The effects of potassium depletion and supplementation on blood pressure: a clinical review

Aldosterone: Renal Action and Physiological Effects

Aldosterone exerts profound effects on renal and cardiovascular physiology. In the kidney, aldosterone acts to preserve electrolyte and acid-base balance in response to changes in dietary sodium (Na+ ) or potassium (K+ ) intake. These physiological actions, principally through activation of mineralocorticoid receptors (MRs), have important effects particularly in patients with renal and cardiovascular disease as demonstrated by multiple clinical trials. Multiple factors, be they genetic, humoral, dietary, or otherwise, can play a role in influencing the rate of aldosterone synthesis and secretion from the adrenal cortex. Normally, aldosterone secretion and action respond to dietary Na+ intake. In the kidney, the distal nephron and collecting duct are the main targets of aldosterone and MR action, which stimulates Na+ absorption in part via the epithelial Na+ channel (ENaC), the principal channel responsible for the fine-tuning of Na+ balance. Our understanding of the regulatory factors that allow aldosterone, via multiple signaling pathways, to function properly clearly implicates this hormone as central to many pathophysiological effects that become dysfunctional in disease states. Numerous pathologies that affect blood pressure (BP), electrolyte balance, and overall cardiovascular health are due to abnormal secretion of aldosterone, mutations in MR, ENaC, or effectors and modulators of their action. Study of the mechanisms of these pathologies has allowed researchers and clinicians to create novel dietary and pharmacological targets to improve human health. This article covers the regulation of aldosterone synthesis and secretion, receptors, effector molecules, and signaling pathways that modulate its action in the kidney. We also consider the role of aldosterone in disease and the benefit of mineralocorticoid antagonists. © 2023 American Physiological Society. Compr Physiol 13:4409-4491, 2023.

Genotypic variation in Na, K and their ratio in 45 commercial cultivars of Indian tropical onion: A pressing need to reduce hypertension among the population

The intake of diets with higher sodium (Na) and lower potassium (K) has been considered a leading factor for the development of hypertension (HTN). Majority of junk, processed and packaged food have higher Na contents. To counter the effects of diet on HTN, the identification of high K/Na ratio plant-based food is needed. Among fruits and vegetables, onion could be the ideal option since it contains high K content. Keeping this in mind, 45 commercially well adapted short day Indian onion cultivars were evaluated for K and Na content and their ratio to isolate suitable cultivars to prevent HTN in the Indian population. The data suggested wide variation among the genotypes for K, Na, and K/Na ratio ranging from 490.2 ± 17.0 to 9160.0 ± 96.7 mg/kg on dry matter basis, 52.7 ± 3.0 to 458.2 ± 61.7 mg/kg on dry matter basis and 3.1 ± 0.7 to 109.5 ± 17.3, respectively. The K content was recorded as significantly highest in the yellow-coloured bulb variety "Arka Pitamber" (9160.1 ± 96.7) followed by Pusa Sona (7933.2 ± 292.8). On the other hand, minimal K was assessed in the white-coloured bulb variety "Agrifound White" (490.3 ± 17.0) followed by Udaipur Local (732.9 ± 93.4). Twelve cultivars exhibited > 7000 mg K content, while nine cultivars recorded < 1500 mg. On the contrary, Na was recorded as significantly highest in the dark-red-coloured bulbs and the lowest in white bulbs. Furthermore, it was determined that there was a more than 35-fold difference observed between the highest (109.5) and lowest (3.1) K/Na ratio in the bulbs of tested cultivars. Cluster analysis revealed three major groups comprising of 23, 13 and 9 genotypes. This information could form the base for public health, food and onion researchers to design suitable cultivars to prevent HTN as a population-wide approach. The next century is going to be food-based for the amelioration of human diseases in a sustainable way without any after-effects on the human body.

Roles of renal ammonia metabolism other than in acid-base homeostasis

The importance of renal ammonia metabolism in acid-base homeostasis is well known. However, the effects of renal ammonia metabolism other than in acid-base homeostasis are not as widely recognized. First, ammonia differs from almost all other solutes in the urine in that it does not result from arterial delivery. Instead, ammonia is produced by the kidney, and only a portion of the ammonia produced is excreted in the urine, with the remainder returned to the systemic circulation through the renal veins. In normal individuals, systemic ammonia addition is metabolized efficiently by the liver, but in patients with either acute or chronic liver disease, conditions that increase the addition of ammonia of renal origin to the systemic circulation can result in precipitation and/or worsening of hyperammonemia. Second, ammonia appears to serve as an intrarenal paracrine signaling molecule. Hypokalemia increases proximal tubule ammonia production and secretion as well as reabsorption in the thick ascending limb of the loop of Henle, thereby increasing delivery to the renal interstitium and the collecting duct. In the collecting duct, ammonia decreases potassium secretion and stimulates potassium reabsorption, thereby decreasing urinary potassium excretion and enabling feedback correction of the initiating hypokalemia. Finally, the stimulation of renal ammonia metabolism by hypokalemia may contribute to the development of metabolic alkalosis, which in turn can stimulate NaCl reabsorption and contribute to the intravascular volume expansion, increased blood pressure and diuretic resistance that can develop with hypokalemia. The evidence supporting these novel non-acid-base roles of renal ammonia metabolism is discussed in this review.

Acid-base and electrolyte abnormalities in heart failure: pathophysiology and implications

Electrolyte and acid–base abnormalities are a frequent and potentially dangerous complication in subjects with congestive heart failure. This may be due either to the pathophysiological alterations present in the heart failure state leading to neurohumoral activation (stimulation of the renin–angiotensin–aldosterone system, sympathoadrenergic stimulation), or to the adverse events of therapy with diuretics, cardiac glycosides, and ACE inhibitors. Subjects with heart failure may show hyponatremia, magnesium, and potassium deficiencies; the latter two play a pivotal role in the development of cardiac arrhythmias. The early identification of these alterations and the knowledge of the pathophysiological mechanisms are very useful for the management of these patients.

Dietary potassium and the renal control of salt balance and blood pressure

Dietary potassium (K(+)) intake has antihypertensive effects, prevents strokes, and improves cardiovascular outcomes. The underlying mechanism for these beneficial effects of high K(+) diets may include vasodilation, enhanced urine flow, reduced renal renin release, and negative sodium (Na(+)) balance. Indeed, several studies demonstrate that dietary K(+) intake induces renal Na(+) loss despite elevated plasma aldosterone. This review briefly highlights the epidemiological and experimental evidences for the effects of dietary K(+) on arterial blood pressure. It discusses the pivotal role of the renal distal tubule for the regulation of urinary K(+) and Na(+) excretion and blood pressure and highlights that it depends on the coordinated interaction of different nephron portions, epithelial cell types, and various ion channels, transporters, and ATPases. Moreover, we discuss the relevance of aldosterone and aldosterone-independent factors in mediating the effects of an altered K(+) intake on renal K(+) and Na(+) handling. Particular focus is given to findings suggesting that an aldosterone-independent downregulation of the thiazide-sensitive NaCl cotransporter significantly contributes to the natriuretic and antihypertensive effect of a K(+)-rich diet. Last but not least, we refer to the complex signaling pathways enabling the kidney to adapt its function to the homeostatic needs in response to an altered K(+) intake. Future work will have to further address the underlying cellular and molecular mechanism and to elucidate, among others, how an altered dietary K(+) intake is sensed and how this signal is transmitted to the different epithelial cells lining the distal tubule.

Chronic renal disease progression: treatment strategies and potassium intake

Disordered potassium homeostasis is a common complication of chronic kidney disease and traditional management focuses on restricting potassium intake to avoid hyperkalemia. Permissive potassium intake carries the risk of hyperkalemia and hyperphosphatemia, and possibly may contribute to the development of uremic neuropathy. Excessive potassium restriction and removal by dialysis carries the risk of worsened chronic hypertension, intradialytic hypotension, renal fibrosis and cyst formation, and ventricular arrhythmias. Cohort studies have associated both hypokalemia and hyperkalemia with increased mortality in CKD. A single study of potassium intake in hemodialysis patients found increased intake associated with increased mortality despite adjustment for serum potassium concentration. We recommend avoiding mandatory potassium restriction in early chronic kidney disease. We endorse routine potassium restriction in advanced chronic kidney disease requiring hemodialysis and close monitoring of serum potassium concentration in any patients receiving renin-angiotensin-aldosterone system blockers.

Endocrine and hypertensive disorders of potassium regulation: primary aldosteronism

The identification of primary aldosteronism as a common cause of resistant hypertension is a significant advance in our ability to care for patients with hypertension. Primary aldosteronism is common, and when unrecognized is associated with an increased incidence of adverse cardiovascular outcomes. Identification of primary aldosteronism is based on use of the plasma aldosterone level, plasma renin activity, and the aldosterone:renin ratio. Differentiation between unilateral and bilateral autonomous adrenal aldosterone production then guides further therapy, with use of mineralocorticoid-receptor blockers for patients with bilateral autonomous adrenal aldosterone production and laparoscopic adrenalectomy for patients with unilateral autonomous aldosterone production. In this review, we discuss in detail the pathogenesis of primary aldosteronism-induced hypertension and potassium disorders, the evaluation of the patient with suspected primary aldosteronism, and the management of primary aldosteronism, both through medications and surgery.

Gut sensing of potassium intake and its role in potassium homeostasis

Extracellular K(+) homeostasis has been explained by feedback mechanisms in which changes in extracellular K(+) concentration drive renal K(+) excretion directly or indirectly via stimulating aldosterone secretion. However, this cannot explain meal-induced kaliuresis, which often occurs without increases in plasma K(+) or aldosterone concentrations. Recent studies have produced evidence supporting a feedforward control in which gut sensing of dietary K(+) increases renal K(+) excretion (and extrarenal K(+) uptake) independent of plasma K(+) concentrations, namely, a gut factor. This review focuses on these new findings and discusses the role of gut factor in acute and chronic regulation of extracellular K(+) as well as in the beneficial effects of high K(+) intake on the cardiovascular system.

Dietary potassium: a key mediator of the cardiovascular response to dietary sodium chloride

Potassium and sodium share a yin/yang relationship in the regulation of blood pressure (BP). BP is directly associated with the total body sodium and negatively correlated with the total body potassium. Epidemiologic, experimental, and clinical studies have shown that potassium is a significant regulator of BP and further improves cardiovascular outcomes. Hypertensive cardiovascular damage, stroke, and stroke-related death are accelerated by salt intake but might be curbed by increasing dietary potassium intake. The antihypertensive effect of potassium supplementation appears to occur through several mechanisms that include regulation of vascular sensitivity to catecholamines, promotion of natriuresis, limiting plasma renin activity, and improving endothelial function. In the absence of chronic kidney disease, the combined evidence suggests that a diet rich in potassium content serves a vasculoprotective function, particularly in the setting of salt-sensitive hypertension and prehypertension.

The importance of potassium in managing hypertension

Dietary potassium intake has been demonstrated to significantly lower blood pressure (BP) in a dose-responsive manner in both hypertensive and nonhypertensive patients in observational studies, clinical trials, and several meta-analyses. In hypertensive patients, the linear dose-response relationship is a 1.0 mm Hg reduction in systolic BP and a 0.52 mm Hg reduction in diastolic BP per 0.6 g per day increase in dietary potassium intake that is independent of baseline potassium deficiency. The average reduction in BP with 4.7 g (120 mmol) of dietary potassium per day is 8.0/4.1 mm Hg, depending race and on the relative intakes of other minerals such as sodium, magnesium, and calcium. If the dietary sodium chloride intake is high, there is a greater BP reduction with an increased intake of dietary potassium. Blacks have a greater decrease in BP than Caucasians with an equal potassium intake. Potassium-induced reduction in BP significantly lowers the incidence of stroke (cerebrovascular accident, CVA), coronary heart disease, myocardial infarction, and other cardiovascular events. However, potassium also reduces the risk of CVA independent of BP reductions. Increasing consumption of potassium to 4.7 g per day predicts lower event rates for future cardiovascular disease, with estimated decreases of 8% to 15% in CVA and 6% to 11% in myocardial infarction.

The effect of nutrition on blood pressure

The incidence and severity of hypertension are affected by nutritional status and intake of many nutrients. Excessive energy intake and obesity are major causes of hypertension. Obesity is associated with increased activity of the renin-angiotensin-aldosterone and sympathetic nervous systems, possibly other mineralcorticoid activity, insulin resistance, salt-sensitive hypertension and excess salt intake, and reduced kidney function. High sodium chloride intake strongly predisposes to hypertension. Increased alcohol consumption may acutely elevate blood pressure. High intakes of potassium, polyunsaturated fatty acids, and protein, along with exercise and possibly vitamin D, may reduce blood pressure. Less-conclusive studies suggest that amino acids, tea, green coffee bean extract, dark chocolate, and foods high in nitrates may reduce blood pressure. Short-term studies indicate that specialized diets may prevent or ameliorate mild hypertension; most notable are the Dietary Approaches to Stop Hypertension (DASH) diet, which is high in fruits, vegetables, and low-fat dairy products, and the DASH low-sodium diet. Long-term compliance to these diets remains a major concern.

Characterization of the rabbit HKalpha2 gene promoter

The HKalpha2 gene directs synthesis of the HKalpha2 subunit of the H(+), K(+)-ATPase. In the kidney and colon, the gene is highly expressed and is thought to play a role in potassium (K(+)) conservation. The rabbit has been an important experimental system for physiological studies of ion transport in the kidney, so the rabbit HKalpha2 gene has been cloned and characterized. The genomic clones and the previously reported HKalpha2a and HKalpha2c subunit cDNAs provided a means to address several issues regarding the structure and expression of the HKalpha2 gene. First, the genomic organization established that the rabbit HKalpha2 gene was unambiguously homologous to the mouse HKalpha2 gene and the human ATP1AL1 gene. Second, the mapping of the transcription start site for the alternate transcript, HKalpha2c, confirmed that it was an authentic rabbit transcript. Finally, isolation of DNA from the 5' end of the HKalpha2 gene enabled us to initiate studies on its regulation in the rabbit cortical collecting duct. The promoter and two putative negative regulatory regions were identified and the effect of cell confluency on gene expression was studied.

Role of muscle in regulating extracellular [K+]

There is a positive association between diets rich in potassium, control of blood pressure, and prevention of stroke. Extracellular [K+] is regulated closely to maintain normal membrane excitability by the concerted regulatory responses of muscle and kidney. Although kidney is responsible for ultimately matching K+ output to K+ intake each day, muscle contains more than 90% of the body's K+ and can buffer changes in extracellular fluid [K+] by either acutely taking up extracellular fluid K+ or releasing intracellular fluid K+ from muscle. It long has been assumed that the changes in muscle K+ transport are a function of sodium pump (Na,K-adenosine triphosphatase [Na, K-ATPasel]) abundance, especially that of the alpha2 isoform, which predominates in skeletal muscle. To test the physiologic significance of changes in muscle Na,K-ATPase expression, we developed the K+ clamp, which measures insulin-stimulated cellular K+ uptake in vivo in the conscious rat. By using the K+ clamp we discovered that significant insulin resistance to cell K+ uptake occurs as follows: (1) early in K+ deprivation before a decrease in muscle sodium pump pool size, and (2) during glucocorticoid treatment, which increases muscle Na,K-ATPase alpha2 levels greater than 50%. We also discovered that adaptation of renal and extrarenal K+ handling to altered K+ balance often occurs without changes in plasma [K+], supporting a feedforward mechanism involving K+ sensing in the splanchnic bed and adjustment of K+ handling. These findings establish the advantage of combining molecular analyses of Na,K-ATPase expression and activity with systems analyses of cellular K+ uptake and excretion in vivo to reveal regulatory mechanisms operating to control K+ homeostasis.

Increased dietary potassium and magnesium attenuate experimental volume dependent hypertension possibly through endogenous sodium-potassium pump inhibitor

We and others have shown that inhibition of cardiovascular muscle (CVM) cell Na+,K-ATPase activity (NKPTA) due to increased level of endogenous sodium potassium pump inhibitor (SPI) is involved in the mechanism of volume expanded (VE) experimental and human essential hypertension (HT). Since diets fortified with very high potassium (K) or very high magnesium (Mg) decrease blood pressure (BP), we have examined the effect of a moderate increase in dietary K alone and a moderate increase in dietary K and Mg on plasma levels of SPI, CVM cell NKPTA, and BP in reduced renal mass (RRM)-salt HT rats, a classical model of VE HT. Seventy Percent-RRM rats were divided in four dietary groups, (1) Na free and normal K and Mg (0Na-K-Mg); (2) normal Na, K and Mg (Na-K-Mg); (3) normal Na and high K (2 x normal), and normal Mg (Na-2K-Mg); and (4) normal Na and high K (2 x normal), and high Mg (2 x normal) (Na-2K-2Mg). As expected, compared to control 0Na-K-Mg rats, Na-K-Mg rats developed HT. Blood pressure increased significantly less in Na-2K-Mg rats whereas, BP did not increase in Na-2K-2Mg rats. Hypertension in NA-K-Mg rats was associated with an increase in plasma SPI and digitalis like factor (DIF) and a decrease in renal and myocardial NKPTA. However, doubling the Mg along with K in the diet (Na-2K-2Mg) normalized SPI and DIF and increased myocardial and renal NKPTA, compared to control 0Na-K-Mg rats. Also, compared to 0Na-K-Mg rats, water consumption, urine excretion, urinary sodium excretion urinary potassium excretion (U(Na)V), and (U(K)V) increased in the other three groups, more so in Na-2K-2Mg rats. These data show that K and Mg have additive effects in preventing an increase in SPI, thus probably preventing the BP increase in RRM rats.

The role of growth factors and ammonia in the genesis of hypokalemic nephropathy

Hypokalemia is a common electrolyte abnormality encountered in clinical practice. It can be identified in an asymptomatic patient undergoing routine electrolyte screening or can manifest itself as part of a number of functional abnormalities in a variety of organs and systems. Among the most commonly recognized complications are profound effects on the cardiovascular and neuromuscular systems, together with abnormalities in acid-base regulation. In humans, hypokalemia contributes to the development of hypertension and predisposes patients to a variety of ventricular arrhythmias, including ventricular fibrillation. Commonly recognized neuromuscular complications include weakness, cramping, and myalgia. Hypokalemia also affects systemic acid-base homeostasis by interfering with multiple components of the renal acid-base regulation and is a frequent cause of metabolic alkalosis. Less known, however, is the role of potassium deficiency in causing progressive renal failure. In animals, potassium deficiency stimulates renal enlargement because of cellular hypertrophy and hyperplasia. If potassium deficiency persists, interstitial infiltrates appear in the renal interstitial compartment, and eventually tubulointerstitial fibrosis develops. In humans, longstanding hypokalemia is associated with the development of renal cysts, chronic interstitial nephritis, and progressive loss of renal function, the so-called hypokalemic nephropathy. This review focuses on the potential mechanisms involved in the development of the hypokalemic nephropathy with emphasis on the role of ammonia and growth factors in its pathogenesis.

Blood pressure responses to high-calcium skim milk and potassium-enriched high-calcium skim milk

OBJECTIVE

This study was designed to evaluate the effect of high-calcium skim milk or potassium-enriched high-calcium skim milk on blood pressure compared with nonenriched skim milk.

DESIGN

This was a randomized double-blind controlled trial. Each milk intervention lasted for 4 weeks, with a minimum of 4 weeks of wash-out between interventions.

METHODS

We recruited 38 healthy people, aged over 40 years, to take part in a double-blind, randomized, controlled cross-over study. We asked them to replace their usual liquid milk with two servings per day of skim milk (control), high-calcium skim milk or potassium-enriched high-calcium skim milk. We measured office blood pressures (seated and standing) at the start and after 2 and 4 weeks of milk intervention and we measured daytime ambulatory blood pressures at the start and after 4 weeks of milk intervention. Each milk intervention was interspaced by a 4-week interval.

RESULTS

Office systolic blood pressure (standing) decreased from 127 +/- 16 to 124 +/- 16 mmHg (P<0.05) after 4 weeks of skim milk and from 130 +/- 18 to 126 +/- 17 mmHg (P<0.05) after 4 weeks of high calcium skim milk. After 4 weeks of consuming the potassium-enriched high-calcium milk, systolic blood pressure decreased from 125 +/- 18 to 117 +/- 16 mmHg (P<0.001) seated, and from 130 +/- 16 to 122 +/- 15 mmHg (P<0.001) standing. There were no significant changes in office diastolic blood pressure after any milk. There was no change in ambulatory blood pressure after either skim milk or high-calcium skim milk. After 4 weeks of potassium-enriched high-calcium milk, ambulatory daytime systolic blood pressure decreased from 138 +/- 13 to 135 +/- 11 mm Hg (P<0.05) and daytime diastolic blood pressure decreased from 80 +/- 8 to 78 +/- 9 mmHg (P<0.05).

CONCLUSIONS

High-calcium milk enriched with potassium has a small hypotensive effect in healthy people aged over 40 years.

Mechanism of antihypertensive effect of dietary potassium in experimental volume expanded hypertension in rats

Dietary potassium supplementation lowers blood pressure (BP) and attenuates complications in hypertensive subjects, particularly those with the low renin volume expanded (LRVE) variety. We and others have shown that the plasma level of a digitalis like substance (DLS) is elevated in this type of hypertension. We therefore, examined the effect of increases in dietary potassium on the plasma level of endogenous DLS, myocardial and renal Na+, K+-ATPase (NKA) activities, BP, and renal excretory function in reduced renal mass (RRM)-salt hypertension in the rat, a classical model of LRVE hypertension. 70% RRM rats were divided in 4 groups, namely those consuming: 1) a sodium free and normal potassium (1.3% as KCl) diet (RRM-0 Na), 2) a normal sodium and normal potassium diet (RRM-NaK), 3) a normal sodium and high potassium (2 X normal) diet (RRM-Na2K), and 4) a normal sodium and 4 times normal potassium diet (RRM-Na4K). At the end of 4 weeks of dietary treatment, direct BP was recorded, plasma level of DLS determined by bioassay and with a radioimmunoassay for digoxin (DIF) and myocardial and renal NKA activities were measured. As expected, compared to RRM-0Na rats, RRM-NaK rats developed hypertension. BP increased significantly less in RRM-Na2K, whereas BP did not increase in RRM-Na4K rats. Hypertension in RRM-NaK rats was associated with an increase in plasma DLS and DIF and decrease in renal and myocardial NKA activities. DLS was increased (DIF was not changed) and myocardial NKA also decreased in rats consuming double potassium. However, quadrupling potassium in the diet (RRM-Na4K) normalized DLS and DIF and increased myocardial and renal NKA activities, compared to RRM-0Na rats. Also compared to RRM-0Na, water consumption, urinary volume excretion, sodium, and potassium increased in the other 3 groups, more so in RRM-Na4K rats. These data show that quadrupling the potassium in the diet prevents the BP increase in RRM rats and this is associated with diuresis/natriuresis and normalization of DLS, perhaps because the diuresis/natriuresis normalizes blood volume.

Potassium augments vascular relaxation mediated by nitric oxide in the carotid arteries of hypertensive Dahl rats

The present study was designed to determine whether and how potassium supplementation improves the endothelial function of carotid arteries of hypertensive Dahl rats. Dahl salt-sensitive rats were fed a high sodium diet, a high sodium plus potassium-supplemented diet, a normal rat chow, or a potassium-supplemented diet for 4 weeks. High sodium intake significantly increased the blood pressure, which was attenuated by potassium supplementation. The isometric tension of rat-isolated carotid rings was measured. In norepinephrine-precontracted rings, the relaxation in response to acetylcholine, adenosine 5'-diphosphate (ADP), and isoproterenol were significantly attenuated in hypertensive Dahl rats, which was improved by potassium supplementation. Pretreatment with N(G)-nitro-L-arginine methyl ester blocked the responses to acetylcholine and ADP, and eliminated the difference in relaxation in response to isoproterenol. The endothelium-independent relaxation in response to forskolin, S-nitroso-N-acetyl-DL-penicillamine, and sodium nitroprusside was significantly attenuated in hypertensive Dahl rats, which was not affected by potassium supplementation. The results indicated that salt-induced hypertension was associated with marked alterations in the endothelial and vascular smooth muscle functions of the carotid arteries of Dahl rats. Potassium supplementation ameliorated the endothelial but not the smooth muscle function. The protective effect of potassium appeared to be achieved through increased endothelial nitric oxide production. The current studies, in conjunction with our recent studies on nitric oxide synthase activity in the kidney, strongly suggest that potassium attenuates development of hypertension by increasing nitric oxide production in Dahl rats.