Sections

Hyperkalemia

DDx

Diagnostic Considerations

Pseudohyperkalemia is the term applied to the clinical situation in which in vitro lysis of cellular contents leads to measurement of a high serum potassium level that does not reflect the true in vivo level. It occurs most commonly with red blood cell hemolysis during the blood draw (eg, when the tourniquet is too tight or left on too long or the blood is left sitting too long). With intravascular hemolysis (eg, from a transfusion reaction, hemolytic sickle crisis, or drug-induced hemolytic reaction), in contrast, the measured potassium level reflects the actual level.

In pediatric patients, factitious hyperkalemia can occur because of “milking” of extremities (which can introduce a significant amount of interstitial fluid into the blood sample) during phlebotomy, especially with heel-poke and finger-stick phlebotomy, which are commonly performed in infants and small children. Hemolysis can also be caused by fist clenching during phlebotomy, which can also lead to an acidotic sample with resultant hyperkalemia.

Blood sampled “upstream” of an intravenous (IV) line infusing potassium-containing fluid (or from a multiple-lumen central venous catheter in which the sampling lumen is near the lumen containing potassium-rich infusate) can have falsely elevated levels of potassium that do not reflect circulating levels.

Thrombocytosis can also lead to false elevations of serum potassium levels. The normal serum potassium level is 0.4 mEq/L higher than the plasma level because of potassium release during clot formation. For every 100,000/µL elevation in the platelet count, the serum potassium increases by approximately 0.15 mEq/L. This can easily be corrected on the basis of a measurement of whole blood potassium level. A similar effect on serum, but not plasma, potassium can also be seen with leukocytosis.

Differential Diagnoses

Workup

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Media Gallery

Widened QRS complexes in patient whose serum potassium level was 7.8 mEq/L.
ECG of patient with pretreatment potassium level of 7.8 mEq/L and widened QRS complexes after receiving 1 ampule of calcium chloride. Note narrowing of QRS complexes and reduction of T waves.
Hyperkalemia diagnosis and treatment flow chart.
Widened QRS complexes in hyperkalemia.

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Author

Eleanor Lederer, MD, FASN Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD, FASN 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, Phi Beta Kappa

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: American Society of Nephrology<br/>Received income in an amount equal to or greater than $250 from: Healthcare Quality Strategies, Inc<br/>Received grant/research funds from Dept of Veterans Affairs for research; Received salary from American Society of Nephrology for asn council position; Received salary from University of Louisville for employment; Received salary from University of Louisville Physicians for employment; Received contract payment from American Physician Institute for Advanced Professional Studies, LLC for independent contractor; Received contract payment from Healthcare Quality Strategies, Inc for independent cont.

Coauthor(s)

Zygimantas C Alsauskas, MD Assistant Professor of Medicine, Division of Nephrology, Kidney Disease Program, University of Louisville School of Medicine

Zygimantas C Alsauskas, MD is a member of the following medical societies: American Society of Nephrology

Disclosure: Nothing to disclose.

Lina Mackelaite, MD Assistant Professor of Medicine, University of Louisville School of Medicine

Lina Mackelaite, MD is a member of the following medical societies: American Society of Hypertension, American Society of Nephrology, American Society of Transplantation, National Kidney Foundation

Disclosure: Nothing to disclose.

Vibha Nayak, MD Assistant Professor of Nephrology, Director of Home Dialysis, Kidney Disease Program, University of Louisville School of Medicine

Vibha Nayak, MD is a member of the following medical societies: American Society of Nephrology

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Interim Chair, Deming Department of Medicine, Tulane University School of Medicine

Vecihi Batuman, MD, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, International Society of Nephrology, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Acknowledgements

Son Dinh, MD Nephrologist, Southland Renal Medical Group, Inc

Son Dinh, MD is a member of the following medical societies: American Society of Nephrology and National Kidney Foundation

Disclosure: Nothing to disclose.

Anil Kumar Mandal, MD Clinical Professor, Department of Internal Medicine, Division of Nephrology, University of Florida School of Medicine

Anil Kumar Mandal, MD is a member of the following medical societies: American College of Clinical Pharmacology, American College of Physicians, American Society of Nephrology, and Central Society for Clinical Research

Disclosure: Nothing to disclose.

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.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape 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 Heart Association, American Society of Nephrology, and Royal College of Physicians

Disclosure: Nothing to disclose.

Factor	Effect on Plasma K⁺	Mechanism
Aldosterone	Decrease	Increases sodium resorption, and increases K⁺ excretion
Insulin	Decrease	Stimulates K⁺ entry into cells by increasing sodium efflux (energy-dependent process)
Beta-adrenergic agents	Decrease	Increases skeletal muscle uptake of K⁺
Alpha-adrenergic agents	Increase	Impairs cellular K⁺ uptake
Acidosis (decreased pH)	Increase	Impairs cellular K⁺ uptake
Alkalosis (increased pH)	Decrease	Enhances cellular K⁺ uptake
Cell damage	Increase	Intracellular K⁺ release
Succinylcholine	Increase	Cell membrane depolarization

Hyperkalemia Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

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