Potassium Disorders: Hypokalemia and Hyperkalemia

 


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Am Fam Physician. 2015 Sep 15;92(6):487-495.

  Patient information: See related handout on potassium, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Hypokalemia and hyperkalemia are common electrolyte disorders caused by changes in potassium intake, altered excretion, or transcellular shifts. Diuretic use and gastrointestinal losses are common causes of hypokalemia, whereas kidney disease, hyperglycemia, and medication use are common causes of hyperkalemia. When severe, potassium disorders can lead to life-threatening cardiac conduction disturbances and neuromuscular dysfunction. Therefore, a first priority is determining the need for urgent treatment through a combination of history, physical examination, laboratory, and electrocardiography findings. Indications for urgent treatment include severe or symptomatic hypokalemia or hyperkalemia; abrupt changes in potassium levels; electrocardiography changes; or the presence of certain comorbid conditions. Hypokalemia is treated with oral or intravenous potassium. To prevent cardiac conduction disturbances, intravenous calcium is administered to patients with hyperkalemic electrocardiography changes. Insulin, usually with concomitant glucose, and albuterol are preferred to lower serum potassium levels in the acute setting; sodium polystyrene sulfonate is reserved for subacute treatment. For both disorders, it is important to consider potential causes of transcellular shifts because patients are at increased risk of rebound potassium disturbances.

Potassium disorders are common. Hypokalemia (serum potassium level less than 3.6 mEq per L [3.6 mmol per L]) occurs in up to 21% of hospitalized patients and 2% to 3% of outpatients.13 Hyperkalemia (serum potassium level more than 5 mEq per L [5 mmol per L] in adults, more than 5.5 mEq per L [5.5 mmol per L] in children, and more than 6 mEq per L [6 mmol per L] in neonates) occurs in up to 10% of hospitalized patients and approximately 1% of outpatients.4,5 The body's plasma potassium concentration is closely regulated by a variety of mechanisms.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Patients with a history of congestive heart failure or myocardial infarction should maintain a serum potassium concentration of at least 4 mEq per L (4 mmol per L).

C

15

Intravenous potassium should be reserved for patients with severe hypokalemia (serum potassium < 2.5 mEq per L [2.5 mmol per L]), hypokalemic ECG changes, or physical signs or symptoms of hypokalemia, or for those unable to tolerate the oral form.

C

22

Prompt intervention and possible ECG monitoring are indicated for patients with severe hypokalemia (serum potassium < 2.5 mEq per L) or severe hyperkalemia (serum potassium > 6.5 mEq per L [6.5 mmol per L]); ECG changes; physical signs or symptoms; possible rapid-onset hyperkalemia; or underlying kidney disease, heart disease, or cirrhosis.

C

7, 15, 24, 30, 3335

Intravenous calcium should be administered if hyperkalemic ECG changes are present.

C

24, 25, 35

Intravenous insulin and glucose, inhaled beta agonists, and dialysis are effective in the acute treatment of hyperkalemia.

B

39

Sodium polystyrene sulfonate (Kayexalate) may be effective in lowering total body potassium in the subacute setting.

C

25


ECG = electrocardiography.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Patients with a history of congestive heart failure or myocardial infarction should maintain a serum potassium concentration of at least 4 mEq per L (4 mmol per L).

C

15

Intravenous potassium should be reserved for patients with severe hypokalemia (serum potassium < 2.5 mEq per L [2.5 mmol per L]), hypokalemic ECG changes, or physical signs or symptoms of hypokalemia, or for those unable to tolerate the oral form.

C

22

Prompt intervention and possible ECG monitoring are indicated for patients with severe hypokalemia (serum potassium < 2.5 mEq per L) or severe hyperkalemia (serum potassium > 6.5 mEq per L [6.5 mmol per L]); ECG changes; physical signs or symptoms; possible rapid-onset hyperkalemia; or underlying kidney disease, heart disease, or cirrhosis.

C

7, 15, 24, 30, 3335

Intravenous calcium should be administered if hyperkalemic ECG changes are present.

C

24, 25, 35

Intravenous insulin and glucose, inhaled beta agonists, and dialysis are effective in the acute treatment of hyperkalemia.

B

39

Sodium polystyrene sulfonate (Kayexalate) may be effective in lowering total body potassium in the subacute setting.

C

25


ECG = electrocardiography.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Causes

The Authors

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ANTHONY J. VIERA, MD, MPH, is an associate professor in the Department of Family Medicine at the University of North Carolina at Chapel Hill School of Medicine....

NOAH WOUK, MD, is a resident in the Department of Family Medicine at the University of North Carolina at Chapel Hill School of Medicine.

Address correspondence to Anthony J. Viera, MD, MPH, University of North Carolina at Chapel Hill School of Medicine, 590 Manning Dr., CB 7595, Chapel Hill, NC 27599 (e-mail: anthony_viera@med.unc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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