to diarrohea </li></ul><ul><li>Correct hypokalemia first </l...
Case 2 <ul><li>36 F </li></ul><ul><li>Diuretics – twice weekly </li></ul><ul><li>HT,JVP – 5cm,skin turgor   </li></ul><ul...
Case 2 - discussion <ul><li>HT,Hypokalemic Metabolic Alkalosis & kaliuresis – PRIMARY HYPERALDOSTERONISM </li></ul><ul><li...
Case 3 <ul><li>22,F </li></ul><ul><li>Weakness – persistent </li></ul><ul><li>O/E – NAD </li></ul><ul><li>LABS – Na 136, K...
Case 3 discussion <ul><li>Low UK – extra renal loss </li></ul><ul><li>Low UNa – volume depletion </li></ul><ul><li>Metabol...
Case 4 <ul><li>22,F </li></ul><ul><li>Easy fatigability & weakness </li></ul><ul><li>LABS – Na 141, K 2.1 ,Cl 85,  Bicarb ...
Case 4 - discussion <ul><li>Unexplained   K, UK wasting & metabolic alkalosis –  diuretic use,  vomiting,  primary hypera...
Case 5 <ul><li>S.K 2.7 </li></ul><ul><li>Bicarb 27 </li></ul><ul><li>PH 7.43 </li></ul><ul><li>UK 10 </li></ul><ul><li>Uos...
Case 6 <ul><li>S.K 2.7 </li></ul><ul><li>Bicarb 27 </li></ul><ul><li>Ca 7.3 </li></ul><ul><li>Alb 4.1 </li></ul><ul><li>Ph...
Case 7 <ul><li>S.K 2.7 </li></ul><ul><li>Bicarb 14 </li></ul><ul><li>Ph 7.28 </li></ul><ul><li>UK 52 </li></ul><ul><li>Uri...
<ul><li>ODUVANTHALAI leaves - Cleistanthus collinus  is an extremely toxic plant poison  </li></ul><ul><li>Cleistanthin A ...
Primary Sjögrens Syndrome Presenting with Distal Renal Tubular Acidosis & Rhabdomyolysis EBS Prakash,  M.Edwin Fernando , ...
CASE 10
 
GITELMAN  SYNDROME
HYPOKALEMIA IN LEPTOSPIROSIS <ul><li>Hypokalemia – 26 to 40%  Seguro AC,Nephron 55:146-151,1990 </li></ul><ul><li>Kaliurei...
 
HYPOKALEMIA  Recap of Major Learning Points <ul><ul><li>Minimise hypokalemia – adequate intake </li></ul></ul><ul><ul><li>...
Dr.M.A. Muthusethupathi Dr.M.Jayakumar Dr.R.Vijayakumar Dr.N.Gopalakrishnan THANKS . . .
 
Potassium Balance:  Critical for Excitable Heart & Nervous Tissues Figure 20-4: Osmolarity changes as fluid flows through ...
Low Renin Low Aldosterone Cortisol Ectopic ACTH Cushing syndrome Liddle’s Licorice AME DOC 11    hydorxylase D 17    hyd...
 
References <ul><li>Cody RJ, Pickworth KK: Approaches to diuretic therapy and electrolyte imbalance in congestive heart fai...
Gitelman’s H
 
HYPOKALEMIA & METABOLIC ALKALOSIS
Lin SH et al. Am J Emerg Med 2003   Blood pressure Renin Renin Aldo K + excretion rate and acid - base status ? H H y y p ...
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CME - Hypokalemia

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CME - Hypokalemia

  1. 1. APPROACH TO HYPOKALEMIA Dr.M.EDWIN FERNANDO Associate Professor & Head Department of Nephrology Chengalpattu Medical College
  2. 2. Goals of this talk . . . <ul><li>SESSION OBJECTIVES </li></ul><ul><ul><li>Learn to effectively assess & manage hypokalemia </li></ul></ul><ul><ul><li>Apply your knowledge to real cases! </li></ul></ul><ul><li>LEARNING METHODS </li></ul><ul><ul><li>Lecture/material review </li></ul></ul><ul><ul><li>Interactive case scenarios </li></ul></ul><ul><ul><li>Practical approach to handling hypokalemia in MOST hospitalized patients </li></ul></ul><ul><li>Guideline for supplementing K based on some evidence-based medical recommendations </li></ul>
  3. 3. <ul><li>Big head - Think big </li></ul><ul><li>Big ears - listen patiently </li></ul><ul><li>Narrow eyes - Watch deeply </li></ul><ul><li>Long nose - Poke around inquisitively </li></ul><ul><li>Small mouth - Speak less & listen more </li></ul>
  4. 4. POTASSIUM. . . <ul><li>Most abundant cation in the human body </li></ul><ul><li>Atomic no.:19 </li></ul><ul><li>Molecular weight : 39 </li></ul><ul><li>Maintenance of k balance – essential for a variety of cellular functions & neuromuscular transmission </li></ul><ul><li>Total body stores : 3000 – 4000mEq </li></ul><ul><li>98% - located in the cells </li></ul>
  5. 5. POTASSIUM. . . <ul><li>Intracellular K + concentration : 140 meq/l </li></ul><ul><li>Extracellular concentration : 4-5 meq/l </li></ul><ul><li>Difference is maintained by the Na + -K + -ATPase </li></ul><ul><li>Ratio of K + concentration inside cell & outside - major determinant of resting membrane potential </li></ul><ul><li>Participates – protein & glycogen synthesis </li></ul>
  6. 6. POTASSIUM METABOLISM
  7. 9. K HOMEOSTASIS – KEY HORMONES Gennari FJ,NEJM,339:451-458:1998
  8. 10. Na & K transport in P cell in CCD www.uptodate.com
  9. 11. ALDOSTERONE ACTION IN PRINCIPAL CELLS
  10. 12. Hypokalemia Overview <ul><li>Plasma K < 3.5 mEq/L </li></ul><ul><li>Occurs in > 20% of hospitalized patients </li></ul><ul><li>May be asymptomatic </li></ul><ul><li>Usually does not require emergency supplementation over minutes to hours </li></ul><ul><li>Can be dangerous - arrhythmias, rhabdomyolysis, paralysis </li></ul>
  11. 13. HYPOKALEMIA <ul><li>Clinical manifestations determine urgency & magnititude of treatment, not laboratory values </li></ul><ul><li>Frequent reassessment of K required </li></ul><ul><li>ABG - useful </li></ul>
  12. 14. HYPOKALEMIA – CLINICAL MANIFESTATIONS <ul><li>CVS : ECG changes,atrial/ventricular arrhythmias,digitoxicity </li></ul><ul><li>SKELETAL MUSCLE : Weakness,cramps,tetany,paralysis, rhabdomyolysis </li></ul><ul><li>SMOOTH MUSCLE : Constipation,Ileus,urinary retention </li></ul><ul><li>ENDOCRINE : Carbohydrate intolerance </li></ul>
  13. 15. HYPOKALEMIA – RENAL EFFECTS <ul><li>Impaired concentrating ability – polyuria & polydipsia – Nephrogenic DI </li></ul><ul><li>Impaired ammonia production – hepatic failure </li></ul><ul><li>Impaired urinary acidification </li></ul><ul><li>Renal insufficiency -  RBF,GFR </li></ul><ul><li>Cl wasting/Metabolic alkalosis </li></ul><ul><li>Renal cyst formation </li></ul><ul><li>Tubular vacuolization </li></ul><ul><li>Interstitial nephritis </li></ul>
  14. 16. PSEUDOHYPOKALEMIA <ul><li>Abnormal WBCs – in large numbers(AML) – can take up extracellular K when stored at room temp </li></ul><ul><li>Apparent hypokalemia – artefact of storage procedure </li></ul><ul><li>Rapid separation of plasma/storing at 4 deg C – confirms diagnosis, avoids this artefact & inappropriate Rx Kamel KS,1996 </li></ul>
  15. 17. HYPOKALEMIA - CAUSES <ul><li>DRUGS </li></ul><ul><li>GI LOSS : Vomiting,NG suction,diarrohea </li></ul><ul><li>SKIN : Profuse sweating,extensive burns </li></ul><ul><li>HORMONES : Aldosterone,Steroids, RVH Malignant HT,Renin secreting tumors,CAH </li></ul><ul><li>BICARBONATURIA : d RTA,Rx of p RTA,Rx of met. Alkalosis </li></ul><ul><li>MAGNESIUM DEFICIENCY </li></ul><ul><li>INTRINSIC RENAL TRANSPORT DEFECTS : Bartter´s,Gitelman´s,Liddle´s syndromes </li></ul>
  16. 18. HYPOKALEMIA – DRUG INDUCED Phenolphthalein Na polystrene sulfonate Acetazolamide Thiazides Loop diuretics Fludrocortisone Pencillin Aminoglycoside Amphotericin B Cisplatin Epinephrine Pseudoephedrine Salbutomol Theophylline Ritodrine Verapamil Chloroquine Insulin overdose  K LOSS IN STOOL  RENAL K LOSS TRANSCELLULAR K SHIFT
  17. 19. HYPOKALEMIA - ECG <ul><li>ST depressions with prominent U waves & prolonged repolarization </li></ul>
  18. 20. HYPOKALEMIA - ECG <ul><li>Prominent U wave in V3 & V4 giving the conjoined T- U wave the appearance of &quot;camel's hump&quot; </li></ul><ul><li>&quot;apparently&quot; prolonged QT interval in S2 & AVF - due to the T wave is actually a U wave with a flattened T wave merging into the following U wave – &quot;roller coaster effect &quot; </li></ul>
  19. 21. HYPOKALEMIA - STEPWISE APPROACH
  20. 22. TTKG
  21. 23. TTKG
  22. 24. Transtubular Potassium Gradient <ul><li>TTKG = Uk x Posm Sk x Uosm </li></ul><ul><li>During hypokalemia -TTKG should fall <3 - indicating appropriately reduced urinary excretion of K </li></ul><ul><li>TTKG > 4 – indicates renal K loss is due to increased distal K secretion Ethier JH, Am. J. Kidney Dis. 15 (4): 309–15,1990 </li></ul>
  23. 26. Approach to Hypokalemia <ul><li>Step 1 : Redistribution or depletion? </li></ul><ul><ul><li>Redistribution causes </li></ul></ul><ul><ul><ul><li>Insulin therapy - DKA </li></ul></ul></ul><ul><ul><ul><li>Beta 2 agonists - Salbutomol </li></ul></ul></ul><ul><ul><ul><li>Metabolic alkalosis </li></ul></ul></ul><ul><ul><ul><li>Beta 2 adrenergic stimulation – AMI </li></ul></ul></ul><ul><ul><ul><li> cell proliferation – Rx of megaloblastic anemia </li></ul></ul></ul><ul><ul><ul><li>Barium poisoining </li></ul></ul></ul><ul><ul><li>Replacement of potassium in these settings may lead to overshoot & hyperkalemia </li></ul></ul>
  24. 27. Approach to Hypokalemia <ul><li>Step 1 : Redistribution or depletion? </li></ul><ul><ul><li>Depletion causes (common) </li></ul></ul><ul><ul><ul><li>GI tract losses (diarrhea, vomiting) </li></ul></ul></ul><ul><ul><ul><li>Loop/thiazide diuretic therapy </li></ul></ul></ul><ul><ul><ul><li>Other medications (e.g. amphotericin B) </li></ul></ul></ul><ul><ul><ul><li>Osmotic diuresis (DKA) </li></ul></ul></ul><ul><ul><ul><li>Refeeding syndrome ( NEVER underestimate!) </li></ul></ul></ul><ul><ul><ul><li>Endocrinopathies (mineralocorticoid excess) </li></ul></ul></ul><ul><ul><ul><li>Salt wasting nephropathies/RTA’s </li></ul></ul></ul><ul><ul><ul><li>Magnesium deficiency ( NEVER overlook!) </li></ul></ul></ul>
  25. 28. Approach to Hypokalemia <ul><li>Step 2 : Estimate the deficit </li></ul><ul><ul><li>For every 100 mEq below normal, serum K + usually drops by 0.3 mEq/L </li></ul></ul><ul><ul><ul><li>Highly variable from patient to patient, however!! </li></ul></ul></ul>
  26. 30. HYPOKALEMIA & TOTAL K DEFICIT Sterns RH, Medicine 60:339-354:1981 500 -750 300-600 150-400 125 -250 TOTAL K deficit (mEq/L,70 kg) <2 2 3 3.5 S.K (mEq/L)
  27. 31. Approach to Hypokalemia <ul><li>Step 3: Choose route to replace K + </li></ul><ul><ul><li>In nearly all situations, ORAL replacement is PREFERRED over IV replacement </li></ul></ul><ul><ul><ul><li>Oral is quicker </li></ul></ul></ul><ul><ul><ul><li>Oral has less side effects (IV burns!) </li></ul></ul></ul><ul><ul><ul><li>Oral is less dangerous </li></ul></ul></ul><ul><ul><li>Choose IV therapy ONLY in patients who are NPO (for whatever reason) or who have severe depletion </li></ul></ul>
  28. 32. Approach to Hypokalemia <ul><li>Step 4: Choose K + preparation </li></ul><ul><ul><li>Oral therapy </li></ul></ul><ul><ul><ul><li>Potassium Chloride is PREFERRED AGENT </li></ul></ul></ul><ul><ul><ul><ul><li>Especially useful in Cl - responsive metabolic alkalosis </li></ul></ul></ul></ul><ul><ul><ul><ul><li> in ECF K quicker with KCl compared to other salts </li></ul></ul></ul></ul><ul><ul><ul><li>Potassium Phosphate useful when coexistant phosphorus deficiency </li></ul></ul></ul><ul><ul><ul><ul><li>Often useful in DKA patients </li></ul></ul></ul></ul><ul><ul><ul><li>Potassium bicarbonate, acetate, gluconate, or citrate useful in metabolic acidosis </li></ul></ul></ul>ORAL POTTASIUM CHLORIDE SOLUTION 15 ML  20 mEq/L
  29. 33. Approach to Hypokalemia <ul><li>Step 4 (con’t): Choose K + prep </li></ul><ul><ul><li>IV therapy </li></ul></ul><ul><ul><ul><li>Adjunct to maintenance fluids (10-20 mEq/L) </li></ul></ul></ul><ul><ul><ul><ul><li>“ The surgical intern’s way” </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Try to avoid using it!!! </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>you often forget it’s there </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>hyperkalemia can then develop, especially in patients that get ARF in the hospital </li></ul></ul></ul></ul></ul><ul><ul><ul><li>IV rider/”piggyback” </li></ul></ul></ul><ul><ul><ul><ul><li>Generally 40-60 mEq </li></ul></ul></ul></ul><ul><ul><ul><ul><li>KCl is PREFERRED AGENT again </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Avoid dextrose solution (trigger insulin, shift K + ) </li></ul></ul></ul></ul>IV 15%POTTASIUM CHLORIDE 1ml  2 mEq/L 10 ml  20 mEq/L
  30. 34. Approach to Hypokalemia <ul><li>Step 5: Choose dose/timing </li></ul><ul><ul><li>Mild/moderate hypokalemia </li></ul></ul><ul><ul><ul><li>3.0 to 3.5 mEq/L </li></ul></ul></ul><ul><ul><ul><li>60-80 mEq PO (or IV) QDay divided doses </li></ul></ul></ul><ul><ul><ul><li>Sometimes will require up to 160 mEq per day (refeeders, lots of diarrhea, IV diuretics) </li></ul></ul></ul><ul><ul><ul><li>Avoid too much PO at once </li></ul></ul></ul><ul><ul><ul><ul><li>GI upset or just poor response </li></ul></ul></ul></ul><ul><ul><ul><li>Usually divide as BID or TID dosing </li></ul></ul></ul>
  31. 35. Approach to Hypokalemia <ul><li>Step 5 (con’t): Choose dose/timing </li></ul><ul><ul><li>Severe hypokalemia (< 3.0 mEq/L) </li></ul></ul><ul><ul><ul><li>Can use combination of IV and PO, again with PO preferred if at all possible </li></ul></ul></ul><ul><ul><ul><li>Avoid more than 60-80 mEq PO in a single dose </li></ul></ul></ul><ul><ul><ul><li>Avoid IV infusion rates faster than 20 mEq/hour—can cause arrhythmia!!! </li></ul></ul></ul><ul><ul><ul><ul><li>Most protocols won’t allow more than 10 mEq/hour rates on the floors (ICU’s too?) </li></ul></ul></ul></ul>
  32. 36. Approach to Hypokalemia <ul><li>Step 6: Monitor/reassess </li></ul><ul><ul><li>Severe hypokalemia, DKA patients </li></ul></ul><ul><ul><ul><li>Reassess labs Q4-6 hours </li></ul></ul></ul><ul><ul><li>Moderate hypokalemia, IV diuresis patients </li></ul></ul><ul><ul><ul><li>Reassess labs BID to TID as needed </li></ul></ul></ul><ul><ul><li>Mild hypokalemia </li></ul></ul><ul><ul><ul><li>Reassess labs QDay or less as needed </li></ul></ul></ul>
  33. 37. K CONCENTRATION OF IV FLUIDS 4 10 17 20 35 K(mEq/L) RL Iso E Iso G Iso P Iso M IV Fluid
  34. 38. Approach to Hypokalemia <ul><li>Step 7: Housekeeping/follow up </li></ul><ul><ul><li>BE AGGRESSIVE in DKA patients & IV diuresis patients </li></ul></ul><ul><ul><ul><li>May want to keep K + over 4.0 or even 4.5 mEQ/L in cardiac patients, especially in those with arrhythmias </li></ul></ul></ul><ul><ul><li>BE GENTLE in patients with acute or chronic renal failure </li></ul></ul><ul><ul><ul><li>May wish to cut doses in half, double intervals, or not replace at all </li></ul></ul></ul><ul><ul><ul><li>May need to monitor very closely </li></ul></ul></ul><ul><ul><li>NEVER forget to check for & treat hypomagnesemia in refractory hypokalemia!!! </li></ul></ul>
  35. 39. Hypokalemia – TAKE CARE . . . <ul><li>Monitor IV K – ECG & S.K levels </li></ul><ul><li>Never give IV push </li></ul><ul><li>Never add KCl to Iso M </li></ul><ul><li>DON’T GIVE MORE THAN </li></ul><ul><li>10-20mEq/hr </li></ul><ul><li>40 mEq/L </li></ul><ul><li>240 mEq/L/day </li></ul>REMEMBER – THAT HYPOKALEMIA IS SAFER THAN HYPERKALEMIA AVOID OVERENTHUSIASM in Rx
  36. 40. K RICH FOOD <ul><li>Fruit juices </li></ul><ul><li>Tender coconut water </li></ul><ul><li>Banana </li></ul><ul><li>Juicy fruits </li></ul><ul><li>Dry fruits </li></ul><ul><li>Chocolate </li></ul><ul><li>Coffee </li></ul><ul><li>Soups </li></ul><ul><li>Salt substitutes </li></ul>
  37. 41. ACID – BASE DISORDERS IN HYPOKALEMIA Liddle, Bartter, Gitelman syndromes Penicillin derivatives Salt-wasing nephropathy Mineralocorticoid excess LGI loss( diarrhea, laxative abuse Vomiting, NG RTA Diuretic therapy DKA Metabolic alkalosis Metabolic acidosis
  38. 42. HYPOKALEMIA & ABG
  39. 44. HYPOKALEMIA & CONTRACTION ALKALOSIS
  40. 45. UCl IN METABOLIC ALKALOSIS &  K
  41. 47. HYPOKALEMIA,HT,METABOLIC ALKALOSIS - DIFFERENTIALS
  42. 49. HYPOKALEMIC METABOLIC ALKALOSIS WITHOUT HT
  43. 50. HYPOKALEMIA & PARALYSIS
  44. 51. Ok, You Think You Got It??? <ul><li>Let’s try it out on some cases </li></ul><ul><ul><li>Real cases from real patients </li></ul></ul><ul><ul><ul><li>Figure out what you would do... </li></ul></ul></ul>
  45. 52. Case 1 <ul><li>30,F </li></ul><ul><li>Diarrohea,muscle weakness </li></ul><ul><li>ECG – s/o hypokalemia </li></ul><ul><li>LABS – Na 140, K 2.1 ,Cl 117, bicarb 10,Ph 7.26,Pco2 23 </li></ul><ul><li>What is your diagnosis? </li></ul><ul><li>Which would you correct first? </li></ul>
  46. 53. Case1 - discussion <ul><li>Hypokalemic metabolic acidosis due to diarrohea </li></ul><ul><li>Correct hypokalemia first </li></ul><ul><li>Correction of acidemia pushes K into cells - further worsening K! </li></ul>
  47. 54. Case 2 <ul><li>36 F </li></ul><ul><li>Diuretics – twice weekly </li></ul><ul><li>HT,JVP – 5cm,skin turgor  </li></ul><ul><li>LABS – Na 136, K 3 ,Cl 98,Bicarb 29, Ph 7.47,UNa 60,UK 45,UCl 48 </li></ul><ul><li>NS 2L in 1hr,UNa 20 </li></ul><ul><li>What is your diagnosis & differentials </li></ul>
  48. 55. Case 2 - discussion <ul><li>HT,Hypokalemic Metabolic Alkalosis & kaliuresis – PRIMARY HYPERALDOSTERONISM </li></ul><ul><li>Diuretic Rx for HT – can mimic </li></ul><ul><li>Hypovolemia, slight  Na,  UNa after NS – BEST EXPLAINS </li></ul><ul><li>UCl – accurate indicator of volume depletion in metabolic alkalosis </li></ul>
  49. 56. Case 3 <ul><li>22,F </li></ul><ul><li>Weakness – persistent </li></ul><ul><li>O/E – NAD </li></ul><ul><li>LABS – Na 136, K 2.7 ,Cl 108,bicarb 17,Ph 7.3, U Na 7,U K 12 </li></ul><ul><li>What is your diagnosis? </li></ul>
  50. 57. Case 3 discussion <ul><li>Low UK – extra renal loss </li></ul><ul><li>Low UNa – volume depletion </li></ul><ul><li>Metabolic acidosis – diarrohea </li></ul><ul><li>SUSPECT LAXATIVE ABUSE </li></ul>
  51. 58. Case 4 <ul><li>22,F </li></ul><ul><li>Easy fatigability & weakness </li></ul><ul><li>LABS – Na 141, K 2.1 ,Cl 85, Bicarb 45 ,UNa 80, UK 170 </li></ul><ul><li>What are your differentials ? </li></ul><ul><li>What further testing you will order ? </li></ul>
  52. 59. Case 4 - discussion <ul><li>Unexplained  K, UK wasting & metabolic alkalosis – diuretic use, vomiting, primary hyperaldosteronism </li></ul><ul><li>Urinary Cl – helps further differentials </li></ul>
  53. 60. Case 5 <ul><li>S.K 2.7 </li></ul><ul><li>Bicarb 27 </li></ul><ul><li>PH 7.43 </li></ul><ul><li>UK 10 </li></ul><ul><li>Uosm 102 – Primary waterload </li></ul><ul><li>PRIMARY POLYDIPSIA </li></ul>
  54. 61. Case 6 <ul><li>S.K 2.7 </li></ul><ul><li>Bicarb 27 </li></ul><ul><li>Ca 7.3 </li></ul><ul><li>Alb 4.1 </li></ul><ul><li>Ph 7.46 </li></ul><ul><li>UK 45 </li></ul><ul><li>HYPOMAGNESEMIA </li></ul>
  55. 62. Case 7 <ul><li>S.K 2.7 </li></ul><ul><li>Bicarb 14 </li></ul><ul><li>Ph 7.28 </li></ul><ul><li>UK 52 </li></ul><ul><li>Urine Ph 6 </li></ul><ul><li>UAG + 25 </li></ul><ul><li>RENAL TUBULAR ACIDOSIS </li></ul>
  56. 63. <ul><li>ODUVANTHALAI leaves - Cleistanthus collinus is an extremely toxic plant poison </li></ul><ul><li>Cleistanthin A & B, the toxins of Cleistanthus collinus, are diphyllin glycosides which produce cardiac arrhythmias, urinary potassium wasting, hypoxia, metabolic acidosis & hypotension </li></ul><ul><li>We report ARDS, distal renal tubular acidosis and distributive shock secondary to inappropriate vasodilatation in a case following ingestion of its leaves J Assoc Physicians India. 2006 Sep;54:742-4 </li></ul>Cleistanthus Collinus Poisoning SPE Benjamin, M Edwin Fernando , J Jerene Jayanth, B Preetha
  57. 64. Primary Sjögrens Syndrome Presenting with Distal Renal Tubular Acidosis & Rhabdomyolysis EBS Prakash, M.Edwin Fernando , Malathi Sathiyasekaran, RM Bhoopathy, JJ Jayanth <ul><li>Primary Sjögrens syndrome (PSS) is rare in India </li></ul><ul><li>Clinically manifest renal disease in PSS is uncommon & is usually an autoimmune tubulointerstitial nephritis presenting with distal renal tubular acidosis (dRTA) or a urinary concentrating defect. </li></ul><ul><li>Hypokalemic paralysis due to dRTA in PSS is rare but well documented in medical literature </li></ul><ul><li>Rhabdomyolysis as a consequence of hypokalemia in PSS is exceptional </li></ul><ul><li>We report a case of PSS with dRTA & rhabdomyolysis causing prolonged respiratory failure and quadriparesis </li></ul>J Assoc Physicians India. 2006 Dec;54:949 - 50
  58. 65. CASE 10
  59. 67. GITELMAN SYNDROME
  60. 68. HYPOKALEMIA IN LEPTOSPIROSIS <ul><li>Hypokalemia – 26 to 40% Seguro AC,Nephron 55:146-151,1990 </li></ul><ul><li>Kaliureis – inhibition of Na reabsorption in PCT with ↑ Na delivery to CD for Na-K exchange Abdulkader RC,Am J Trop Hyg 54:1-6,1996 </li></ul><ul><li>OMP of leptospires – inhibit Na – K ATP ase – secondary effects on Na transport at luminal sites Younes-Ibrahim M,CR Acad Sci III 318:619-625,1995 </li></ul><ul><li>Inhibition of Na –K - Cl cotransport in m TAHL Yang CW J Am Soc Nephrol 11;2017-2026,2000 </li></ul><ul><li>Urinary concentrating ability  </li></ul><ul><li>Respiratory alkalosis - hyperkaliuria </li></ul>Leptospirosis - current scenario in India,S. Shivakumar Medicine Update 2008
  61. 70. HYPOKALEMIA Recap of Major Learning Points <ul><ul><li>Minimise hypokalemia – adequate intake </li></ul></ul><ul><ul><li>PO almost always preferred over IV </li></ul></ul><ul><ul><li>KCl is preferred preparation </li></ul></ul><ul><ul><li>Don’t give too much too quickly </li></ul></ul><ul><ul><li>Be aggressive in DKA & IV diuresis patients,arrhythmia,musular paralysis </li></ul></ul><ul><ul><li>Be gentle in renal failure patients </li></ul></ul><ul><ul><li>Don’t forget to check magnesium levels in refractory hypokalemic patients </li></ul></ul><ul><ul><li>Remember genetic & endocrine causes galore – deligent work up essential </li></ul></ul>
  62. 71. Dr.M.A. Muthusethupathi Dr.M.Jayakumar Dr.R.Vijayakumar Dr.N.Gopalakrishnan THANKS . . .
  63. 73. Potassium Balance: Critical for Excitable Heart & Nervous Tissues Figure 20-4: Osmolarity changes as fluid flows through the nephron
  64. 74. Low Renin Low Aldosterone Cortisol Ectopic ACTH Cushing syndrome Liddle’s Licorice AME DOC 11  hydorxylase D 17  hydorxylase D High Normal Low Lin SH, et al. Am J Med Sci 2003; 325: 153-156.
  65. 76. References <ul><li>Cody RJ, Pickworth KK: Approaches to diuretic therapy and electrolyte imbalance in congestive heart failure. Card Clin 1994; 12: 37-50. </li></ul><ul><li>Kim G, Han J: Therapeutic approach to hypokalemia. Nephron 2002; 92(suppl 1): 28-32. </li></ul><ul><li>Kim H, Han S: Therapeutic approach to Hyperkalemia. Nephron 2002; 92(suppl 1); 33-40. </li></ul><ul><li>Whitmire SF: Fluid and electrolytes; in Gottschlich MM (ed): The Science and Practice of Nutrition Support; A Case-Based Core Curriculum. Dubuque, Kendall/Hunt, 2001, pp 53-84. </li></ul><ul><li>Up to Date On-line </li></ul>
  66. 77. Gitelman’s H
  67. 79. HYPOKALEMIA & METABOLIC ALKALOSIS
  68. 80. Lin SH et al. Am J Emerg Med 2003 Blood pressure Renin Renin Aldo K + excretion rate and acid - base status ? H H y y p p o o k k a a l l e e m m i i a a & & P P a a r r a a l l y y s s i i s s L L o o w w K K + + e e x x c c r r e e t t i i o o n n a a n n d d n n o o r r m m a a l l a a c c i i d d - - b b a a s s e e   SPP   Barium poisoni ng   FPP   Hypernatremic HPP None Family history Hypernatremia High K + excretion and abnormal acid - base Acid - base state ? Clue Hyperthyroidism ?   TPP YES NO Metabolic Acidosis NH + 4 excretion (UAG, UOG) Low High Toluene Profound diarrhea RTA Metabolic Alkalosis R enin Normal GS or BS Diuretics Vomiting High Primary mineralocorticoid excess Aldo Aldo Primary Aldo steronism Licorice use AME Ectopic ACTH Liddle syndrome

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