00:01
Let's move on to hyperkalemia.
00:03
Hyperkalemia is clinically
defined by serum potassium
greater than 5.2 milli
equivalents per liter.
00:08
When we think about
the ideologies
we can group the mean either
into pseudo hyperkalemia,
transcellular shift,
or we know mechanisms
with decreased excretion.
00:17
Let's start with
sudo hyperkalemia.
00:20
This occurs when
there's a elevation
in measured serum potassium
due to potassium movement
out of cells either
during a blood draw
or after a blood
specimen has been drawn.
00:31
So it's not in vivo.
00:33
This could be because of
hemolysis or destruction
of red blood cells
due to a technique
during the blood draw
if somebody's clenching or they
have a prolonged tourniquet use
during a venipuncture or
you have venipuncture trauma
that can cause hemolysis
and release a potassium.
00:48
Thrombocytosis
increased platelets
can also cause
e-flux of potassium
once the blood has been drawn.
00:56
Same thing with leukocytosis.
00:57
So if I have a patient
with acute leukemia
who's coming in with an
extraordinary high Y count
I might see hyperkalemia.
01:05
However,
this is really in vitro.
01:07
This does not happen
in the patient and potassium
is moving out of the cell.
01:11
Once that blood specimen
has been drawn already.
01:16
Now we think about things
like transcellular shift
similar to hypokalemia
there are things that can cause
potassium e-flux from the cell
to the extracellular fluid.
01:24
These are things like
metabolic acidosis.
01:27
So think about what
happens in acidosis.
01:29
Protons are going
to enter the cell
in order to buffer that
extra cellular pth,
but in order to maintain
electroneutrality,
we will have potassium enter the
extracellular fluid in return.
01:40
This primarily applies
to inorganic acids,
not really organic acids
like diabetic ketoacids.
01:45
It's so it really
overall has a very
small contribution or effect.
01:49
We have to think about
hyperglycemia and hyperosmolarity.
01:53
So when somebody has an
increase in elevation
in serum osmolarity,
think about what happens,
water is going to move
from the intracellular compartment
to the extracellular compartment,
and when that
happens that results,
in that results
in an increase in
intracellular
potassium in the cell
that high potassium will
move out of the cell
down its concentration
gradient into the ECF.
02:14
So by solvent drag or from
water movement out of the cell
we end up with potassium
e-flux seeing into that ECF.
02:20
Other mechanisms include
non-selective beta antagonists.
02:24
These will interfere with
potassium uptake into the cell
by those beta
adrenergic receptors.
02:30
Exercise also causes
transcellular shift
because potassium is
released by muscle cells.
02:36
We need that because it
causes local vasodilation
for an increase in blood flow.
02:40
Tissue breakdown can also
cause transcellular shift.
02:43
Things like Rhabdomyolysis,
which is muscle breakdown
or tumor lysis syndrome
from a large tumor
burden after chemotherapy
and finally burns can all
cause potassium release
into that vascular circulation.
02:57
Digitalis or digoxin toxicity
can inhibit that sodium
potassium ATPase pump
and that can lead to an increase
in interest extracellular
fluid potassium concentration.
03:07
And then finally there's hyperkalemic
familial periodic paralysis.
03:11
This is kind of like a twin
of the hypokalemic variant.
03:14
This is also an autosomal
dominant process,
but it's a point mutation in the
skeletal muscle sodium channel
rather than the dihydropyridine
calcium channel.
03:21
And this is going to be
precipitated by exactly
the opposite things of
hypokalemic periodic paralysis.
03:27
So this is going to
be rest after exercise
or having a large
potassium ingestion.
03:33
So finally we come to our renal
regulation of hyperkalemia,
and this is due to a decrease
in urinary excretion.
03:41
This can be due to either renal
failure, volume depletion
or functional
hyperaldosteronism.
03:46
So in patients
with renal failure,
they're able to maintain
near normal levels
of potassium as long as
that distal flow rate
and aldosterone
secretion is maintained.
03:55
Remember those were two
of the four regulators
that we talked about
at that principal cell
in terms of maintaining
potassium balance.
04:02
So remember what L
dosterone does again,
I'm going to remind
you one more time.
04:05
It's going to open
those epithelial
sodium channels,
those renal outer medullary
potassium channels
and turn on that sodium
potassium ATPase.
04:13
And that's really how potassium
excretion is maintained.
04:17
Now hyperkalemia is going to develop
in these particular patients,
If they're oliguric, that means
that they're not going to have
that distal flow rate intact.
04:24
And if they have an
additional problem as well
like an excess potassium load
or if they're on
aldosterone blockade
things like ACE inhibitors,
angiotensin receptor blockers
and aldosterone blockers.
04:36
We can also see hyperkalemia
in states of volume depletion
where we have a decrease
in distal sodium delivery.
04:43
These are going to be
states like hypovolemia
or a decrease in effect
of arterial blood volume,
even though that patient
may have total
extracellular volume excess.
04:52
That's going to be a
state like heart failure
or cirrhosis of the liver.
04:55
Again, the mechanism here is
that we have a decrease
in distal sodium delivery
in tubular flow rate.
05:02
Finally, we can have
functional hyperaldosteronism
either a low aldosterone state
or resistance to the
effect of aldosterone
as a means of
causing Hyperkalemia.
05:13
This can be due to either a
mineralocorticoid deficiency
in that could be primary
adrenal insufficiency.
05:18
That means that the
adrenal gland itself
does not generate aldosterone
from the Zona glomerulosa
in response to renin.
05:26
This could be due to
hyporeninemic hypoaldosteronism.
05:31
That is what we talk
about as a diabetic
or a type 4 renal
tubular acidosis.
05:37
In any state that causes
a low plasma renin level
and a low aldosterone level.
05:42
We can also see this with
tubular interstitial diseases
things like sickle cell disease
or urinary tract obstruction,
which can affect
the principal cell.
05:50
If we don't have that
principle cell there
or if it's not working properly
remember that's the major
site of potassium excretion.
05:56
And so if I don't have those
epithelial sodium channels
or renal outer medullary
potassium channels to regulate
my potassium excretion,
I can end up with hyperkalemia.
06:06
And that is referred to as a distal
hyperkalemic renal tubular acidosis.
06:10
Again, this is due to that
impaired sodium reabsorption
in the principal cell
reducing both potassium
and proton excretion.
06:17
There are drugs that
can also mediate this.
06:19
So drugs that block
the conversion to
aldosterone or binding
to aldosterone receptor.
06:25
These are things
like a ACE inhibitors
angiotensin receptor blockers,
aldosterone antagonists like
spironolactone or eplerenone.
06:33
We can have drugs
that actually affect
renin release.
06:36
So non-steroidal anti-inflammatories
inhibit renin release
beta blockers to a slight degree
will also cause run an inhibition
and then there's direct renin
inhibitors like tekturna or aliskerin.
06:47
We have drugs that bind the
luminol sodium potassium
or luminal sodium channel
that epithelial sodium
channel at the principal cell.
06:55
Those are drugs like amilloride,
triamterene,
trimethoprim or pentamidine,
all of those bind
that ENaC Channel
and because of that remember,
that's going to abolish that
electrochemical gradient.
07:06
So potassium will not
favor, will not be favored
to e-flux in the tubular fluid.
07:10
And then you can have drugs
that cause multiple effects.
07:12
These are calcineurin
inhibitors,
drugs that we use
for organ transplant
to prevent rejection
and they have an effect
on both the epithelial
sodium channel as well as
that sodium potassium ATPase.