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DOI 10.1007/s00467-017-3635-2
EDUCATIONAL REVIEW
Received: 11 September 2016 / Revised: 13 February 2017 / Accepted: 21 February 2017 / Published online: 4 April 2017
# IPNA 2017
compartments. To maintain homeostasis, potassium intake increases urinary potassium excretion in the absence of any
should be equal to potassium excretion. The kidneys are re- elevation in plasma [K+]. This effect is abolished by bumeta-
sponsible for excreting 90% of potassium intake, while only nide, suggesting that the presence of an isoform of the Na+-
10% is excreted through the gastrointestinal tract. Changes in K+-2Cl− cotransporter, NKCC1, in the hepatoportal system
potassium intake result in changes in renal excretion. that mediates a signal transmission to the kidneys with conse-
However, the renal response to changes in potassium intake quent kaliuresis [9, 10]. The inverse is observed during con-
is a slow process that may take several hours before proper ditions of chronic dietary potassium restriction. Before hypo-
adjustments occur. Consequently, to prevent life-threatening kalemia develops, the renal excretion of potassium is reduced,
fluctuations in EC [K+], the human body shifts potassium probably mediated by sensors in the gastric or hepatoportal
from the EC to the IC compartment, thereby maintaining a circulation that in some way inactivates renal outer medullary
normal serum level. potassium channels (ROMK) [11].
Fig. 1 Developmental adaptations in renal potassium transport along the this segment. The immature aldosterone-sensitive distal nephron receives
nephron. 1 Low glomerular filtration rate (GFR) limits the filtration of 35% of filtered K+ load, compared to 20% in mature nephrons. 4 The
potassium ions (K+) through the glomerulus. 2 Low Na+-K+-ATPase immature collecting duct is resistant to aldosterone. Low Na+-K+-ATPase
activity decreases proximal sodium ion (Na+) and fluid absorption, activity maintains higher IC [Na+] concentration and in conjunction with
limiting the solvent drag effect. Immaturity of tight junctions alters K+ low epithelial sodium channel (ENaC) activity Na+ absorption is limited
absorption through paracellular pathways. Similar to adult nephrons, the in this segment. Low ROMK activity decreases K+ secretion at physio-
immature proximal tubule delivers 30–40% of filtered K+ to the thick logic flow. Low big-conductance potassium (BK) channel activity limits
ascending limb. 3 Low Na+-K+-ATPase maintains a higher intracellular flow-stimulated K+ secretion. High H+-K+-ATPase expression in α-
(IC) sodium ion concentration [Na+] and lower IC [K+]. Renal outer intercalated cells favors K+ absorption over secretion in the immature
medullary potassium channel (ROMK) activity and NKCC2 (a Na+-K+- collecting duct (CD)
2Cl− cotransporter isoform) expression are low, limiting K+ absorption in
increased expression of claudin 2 and decreased expression of medulla [29]. This channel provides a continuous sup-
occludin in comparison with adult tubules [25]. The exact ply of potassium ions required for the NKCC2 pump
effect of these changes on K+ transport are not known, but and keeps a positive luminal voltage that drives potas-
they are likely to affect K+ absorption in this segment. sium absorption through paracellular pathways, as well
Micropuncture studies in rats show that the fraction of the as calcium and magnesium. The IC potassium leaves the
K+-filtered load absorbed by the PT is similar in immature cell through the basolateral membrane, primarily
and adult kidneys [26]. cotransported with chloride, or via a potassium channel.
Igarashi and colleagues demonstrated that mRNA ex-
Loop of Henle pression of NKCC2 in mice is developmentally regulated
[30]. During the early embryonic stage the signal is un-
The mature loop of Henle absorbs 25% of filtered po- detectable, with expression first observed in the meta-
tassium through both, transcellular and paracellular path- nephros by day 14.5 post conception, following which
ways [27]. The ubiquitous Na+/K+-ATPase present in time it continues to increase progressively through late
the basolateral membrane maintains low IC gestation. By the end of the first week of postnatal life
[Na+], which provides the driving force for the luminal the mRNA expression is stronger, which coincides with
Na-K+-2Cl− transporter NKCC2 [28]. A high IC [K+] completion of nephrogenesis in rats [30]. This delay in
promotes recycling of some of the absorbed potassium NKCC2 expression limits potassium absorption in this
into the lumen via an apical low-conductance secretory segment during early development. As a result, the imma-
potassium channel, known as the renal outer medullary ture distal nephron receives up to 35% of the potassium
potassium (ROMK) channel since it was originally iden- filtered load, in contrast to 15–20% in the adult kidney
tified in the thick ascending limb of the rat outer [26, 31].
Pediatr Nephrol (2017) 32:2037–2049 2041
Aldosterone-sensitive distal nephron increases in sodium delivery to the connecting tubule and CD;
this turns on ENAC, which in turn enhances K+ secretion in
The immature distal nephron is resistant to mineralocorticoids. the CD [46]. Moreover, mutations in the serine–threonine ki-
Healthy newborn infants exhibit high plasma levels of aldo- nases WNK1 and WNK4, which regulate NCC, result in
sterone and renin, which contrast with biologic signs of func- hyperkalemia and hypertension (pseudohypoaldosteronism
tional hypoaldosteronism, including hyperkalemia and uri- Type II) by inhibiting ROMK and stimulating NCC [47, 48].
nary sodium loss [32]. Aperia and colleagues demonstrated Except for an in situ hybridization study in neonatal rats show-
that the correlation between aldosterone excretion and the uri- ing that NCC expression follows expression of NKCC2, little
nary potassium/sodium quotient is higher in full-term infants information is currently available on the ontogeny of NCC
than in pre-term ones, suggesting unresponsiveness to aldo- [49]. Similarly, the maturation of WNK in the kidney has
sterone at this developmental stage [33]. Moreover, in rabbits not been characterized, except for a study in mouse tissues
Vehaskari demonstrated that glucocorticoid pretreatment did using in situ hybridization that showed more prominent renal
not affect Na+ transport measured in isolated microperfused expression of WNK1 in the postnatal period, compared with
cortical collecting ducts (CCD) in the first 2 weeks of life. embryos [50].
However, a marked increase in the response to aldosterone Potassium secretion, measured as transtubular potassium
pretreatment is observed after 22 days of age [34]. More re- gradient (TTKG), is decreased in premature infants during
cently, low renal expression of mineralocorticoid receptor, de- the first 2 weeks of life, especially in those born at <30 weeks
spite high aldosterone levels, was shown in human and mouse of postmenstrual age [51]. Satlin et al. demonstrated in isolat-
kidney at birth, which could partly explain aldosterone resis- ed microperfused CCD from neonatal rabbits that at physio-
tance in the immature kidney [35]. logic flow rates net potassium secretion was absent at birth,
The three major players in potassium secretion in this seg- first becoming evident at 4 weeks of age and increasing
ment are: (1) Na+/K+-ATPase, (2) apical potassium secretory abruptly thereafter, reaching maturity by 6 weeks of age
channels and (3) epithelial sodium channel (ENaC) [17]. A [52]. Patch clamp analysis in maturing rabbit CCDs showed
negative luminal charge favoring potassium efflux from cells a clear developmental increase in ROMK channel activity
through apical potassium channels is generated by sodium between 2 and 5 weeks of age, consistent with data from
absorption via ENaC. Potassium secretion in this segment is isolated perfused CCDs at low flow rates. This observation
enhanced by high-flow rates, probably the result of activation suggests that the appearance of baseline potassium secretion
of BK channels by increased intracellular Ca++ mediated by in the CCD is the result of the development of SK/ROMK
hydrodynamic forces on the apical cilia of principal and inter- channels [53]. Flow-stimulated potassium secretion in the rab-
calated cells of the CD [36–38]. bit appears by 5 weeks of postnatal life, parallel with the
Earlier in this review I mentioned that the activity of Na+/ appearance of BK expression [54]. In human fetuses, the ex-
+
K -ATPase is very low in all nephron segments during early pression of ENAC is low during early development. After 32
development [19]. The resulting high IC [Na+] diminishes weeks of postmenstrual age the expression increases, correlat-
apical sodium absorption and potassium secretion. There are ing with better abilities to absorb sodium. This increase pre-
at least two different potassium channels: the ROMK cedes the maturation of potassium secretion [55].
[low-conductance secretory K (SK)] channel, which is respon-
sible for basal potassium secretion under physiologic flow
rates and is expressed in apical membranes along the entire Role of H+/K+-ATPase
distal nephron from the thick ascending limb through the CD,
and the big-conductance (BK or maxi-K channel), which re- In the CCD, the alpha intercalated cells absorb potassium
sponds to stretch and mediates flow-dependent potassium se- actively in exchange for protons through H+/K+-ATPase
cretion and is expressed along the distal nephron, but more (HKα2). In adults, this mechanism is important in conditions
prominently in the apical membranes of intercalated cells of potassium depletion. Scanning electron micrographs of rat
[39–43]. CDs demonstrate that potassium deprivation induces hyper-
The thiazide-sensitive NaCl co-transporter (NCC), al- trophy of the luminal surface of the intercalated cells, where
though not directly involved in potassium secretion, is very H+/K+-ATPase is expressed [56]. Chronic hypokalemia is the
sensitive to EC [K+] and plays a key role in renal potassium most potent stimulus for upregulation of HKα2, suggesting a
excretion [44]. Its importance in K+ regulation is evident in key role for this exchanger in preserving body potassium [57].
Gitelman syndrome in which a mutation in the NCC gene is In rats the mRNA and protein expression of HKα2C, one of
associated with renal potassium wasting [45]. NCC is regulat- the splice variants of HKα2, is specifically upregulated in
ed by dietary potassium and aldosterone. A high K+ diet turns neonates, eventually becoming undetectable in adults. These
off NCC and turns on ENAC. Inhibition of NCC decreases data suggest a mechanism for increased potassium absorption
sodium absorption in the distal convoluted tubule, resulting in in the neonate via HKα2C [57].
2042 Pediatr Nephrol (2017) 32:2037–2049
K+ excretion [67]. In addition, an adequate urine [Na+] (>25 worsen and become refractory to treatment in the presence
meq/L) and a urine that is hypertonic compared to plasma are of hypomagnesemia [68]. If hypokalemia is associated with
two parameters required to be able to use TTKG for the evalua- polyuria, which is common, intravascular volume should be
tion of patients with potassium disturbances [67]. promptly restored. The rate and route for replacement of po-
TTKG in preterm neonates is low during the early neonatal tassium depends on the presence of symptoms or changes in
period and does not correlate with plasma aldosterone levels, the ECG.
consistent with the low tubular K+ excretion and mineralocor- The safest treatment of mild asymptomatic hypokalemia is
ticoid resistance. This finding probably has a physiologic ba- via the oral/enteral route using potassium salts in a dose of 1–2
sis or is related to the presence of associated medical condi- meq/kg/day (Fig. 2). In the presence of alkalosis, potassium
tions, such as the use of mechanical ventilation [51]. should be given as KCl to replenish chloride [69].
Therefore, TTKG should not be used in premature infants as Moderate-to-severe symptomatic hypokalemia ([K+] <2.5
the interpretation of this test is troublesome since immaturity meq/L) or patients with gastrointestinal complications who
of the nephron and normal developmental changes in renal cannot tolerate oral salts should be treated using intravenous
potassium handling and urine concentration may confound preparations of potassium. The addition of KCl to intravenous
the results. fluid (not to exceed 40 meq/L) can be sufficient in cases of
In patients with hypokalemia the serum concentration of moderate hypokalemia. Higher concentrations (60–80 meq/L)
magnesium should be measured as hypokalemia might are required if the patient fails to respond, but these should be
Fig. 2 Management of
hypokalemia in newborn infants.
GI Gastrointestinal, ECG
electrocardiogram, NS normal
saline, iv intravenous, IVF’s
intravenous fluids
2044 Pediatr Nephrol (2017) 32:2037–2049
given through a central vein under continuous ECG monitor- of tourniquet as these should be considered to be hemolyzed
ing. Rapid administration of KCl can lead to life-threatening samples. Other sources of hyperkalemia include elevated
arrhythmias. In cases of profound (serum [K+] <1.5 meq/L) or platelet, leukocyte or red blood cell counts [73].
symptomatic hypokalemia, KCl diluted in normal saline can The presence of metabolic acidosis promotes a shift of
be carefully given intravenously in doses up to 0.5–1 meq/kg potassium from the cell to the EC space. Several medications
over 1–2 h [70]. Continuous ECG monitoring is required. can promote cellular shifts of potassium. Succinylcholine, by
Potassium salts should not be diluted in dextrose-containing depolarizing the muscle membrane, induces the efflux of K+
solutions as it provokes insulin secretion and cellular potassi- from the cell, which can lead to life-threatening hyperkalemia.
um uptake, lowering the plasma [K+] even further [71]. Digoxin overdose and β 2 adrenergic blockers cause
hyperkalemia by inhibiting Na+/K+-ATPase [74]. Other med-
ications can induce hyperkalemia by acting on the angioten-
Hyperkalemia sin–aldosterone axis. Spironolactone is an antagonist of min-
eralocorticoids. Indomethacin produces hyporeninemic
Hyperkalemia in the neonatal period can be defined as a plas- hypoaldosteronism and decreased GFR. Angiotensin
ma [K+] of >6 meq/L in full-term neonates and of >6.5 meq/L converting enzyme inhibitors can also cause hyperkalemia
in premature infants. In very premature infants (postmenstrual by blocking angiotensin II synthesis and the subsequent gen-
age <32 weeks), normal plasma [K+] could be up to 6.7 meq/L eration of aldosterone. Amiloride and trimethoprim inhibit
during the first week of life [1, 72]. Hyperkalemia is life- ENaC, thereby reducing sodium reabsorption and potassium
threatening as it causes cardiac arrhythmias. excretion [75]. Endogenous potassium load results from tissue
The most common causes of hyperkalemia in the neonate breakdown, as in hemolysis, gastrointestinal bleeding and tis-
are shown in Table 2. Pseudohyperkalemia or in vitro hemo- sue necrosis. Because of the developmental adaptations
lysis due to technical difficulties in obtaining an adequate discussed earlier in this review (see Fig. 1), neonates are more
blood sample in small infants are the most common sources susceptible to the effects of these medications, which can limit
of an elevated [K+], as K+ is released from the IC compartment the already compromised Na+/K+-ATPase activity, the ability
into the serum. In most instances, assessment of the degree of to shift K + into the cell and the tubular response to
hemolysis in a blood sample is subjective, based on visual mineralocorticoids.
inspection of the color of the plasma. Therefore, as a general Careful attention should be given to excess oral or in-
rule, therapeutic decisions should not be based on samples travenous potassium supplementation/nutrition, medica-
obtained by a heelstick, from fingertip or after prolonged use tions with potassium salts, such as penicillin, or blood
transfusions. Acute kidney injury and CKD also result in
Table 2 Causes of hyperkalemia in neonates impairment of urinary potassium excretion. Decreased al-
dosterone activity results from a deficiency in mineralo-
Causes Specific examples
corticoids or resistance to its effects. Both will result in
Pseudohyperkalemia Heelstick variable degrees of metabolic acidosis, renal salt wasting
Finger tip and hyperkalemia. Aldosterone synthase deficiency is a
Prolonged tourniquet rare autosomal recessive disease characterized by defec-
Increased potassium load Diet tive biosynthesis of aldosterone that results in isolated
Blood transfusions hypoaldosteronism. Patients exhibit salt wasting, recurrent
Hemorrhages (GI, IVH)
dehydration, hyperkalemia and failure to thrive. Neonatal
Hemolysis
screening using 17-hydroxyprogesterone measurement
Tissue necrosis
identifies a defect in 21-hydroxylase but fails to detect
aldosterone synthase deficiency, a diagnosis which may
Decreased renal excretion AKI and CKD
be missed until the patient presents with a salt-wasting
Aldosterone deficiency/resistance
crisis [76, 77]. Pseudohypoaldosteronism is a rare hered-
RTA Type 4
itary disorder that results from end-organ resistance to
Urinary obstruction
aldosterone, characterized by high plasma aldosterone
Drugs Spironolactone
and renin concentrations. Type 1 is caused by a defect
Amiloride
in the mineralocorticoid receptor and presents in the neo-
Trimethoprim
natal period as hypovolemia, hyponatremia,
Redistribution (internal shifts) Acidosis
hyperkalemia, vomiting, failure to thrive, metabolic aci-
Non-oliguric hyperkalemia
d o s i s a n d d e h y d r a t i o n o r s h o c k [ 7 8 ] . Ty p e 2
AKI, Acute kidney injury; CKD, chronic kidney disease; IVH, intraven- pseudohypoaldosteronism, also known as Gordon syn-
tricular hemorrhage; RTA, renal tubular acidosis drome, is a rare form of familial hypertension caused by
Pediatr Nephrol (2017) 32:2037–2049 2045
mutations in WNK kinases [48]. Previously known as the function for age. Although the pathophysiology is not
adolescent chloride shunt, because it typically presents completely understood, it seems to be the result of immaturity
during adolescence as hypertension and hyperkalemic ac- of the mechanisms that regulate internal distribution of potas-
idosis, the disorder responds to treatment with salt restric- sium (see section Extrarenal regulation of potassium—inter-
tion and thiazide diuretics. Although hypertension does nal distribution) [14]. Because hyperkalemia could cause se-
not develop until late childhood, the electrolyte distur- rious arrhythmias and mortality, it is important to monitor
bances (hyperkalemic acidosis) can already be present in plasma [K+] during the first 72 h of life in all premature infants
the neonatal period [79]. A renal ultrasound looking for born at <32 weeks of postmenstrual age [80, 81].
hydronephrosis should be carried out as renal tubular ac-
idosis type 4 is a common finding in infants with urinary Evaluation and management of neonatal hyperkalemia
tract obstruction.
The evaluation of hyperkalemia starts by identifying
NOH in the neonate life-threatening signs. Initial ECG changes are a prolonged
PR interval and peaked T waves, followed by the absence of
This entity is defined as a plasma [K+] of >6.5 meq/L within P wave, widened QRS with S–T depression and persistent
the first 72 h of life in very low birthweight (birthweight lower peaked T waves. The QRS continues to widen with higher
than 1500 g) or very pre-term (less than 32 weeks serum [K+] until ventricular fibrillation develops. Muscle
postmenstrual age) infants in the presence of normal renal weakness and hypotension occur only rarely. The blood
Fig. 3 Management of
hyperkalemia in newborn infants.
po Orally
2046 Pediatr Nephrol (2017) 32:2037–2049
pressure, as well as volume status and the genitalia, should orally or as enemas, is of questionable efficacy in neonates
also be assessed since infants with congenital adrenal hyper- [90]. Moreover, because this treatment carries a risk of intes-
plasia can present with salt wasting, severe dehydration, hy- tinal perforation and obstruction, it is contraindicated in in-
potension and virilization. fants with necrotizing enterocolitis or very premature infants
Pseudohyperkalemia should always be considered and the [91, 92].
blood collection technique identified. In the case of true
hyperkalemia, the plasma concentrations of sodium, chloride,
bicarbonate, creatinine should be evaluated, as well a com- Key summary points
plete blood count ordered. If the GFR is normal and no
offending agent can be identified, hypoaldosteronism should 1. Neonates are in a net positive potassium balance.
be ruled out. In these patients, hyperkalemia will be accom- Although this balance is appropriate for somatic growth,
panied by hyponatremia and metabolic acidosis. TTKG could it places the infant at high risk for life-threatening
assist to discriminate between renal and extrarenal causes in hyperkalemia.
term infants—keeping in mind the previously discussed lim- 2. The positive potassium balance is the result of increased
itations. In children with hyperkalemia due to a non-renal intestinal absorption of potassium and decreased renal
cause, the urinary potassium excretion is very high and there- excretion.
fore the TTKG is high (>11). In newborns with 3. Infants born at <32 weeks of postmenstrual age should be
hypoaldosteronism and pseudohypoaldosteronism, the monitored for NOH during the first 72 h of life.
TTKG is very low (1.4–4.1) [66]. If adrenal etiology is 4. When treating hyperkalemia in the neonate, resins should
suspected, one should measure serum levels of aldosterone, be used very cautiously due to the risk of serious compli-
renin and cortisol. cations, such as intestinal obstruction and perforation.
Therapeutic targets for hyperkalemia are to prevent ar-
rhythmias and to decrease the plasma [K+] by stimulating its
shift into the cell or by depleting body potassium. If the ECG
shows changes consistent with hyperkalemia, calcium gluco- Multiple choice questions (answers are provided
nate 10% should be administered at a dose of 0.5 ml/kg over following the reference list)
5–15 minutes (Fig. 3). The effect of stabilizing the cardiac
membrane is evident within 1–3 min and lasts for 30–60 1. Potassium regulation by the feedforward mechanism:
min. The dose may be repeated after 5 min if the ECG changes
persist [82]. Insulin/glucose administration and albuterol neb- a. Is mediated by aldosterone
ulization enhance transcellular potassium shifts into the cell. b. Is activated 6 h after a glucose-containing meal
Insulin can be administered at a dose of 0.1–0.6 U/kg/h with a c. Is activated 6 h after ingesting a potassium-containing
glucose infusion of 0.5–1 g/kg/h (5–10 ml/kg/h of glucose meal
10%) [83]. The onset of action is approximately 15 min and d. Is triggered by elevated [K+] in gastrointestinal tract
lasts a few hours. β-agonists, such as albuterol, have a rapid e. Is triggered by elevated [K+] in plasma.
onset of action. Albuterol can be administered by nebulizer at
a dose of 400 μg to 2.5 mg diluted in 2 ml of normal saline 2. The neonatal kidney is programmed to preserve potassi-
[84]. This decreases the plasma concentration of potassium by um. A potential mechanism involves the following:
0.5–1 meq/L. Intravenous albuterol at a dose of 4 μg/kg, given
as an intravenous slow bolus over 5 min, decreases plasma a. Increased activity of Na+/K+-ATPase
[K+] by 0.9–1.5 meql/L [85, 86]. In the presence of metabolic b. Increased activity of apical ROMK
acidosis, sodium bicarbonate infusion can also promote potas- c. Increased expression of H+/K+-ATPase
sium shifting into the cell. Because sodium bicarbonate is d. Increased expression of Maxi-K channels
hyperosmolar and due to its potential association with intra- e. Increased expression of NKCC2.
ventricular hemorrhages in premature infants, it should be
used very judiciously [87–89]. In our department, we recom- 3. Which following statement is TRUE, regarding NOH of
mend a dose of 1 meq/kg diluted 1:4 in sterile water, admin- the newborn:
istered over 30–60 minutes to decrease the adverse hemody-
namic effects. The efficacy is questionable in the absence of a. Is a benign condition
acidosis. To remove body potassium stores, loop or thiazide b. Is more frequent in late pre-term infants
diuretics can be used if the patient is making urine; for severe, c. Is the result of impaired feedforward mechanism
unremitting hyperkalemia, dialysis is required. The use of d. Is the result of impaired transcellular potassium shift
resins, such as sodium polystyrene given at a dose of 1 g/kg e. Should be treated if plasma [K+] exceeds 6 meq/L.
Pediatr Nephrol (2017) 32:2037–2049 2047
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