Letters to the Editor – Brief Case Reports
Severe arrhythmia due to hypokalemia. Influence from diuretic substances
Arritmia cardiaca grave por hipopotasemia. Influencia de las sustancias diuréticas
Servicio de Nefrología, Hospital de La Princesa, Madrid, Spain
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Influence from diuretic substances" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "334" "paginaFinal" => "336" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Laura Salanova-Villanueva, Carmen Bernis-Carro, Luis Alberto-Blazquez, Jose Antonio Sanchez-Tomero" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Laura" "apellidos" => "Salanova-Villanueva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Carmen" "apellidos" => "Bernis-Carro" ] 2 => array:2 [ "nombre" => "Luis" "apellidos" => "Alberto-Blazquez" ] 3 => array:2 [ "nombre" => "Jose Antonio" "apellidos" => "Sanchez-Tomero" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Nefrología, Hospital de La Princesa, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Arritmia cardiaca grave por hipopotasemia. Influencia de las sustancias diuréticas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1611 "Ancho" => 2333 "Tamanyo" => 384857 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Distal tubule. Action of aldosterone on distal tubule.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">This was a case of a 25-year-old woman with no known allergies or relevant medical history and no toxic habits. She is an attorney and drinks 500–750<span class="elsevierStyleHsp" style=""></span>ml of beverages containing taurine and 1<span class="elsevierStyleHsp" style=""></span>l of caffeinated soda per day due to stress. The following details were observed: height 170<span class="elsevierStyleHsp" style=""></span>cm, weight 58<span class="elsevierStyleHsp" style=""></span>kg and BMI 20. She was admitted to the hospital for headache and tachycardia during the last two days after she did some sports and coinciding with an increase in the consumption of a beverages containing taurine. She denied chest pain or dyspnoea. Had no vomiting or diarrhoea and had no change in diuresis. She did not consume herbal products, drugs, teas, diuretics, liquorice or alcohol. <span class="elsevierStyleItalic">Physical examine</span>: Conscious, oriented, blood pressure 108/86, heart rate 110 beats per minute. Afebrile. Anodyne cardiopulmonary auscultation. Rest of the examination was normal. <span class="elsevierStyleItalic">Blood test</span>: normal red cell count, no elevation of cardiac or hepatic enzymes and coagulation test without alterations; creatinine 1.04<span class="elsevierStyleHsp" style=""></span>mg/dL, urea 31<span class="elsevierStyleHsp" style=""></span>mg/dL, potassium 1.73<span class="elsevierStyleHsp" style=""></span>mEq/L, sodium 134<span class="elsevierStyleHsp" style=""></span>mEq/L, magnesium 2.2<span class="elsevierStyleHsp" style=""></span>mg/dL, chloride 85<span class="elsevierStyleHsp" style=""></span>mEq/L, Albumin 4<span class="elsevierStyleHsp" style=""></span>g/dL. Arterial blood gas: Ph 7.580, PCO<span class="elsevierStyleInf">2</span> 46<span class="elsevierStyleHsp" style=""></span>mmHg, PO<span class="elsevierStyleInf">2</span> 86<span class="elsevierStyleHsp" style=""></span>mmHg, bicarbonate 43.1<span class="elsevierStyleHsp" style=""></span>mmol/L. Plasma anion gap (AG): 5.9<span class="elsevierStyleHsp" style=""></span>mEq/L. Urine: chloride 22.2<span class="elsevierStyleHsp" style=""></span>mEq/L, potassium 68.28<span class="elsevierStyleHsp" style=""></span>mEq/L, sodium 210<span class="elsevierStyleHsp" style=""></span>mmol/L, urea 920<span class="elsevierStyleHsp" style=""></span>mg/dL, creatinine 192.72<span class="elsevierStyleHsp" style=""></span>mg/dL, glucose 15<span class="elsevierStyleHsp" style=""></span>mg/dL. Urine anion gap: 256<span class="elsevierStyleHsp" style=""></span>mEq/L. Plasma osmolality: 278.2<span class="elsevierStyleHsp" style=""></span>mOsm/L. Urine osmolality: 573.3<span class="elsevierStyleHsp" style=""></span>mOsm/l. Transtubular potassium gradient: 15. Cortisol at 8<span class="elsevierStyleHsp" style=""></span>am and aldosterone in supine position were within the normal range. No alterations in urinary sediment. ECG: sinus rhythm, markedly enlarged QT (580<span class="elsevierStyleHsp" style=""></span>ms; corrected 700<span class="elsevierStyleHsp" style=""></span>ms); with frequent polymorphic ventricular tachycardia (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). An infusion of CLK was initiated via central line: 80<span class="elsevierStyleHsp" style=""></span>mEq within two hours and maintained with an infusion of 120<span class="elsevierStyleHsp" style=""></span>mEq/day. After 18<span class="elsevierStyleHsp" style=""></span>h, urine test was: sodium 25.3<span class="elsevierStyleHsp" style=""></span>mEq/L, potassium 6.2<span class="elsevierStyleHsp" style=""></span>mEq/L; in serum: sodium 142<span class="elsevierStyleHsp" style=""></span>mEq/L, potassium 2.8<span class="elsevierStyleHsp" style=""></span>mEq/L transtubular potassium gradient: 4. Venous blood gas: Ph 7.380, PCO<span class="elsevierStyleInf">2</span> 52<span class="elsevierStyleHsp" style=""></span>mmHg, HCO<span class="elsevierStyleInf">3</span> 30.8. Blood test at discharge: sodium 143<span class="elsevierStyleHsp" style=""></span>mEq/L, potassium 4.84<span class="elsevierStyleHsp" style=""></span>mEq/L, chloride 105<span class="elsevierStyleHsp" style=""></span>m Eq/L, pH 7.380, pCO<span class="elsevierStyleInf">2</span> 49<span class="elsevierStyleHsp" style=""></span>mmHg, bicarbonate 29<span class="elsevierStyleHsp" style=""></span>mmol/L. Urine: potassium 11.59<span class="elsevierStyleHsp" style=""></span>mmol/L, sodium 89<span class="elsevierStyleHsp" style=""></span>mmol/L, creatinine 266.27<span class="elsevierStyleHsp" style=""></span>mg/dL, urea 642<span class="elsevierStyleHsp" style=""></span>mg/dL. The ECG was normal. The evolution of ions in the urine suggested the presence of a diuretic substance that was suspended at admission. <span class="elsevierStyleItalic">Diagnoses</span>: hypokalaemia due to diuretic substances: taurine and caffeine, but not being able to rule out the presence of other diuretics, aggravated by the increase of insensitive losses and alkalemic state. A Bartter vs Gitelman-type tubulopathy was ruled out given the evolution of the ions in urine and the hormonal axis normality. Alteration in heart conduction due to hypokalaemia. Mixed alkalaemia: Chloride-resistant metabolic alkalosis due to diuretic substances and reactive respiratory alkalosis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Ninety percent of the potassium filtered at glomerular level is reabsorbed in the proximal tube. The distal tubule, by effect of the aldosterone, regulates the urinary output according to the body needs (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Distal excretion of Kis modified by the amount of fluid, distal contribution of sodium, mineral corticoids and excretion of non-reabsorbable anions. The most common cause of hypokalaemia due to renal losses are non-potassium-sparing and similar diuretics. Hereditary tubulopathies (Bartter and Gitelman) may not be distinguishable from the intake of diuretics. Hyperaldosteronism and hypermineralcorticoidism cause hypokalaemia due to their action on the distal nephron. Potassium is a predominant intracellular cation. The best marker to assess the renal management of potassium is TTKG in euvolemia that assesses the mineralocorticoid action on the distal nephron: values <4 indicates absence and >7 presence of activity. Blood pressure, extrarenal losses, acid-base state, urinary ions and urine and plasma AG have to be assessed. In the presence of metabolic alkalosis, as in our case, chloride concentration decreases in order to compensate for the elevation of bicarbonate and the AG increases in proportion to the alkalosis severity, due to the lactate and the concentration of more anionic serum proteins. In turn, the kidney tends to increase the excretion of bicarbonate at proximal and distal tube level where there is a Cl<span class="elsevierStyleSup">−</span>/HCO<span class="elsevierStyleInf">3</span> exchange in the beta-intercalated cells of the collecting tubule. Serious chloride, potassium or extracellular space depletion inhibits this exchange. Urine AG is an indicator of urinary acidification. Positive values indicate that renal acidification is intact. Treatment must be oral. The intravenous line is reserved for serious hypokalaemia (<span class="elsevierStyleItalic">K</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>2.5<span class="elsevierStyleHsp" style=""></span>mEq/l), arrhythmia, acute myocardial infarction or digitalisation.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Some characteristics of the energy drinks diuretic components:</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Caffeine</span><p id="par0020" class="elsevierStylePara elsevierViewall">Natural xanthine. Energy drinks have levels between 75 and 174<span class="elsevierStyleHsp" style=""></span>mg per serving, others exceed 500<span class="elsevierStyleHsp" style=""></span>mg.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> This stimulates the central nervous system, cardiovascular system, and central respiratory system; it relaxes the smooth bronchial muscle and striated muscle, increases acid gastric secretion and renal blood fluid and has diuretic properties. Many of these effects are caused by antagonic action on adenosine receptors.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> It is rapidly distributed through the organism and crosses the placental and blood–brain barrier. It has hepatic metabolism (cytochrome P-450). It is clinically used as a respiratory stimulant in newborns with apnoea of prematurity. The adverse effects include insomnia, agitation, headache and tachycardia at elevated doses.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> The changes in blood pressure response are not conclusive.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a> It can produce dependence syndrome.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Taurine</span><p id="par0025" class="elsevierStylePara elsevierViewall">Conditionally essential amino acid. Its deficit is associated with cardiomyopathy, retinal degeneration and failure to thrive.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> Metabolic actions include: bile acids conjugation, osmolar regulation, detoxification, membranes stabilisation and modification of cellular sodium and calcium levels. It has positive inotropic action and protects the cardiac membrane from the adverse effects of hyperglycaemia.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">7,8</span></a> Its renalprotective effect is caused by its antioxidant action by controlling the effects generated by TGF-B1 and type I and IV collagen.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a> It increases the glomerular filtration rate, reduces sodium tubular reabsorption, reduces urine protein and inhibits antidiuretic hormone production.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">8,9</span></a> Clinically, it has been used in hypercholesterolaemia, epilepsy, cardiopathy, retinal macular degeneration, Alzheimer's disease, cystic fibrosis and hepatic diseases.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Both of them increase natriuresis increasing the arrival of sodium at the distal tubule: activating aldosterone and producing the entry of cellular sodium and the exit of potassium to the tubular light causing hypokalaemia.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Most of the supplements contained in the energy drinks have concentrations below the amounts associated with adverse effects.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> The association of heart conduction alterations is not clear with studies for and against them.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">11,12</span></a> The combination of these drinks with alcohol may cause arrhythmias in subjects prone to them.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Caffeine" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Taurine" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Salanova-Villanueva L, Bernis-Carro C, Alberto-Blazquez L, Sanchez-Tomero JA. Arritmia cardiaca grave por hipopotasemia. Influencia de las sustancias diuréticas. Nefrologia. 2015;35:334–336.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2118 "Ancho" => 3007 "Tamanyo" => 1406383 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Polymorphic ventricular tachycardia. Increased QT.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1611 "Ancho" => 2333 "Tamanyo" => 384857 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Distal tubule. 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| Year/Month | Html | Total | |
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| 2024 November | 12 | 12 | 24 |
| 2024 October | 69 | 50 | 119 |
| 2024 September | 80 | 39 | 119 |
| 2024 August | 85 | 76 | 161 |
| 2024 July | 82 | 32 | 114 |
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| 2024 May | 84 | 43 | 127 |
| 2024 April | 85 | 35 | 120 |
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| 2024 February | 54 | 41 | 95 |
| 2024 January | 47 | 21 | 68 |
| 2023 December | 37 | 20 | 57 |
| 2023 November | 48 | 29 | 77 |
| 2023 October | 47 | 21 | 68 |
| 2023 September | 51 | 22 | 73 |
| 2023 August | 60 | 22 | 82 |
| 2023 July | 46 | 27 | 73 |
| 2023 June | 64 | 23 | 87 |
| 2023 May | 68 | 42 | 110 |
| 2023 April | 50 | 16 | 66 |
| 2023 March | 84 | 23 | 107 |
| 2023 February | 86 | 26 | 112 |
| 2023 January | 85 | 27 | 112 |
| 2022 December | 81 | 25 | 106 |
| 2022 November | 87 | 35 | 122 |
| 2022 October | 106 | 36 | 142 |
| 2022 September | 78 | 27 | 105 |
| 2022 August | 80 | 49 | 129 |
| 2022 July | 62 | 54 | 116 |
| 2022 June | 103 | 28 | 131 |
| 2022 May | 93 | 28 | 121 |
| 2022 April | 117 | 48 | 165 |
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| 2021 December | 111 | 39 | 150 |
| 2021 November | 88 | 57 | 145 |
| 2021 October | 63 | 40 | 103 |
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| 2021 July | 97 | 24 | 121 |
| 2021 June | 94 | 34 | 128 |
| 2021 May | 79 | 32 | 111 |
| 2021 April | 210 | 49 | 259 |
| 2021 March | 117 | 48 | 165 |
| 2021 February | 89 | 28 | 117 |
| 2021 January | 82 | 24 | 106 |
| 2020 December | 75 | 20 | 95 |
| 2020 November | 65 | 16 | 81 |
| 2020 October | 43 | 13 | 56 |
| 2020 September | 61 | 13 | 74 |
| 2020 August | 59 | 12 | 71 |
| 2020 July | 75 | 11 | 86 |
| 2020 June | 59 | 11 | 70 |
| 2020 May | 83 | 17 | 100 |
| 2020 April | 85 | 15 | 100 |
| 2020 March | 52 | 15 | 67 |
| 2020 February | 51 | 21 | 72 |
| 2020 January | 75 | 15 | 90 |
| 2019 December | 86 | 19 | 105 |
| 2019 November | 84 | 36 | 120 |
| 2019 October | 61 | 10 | 71 |
| 2019 September | 100 | 23 | 123 |
| 2019 August | 52 | 25 | 77 |
| 2019 July | 62 | 28 | 90 |
| 2019 June | 47 | 19 | 66 |
| 2019 May | 62 | 17 | 79 |
| 2019 April | 109 | 45 | 154 |
| 2019 March | 56 | 24 | 80 |
| 2019 February | 52 | 23 | 75 |
| 2019 January | 38 | 22 | 60 |
| 2018 December | 173 | 42 | 215 |
| 2018 November | 298 | 30 | 328 |
| 2018 October | 259 | 40 | 299 |
| 2018 September | 108 | 23 | 131 |
| 2018 August | 50 | 18 | 68 |
| 2018 July | 52 | 13 | 65 |
| 2018 June | 78 | 15 | 93 |
| 2018 May | 89 | 12 | 101 |
| 2018 April | 119 | 7 | 126 |
| 2018 March | 60 | 9 | 69 |
| 2018 February | 71 | 9 | 80 |
| 2018 January | 57 | 9 | 66 |
| 2017 December | 78 | 8 | 86 |
| 2017 November | 60 | 11 | 71 |
| 2017 October | 77 | 12 | 89 |
| 2017 September | 49 | 10 | 59 |
| 2017 August | 45 | 14 | 59 |
| 2017 July | 61 | 17 | 78 |
| 2017 June | 73 | 18 | 91 |
| 2017 May | 75 | 13 | 88 |
| 2017 April | 87 | 11 | 98 |
| 2017 March | 49 | 20 | 69 |
| 2017 February | 87 | 24 | 111 |
| 2017 January | 44 | 16 | 60 |
| 2016 December | 69 | 10 | 79 |
| 2016 November | 137 | 23 | 160 |
| 2016 October | 208 | 24 | 232 |
| 2016 September | 285 | 6 | 291 |
| 2016 August | 252 | 10 | 262 |
| 2016 July | 229 | 9 | 238 |
| 2016 June | 163 | 0 | 163 |
| 2016 May | 195 | 0 | 195 |
| 2016 April | 156 | 0 | 156 |
| 2016 March | 130 | 0 | 130 |
| 2016 February | 159 | 0 | 159 |
| 2016 January | 131 | 0 | 131 |
| 2015 December | 115 | 0 | 115 |
| 2015 November | 139 | 0 | 139 |
| 2015 October | 168 | 0 | 168 |
| 2015 September | 185 | 0 | 185 |
| 2015 August | 168 | 0 | 168 |
| 2015 July | 41 | 0 | 41 |
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