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(searched for: Hypokalemia: A Practical Approach to Diagnosis and Treatment)
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Secondary Hypertension pp 59-78; doi:10.1007/978-3-030-45562-0_4

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Roberto Javier Rueda Esteban, Juan Daniel Pedraza-Rodriguez, Daniela Paola Ramirez, Felipe Perdomo
Published: 19 April 2020
by FASEB
The FASEB Journal, Volume 34, pp 1-1; doi:10.1096/fasebj.2020.34.s1.07266

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Mohammad Tinawi
Archives of Clinical and Biomedical Research, Volume 4, pp 48-66; doi:10.26502/acbr.50170088

Abstract:
Potassium (K+) is the predominant intracellular cation. It is essential to the function of all living cells. Intracellular K+ concentration is over 30 times its extracellular concentration. Serum K+ is dependent on its intake, excretion, and transcellular distribution. Most of the body’s K+ is in the muscles. Aldosterone is the main regulator of K+ renal excretion. Hypokalemia (serum K+ < 3.5 mEq/l) has multiple manifestations affecting different organ systems. Careful history and basic laboratory tests are usually adequate to diagnose most cases of hypokalemia. K+ should be replaced orally whenever feasible. Intravenous K+ replacement is needed for emergency management of hypokalemia and in patients who cannot take oral potassium.
K Gellner, P Emonts, E Hamoir, A Beckers, H Valdes-Socin
Published: 1 December 2018
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Sciprofile linkFrederick-Anthony Farrugia, Sciprofile linkEvangelos Misiakos, Georgios Martikos, Panagiotis Tzanetis, Anestis Charalampopoulos, Nicolaos Zavras, Dimitrios Sotiropoulos, Nikolaos Koliakos
Romanian Journal of Internal Medicine, Volume 55, pp 188-197; doi:10.1515/rjim-2017-0025

Abstract:
Objectives. To present a step by step approach for the diagnosis of adrenal incidentaloma (AI). Method. An extensive review of the literature was conducted, searching the Pub-Med and Google Scholar using the Mesh terms; Adrenal; Incidentaloma; Adrenal tumours; Radiology; Diagnosis. We also did a cross-referencing search of the literature. Comments on the new European guidelines are presented. Results. The majority of the tumours are non-functioning benign adenomas. The most important radiological characteristic of an adrenal incidentaloma is the radiation attenuation coefficient. Wash out percentage and the imaging characteristics of the tumour may help in diagnosis. Conclusion. Density less than 10 HU is in most cases characteristic of a lipid rich benign adenoma. More than 10 HU or/and history of malignancy raise the possibility for cancer. 1 mg dexamethasone test and plasma metanephrines should be done in all patients. If there is history of hypokalemia and/or resistant hypertension we test the plasma aldosterone to plasma renin ratio (ARR). Newer studies have shown that tumours even nonfunctioning and less than 4 cm may increase the metabolic risks so we may consider surgery at an earlier stage.
Abdulla K. Salahudeen, Sciprofile linkBijin Thajudeen
Cancer Management and Research pp 105-114; doi:10.2147/cmar.s90169

Abstract:
Role of tolvaptan in the management of hyponatremia in patients with lung and other cancers: current data and future perspectives Bijin Thajudeen,1 Abdulla K Salahudeen1,2 1Department of Nephrology, Banner University of Arizona Medical Center, 2Department of Nephrology, Southern Arizona Veterans Health Care System, Tucson, AZ, USA Hyponatremia is the most frequently observed electrolyte abnormality in clinical practice, and its frequency is almost double in hospitalized cancer patients. As a subset of cancer, hyponatremia is quite common in lung cancer patients, and it is often coupled with the diagnosis of syndrome of inappropriate antidiuretic hormone secretion. The presence of hyponatremia is consequential in that its presence adversely affects cancer patients’ prognosis and outcomes. Limited data suggest that correcting hyponatremia in lung cancer patients can increase response to anticancer treatment, may help reduce length of hospital stay and cost, and reduce morbidity and mortality. The type of treatment for hyponatremia depends on several factors; the key factors are the duration and severity of neurological symptoms of hyponatremia and the status of extracellular volume. When hyponatremia is caused by syndrome of inappropriate antidiuretic hormone, hypertonic saline is indicated for acute symptomatic cases, whereas fluid restriction is recommended in chronic asymptomatic hyponatremia. The latter allows a slower rate of correction, thus avoiding the dreaded complication of osmotic demyelination syndrome. Fluid restriction is, however, insufficient or impractical, and often the use of pharmacological therapy such as antidiuretic hormone receptor antagonists becomes necessary. Availability of these antagonists as an effective treatment in the management of hyponatremia has been a major breakthrough, and furthermore, its clinical or investigational use in cancer-related hyponatremia may offer a potential opportunity to gain further insights into the prognostic impact of hyponatremia correction on cancer patients’ outcomes. Tolvaptan is a prototype of ADH receptor antagonists that acts at renal tubular levels to increase free water excretion without inducing major systemic electrolyte abnormalities such as hypokalemia or alkalosis. The aim of this paper is to provide a brief review while focusing on cancer hyponatremia; (1) of the epidemiology of hyponatremia and its pathophysiology and diagnostic approaches and (2) of the pharmacokinetics of tolvaptan and its clinical efficacy, safety, and compliance. Keywords: treatment, pharmacology, safety, tolerability, efficacy, adherence
Sciprofile linkVidhia Umami, Dina Oktavia, Sri Kunmartini, Djoko Wibisana, Parlindungan Siregar
Published: 1 January 2011
Acta medica Indonesiana, Volume 43

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Sciprofile linkMark C. Henderson, Gurpreet Dhaliwal, Stephen R. Jones, Charles Culbertson, Judith L. Bowen
Journal of General Internal Medicine, Volume 25, pp 84-87; doi:10.1007/s11606-009-1187-2

Abstract:
This case illustrates the importance of developing and refining the problem representation.1–3 The discussant systematically transforms the nonspecific issues of palpitations, weakness, and faintness in a 59-year-old man into a highly focused problem: severe hypertension due to excess mineralocorticoid activity of a transient nature. The diagnostic process evolves as more data become available and involves knowing which aspects of the case require explanation (e.g., severe hypokalemia) and which ones do not (e.g., history of anxiety). Comparing and contrasting the competing plausible disease states4 (Table 1) and finding the closest match to the problem representation determined the final answer. In this case, distinguishing among the various competing diagnoses relied more heavily on laboratory data (urine electrolytes, plasma renin activity) than history and physical examination findings. This approach ultimately prompted a detailed revisiting of historical information to discover the final answer. The marker of diagnostic skill in such a case lies not in suspecting licorice—in fact, the discussant did not—but in being able to recognize the critical features that did not seem to fit with the working differential diagnosis, prompting iterative revision of the problem representation. Equipped with this highly synthesized problem statement, the clinician then knows where to look—in his memory, to his consultants, or a search of electronic resources—for the potential solution. The combination of refractory hypertension and hypokalemia is most often explained by hyperaldosteronism, renovascular disease and diuretic therapy for severe primary hypertension. Licorice ingestion (glycyrrhizic acid toxicity) is a rare cause that results in an acquired mineralocorticoid excess state and consequently low plasma renin and aldosterone levels. The initial diagnostic evaluation of patients with hypertension and unexplained hypokalemia or drug-resistant hypertension should include a plasma aldosterone to renin ratio.5 Use of licorice root in candies and other confections is uncommon in the US, but licorice root is still available in a variety of products including herbal teas. These sources should be considered in patients with unexplained hypertension and hypokalemia. Glycyrrhizic acid, a sweet tasting compound found in licorice root, is hydrolyzed in the intestine to glycyrrhetic acid, which inhibits the enzyme responsible for peripheral conversion of cortisol to cortisone (11 beta-hydroxysteroid dehydrogenase), leading to increased cortisol levels. Cortisol binds with the same affinity as aldosterone to the mineralocorticoid receptor, resulting in an acquired mineralocorticoid excess state.6 Chang RW, Bordage G, Connell KJ. The importance of early problem representation during case presentations. Acad Med. 1998;73(Suppl):S109–11. CAS Article PubMed Google Scholar Bordage G, Lemieux M. Semantic structures and diagnostic thinking of experts and novices. Acad Med. 1991;66(Suppl):S70–2. CAS Article PubMed Google Scholar Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006;355(21):2217–25. CAS Article PubMed Google Scholar Schmidt HG, Rikers RM. How expertise develops in medicine: knowledge encapsulation and illness script formation. Med Educ. 2007;41(12):1133. Epub 2007 Nov 13. PubMed Google Scholar Funder JW, Carey RM, Fardella C, et al. Case detection, diagnosis, and treatment of patients with primary aldosteronism: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2008;93(9):3266. Epub 2008 Jun 13. CAS Article PubMed Google Scholar Størmer FC, Reistad R, Alexander J. Glycyrrhizic acid in liquorice–evaluation of health hazard. Food Chem Toxicol. 1993;31(4):303–12. Article PubMed Google Scholar Download references Dr. Henderson is supported by a Residency Training in Primary Care grant from the Department of Health and Human Services (HRSA D58HP05139). Department of Internal Medicine, UC Davis Medical Center, 4150 V Street, Suite 3100, Sacramento, CA, 95718, USA Mark C. Henderson MD & Judith L. Bowen MD Department of Medicine, University of California, San Francisco and the San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA Gurpreet Dhaliwal MD Department of Internal Medicine, Legacy Health System and Oregon Health and Sciences University, Portland, OR, USA Stephen R. Jones MD & Charles Culbertson DO You can also search for this author in PubMed Google Scholar You can also search for this author in PubMed Google Scholar You can also search for this author in PubMed Google Scholar You can also search for this author in PubMed Google Scholar You can also search for this author in PubMed Google Scholar Correspondence to Mark C. Henderson MD. An erratum to this article can be found at http://dx.doi.org/10.1007/s11606-010-1339-4 Open Access This is an open access article distributed under the terms of the Creative Commons Attribution Noncommercial License (https://creativecommons.org/licenses/by-nc/2.0), which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. Reprints and Permissions Henderson, M.C., Dhaliwal, G., Jones, S.R. et al. Doing What Comes Naturally. J GEN INTERN MED 25, 84–87 (2010). https://doi.org/10.1007/s11606-009-1187-2 Download citation Published: 20 January 2010 Issue Date: January 2010 DOI: https://doi.org/10.1007/s11606-009-1187-2
Sciprofile linkShih-Hua Lin, Mitchell L Halperin
Current Medicinal Chemistry, Volume 14, pp 1551-1565; doi:10.2174/092986707780831050

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Sciprofile linkR B Thakkar, Suzanne Oparil
Published: 21 June 2001
by Wiley
The Journal of Clinical Hypertension, Volume 3, pp 189-195; doi:10.1111/j.1524-6175.2001.00496.x

Abstract:
Primary aldosteronism (PA) may account for as many as 10%-14% of hypertension cases. The plasma aldosterone concentration/plasma renin activity ratio is a simple screening test for PA that should be performed in all patients with refractory/severe hypertension, spontaneous or provoked (by diuretics) hypokalemia, or a requirement for excessive potassium supplementation to maintain normokalemia. PA can be confirmed by a fludrocortisone suppression test or 24-hour urine collection for aldosterone. Confirmatory testing should be followed by high-resolution computerized tomography of the adrenal glands to distinguish bilateral hyperplasia or an adenoma. A solitary tumor greater than 1 cm in size in a younger patient is an indication for surgery; all other (nondiagnostic) findings should be followed by bilateral adrenal venous sampling (if available) to identify a unilateral cause of PA. Treatment for a lateralizing positive study is surgical; spironolactone or another mineralocorticoid receptor antagonist is the treatment of choice for a nonlateralizing study. If adrenal venous sampling is not readily available, patients may be successfully treated pharmacologically.
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