Electrolyte disturbance

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Electrolyte Disturbance Main Page

Patient Information

Overview

Classification

Hyponatremia
Hypernatremia
Hypokalemia
Hyperkalemia
Hypocalcemia
Hypercalcemia
Hypophosphatemia
Hyperphosphatemia
Hypomagnesemia
Hypermagnesemia

Causes

Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]Mohamadmostafa Jahansouz M.D.[3]

Synonyms and keywords: abnormal electrolytes, abnormal lytes, lytes

Overview

Electrolytes are electrically charged solutes necessary to maintain body homeostasis. The main electrolytes include Sodium (Na), Potassium (K), Chloride (Cl), Calcium (Ca), Phosphorus (P), and Magnesium (Mg). These electrolytes are involved in multiple physiologic and neurohormonal reactions necessary to maintain neuromuscular, neuronal, myocardial, and acid-base balance. Their balance are mainly regulated by renal and endocrine systems, any changes in their balance may be life threatening. Electrolytes are in balance to achieve neutral electrical charges. Electrolytes could be classified based on their electrical charge to anions and cations. Anions include bicarbonate, chloride, and phosphorus. Cations are calcium, magnesium, potassium, and sodium. Sodium and chloride are the major extracellular ions that has the greatest impact on serum osmolality (solute concentration in 1 liter of water). Calcium and bicarbonate are the other major extracellular electrolytes. Main intracellular electrolytes are potassium, phosphorus, and magnesium.

Causes

The following table summarize the common causes for electrolytes imbalance.

Electrolyte Ionic formula Normal limits (meq/l) Disturbance Lab value Common causes
Sodium Na+ 135-145 Hyponatremia <135 meq/L Hypovolemic[1]
Euvolemic[2][3][4] SIADH, glucocorticoid deficiency, psychogenic polydipsia
Hypervolemic[5][6][7] CHF, cirrhosis, nephrotic syndrome, renal failure
Hypernatremia >145 meq/L Extrarenal loss[8][9] Vomiting, diarrhea, insensible loss
Renal loss[10] Diuretics, diabetes insipidus (central and nephrogenic)
Potassium K+ 3.5-5 Hypokalemia <3.5 meq/L Transcellular shifts[11][12] Insulin therapy, alkalosis
GI loss[13][14] Diarrhea, laxative abuse, vomiting
Renal loss[15][16][17][18]
Hyperkalemia[19][20][21] >5 meq/L ACE inhibitors, acidosis, addisonian crisis, beta blockers, blood transfusion, cirrhosis, diabetic nephropathy, high potassium diet, malnutrition, renal tubular acidosis type IV, renal failure
Calcium Ca2+ 8.5-10.2 Hypocalcemia[22][23][24] <8.5 meq/L Hypoparathyroidism, pseudohypoparathyroidism, hypomagnesemia, hypovitaminosis D,

chronic kidney disease, hypoalbuminemia

Hypercalcemia[25][26][27][28] >10.2 meq/L Hyperparathyroidism, familial hypocalciuric hypercalcemia, malignancy, Milk-alkali syndrome,

vitamin D toxicity, sarcoidosis, diuretics, lithium

Phosphate PO43- 2.5-4.5 Hypophosphatemia[29][30][31] <2.5 meq/L Refeeding syndrome, respiratory alkalosis, alcohol abuse, malabsorption
Hyperphosphatemia[32][33] >4.5 meq/L Transcellular shift, tumor lysis syndrome , rhabdomyolysis, hypoparathyroidism, pseudohypoparathyroidism, acute kidney injury, chronic kidney disease
Magnesium Mg2+ 1.5-2.5 Hypomagnesemia[34][35][36] <1.5 meq/L Alcohol use, uncontrolled diabetes mellitus, hypercalcemia, Gitelman syndrome, loop and thiazide diuretics
Hypermagnesemia[37][38] >2.5 meq/L Renal failure, massive oral ingestion

Diagnosis

Diagnosis of electrolyte disturbances is suspected by clinical presentation and will be confirmed by laboratory values. Clinical manifestations depend on the severity of disturbances and their chronicity however, the presentation may vary according to underlying condition. The following table summarizes common symptoms and signs of electrolytes disturbances and important ECG findings.


Disturbance Chronicity/ Level (meq/L) Common clinical manifestations ECG findings
Symptoms Signs
Hyponatremia Early/125-130 Nausea, malaise Muscle cramps N/A
Late/115-120 Headache, lethargy Respiratory distress, coma, seizure Non specific ST-T changes
Hypernatremia >145 Malaise Lethargy, confusion, coma Non specific ST-T changes
Hypokalemia[39] <2.5-3 Nausea, anorexia, vomiting, muscle weakness, muscle cramps Rhabdomyolysis, respiratory failure
Hyperkalemia[40][41] >7.5 Muscle weakness, polyuria, polydipsia Paralysis
Hypocalcemia[42][43] <7-7.5 Paresthesias, muscle spasm Trousseau's sign, Chvostek's sign, seizures
Hypercalcemia[44] >12 Fatigue, depression, insomnia, nausea, vomiting, constipation, polyuria Hyperreflexia, confusion, coma
Hypophosphatemia[45][46][47] <1 Irritability, paresthesias, dysphagia Delirium, seizure, coma Ventricular arrhythmias
Hyperphosphatemia[48] >4.5 Muscle cramps, paresthesias Tetanus QT interval prolongation (mainly due to associated hypocalcemia)
Hypomagnesemia[49] <1 Tremor, tetanus, weakness Apathy, delirium, coma
Hypermagnesemia[50] >4 Nausea, flushing, headache Somnolence, hypotension, absent DTR

References

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  2. ↑ Pham PC, Pham PM, Pham PT (May 2006). "Vasopressin excess and hyponatremia". Am. J. Kidney Dis. 47 (5): 727–37. doi:10.1053/j.ajkd.2006.01.020. PMID 16632011.
  3. ↑ Ellison DH, Berl T (May 2007). "Clinical practice. The syndrome of inappropriate antidiuresis". N. Engl. J. Med. 356 (20): 2064–72. doi:10.1056/NEJMcp066837. PMID 17507705.
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  45. ↑ Silvis SE, DiBartolomeo AG, Aaker HM (March 1980). "Hypophosphatemia and neurological changes secondary to oral caloric intake: a variant of hyperalimentation syndrome". Am. J. Gastroenterol. 73 (3): 215–22. PMID 6773412.
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  47. ↑ Ognibene A, Ciniglio R, Greifenstein A, Jarjoura D, Cugino A, Blend D, Whittier F (January 1994). "Ventricular tachycardia in acute myocardial infarction: the role of hypophosphatemia". South. Med. J. 87 (1): 65–9. PMID 7506845.
  48. ↑ Ketteler M, Block GA, Evenepoel P, Fukagawa M, Herzog CA, McCann L, Moe SM, Shroff R, Tonelli MA, Toussaint ND, Vervloet MG, Leonard MB (July 2017). "Executive summary of the 2017 KDIGO Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) Guideline Update: what's changed and why it matters". Kidney Int. 92 (1): 26–36. doi:10.1016/j.kint.2017.04.006. PMID 28646995.
  49. ↑ VALLEE BL, WACKER WE, ULMER DD (January 1960). "The magnesium-deficiency tetany syndrome in man". N. Engl. J. Med. 262: 155–61. doi:10.1056/NEJM196001282620401. PMID 13840893.
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