Refractory Electrolytes
Advanced management for persistent or resistant electrolyte disorders.
Refractory Hyperkalemia
Persistent K+ > 5.5 despite medical therapy
1. Rule Out Pseudohyperkalemia
- Hemolysis (Check K+ in plasma vs serum).
- Thrombocytosis (Platelets > 500k) or Leukocytosis (WBC > 100k).
- Fist clenching during draw.
2. Advanced Medical Management
- Diuretics: Add Thiazide (Metolazone) to Loop diuretic for synergistic kaliuresis (if producing urine).
- Binders: Sodium Zirconium Cyclosilicate (Lokelma) 10g TID x 48h, then QD. Faster onset (1h) than Kayexalate.
- Fludrocortisone: 0.1 - 0.2 mg daily (if hypoaldosteronism/RTA type 4).
Indication for Dialysis: Refractory HyperK with ECG changes or arrhythmia.
Refractory Hypokalemia
Persistent K+ < 3.5 despite supplementation
1. The "Magnesium Trap"
Always check Mg++. Hypomagnesemia causes renal K+ wasting via ROMK channels. K+ cannot be corrected until Mg++ is replete (> 2.0 mg/dL).
2. Diagnosis of Renal Wasting
- Check Urine K+ / Creatinine Ratio or TTKG.
- High BP + Low K: Hyperaldosteronism, Liddle's, Cushing's, Renal Artery Stenosis.
- Normal BP + Low K: Diuretics, Gitelman's, Bartter's, RTA (Type 1 or 2).
3. K-Sparing Agents
SpironolactoneAmilorideTriamterene
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