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This lecture was conducted during the Nephrology Unit Grand

Ground by Registrar under Nephrology Division under the

supervision and administration of Prof. Jamal Al Wakeel, Head

of Nephrology Unit, Department of Medicine and Dr.

Abdulkareem Al Suwaida, Chairman of Department ofMedicine. Nephrology Division is not responsible for the

content of the presentation for it is intended for learning and

/or education purpose only.

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HYPOKALEMIA ASSOCIATED WITH

HYPERTENSION

SALEEM S. SALEEM AL-ANAZI

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POTASSIUM HOMEOSTASIS

Approximately 98% of total body K+ stores are intracellular .

Normal serum [ K+ ] ranges from 3.5 5.0 mmol / L .

Insulin , aldosterone , catecholamine and acid-base status influence K+

movement in to the cells .

Potassium excretion is regulated at the distal nephron .

K+ excretion = ( urine flow rate ) x ( urine K+ concentration ) .

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Cont ,

Serum levels of K+ is regulated by :-

1- Uptake of K+ in to cells by altering activity of the NA K ATPase pump in the

cell membrane .

2- Renal excretion mainly controlled by aldosterone .

3- Extrarenal loss , e.g. gastrointestinal .

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HYPOKALEMIA WITH HYPERTENSION

Definition of hypokalemia :-

This is a serum potassium concentration of < 3.5 mmol / L .

Aetiology :-

- Primary hyperaldosteronism ( conn`s syndrome ) .

- Secondary hyperaldosteronism ( renovascular disease , renin tumor ) .

- Non aldosterone minrealcorticoid ( cushing`s syndrome ) .

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Cont,

We approach these patients by check there U K+ excretion and look for

TTKG ( transtubular potassium gradient ) .

TTKG = ( U k / P k ) / ( U osm / P osm ) .

increased loss

24 h Uk , TTKG

Uk > 30 mEq / day , TTKG > 7

Renal loss

Check BP

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Primary hyperaldosteronism

Definition :-

diastolic hypertension without edema , decrease renin and increased aldosterone secretion

Aetiology :-

1- aldosterone producing adrenal adenoma ( conn`s syndrome )2- adrenal hyperplasia ( 25 % ) .

Clinical features :-

hypertension

Polyuria polydipsia nocturia

Fatigue weakness paresthesia

Headache

Sever case there is tetany intermittent paralysis

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Investigation :-

- Urea end Electrolytes :- hypokalemia , mild hypernatermia , hypomagnesemia .

- High 24 h urinary or plasma aldosterone + low random plasma renin .

- CT or MRI ( for differentiate adenoma from hyperplasia ) .

Treatment :-

Medical :- spironolactone ( aldosternoe antagonist ) or amiolride , ACE might to beadded for better blood pressure control .

surgical :- removal of adenoma .

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Secondary hyperaldosteronism

Definition :-

increase in the aldosterone in response to activation renin-angiotensin system.

Renovascular Hypertension :-

This is HTN caused secondary to renovascular disease .

Suspected if :-

Negative family history of HTN .

Spontaneous hypokalemia .

Sudden onset or exacerbation of HTN .

Difficult to control with antihypertensive therapy .

There is decreased in renal perfusion of one or both kidneys leads to increased reninrelease and subsequent angiotensin ( AII ) production .

2 types :-

1- atherosclerotic plague : proximal 1/3 renal artery , usually male > 55 y .

2- fibromuscular hyperplasia :- distal 2/3 renal artery usually in young females .

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Cont,

Investigation :-

- Renal U/S

- Gold standard is renal angiography .

- Treatment :-

- BP lowering medication ( ACE inhibitors ) .

-

Surgical , angioplasty .

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Cushing`s syndrome

Definition :-

Clinical syndrome results from chronic glucocorticoid excess .

Aetiology :-

1- ACTH dependent ( 85% ) :

- ACTH secreting pituitary adenoma ( cushing`s disease 80% ) .

- Ectopic ACTH secreting tumor ( SCLC ) .

- 2- ACTH independent :-

- Long term use of exogenous glucocorticoid ( cushing`s syndrome ) .

- Primary adrenocortical tumor ( adenoma , carcinoma ) uncommon .

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Cont ,

Symptoms :-

- Weight gain ( central ) .

- Depression , psychosis , insomnia .

- Amenorrhea , oligomenorrhoea .

- Thin skin , easy bruising .- Acne .

- Polyuria , polydipsia .

- Signs :-

-

Moon face .- Proximal myopathy .

- Purple stria .

- Buffalo-hump .

- Kyphosis .

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Algorithm for diagnosis

24 h urinary free cortisol

Normal < 4x increase > 4x increase

No cushing`s low dose DST diagnosis of

syndrome to confirm the diagnosis cushing`s syndrome

measure ACTH

ACTH increased ACTH decreased

MRI pituitary CT adrenal

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Treatment

Pituitary :-

- transsphenoidal resection .

- Irradiation only 50% effective .

Adrenal :-

- Adenoma :- unilateral adrenalectomy ( curative ) .

- Carcinoma :- palliative .

Ectopic ACTH :-

- Chemotherapy , radiation .

- Ketoconazole , metyrapone ( block adrenal steroid synthesis ) .

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