Hyperkalemia

Aka: Hyperkalemia, Hyperkalemia Related EKG Changes

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II. Pathophysiology

  1. See Potassium Homeostasis
  2. See Genetic Syndromes Affecting Serum Potassium and Blood Pressure
  3. Images
    1. potassiumHomeostasis.png

III. Epidemiology

  1. Prevalence
    1. General population: 3.3%
    2. Emergency Department: 3.6%
    3. Chronic Kidney Disease: 18%
    4. Inpatient: 6.9 to 12.3%
    5. Brookes (2021) Intern Med J 51(11): 1906-18 [PubMed]
    6. Kovesdy (2018) Eur Heart J 39(17): 1535-42 [PubMed]
    7. Singer (2017) Clin Exp Emerg Med 4(2): 73-9 [PubMed]

IV. Causes

  1. See Hyperkalemia Causes

V. Findings: Signs and Symptoms

  1. Symptoms occur when Serum Potassium > 6.0 to 6.5 meq/L
  2. Neurologic Changes
    1. Weakness
    2. Paresthesias
    3. Areflexia
    4. Ascending paralysis
    5. Respiratory Failure
  3. Cardiovascular Changes
    1. Bradycardia to Asystole or Ventricular Fibrillation
    2. AV prolonged transmission to complete Heart Block

VI. Labs

  1. Chemistry Panel
    1. Serum Potassium
    2. Serum Electrolytes including serum bicarbonate
    3. Renal Function tests (BUN, Creatinine)
  2. Spot urine for Urine Potassium, Urine Sodium and Urine Creatinine
    1. Fractional Excretion of Potassium
    2. Transtubular Potassium Gradient
    3. Urine Sodium <25 mEq/L suggests decreased distal renal flow
      1. See Hyperkalemia Causes
  3. Other labs to consider (see evaluation below)
    1. Serum Aldosterone
    2. Serum renin

VII. Diagnostics: Electrocardiogram

  1. General
    1. EKG changes occur when Serum Potassium >6.0 meq/L
      1. EKG may however be normal despite significant Hyperkalemia
      2. When significant EKG changes are present, pursue aggressive Hyperkalemia Management
    2. Changes are listed in the classic, textbook description
      1. However, patient's EKG findings often fail to follow the typical pattern
  2. Initial
    1. T Waves peaked or Tented (increased amplitude) in V2, V3, II, III
  3. Next
    1. ST depression
    2. First degree AV Block (PR Interval increases)
    3. QT Interval shortening
  4. Next (ominous harbinger)
    1. QRS Duration widening (>110 msec)
    2. Loss of P Wave (Junctional Rhythm)
    3. Sine Wave appearance
    4. New Bundle Branch Block
  5. Final
    1. Biphasic wave (sine wave) QRS and T fusion
    2. Severe Bradycardia
    3. Imminent Asystole, Ventricular Tachycardia or Ventricular Fibrillation
  6. Changes exacerbated by
    1. Hyponatremia
    2. Hypocalcemia
    3. Metabolic Acidosis
    4. Hypermagnesemia
    5. Chronic Renal Failure with frequent, recurrent Hyperkalemia
      1. Change from normal EKG to Cardiac Arrest may be rapid in these patients

VIII. Evaluation: Non-Renal Causes (transcellular shift, Potassium load, Pseudohyperkalemia)

  1. Serious signs of Hyperkalemia present (EKG, symptoms)
    1. Urgent Hyperkalemia Management
  2. Consider Pseudohyperkalemia
    1. Consider confirmatory testing (re-draw sample)
  3. Consider exogenous source or transcellular shift
    1. See Hyperkalemia Causes
    2. Eliminate causative factors

IX. Evaluation: Decreased renal excetion

  1. Urine Sodium <25 mEq/L suggests decreased distal renal flow
    1. See Hyperkalemia Causes
    2. Acute Kidney Injury or Chronic Kidney Disease
    3. Congestive Heart Failure
    4. Cirrhosis
  2. Urine Sodium >25 mEq/L with normal serum Aldosterone
    1. Primary tubular defects (e.g. RTA-4)
    2. Obstructive uropathy
    3. Tubular unresponsiveness to Aldosterone (e.g. SLE, Multiple Myeloma, Sickle Cell Anemia)
    4. Medications (e.g. Potassium sparing Diuretics, Lithium, Trimethoprim)
  3. Urine Sodium >25 mEq/L with low serum Aldosterone and normal serum renin
    1. Primary Adrenal Insufficiency
    2. Medications (Heparin, Cyclosporine, ACE Inhibitor, ARB)
  4. Urine Sodium >25 mEq/L with low serum Aldosterone and low serum renin
    1. Hyperglycemia
    2. Primary renal tubular defects
    3. Medications (e.g. NSAIDs, Beta Blockers)

X. Management

  1. See Hyperkalemia Management

XI. References

  1. Gibbs in Marx (2002) Rosen's Emerg Med, p. 1730-1
  2. Klahr (2001) in Noble (2001) Primary Care p. 1359-62
  3. Kim (2023) Am Fam Physician 107(1): 59-70 [PubMed]
  4. Viera (2015) Am Fam Physician 92(6): 487-95 [PubMed]

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Related Studies

Ontology: Hyperkalemia (C0020461)

Definition (NCI) Higher than normal levels of potassium in the circulating blood; associated with kidney failure or sometimes with the use of diuretic drugs.
Definition (NCI_CTCAE) A disorder characterized by laboratory test results that indicate an elevation in the concentration of potassium in the blood; associated with kidney failure or sometimes with the use of diuretic drugs.
Definition (MSH) Abnormally high potassium concentration in the blood, most often due to defective renal excretion. It is characterized clinically by electrocardiographic abnormalities (elevated T waves and depressed P waves, and eventually by atrial asystole). In severe cases, weakness and flaccid paralysis may occur. (Dorland, 27th ed)
Definition (CSP) abnormally high potassium concentration in the blood, most often due to defective renal excretion; characterized clinically by electrocardiographic abnormalities; in severe cases, weakness and flaccid paralysis may occur.
Concepts Finding (T033)
MSH D006947
ICD9 276.7
ICD10 E87.5
SnomedCT 154761005, 154764002, 166689004, 14140009, 238142003
English Hyperkalemias, Hyperpotassemia, Hyperpotassemias, HYPERKALAEMIA, HYPERKALEMIA, HYPERPOTASSAEMIA, hyperkalemia (diagnosis), high blood potassium level, hyperkalemia, Potassium [K] excess, Potassium [K] overload, Hyperkalemia [Disease/Finding], Hyperkalemia, potassium overload, excess k, excess potassium, potassium excess, hyperpotassemia, excessive potassium in the blood, Hyperkalaemia (disorder), Hyperkalemic disorder, Serum potassium concentration increased above normal, Hyperkalemic syndrome, K excess, K overload, Potassium excess, Hyperkalaemia, Potassium overload, Raised serum potassium level, Hyperpotassaemia, Hyperkalaemic syndrome, Hyperkalemia (disorder), Potassium overload (disorder), Raised serum potassium level (finding), excess; potassium, hyperkalemic; syndrome, overload; potassium, potassium; excess, potassium; overload, syndrome; hyperkalemic, hyperkalaemia
French HYPERKALIEMIE, Hyperpotassémie, HYPERPOTASSEMIE, Hyperkaliémie
German HYPERKALIAEMIE, KALIUMSPIEGEL ERHOEHT, Hyperkaliaemie, Hyperpotassemia, Hyperkaliämie
Portuguese HIPERPOTASSEMIA, HIPERKALIEMIA, Hipercaliemia, Hiperpotassemia
Spanish HIPERPOTASEMIA, Hiperkaliemia, Hipercaliemia, HIPERCALIEMIA, hipercalemia, síndrome hiperpotasémico, hiperkalemia, exceso de K, exceso de potasio, hipercaliemia (trastorno), hipercaliemia, hiperpotasemia, nivel de potasio sérico elevado (hallazgo), nivel de potasio sérico elevado, sobrecarga de potasio (trastorno), sobrecarga de potasio, Hiperpotasemia, Hiperkalemia
Italian Iperkaliemia, Iperpotassemia, Iperpotassiemia
Swedish Hyperkalemi
Japanese ｺｳｶﾘｳﾑｹｯｼｮｳ, ｺｳｶﾘｳﾑｹﾂｼｮｳ, 過ポタシウム血症, 高カリウム血症, カリウム過剰血, カリウム過剰血症, 高カリウム血, 高K血症
Finnish Hyperkalemia
Russian GIPERKALIEMIIA, ГИПЕРКАЛИЕМИЯ
Czech Hypekalemie, hyperkalemie, hyperkalémie
Korean 고칼륨혈증
Croatian HIPERKALIJEMIJA
Polish Hiperkaliemia, Hiperpotasemia
Hungarian Hyperpotassaemia, Hyperkalaemia
Norwegian Hyperkalemi
Dutch hyperkaliëmisch; syndroom, kalium; overbelasting, kalium; overmaat, overbelasting; kalium, overmaat; kalium, syndroom; hyperkaliëmisch, hyperkaliëmie, Hyperpotassemie, Hyperkaliëmie, Kaliëmie, hyper-
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Potassium Disorders

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