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Hypokalemia

Updated 2013 Nov 15 01:39:00 PM: review of hypokalemia (BMJ 2013 Sep 24) view update Show more updates

Related Summaries:
Potassium supplements

General Information

Description:
serum potassium < 3.6 mEq/L (3.6 mmol/L)(1, 2, 3) (reference ranges may vary between laboratories)
clinical symptoms usually occur with more severe hypokalemia (< 2.5 mEq/L [2.5 mmol/L])(1)

Also called:
hypopotassemia
low potassium

Types:
mild hypokalemia - potassium 3-3.5 mEq/L (3-3.5 mmol/L)(1)
severe hypokalemia - potassium < 2.5 mEq/L (2.5 mmol/L) or symptomatic(1, 3, 4)

Who is most affected:

patients taking potassium-wasting medications, especially diuretics(2)
hospitalized patients(1)
patients with cardiovascular disease may be more likely to have clinical implications(1)

Incidence/Prevalence:
2.6% hospitalized patients may have significant hypokalemia (potassium < 3 mEq/L [3 mmol/L])
based on retrospective study at a tertiary care center in Jerusalem, Israel in 1997
866 patients (2.6% of annual hospitalizations) had 975 episodes of severe hypokalemia defined as serum potassium level
< 3 mEq/L (3 mmol/L)
7 episodes (0.7%) < 2 mEq/L (2 mmol/L)
83 episodes (8.5%) ≤ 2.4 mEq/L (2.4 mmol/L)
885 episodes (90.8%) 2.5-2.9 mEq/L (2.5-2.9 mmol/L)
severe hypokalemia was reason for admission for 274 episodes (28.1%), 701 episodes (71.9%) occurred during
hospitalization
Reference - Arch Intern Med 2001 Apr 23;161(8):1089
21% hospitalized patients develop hypokalemia (5.2% with potassium < 3 mEq/L [3 mmol/L])
based on retrospective study of biochemical data from 58,167 inpatient records
21% developed hypokalemia during hospitalization
5.2% had serum potassium < 3 mEq/L (3 mmol/L)
56% cases attributed to drug or IV fluid
Reference - Postgrad Med J 1986 Mar;62(725):187 EBSCOhost Full Text
hypokalemia may be present in 10%-40% of outpatients taking thiazide diuretic ((1), Am J Cardiol 1990 Mar 6;65(10):4E)
Causes and Risk Factors

Causes:
drug-induced causes(1)
drugs causing potassium shift into intracellular space
beta-2-adrenergic agonists
epinephrine
decongestants
pseudoephedrine
phenylpropanolamine
bronchodilators

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albuterol
terbutaline
pirbuterol
isoetharine
fenoterol
ephedrine
isoproterenol
metaproterenol
tocolytic agents
ritodrine
nylidrin
theophylline
caffeine
verapamil
chloroquine
retrospective study of 191 cases of hypokalemia due to chloroquine poisoning can be found in Lancet 1995 Sep
30;346(8979):877, commentary can be found in Lancet 1995 Dec 16;346(8990):1625, Lancet 1996 Feb
10;347(8998):404
insulin
drugs causing increased renal loss
diuretics (degree of hypokalemia related to dose and half-life of drug)
acetazolamide
thiazides
chlorthalidone
indapamide
metolazone
quinethazone
loop diuretics
bumetanide
ethacrynic acid
furosemide
torsemide
diuretics reported to account for 36% cases in cohort of 866 hospitalized patients with severe hypokalemia (Arch
Intern Med 2001 Apr 23;161(8):1089)
mineralocorticoids (fludrocortisone)
carbenoxolone
high-dose glucocorticoids
corticosteroids reported to account for 31% cases in cohort of 866 hospitalized patients with severe hypokalemia
(Arch Intern Med 2001 Apr 23;161(8):1089)
high-dose antibiotics
penicillin (penicillin G)
nafcillin
ampicillin
carbenicillin
drugs associated with magnesium depletion
aminoglycosides
cisplatin
foscarnet
amphotericin B
drugs that increase potassium loss in stool
phenolphthalein
sodium polystyrene sulfonate
oral sodium phosphate (bowel preparation for colonoscopy or barium enema)
hypocalcemia and hypokalemia seen in 56%-58% of 36 elderly patients receiving oral sodium
phosphate for colon preparation prior to colonoscopy or barium enema
hypokalemia associated with dementia and lower baseline potassium levels
hypocalcemia associated with hyperphosphatemia

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Reference - Arch Intern Med 2003 Apr 14;163(7):803
sodium bicarbonate administration in patients with untreated type II or proximal renal tubular acidosis
non-drug-induced causes(1)
transcellular shift or cellular uptake
refeeding syndrome
thyrotoxic periodic paralysis
estimated incidence 2%-8% in Asian countries
report of 7 cases of thyrotoxic periodic paralysis in United States can be found in Medicine (Baltimore) 1992
May;71(3):109
familial hypokalemic periodic paralysis
rare, autosomal dominant disease
characterized by sudden attacks of muscle paralysis and severe hypokalemia (serum potassium often < 2.5
mEq/L [2.5 mmol/L])
delirium tremens
hypokalemia presumably due to beta-adrenergic stimulation of severe alcohol withdrawal
severity of hypokalemia correlates with plasma epinephrine concentration
ingestion of barium compounds
blocks transfer of potassium out of cells
severe cases may be associated with muscle weakness, paralysis, and rhabdomyolysis
hypokalemia can be exacerbated by nausea and vomiting caused by barium intake
acute reduction in serum potassium due to rapid potassium uptake
for example, potassium uptake by newly forming cells (for example, following treatment of severe pernicious
anemia)
mean 0.4 mEq/L (0.4 mmol/L) decrease in serum potassium associated with treatment of megaloblastic
anemia after mean 2.5 days in study of 18 patients with initial packed cell volume < 25% (Clin Sci Mol Med
1975 Jul;49(1):77)
transfusion of previously frozen washed red cells (which take up potassium)
substances with mineralocorticoid effects
licorice
chewing gum flavored with licorice (glycyrrhizinic acid) associated with sodium retention, hypokalemia,
hypertension, alkalosis and renin-aldosterone suppression in 2 case reports (BMJ 1997 Mar 8;314(7082):731
EBSCOhost Full Text full-text)
hypokalemic paralysis due to licorice consumption in case report (Mayo Clin Proc 2003 Jun;78(6):767
EBSCOhost Full Text PDF)
severe licorice-induced hypokalemia resulting in ventricular fibrillation in case report (Lancet 2009 Mar
28;373(9669):1144)
glycyrrhizin-induced hypokalemia reported in series of 14 patients in Japan, mostly in elderly taking herbal medicine (J
Am Geriatr Soc 2008 Aug;56(8):1579)
gossypol (found in cottonseed oil)
inadequate dietary intake
dietary intake < 1 g/day (25 mmol/day) can cause potassium depletion and hypokalemia
hypokalemia rarely due to decreased intake
loss due to increased stool volume (stool potassium concentration 80-90 mEq/L [80-90 mmol/L], daily loss about 10
mEq [10 mmol])
acute diarrhea
chronic diarrhea
ileostomy
short bowel syndrome
renal loss
chloride-associated metabolic alkalosis - chloride depletion from vomiting or nasogastric suction
rarely chloride-resistant metabolic alkalosis due to
true mineralocorticoid excess
primary hyperaldosteronism (adrenal adenoma, adrenal carcinoma or bilateral adrenal hyperplasia)
congenital adrenal hyperplasia (11-beta or 17-alphahydroxylase deficiency)
renin-secreting tumors
ectopic corticotropin stimulation (ectopic ACTH syndrome)
Cushing disease or Cushing syndrome (pituitary/adrenal)

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hereditary glucocorticoid-responsive aldosteronism
renovascular hypertension (renal artery stenosis)
hypertensive emergency
vasculitis
apparent mineralocorticoid excess
Liddle syndrome
11-beta-hydroxysteroid dehydrogenase deficiency
impaired chloride-associated sodium transport
Bartter syndrome
Gitelman syndrome
metabolic acidosis due to type I (distal) renal tubular acidosis (RTA)
associated with severe hypokalemia (< 2 mEq/L [2 mmol/L]), may be life-threatening
requires correction with sodium bicarbonate and usually long-term potassium supplementation
uncontrolled diabetes
osmotic diuresis causes increased potassium loss
insulin administration can unmask underlying deficit
insulin administration without potassium replacement in patients with diabetic ketoacidosis or severe nonketotic
hyperglycemia can lead to hypokalemia
ureteral diversion into colon (intestinocystoplasty, ureterosigmoidostomy) - can lead to hyperchloremic acidosis and
increased loss of potassium in the gut (Urology 2003 Aug;62(2):254, World J Surg 1999 Feb;23(2):207, J Urol 1987
Sep;138(3):579)
other diseases or conditions
magnesium depletion (dietary restriction or abnormal losses)
reduces intracellular potassium concentration and causes renal potassium wasting
magnesium depletion and potassium depletion often coexist because some drugs and conditions cause loss of
both magnesium and potassium
leukemia (myeloid, monomyeloblastic or lymphoblastic)
hypokalemic myopathy related to excessive cola intake (4-10 L/day) reported in 1 case (Lancet 2004 Sep
25;364(9440):1190 EBSCOhost Full Text)

Pathogenesis:
disruption of normal potassium homeostasis(1)
depletion of potassium and hypokalemia can occur through decreased intake or increased output and persist despite normal
hormonal signalling and renal function
0.3 mEq/L (0.3 mmol) decrease in serum potassium levels associated with 100 mmol reduction in total body stores (in
absence of transcellular redistribution)
in normal potassium homeostasis, potassium distribution regulated by insulin and beta-adrenergic catecholamines
increase cellular uptake via Na+/K+-ATPase
increased intracellular potassium stimulates increased production of insulin and aldosterone
aldosterone promotes potassium excretion
diuretic-induced renal potassium wasting(1)
both thiazide-type diuretics and loop diuretics block sodium reabsorption in proximal nephron
increased delivery of sodium to distal nephron creates electrochemical gradient favoring potassium secretion
degree of potassium wasting is proportional to dose of thiazide diuretic and dietary sodium intake
Complications and Associated Conditions

Complications:
cardiac arrhythmias may occur in patients with mild-to-moderate hypokalemia and history of(1, 2, 4)
cardiac ischemia
heart failure
left ventricular hypertrophy
digoxin use (hypokalemia potentiates arrhythmogenicity)
case report of life-threatening arrhythmia in patient with severe hypokalemia (BMJ Case Rep 2012 Oct 19;2012)
hypokalemia may increase risk of perioperative arrhythmia and need for cardiopulmonary resuscitation (CPR)
in patients having elective coronary artery bypass grafting
based on prospective cohort study of 2,402 patients having elective coronary artery bypass grafting
1,290 patients (53.7%) had perioperative arrhythmias
238 patients (10.7%) had intraoperative arrhythmias

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329 patients (13.7%) had postoperative nonatrial arrhythmias
865 patients (36%) had postoperative atrial flutter of fibrillation
3.6% mortality, 2% cardiac mortality, 3.5% had CPR
serum potassium < 3.5 mEq/L (3.5 mmol/L) predictive of
perioperative arrhythmia (odds ratio [OR] 2.2, 95% CI 1.2-4)
intraoperative arrhythmia (OR 2, 95% CI 1-3.6)
postoperative atrial flutter/fibrillation (OR 1.7, 95% CI 1-2.7)
need for CPR associated with serum potassium level < 3.3 mEq/L (3.3 mmol/L) or > 5.2 mEq/L (5.2 mmol/L) but not
significant after adjusting for confounders
Reference - JAMA 1999 Jun 16;281(23):2203
hypokalemia may be associated with increased risk of stroke
based on case-control study
593 patients with ischemic stroke were compared to 125 patients with hemorrhagic stroke and 2,397 controls without stroke
all cases and controls were treated hypertensive adults aged 30-79 years
hypokalemia (serum potassium ≤ 3.4 mEq/L [3.4 mmol/L] on most recent measure in previous year) was found in 3%
ischemic stroke patients, 6% hemorrhagic stroke patients and 2% controls
hypokalemia associated with risk of ischemic stroke (OR 2.04, 95% CI 1.14-3.64) and hemorrhagic stroke (OR 3.29, 95%
CI 1.45-7.48) in adjusted analyses, associations not modified by diuretic use
Reference - Am J Hypertens 2003 Oct;16(10):806
elevated blood pressure
potassium depletion and hypokalemia increase systolic and diastolic blood pressure when sodium intake not restricted(1)
short-term potassium depletion in normotensive subjects ingesting normal amounts of sodium increases mean arterial
pressure
normal potassium ingestion protects against hypertension due to acute sodium loading
Reference - J Am Soc Nephrol 1990 Jul;1(1):43 PDF
myopathy
muscle necrosis with serum potassium < 2.5 mEq/L (2.5 mmol/L)(1)
case reports of hypokalemic myopathy due to excessive cola consumption can be found in Lancet 2004 Sep 25-Oct
1;364(9440):1190 EBSCOhost Full Text, Obstet Gynecol 2001 May;97(5 Pt 2):805, Intern Med J 2001 Jul;31(5):317
myopathy may progress to rhabdomyolysis, myoglobinuria and acute renal failure (most often seen in hypokalemia due to
alcohol abuse)(2)
paralytic ileus - in retrospective review of 48 cases of colonic ileus, 29% had hypokalemia (Dis Colon Rectum 1992
Dec;35(12):1135)
case report of acute anuric renal failure in patient with chronic hypokalemia can be found in Nephrol Dial Transplant 1999
Sep;14(9):2216 EBSCOhost Full Text full-text
respiratory distress may occur with serum potassium < 2 mEq/L (2 mmol/L)(1)

Associated conditions:
hypomagnesemia(1)
nocturnal leg cramps
based on questionnaire survey of 490 Veterans Affairs outpatients
276 (56%) reported nocturnal leg cramps
hypokalemia associated with nocturnal leg cramps (OR 1.74, 95% CI 1.01-3.01)
Reference - West J Med 1991 Sep;155(3):256 PDF, commentary can be found in West J Med 1992 Feb;156(2):211
History and Physical

History:

Chief concern (CC):

risk of symptoms related to speed of decrease in serum potassium(1, 4)
mild hypokalemia (3-3.5 mEq/L [3-3.5 mmol/L])(1, 4)
often asymptomatic
if symptomatic, may present with fatigue or minimal muscle weakness
symptoms associated with more severe hypokalemia(1, 2, 4)
muscle weakness, lower limbs more commonly affected than upper limbs
fatigue
constipation (paralytic ileus)
ascending paralysis and respiratory distress with serum potassium < 2 mEq/L (2 mmol/L)

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Medication history:
ask about medications that can cause hypokalemia (see drug-induced causes)(1)

Past medical history (PMH):

ask about history of(2)
heart failure
nephrotic syndrome
cirrhosis
vomiting
diarrhea

Physical:

General physical:
measure blood pressure
potassium depletion and hypokalemia increase systolic and diastolic blood pressure when sodium intake not restricted(1)
hypertension may be due to
syndrome of apparent mineralocorticoid excess(1)
Cushing syndrome (Ann N Y Acad Sci 2002 Sep;970:134)
low blood pressure may be present in patients with Bartter syndrome, Gitelman syndrome, or diuretic abuse(5), or diarrhea
(with hypovolemia)
respiratory distress may occur with serum potassium < 2 mEq/L (2 mmol/L)(1)

Cardiac:
irregular heart rate with arrhythmias, especially in patients with underlying heart disease(1, 2, 4)

Abdomen:
decreased bowel sounds (paralytic ileus)(2)

Neuro:
ascending paralysis with serum potassium < 2 mEq/L (2 mmol/L)(1)
decreased deep tendon reflexes
Diagnosis

Making the diagnosis:

serum potassium < 3.6 mEq/L (3.6 mmol/L)(1, 2, 3) (reference ranges may vary between laboratories)
clinical symptoms usually occur with more severe hypokalemia (< 2.5 mEq/L [2.5 mmol/L])(1)

Differential diagnosis:
underlying cause (see Causes)
pseudohypokalemia due to lab error
hypomagnesemia(1)

Testing overview:
initial tests include(1, 4)
serum potassium, sodium, chloride, bicarbonate
serum magnesium
glucose
creatinine
electrocardiogram (ECG)
tests to consider in evaluation of underlying causes
urine tests
spot urine measurements of sodium, potassium, chloride, and creatinine(4)
urine calcium(5)
24-hour urine potassium excretion
plasma renin and aldosterone(4)
arterial blood gas (if considering metabolic alkalosis)(4)

Blood tests:
laboratory parameters for diseases associated with chronic hypokalemia
Gitelman syndrome
metabolic alkalosis

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normal renal function
elevated serum total calcium, plasma renin activity and plasma aldosterone
decreased serum potassium, magnesium, sodium and chloride
Bartter syndrome
metabolic alkalosis
normal renal function
elevated plasma renin activity and plasma aldosterone
decreased serum potassium
serum magnesium, total calcium, sodium and chloride may be normal or decreased
loop diuretic abuse(5)
metabolic alkalosis
decreased renal function
elevated plasma renin activity and plasma aldosterone
decreased serum potassium, magnesium, total calcium, sodium
serum chloride may be normal or decreased

Urine studies:
24-hour urine potassium excretion(5)
< 30 mEq (30 mmol) suggests extrarenal loss (such as diarrhea, vomiting, laxative abuse)
> 30 mEq (30 mmol) suggests renal cause (such as proximal or distal tubular acidosis, Bartter syndrome, Gitelman
syndrome, chronic diuretic abuse)
urine study parameters for diseases associated with chronic hypokalemia(5)
Gitelman syndrome
normal urine output
normal renal function
increased urine potassium, sodium, magnesium, and chloride excretion
decreased urine calcium excretion
Bartter syndrome
increased urine output
normal renal function
increased urine calcium, potassium, sodium, magnesium, and chloride excretion
loop diuretic abuse
increased urine output
decreased renal function
increased urine calcium, potassium, sodium, magnesium, and chloride excretion
transtubular potassium concentration gradient and potassium-creatinine ratio may differentiate hypokalemic periodic paralysis
(HPP) from non-HPP
based on series of 43 patients with hypokalemia and paralysis
Reference - Arch Intern Med 2004 Jul 26;164(14):1561

Electrocardiography (ECG):
ECG changes associated with hypokalemia
not common with mild to moderate hypokalemia, usually occurs when serum potassium < 2.7 mEq/L (2.7 mmol/L)
most common changes(2, 3, 4)
decreased T wave amplitude (inverted or flat T waves)
ST-segment depression
presence of U wave (giant U waves may be mistaken for peaked T-waves)
other findings (especially with concomitant hypomagnesemia) may include
QT interval prolongation
ventricular extrasystoles (with serum potassium < 2.5-3 mEq/L [2.5-3 mmol/L])
ventricular arrhythmias
premature ventricular complexes
ventricular tachycardia
torsades de pointes
ventricular fibrillation
supraventricular arrhythmias
paroxysmal atrial tachycardia
multifocal atrial tachycardia

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atrial fibrillation
atrial flutter
Reference - BMJ 2002 Jun 1;324(7349):1320 EBSCOhost Full Text full-text EBSCOhost Full Text, corrections
can be found in BMJ 2002 Aug 3;325(7358):259, BMJ 2007 May 26;334(7603):1118
ECG abnormalities in severe hypokalemia in case report (Arch Intern Med 2012 Oct 22;172(19):1439), discussion can be found
in Arch Intern Med 2012 Oct 22;172(19):1440
Treatment

Treatment overview:
treat underlying cause
increasing dietary potassium may be sufficient treatment for asymptomatic patients without underlying cardiac disease with
serum potassium level between 3-3.5 mEq/L (3-3.5 mmol/L)
replace magnesium if magnesium deficiency
potassium replacement
potassium chloride most effective form for replacing acute potassium loss
may be indicated if serum potassium < 3.5 mEq/L (3.5 mmol/L), even if patient asymptomatic
40-100 mEq/day (40-100 mmol/day) orally in divided doses usually adequate for treatment
IV potassium repletion
avoid if possible due to risk of hyperkalemia
initial dose 20-80 mEq (20-80 mmol) in saline, depending on severity of hypokalemia, decrease dose by ≥ 50% if renal
insufficiency
infusion rate 10-20 mEq/hour (10-20 mmol/hour)
use central venous catheter for infusion rates > 10 mEq/hour (10 mmol/hour)
80 mEq/L [80 mmol/L] maximum concentration via peripheral vein
continuous cardiac monitoring recommended
never administer as rapid infusion
concentrated potassium chloride (200 mEq/L [200 mmol/L]) at 20 mEq (20 mmol) per hour appears safe for
correcting hypokalemia in intensive care unit patients (level 2 [mid-level] evidence)

Fluid and electrolytes:

for hypokalemia due to chloride-responsive metabolic alkalosis, use IV normal saline(1)
potassium replacement
general indications for potassium replacement from National Council on Potassium in Clinical Practice(2)
patients who are sensitive to sodium
patients unable or unwilling to reduce salt intake
patients who are prone to nausea, vomiting, diarrhea, bulimia, or diuretic/laxative abuse
patients with drug-related hypokalemia (treatment with non-potassium-sparing diuretic)
patients with heart failure, even if initial serum potassium level appears normal (4 mEq/L [4 mmol/L])
forms of potassium available salts for repletion(1, 2, 3)
potassium chloride most commonly used (most effective for replacing acute losses)
liquid form less expensive but often not tolerated due to unpleasant taste
slow-release tablet form well tolerated but associated with low risk of ulceration and gastrointestinal bleeding
potassium phosphate used to replace phosphate losses
potassium bicarbonate recommended in setting of metabolic acidosis
potassium citrate or potassium gluconate may also be used for oral repletion
oral potassium supplementation
administer orally in moderate dose over days to weeks for full repletion(1, 2)
40-100 mEq/day (40-100 mmol/day) usually adequate(2, 3)
usually should not exceed 200 mEq/day (200 mmol/day) in adults, 3 mEq/kg/day (3 mmol/kg/day) in young children
divide total daily dosage into 2-4 doses to avoid adverse gastrointestinal effects(3)
IV potassium supplementation
supplemental potassium most common cause of severe hyperkalemia in hospitalized patients, risk is greater with IV
supplementation(1)
indicated for treatment of severe hypokalemia (< 2.5 mEq/L [2.5 mmol/L]), symptomatic hypokalemia, or for patients
with nonfunctioning gastrointestinal tract(2)
administer at ≤ 20 mEq/hour (20 mmol/hour) and monitor cardiac rhythm(1)
recommendations for IV potassium repletion for intensive care unit patients(3)
initial IV dose

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20-40 mEq (20-40 mmol) in saline for mild-to-moderate hypokalemia (2.5-3.4 mEq/L [2.5-3.4 mmol/L]
40-80 mEq (40-80 mmol) in saline for severe hypokalemia (< 2.5 mEq/L [2.5 mmol/L])
decrease dose by ≥ 50% for patients with renal insufficiency
maximum daily dose 240-400 mEq/day (240-400 mmol/day)
infusion rate 10-20 mEq/hour (10-20 mmol/hour), maximum rate 40 mEq/hour (40 mmol/hour) but usually not
needed
continuous cardiac monitoring recommended for infusion rate > 10 mEq/hour (10 mmol/hour)
infusion via central venous catheter recommended for infusion rates > 10 mEq/hour (10 mmol/hour), due to pain
and risk for phlebitis
maximum concentration of potassium solutions 80 mEq/L (80 mmol/L) via peripheral vein, 120 mEq/L (120
mmol/L) via central vein infusion
check serum potassium within 1-4 hours after total dose of 60-80 mEq (60-80 mmol) before giving additional
potassium
never administer as rapid infusion
replace IV potassium therapy with oral supplements and/or ingestion of potassium-rich foods as soon as possible
concentrated potassium chloride (200 mEq/L [200 mmol/L]) at 20 mEq (20 mmol) per hour appears
safe for correcting hypokalemia in intensive care unit patients (level 2 [mid-level] evidence)
based on retrospective cohort study
495 sets of potassium chloride infusions administered in medical intensive care unit were evaluated
sets included potassium 20 mEq (20 mmol) in saline 100 mL for 1-8 consecutive infusions
mean 0.25 mEq/L (0.25 mmol/L) increment in serum potassium level per 20 mEq (20 mmol/L) infusion
no temporally related life-threatening arrhythmias noted, but 10 episodes of mild hyperkalemia reported
Reference - Arch Intern Med 1990 Mar;150(3):613, commentary can be found in Arch Intern Med 1990
Dec;150(12):2603, Arch Intern Med 1991 Jan;151(1):203
see also Potassium supplements
concurrent magnesium deficiency
hypomagnesemia causes renal potassium loss and often co-exists with hypokalemia(1, 2, 3)
potassium repletion will not be effective unless magnesium depletion is corrected(1, 2, 3)
magnesium supplementation may improve potassium balance in intensive care unit (level 3 [lacking direct]
evidence)
based on small randomized trial without clinical outcomes
32 critically ill adults admitted to surgical intensive care unit with hypokalemia (serum potassium < 3.5 mEq/L [3.5
mmol/L]) in previous 24 hours were randomized to magnesium sulfate 2 g IV in 5% dextrose 50 mL vs. placebo (5%
dextrose in water [D5W]) given over 30 minutes every 6 hours for 8 doses
magnesium sulfate withheld for magnesium > 2.8 mg/dL (1.15 mmol/L)
all patients received standard potassium replacement (potassium chloride 20 mmol in D5W 100 mL over 1 hour) for
potassium < 3.5 mEq/L (3.5 mmol/L) and magnesium replacement (magnesium sulfate 2 g) for magnesium < 1.8
mg/dL (0.74 mmol/L)
potassium replacements and serum potassium levels were not significantly different between groups but high-dose
magnesium group had positive potassium balance while standard group had negative potassium balance
trend toward less ventricular ectopy in treatment group, no complications of magnesium treatment noted
no complications associated with magnesium sulfate administration
Reference - Crit Care Med 1996 Jan;24(1):38
review of refractory potassium repletion due to magnesium deficiency can be found in Arch Intern Med 1992 Jan;152(1):40

Diet:
ensure adequate dietary potassium intake(1, 2, 4)
high dietary potassium intake may not be effective for correcting potassium loss associated with chloride depletion (from
diuretics, vomiting or nasogastric drainage) unless adequate chloride intake
may be sufficient treatment for asymptomatic patients without underlying cardiac disease and serum potassium between
3-3.5 mEq/L (3-3.5 mmol/L)
examples of high-potassium foods
> 1,000 mg (25 mmol) per 100 grams - figs, molasses, seaweed
> 500 mg (12.5 mmol) per 100 grams - dried fruits, nuts, avocados, bran, wheat germ, lima beans
> 250 mg (6.2 mmol) per 100 grams - many vegetables (spinach, tomatoes, broccoli, winter squash, beets, carrots,
cauliflower, potatoes), fruits (bananas, cantaloupe, kiwis, oranges, mangos) and meats (beef, pork, veal, lamb)
salt substitutes have about 12 mmol potassium chloride per gram
salt substitutes can correct potassium losses but may lead to hyperkalemia with excess intake(1)
(2)
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low-sodium diet may decrease urinary potassium loss (2)

Medications:
special considerations for patients on diuretics(1, 2)
attempt to reduce dose of or discontinue diuretic treatment if appropriate
second drug may be needed that inhibits potassium excretion (such as amiloride, triamterene, or spironolactone)
potassium-sparing diuretics increases risk for hyperkalemia, especially in patients with diabetes and renal insufficiency
monitor renal function and serum potassium levels frequently
proton pump inhibitor used in case report to correct hypokalemia and metabolic alkalosis associated with persistent self-induced
vomiting (N Engl J Med 2002 Jan 10;346(2):140), commentary can be found in N Engl J Med 2002 Aug 1;347(5):373

Follow-up:
electrocardiographic (ECG) monitoring with IV potassium supplementation(1)
monitor serum potassium levels every 1-6 hours in patients with severe symptomatic hypokalemia or with aggressive IV
repletion(3)
if refractory to potassium repletion - consider magnesium deficiency, especially if patient has history of
heart failure
digoxin overdose
treatment with cisplatin
treatment with loop diuretics
Reference - Arch Intern Med 1992 Jan;152(1):40, commentary can be found in Arch Intern Med 1992 Nov;152(11):2346
Prognosis
depends on cause
serum potassium < 3 mEq/L (3 mmol/L) in the hospital may be associated with increased mortality
based on retrospective study of all hospitalized patients who had serum potassium level at a tertiary care center in
Jerusalem, Israel in 1997
866 (2.6%) had severe hypokalemia (< 3 mEq/L [3 mmol/L])
1.89% overall mortality among 37,458 hospital admissions
20.4% crude mortality among 866 patients with severe hypokalemia
Reference - Arch Intern Med 2001 Apr 23;161(8):1089
elderly hypertensive patients who develop hypokalemia when treated with chlorthalidone may not experience
reduction in rate of strokes
based on secondary analysis of randomized trial
4,126 patients > 60 years old with isolated systolic hypertension randomized to chlorthalidone vs. placebo for 5 years in
Systolic Hypertension in the Elderly Program (SHEP)
7.2% chlorthalidone vs. 1% placebo patients had serum potassium < 3.5 mEq/L (3.5 mmol/L) after 1 year of treatment
(p < 0.001)
rates of stroke per 1,000 person-years
16.5 for 2,003 placebo patients without hypokalemia
9.1 for 1,951 chlorthalidone patients without hypokalemia (NNT 135 person-years)
22.3 for 151 chlorthalidone patients with hypokalemia (NNH 172 person-years)
similar pattern reported for coronary heart disease but not statistically significant
Reference - Hypertension 2000 May;35(5):1025 full-text, editorial can be found in Hypertension 2000 May;35(5):1031 full-
text
Prevention and Screening

Prevention:
maintain serum potassium ≥ 4 mEq/L (4 mmol/L) in patients with asymptomatic hypertension or cardiac arrhythmias(2)
consider potassium replacement in patients with heart failure, even if normokalemia initially (2)
strategies to prevent hypokalemia in patients receiving diuretic therapy (2)
oral potassium 20 mEq (20 mmol) per day
use low-dose diuretic
use combination treatments (such as potassium-sparing diuretics, beta blockers, ACE inhibitors, angiotensin II receptor
blockers)
potassium-rich diet appears as effective as potassium chloride supplementation in patients taking potassium-
wasting diuretics following cardiac surgery and might be associated with earlier discharge (level 2 [mid-level]
evidence)
based on small randomized trial
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48 precardiac surgery patients who would be receiving oral furosemide were randomized to potassium-rich diet vs.
potassium chloride supplement to provide potassium (mEq) equivalent to half furosemide dose
38 patients (79%) completed the trial, all 10 dropouts occurred in diet group
no significant differences in serum potassium levels preoperatively or at postoperative days 3 or 4
length of stay shorter in diet group (5 vs. 6.3 days)
Reference - Chest 2004 Feb;125(2):404 full-text

Screening:
checking potassium level within 2-8 weeks should detect most cases of hypokalemia after initiation of diuretics
based on review of case series
patients with heart failure or renal disease should be monitored shortly after initiation of diuretics due to potentially more
rapid electrolyte and fluid changes
mild hypokalemia (potassium 3.1-3.4 mEq/L [3.1-3.4 mmol/L]) may be transient so consider rechecking potassium before
starting potassium replacement
dietary sodium restriction may conserve potassium
Reference - J Fam Pract 2001 Mar;40(3):207
Guidelines and Resources
Patient Information
ICD-9/ICD-10 Codes
References

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