eMedicine Specialties > Nephrology > Acid-Base, Fluid, and Electrolyte Disorders

Hyporeninemic Hypoaldosteronism: Follow-up

Author: James H Sondheimer, MD, Director of Hemodialysis Unit, Harper Hospital; Associate Professor, Department of Internal Medicine, Division of Nephrology, Wayne State University School of Medicine
Contributor Information and Disclosures

Updated: Oct 7, 2009

Follow-up

Further Inpatient Care

  • Prior to discharge, ensure that the patient's potassium level is stable in an acceptable range using a regimen suitable for outpatient use. Generally, a stable potassium level below 5.5 mEq/L is acceptable, provided that the patient is compliant with diet, medications, and follow-up care. For those patients who may be less compliant, tighter control may be targeted to provide some margin of safety.
  • Ensure that the patient received dietary counseling.
  • Schedule timely outpatient follow-up care and laboratory testing.

Further Outpatient Care

  • Outpatient care consists of monitoring the response to therapy, with particular attention to blood pressure, volume status, and electrolytes.
  • If the RTA type IV was exacerbated by a drug that was discontinued, further therapy directed toward lowering potassium may no longer be needed and may even be harmful by causing hypokalemia and alkalosis.

Deterrence/Prevention

  • Because the tendency of many clinically important classes of medications is to produce an RTA type IV picture, preventing this condition by eliminating the patient's use of those agents is impossible. Rather, enable early detection by conducting laboratory screenings of patients at risk, after starting medicines in those classes.

Prognosis

  • RTA type IV can almost always be treated through some combination of adding and eliminating medications and implementing dietary restraint. The underlying renal disease, however, often progresses towards eventual end-stage renal disease (ESRD). Note that the 2 classes of agents (ie, ACE inhibitors, ARBs) with proven benefit in delaying progression of renal disease also are common causes of hyperkalemia, which may limit their utility in delaying the progression of CKD in some patients.

Patient Education

  • Educate patients about the risk of sudden catastrophic events from hyperkalemia and the importance of compliance with medications, diet, and follow-up procedures.

Miscellaneous

Medicolegal Pitfalls

  • Failure to adhere to monitoring guidelines after starting medications that have a risk of exacerbating RTA type IV is a pitfall, because although hyperkalemia is treatable, it may be lethal if undetected. (Early detection of renal disease may help in identifying those patients who are at greatest risk.)
  • Drug therapy of hyperkalemia may itself have adverse effects; in particular, patients must be adequately monitored for overtreatment with resulting hypokalemia, CHF, or metabolic alkalosis (depending on the agent[s] used).

Special Concerns

  • True RTA type IV and its drug-induced counterpart are increasing problems among elderly patients and are aggravated by polypharmacy.
 
Acknowledgments

The author would like to thank Dr. Jaideep Hingorani for his many helpful comments and suggestions.



More on Hyporeninemic Hypoaldosteronism

Overview: Hyporeninemic Hypoaldosteronism
Differential Diagnoses & Workup: Hyporeninemic Hypoaldosteronism
Treatment & Medication: Hyporeninemic Hypoaldosteronism
Follow-up: Hyporeninemic Hypoaldosteronism
References
Further Reading
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References

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Keywords

hyporeninemic hypoaldosteronism, aldosterone, renin, angiotensin renin, aldosterone angiotensin, renal tubular acidosis, distal renal tubular acidosis, hyperkalemia, hyperkalemic renal tubular acidosis, tubular hyperkalemia, cortical collecting tubule

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Contributor Information and Disclosures

Author

James H Sondheimer, MD, Director of Hemodialysis Unit, Harper Hospital; Associate Professor, Department of Internal Medicine, Division of Nephrology, Wayne State University School of Medicine
James H Sondheimer, MD is a member of the following medical societies: American College of Physicians and American Society of Nephrology
Disclosure: Nothing to disclose.

Medical Editor

Donald A Feinfeld, MD, FACP, FASN, Consulting Staff, Division of Nephrology & Hypertension, Beth Israel Medical Center
Donald A Feinfeld, MD, FACP, FASN is a member of the following medical societies: American Academy of Clinical Toxicology, American Society of Hypertension, American Society of Nephrology, and National Kidney Foundation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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

CME Editor

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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