DISORDERS OF K + BALANCE 135 TABLE 5–2: Basics of K + Homeostasis K + is the predominant intracellular cation in the body Regulation of K + homeostasis is achieved through cellular K + shifts and renal K + excretion • Disturbances in these homeostatic mechanisms result in either hypokalemia or hyperkalemia Hypo- and hyperkalemia disrupt action potential formation and promote various clinical symptoms and physical findings based on the following: • Neuromuscular dysfunction • Inhibition of normal cell enzymatics Rapid recognition and treatment of these K + disorders is required to avoid serious morbidity and mortality 136 DISORDERS OF K + BALANCE K + HOMEOSTASIS TABLE 5–3: Total Body K + Stores K + homeostasis involves maintenance of total body K + stores within the normal range Total body K + stores in an adult are between 3000 and 4000 mEq • 50–60 mEq/kg body weight Total body K + content is also influenced by age and sex • Compared with the young, the elderly have 20% less total body K + content • Females have 25% less total body K + than males K + is readily absorbed from the GI tract and subsequently distributed in cells of muscle, liver, bone, and red blood cells Maintenance of total body K + stores within narrow limits is achieved by: • Regulation of K + distribution between ECF and ICF • Zero net balance between input and output K + is an intracellular cation (98% of body K + located in ICF) • Intracellular K + concentration (145 mEq/L) • Extracellular K + concentration (4–5 mEq/L) Dietary K + is excreted mainly in urine (90%) and in feces (10%) DISORDERS OF K + BALANCE 137 ROLE OF K + IN THE RESTING MEMBRANE POTENTIAL TABLE 5–3 (Continued) The serum K + concentration is an index of K + balance • It reasonably reflects total body K + content • In disease states, serum [K + ] may not always reflect total body K + stores Abbreviations: GI, gastrointestinal; ECF, extracellular fluid; ICF, intracellular fluid TABLE 5–4: Role of K + in Resting Membrane Potential (E m ) The location of K + and Na + in their respective compartments is maintained by Na + -K + ATPase action in the cell membrane The Na + -K + ATPase hydrolyzes ATP to create the energy required to pump Na + out and K + into the cell in 3:2 ratio K + moves out of cells at a rate dependent on the electrochemical gradient, creating the E m The Goldman-Hodgkin-Katz equation calculates the membrane potential on the inside of the membrane using Na + and K + 138 DISORDERS OF K + BALANCE TABLE 5–5: Three Factors Determine Resting Membrane Potential (E m ) Electrical charge of each ion Membrane permeability to each ion Concentration of the ion on each side of the membrane TABLE 5–6: The Resting Membrane Potential (E m ) Inserting intracellular K + (145) and Na + (12) concentrations and extracellular K + (4.0) and Na + (140) concentrations into the Goldman-Hodgkin-Katz equation results in E m = – 90 mV The cell interior is –90 mV, largely due to the movement of K + out of the cell via the Na + -K + ATPase pump The E m sets the stage for membrane depolarization and generation of the action potential; any change in plasma [K + ] alters action potential and cell excitability Physiologic and pathologic factors affect K + distribution between ICF and ECF Abbreviations: ICF, intracellular fluid; ECF, extracellular fluid E m =− + + 61 3 2 140 0 01 12 3240 001 145 log /( ) . ( ) /( . ) . ( )) =−90mv DISORDERS OF K + BALANCE 139 CELLULAR K + DISTRIBUTION TABLE 5–7: Cellular K + Distribution Maintenance of plasma K + homeostasis following a K + rich meal requires K + shift into cells Cellular K + movement is the first response of the body This is critical to prevent a lethal acute rise in plasma K + concentration as renal K + excretion requires several hours Multiple physiologic and pathologic factors affect cellular K + distribution 140 DISORDERS OF K + BALANCE TABLE 5–8: Factors Affecting Cellular K + Distribution Insulin (secreted following a meal) • K + concentration is maintained in the normal range by physiologic effects of insulin ■ Insulin moves K + into cells following a meal ■ Insulin stimulates K + uptake by increasing the activity and number of Na + -K + ATPase pumps in the cell membrane ■ Intracellular K + shift is independent of glucose transport ■ Insulin deficiency (type 1 diabetic patients) is associated with hyperkalemia from impaired cellular K + uptake Endogenous catecholamines ( β 2 adrenergic) • Promotes K + movement into cells (stimulation of Na + -K + ATPase) • Activation of β 2 receptors generates cyclic AMP and stimulates Na + -K + ATPase to shift K + into cells • Albuterol, a β 2 adrenergic agonist used for asthma lowers plasma [K + ] through increased cell uptake • Propranolol, an antihypertensive medication, blocks β 2 adrenergic receptors and raises plasma [K + ] • Digoxin intoxication raises plasma [K + ] by disrupting the Na + -K + ATPase, thereby blocking cellular K + uptake Exercise • Exercise has a dual effect on cellular K + movement ■ A transient rise in plasma K + concentration occurs to increase blood flow to ischemic muscle DISORDERS OF K + BALANCE 141 TABLE 5–8 (Continued) ■ Endogenous catecholamine secretion develops with exercise, moving K + back into the ICF ( β 2 adrenergic receptors) and restores plasma K + concentration to normal ■ Level of exercise influences cellular K + release ■ Slow walking (0.3–0.4 mEq/L rise) ■ Moderate exercise (0.7–1.2 mEq/L rise ■ Point of exhaustion (2.0 mEq/L rise) Change in pH (acidemia/alkalemia) • Changes in pH are associated with cellular K + movement ■ Metabolic acidosis promotes K + exit from cells in exchange for protons (H + ) as the cells attempt to buffer the ECF pH ■ K + exchange for H + maintains electroneutrality across membranes ■ This effect occurs in nonanion gap metabolic acidoses rather than organic anion acidoses ■ In mineral metabolic acidosis, the anion Cl − is unable to cross the membrane (K + must exit the cell to maintain electroneutrality) ■ In organic anion acidosis, the anion (lactate) crosses the membrane and K + is not required to exit the cell to maintain electroneutrality ■ Metabolic alkalosis causes an opposite effect (continued) 142 DISORDERS OF K + BALANCE TABLE 5–8 (Continued) • Plasma [K + ] increases/decreases by 0.4 mEq/L for every 0.1 unit decrease/increase in pH ■ There is wide variability (0.2–1.7 mEq/L for every 0.1 unit fall in pH) with pH change Plasma osmolality • Increased plasma osmolality (hyperglycemia) raises plasma [K + ] as a result of a shift of K + out of cells ■ K + diffuses with water from the ICF into the ECF via solvent drag ■ Intracellular K + concentration rises as water exits the cell, increasing K + diffusion out of the cell ■ K + concentration rises by 0.4–0.8 mEq/L per 10 mosm/kg increase in effective osmolality Aldosterone • Aldosterone may increase cellular K + uptake, but its major effect is to enhance renal K + excretion Abbreviations: AMP, adenosine monophosphate; ICF, intracellular fluid, ECF, extracellular fluid DISORDERS OF K + BALANCE 143 K + HANDLING BY THE KIDNEY TABLE 5–9: K + Handling by the Kidney Renal K + handling occurs through glomerular filtration and both tubular reabsorption and secretion Proximal tubule 100% of plasma K + reaches the proximal tubule (freely filtered) Proximal tubule reabsorbs 60–80% of filtered K + K + uptake occurs via passive mechanisms • K + is reabsorbed by a K + transporter and through paracellular pathways coupled with Na + and water • Volume depletion increases Na + and water reabsorption increasing K + uptake • Volume expansion inhibits passive diffusion of K + Loop of Henle K + is both secreted and reabsorbed Twenty-five percent of filtered K + net is reabsorbed in this nephron segment K + enters the thin descending limb and at the tip of the loop of Henle reaches amounts that equal the original filtered load In medullary thick ascending limb, K + is actively and passively reabsorbed • Active K + transport occurs by the Na + -K + -2Cl − cotransporter, which is powered by Na + -K + ATPase (continued) 144 DISORDERS OF K + BALANCE TABLE 5–9 (Continued) Secondary active cotransport is driven by the steep Na + gradient across the apical membrane created by the ATPase Medications such as loop diuretics and genetic disorders impair the activity of this cotransporter and result in Na + and K + wasting Distal nephron Approximately 10% of filtered K + reaches the distal tubule K + secretion or reabsorption occurs in distal tubule, primarily in CCD • High luminal Na + concentration and low luminal Cl − concentration stimulate K + -Cl − cotransporter to secrete K + Abbreviation: CCD, cortical collecting duct [...]... blocks carbonic anhydrase and induces bicarbonaturia and K+ wasting • Osmotic diuretics increase flow through PCT, reducing Na+, water and K+ reabsorption • Aminoglycosides and cisplatin injure PCT cells and cause K+ wasting In TALH • Na+-K +-2 Cl− transporter reabsorbs K+ in TALH • Loop diuretics inhibit function of this transporter and reduce K+ reabsorption via paracellular and transcellular pathways... Stabilize membranes Insulin and glucose 10–20 U of IV insulin and 25 g of glucose 30 min 4 6 h Cell uptake Albuterol (β2-agonist) 20 mg in 4 mL normal saline in nebulizer 30 min 1–2 h Cell uptake Terbutaline (β2-agonist) 0.7 mg/kg SQ 20–30 min 1–2 h Cell uptake Na bicarbonate 50–75 mEq IV 5–10 min 2–12 h Cell uptake Na polystyrene sulfonate 30 45 g oral 50–100 g enema 2 4 h 4 12 h GI excretion Hemodialysis... measuring urinary and serum K+ and osmolality (osm), respectively and inserting the values into the formula • In order to calculate the TTKG the urine [Na+] must be greater than as equal to 20 mEg/L and the urine osmolality must be greater than serum osmolality TTKG = Urine [K+] ÷ (urine osm/plasma osm) ÷ serum [K+] Step 3 Assess urinary K+ excretion and TTKG data • Reduced urine K+ excretion and a TTKG . (E m ) Inserting intracellular K + ( 145 ) and Na + (12) concentrations and extracellular K + (4. 0) and Na + ( 140 ) concentrations into the Goldman-Hodgkin-Katz equation results in E m = –. OF K + BALANCE 143 K + HANDLING BY THE KIDNEY TABLE 5–9: K + Handling by the Kidney Renal K + handling occurs through glomerular filtration and both tubular reabsorption and secretion Proximal. limb, K + is actively and passively reabsorbed • Active K + transport occurs by the Na + -K + -2 Cl − cotransporter, which is powered by Na + -K + ATPase (continued) 144 DISORDERS OF K +