Assessment of hyperkalaemia

Assessment of hyperkalaemia Straight to the point of care Last updated: Jun 18, 2021 Table of Contents Overview 3 Summary 3 Theory 5 Aetiology 5 Emergencies 8 Urgent considerations 8 Diagnosis 11 Approach 11 Differentials overview 17 Differentials 18 Guidelines 44 References 45 Images 48 Disclaimer 49 Assessment of hyperkalaemia Overview Summary Significant hyperkalaemia is defined as a serum potassium value >6.0 mmol/L (>6.0 mEq/L). Moderate hyperkalaemia is defined as serum potassium values in the 5.0 to 6.0 mmol/L (5.0-6.0 mEq/L) range. Small changes in serum potassium values can have significant muscular and cardiac effects when significant hyperkalaemia is present. Hyperkalaemia is most commonly due either to high intake of potassium in the setting of decreased renal excretion or to extracellular redistribution of potassium from intracellular locations. There is a limited correlation between an elevated serum potassium value and an excess in total body potassium stores. Clinical manifestations of hyperkalaemia are uncommon with values <6 .0="" .="" 18="" 2009="" 2021.="" 2="" 30="" 339:b4114.="" 3="" 4="" 5000="" 5="" 60="" 6="" a="" ability="" abnormalities="" absolute="" accentuated="" accompanied="" ace="" acid-base="" acid.="" acidosis="" action="" actions="" activity="" acute="" addison="" administered="" administration="" adrenal="" aetiology="" after="" aldosterone.="" aldosterone="" alkalosis="" all="" already="" also="" amiloride-like="" amiloride:="" amount="" amounts="" an="" and="" angiotensin-receptor="" antagonists="" anti-inflammatory="" antibiotic="" any="" apparent.="" apparent="" are="" arginine="" arrhythmia.="" arrhythmias="" as="" ascertainment="" assessment="" associated="" association="" away="" based="" be="" been="" begins="" behave="" being="" below="" best="" bestpractice.bmj.com="" between="" blockers="" blood="" bmj="" both="" brought="" buffering="" but="" by="" calcineurin="" can="" cardiotoxicity="" case="" cause="" causes.="" causes="" cells="" cellular="" change="" changes="" chronic="" ciclosporin="" collecting="" combination="" common="" commonly="" compared="" compartments.="" compounds="" compromise="" concentration.="" concentration="" concomitant="" concurrently="" conditions="" congenital="" considered="" content="" continuous="" contribute="" copyright="" cyclosporine="" daily="" days="" decline="" decrease="" decreased="" defects="" deficiency="" degree="" dependent="" depletion.="" development="" diabetes.="" diabetes="" diet="" dietary="" diets="" difference="" diminution="" direct="" disclaimer.="" disease="" disorders.="" disproportionate="" disproportionately="" distal="" distinguished="" disturbances="" diuretic="" diuretics.="" diuretics="" does="" dose-dependent="" dose="" doses="" drag="" drugs="" duct="" due="" dysfunction="" e="" ecg="" effect="" effects="" either="" electrocardiographic="" elevated="" emergency="" entry="" eplerenone="" erythematosus="" especially="" establish="" even="" excessive="" exchange="" excrete="" excretion.="" excretion="" exit.="" exit="" extracellular="" facilitates="" facilitating="" factors="" failure="" falls="" faster="" filtration="" findings="" fluid="" following="" follows:="" foodstuffs="" for="" form="" found="" from="" function.="" function="" functional="" given="" glomerular="" gradients="" greatest="" group="" h="" handling="" has="" have="" having="" heparin.="" heparin:="" hepatic="" high="" hiv-positive="" homeostasis.="" homeostasis="" however="" hydrochloric="" hydrochloride="" hydrogen="" hyperglycaemia="" hyperkalaemia.="" hyperkalaemia="" hyperosmolality="" hyperplasia="" hypoaldosteronism.="" hypoaldosteronism="" hypokalaemia="" hyporeninaemic="" i.e.="" if="" impaired="" impairing="" implementation="" in="" include:="" include="" including="" increase="" increased="" independent="" individuals="" infections="" ingested="" inhibition="" inhibitor="" inhibitors:="" inhibitors="" insufficiency.="" insufficiency="" intake="" into="" intracellular="" ions.="" is="" it="" its="" jun="" kidney="" known="" l="" laboratory="" lag="" last="" latter="" leading="" level="" levels.="" life-threatening="" linked="" location="" long-acting="" loop="" losses="" low-sodium="" low="" ltd="" lupus="" main="" maintain="" manifestations="" mannitol.="" mannitol="" marked="" mask="" may="" measures="" mechanisms.="" medical="" medications="" mellitus.="" meq="" metabolic="" metabolise="" might="" mildly="" mineralocorticoid="" minute="" minutes="" ml="" mmol="" molecular="" monitoring="" more="" most="" movement="" much="" muscle="" nephrotoxic="" non-steroidal="" normal="" not="" note="" nsaids.="" number="" o="" obtained="" occur="" occurs.="" occurs="" of="" older="" on="" only="" or="" osmolality="" osmotic="" other="" otherwise="" our="" out="" overview="" particularly="" patient="" patients.="" patients="" pdf="" pentamidine:="" people="" pge2="" pgi2="" phenomenon="" plasma="" poorly="" potassium-enriched="" potassium-sparing="" potassium.="" potassium="" potential="" practice="" pre-emptive="" pre-existing="" presence="" present.="" present="" process.="" process="" production="" progress="" properties="" pseudohyperkalaemia.="" pseudohypoaldosteronism="" publishing="" r="" range="" rapid="" rapidly="" rare="" rarely="" rate="" receiving="" recent="" receptor="" redistribution="" reduce="" reduces="" reduction="" regularly="" relates="" relating="" relative="" release="" remain="" renal="" renin="" represents="" requires="" reserved.="" residual="" resistance="" resolved.="" respiratory="" response="" result="" results="" rights="" rises="" rta="" ruled="" s="" safe="" salt-wasting="" sampling="" secondary="" secretion="" seem="" serum="" setting="" several="" shift.="" shift="" shifts="" should="" significance="" significant="" significantly="" small="" smaller="" so-called="" so="" sodium="" solvent="" some="" sometimes="" spironolactone="" standard="" starting="" state="" stimulate="" stopped.="" subject="" substances="" substantial="" such="" supplements.="" supplements="" synthesis="" t="" tacrolimus:="" takes="" tendencies="" test-tube="" than="" that="" the="" theory="" therapy:="" therapy="" there="" thereby="" these="" thiazide-type="" this="" those="" time="" to="" topic="" topics="" tract="" transcellular="" transport="" treat="" treatment.="" treatment="" triamterene="" trimethoprim-sulfamethoxazole="" trimethoprim="" true="" tubular="" tubule="" tubulointerstitial="" twice="" type="" typically="" uncommon="" unfractionated="" units="" unresponsiveness="" until="" updated:="" updated="" urinary="" urine="" use="" used="" usually="" v="" values.="" values="" version="" very="" vie="" volume="" w="" was="" way="" weakness="" web="" weight="" when="" whereas="" whether="" which="" while="" who="" with="" within="" without="" work="" y="">1 g/kg body weight) given determines the extent of extracellular potassium flux. Insulin and beta-agonists facilitate the cellular entry of potassium.[14] As such, a deficiency in insulin as well as blockade of beta-receptors (as occurs with non-cardioselective beta-blocker therapy) can be followed by a rise in serum potassium values.[15] Life-threatening arrhythmias are uncommon with beta-blockers, since the associated increase in serum potassium values is both minor and transient. Digitalis overdose, by inhibiting Na-K-ATPase, can cause dramatic and sometimes life-threatening increases in serum potassium.[16] Hyperkalaemia occurs in a small subset of patients after administration of suxamethonium (succinylcholine), a depolarising neuromuscular drug, and can be fatal.[17] In patients without neuromuscular disease, suxamethonium (succinylcholine) administration results in small, transient serum potassium increases of about 50 mmol/L (50 mEq/L). When skeletal muscle undergoes prolonged disuse or normal neural stimulation is absent, acetylcholine receptors up-regulate, permitting a massive efflux of potassium from muscle cells with exposure to suxamethonium (succinylcholine). Increased cell turnover Increased cell turnover can result in hyperkalaemia. This can occur in the course of strenuous exercise, particularly when volume depletion and a resultant fall in glomerular filtration rate coexist. Increased cell damage, as occurs with rhabdomyolysis and tumour lysis syndrome, can also result in significant hyperkalaemia, with or without a major fall in the level of renal function.[18] [19]

<6 .0="" .="" 18="" 2009="" 2021.="" 2="" 30="" 339:b4114.="" 3="" 4="" 5000="" 5="" 60="" 6="" a="" ability="" abnormalities="" absolute="" accentuated="" accompanied="" ace="" acid-base="" acid.="" acidosis="" action="" actions="" activity="" acute="" addison="" administered="" administration="" adrenal="" aetiology="" after="" aldosterone.="" aldosterone="" alkalosis="" all="" already="" also="" amiloride-like="" amiloride:="" amount="" amounts="" an="" and="" angiotensin-receptor="" antagonists="" anti-inflammatory="" antibiotic="" any="" apparent.="" apparent="" are="" arginine="" arrhythmia.="" arrhythmias="" as="" ascertainment="" assessment="" associated="" association="" away="" based="" be="" been="" begins="" behave="" being="" below="" best="" bestpractice.bmj.com="" between="" blockers="" blood="" bmj="" both="" brought="" buffering="" but="" by="" calcineurin="" can="" cardiotoxicity="" case="" cause="" causes.="" causes="" cells="" cellular="" change="" changes="" chronic="" ciclosporin="" collecting="" combination="" common="" commonly="" compared="" compartments.="" compounds="" compromise="" concentration.="" concentration="" concomitant="" concurrently="" conditions="" congenital="" considered="" content="" continuous="" contribute="" copyright="" cyclosporine="" daily="" days="" decline="" decrease="" decreased="" defects="" deficiency="" degree="" dependent="" depletion.="" development="" diabetes.="" diabetes="" diet="" dietary="" diets="" difference="" diminution="" direct="" disclaimer.="" disease="" disorders.="" disproportionate="" disproportionately="" distal="" distinguished="" disturbances="" diuretic="" diuretics.="" diuretics="" does="" dose-dependent="" dose="" doses="" drag="" drugs="" duct="" due="" dysfunction="" e="" ecg="" effect="" effects="" either="" electrocardiographic="" elevated="" emergency="" entry="" eplerenone="" erythematosus="" especially="" establish="" even="" excessive="" exchange="" excrete="" excretion.="" excretion="" exit.="" exit="" extracellular="" facilitates="" facilitating="" factors="" failure="" falls="" faster="" filtration="" findings="" fluid="" following="" follows:="" foodstuffs="" for="" form="" found="" from="" function.="" function="" functional="" given="" glomerular="" gradients="" greatest="" group="" h="" handling="" has="" have="" having="" heparin.="" heparin:="" hepatic="" high="" hiv-positive="" homeostasis.="" homeostasis="" however="" hydrochloric="" hydrochloride="" hydrogen="" hyperglycaemia="" hyperkalaemia.="" hyperkalaemia="" hyperosmolality="" hyperplasia="" hypoaldosteronism.="" hypoaldosteronism="" hypokalaemia="" hyporeninaemic="" i.e.="" if="" impaired="" impairing="" implementation="" in="" include:="" include="" including="" increase="" increased="" independent="" individuals="" infections="" ingested="" inhibition="" inhibitor="" inhibitors:="" inhibitors="" insufficiency.="" insufficiency="" intake="" into="" intracellular="" ions.="" is="" it="" its="" jun="" kidney="" known="" l="" laboratory="" lag="" last="" latter="" leading="" level="" levels.="" life-threatening="" linked="" location="" long-acting="" loop="" losses="" low-sodium="" low="" ltd="" lupus="" main="" maintain="" manifestations="" mannitol.="" mannitol="" marked="" mask="" may="" measures="" mechanisms.="" medical="" medications="" mellitus.="" meq="" metabolic="" metabolise="" might="" mildly="" mineralocorticoid="" minute="" minutes="" ml="" mmol="" molecular="" monitoring="" more="" most="" movement="" much="" muscle="" nephrotoxic="" non-steroidal="" normal="" not="" note="" nsaids.="" number="" o="" obtained="" occur="" occurs.="" occurs="" of="" older="" on="" only="" or="" osmolality="" osmotic="" other="" otherwise="" our="" out="" overview="" particularly="" patient="" patients.="" patients="" pdf="" pentamidine:="" people="" pge2="" pgi2="" phenomenon="" plasma="" poorly="" potassium-enriched="" potassium-sparing="" potassium.="" potassium="" potential="" practice="" pre-emptive="" pre-existing="" presence="" present.="" present="" process.="" process="" production="" progress="" properties="" pseudohyperkalaemia.="" pseudohypoaldosteronism="" publishing="" r="" range="" rapid="" rapidly="" rare="" rarely="" rate="" receiving="" recent="" receptor="" redistribution="" reduce="" reduces="" reduction="" regularly="" relates="" relating="" relative="" release="" remain="" renal="" renin="" represents="" requires="" reserved.="" residual="" resistance="" resolved.="" respiratory="" response="" result="" results="" rights="" rises="" rta="" ruled="" s="" safe="" salt-wasting="" sampling="" secondary="" secretion="" seem="" serum="" setting="" several="" shift.="" shift="" shifts="" should="" significance="" significant="" significantly="" small="" smaller="" so-called="" so="" sodium="" solvent="" some="" sometimes="" spironolactone="" standard="" starting="" state="" stimulate="" stopped.="" subject="" substances="" substantial="" such="" supplements.="" supplements="" synthesis="" t="" tacrolimus:="" takes="" tendencies="" test-tube="" than="" that="" the="" theory="" therapy:="" therapy="" there="" thereby="" these="" thiazide-type="" this="" those="" time="" to="" topic="" topics="" tract="" transcellular="" transport="" treat="" treatment.="" treatment="" triamterene="" trimethoprim-sulfamethoxazole="" trimethoprim="" true="" tubular="" tubule="" tubulointerstitial="" twice="" type="" typically="" uncommon="" unfractionated="" units="" unresponsiveness="" until="" updated:="" updated="" urinary="" urine="" use="" used="" usually="" v="" values.="" values="" version="" very="" vie="" volume="" w="" was="" way="" weakness="" web="" weight="" when="" whereas="" whether="" which="" while="" who="" with="" within="" without="" work="" y="">This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Emergencies asystole).[23] The presence of cardiotoxic ECG changes from hyperkalaemia require continuous monitoring until serum potassium values have been brought into a safe range and the ECG changes have been corrected. ECG changes in patients with hyperkalaemia BMJ 2009; 339:b4114. Copyright ©2009 by the BMJ Publishing Group Severe muscle weakness or paralysis Severe muscle weakness is a complication of significant hyperkalaemia, commonly presenting as ascending paralysis. This process occurs as a function of depolarisation blockade.[28] Muscle weakness secondary to hyperkalaemia can be of sufficient severity to suppress respiratory effort. The effect of non-depolarising muscle relaxants can be accentuated by concurrent hyperkalaemia. Cardiac arrhythmias often, but not always, accompany muscle paralysis. Urgent reduction in serum potassium values is required. E M E R G E N CIE S This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 9 Assessment of hyperkalaemia Emergencies E M E R G E N CIE S Hyperkalaemic periodic paralysis Hyperkalaemic period paralysis can episodically cause muscle weakness/stiffness. These episodes are brief, lasting for only minutes, and often occur during rest after exercise. In most patients, the level of potassium does not rise above normal when an attack occurs.[22] The term 'hyperkalaemic' is applied to this disturbance as the attacks may be prompted by administration of potassium or the ingestion of foods high in potassium content. Although it is difficult to capture the 'hyperkalaemic' component of this illness, repetitive sampling during attack-free intervals will often pick up high normal serum potassium values. The level of treatment is determined by the frequency of episodes. Patients with infrequent episodes can be managed by dietary means. Those with more frequent episodes require diuretic therapy (particularly acetazolamide), inhaled beta-agonists, and oral calcium gluconate. Situations needing particular caution In patients with significant hyperglycaemia there is movement of potassium from the intracellular to the extracellular compartment. The ensuing rise in serum potassium values is often of a sufficient magnitude that any underlying state of potassium depletion is poorly recognised. Treatment of the hyperglycaemia is required before the level of total body potassium depletion can be accurately gauged. Hyperkalaemia which occurs with use of the aldosterone-receptor antagonist spironolactone can be prolonged owing to the very long half-life of its active metabolites. Measures implemented to reduce serum potassium values in such patients should be continued for 2 to 3 days after being started. When diuretic therapy is used to increase urine flow rate and thereby potassium excretion, care should be taken not to allow the patient to become volume-depleted. Dehydration will slow urine flow rate and reduce sodium delivery to the distal tubular exchange site. As a result, potassium values may no longer drop with therapy and may even rise. When calcium is being used as a physiological antagonist to the membrane effects of hyperkalaemia, care should be taken to use adequate amounts of elemental calcium. Of note, an ampoule of calcium gluconate contains much less elemental calcium than an ampoule of calcium chloride. There is a time lag for a potassium-lowering effect with potassium-binding resins that may be as long as several hours. Potassium-binding resins exchange sodium for potassium and, as such, a significant sodium load may be given to a patient based on the dose amount and dose frequency of the resin. 10 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Diagnosis Approach Hyperkalaemia can be difficult to detect clinically because associated symptoms are typically vague. Hyperkalaemia is for the most part detected as an incidental laboratory finding. The history is most useful in identifying conditions, such as renal failure or adrenal insufficiency, commonly associated with hyperkalaemia, or determining whether medications, such as potassium-sparing diuretics or potassium supplements, are in use. An obvious cause of hyperkalaemia can usually be detected based on the history, once transcellular shifts of potassium, sampling conditions, and decreased renal excretion have been taken into account. Clinical features Low-level hyperkalaemia, in the range of 5.0 to 6.0 mmol/L (5.0-6.0 mEq/L), is almost always asymptomatic. Values of serum potassium >7.0 mmol/L (>7.0 mEq/L) are more often symptomatic by way of muscle weakness and are evident on ECG. DIA G N O SIS This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 11 Assessment of hyperkalaemia Diagnosis DIA G N O SIS ECG changes in patients with hyperkalaemia BMJ 2009; 339:b4114. Copyright ©2009 by the BMJ Publishing Group Muscle weakness is uncommon below serum potassium values of 7.0 mmol/L (7.0 mEq/L). Electrocardiographic changes with hyperkalaemia can progress rapidly from asymptomatic findings to lifethreatening arrhythmias. Features that should be elicited from the history include common causes of hyperkalaemia, including: acute or chronic renal failure with or without a high potassium intake; muscle trauma;[18] chemotherapy for a rapidly proliferating tumour;[19] and poorly controlled diabetes with significant hyperglycaemia. Patients with recent significant muscle injury, prolonged seizures, and/or a history of having exercised excessively in a warm environment should be suspected of having some degree of rhabdomyolysis. A symptom complex characterised by weight loss, fatigue, excessive skin pigmentation, cold intolerance, hypotension, and a tendency to develop hyponatraemia and hypoglycaemia should arouse suspicion of Addison's disease. A complete drug history should also be obtained. Drug history should include intake of high doses of potassium supplements and the use of any of several different medications, such as: non-steroidal anti-inflammatory 12 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Diagnosis drugs,[4] ACE inhibitors,[7] angiotensin-receptor blockers,[8] heparin,[10] pentamidine,[6] ciclosporin (cyclosporine), tacrolimus,[11] trimethoprim,[5] and/or potassium-sparing diuretics (e.g., spironolactone, eplerenone, canrenone, triamterene, and amiloride).[3] Step-by-step consideration of potential causes It is not unusual for there to be multiple contributing factors causing hyperkalaemia.[29] The physician should exclude pseudohyperkalaemia in a patient with normal renal function, a normal ECG and/or a history of a haematological disorder. Pseudohyperkalaemia is identified by a serum (clotted blood) potassium that is >0.4 millimol/L higher than the potassium level in a simultaneously-obtained plasma (nonclotted blood) sample. Spurious hyperkalaemia can be caused by difficult venepuncture, prolonged transit time and poor storage conditions.[23] A quick review of a recent FBC, seeking out significant leukocytosis (>100,000 x 10⁹/L) or thrombocytosis (>500,000 x 10⁹/L), will establish whether these causes of pseudohyperkalaemia are present. Once pseudohyperkalaemia has been ruled out, the pathophysiological mechanism of cellular redistribution is considered and is a likely cause if there is significant hyperglycaemia, and/or a medication history of mannitol, arginine hydrochloride (rarely used to treat significant metabolic alkalosis), suxamethonium (succinylcholine), digoxin, and/or beta-blocker. If both pseudohyperkalaemia and cellular redistribution have been ruled out as causes, the next consideration is an imbalance between potassium intake and excretion. Consideration of potassium intake relative to the level of renal function becomes most important. Dietary potassium intake can be difficult to establish based on recall; only when salt substitutes or potassium supplements are being used can a high intake be definitively established. Reduced renal function alone seldom results in hyperkalaemia without there being a significant dietary intake. In those instances when serum potassium values are much higher than would be expected for the level of renal function, the differentials of hyporeninaemic hypoaldosteronism or hypoaldosteronism should be investigated. The following tests should be done for confirmation: plasma renin activity, plasma cortisol, and plasma aldosterone. Interpretation of serum potassium concentrations There is a limited correlation between the serum potassium concentrations and total body potassium stores. Spurious laboratory values, termed pseudohyperkalaemia, can falsely increase the serum potassium value; accordingly, it is important to consider repeating the test for confirmation. Pending confirmatory testing, the serum potassium value in question should be viewed as being correct and appropriate treatment measures instituted. Investigations All patients presenting with hyperkalaemia should have the following initial tests: basic metabolic panel (including serum potassium, glucose, bicarbonate, urea, and serum creatinine), serum calcium, FBC, and an ECG. Subsequent tests performed depend on the clinical findings, and include: • urine dipstick creatine kinase, if rhabdomyolysis is a possibility • cortisol and aldosterone levels, if Addison's disease is suspected • arterial blood gases, if metabolic acidosis needs to be established DIA G N O SIS This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 13 Assessment of hyperkalaemia Diagnosis DIA G N O SIS • serum digoxin level, if the patient is receiving digoxin or suicide is known to have been attempted with digoxin ingestion • urine pH, to evaluate for inappropriately elevated value (pH >5.5) in the setting of metabolic acidosis, suggesting renal tubular acidosis • transtubular potassium gradient, to evaluate for various forms of impaired distal tubular secretion of potassium (determination of the transtubular gradient for potassium requires urine and plasma samples for potassium and osmolality) • plasma renin activity, usually elevated in pseudohypoaldosteronism • 17-hydroxyprogesterone, if 21-hydroxylase deficiency is suspected in newborns. Electrocardiogram An ECG should be performed in all patients with significant hyperkalaemia. ECG findings are usually progressive and include first degree heart block (prolonged PR interval >0.2 seconds), flattened or absent P waves, peaked (tented) T waves (i.e. T wave larger than R wave in >1 lead), ST-segment depression, widened QRS (>0.12 seconds), ventricular tachycardia, bradycardia and eventually cardiac arrest (pulseless electrical activity, ventricular fibrillation/paroxysmal ventricular tachycardia, asystole).[23] 14 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Diagnosis ECG changes in patients with hyperkalaemia BMJ 2009; 339:b4114. Copyright ©2009 by the BMJ Publishing Group Hyperkalaemia with decreased urine potassium excretion A 24-hour urine potassium excretion of <20 causes="" distinguish="" excretion="" extra-renal="" from="" meq="" mmol="" potassium="" renal="" will="">40 mmol/L [>40 mEq/L]) of hyperkalaemia. However, urinary potassium measurements may prove difficult to interpret, since multiple factors influence these values independent of level of renal function. For values that are difficult to interpret, the transtubular gradient for potassium is of some use. The transtubular gradient for potassium (TTKG = [K+] urine/(U/P)osm/plasma K+) corrects urinary potassium for changes in osmolality that occur with absorption of water in the collecting duct. A value consistently <7 a="" aldosterone="" distal="" either="" hypoaldosteronism="" impaired="" of="" or="" potassium="" resistance="" secondary="" secretion="" suggests="" to="" tubular="" value="">10 favours increased intake and intact distal tubular handling of potassium.[30] DIA G N O SIS This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 15 Assessment of hyperkalaemia Diagnosis DIA G N O SIS Hyperkalaemic periodic paralysis Hyperkalaemic periodic paralysis should be considered when there is intermittent muscle weakness in the setting of cold exposure, ethanol use, potassium administration, and/or a high-potassium diet. With weekly determinations of potassium values, high normal values can occasionally be detected during attack-free intervals, which then allows for a presumptive diagnosis. 16 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Diagnosis Differentials overview Common Chronic kidney disease Diabetic ketoacidosis/hyperosmolar hyperglycaemic state Drug-related decreased cellular entry or increased cellular exit of potassium Potassium supplementation with underlying renal dysfunction Drug-related reduced urinary potassium excretion Uncommon Acute kidney failure Renal tubular acidosis Metabolic acidosis Congenital adrenal hyperplasia Addison's disease Pseudohypoaldosteronism Hyperkalaemic periodic paralysis Tumour lysis syndrome Rhabdomyolysis Pseudohyperkalaemia Ureterojejunostomy DIA G N O SIS This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 17 Assessment of hyperkalaemia Diagnosis DIA G N O SIS Differentials Common ◊ Chronic kidney disease History Exam 1st Test Other tests history of underlying disease, often due to diabetes and/or hypertension; possible lupus or vasculitis; history of abdominal pain and discomfort pallor, dry skin, pruritus, memory changes, weight loss or weight gain (if oedematous), as well as findings consistent with the underlying cause of renal failure »serum potassium: elevated Relates to decreased ability to excrete potassium. Can occur early in the course of chronic kidney disease, particularly in patients with diabetes or hyporeninaemic hypoaldosteronism. Less common than in the case of acute kidney failure, in that adaptive gastrointestinal and cellular processes evolve to facilitate potassium handling. Urine flow rate and sodium intake are important determinants of potassium clearance by the chronic renal failure kidney. In lupus erythematosus, decreased tubular secretion of potassium relating to tubulointerstitial disease is sometimes disproportionate to the level of renal function. »serum creatinine: elevated Increase in serum creatinine values more 18 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Diagnosis Common ◊ Chronic kidney disease History Exam 1st Test Other tests closely approximate glomerular filtration rate than in the case of acute kidney failure. Potassium excretion begins to decrease at a glomerular filtration rate of about 30 mL/ minute. Often appears in the setting of potassium supplements being given and/or potassium-sparing medications being administered. »ECG: findings are usually progressive and include first degree heart block (prolonged PR interval >0.2 s), flattened or absent P waves, tall, peaked (tented) T waves (i.e. T wave larger than R wave in more than 1 lead), ST-segment depression, widened QRS (>0.12 s), ventricular tachycardia, bradycardia and eventually cardiac arrest (pulseless electrical activity, ventricular fibrillation/ paroxysmal ventricular tachycardia, asystole) Life-threatening arrhythmias occur most commonly when factors impairing cellular uptake of potassium coexist and/or there is a sudden intake in potassium. DIA G N O SIS This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 19 Assessment of hyperkalaemia Diagnosis DIA G N O SIS Common ◊ Chronic kidney disease History Exam 1st Test Other tests ECG changes in patients with hyperkalaemia BMJ 2009; 339:b4114. Copyright ©2009 by the BMJ Publishing Group Presence of hyponatraemia and/ or hypocalcaemia can intensify the cardiotoxicity of hyperkalaemia. Diabetic ketoacidosis/hyperosmolar hyperglycaemic state History Exam 1st Test Other tests history of diabetes with intercurrent illness, recent corticosteroid therapy, non-adherence to insulin therapy, polyuria, fatigue, weight loss, nausea, abdominal pain, vomiting fever, tachycardia, poor skin turgor, postural hypotension, abdominal tenderness »serum potassium: elevated Relates to the extracellular movement of fluid and potassium (solvent drag) in response to the higher extracellular osmolality attributable to hyperglycaemia. 20 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Diagnosis Common Diabetic ketoacidosis/hyperosmolar hyperglycaemic state History Exam 1st Test Other tests The effect on serum potassium values of the hyperglycaemiarelated extracellular shift in potassium can be variable, relating in part to the extent to which total body potassium stores have been depleted. »blood glucose: elevated »ECG: findings are usually progressive and include first degree heart block (prolonged PR interval >0.2 s), flattened or absent P waves, tall, peaked (tented) T waves (i.e. T wave larger than R wave in more than 1 lead), ST-segment depression, widened QRS (>0.12 s), ventricular tachycardia, bradycardia and eventually cardiac arrest (pulseless electrical activity, ventricular fibrillation/ paroxysmal ventricular tachycardia, asystole) Life-threatening arrhythmias can occur when hyperglycaemia rapidly develops, in part because of a relative, if not absolute, deficiency in insulin. DIA G N O SIS This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 21 Assessment of hyperkalaemia Diagnosis DIA G N O SIS Common Diabetic ketoacidosis/hyperosmolar hyperglycaemic state History Exam 1st Test Other tests ECG changes in patients with hyperkalaemia BMJ 2009; 339:b4114. Copyright ©2009 by the BMJ Publishing Group Drug-related decreased cellular entry or increased cellular exit of potassium History Exam 1st Test Other tests history of exposure to mannitol (typically in a patient with brain injury or undergoing craniotomy); suxamethonium (succinylcholine); arginine hydrochloride; beta-blockers; or digoxin (overdose of digoxin can cause weakness, fatigue, confusion, nausea/ vomiting, yellow/green chromatopsia) may have features of underlying disorders »serum potassium: elevated »ECG: findings are usually progressive and include first degree heart block (prolonged PR interval >0.2 s), flattened or absent P waves, tall, peaked (tented) T waves (i.e. T wave larger than R wave in more than 1 lead), ST-segment depression, widened QRS (>0.12 s), ventricular tachycardia, bradycardia and eventually cardiac arrest (pulseless »serum digoxin level (digoxin toxicity): typically 3.84 nanomol/ L (>3 nanogram/mL) Timing of sampling important to determination of chronic toxicity. Blood samples obtained within 6 to 8 hours of ingestion may be falsely elevated, since the drug has yet to completely distribute to body tissues. 22 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Diagnosis Common Drug-related decreased cellular entry or increased cellular exit of potassium History Exam 1st Test Other tests electrical activity, ventricular fibrillation/ paroxysmal ventricular tachycardia, asystole); digoxin overdose: dysrhythmias associated with increased automaticity, such as accelerated junctional rhythms or bidirectional ventricular tachycardia, premature ventricular contractions, bigeminy, trigeminy, complete atrioventricular dissociation, thirddegree heart block, ventricular fibrillation, asystole Life-threatening arrhythmias can occur rapidly with arginine in patients with hepatic disease who more poorly metabolise arginine and in patients with pre-existing renal failure and/or diabetes mellitus. DIA G N O SIS This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 23 Assessment of hyperkalaemia Diagnosis DIA G N O SIS Common Drug-related decreased cellular entry or increased cellular exit of potassium History Exam 1st Test Other tests ECG changes in patients with hyperkalaemia BMJ 2009; 339:b4114. Copyright ©2009 by the BMJ Publishing Group Life-threatening arrhythmias are uncommon with betablockers, since the associated increase in serum potassium values is both minor and transient. »trial of discontinuation of causative medication: hyperkalaemia resolves Alternative drug options may be necessary before discontinuation of offending drug. 24 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Diagnosis Common Potassium supplementation with underlying renal dysfunction History Exam 1st Test Other tests history of either oral or intravenous potassium supplementation; can be from prescription products, administration during hospitalisation, or over-the-counter salt substitutes (60 mmol [60 mEq] of potassium chloride/teaspoon) non-specific findings, muscle weakness, decreased bowel sounds »serum potassium: elevated »ECG: findings are usually progressive and include first degree heart block (prolonged PR interval >0.2 s), flattened or absent P waves, tall, peaked (tented) T waves (i.e. T wave larger than R wave in more than 1 lead), ST-segment depression, widened QRS (>0.12 s), ventricular tachycardia, bradycardia and eventually cardiac arrest (pulseless electrical activity, ventricular fibrillation/ paroxysmal ventricular tachycardia, asystole) An ECG should be performed in all patients with significant hyperkalaemia. DIA G N O SIS This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 25 Assessment of hyperkalaemia Diagnosis DIA G N O SIS Common Potassium supplementation with underlying renal dysfunction History Exam 1st Test Other tests ECG changes in patients with hyperkalaemia BMJ 2009; 339:b4114. Copyright ©2009 by the BMJ Publishing Group »serum creatinine: elevated Drug-related reduced urinary potassium excretion History Exam 1st Test Other tests use of known causative medications including potassiumsparing diuretics (spironolactone, eplerenone, canrenone, triamterene, or amiloride), trimethoprim, pentamidine, heparin, ACE inhibitor or angiotensin-receptor blocker, non-steroidal anti-inflammatory drugs, tacrolimus, ciclosporin may have features of underlying disorders »serum potassium: elevated »trial of discontinuation of causative medication: hyperkalaemia resolves »serum creatinine: elevated The risk of hyperkalaemia is proportional to the level of renal function, but the serum potassium can increase significantly with »coagulation studies (heparin): normal to elevated partial thromboplastin time Poor correlation between the degree of change in clotting parameters and increases in serum potassium values. »ciclosporin serum level: normal to elevated 26 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Diagnosis Common Drug-related reduced urinary potassium excretion History Exam 1st Test Other tests only moderate renal failure in the setting of hyporeninaemic hypoaldosteronism. »ECG: findings are usually progressive and include first degree heart block (prolonged PR interval >0.2 s), flattened or absent P waves, tall, peaked (tented) T waves (i.e. T wave larger than R wave in more than 1 lead), ST-segment depression, widened QRS (>0.12 s), ventricular tachycardia, bradycardia and eventually cardiac arrest (pulseless electrical activity, ventricular fibrillation/ paroxysmal ventricular tachycardia, asystole) Life-threatening arrhythmias can occur, particularly with spironolactone use in patients with moderate to advanced renal failure and/or sudden falls in renal function as arise with intercurrent illnesses. Can occur at normal therapeutic plasma levels. More common with high plasma levels of the calcineurin inhibitor. »tacrolimus serum level: normal to elevated Can occur at normal therapeutic plasma levels. More common with high plasma levels of the calcineurin inhibitor. DIA G N O SIS This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 27 Assessment of hyperkalaemia Diagnosis DIA G N O SIS Common Drug-related reduced urinary potassium excretion History Exam 1st Test Other tests ECG changes in patients with hyperkalaemia BMJ 2009; 339:b4114. Copyright ©2009 by the BMJ Publishing Group Uncommon Acute kidney failure History Exam 1st Test Other tests history of exposure to nephrotoxic medications, trauma, or persistently low blood pressure can range from nonspecific findings to hypotension, multisystem failure, altered mental status, and muscle trauma »serum potassium: elevated Relates to decreased ability to excrete potassium. Can occur early in the course of acute kidney failure, often relating to very catabolic state and/or having received potassium supplements. Less common in non-oliguric forms of disease. 28 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Diagnosis Uncommon Acute kidney failure History Exam 1st Test Other tests »serum creatinine: elevated Increase in serum creatinine values can lag behind rises in serum potassium. Serum creatinine values poorly reflect level of renal function, and can be minimally elevated in the presence of significant changes in potassium homeostasis. »ECG: findings are usually progressive and include first degree heart block (prolonged PR interval >0.2 s), flattened or absent P waves, tall, peaked (tented) T waves (i.e. T wave larger than R wave in more than 1 lead), ST-segment depression, widened QRS (>0.12 s), ventricular tachycardia, bradycardia and eventually cardiac arrest (pulseless electrical activity, ventricular fibrillation/ paroxysmal ventricular tachycardia, asystole) Life-threatening arrhythmias occur most commonly when factors impairing cellular uptake of potassium coexist. Presence of hyponatraemia and/ or hypocalcaemia can intensify the DIA G N O SIS This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 29 Assessment of hyperkalaemia Diagnosis DIA G N O SIS Uncommon Acute kidney failure History Exam 1st Test Other tests cardiotoxicity of hyperkalaemia. ECG changes in patients with hyperkalaemia BMJ 2009; 339:b4114. Copyright ©2009 by the BMJ Publishing Group ◊ Renal tubular acidosis History Exam 1st Test Other tests history of diabetes, renal disease, nephrocalcinosis no specific findings »serum potassium: elevated Relates to decreased ability to excrete potassium. Metabolic acidosis and hyperkalaemia are disproportionate to the level of renal failure, especially in patients with hyporeninaemic hypoaldosteronism. Often appears in the setting of potassium supplements »arterial blood gas: metabolic acidosis Non-anion gap form of metabolic acidosis. »urine pH: typically >5.5 In patients with a pH <5 .5="" .="" 18="" 1st="" 2021.="" 30="" a="" acidosis="" addison="" administered.="" aldosterone="" all="" and="" are="" assessment="" based="" be="" being="" best="" bestpractice.bmj.com="" bmj="" can="" content="" cortisol="" deficiency.="" diagnosis="" disclaimer.="" disease="" establishes="" exam="" form="" found="" given="" group="" history="" hyperkalaemia="" if="" is="" jun="" last="" likely="" low="" ltd="" medications="" most="" normal="" of="" on="" or="" other="" our="" pdf="" ph="" plasma="" potassium-sparing="" practice="" present.="" present="" publishing="" recent="" regularly="" renal="" reserved.="" rights="" s="" selective="" subject="" test="" tests="" that="" the="" this="" to="" topic="" topics="" tubular="" uncommon="" updated:="" updated="" urine="" use="" value="" version="" voltage-dependent="" was="" web="" when="" with="">5.5 and hyperkalaemia is present. ◊ Metabolic acidosis History Exam 1st Test Other tests may have history of renal disease, uncontrolled diabetes, other causes of hypoaldosteronism, hyperparathyroidism, infection may have hypotension or features of underlying disease »serum potassium: elevated Relates to movement of potassium from the intracellular to the extracellular location as hydrogen ions move intracellularly. Minimal transcellular shifts of potassium occur with respiratory acidosis. The degree of change in serum potassium concentration is difficult to predict for any specific fall in pH. »serum bicarbonate: <20 .="" 18="" 1st="" 2021.="" 21-="" 31="" 3="" a="" acidosis.="" acidosis="" acne="" activity:="" adrenal="" after="" alkalosis.="" all="" already="" also="" ambiguous="" amniocentesis="" an="" analysis:="" and="" anion="" antenatal="" are="" arterial="" as="" assessment="" at="" autosomal="" azotaemia="" baldness="" based="" be="" best="" bestpractice.bmj.com="" bicarbonate="" block="" blood="" bmj="" both="" can="" carriers="" carry="" chemistry:="" chorionic="" classic="" collection.="" compensatory="" congenital="" content="" corticosteroids="" cystic="" day="" deficiency.="" degree="" determine="" dia="" diagnosis="" disclaimer.="" effect="" either="" exam="" failure="" false="" feeding="" fetus="" findings="" first="" for="" found="" g="" gap="" gases:="" genetic="" genitalia="" gives="" group="" haemoconcentration="" haemolysed="" have="" heart="" high="" hirsutism="" history="" hydroxylase="" hyperkalaemia="" hyperkalaemic="" hyperplasia="" hyponatraemic="" hypotension="" ideally="" if="" in="" include="" infants="" infertility="" inheritance="" inorganic="" interval="" irregular="" is="" jun="" ketoacidosis.="" l="" lactic="" last="" least="" life="" loss="" low="" ltd="" male-pattern="" may="" medications="" menses="" meq="" metabolic="" mineralocorticoids="" mmol="" more="" most="" mutation.="" mutation="" n="" necessary="" newborns="" non-anion="" o="" of="" on="" or="" organic="" other="" our="" ovaries="" parents="" particularly="" patient="" pattern="" pdf="" performed="" ph="" plasma="" polycystic="" poor="" positive="" potassium="" pr="" practice="" precocious="" predisposition="" prior="" progressive="" prolonged="" puberty="" publishing="" recent="" recessive="" recommended="" reflected="" regularly="" renin="" reserved.="" respiratory="" response="" result.="" rights="" rise="" risk="" salt-waster="" sample="" sampling.="" seen="" serum="" severe="" short="" should="" since="" sis="" so="" stature="" stopped="" subject="" such="" taking="" test="" testing="" tests="" than="" that="" the="" they="" this="" thrive="" to="" topic="" topics="" treatment="" type="" uncommon="" until="" updated:="" updated="" use="" useful="" usually="" value="" version="" via="" villus="" vomiting="" was="" web="" weeks="" weight="" with="">0.2 s), flattened or absent P waves, tall, peaked (tented) T waves (i.e. T wave larger than R wave in more than 32 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Diagnosis Uncommon Congenital adrenal hyperplasia History Exam 1st Test Other tests High plasma renin activity levels indicate low serum sodium. »17- hydroxyprogesterone: high (newborn) A cortisol precursor that accumulates in elevated concentrations in 21-hydroxylase deficiency. 1 lead), ST-segment depression, widened QRS (>0.12 s), ventricular tachycardia, bradycardia and eventually cardiac arrest (pulseless electrical activity, ventricular fibrillation/ paroxysmal ventricular tachycardia, asystole) An ECG should be performed in all patients with significant hyperkalaemia. ECG changes in patients with hyperkalaemia BMJ 2009; 339:b4114. Copyright ©2009 by the BMJ Publishing Group ◊ Addison's disease History Exam 1st Test Other tests symptom onset is insidious and nonspecific; symptoms include skin changes, progressive muscle increased skin pigmentation, occasional vitiligo, hypotension (baseline »serum potassium: elevated Relates to inability to excrete potassium DIA G N O SIS This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 33 Assessment of hyperkalaemia Diagnosis DIA G N O SIS Uncommon ◊ Addison's disease History Exam 1st Test Other tests weakness, salt craving, fatigue, poor appetite, weight loss, nausea, vomiting, occasional diarrhoea, orthostatic dizziness, decreased libido, amenorrhoea, depression or postural), decreased axillary and pubic hair effectively. Hyperkalaemia becomes most prominent when mechanisms for intracellular migration of potassium are defective. »urine electrolytes: urine potassium variable Urine potassium is typically low, reflecting an absence of aldosterone effect. Spot urine samples are difficult to interpret. 24-hour samples are typically less than dietary potassium intake. »serum cortisol: random level low Any stressful condition will increase cortisol levels. A value of 690 nanomol/L (25 microgram/dL) will exclude Addison's disease. »rapid ACTH stimulation test: blunted if not absent cortisol response (at least doubling of cortisol level is normal at 1 hour) »ECG: findings are usually progressive and include first degree heart block (prolonged PR interval >0.2 s), 34 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Diagnosis Uncommon ◊ Addison's disease History Exam 1st Test Other tests flattened or absent P waves, tall, peaked (tented) T waves (i.e. T wave larger than R wave in more than 1 lead), ST-segment depression, widened QRS (>0.12 s), ventricular tachycardia, bradycardia and eventually cardiac arrest (pulseless electrical activity, ventricular fibrillation/ paroxysmal ventricular tachycardia, asystole) Findings generally correlate with the level of hyperkalaemia; severe hyperkalaemia is uncommon. ECG changes in patients with hyperkalaemia BMJ 2009; 339:b4114. Copyright ©2009 by the BMJ Publishing Group DIA G N O SIS This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 35 Assessment of hyperkalaemia Diagnosis DIA G N O SIS Uncommon ◊ Pseudohypoaldosteronism History Exam 1st Test Other tests family history of pseudohypoaldosteronism type 1: hypotension and signs of volume depletion (e.g., reduced skin turgor, oliguria); type 2: HTN and signs of volume expansion (e.g., oedema) »serum electrolytes: hyperkalaemia, hyponatraemia, hyperchloraemic metabolic acidosis »serum creatinine: normal »urinary sodium: elevated in type 1 »plasma aldosterone and renin: type 1: elevated; type 2: low to normal »renal ultrasound: type 1: may show nephrocalcinosis; type 2: may show nephrolithiasis ◊ Hyperkalaemic periodic paralysis History Exam 1st Test Other tests suspected based on family history of the disorder, intermittent muscle weakness; may be a recent history of fasting, cold exposure, ethanol use, potassium administration, and/ or ingestion of a highpotassium diet between episodes, the physical examination is normal unless chronic attacks have been occurring; during an attack, muscle reflexes may disappear and weakness/stiffness in the shoulders and hips exceeds that in the arms and legs; findings typically exist for <24 .="" 18="" 1="" 1st="" 2021.="" 36="" 3="" a="" abdominal="" addition="" all="" altered="" and="" are="" as="" assessment="" attack="" based="" be="" best="" bestpractice.bmj.com="" block="" blood="" bmj="" burden="" burkitt="" calcium="" can="" checked="" chemotherapy.="" chemotherapy="" chvostek="" compatible="" content="" days="" degree="" depending="" deposition="" detected.="" development="" diagnosis="" disclaimer.="" do="" during="" either="" electrocardiographic="" elements="" elevated="" exam="" fever="" findings="" first="" found="" free="" function.="" group="" heart="" high="" history="" hours="" hyperkalaemia="" hypocalcaemia.="" hypocalcaemia="" in="" include="" increase="" increased="" initiating="" initiation="" interval="" intervals="" involving="" is="" jun="" last="" level="" loss="" ltd="" lymphadenopathy="" lymphoma.="" lymphoma="" lysis="" malignancy="" may="" mental="" most="" muscle="" normal="" not="" occur="" occurs="" of="" often="" on="" or="" organomegaly="" other="" our="" paraesthesias="" particularly="" pdf="" phosphate:="" phosphate="" positive="" potassium:="" potassium="" pr="" practice="" product="" progressive="" proliferation="" prolonged="" publishing="" radiotherapy="" rapidity="" recent="" regularly="" relates="" release="" renal="" repetitively="" reserved.="" rights="" s="" same="" serum="" sign="" significantly="" solid="" specific="" status="" subject="" such="" symptoms="" syndrome="" test="" tests="" tetany="" that="" the="" this="" tissue="" to="" topic="" topics="" trousseau="" tumour="" tumours="" turnover="" uncommon="" updated:="" updated="" use="" usually="" values="" version="" was="" weakness="" web="" weight="" when="" with="" within="">0.2 s), flattened or absent P waves, tall, peaked (tented) T waves (i.e. T wave larger than R wave in more than 1 lead), ST-segment depression, widened QRS (>0.12 s), ventricular tachycardia, bradycardia and eventually cardiac arrest (pulseless electrical activity, ventricular fibrillation/ paroxysmal ventricular tachycardia, asystole). Findings generally correlate with the level of hyperkalaemia. Life-threatening arrhythmias can occur rapidly if tumour turnover is rapid, acute kidney failure is present, and significant DIA G N O SIS This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 37 Assessment of hyperkalaemia Diagnosis DIA G N O SIS Uncommon Tumour lysis syndrome History Exam 1st Test Other tests hypocalcaemia develops. ECG changes in patients with hyperkalaemia BMJ 2009; 339:b4114. Copyright ©2009 by the BMJ Publishing Group Rhabdomyolysis History Exam 1st Test Other tests recent history of muscle damage relating to exercise, seizures, ischaemia, trauma, drug overdose, or medications such as statins localised or diffuse muscle fullness and tenderness, low blood pressure, altered mental status if seizures are or have been present; tense muscles may reflect development of a compartment syndrome »serum potassium: elevated Level of hyperkalaemia relates to extent of muscle damage and presence of acute kidney failure. In exercise-related hyperkalaemia without rhabdomyolysis, a hyperkalaemia may be attributable to a Na+-K+ pump that does not keep 38 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Diagnosis Uncommon Rhabdomyolysis History Exam 1st Test Other tests pace with K+ efflux from muscle during the depolarisationrepolarisation process of the sarcolemmal membrane during muscle contraction.[31] »serum creatinine: elevated Analytical assessment of serum creatinine may have falsely increased values owing to release of noncreatinine chromogens from damaged muscle. »creatine kinase: >10,000 units/litre »urine dipstick: positive for blood without red blood cells being present on microscopic examination Myoglobin released from muscle enters the urine freely and registers a false positive for blood. »ECG: findings are usually progressive and include first degree heart block (prolonged PR interval >0.2 s), flattened or absent P waves, tall, peaked (tented) T waves (i.e. T wave larger than R wave in more than 1 lead), ST-segment depression, widened QRS (>0.12 s), ventricular tachycardia, bradycardia and DIA G N O SIS This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 39 Assessment of hyperkalaemia Diagnosis DIA G N O SIS Uncommon Rhabdomyolysis History Exam 1st Test Other tests eventually cardiac arrest (pulseless electrical activity, ventricular fibrillation/ paroxysmal ventricular tachycardia, asystole). Findings generally correlate with the level of hyperkalaemia. Lifethreatening arrhythmias can occur rapidly if muscle damage is progressive and acute kidney failure significant. ECG changes in patients with hyperkalaemia BMJ 2009; 339:b4114. Copyright ©2009 by the BMJ Publishing Group ◊ Pseudohyperkalaemia History Exam 1st Test Other tests difficult-to-draw blood and/or fist-clenching; no specific findings »simultaneous serum and plasma potassium values: potassium value in 40 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Diagnosis Uncommon ◊ Pseudohyperkalaemia History Exam 1st Test Other tests mostly no specific history serum exceeds that in plasma by >0.5 mmol/L (>0.5 mEq/L) Test-tube phenomenon due to release of potassium into serum from cells undergoing lysis during the clotting process, a timedependent process relating to delayed processing. Potassium value in serum is artefactually elevated secondary to red blood cell haemolysis. Bloody tinge to appearance of the serum. Avoid repeated blood draw with syringe and heavy suctioning. »WBC: >100,000 x 10⁹/ L »platelet count: >500,000 x 10⁹/L ◊ Ureterojejunostomy History Exam 1st Test Other tests history of gastrointestinal surgery with ureteric implants evidence of abdominal surgery, low blood pressure, orthostatic hypotension »serum potassium: elevated Relates to loss of sodium chloride into jejunal fluid and absorption of potassium. »urine electrolytes (urine potassium): DIA G N O SIS This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 41 Assessment of hyperkalaemia Diagnosis DIA G N O SIS Uncommon ◊ Ureterojejunostomy History Exam 1st Test Other tests urine potassium variable The degree to which secondary hyperaldosteronism occurs owing to loss of sodium chloride determines urinary potassium levels and the degree to which hyperkalaemia develops. »ECG: peaked Twaves, findings are usually progressive and include first degree heart block (prolonged PR interval >0.2 s), flattened or absent P waves, tall, peaked (tented) T waves (i.e. T wave larger than R wave in more than 1 lead), ST-segment depression, widened QRS (>0.12 s), ventricular tachycardia, bradycardia and eventually cardiac arrest (pulseless electrical activity, ventricular fibrillation/ paroxysmal ventricular tachycardia, asystole). Findings generally correlate with the level of hyperkalaemia; however, lifethreatening arrhythmias can occur without warning at almost any level of hyperkalaemia. 42 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Diagnosis Uncommon ◊ Ureterojejunostomy History Exam 1st Test Other tests ECG changes in patients with hyperkalaemia BMJ 2009; 339:b4114. Copyright ©2009 by the BMJ Publishing Group DIA G N O SIS This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 43 Assessment of hyperkalaemia Guidelines G UID E LIN E S Guidelines United Kingdom Guidelines for the treatment of hyperkalaemia in hospitalised adults (https:// www.rqia.org.uk/RQIA/files/b0/b071ebc3-f2b3-48ab-8e46-c690df790177.pdf) Published by: The Regulation and Quality Improvement Authority Last published: 2021 Treatment of acute hyperkalaemia in adults (https://renal.org/sites/renal.org/ files/RENAL%20ASSOCIATION%20HYPERKALAEMIA%20GUIDELINE %202020.pdf) Published by: The Renal Association (UK) Last published: 2020 Europe European Resuscitation Council Guidelines for Resuscitation 2021: Section 6. Cardiac arrest in special circumstances (https://www.cprguidelines.eu/ assets/guidelines/RESUS-8904-Special-Circs.pdf) Published by: European Resuscitation Council Last published: 2021 Dutch guideline for the management of electrolyte disorders (https:// pubmed.ncbi.nlm.nih.gov/23712815) Published by: Dutch Society of Internal Medicine Last published: 2012 44 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia References Key articles • Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. 2000;18:721-729. Abstract • Palmer BF. Managing hyperkalemia caused by inhibitors of the renin-angiotensin-aldosterone system. N Engl J Med. 2004;351:585-592. Abstract • Sica DA. Antihypertensive therapy and its effects on potassium homeostasis. J Clin Hypertens (Greenwich). 2006;8:67-73. Abstract References 1. Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. 2000;18:721-729. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/11043630? tool=bestpractice.bmj.com) 2. Chan R, Sealey JE, Michelis MF, et al. Renin-aldosterone system can respond to furosemide in patients with hyperkalemic hyporeninism. J Lab Clin Med. 1998;132:229-235. Abstract (http:// www.ncbi.nlm.nih.gov/pubmed/9735929?tool=bestpractice.bmj.com) 3. Tamarisa KP, Aaronson KD, Koelling TM. Spironolactone-induced renal insufficiency and hyperkalemia in patients with heart failure. Am Heart J. 2004;148:971-978. Abstract (http://www.ncbi.nlm.nih.gov/ pubmed/15632880?tool=bestpractice.bmj.com) 4. Schlondorff D. Renal complications of nonsteroidal anti-inflammatory drugs. Kidney Int. 1993;44:643-653. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/8231040?tool=bestpractice.bmj.com) 5. Velazquez H, Perazella MA, Wright FS, et al. Renal mechanism of trimethoprim-induced hyperkalemia. Ann Intern Med. 1993;119:296-301. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/8328738? tool=bestpractice.bmj.com) 6. Lachaal M, Venuto RC. Nephrotoxicity and hyperkalemia in patients with acquired immunodeficiency syndrome treated with pentamidine. Am J Med. 1989;87:260-263. Abstract (http:// www.ncbi.nlm.nih.gov/pubmed/2773964?tool=bestpractice.bmj.com) 7. Palmer BF. Managing hyperkalemia caused by inhibitors of the renin-angiotensin-aldosterone system. N Engl J Med. 2004;351:585-592. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/15295051? tool=bestpractice.bmj.com) 8. Bakris GL, Siomos M, Richardson D, et al. ACE inhibition or angiotensin receptor blockade: impact on potassium in renal failure. VAL-K Study Group. Kidney Int. 2000;58:2084-2092. Full text (http://www.kidney-international.org/article/S0085-2538(15)47317-X/fulltext) Abstract (http:// www.ncbi.nlm.nih.gov/pubmed/11044229?tool=bestpractice.bmj.com) R E F E R E N C E S This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 45 Assessment of hyperkalaemia References R E F E R E N C E S 9. Venzin RM, Cohen CD, Maggiorini M, et al. Aliskiren-associated acute renal failure with hyperkalemia. Clin Nephrol. 2009;98:326-328. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/19281746? tool=bestpractice.bmj.com) 10. Oster JR, Singer I, Fishman LM. Heparin-induced aldosterone suppression and hyperkalemia. Am J Med. 1995;71:575-586. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/7778574? tool=bestpractice.bmj.com) 11. Pei Y, Richardson R, Greenwood C, et al. Extrarenal effect of cyclosporine A on potassium homeostasis in renal transplant recipients. Am J Kidney Dis. 1993;22:314-319. Abstract (http:// www.ncbi.nlm.nih.gov/pubmed/8352259?tool=bestpractice.bmj.com) 12. Bushinsky DA, Gennari FJ. Life-threatening hyperkalemia induced by arginine. Ann Intern Med. 1978;89:632-634. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/717931?tool=bestpractice.bmj.com) 13. Seto A, Murakami M, Fukuyama H, et al. Ventricular tachycardia caused by hyperkalemia after administration of hypertonic mannitol. Anesthesiology. 2000;93:1359-1361. Abstract (http:// www.ncbi.nlm.nih.gov/pubmed/11046231?tool=bestpractice.bmj.com) 14. Gennari FJ. Hypokalemia. N Engl J Med. 1998;339:451-458. Abstract (http://www.ncbi.nlm.nih.gov/ pubmed/9700180?tool=bestpractice.bmj.com) 15. Sica DA. Antihypertensive therapy and its effects on potassium homeostasis. J Clin Hypertens (Greenwich). 2006;8:67-73. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/16407694? tool=bestpractice.bmj.com) 16. Borron SW, Bismuth C, Muszynski J. Advances in the management of digoxin toxicity in the older patient. Drugs Aging. 1997;10:18-33. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/9111705? tool=bestpractice.bmj.com) 17. Gronert GA. Cardiac arrest after succinylcholine: Mortality greater with rhabdomyolysis than receptor upregulation. Anesthesiology. 2001;94:523-529. Abstract (http://www.ncbi.nlm.nih.gov/ pubmed/11374616?tool=bestpractice.bmj.com) 18. Ochoa-Gomez J, Villar-Arias A, Aresti I, et al. A case of severe hyperkalaemia and compartment syndrome due to rhabdomyolysis after drugs abuse. Resuscitation. 2002;54:103-105. Abstract (http:// www.ncbi.nlm.nih.gov/pubmed/12104115?tool=bestpractice.bmj.com) 19. Kalemkerian GP, Darwish B, Varterasian ML. Tumor lysis syndrome in small cell carcinoma and other solid tumors. Am J Med. 1997;103:363-367. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/9375703? tool=bestpractice.bmj.com) 20. Colussi G, Cipriani D. Pseudohyperkalemia in extreme leukocytosis. Am J Nephrol. 1995;15:450-452. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/7503149?tool=bestpractice.bmj.com) 21. Graber M, Subramani K, Corish D, et al. Thrombocytosis elevates serum potassium. Am J Kidney Dis. 1988;12:116-120. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/3400632?tool=bestpractice.bmj.com) 46 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia References 22. Saperstein DS. Muscle channelopathies. Semin Neurol. 2008;28:260-269. Abstract (http:// www.ncbi.nlm.nih.gov/pubmed/18351527?tool=bestpractice.bmj.com) 23. Lott C, Truhlář A, Alfonzo A, et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation. 2021 Apr;161:152-219. Full text (https://www.doi.org/10.1016/ j.resuscitation.2021.02.011) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/33773826? tool=bestpractice.bmj.com) 24. Deakin c, Soar J, Davies R. Resuscitation Council UK. Special circumstances guidelines. May 2021 [internet publication]. Full text (https://www.resus.org.uk/library/2021-resuscitation-guidelines/specialcircumstances-guidelines) 25. Mahoney BA, Smith WA, Lo DS, et al. Emergency interventions for hyperkalaemia. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003235. Full text (https://www.cochranelibrary.com/ cdsr/doi/10.1002/14651858.CD003235.pub2/full) Abstract (http://www.ncbi.nlm.nih.gov/ pubmed/15846652?tool=bestpractice.bmj.com) 26. National Institute for Health and Care Excellence. Patiromer for treating hyperkalaemia. Feb 2020 [internet publication]. Full text (https://www.nice.org.uk/guidance/ta623) 27. National Institute for Health and Care Excellence. Sodium zirconium cyclosilicate for treating hyperkalaemia. Sep 2019 [internet publication]. Full text (https://www.nice.org.uk/guidance/ta599) 28. Cheng CJ, Chiu JS, Huang WH, et al. Acute hyperkalemic paralysis in a uremic patient. J Nephrol. 2005;18:630-633. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/16299694? tool=bestpractice.bmj.com) 29. Viera AJ, Wouk N. Potassium disorders: hypokalemia and hyperkalemia. Am Fam Physician. 2015 Sep 15;92(6):487-95. Full text (https://www.aafp.org/afp/2015/0915/p487.html) Abstract (http:// www.ncbi.nlm.nih.gov/pubmed/26371733?tool=bestpractice.bmj.com) 30. Choi MJ, Ziyadeh FN. The utility of the transtubular potassium gradient in the evaluation of hyperkalemia. J Am Soc Nephrol. 2008;19:424-426. Full text (http://jasn.asnjournals.org/cgi/content/ full/19/3/424) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/18216310?tool=bestpractice.bmj.com) 31. Wasserman K, Stringer WW, Casaburi R, et al. Mechanism of the exercise hyperkalemia: an alternate hypothesis. J Appl Physiol 1997;83:631-643. Full text (http://jap.physiology.org/cgi/content/ full/83/2/631) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/9262462?tool=bestpractice.bmj.com) R E F E R E N C E S This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 47 Assessment of hyperkalaemia Images IM A G E S Images Figure 1: ECG changes in patients with hyperkalaemia BMJ 2009; 339:b4114. Copyright ©2009 by the BMJ Publishing Group 48 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Assessment of hyperkalaemia Disclaimer Disclaimer BMJ Best Practice is intended for licensed medical professionals. BMJ Publishing Group Ltd (BMJ) does not advocate or endorse the use of any drug or therapy contained within this publication nor does it diagnose patients. As a medical professional you retain full responsibility for the care and treatment of your patients and you should use your own clinical judgement and expertise when using this product. This content is not intended to cover all possible diagnosis methods, treatments, follow up, drugs and any contraindications or side effects. In addition, since such standards and practices in medicine change as new data become available, you should consult a variety of sources. We strongly recommend that you independently verify specified diagnosis, treatments and follow-up and ensure it is appropriate for your patient within your region. In addition, with respect to prescription medication, you are advised to check the product information sheet accompanying each drug to verify conditions of use and identify any changes in dosage schedule or contraindications, particularly if the drug to be administered is new, infrequently used, or has a narrow therapeutic range. You must always check that drugs referenced are licensed for the specified use and at the specified doses in your region. Information included in BMJ Best Practice is provided on an “as is” basis without any representations, conditions or warranties that it is accurate and up to date. BMJ and its licensors and licensees assume no responsibility for any aspect of treatment administered to any patients with the aid of this information. To the fullest extent permitted by law, BMJ and its licensors and licensees shall not incur any liability, including without limitation, liability for damages, arising from the content. All conditions, warranties and other terms which might otherwise be implied by the law including, without limitation, the warranties of satisfactory quality, fitness for a particular purpose, use of reasonable care and skill and non-infringement of proprietary rights are excluded. Where BMJ Best Practice has been translated into a language other than English, BMJ does not warrant the accuracy and reliability of the translations or the content provided by third parties (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages). BMJ is not responsible for any errors and omissions arising from translation and adaptation or otherwise.Where BMJ Best Practice lists drug names, it does so by recommended International Nonproprietary Names (rINNs) only. It is possible that certain drug formularies might refer to the same drugs using different names. Please note that recommended formulations and doses may differ between drug databases drug names and brands, drug formularies, or locations. A local drug formulary should always be consulted for full prescribing information. Treatment recommendations in BMJ Best Practice are specific to patient groups. Care is advised when selecting the integrated drug formulary as some treatment recommendations are for adults only, and external links to a paediatric formulary do not necessarily advocate use in children (and vice-versa). Always check that you have selected the correct drug formulary for your patient. Where your version of BMJ Best Practice does not integrate with a local drug formulary, you should consult a local pharmaceutical database for comprehensive drug information including contraindications, drug interactions, and alternative dosing before prescribing. Interpretation of numbers Regardless of the language in which the content is displayed, numerals are displayed according to the original English-language numerical separator standard. For example 4 digit numbers shall not include a comma nor a decimal point; numbers of 5 or more digits shall include commas; and numbers stated to be less than 1 shall be depicted using decimal points. See Figure 1 below for an explanatory table. BMJ accepts no responsibility for misinterpretation of numbers which comply with this stated numerical separator standard. This approach is in line with the guidance of the International Bureau of Weights and Measures Service. Figure 1 – BMJ Best Practice Numeral Style DIS C L AIM E R This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. 49 Assessment of hyperkalaemia Disclaimer DIS C L AIM E R 5-digit numerals: 10,000 4-digit numerals: 1000 numerals < 1: 0.25 Our full website and application terms and conditions can be found here: Website Terms and Conditions. Contact us + 44 (0) 207 111 1105 support@bmj.com BMJ BMA House Tavistock Square London WC1H 9JR UK 50 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 18, 2021. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved. Contributors: // Authors: Sri G. Yarlagadda, MD Associate Professor Kidney Institute, The University of Kansas Medical Center, Kansas City, KS DISCLOSURES: SGY declares that she has no competing interests. // Acknowledgements: Dr Sri G. Yarlagadda would like to gratefully acknowledge Dr Domenic Sica, a previous contributor to this topic. DS declares that he has no competing interests. // Peer Reviewers: Manish Suneja, MD Assistant Professor Department of Internal Medicine, Division of Nephrology, University of Iowa Hospital and Clinics, Iowa City, IA DISCLOSURES: MS declares that he has no competing interests. Raj Thuraisingham, MBBS, MRCP, FRCP, MD Consultant Nephrologist Royal London Hospital, London, UK DISCLOSURES: RT declares that he has no competing interests.

all in one blogs amazon health etc

Search This Blog

Assessment of hyperkalaemia

Comments

Post a Comment