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==Overview==
==Overview==
The etiology of hypokalemia can be quite difficult to diagnose. As a matter of fact, many organ systems are involved in the regulation of [[potassium]] level and any derangement to their normal function can cause hypokalemia. [[Drugs]], [[diarrhea]], [[kidney disease]], [[endocrine disease]]s and many others are potential culprits.
The etiology of hypokalemia can be quite difficult to diagnose. As a matter of fact, many organ systems are involved in the regulation of [[potassium]] level and any derangement to their normal function can cause hypokalemia. [[Drugs]], [[diarrhea]], [[kidney disease]], [[endocrine disease]]s and many others are potential culprits. Hypokalemia can be the consequence of decreased [[ingestion]], increased losses (renal, [[GI]] or [[excessive sweating]]) or transcellular shift from the extracellular to the intracellular compartment. The most common causes are [[diarrhea]], [[vomit]]ing and [[diuretic]] use (mostly loop and [[thiazide]] diuretics).
 
Hypokalemia can be the consequence of decreased [[ingestion]], increased losses (renal, GI or [[excessive sweating]]) or transcellular shift from the extracellular to the intracellular compartment. The most common causes are [[diarrhea]], [[vomit]]ing and [[diuretic]] use (mostly loop and [[thiazide]] diuretics).


==Causes==
==Causes==


Hypokalemia can be the consequence of decreased ingestion, increased losses or transcellular shift from the extracellular to the intracellular compartment.
[[Hypokalemia]] might be the result of excessive K loss ([[renal]] or extra-renal losses), insufficient intake, or increased [[transcellular]] shift of the [[potassium]] to the [[intracellular]] space.<ref name="PalmerClegg2016">{{cite journal|last1=Palmer|first1=Biff F.|last2=Clegg|first2=Deborah J.|title=Physiology and pathophysiology of potassium homeostasis|journal=Advances in Physiology Education|volume=40|issue=4|year=2016|pages=480–490|issn=1043-4046|doi=10.1152/advan.00121.2016}}</ref>
 
* Perhaps the most obvious cause is insufficient [[eating|consumption]] of potassium (that is, a low-potassium diet). However, without excessive potassium loss from the body, this is a rare cause of hypokalemia. [[Alcoholism]], [[anorexia nervosa]], dental problems and [[dysphagia]] can all impair food intake and cause hypokalemia. In the hospital setting, hypokalemia can present in patients on total parenteral nutrition or potassium-free IV fluids.   
* Perhaps the most obvious cause is insufficient [[eating|consumption]] of potassium (that is, a low-potassium diet). However, without excessive potassium loss from the body, this is a rare cause of hypokalemia. [[Alcoholism]], [[anorexia nervosa]], dental problems and [[dysphagia]] can all impair food intake and cause hypokalemia. In the hospital setting, hypokalemia can present in patients on total parenteral nutrition or potassium-free IV fluids.   


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** Certain [[medication]]s can accelerate the removal of potassium from the body; including [[thiazide diuretic]]s, such as [[hydrochlorothiazide]]; [[loop diuretic]]s, such as [[furosemide]]; as well as various [[laxative]]s.  The antifungal [[amphotericin B]] has also been associated with hypokalemia.  
** Certain [[medication]]s can accelerate the removal of potassium from the body; including [[thiazide diuretic]]s, such as [[hydrochlorothiazide]]; [[loop diuretic]]s, such as [[furosemide]]; as well as various [[laxative]]s.  The antifungal [[amphotericin B]] has also been associated with hypokalemia.  
** A special case of potassium loss occurs with [[DKA|diabetic ketoacidosis]].  In addition to urinary losses from [[polyuria]] and volume contraction, there is also obligate loss of potassium from kidney tubules as a [[cationic]] partner to the negatively charged [[ketone]], β-hydroxybutyrate.
** A special case of potassium loss occurs with [[DKA|diabetic ketoacidosis]].  In addition to urinary losses from [[polyuria]] and volume contraction, there is also obligate loss of potassium from kidney tubules as a [[cationic]] partner to the negatively charged [[ketone]], β-hydroxybutyrate.
** [[Hypomagnesemia]] can cause hypokalemia. [[Magnesium]] is required for adequate processing of potassium. This may become evident when hypokalemia persists despite potassium supplementation.  Other electrolyte abnormalities may also be present.
** [[Hypomagnesemia]] can cause hypokalemia. [[Magnesium]] is required for adequate processing of potassium. This may become evident when hypokalemia persists despite potassium supplementation.  Other electrolyte abnormalities may also be present.
** Disease states that lead to abnormally high [[aldosterone]] levels can cause hypertension and excessive urinary losses of potassium.  These include [[renal artery stenosis]] and tumors (generally non-malignant) of the [[adrenal]] glands.  [[Hypertension]] and hypokalemia can also be seen with a deficiency of the [[11β-hydroxylase]] enzyme which allows cortisol to stimulate [[aldosterone]] receptors.  This deficiency can either be congenital or caused by consumption of [[glycyrrhizin]], which is contained in extract of licorice, sometimes found in [[Herbal supplements]], candies and chewing tobacco.
** Disease states that lead to abnormally high [[aldosterone]] levels can cause hypertension and excessive urinary losses of potassium.  These include [[renal artery stenosis]] and tumors (generally non-malignant) of the [[adrenal]] glands.  [[Hypertension]] and hypokalemia can also be seen with a deficiency of the [[11β-hydroxylase]] enzyme which allows cortisol to stimulate [[aldosterone]] receptors.  This deficiency can either be congenital or caused by consumption of [[glycyrrhizin]], which is contained in extract of licorice, sometimes found in [[Herbal supplements]], candies and chewing tobacco.
**Rare [[hereditary]] defects of renal salt transporters, such as [[Bartter syndrome]] or [[Gitelman syndrome]] can cause hypokalemia, in a manner similar to that of diuretics.
**Rare [[hereditary]] defects of renal salt transporters, such as [[Bartter syndrome]] or [[Gitelman syndrome]] can cause hypokalemia, in a manner similar to that of diuretics.
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===Causes in Alphabetical Order <ref name="pmid25798039">{{cite journal |vauthors=Veltri KT, Mason C |title=Medication-induced hypokalemia |journal=P T |volume=40 |issue=3 |pages=185–90 |date=March 2015 |pmid=25798039 |pmc=4357351 |doi= |url=}}</ref> <ref name="pmid23839104">{{cite journal |vauthors=Marti G, Schwarz C, Leichtle AB, Fiedler GM, Arampatzis S, Exadaktylos AK, Lindner G |title=Etiology and symptoms of severe hypokalemia in emergency department patients |journal=Eur J Emerg Med |volume=21 |issue=1 |pages=46–51 |date=February 2014 |pmid=23839104 |doi=10.1097/MEJ.0b013e3283643801 |url=}}</ref> <ref name="pmid24490479">{{cite journal |vauthors=Wojtaszek E, Matuszkiewicz-Rowińska J |title=[Hypokalemia] |language=Polish |journal=Wiad. Lek. |volume=66 |issue=4 |pages=290–3 |date=2013 |pmid=24490479 |doi= |url=}}</ref> <ref name="pmid25107385">{{cite journal |vauthors=Jensen HK, Brabrand M, Vinholt PJ, Hallas J, Lassen AT |title=Hypokalemia in acute medical patients: risk factors and prognosis |journal=Am. J. Med. |volume=128 |issue=1 |pages=60–7.e1 |date=January 2015 |pmid=25107385 |doi=10.1016/j.amjmed.2014.07.022 |url=}}</ref> <ref name="pmid26671430">{{cite journal |vauthors=Lodin K, Palmér M |title=[Investigation of hypokalemia] |language=Swedish |journal=Lakartidningen |volume=112 |issue= |pages= |date=December 2015 |pmid=26671430 |doi= |url=}}</ref> <ref name="pmid25818223">{{cite journal |vauthors=Trefz FM, Lorch A, Zitzl J, Kutschke A, Knubben-Schweizer G, Lorenz I |title=Risk factors for the development of hypokalemia in neonatal diarrheic calves |journal=J. Vet. Intern. Med. |volume=29 |issue=2 |pages=688–95 |date=2015 |pmid=25818223 |pmc=4895488 |doi=10.1111/jvim.12541 |url=}}</ref> <ref name="pmid27750339">{{cite journal |vauthors=Alscher MD |title=["The silent killer: hyper- and hypokalaemia"] |language=German |journal=Dtsch. Med. Wochenschr. |volume=141 |issue=21 |pages=1531–1536 |date=October 2016 |pmid=27750339 |doi=10.1055/s-0042-109043 |url=}}</ref> <ref name="pmid23318823">{{cite journal |vauthors=Vavruk AM, Martins C, Nascimento MM, Hayashi SY, Riella MC |title=[Association between hypokalemia, malnutrition and mortality in peritoneal dialysis patients] |language=Portuguese |journal=J Bras Nefrol |volume=34 |issue=4 |pages=349–54 |date=2012 |pmid=23318823 |doi= |url=}}</ref> <ref name="pmid9700180">{{cite journal |vauthors=Gennari FJ |title=Hypokalemia |journal=N. Engl. J. Med. |volume=339 |issue=7 |pages=451–8 |date=August 1998 |pmid=9700180 |doi=10.1056/NEJM199808133390707 |url=}}</ref>===
===Causes in Alphabetical Order <ref name="pmid25798039">{{cite journal |vauthors=Veltri KT, Mason C |title=Medication-induced hypokalemia |journal=P T |volume=40 |issue=3 |pages=185–90 |date=March 2015 |pmid=25798039 |pmc=4357351 |doi= |url=}}</ref> <ref name="pmid23839104">{{cite journal |vauthors=Marti G, Schwarz C, Leichtle AB, Fiedler GM, Arampatzis S, Exadaktylos AK, Lindner G |title=Etiology and symptoms of severe hypokalemia in emergency department patients |journal=Eur J Emerg Med |volume=21 |issue=1 |pages=46–51 |date=February 2014 |pmid=23839104 |doi=10.1097/MEJ.0b013e3283643801 |url=}}</ref> <ref name="pmid24490479">{{cite journal |vauthors=Wojtaszek E, Matuszkiewicz-Rowińska J |title=[Hypokalemia] |language=Polish |journal=Wiad. Lek. |volume=66 |issue=4 |pages=290–3 |date=2013 |pmid=24490479 |doi= |url=}}</ref> <ref name="pmid25107385">{{cite journal |vauthors=Jensen HK, Brabrand M, Vinholt PJ, Hallas J, Lassen AT |title=Hypokalemia in acute medical patients: risk factors and prognosis |journal=Am. J. Med. |volume=128 |issue=1 |pages=60–7.e1 |date=January 2015 |pmid=25107385 |doi=10.1016/j.amjmed.2014.07.022 |url=}}</ref> <ref name="pmid26671430">{{cite journal |vauthors=Lodin K, Palmér M |title=[Investigation of hypokalemia] |language=Swedish |journal=Lakartidningen |volume=112 |issue= |pages= |date=December 2015 |pmid=26671430 |doi= |url=}}</ref> <ref name="pmid25818223">{{cite journal |vauthors=Trefz FM, Lorch A, Zitzl J, Kutschke A, Knubben-Schweizer G, Lorenz I |title=Risk factors for the development of hypokalemia in neonatal diarrheic calves |journal=J. Vet. Intern. Med. |volume=29 |issue=2 |pages=688–95 |date=2015 |pmid=25818223 |pmc=4895488 |doi=10.1111/jvim.12541 |url=}}</ref> <ref name="pmid27750339">{{cite journal |vauthors=Alscher MD |title=["The silent killer: hyper- and hypokalaemia"] |language=German |journal=Dtsch. Med. Wochenschr. |volume=141 |issue=21 |pages=1531–1536 |date=October 2016 |pmid=27750339 |doi=10.1055/s-0042-109043 |url=}}</ref> <ref name="pmid23318823">{{cite journal |vauthors=Vavruk AM, Martins C, Nascimento MM, Hayashi SY, Riella MC |title=[Association between hypokalemia, malnutrition and mortality in peritoneal dialysis patients] |language=Portuguese |journal=J Bras Nefrol |volume=34 |issue=4 |pages=349–54 |date=2012 |pmid=23318823 |doi= |url=}}</ref> <ref name="pmid9700180">{{cite journal |vauthors=Gennari FJ |title=Hypokalemia |journal=N. Engl. J. Med. |volume=339 |issue=7 |pages=451–8 |date=August 1998 |pmid=9700180 |doi=10.1056/NEJM199808133390707 |url=}}</ref>===
{{columns-list|3|
{{columns-list|
* [[ Ammonium Chloride    ]]
* [[ Ammonium Chloride    ]]
* [[Apparent mineralocorticoid excess    ]]
* [[Apparent mineralocorticoid excess    ]]

Latest revision as of 12:37, 27 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Aditya Govindavarjhulla, M.B.B.S. [3], Aida Javanbakht, M.D.; Assistant Editor(s)-In-Chief: Jack Khouri

Overview

The etiology of hypokalemia can be quite difficult to diagnose. As a matter of fact, many organ systems are involved in the regulation of potassium level and any derangement to their normal function can cause hypokalemia. Drugs, diarrhea, kidney disease, endocrine diseases and many others are potential culprits. Hypokalemia can be the consequence of decreased ingestion, increased losses (renal, GI or excessive sweating) or transcellular shift from the extracellular to the intracellular compartment. The most common causes are diarrhea, vomiting and diuretic use (mostly loop and thiazide diuretics).

Causes

Hypokalemia might be the result of excessive K loss (renal or extra-renal losses), insufficient intake, or increased transcellular shift of the potassium to the intracellular space.[1]

  • Perhaps the most obvious cause is insufficient consumption of potassium (that is, a low-potassium diet). However, without excessive potassium loss from the body, this is a rare cause of hypokalemia. Alcoholism, anorexia nervosa, dental problems and dysphagia can all impair food intake and cause hypokalemia. In the hospital setting, hypokalemia can present in patients on total parenteral nutrition or potassium-free IV fluids.
  • Excessive loss of potassium, often associated with excess water loss, which "flushes" potassium out of the body. Typically, this is a consequence of GI losses (vomiting and diarrhea), or excessive perspiration.
  • Transcellular potassium shift to the intracellular space:
    • Increased extracellular pH (each 0.11 unit increase in pH corresponds to a 0.4 meq/l decrease in potassium level)
    • Elevated insulin
    • Elevated beta-adrenergic activity (stress, beta-agonist intake, etc)
    • Rare hereditary defects of muscular ion channels and transporters that cause hypokalemic periodic paralysis can precipitate occasional attacks of severe hypokalemia and muscle weakness. These defects cause a heightened sensitivity to catechols and/or insulin and/or thyroid hormone that lead to sudden influx of potassium from the extracellular fluid into the muscle cells.
    • Hypothermia
    • Thyrotoxicosis
    • Theophylline
    • Rapid expansion of cell mass (eg, during refeeding after prolonged starvation, when patients with pernicious anemia are treated with vitamin B12 and with tumors having rapid cell turnover)

Common Causes

Causes by Organ System

Cardiovascular Heart failure, Hypertension
Chemical / poisoning Ackee Fruit Food poisoning, Aloe poisoning, Amitraz, Cascara sagrada, Herbal Agent overdose, Licorice, Mayapple poisoning, Organophosphates, Phenolphthalein
Dermatologic No underlying causes
Drug Side Effect Abiraterone, Acetaminophen, Ammonium Chloride, Amikacin, Aminophylline, Amlodipine and Benazepril, Amphotericin B, Anidulafungin, Arsenic trioxide, Artemether and lumefantrin, Bendrofluazide, Bufotenine poisoning, Bumetanide, Calcium resonium, Carbenoxolone, Caspofungin, Capreomycin sulfate, Cetuximab, Cyanocobalamin, Chlorothiazide, Chlortalidone, Clopamide, Corticosteroid medications, Cyclopenthiazide, Cytarabine Dexlansoprazole,Dolasetron mesylate, Diuretic use, Eribulin, Etacrynic acid, Ethacrynic Acid, Febuxostat, Felbamate, Formoterol, Frusemide, Gentamicin, Galantamine hydrobromide, Glycyrrhizic acid, Hydrochlorothiazide, Hydroflumethiazide, Imatinib mesylate, Indapamide, Ixabepilone, Kanamycin, Levalbuterol, Lithium, Losartan and Hydrochlorothiazide, Meropenem, Methyclothiazide, Metolazone, Mifepristone, Netilmicin, Nilotinib,Olodaterol, Ondansetron, Oxcarbazepine, Pamidronic acid, Panitumumab, Pramipexole, Para amino salicylic acid, Penicillin, Polythiazide, Pertuzumab, Prednisolone, Prednisone, Reproterol, Ritodrine, Salbutamol, Sorafenib, Sirolimus, Tacrolimus, Thiazides, Tiagabine, Toluene, Trichlormethiazide, Vancomycin, Voriconazole
Ear Nose Throat No underlying causes
Endocrine Aldosteronism, Congenital adrenal hyperplasia, Cushing's Syndrome, Diabetes, Glucocorticoid resistance, Hyperaldosteronism, Primary aldosteronism, Secondary aldosteronism, SIADH, Thyrotoxicosis, VIPoma
Environmental No underlying causes
Gastroenterologic Acute liver failure, Bowel fistulae, Bowel obstruction, Chloridorrhea, Colonic villous adenomata, Congenital chloride diarrhea, Diarrhea, Gastric fistula, Liver Cirrhosis
Genetic Cortisol 11 beta ketoreductase deficiency, Fanconi renotubular syndrome, Hypokalemic periodic paralysis, Liddle syndrome, Lightwood Albright syndrome
Hematologic Acute myeloid leukemia
Iatrogenic Insulin, IV fluids, Post operative , Sodium polystyrene sulfonate, Steroids, Ureterosigmoidostomy
Infectious Disease Diarrhea, Cholera, Pyelonephritis
Musculoskeletal / Ortho No underlying causes
Neurologic No underlying causes
Nutritional / Metabolic Acid Base Imbalance, Alcoholism, Alkalosis, Beer drinker syndrome, Diabetic ketoacidosis, Inadequate potassium in diet, Licorice, Refeeding syndrome, Vomiting
Obstetric/Gynecologic No underlying causes
Oncologic Acute myeloid leukemia, Functioning pancreatic endocrine tumor, Gastro enteropancreatic neuroendocrine tumor, Tumors
Opthalmologic No underlying causes
Overdose / Toxicity Iodine overuse, Laxative abuse, Mineralocorticoid excess
Psychiatric Anorexia nervosa, Bulimia nervosa, Eating disorder
Pulmonary No underlying causes
Renal / Electrolyte Apparent mineralocorticoid excess, Chronic pyelonephritis, Bartter's syndrome, Classic Distal Renal Tubular Acidosis, Conn's Syndrome, Gitelman syndrome, Gullner Syndrome, Hyperreninemic Hypoaldosteronism, Hypokalaemic distal renal tubular acidosis, Hypomagnesemia, Liddle syndrome, Proximal renal tubular acidosis, Renal tubular acidosis, Sodium polystyrene sulfonate, Ureterosigmoidostomy, Urinary tract obstruction
Rheum / Immune / Allergy Sjogren's Syndrome
Sexual No underlying causes
Trauma No underlying causes
Urologic No underlying causes
Dental No underlying causes
Miscellaneous Drip arm sample, Excessive sweating, Hypothermia

Causes in Alphabetical Order [2] [3] [4] [5] [6] [7] [8] [9] [10]

| style="text-align: left; vertical-align: top; " |

References

  1. ↑ Palmer, Biff F.; Clegg, Deborah J. (2016). "Physiology and pathophysiology of potassium homeostasis". Advances in Physiology Education. 40 (4): 480–490. doi:10.1152/advan.00121.2016. ISSN 1043-4046.
  2. ↑ Veltri KT, Mason C (March 2015). "Medication-induced hypokalemia". P T. 40 (3): 185–90. PMC 4357351. PMID 25798039.
  3. ↑ Marti G, Schwarz C, Leichtle AB, Fiedler GM, Arampatzis S, Exadaktylos AK, Lindner G (February 2014). "Etiology and symptoms of severe hypokalemia in emergency department patients". Eur J Emerg Med. 21 (1): 46–51. doi:10.1097/MEJ.0b013e3283643801. PMID 23839104.
  4. ↑ Wojtaszek E, Matuszkiewicz-Rowińska J (2013). "[Hypokalemia]". Wiad. Lek. (in Polish). 66 (4): 290–3. PMID 24490479.
  5. ↑ Jensen HK, Brabrand M, Vinholt PJ, Hallas J, Lassen AT (January 2015). "Hypokalemia in acute medical patients: risk factors and prognosis". Am. J. Med. 128 (1): 60–7.e1. doi:10.1016/j.amjmed.2014.07.022. PMID 25107385.
  6. ↑ Lodin K, Palmér M (December 2015). "[Investigation of hypokalemia]". Lakartidningen (in Swedish). 112. PMID 26671430.
  7. ↑ Trefz FM, Lorch A, Zitzl J, Kutschke A, Knubben-Schweizer G, Lorenz I (2015). "Risk factors for the development of hypokalemia in neonatal diarrheic calves". J. Vet. Intern. Med. 29 (2): 688–95. doi:10.1111/jvim.12541. PMC 4895488. PMID 25818223.
  8. ↑ Alscher MD (October 2016). "["The silent killer: hyper- and hypokalaemia"]". Dtsch. Med. Wochenschr. (in German). 141 (21): 1531–1536. doi:10.1055/s-0042-109043. PMID 27750339.
  9. ↑ Vavruk AM, Martins C, Nascimento MM, Hayashi SY, Riella MC (2012). "[Association between hypokalemia, malnutrition and mortality in peritoneal dialysis patients]". J Bras Nefrol (in Portuguese). 34 (4): 349–54. PMID 23318823.
  10. ↑ Gennari FJ (August 1998). "Hypokalemia". N. Engl. J. Med. 339 (7): 451–8. doi:10.1056/NEJM199808133390707. PMID 9700180.


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