Role of the kidney in potassium homeostasis: lessons from acid-base disturbances

Neuroendocrine response to diclofenac in healthy subjects: a pilot study

PURPOSE

The precise effects of non-steroidal anti-inflammatory drugs on the neuroendocrine hydro-electrolytic regulation are not precisely understood. The aim of this pilot study was to evaluate, in healthy subjects, the neuroendocrine response of the antidiuretic system to intravenous diclofenac infusion.

METHODS

For this single-blinded, cross-over study, we recruited 12 healthy subjects (50% women). Test sessions were divided into three observation times (pre-test; test; 48 h post-test), which were repeated equally on two different occasions, with the administration of diclofenac (75 mg in saline solution 0.9% 100 cc) on 1 day, or placebo (saline solution 0.9% 100 cc) on another day. The night before the test the subjects were asked to collect a salivary cortisol and cortisone sample, which was repeated on the night of the procedure session. Serial urine and blood samples were collected on the test day (for osmolality, electrolytes, ACTH, cortisol, copeptin, MR-proADM, MR-proANP; the last three represent more stable and analytically reliable molecules than their respective active peptides). Moreover, the subjects were evaluated with the bioimpedance vector analysis (BIVA) before and after the test. Forty-eight hours after the end of the procedure urine sodium, urine potassium, urine osmolality, serum sodium and copeptin were revaluated together with BIVA.

RESULTS

No significant changes in circulating hormone levels were observed; anyway, 48 h after diclofenac, BIVA showed a significant water retention (p < 0.00001), especially in extracellular fluid (ECF) (16.47 ± 1.65 vs 15.67 ± 1.84, p < 0.001). Salivary cortisol and cortisone tended to increase only the night after placebo administration (p = 0.054 cortisol; p = 0.021 cortisone).

CONCLUSION

Diclofenac resulted in an increased ECF at 48 h, but this phenomenon seems to be associated with a greater renal sensibility to the action of vasopressin rather than with an increase in its secretion. Moreover, a partial inhibitory effect on cortisol secretion can be hypothesized.

Determinants of hypokalemia following hypertonic sodium bicarbonate infusion

The hypokalemic response to alkali infusion has been attributed to the resulting extracellular fluid (ECF) expansion, urinary potassium excretion, and internal potassium shifts, but the dominant mechanism remains uncertain. Hypertonic NaHCO₃ infusion (1 N, 5 mmol/kg) to unanesthetized dogs with normal acid-base status or one of the four chronic acid-base disorders decreased plasma potassium concentration ([K⁺]_p) at 30 min in all study groups (Δ[K⁺]_p, - 0.16 to - 0.73 mmol/L), which remained essentially unaltered up to 90-min postinfusion. ECF expansion accounted for only a small fraction of the decrease in ECF potassium content, (K⁺)_e. Urinary potassium losses were large in normals and chronic respiratory acid-base disorders, limited in chronic metabolic alkalosis, and minimal in chronic metabolic acidosis, yet, ongoing kaliuresis did not impact the stability of [K⁺]_p. All five groups experienced a reduction in (K⁺)_e at 30-min postinfusion, Δ(K⁺)_e remaining unchanged thereafter. Intracellular fluid (ICF) potassium content, (K⁺)_i, decreased progressively postinfusion in all groups excluding chronic metabolic acidosis, in which a reduction in (K⁺)_e was accompanied by an increase in (K⁺)_i. We demonstrate that hypokalemia following hypertonic NaHCO₃ infusion in intact animals with acidemia, alkalemia, or normal acid-base status and intact or depleted potassium stores is critically dependent on mechanisms of internal potassium balance and not ECF volume expansion or kaliuresis. We envision that the acute NaHCO₃ infusion elicits immediate ionic shifts between ECF and ICF leading to hypokalemia. Thereafter, maintenance of a relatively stable, although depressed, [K⁺]_e requires that cells release potassium to counterbalance ongoing urinary potassium losses.

Current and future treatment options for managing hyperkalemia

Hyperkalemia is associated with life-threatening cardiac arrhythmias and increased mortality. Hyperkalemia is most often observed in patients with chronic kidney disease and/or in those with congestive heart failure being treated with drugs that limit renal potassium excretion, especially drugs that inhibit the renin-angiotensin-aldosterone system. Treatment of hyperkalemia may be either acute, as needed during rapid changes in serum potassium, which are associated with cardiac arrhythmia, or chronic, which stabilizes serum potassium levels and limits the development of life-threatening arrhythmias. There are a number of both acute and chronic treatments available for the treatment of hyperkalemia, but some are limited by complex administration requirements and/or serious side effects. Hyperkalemia remains a vexing problem for clinicians, particularly in the care of patients with chronic kidney disease and cardiovascular disease.

Differential diagnosis of nongap metabolic acidosis: value of a systematic approach

Nongap metabolic acidosis is a common form of both acute and chronic metabolic acidosis. Because derangements in renal acid-base regulation are a common cause of nongap metabolic acidosis, studies to evaluate renal acidification often serve as the mainstay of differential diagnosis. However, in many cases, information obtained from the history and physical examination, evaluation of the electrolyte pattern (to determine if a nongap acidosis alone or a combined nongap and high anion gap metabolic acidosis is present), and examination of the serum potassium concentration (to characterize the disorder as hyperkalemic or hypokalemic in nature) is sufficient to make a presumptive diagnosis without more sophisticated studies. If this information proves insufficient, indirect estimates or direct measurement of urinary NH(4)(+) concentration, measurement of urine pH, and assessment of urinary HCO(3)(-) excretion can help in establishing the diagnosis. This review summarizes current information concerning the pathophysiology of this electrolyte pattern and the value and limitations of all of the diagnostic studies available. It also provides a systematic and cost-effective approach to the differential diagnosis of nongap metabolic acidosis.

Effects of pH on potassium: new explanations for old observations

Maintenance of extracellular K(+) concentration within a narrow range is vital for numerous cell functions, particularly electrical excitability of heart and muscle. Potassium homeostasis during intermittent ingestion of K(+) involves rapid redistribution of K(+) into the intracellular space to minimize increases in extracellular K(+) concentration, and ultimate elimination of the K(+) load by renal excretion. Recent years have seen great progress in identifying the transporters and channels involved in renal and extrarenal K(+) homeostasis. Here we apply these advances in molecular physiology to understand how acid-base disturbances affect serum potassium.

Effects of pH on potassium: new explanations for old observations

Maintenance of extracellular K(+) concentration within a narrow range is vital for numerous cell functions, particularly electrical excitability of heart and muscle. Potassium homeostasis during intermittent ingestion of K(+) involves rapid redistribution of K(+) into the intracellular space to minimize increases in extracellular K(+) concentration, and ultimate elimination of the K(+) load by renal excretion. Recent years have seen great progress in identifying the transporters and channels involved in renal and extrarenal K(+) homeostasis. Here we apply these advances in molecular physiology to understand how acid-base disturbances affect serum potassium.

The effect of oral sodium acetate administration on plasma acetate concentration and acid-base state in horses

Aim

Sodium acetate (NaAcetate) has received some attention as an alkalinizing agent and possible alternative energy source for the horse, however the effects of oral administration remain largely unknown. The present study used the physicochemical approach to characterize the changes in acid-base status occurring after oral NaAcetate/acetic acid (NAA) administration in horses.

Methods

Jugular venous blood was sampled from 9 exercise-conditioned horses on 2 separate occasions, at rest and for 24 h following a competition exercise test (CET) designed to simulate the speed and endurance test of 3-day event. Immediately after the CETs horses were allowed water ad libitum and either: 1) 8 L of a hypertonic NaAcetate/acetic acid solution via nasogastric tube followed by a typical hay/grain meal (NAA trial); or 2) a hay/grain meal alone (Control trial).

Results

Oral NAA resulted in a profound plasma alkalosis marked by decreased plasma [H⁺] and increased plasma [TCO₂] and [HCO₃^-] compared to Control. The primary contributor to the plasma alkalosis was an increased [SID], as a result of increased plasma [Na⁺] and decreased plasma [Cl^-]. An increased [A_tot], due to increased [PP] and a sustained increase in plasma [acetate], contributed a minor acidifying effect.

Conclusion

It is concluded that oral NaAcetate could be used as both an alkalinizing agent and an alternative energy source in the horse.

Is routine electrolyte testing necessary for diabetic patients who present to the emergency department with moderate hyperglycemia?

OBJECTIVES

No consensus standard is established for the workup of diabetic patients with moderate hyperglycemia [fingerstick glucose of 11.00-33.00 mmol/l (200-600 mg/dl)]. We measured the incidence of serious electrolyte abnormalities in patients with moderate hyperglycemia and attempted to identify a subset of these patients who can safely forego routine electrolyte testing.

METHODS

Prospective cohort study in two affiliated emergency departments.

INCLUSION CRITERIA

Moderate hyperglycemia.

EXCLUSION CRITERIA

new onset diabetes or renal failure. The composite outcome was defined as an abnormal potassium K >5.00 or <3.50 mmol/l or diabetic ketoacidosis. Univariate analyses were performed using t-test and Fisher's exact test (alpha=0.05, two-tails). Logistic regression models were generated to identify variables that could predict the composite outcome.

RESULTS

Three hundred and ninety-nine adults were enrolled (294 type II, 38% men). Mean age was 59+/-15 (20-97 years) years. The incidence of the composite outcome was 22% (95% confidence interval, 17.8-26.0%, n=86). The univariate analysis identified potassium-altering medications and insulin use as risk factors for the composite outcome. Logistic regression analysis identified potassium-altering medications as an increased risk (relative risk: 1.64, 95% confidence interval, 1.14-2.37) and use of oral hypoglycemics as a decreased risk (relative risk: 0.62, 95% confidence interval, 0.43-0.90) of the composite outcome. Cross-validation of the model demonstrated poor sensitivity (76%) and even worse accuracy (51%).

CONCLUSION

We failed to identify any subgroup of patients with moderate hyperglycemia who can be safely excluded from routine electrolyte testing. We recommend routine electrolyte testing for all moderate hyperglycemia patients in the emergency department.

Dietary K+ regulates apical membrane expression of maxi-K channels in rabbit cortical collecting duct

The cortical collecting duct (CCD) is a final site for regulation of K(+) homeostasis. CCD K(+) secretion is determined by the electrochemical gradient and apical permeability to K(+). Conducting secretory K(+) (SK/ROMK) and maxi-K channels are present in the apical membrane of the CCD, the former in principal cells and the latter in both principal and intercalated cells. Whereas SK channels mediate baseline K(+) secretion, maxi-K channels appear to participate in flow-stimulated K(+) secretion. Chronic dietary K(+) loading enhances the CCD K(+) secretory capacity due, in part, to an increase in SK channel density (Palmer et al., J Gen Physiol 104: 693-710, 1994). Long-term exposure of Ambystoma tigrinum to elevated K(+) increases renal K(+) excretion due to an increase in apical maxi-K channel density in their CDs (Stoner and Viggiano, J Membr Biol 162: 107-116, 1998). The purpose of the present study was to test whether K(+) adaptation in the mammalian CCD is associated with upregulation of maxi-K channel expression. New Zealand White rabbits were fed a low (LK), control (CK), or high (HK) K(+) diet for 10-14 days. Real-time PCR quantitation of message encoding maxi-K alpha- and beta(2-4)-subunits in single CCDs from HK animals was greater than that detected in CK and LK animals (P < 0.05); beta(1)-subunit was not detected in any CCD sample but was present in whole kidney. Indirect immunofluorescence microscopy revealed a predominantly intracellular distribution of alpha-subunits in LK kidneys. In contrast, robust apical labeling was detected primarily in alpha-intercalated cells in HK kidneys. In summary, K(+) adaptation is associated with an increase in steady-state abundance of maxi-K channel subunit-specific mRNAs and immunodetectable apical alpha-subunit, the latter observation consistent with redistribution from an intracellular pool to the plasma membrane.

Disorders of potassium homeostasis. Hypokalemia and hyperkalemia

This article reviews the diagnosis and management of clinical disorders of potassium balance, with particular attention to the critically ill patient. The normal regulation of potassium balance is reviewed as a background for understanding these disorders, followed by a discussion of the causes and management of hypo- and hyperkalemia. Practical guidelines are presented for acute and chronic management.

Use of base in the treatment of severe acidemic states

Severe acidemia (blood pH < 7.1 to 7.2) suppresses myocardial contractility, predisposes to cardiac arrhythmias, causes venoconstriction, and can decrease total peripheral vascular resistance and blood pressure, reduce hepatic blood flow, and impair oxygen delivery. These alterations in organ function can contribute to increased morbidity and mortality. Although it seemed logical to administer sodium bicarbonate to attenuate acidemia and therefore lessen the impact on cardiac function, the routine use of bicarbonate in the treatment of the most common causes of severe acidemia, diabetic ketoacidosis, lactic acidosis, and cardiac arrest, has been an issue of great controversy. Studies of animals and patients with these disorders have reported conflicting data on the benefits of bicarbonate, showing both beneficial and detrimental effects. Alternative alkalinizing agents, tris-hydroxymethyl aminomethane and Carbicarb, have shown some promise in studies of animals and humans, and reevaluation of these buffers in the treatment of severe acidemic states seems warranted. The potential value of base therapy in the treatment of severe acidemia remains an important issue, and further studies are required to determine which patients should be administered base therapy and what base should be used.

The importance of the refeeding syndrome

In this review we discuss the refeeding syndrome. This potentially lethal condition can be defined as severe electrolyte and fluid shifts associated with metabolic abnormalities in malnourished patients undergoing refeeding, whether orally, enterally, or parenterally. It can be associated with significant morbidity and mortality. Clinical features are fluid-balance abnormalities, abnormal glucose metabolism, hypophosphatemia, hypomagnesemia, and hypokalemia. In addition, thiamine deficiency can occur. We describe which patient groups are more at risk for this syndrome and the clinical management of the condition.

Potassium transport in the mammalian collecting duct

The mammalian collecting duct plays a dominant role in regulating K(+) excretion by the nephron. The collecting duct exhibits axial and intrasegmental cell heterogeneity and is composed of at least two cell types: collecting duct cells (principal cells) and intercalated cells. Under normal circumstances, the collecting duct cell in the cortical collecting duct secretes K(+), whereas under K(+) depletion, the intercalated cell reabsorbs K(+). Assessment of the electrochemical driving forces and of membrane conductances for transcellular and paracellular electrolyte movement, the characterization of several ATPases, patch-clamp investigation, and cloning of the K(+) channel have provided important insights into the role of pumps and channels in those tubule cells that regulate K(+) secretion and reabsorption. This review summarizes K(+) transport properties in the mammalian collecting duct. Special emphasis is given to the mechanisms of how K(+) transport is regulated in the collecting duct.

NaHCO(3) and KHCO(3) ingestion rapidly increases renal electrolyte excretion in humans

This paper describes and quantifies acute responses of the kidneys in correcting plasma volume, acid-base, and ion disturbances resulting from NaHCO(3) and KHCO(3) ingestion. Renal excretion of ions and water was studied in five men after ingestion of 3.57 mmol/kg body mass of sodium bicarbonate (NaHCO(3)) and, in a separate trial, potassium bicarbonate (KHCO(3)). Subjects had a Foley catheter inserted into the bladder and indwelling catheters placed into an antecubital vein and a brachial artery. Blood and urine were sampled in the 30-min period before, the 60-min period during, and the 210-min period after ingestion of the solutions. NaHCO(3) ingestion resulted in a rapid, transient diuresis and natriuresis. Cumulative urine output was 44 +/- 11% of ingested volume, resulting in a 555 +/- 119 ml increase in total body water at the end of the experiment. The cumulative increase (above basal levels) in renal Na(+) excretion accounted for 24 +/- 2% of ingested Na(+). In the KHCO(3) trial, arterial plasma K(+) concentration rapidly increased from 4.25 +/- 0.10 to a peak of 7.17 +/- 0.13 meq/l 140 min after the beginning of ingestion. This increase resulted in a pronounced, transient diuresis, with cumulative urine output at 270 min similar to the volume ingested, natriuresis, and a pronounced kaliuresis that was maintained until the end of the experiment. Cumulative (above basal) renal K(+) excretion at 270 min accounted for 26 +/- 5% of ingested K(+). The kidneys were important in mediating rapid corrections of substantial portions of the fluid and electrolyte disturbances resulting from ingestion of KHCO(3) and NaHCO(3) solutions.

Potassium and anaesthesia

Potassium is the principle intracellular ion, and its concentration and gradients greatly influence the electrical activity of excitable membranes. Because anaesthesia is so intimately involved with electrically active cells, potassium concentrations in surgical patients have received considerable attention in diagnostic and therapeutic applications. With the ongoing evolution in the indications for potassium, it is important to review the role of potassium in cellular activity, in storage and regulation, in diseases that alter potassium homeostasis, and in the therapeutic implications of perioperative alterations of potassium concentration. A rational approach to abnormal potassium values and the use of potassium in the operating room is sought, based on a physiological understanding of risks and benefits.

Detecting bacteriuria in a primary maternal and child health care programme

Urinary tract infection in pregnancy has not been adequately dealt with in developing countries, though its consequences are well recognised. This is primarily because of constraints on resources coupled with a lack of technological infrastructure. An evaluation of the Griess test for the mass screening of urinary tract infection among antenatal women was carried out prospectively using a case-control method. The Griess test was found to be a valid, reliable, and economical screening test for urinary tract infection which can be integrated into a primary maternal and child health care programme.

Potassium homeostasis and clinical implications

The clinical estimation of potassium balance generally depends on the level of serum potassium. Since the extracellular fluid contains only 2 percent of the total body potassium, it must be recognized that potassium deficits are usually large before significant hypokalemia occurs, whereas smaller surfeits of potassium will cause hyperkalemia. The total body potassium is regulated by the kidney in which distal nephron secretion of potassium into the urine is enhanced by aldosterone, alkalosis, adaptation to a high potassium diet, and delivery of increased sodium and tubular fluid to the distal tubule. However, the distribution of potassium between the intracellular and extracellular fluids can markedly affect the serum potassium level without a change in total body potassium. Cellular uptake of potassium is regulated by insulin, acid-base status, aldosterone, and adrenergic activity. Hypokalemia, therefore, may be caused by redistribution of potassium into cells due to factors that increase cellular potassium uptake, in addition to total body depletion of potassium due to renal, gastrointestinal, or sweat losses. Similarly hyperkalemia may be caused by redistribution of potassium from the intracellular to the extracellular fluid due to factors that impair cellular uptake of potassium, in addition to retention of potassium due to decreased renal excretion. An understanding of the drugs that affect potassium homeostasis, either by altering the renal excretion of potassium or by modifying its distribution, is essential to the proper assessment of many clinical potassium abnormalities. Both hypokalemia and hyperkalemia may cause asymptomatic electrocardiographic changes, serious arrhythmias, muscle weakness, and death. Hypokalemia has also been associated with several other consequences, including postural hypotension, potentiation of digitalis toxicity, confusional states, glucose intolerance, polyuria, metabolic alkalosis, sodium retention, rhabdomyolysis, intestinal ileus, and decreased gastric motility and acid secretion.

Intracellular potential and K+ activity in rat kidney proximal tubular cells in acidosis and K+ depletion

Techniques were developed for the measurement of intracellular potentials and potassium activities in rat proximal tubule cells using double barreled K+ liquid-ion-exchanger microelectrodes. After obtaining measurements of stable and reliable control values, the effects of K+ depletion and metabolic and respiratory acidosis on the intracellular potential and K+ activity in rat kidney proximal tubular cells were determined. At a peritubular membrane potential of -66.3 +/- 1.3 mV (mean +/- SE), intracellular K+ activity was 65.9 +/- 2.0 mEq/liter in the control rats. In metabolic acidosis [70 mg NH4Cl/100 g body wt) the peritubular membrane potential was significantly reduced to -47.5 +/- 1.9 mV, and cellular K+ activity to 53.5 +/- 2.0 mEq/liter. In contrast, in respiratory acidosis (15% CO2) the peritubular membrane potential was significantly lowered to -46.1 +/- 1.39 mV, but the cellular K+ activity was maintained at an almost unchanged level of 63.7 +/- 1.9 mEq/liter. In K+ depleted animals (6 weeks on low K+ diet), the peritubular membrane potential was significantly higher than in control animals, -74.8 +/- 2.1 mV, and cellular K+ activity was moderately but significantly reduced to 58.1 +/- 2.7 mEq/liter, Under all conditions studied, cellular K+ was above electrochemical equilibrium. Consequently, an active mechanism for cellular K+ accumulation must exist at one or both cell membranes. Furthermore, peritubular HCO3- appears to be an important factor in maintaining normal K+ distribution across the basolateral cell membrane.

Inefficacy of bicarbonate infusions on the course of postischaemic acute renal failure in the rat

Since bicarbonate has been reported to elicit fast recovery from acute renal failure in man, clearance studies were performed to compare the effects of sodium bicarbonate and saline infusion on renal function in postischaemic renal failure in the rat. In a first set of experiments the left kidney and in a second both kidneys were clamped for a period of 45 min and renal function monitored up to 210 min after release of the clamp. Glomerular filtration rate (ml/min) decreased following clamping from (mean values +/- SEM) 1.33 +/- 0.09 to 0.12 +/- 0.02 (saline) or 1.43 +/- 0.1 to 0.08 +/- 0.01 (bicarbonate) in the unilaterally clamped kidney and from 2.94 +/- 0.20 to 0.41 +/- 0.10 (saline) or 2.81 +/- 0.17 to 0.22 +/- 0.03 (bicarbonate) when both kidneys were clamped. Fractional excretion of water and sodium increased to a similar extent in saline and bicarbonate treated animals. Plasma potassium decreased (from 3.37 +/- 0.10 to 2.95 +/- 0.07 [unilaterally clamped kidneys] or from 5.2 +/- 0.4 to 4.4 +/- 0.2 [bilaterally clamped kidneys]) in bicarbonate treated but remained constant in saline treated animals, an effect not related to altered renal potassium excretion. In conclusion, no evidence was found that bicarbonate improves renal function in postischaemic renal failure.

Effect of acute metabolic acidemia on renal electrolyte transport in man

The effect of acute NH4C1-induced metabolic acidemia on renal electrolyte excretion was examined in nine healthy subjects during steady state water diuresis. Following oral NH4C1, venous pH and bicarbonate concentration declined significantly (p less than 0.01) while inulin and PAH clearances remained unchanged. Mean sodium excretion (UNaV) increased from 142 +/- 16 mueq/min (mean +/- SEM) to 310 +/- 49 mueq/min (p less than 0.01) at 8 hr without change in plasma aldosterone or renin levels. Urine flow remained unchanged while CH2O/(CH2O + CCl) declined significantly, suggesting that acute metabolic acidemia inhibits sodium transport in the distal nephron. Similar results were observed in two subjects with central diabetes insipidus. Three subjects restudied following the ingestion of an equivalent amount of chloride administered as NaCl, failed to demonstrate a significant rise in UNaV. UKV fell acutely from 91 +/- 13 to 45 +/- 5 mueq/min (p less than 0.001) despite an increase in serum potassium concentration. No change in plasma insulin was observed. UCaV rose from 66 +/- 15 to 143 +/- 18 microgram/min and fractional excretion of calcium increased from 0.55 +/- 0.13 to 1.24 +/- 0.21% (p less than 0.001). Total serum calcium fell slightly, but ionized calcium rose from 3.99 +/- 0.05 to 4.30 +/- 0.03 mg/dl (p less than 0.001). No change in nephrogenous cyclic (cAMP) excretion was observed. In conclusion, acute metabolic acidemia in man (1) inhibits sodium reabsorption in the distal nephron independent of changes in plasma aldosterone concentration, filtered chloride load, or volume expansion; (2) inhibits potassium excretion despite a rise in serum potassium concentration; and (3) inhibits tubular calcium reabsorption independetn of changes in parathyroid hormone (as reflected by urinary cAMP).

Potassium metabolism

In man, mechanisms for potassium excretion are complex and highly developed, while potassium conservation is potentially inadequate. Potassium balance is regulated by alterations in excretion in the distal renal tubule, where mineralocorticoid hormones and Na-K ATPase are the major regulating factors. The distribution of potassium across cell membranes is influenced by changes in acid-base status, by pancreatic hormones and by the autonomic nervous system. Potassium stimulates insulin and aldosterone secretion and increases Na-K ATPase in the distal nephron, so promoting its own redistribution or excretion. Emergency management of hyperkalaemia is best effected by promoting cell-entry of potassium, rather than renal excretion. The speed of replacement of deficits is always limited by the small extracellular potassium pool.

Potassium homeostasis

Potassium balance is regulated by appropriate changes in potassium excretion in the distal portion of the nephron. By contrast, potassium intake, absorption and proximal renal reabsorption do not show regulatory variation. Extracellular potassium concentration, which is a critical factor in membrane polarization, may at times vary in a direction opposite to total body content, because of altered distribution across cell membranes. Alterations in acid-base status frequently disturb homeostasis by altering potassium movement into cells, while insulin has an important regulatory effect on distribution. In general, the multiple renal and extra-renal mechanisms which prevent potassium overload are highly developed, while conservation is relatively ineffective. Consequently, depletion occurs more easily than spontaneous potassium overload. Homeostasis can be disturbed by renal impairment, excessive tissue breakdown, disturbances of acid-base balance, abnormal routes of loss, mineralocorticoid abnormalities and aberrations of sodium balance.