Electrolytes


Article Author:
Isha Shrimanker


Article Editor:
Sandeep Bhattarai


Editors In Chief:
Michael Firstenberg
Lawrence Greiten


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
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Radia Jamil
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Saad Nazir
William Gossman
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Navid Mahabadi
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John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
5/3/2019 9:45:16 AM

Introduction

Electrolytes are essential for basic life functioning such as maintaining electrical neutrality in the cells, generation, and conduction of action potentials in the nerves and muscles. Sodium, potassium, and chloride are the significant electrolytes along with magnesium, calcium, phosphate, and bicarbonates. Electrolytes come from our food and fluids. 

These electrolytes can have an imbalance, leading to either high or low levels. A high or a low level of electrolytes disrupts the normal bodily functions and can lead to even life-threatening complications. This article reviews the basic physiology of electrolytes and their abnormalities, and the consequences of electrolyte imbalance.  

Sodium

Sodium, which is an osmotically active anion, is one of the most important electrolytes in the extra-cellular fluid. It is responsible for maintaining the extracellular fluid volume, and also for regulation of the membrane potential of cells. Sodium is exchanged along with potassium across cell membranes as part of active transport. 

Sodium regulation occurs in the kidneys. The proximal tubule is where the majority of the sodium reabsorption takes place. In the distal convoluted tubule, sodium undergoes reabsorption.  Sodium transport takes place via sodium-chloride symporters which is by the action of the hormone aldosterone.[1]

Among the electrolyte disorders, hyponatremia is the most frequent. It is diagnosed when the serum sodium level less than 135 mmol/L. Hyponatremia has neurological manifestations. Patients may present with headache, confusion, nausea, deliriums. Hypernatremia presents when the serum sodium levels greater than145 mmol/L. Symptoms of hypernatremia include tachypnea, sleeping difficulty, and feeling restless. Rapid sodium corrections can have serious consequences like cerebral edema and osmotic demyelination syndrome. 

Potassium

Potassium is mainly an intracellular ion. The sodium-potassium adenosine triphosphatase pump is primarily responsible for regulating the homeostasis between sodium and potassium which pumps out sodium in exchange for potassium which moves into the cells. In the kidneys, filtration of potassium takes place at the glomerulus. Reabsorption of potassium takes place at the proximal convoluted tubule and thick ascending loop of Henle.[2] Potassium secretion takes place at the distal convoluted tubule. Aldosterone increases potassium secretion.[3] Potassium channels and potassium-chloride cotransporters at the apical membrane also secrete potassium.[2]

Potassium disorders are related to cardiac arrhythmias. Hypokalemia occurs when serum potassium levels under 3.6 mmol/L. Weakness, fatigue and muscle twitching present in hypokalemia. Hyperkalemia occurs when the serum potassium levels above 5.5 mmol/L which can result in arrhythmias. Muscle cramps, muscle weakness, rhabdomyolysis, myoglobinuria are presenting signs and symptoms in hyperkalemia.[4]

Calcium

Calcium has a significant physiological role in the body. It is involved in skeletal mineralization, contraction of muscles, transmission of nerve impulse, blood clotting and secretion of hormones. The diet is the predominant source of calcium. It is mostly present in the extracellular fluid. Absorption of calcium in the intestine is primarily under the control of the hormonally active form of Vitamin D which is 1,25-dihydroxy vitamin D3. Parathyroid hormone also regulates calcium secretion in the distal tubule of kidneys.[5] Calcitonin acts on bone cells to increase calcium level in blood.

Hypocalcemia diagnosis requires checking the serum albumin level to correct for total calcium, and the diagnosis is when the corrected serum total calcium levels are less than 8.8 mg/dl, as in vitamin D deficiency or hypoparathyroidism. CHecking serum calcium levels is a recommended test in post-thyroidectomy patients.[6] Hypercalcemia is when corrected serum total calcium levels exceed 10.7 mg/dl, as seen with primary hyperparathyroidism. Humoral hypercalcemia presents in malignancy, primarily due to PTHrP secretion.[7] 

Bicarbonate

The acid-base status of the blood drives bicarbonate levels. The kidneys predominantly regulate bicarbonate concentration and are responsible for maintaining the acid-base balance. Kidneys reabsorb the filtered bicarbonate and also generate new bicarbonate by net acid excretion, which occurs by excretion of both titrable acid and ammonia. Diarrhea usually results in loss of bicarbonate, thus causing an imbalance in acid-base regulation.[8] 

Magnesium

Magnesium is an intracellular cation. Magnesium is mainly involved in ATP metabolism, contraction and relaxation of muscles, proper neurological functioning and neurotransmitter release. When muscle contracts, calcium re-uptake by the calcium-activated ATPase of the sarcoplasmic reticulum is brought about by magnesium.[9] Hypomagnesemia occurs when the serum magnesium levels are less under 1.46 mg/dl. It can present with alcoholism and gastrointestinal and renal losses. Ventricular arrhythmias which include torsades de pointes seen in hypomagnesemia. 

Chloride

Chloride is an anion found predominantly in the extracellular fluid. The kidneys predominantly regulate serum chloride level. Most of the chloride which is filtered by the glomerulus is reabsorbed by both proximal and distal tubules (majorly by proximal tubule) by both active and passive transport.[10] 

Hyperchloremia can occur due to gastrointestinal bicarbonate loss. Hypochloremia presents in gastrointestinal losses like vomiting or excess water gain like congestive heart failure. 

Phosphorus

Phosphorus is an extracellular fluid cation. Eighty-five percent of the total body phosphorus is in the bones and teeth in the form of hydroxyapatite; the soft tissues contain the remaining 15%. Phosphate plays a vital role in metabolic pathways. It is a component of many metabolic intermediates and most importantly of adenosine triphosphate(ATPs) and nucleotides. Phosphate is regulated simultaneously with calcium by Vitamin D3, PTH, and calcitonin. The kidneys are the primary avenue of phosphorus excretion. 

Phosphorus imbalance may result due to three processes: dietary intake, gastrointestinal disorders, and excretion by the kidneys.[11]

Specimen Collection

A blood specimen for electrolytes uses lithium heparin tubes,[12] plus the standard phlebotomy equipment and personnel as with any blood draw.[12]

Procedures

Blood collected in lithium heparin tubes then goes to the laboratory for evaluation of serum electrolytes.[12]

Indications

Indications to order serum electrolyte panel are numerous. Some of which include:

  1. As a part of routine blood investigations  
  2. For in-patients and ICU patients, serum electrolytes are monitored often daily or more frequently as they can be affected by the medications, fluid therapy, diet changes, and illnesses.
  3. Any illness that can cause electrolyte derangement- malnutrition, gastrointestinal disorders, cardiac disorders, kidney dysfunction, endocrine disorders, circulatory disorders, lung disorders, acid-base imbalance
  4. Arrhythmias, cardiac arrest
  5. Use of diuretics or any medications that can interfere with fluid and electrolyte homeostasis

Potential Diagnosis

Measurement of electrolytes will help the clinicians in the diagnosis of a medical condition, the effectivity of treatment and the potential side effect of medications. Examples include: 

  1. A patient with heart failure receiving diuretics needs a workup for potassium, bicarbonate, magnesium as diuretics can exert adverse effects on electrolyte balance
  2. A patient that presents with weakness needs a basic electrolyte workup, as an electrolyte imbalance, especially in sodium and potassium levels, can lead to fatigue

Normal and Critical Findings

Laboratory Values: 

Serum Sodium: 

Normal Range: 135 to 145 mmol/L  

Mild-moderate Hyponatremia: 125 to 135 mmol/L, Severe: less than 125 mmol/L

Hypernatremia: Mild-moderate: 145 to 160 mmol/L, Severe: over 160 mmol/L

Serum Potassium:

Normal Range: 3.6 to 5.5 mmol/L 

Hypokalemia: Mild Hypokalemia under 3.6 mmol/L, Moderate: 2.5 mmol/L, Severe : greater than 2.5 mmol/L

Hyperkalemia: Mild hyperkalemia: 5 to 5.5 mmol/L, Moderate- 5.5 to 6.5, Severe: 6.5 to 7 mmol/L

Serum Calcium: 

Normal Range: 8.8 to 10.7 mg/dl

Hypercalcemia: greater than 10.7 mg/dl , Severe: over 11.5 mg/dl 

Hypocalcemia: less than 8.8 mg/dl

Serum Magnesium: 

Normal Range: 1.46 to 2.68 mg/dl 

Hypomagnesemia: under 1.46 mg/dl

Hypermagenesemia: over 2.68

Bicarbonate:

Normal Range: 22 to 26 mg/dl

It increases or decreases depending on the acid-base status.

Phosphorus:

Normal Range: 3.4 to 4.5 mg/dl 

Hypophosphatemia: less than 2.5 mg/dl

Hyperphosphatemia: greater than 4.5 mg/dl

Interfering Factors

Hypomagnesemia can lead to hypocalcemia as it interferes with the action of parathormone. 

Administration of intravenous insulin is associated with a spurious decrease in potassium levels as insulin shifts potassium intracellularly.[13]

Most of the calcium is bound to proteins, out of which albumin-bound calcium comprises about 80%. Therefore, a patient with hypoalbuminemia as seen in liver cirrhosis, the nephrotic syndrome will have low calcium levels as compared to the actual values.[14]

Complications

Both hyponatremia and hypernatremia, as well as hypomagnesemia, can lead to neurological consequences such as seizure disorders. 

Hypokalemia and hyperkalemia, as well as hypocalcemia, are more responsible for arrhythmias. 

Bicarbonate imbalance can lead to metabolic acidosis or alkalosis.

Patient Safety and Education

A piece of valuable advice to the patients would be to take the medications exactly as prescribed the doctor to avoid electrolyte imbalance as a consequence of not taking the prescribed dose. 

One should call for immediate medical help when the patient feels weak, has muscle ache, or has altered consciousness.  

Clinical Significance

Some of the common causes of electrolyte disorders seen in clinical practices are:

  • Hyponatremia: low dietary sodium intake, primary polydipsia, SIADH, congestive heart failure, hepatic cirrhosis, failure of adrenal glands, hyperglycemia, dyslipidemia
  • Hypernatremia: unreplaced fluid loss through the skin and gastrointestinal tract, osmotic diuresis, hypertonic saline administration
  • Hypokalemia: hyperaldosteronism, loop diuretics 
  • Hyperkalemia: increase release from cells as in metabolic acidosis, insulin deficiency, beta-blocker or decreased potassium excretion as in acute or chronic kidney disease, aldosterone deficiency or resistance
  • Hypercalcemia: malignancy, hyperparathyroidism, chronic granulomatous disease
  • Hypocalcemia: acute pancreatitis, parathyroid hormone deficiency after thyroidectomy, neck dissection, resistance to parathormone, hypomagnesemia, sepsis 
  • Hypermagnesemia: increase oral magnesium intake
  • Hypomagnesemia: renal losses as in diuretics, alcoholism or GI losses as in diarrhea
  • Bicarbonate level: increases in primary metabolic alkalosis or compensation to primary respiratory acidosis - decreases in primary metabolic acidosis or compensation to primary respiratory alkalosis
  • Hyperchloremia: normal saline infusion
  • Hypochloremia: GI loss as in diarrhea, renal losses with diuretics
  • Hypophosphatemia: refeeding syndrome, vitamin D deficiency, hyperparathyroidism
  • Hyperphosphatemia: hypoparathyroidism, chronic kidney disease

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Electrolytes - Questions

Take a quiz of the questions on this article.

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A 22-year-old man presents to the clinic with 6 days of watery diarrhea and decreased oral intake. A week prior he had gone a hiking trip with his college friends. Upon returning home, he started developing 2 episodes of watery diarrhea on day 1. They gradually increased in frequency to 3-4 times a day. He has not noticed any blood or mucus. He denies complaints of nausea, vomiting, fever, or abdominal pain. On arrival, his vitals include a pulse of 108 beats/minute, blood pressure of 100/70 mmHg, and oxygen saturation 99% on room air. Physical examination reveals dry mucous membranes. Which of the following abnormalities will be seen in this patient?



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A 15-year-old boy comes to the clinic with his mother. He complains of intermittent muscle weakness for the past few months. Initially, he thought that it could be due to the excessive fatigue since he joined the football team 4 months back. But his fatigue has increased gradually, and he experiences weakness sometimes even while performing mild household chores. His mother states that there is a family history of Bartter's syndrome. His vital signs include a pulse of 90 beats/minute, blood pressure of 110/70 mm Hg and a respiratory rate of 16 breaths/minute. Blood workup is ordered for the patient. Which of the following abnormalities is most likely to be seen in this patient?



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A charge nurse is reviewing lab results on several clients in preparation for the off-going shift report. Which of the following values are outside the normal range? Select all that apply.



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Electrolytes - References

References

Cooper MS,Gittoes NJ, Diagnosis and management of hypocalcaemia. BMJ (Clinical research ed.). 2008 Jun 7;     [PubMed]
Turner JJO, Hypercalcaemia - presentation and management . Clinical medicine (London, England). 2017 Jun;     [PubMed]
Gumz ML,Rabinowitz L,Wingo CS, An Integrated View of Potassium Homeostasis. The New England journal of medicine. 2015 Jul 2;     [PubMed]
Ellison DH,Terker AS,Gamba G, Potassium and Its Discontents: New Insight, New Treatments. Journal of the American Society of Nephrology : JASN. 2016 Apr;     [PubMed]
Palmer LG,Schnermann J, Integrated control of Na transport along the nephron. Clinical journal of the American Society of Nephrology : CJASN. 2015 Apr 7;     [PubMed]
Veldurthy V,Wei R,Oz L,Dhawan P,Jeon YH,Christakos S, Vitamin D, calcium homeostasis and aging. Bone research. 2016;     [PubMed]
Hamm LL,Nakhoul N,Hering-Smith KS, Acid-Base Homeostasis. Clinical journal of the American Society of Nephrology : CJASN. 2015 Dec 7;     [PubMed]
Jahnen-Dechent W,Ketteler M, Magnesium basics. Clinical kidney journal. 2012 Feb;     [PubMed]
Morrison G, Serum Chloride 1990;     [PubMed]
Viera AJ,Wouk N, Potassium Disorders: Hypokalemia and Hyperkalemia. American family physician. 2015 Sep 15;     [PubMed]
Berkelhammer C,Bear RA, A clinical approach to common electrolyte problems: 3. Hypophosphatemia. Canadian Medical Association journal. 1984 Jan 1;     [PubMed]
Toffaletti J,Ernst P,Hunt P,Abrams B, Dry electrolyte-balanced heparinized syringes evaluated for determining ionized calcium and other electrolytes in whole blood. Clinical chemistry. 1991 Oct     [PubMed]
Liamis G,Liberopoulos E,Barkas F,Elisaf M, Spurious electrolyte disorders: a diagnostic challenge for clinicians. American journal of nephrology. 2013     [PubMed]
Boden SD,Kaplan FS, Calcium homeostasis. The Orthopedic clinics of North America. 1990 Jan     [PubMed]

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