Endocrine Hypertension:

Differential diagnoses in
hypokalaemic hypertension
Calvin Chong
Chemical Pathology, PMH

Significance
Relationship of hypokalaemia and
endocrine hypertension
Medicolegal concerns
o Guidelines available (but are they read?)

Investigations
Aldosterone-renin ratio
Overnight dexamethasone
suppression test
Balance study
Adrenal venous sampling

Investigations
Renal function test
Venous blood gas
Transtubular potassium gradient

How to investigate
hypokalaemic hypertension?
Never a problem even in medical
student examination
Always a problem in clinical practice
Problem: Not doing the tests

Investigations in
hypokalaemia

Repeat renal function test

Venous blood gas
Urine potassium
Transtubular potassium gradient

Hypokalaemia

Hypokalaemia

Hypokalaemia
Venous blood gas will do
no need for arterial puncture

Instead of doing it in two steps,

do the thing in one go.

Hypokalaemia

Investigation of renal tubular

acidosis is complex and may
need dynamic function tests
consider referring to renal units.

Hypokalaemia

Extra-renal loss
Could it be due to drugs?

Hypokalaemia

Renal loss mineralocorticoid

excess syndrome must be
considered.

Hypokalaemia
If it is transient, does it mean
that its not sinister?

Phaeochromocytoma may
present like this!

TTKG
Transtubular potassium gradient
o (Urine K/Plasma K)
(Urine osmolality/Plasma osmolality)
o Normally 3-7, a dimensionless value

In hypokalaemia, expect < 3

Reflects mineralocorticoid action

TTKG
To be interpretable:
Urine sodium >= 40 mmol/L
Urine osmolality > Serum osmolality
Not on potassium supplement

Mineralocorticoid excess syndromes

Investigations
Aldosterone-renin ratio
Overnight dexamethasone
suppression test

Aldosterone-renin ratio
Out of bed for >=2 hours
Seated for 5-15 minutes
Unrestricted salt intake

Discussions

Thanks!