Wednesday, August 4, 2010

hypokalemia and hepatic encephalopathy - good or bad??


Hypokalemia can be a precipitating factor for hepatic encephalopathy, and its not uncommon, as we use large doses of loop diuretics in these patients.

Although, the mechanism is not entirely clear, the likely hypothesis is as follows:
*Hypokalemia causes the movement of potassium out of the cells in proximal tubule.
*To maintain electric neutrality, H+ ions move into the cells leading to intracellular acidosis
*This triggers the conversion of glutamine in the proximal tubule, to NH4+ and bicarbonate. *Ammonia (NH3+ and NH4+) is selectively, either excreted in the urine or returned to the renal venous circulation (~25-45%).
*Ammonia, that subsequently enters portal circulation, is not metabolized by the cirrhotic liver, therefore likely to precipitate encephalopathy.

Frequently, hyperkalemia, and not hypokalemia, is a cause of concern among physicians, and frequently leads to discontinuation of spironolactone, administration of loop diuretics, dietary potassium restrictions, all of which further add to the risk of encephalopathy. So, conversely, can high potassium be protective?

Potassium competes with NH4+ for absorption by the NKCC2 transporter at the thick ascending limb of loop of henle, thereby reducing ammonia accumulation in the medullary interstitium and hence less ammonia available for absorption in the systemic circulation. In an interesting study done by Zavagli et al, patients with higher potassium levels (5.4-5.5 meq/l) had a much better survival and less hepatic encephalopathy episodes as compared to patients with lower potassium levels (3.4-3.5meq/l).

Given these, it would be reasonable to try and keep these patients at a high normal range of potassium. As we all know potassium is a double edged sword.So this has to be monitored closely so they dont become severely hyperkalemic (> 5.5meq/L) .

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