Hypokalemia Treatment & Management

  • Author: Eleanor Lederer, MD; Chief Editor: Vecihi Batuman, MD, FACP, FASN   more...
 
Updated: Aug 5, 2009
 

Medical Care

Orient medical care toward 4 different aims: (1) decreasing potassium losses, (2) replenishing potassium stores, (3) evaluating for potential toxicities, and (4) determining the cause to prevent future episodes.

  • In treating hypokalemia, the first step is to identify and stop ongoing losses of potassium.
    • Discontinue diuretics/laxatives.
    • Use potassium-sparing diuretics if diuretic therapy is required (eg, severe heart failure).
    • Treat diarrhea or vomiting.
    • Use H2 blockers to decrease nasogastric suction losses.
    • Control hyperglycemia if glycosuria is present.
  • Repletion of potassium losses is the second step.
    • As a first approximation, for every decrease in serum potassium of 1 mEq/L, the potassium deficit is approximately 200-400 mEq. However, bear in mind that many factors in addition to the total body potassium stores contribute to the serum potassium concentration. Therefore, this calculation could either overestimate or underestimate the true potassium deficit.
    • Oral potassium is absorbed readily. Relatively large doses can be given safely. Oral administration is limited by patient tolerance because some individuals develop nausea or even gastrointestinal ulceration with enteral potassium formulations.
    • Intravenous potassium is less well tolerated because it can be highly irritating to veins and can be given only in relatively small doses, generally 10 mEq/h. Under close cardiac supervision in emergent circumstances, as much as 40 mEq/h can be administered through a central line.
    • Oral and parenteral potassium can be used safely simultaneously.
    • Take ongoing potassium losses into consideration by measuring the volume and potassium concentration of body fluid losses.
    • If the patient is severely hypokalemic, avoid glucose-containing parenteral fluids to prevent an insulin-induced shift of potassium into the cells.
    • If the patient is acidotic, correct the potassium first to prevent an alkali-induced shift of potassium into the cells.
    • Replete magnesium if low.
    • Tailor treatment to the individual patient. For example, if diuretics cannot be discontinued due to an underlying disorder such as congestive heart failure, institute potassium-sparing therapies such as a low-sodium diet, potassium-sparing diuretics, ACE inhibitors, and angiotensin receptor blockers. The low-sodium diet and potassium-sparing diuretics limit the amount of sodium reabsorbed at the cortical collecting tubule, thus limiting the amount of potassium secreted. ACE inhibitors and angiotensin receptor blockers inhibit the release of aldosterone, thus blocking the kaliuretic effects of that hormone.
  • Monitor for toxicity of hypokalemia. Generally, the toxicity of hypokalemia is cardiac in nature. Monitor the patient if evidence of cardiac arrhythmias is observed, and institute very aggressive replacement parenterally under monitored conditions.
  • Determine the underlying cause to treat and prevent further episodes.
    • Again, history and physical examination findings clarify the cause in the vast majority of cases.
    • Look for clues to the etiology.
      • Urine potassium concentration
      • Presence of hypertension or hypotension
      • Acid-base disturbances
      • Family history
      • Tooth erosion; melanosis coli; obsession with body image; high-risk behaviors such as cheerleading, wrestling, or modeling; or evidence of alcohol abuse
    • Tailor the workup to the individual patient if the cause is not completely apparent.
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Surgical Care

Generally, hypokalemia is a medical, not a surgical, condition. Surgical intervention is required only after determining that the etiology requires it. Etiologies that may require surgery include the following:

  • Renal artery stenosis
  • Adrenal adenoma
  • Intestinal obstruction producing massive vomiting
  • Villous adenoma
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Consultations

The following consultations may be appropriate, depending on the clinical findings:

  • Renal specialist for evaluation of unexplained urinary potassium losses suggested to be secondary to a tubular disorder
  • Endocrinologist if Cushing syndrome, primary hyperaldosteronism, glucocorticoid-remediable hypertension, or congenital adrenal hyperplasia is suggested
  • Psychiatrist for alcoholism or eating disorders
  • Surgeon (see Surgical Care)
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Diet

In general, a low-sodium and high-potassium diet is appropriate.

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Activity

Unless the patient has severe underlying cardiac disease, no restrictions are necessary. Instruct patients to discontinue exercise if muscle pain or cramps develop because this may herald hypokalemia significant enough to produce rhabdomyolysis.

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Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Eleanor Lederer, MD  Consulting Staff, Louisville VA Hospital; Professor of Medicine; Interim Chief of Nephrology; Director of Nephrology Training Program; Director, Metabolic Stone Clinic; Director of Outpatient Clinics, Kidney Disease Program, University of Louisville School of Medicine

Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Rosemary Ouseph, MD  Professor of Medicine, Director of Kidney Transplant, University of Louisville School of Medicine

Rosemary Ouseph, MD is a member of the following medical societies: American Society for Bone and Mineral Research, American Society of Nephrology, and American Society of Transplant Surgeons

Disclosure: Nothing to disclose.

Leslie Ford, MD  Assistant Professor of Medicine, Kidney Disease Program, University of Louisville School of Medicine

Leslie Ford, MD is a member of the following medical societies: American Medical Association, American Society of Nephrology, and Kentucky Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

James W Lohr, MD  Fellowship Program Director, Professor, Department of Internal Medicine, Division of Nephrology, State University of New York at Buffalo

James W Lohr, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Nephrology, and Central Society for Clinical Research

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Christie P Thomas, MBBS, FRCP, FASN, FAHA  Professor, Department of Internal Medicine, Division of Nephrology; Medical Director, Kidney and Kidney/Pancreas Transplant Program, University of Iowa Hospitals and Clinics

Christie P Thomas, MBBS, FRCP, FASN, FAHA is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Heart Association, American Society of Nephrology, American Society of Transplantation, American Thoracic Society, International Society of Nephrology, and Royal College of Physicians

Disclosure: Genzyme Grant/research funds Other

Rebecca J Schmidt, DO, FACP, FASN  Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine

Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association

Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Amgen Honoraria Speaking and teaching; Ortho Biotech Honoraria Speaking and teaching

Chief Editor

Vecihi Batuman, MD, FACP, FASN  Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology

Disclosure: Nothing to disclose.

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