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Approach to

HYPOKALEMIA
Case of J. D. R.
Ba utista | Rucio | A dap , Da quina g

OBJECTIVES

OBJECTIVES
CASE OF HYPOKALEMIA

CASE PRESENTATION
To present a case of
hypokalemia

APPROACH
TO
To discuss an
DIAGNOSIS
approach in
diagnosing
hypokalemia

PROGNOSIS

MANAGE
To present the management
for hypokalemia

To discuss the
prognosis of
the case

THE CASE

R. D. C.
30/M
Filipino
Roman Catholic
Single
High
school
graduate
Company worker
Born in Aklan
Currently residing
in
Donggalo,
Paranaque City
Admitted for the 1st
time

Bilateral Leg
Weakness

HISTORY OF PRESENT
Comorbi
2ILLNESS
days
In the
ds

(-) known
thyroid or
kidney
disease

PTA

Weakness of lower
extremities: thighs
> legs
(-) strenuous
activities
(-) binge
eating/drinking
(-) dyspnea, chest
pain
(-) vomiting
(-) headache, loss
of sensation,
dizziness, seizure,
limitation of motion
(-) consult
(-) medications
taken

interim

Progression of
weakness

On the day
of consult

Persistence of
weakness
Inability to
ambulate

MEDICAL HISTORY
Past Medical
History

(-) hypertension, DM
bronchial asthma, liver
disease, cancer
(-) PTB treatment
(-) medications taken
(-) allergy to food and
drugs
(-) previous surgeries
(-) previous
hospitalizations

Family
Medical
(-) neuromuscular
History

disease, hypertension,
DM, stroke, heart
disease
(-) bronchial asthma,
PTB
(-) bleeding diathesis,
cancer
(-) thyroid, liver and
kidney disease

Personal and
Social

Nonsmoker
Occasional alcoholic
beverage drinker, 1-2
bottles/drinking spree,
2x/month
Denies illicit drug use
Company worker

Review
of Systems
SHEENT: No
scars, skin
lesions,
blurring of
vision, hearing
loss, eye/ear
discharge,
tinnitus, neck
mass
Respiratory:
No dyspnea,
cough, colds,
hemoptysis
Cardiovascular
: No chest
pain,
orthopnea,
paroxysmal
nocturnal
dyspnea,
palpitations

GENERAL: No
weight
gain/loss,
fever, loss of
appetite, easy
fatigability

Gastrointestin
al: No
abdominal
pain, changes
in bowel
movement,
melena,
hematochezia,
vomiting,
Genitourinary:
hematemesis
a No dysuria,
nocturia,
polyuria,
frequency,
urgency,
frothy urine,
hematuria
Endocrine: No
polydipsia,
heat and cold
intolerance

Physical Examination
General

Awake
Alert
Coherent
With difficulty
ambulating
Speaks in
sentences
Not in
cardiorespiratory
distress

Vital Signs

BP: 120/80
HR: 71
RR: 20
Temp: 36.2
O2 saturation:
98%
Weight: 62.5 kgs
Height: 165 cm
BMI: 22.96

SHEENT

No skin lesions,
masses
Good skin turgor
Anicteric sclerae
Pink palpebral
conjunctivae
No eye
discharge
No nasoaural
discharge
No
tonsillopharynge
al congestion
Moist oral
mucosa

Physical Examination
Chest and Lungs

Symmetric chest
expansion
No retractions
Bronchovesicular
breath sounds

Heart

Adynamic
precordium
Normal rate
Regular rhythm
Point of maximal
impulse at 5th
ICS left
midclavicular
line
Distinct S1 and
S2
No murmurs
appreciated

Abdomen

Flat
Normoactive
bowel sounds
Soft
Nontender

Physical Examination
Extremities

Full and equal


pulses
No bipedal edema
No cyanosis
CRT <2 secs

Neurological

Conversant
Coherent
Oriented to
time, place, and
person
Follows
instructions
Intact recent
and remote
memory

Neurological: Cranial
Nerves
I able to smell coffee
II, III- pupils equally
and briskly reactive to
light and
accommodation (2-3
mm)
III, IV, VI - Extraocular
muscle movements
intact
V- No facial sensory
loss in the forehead,
cheeks, and jaw; brisk
corneal reflex
VII- No facial
asymmetry
VIII - With intact gross
hearing
IX, X- Positive gag
reflex, no deviation of
the uvula

Physical Examination
Neurological: Motor

5/
5

4/
5
3/
5
5/
5

4/
5 5/
5
3/
5
5/
5

Good muscle tone, no


fasciculations, atrophy

Neurological: Sensory

10
0

10
0
10
0
10
0

10
0 10
0
10
0
10
0

Neurological: Reflexes

+
+

+
+
+
+
+
+

+
+ +
+
+
+
+
+

Physical Examination
Neurological: Cerebellar

No dysmetria
No
dysdiadochokines
ia

Neurological: Other
Reflexes

No Babinski
No nuchal
rigidity

SALIENT FEATURES

SALIENT FEATURES
30/M

Bilateral
leg
weakness

2 days history
No known
comorbids

Progressive
weakness:
thighs >>>
legs

No past
medical or
familial
history
No
medication
s taken

No
Strenuous activities
Binge
eating/drinkng
Associated
symptoms

No other
subjective
complaints

Occasional alcoholic
beverage drinker
Denies illicit drug use
Company worker

SALIENT FEATURES
120/80
71
20
36.2
98%

Pink palpebae, flat neck


veins, no bruits, no anterior
neck mass
Bronchovesicular breath
sounds
Adynamic precordium, no
murmurs
Full and equal pulses

Good muscle tone


No fasciculations,
atrophy
No sensory loss
No decrease in reflexes
No dysmetria
No Babinski

Follows command
Oriented to 3 spheres
Intact memory
No facial asymmetry
No slurring of speech
Good gag

5/
5

5/
5
4/ 4/
5 5
3/ 3/
5 5

5/

5/

In the ER

IN THE ER
S

Assessment

O
A
P

Muscle paresis probably


secondary to electrolyte
imbalance probably
hypokalemia

IN THE ER
Diet
and
Fluids
S High potassium, regular diet

IVF: PNSS 1L + 40 mEqs KCl to run for 125 cc/hr

O
A
P

IN THE ER
S
O
A
P

Diagnostics

12 LECG
Na, K, Cl
CBC with PC
Urinalysis
BUN, Crea
Chest Xray PA
ABGs

1
2
L
E
C
G

ECG Changes
Flattening of T waves
T wave inversion
ST sagging
Prominent u waves
Prolonged PR interval
Widened QRS complex
Ventricular fibrillation

IN THE ER
S
O
A
P

Diagnostics

12 LECG
Na, K, Cl
CBC with PC
Urinalysis
BUN, Crea
Chest Xray PA
ABGs

BLOOD CHEMISTRY
Paramete
r
BUN
Crea
Na
K
Cl

Normal

05/21

1.7 8.3
89 104
134 -145
3.4 5.0
93 109

4.91
79.63
137.1
1.59
108.4

IN THE ER
S
O
A
P

Diagnostics

12 LECG
Na, K, Cl
CBC with PC
Urinalysis
BUN, Crea
Chest Xray PA
ABGs

COMPLETE BLOOD COUNT


Parameter
WBC
Neutro
Lympho
Mono
Eosino
Baso
RBC
Hgb
Hct
MCV
MCH
MCHC
RDW
Plt

Normal
5.2-12.4
40-74
19-48
3.4-9
0-7
0-1.5
4.5-6.2
14-18
42-52
80-94
27-31
33-37

150-450

05/21
13.67
73.7
16.3
7.4
2.5
0.1
5.96
14.4
45.6
76.6
24.1
31.5

488

IN THE ER
S
O
A
P

Diagnostics

12 LECG
Na, K, Cl
CBC with PC
Urinalysis
BUN, Crea
Chest Xray PA
ABGs

URINALYSIS
Parameter
PHYSICAL
Color
Transparency
CHEMICAL
Albumin
Sugar
Specific Gravity
pH
MICROSCOPIC
Epithelial Cell
Mucus Thread
Amorphous Phosphate
WBC
RBC

05/21

Straw
Clear

Trace
Negative
1.010
7.0

Few
Few
Few
1-2
0-1

IN THE ER
S
O
A
P

Diagnostics

12 LECG
Na, K, Cl
CBC with PC
Urinalysis
BUN, Crea
Chest Xray PA
ABGs

CHEST XRAY

Move to
Therapy
YES
Emergency
NO
Treat according
and reevaluate
K

Hypokalemi
a
Serum K+ <3.5
mmol/L

3.4 5.0

Treat
accordingly
1.59
YES

YES
Clear evidence
of low intake

No further
Insulin excess
workup
Beta-adrenergic
agonists
YES
FHPP
Pseudohypokale
Hyperthyroidism
mia
Barium intoxication
Theophylline
NO
Chloroquine

History, PE, and


basic laboratory
tests

Clear evidence
of intracellular
shift

Body K+ distribution and cellular K+ flux


Taal, M. W. et. Al. 2012. Brenner & Rectors The Kidney, Ninth Edition. USA: Elsevier.

Factors Affecting
Distribution of Potassium
between Intracellular and
Extracellular
Compartments

Taal, M. W. et. Al. 2012. Brenner & Rectors The Kidney,


Ninth Edition. USA: Elsevier.
Giebisch, G. 1998. Renal potassium transport:
mechanism and regulation. Am J Physiol, 274: F817-F833.

Consequences of
Excitable Muscles Hypokalemia
Renal
Cardiovascular
Risk factor for both
ventricular and atrial
arrhythmia
Impaired muscle
contraction

Proximal tubular
vacuolization
Interstitial nephritis
Renal cysts
ESRD
Acute renal failure with
proximal tubular
vacuolopathy

Worsening of hypertension,
heart failure, and stroke
Reduction of insulin
secretion

IN THE ER
S
O
A
P

Diagnostics

12 LECG
Na, K, Cl
CBC with PC
Urinalysis
BUN, Crea
Chest Xray PA
ABGs

ARTERIAL BLOOD GASES


Paramet
er
pH
pCO2
pO2
HCO3
BE
O2St
TCO2
SBc

Normal

05/21

7.35-7.45
35-45

22-26

7.364
31
108
13.4
-11
96.9
12.2
15.1

IN THE ER
Diet
and
Fluids
S High potassium, regular diet

IVF: PNSS 1L + 40 mEqs KCl to run for 125 cc/hr

O
A
P

Foods with High Potassium


Content

Gennari, FJ. 1998. Hypokalemia. N Engl J Med, 339: 451-458.


Taal, M. W. et. Al. 2012. Brenner & Rectors The Kidney, Ninth Edition.

IN THE ER
S

Medications

O
A
P

KCl tablet 1 tablet thrice a day for 3 days

IN THE ER
Supplementary
S Hook to cardiac monitor if available; if not, do daily 12
O
A
P

LECG
Moderate to high back rest
Strict I and O monitoring
WOF: weakness, dyspnea, chest pain, changes in
sensorium, and hypertension
VSQ1

COURSE IN THE
WARDS

On the 1 hospital day


st

S
O
A
P

Subjective
Objective
110/70, 78, 20, 36.1
No dyspnea

No chest pain
No abdominal pain
No cramps
Progression of
weakness

Awake, alert, not in


distress
Moist mucosae
With bronchovesicular
breath sounds
Adynamic precordium,
no murmurs
No edema
I/O: 1200/700: +500

5/
5

5/
5
2/
5
4/
5

5/
5 5/
5
2/
5
4/
5

On the 1 hospital
day
Assessment Plan
st

O
A
P

Hypokalemia
etiology to be
determined
PTB Suspect

High K diet
IVF: PNSS 1L + 40 mEqs KCl x 125
cc/hr
Other diagnostics facilitated
Medications:
KCl tab 1 tab TID
Management continued

On the 2
S
O
A
P

nd

hospital day

Subjective
Objective
110/60, 66, 19 , 36.1
No dyspnea

No chest pain
No abdominal pain
No cramps
Progression of
weakness

Awake, alert, not in


distress
Moist mucosae
With bronchovesicular
breath sounds
Adynamic precordium,
no murmurs
No edema
I/O: 2400/1050: +1350

5/
5

5/
5
2/
5
2/
5

5/
5 5/
5
2/
5
2/
5

BLOOD CHEMISTRY
Paramet
er
K

Normal

05/21

05/22

3.4 5.0

1.59

2.13

KUB ULTRASOUND
The right kidney measures 10.3 x 5.8 x 5.1 cmn with cortical thickness of 0.8 cm and the
left kidney measures 11.0 x 5.0 x 4.5 cm with cortical thickness of 1.0 cm. the cortices
are intact. The medullary pyramids are markedly echogenic, bilaterally. A 1.2 cm cyst is
seen in the right midportion. Two cysts measuring 1.1 cm and 0.4 cm are also noted in
the right midportion. Two hypoechoic foci with high intensity echoes (measuring 0.5 cm
and 0.3 cm) within are also seen in the left superior pole. The pelvocalyces are mildly
dilated, bilaterally.

The urinary bladder is smooth in outline. Wall is not thickened. There are no abnormal
intraluminal echoes.

Consider bilateral medullary


nephrocalcinosis
Nephrolithiasis with focal caliectasia, left
Simple renal cysts, bilateral
Mild pelvocaliectasia, bilateral

On the 2 hospital
day
Assessment Plan
nd

O
A
P

Hypokalemia
etiology to be
determined
PTB Suspect

High K diet
IVF: PNSS 1L + 40 mEqs KCl x 125
cc/hr
Other diagnostics facilitated
Medications:
KCl tab 1 tab TID
Management continued

On the 3 hospital day


rd

S
O
A
P

Subjective
Objective
110/70, 80, 19, 37
No dyspnea

No chest pain
No abdominal pain
No cramps
Decreased
weakness

Awake, alert, not in


distress
Moist mucosae
With bronchovesicular
breath sounds
Adynamic precordium,
no murmurs
No edema
I/O: 2200/1400: +800

5/
5

5/
5
4/
5
4/
5

5/
5 5/
5
4/
5
4/
5

BLOOD CHEMISTRY
Parame
ter
K

Normal

05/23

3.4 5.0

3.35

URINE ELECTROLYTES
Parameters
Creatinine
Sodium
Potassium

Normal
Values

5/23

100-200
40-220
25-125

36.39
41.9
9.2

Move to
Therapy
YES
Emergency
NO

No further
workup

Hypokalemi
a
Serum K+ <3.5
mmol/L

NO

YES

YES

NO

Pseudohypokale
mia

Treat
accordingly

Treat according
and reevaluate

Clear evidence
of low intake

YES

History, PE, and


basic laboratory
tests

Clear evidence
of intracellular
shift
NO

Normal
Parameters
Values
Urine
K
100-200
Creatinine
mg/dL
25-125
Potassium
<15 mmol/day
mmol/L

5/23
36.39
9.2

OR <15 mmol/g
Cr

>15 mmol/day
OR >15 mmol/g
Cr

Urine K = K mmol/g Crea


= ______________9.2 mmol/L____________
(36.39 mg/dL) (1 g/1000 mg) (10 dL/1L)
= 25.28 mmol/g Crea

Urine K

<15 mmol/day
OR <15 mmol/g
Cr
Extrarenal loss/
remote renal
loss
Acid-base
status

>15 mmol/day
OR >15 mmol/g
Cr

Metabolic
Alkalosis
Metabolic
acidosis
GI K+ loss

Normal
Profuse
sweating

Remote
diuretic use
Remote
vomiting or
stomach
drainage
Profuse
sweating

Urine K

<15 mmol/day
OR <15 mmol/g
Cr

>15 mmol/day
OR >15 mmol/g
Cr

Extrarenal loss/
remote renal
loss

Renal loss

Acid-base
status

TTKG

TTKG (Transtubular Potassium


Gradient)
TTKG = [K+]urine x osmolserum
[K+]serum x osmolurine

Osmolserum = 2 (Na + K) + BUN


+ Glucose
= 2 (137.1 + 1.59) + 4.91 +
5.72
= 288.82

Osmolurine = (Urine SG 1) x
40000
= (1.010 1) x 40000
= 400

TTKG = [K+]urine x osmolserum


[K+]serum x osmolurine
= 9.2 x 288.82
1.59 x 400
= 4.17

>4

distal
secretion

Low OR normal

<2

BP and/or
Volume

tubular flow
Osmotic
diuresis

High

Aldosterone

High

Low

Renin

Cortisol

High
RAS
RST
Malignant
HPN

Low

PA
FH-I

High

Normal

Cushings
Syndrome

Liddles
syndrome
Licorice
SAME

>4

distal
secretion

Low OR normal

<2

BP and/or
Volume

tubular flow
Osmotic
diuresis

High

Acid-Base
status

Parame
ter
pH
pCO2
pO2
HCO3
BE
O2St
TCO2
SBc

Normal

05/21

7.35-7.45
35-45

22-26

7.364
31
108
13.4
-11
96.9
12.2
15.1

Metabolic Acidosis with


adequate compensation

Variable

Acid-Base
status

Nonreabsorbable
anions other
than HCO3Hippurate
Penicillins

Metabolic
Acidosis

Metabolic
Alkalosis

Urine Cl(mmol/L)

>20

<10

Urine Ca/Cr
(molar ratio)

Vomiting
Chloride
Diarrhea

>0.20

<0.15

Loop diuretic
Bartters
syndrome

Thiazide
diuretic
Gitelmans
syndrome

Variable

Acid-Base
status

Nonreabsorbable
anions other
than HCO3Hippurate
Penicillins

Metabolic Acidosis with


adequate compensation

Metabolic
Acidosis

Metabolic
Alkalosis

Proximal RTA
Distal RTA
DKA
Ampothericin B
Acetazolamide

Urine Cl(mmol/L)

On the 3 hospital
day
Assessment Plan
rd

O
A
P

Hypokalemia
etiology to be
determined
t/c RTA
PTB Suspect

High K diet
Shift IVF to heplock
Other diagnostics facilitated
Medications:
KCl tab 1 tab TID
Management continued

Possible reasons to develop


nephrocalcinosis and nephrolithiasis in
RTAphosphate
Type from
1: bones to buffer the
Constant release of calcium
extracellular H+
Decreased reabsorption of calcium and phosphate, leading to
hypercalciuria and hyperphosphaturia
Patients have relative alkaline urine, which promotes calcium
phosphate precipitation
Metabolic acidosis and hypokalemia lead to hypocitraturia

Decreased in potassium is due to:


Decreased net H+ secretion results in more Na+ reabsorption in
exchange for K+ secretion
Drop in serum HCO3- and, therefore, filtered HCO3-, reduces the
amount of Na+ reabsorbed by the Na+/H+ exchanger in the proximal
tubule, leading to mild volume depletion
Possible defect in K+/H+-ATPase results in decreased H+ secretion
and decreased K+ reabsorption

On the 4 hospital day


th

S
O
A
P

Subjective
Objective
90/60, 60, 19, 36.1
No dyspnea

No chest pain
No abdominal pain
No cramps
Progression of
weakness

Awake, alert, not in


distress
Moist mucosae
With bronchovesicular
breath sounds
Adynamic precordium,
no murmurs
No edema
I/O: 2600/1600: +1000

5/
5

5/
5
5/
5
5/
5

5/
5 5/
5
5/
5
5/
5

On the 4 hospital
day
Assessment Plan
th

O
A
P

Hypokalemia
etiology to be
determined
t/c RTA
PTB Suspect

High K diet
Heplock
Other diagnostics facilitated
Medications:
KCl tab 1 tab TID
Management continued

On the 5 hospital day


th

S
O
A
P

Subjective
Objective
110/70, 66, 19, 37,
No dyspnea
No chest pain
No abdominal pain
No body weakness

98%
Awake, alert, not in
distress
Moist mucosae
With bronchovesicular
breath sounds
Adynamic precordium,
no murmurs
No edema

I/O: 2550/1450: +1100

5/
5

5/
5
5/
5
5/
5

5/
5 5/
5
5/
5
5/
5

On the 5 hospital
day
AssessmentMay go home orders
th

O
A
P

Hypokalemia
etiology to be
determined
t/c RTA
PTB Suspect

Diagnostics:
FT4, TSH
Urine Calcium, phosphorus
DSSM x 2
Medications:
Potassium Citrate 1 tab 3 x a day

PLAN and
PROGNOSIS

PLAN and
PROGNOSIS

Further work-up: Thyroid function test

Work-up for possible RTA and give proper management


Advise regarding possible recurrence of hypokalemia
Refer to Surgery regarding nephrocalcinosis and nephrolithiasis
For DSSM OPD-basis
Good prognosis

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