Clinical manifestations of hyperkalemia in adults
- David B Mount, MD
David B Mount, MD
- Assistant Professor of Medicine
- Harvard Medical School
Hyperkalemia is a common clinical problem that is most often due to impaired urinary potassium excretion due to acute or chronic kidney disease and/or disorders or drugs that inhibit the renin-angiotensin-aldosterone axis. Therapy for hyperkalemia due to potassium retention is ultimately aimed at inducing potassium loss [1-3]. In some cases, the primary problem is movement of potassium out of the cells, even though the total body potassium may be reduced. Redistributive hyperkalemia most commonly occurs in uncontrolled hyperglycemia (eg, diabetic ketoacidosis or hyperosmolar hyperglycemic state). (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment", section on 'Potassium replacement'.)
The clinical manifestations of hyperkalemia will be reviewed here. The causes, diagnosis, treatment, and prevention of hyperkalemia are discussed separately. (See "Causes and evaluation of hyperkalemia in adults" and "Treatment and prevention of hyperkalemia in adults".)
The most serious manifestations of hyperkalemia are muscle weakness or paralysis, cardiac conduction abnormalities, and cardiac arrhythmias. These manifestations usually occur when the serum potassium concentration is ≥7.0 meq/L with chronic hyperkalemia or possibly at lower levels with an acute rise in serum potassium. Patients with skeletal muscle or cardiac manifestations typically have one or more of the characteristic ECG abnormalities associated with hyperkalemia.
Other manifestations in hyperkalemic patients may be related to the cause of the hyperkalemia, such as polyuria and polydipsia with uncontrolled diabetes.
Severe muscle weakness or paralysis — Hyperkalemia can cause ascending muscle weakness that begins with the legs and progresses to the trunk and arms [4-6]. This can progress to flaccid paralysis, mimicking Guillain-Barré syndrome [5,6]. Sphincter tone and cranial nerve function are typically intact, and respiratory muscle weakness is rare . These manifestations resolve with correction of the hyperkalemia.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Mount DB, Zandi-Nejad K. Disorders of potassium balance. In: Brenner and Rector's The Kidney, 9th Ed, WB Saunders & Company, Philadelphia 2011. p.640.
- Rose BD, Post TW. Clinical Physiology of Acid-Base and Electrolyte Disorders, 5th ed, Mc-Graw Hill, New York 2001. p.913.
- Kamel KS, Wei C. Controversial issues in the treatment of hyperkalaemia. Nephrol Dial Transplant 2003; 18:2215.
- FINCH CA, SAWYER CG, FLYNN JM. Clinical syndrome of potassium intoxication. Am J Med 1946; 1:337.
- Evers S, Engelien A, Karsch V, Hund M. Secondary hyperkalaemic paralysis. J Neurol Neurosurg Psychiatry 1998; 64:249.
- BELL H, HAYES WL, VOSBURGH J. HYPERKALEMIC PARALYSIS DUE TO ADRENAL INSUFFICIENCY. Arch Intern Med 1965; 115:418.
- Freeman SJ, Fale AD. Muscular paralysis and ventilatory failure caused by hyperkalaemia. Br J Anaesth 1993; 70:226.
- Montague BT, Ouellette JR, Buller GK. Retrospective review of the frequency of ECG changes in hyperkalemia. Clin J Am Soc Nephrol 2008; 3:324.
- Acker CG, Johnson JP, Palevsky PM, Greenberg A. Hyperkalemia in hospitalized patients: causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines. Arch Intern Med 1998; 158:917.
- Szerlip HM, Weiss J, Singer I. Profound hyperkalemia without electrocardiographic manifestations. Am J Kidney Dis 1986; 7:461.
- Surawicz B, Chlebus H, Mazzoleni A. Hemodynamic and electrocardiographic effects of hyperpotassemia. Differences in response to slow and rapid increases in concentration of plasma K. Am Heart J 1967; 73:647.
- Aslam S, Friedman EA, Ifudu O. Electrocardiography is unreliable in detecting potentially lethal hyperkalaemia in haemodialysis patients. Nephrol Dial Transplant 2002; 17:1639.
- Somers MP, Brady WJ, Perron AD, Mattu A. The prominent T wave: electrocardiographic differential diagnosis. Am J Emerg Med 2002; 20:243.
- Arnsdorf MF. Electrocardiogram in Hyperkalemia: electrocardiographic pattern of anteroseptal myocardial infarction mimicked by hyperkalemia-induced disturbance of impulse conduction. Arch Intern Med 1976; 136:1161.
- Littmann L, Monroe MH, Taylor L 3rd, Brearley WD Jr. The hyperkalemic Brugada sign. J Electrocardiol 2007; 40:53.
- Bashour T, Hsu I, Gorfinkel HJ, et al. Atrioventricular and intraventricular conduction in hyperkalemia. Am J Cardiol 1975; 35:199.
- Greenberg A. Hyperkalemia: treatment options. Semin Nephrol 1998; 18:46.
- Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med 2000; 18:721.
- Karet FE. Mechanisms in hyperkalemic renal tubular acidosis. J Am Soc Nephrol 2009; 20:251.
- Szylman P, Better OS, Chaimowitz C, Rosler A. Role of hyperkalemia in the metabolic acidosis of isolated hypoaldosteronism. N Engl J Med 1976; 294:361.
- Matsuda O, Nonoguchi H, Tomita K, et al. Primary role of hyperkalemia in the acidosis of hyporeninemic hypoaldosteronism. Nephron 1988; 49:203.
- Tannen RL, Wedell E, Moore R. Renal adaptation to a high potassium intake. The role of hydrogen ion. J Clin Invest 1973; 52:2089.
- DuBose TD Jr, Good DW. Effects of chronic hyperkalemia on renal production and proximal tubule transport of ammonium in rats. Am J Physiol 1991; 260:F680.
- FULLER GR, MACLEOD MB, PITTS RF. Influence of administration of potassium salts on the renal tubular reabsorption of bicarbonate. Am J Physiol 1955; 182:111.
- Jaeger P, Karlmark B, Giebisch G. Ammonium transport in rat cortical tubule: relationship to potassium metabolism. Am J Physiol 1983; 245:F593.
- DuBose TD Jr, Good DW. Chronic hyperkalemia impairs ammonium transport and accumulation in the inner medulla of the rat. J Clin Invest 1992; 90:1443.
- Good DW. Ammonium transport by the thick ascending limb of Henle's loop. Annu Rev Physiol 1994; 56:623.
- Sleeper RS, Belanger P, Lemieux G, Preuss HG. Effects of in vitro potassium on ammoniagenesis in rat and canine kidney tissue. Kidney Int 1982; 21:345.
- Berne RM, Levy MN. Cardiovascular Physiology, 4th ed, Mosby, St. Louis 1981.
- Parham WA, Mehdirad AA, Biermann KM, Fredman CS. Hyperkalemia revisited. Tex Heart Inst J 2006; 33:40.
- Guo J, Massaeli H, Xu J, et al. Extracellular K+ concentration controls cell surface density of IKr in rabbit hearts and of the HERG channel in human cell lines. J Clin Invest 2009; 119:2745.
- Sanguinetti MC, Jiang C, Curran ME, Keating MT. A mechanistic link between an inherited and an acquired cardiac arrhythmia: HERG encodes the IKr potassium channel. Cell 1995; 81:299.
- Paice B, Gray JM, McBride D, et al. Hyperkalaemia in patients in hospital. Br Med J (Clin Res Ed) 1983; 286:1189.
- Charytan D, Goldfarb DS. Indications for hospitalization of patients with hyperkalemia. Arch Intern Med 2000; 160:1605.