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Hypokalemia

Hypokalemia is a potentially fatal condition in which the body fails to retain sufficient potassium to maintain health. The condition is also known as potassium deficiency. The prefix hypo- means low (contrast with hyper-, meaning high). The middle kal refers to kalium, which is Latin for potassium. The end portion of the word, -emia, means 'in the blood' (note, however, that hypokalemia is usually indicative of a systemic potassium deficit). more...

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Signs and symptoms

There may be no symptoms at all but severe hypokalemia may cause:

  • Muscle weakness
  • Disturbed heart rhythm (arrhythmias), leading to ectopic beats
  • Serious arrhythmias
  • Increased risk of hyponatraemia with resultant confusion and seizures

Causes

Hypokalemia can result from a variety of medical conditions:

  • Perhaps most obviously, insufficient consumption of potassium (that is, a low-potassium diet) can result in the condition. More commonly, however, hypokalemia occurs due to excessive loss of potassium, often associated with excess water loss, which "flushes" potassium out of the body. Typically, this is a consequence of vomiting and diarrhea.
  • Hypomagnesemia can also cause hypokalemia. This is realized as a possibility when hypokalemia persists despite potassium supplementation.
  • Certain medications can also accelerate the removal of potassium from the body, including loop diuretics, such as furosemide or bumetanide, as well as various laxatives. The antifungal amphotericin B is also associated with hypokalemia. Often doctors and pharmacists will suggest changes in their patients' diets to compensate for the effects of medication. For instance, recommending that a patient eat a (potassium-rich) banana daily; sometimes, doctors will co-prescribe a potassium supplement when a potassium-depleting drug is prescribed.

Pathophysiology

Potassium is essential for many body functions, including muscle and nerve activity. Potassium is the principal intracellular cation, with a concentration of about 145 mEq/L, as compared with a normal value of about 4 mEq/L in extracellular fluid, including blood. More than 98% of the body's potassium is intracellular; measuring it from a blood sample is relatively insensitive, with small fluctuations in the blood corresponding to very large changes in the total bodily reservoir of potassium.

The osmotic gradient of potassium between intracellular and extracellular space is essential for nerve function; in particular, potassium is needed to repolarize the cell membrane to a resting state after an action potential has passed. Decreased potassium levels in the extracellular will cause hyperpolarization of the resting membrane potential. As a result, a greater than normal stimulus is required for depolarization of the membrane in order to initiate an action potential.

Potassium is also essential to the normal muscular function, in both voluntary muscle (e.g. the arms and hands) and involuntary muscle (e.g. the heart and intestines). Severe abnormalities in potassium levels can seriously disrupt cardiac function, even to the point of causing cardiac arrest and death.

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A case of hypokalemia and rhabdomyolysis in a patient with short bowel syndrome
From JPEN: Journal of Parenteral and Enteral Nutrition, 7/1/03 by Guardino, Jason M

Rhabdomyolysis caused by the metabolic disturbances seen in chronic short bowel syndrome has not been reported in the English literature to our knowledge. Presented is a case of hypokalemic-induced rhabdomyolysis associated with short bowel syndrome.

A 48-year-old man was presented to the emergency department with complaints of severe generalized weakness and pain. He had a history of acute aortic dissection with resultant ischemic bowel, necessitating partial resection of the small bowel, ileostomy, and colostomy. He developed chronic diarrhea because of the short bowel syndrome and required parenteral nutrition. This was complicated by multiple episodes of central venous catheter bloodstream infections. For 2 years he demonstrated poor tolerance of oral nutrition; 7 weeks before presentation, he underwent surgical ileocolic anastomosis, with discontinuation of parenteral nutrition. Subsequently, he reported pain and weakness of the extremities, poor appetite, and a weight loss of 14 kg. He denied any fevers, chills, seizures, trauma, vomiting, nausea, contacts with ill individuals, and recent travel, and also denied abuse of diuretics, laxatives, alcohol, or illicit drugs. His medications included metoprolol and codeine, with no recent change in his doses.

Physical examination was remarkable for temperature 35.8, pulse 111, respiration 22, and blood pressure 159/86; the patient was a cachectic appearing male. Mucosal membranes were dry, and there was no jugular venous distention. Neuromuscular examination revealed tenderness to palpation at the proximal muscle groups of upper and lower extremities. There was demonstrable weakness of the same muscle groups. Sensation, reflex, and cranial nerve test results were normal.

Laboratory data are summarized in Table I.

An electrocardiogram (EKG) revealed sinus rhythm and left ventricular hypertrophy with new ST segment changes and U waves.

The patient was diagnosed with rhabdomyolysis secondary to hypokalemia. He received IV hydration and potassium replacement totaling 710 mmol. The patient did well and on the day of discharge reported resolution of his symptoms. Follow-up laboratory results are shown in Table I. A repeated EKG result was normal.

Nontraumatic rhabdomyolysis associated with hypokalemia may be a relatively common occurrence1 and has been documented in several settings.2-4 The mechanism of hypokalemic-induced rhabdomyolysis may relate to the impairment of the physiologic vasodilatory effects mediated by the local release of potassium by skeletal muscle cells.5

No other obvious cause for rhabdomyolysis in this patient was identified. The presence of short bowel syndrome in this case was a predisposing factor to the development of severe hypokalemia and subsequent rhabdomyolysis.

REFERENCES

1. Singhal PC, Abramovici M, Venkatesan J, et al: Hypokalemia and rhabdomyolysis. Mineral Electrolyte Metab 17:335-339, 1991

2. Lucatello A, Sturani A, Di Nardo A, et al: Acute renal failure in rhabdomyolysis associated with hypokalemia. Nephron 67:115-116, 1994

3. Prat G, Petrognani R, Diatta B, et al: Hypokalemia causing rhabdomyolysis and precordialgia. Intensive Care Med 27:1096, 2001

4. Cervello A, Alfaro A, Chumillas MJ: Hypokalemic myopathy induced by Giardia lamblia. N Engl J Med 329:210-211, 1993

5. Rose, BD, ed. Hypokalemia. IN Clinical Physiology of Acid-Base and Electrolyte Disorders, 5th ed. McGraw-Hill, New York, NY, 2001, pp 859-860

Jason M. Guardino, DO, MS; John K. Hix, MD; and Douglas Seidner, MD

From the Cleveland Clinic Foundation, Cleveland, Ohio

Received for publication, February 28, 2003.

Accepted for publication, March 26, 2003.

Correspondence: Dr. Jason M. Guardino, Desk E13, Internal Medicine, 9500 Euclid Avenue, Cleveland, OH 44195. Electronic mail may be sent to guardij@ccf.org.

Copyright American Society for Parenteral and Enteral Nutrition Jul/Aug 2003
Provided by ProQuest Information and Learning Company. All rights Reserved

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