History

The symptoms of hypokalemia are nonspecific and predominantly are related to muscular or cardiac function. Weakness and fatigue are the most common complaints. The muscular weakness that occurs with hypokalemia can manifest in protean ways (eg, dyspnea, constipation or abdominal distention, exercise intolerance). Rarely, muscle weakness progresses to frank paralysis. With severe hypokalemia or total body potassium deficits, muscle cramps and pain can occur with rhabdomyolysis.

Occasionally, a patient may complain of worsening diabetes control or polyuria due to a recent onset of hyperglycemia or nephrogenic diabetes insipidus. Patients also may complain of palpitations. Psychological symptoms may include psychosis, delirium, hallucinations, and depression.^[49]

Patients are often asymptomatic, particularly with mild hypokalemia. Symptoms that are present are often from the underlying cause of the hypokalemia rather than the hypokalemia itself.

When the diagnosis of hypokalemia is discovered, investigate potential pathophysiologic mechanisms.

Poor intake may result from the following:

Eating disorders
Dental problems
Poverty

Increased excretion may be due to the following:

Medications (eg, diuretics, antiretroviral agents, antibiotics; see Etiology)
Polyuria
Vomiting or diarrhea

Shift of potassium into the intracellular space may occur due to the following:

Recurrent episodes of paralysis
Use of high doses of insulin
High-dose beta-agonist therapy (eg, for chronic obstructive pulmonary disease)

Ask whether the patient has had similar episodes in the past. Familial historical data may include surgery for pituitary or adrenal tumors or acute intermittent episodes of paralysis, with or without association with hyperthyroidism.

Physical Examination

Physical examination findings are often within the reference range. Vital signs generally are normal, except for occasional tachycardia with irregular beats or tachypnea resulting from respiratory muscle weakness. Hypertension may be a clue to primary hyperaldosteronism, renal artery stenosis, licorice ingestion, or the more unusual forms of genetically transmitted hypertensive syndromes, such as congenital adrenal hyperplasia, glucocorticoid-remediable hypertension, or Liddle syndrome.

Relative hypotension should suggest occult laxative use, diuretic use, bulimia, or one of the unusual tubular disorders, such as Bartter syndrome or Gitelman syndrome. Bear in mind that occult diuretic use is far more common than either of those congenital tubular disorders and is, in fact, also called "pseudo-Bartter syndrome."

Muscle weakness and flaccid paralysis may be present. Patients may have depressed or absent deep-tendon reflexes. Hypoactive bowel sounds may suggest hypokalemic gastric hypomotility or ileus.

Severe hypokalemia may manifest as bradycardia with cardiovascular collapse. Cardiac arrhythmias and acute respiratory failure from muscle paralysis are life-threatening complications that require immediate diagnosis.

Tooth erosion may be present in patients with bulimia. This finding has particular significance in patients whose history indicates high risk (eg, obsession with body image or participation in activities such as cheerleading, wrestling, or modeling).

Differential Diagnoses

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Media Gallery

A model of transport mechanisms in the distal convoluted tubule. Sodium-chloride (NaCl) enters the cell via the apical thiazide-sensitive NCC and leaves the cell through the basolateral Cl− channel (ClC-Kb), and the Na+/K+-ATPase. Indicated also are the recently identified magnesium channel TRPM6 in the apical membrane, and a putative Na/Mg exchanger in the basolateral membrane. These transport mechanisms play a role in familial hypokalemia-hypomagnesemia or Gitelman syndrome.

of 1

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 Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation

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.

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.

Chief Editor

Vecihi Batuman, MD, FASN Professor of Medicine, Section of Nephrology-Hypertension, 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, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Acknowledgements

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.

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.

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 Reference 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