Differential Diagnosis: Hyperkalemia

Julie Allen, BVMS, MS, MRCVS, DACVIM (SAIM), DACVP (Clinical), Durham, North Carolina

ArticleLast Updated November 20191 min readPeer Reviewed
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Following are differential diagnoses, listed in order of likelihood,* for patients presented with hyperkalemia.

  • Pseudohyperkalemia

    • Potassium EDTA contamination

    • Hemolysis (in vitro or in vivo) or RBC leakage in certain Asian breeds that have high-potassium erythrocytes (eg, Shiba Inu) or any breed with marked reticulocytosis

    • Thrombocytosis and, possibly, marked leukocytosis (eg, leukemia)

    • Contamination with high-potassium fluids due to collection from improperly flushed IV line

  • Urethral (or, less likely, bilateral ureteral) obstruction

  • Acute kidney injury (oliguric/anuric)

  • End-stage kidney disease (oliguric/anuric) 

  • Uroabdomen

  • Hypoadrenocorticism

  • Chronic kidney disease

  • Drug-induced/iatrogenic cause; usually only in combination with other issues (eg, decreased renal function). May decrease renal excretion and/or affect transcellular movement

    • ACE inhibitors (eg, enalapril)

    • Aldosterone antagonists (eg, spironolactone)

    • Angiotensin II-receptor blockers (eg, telmisartan) 

    • NSAIDs

    • Cyclosporine or tacrolimus

    • Trimethoprim/sulfonamides (trimethoprim decreases potassium excretion in the distal renal tubule) 

    • Trilostane

    • Mitotane

    • Heparin

    • Total parenteral nutrition

    • Digoxin

    • β blockers

  • Metabolic (rarely respiratory) acidosis

  • Insulin deficiency

  • Massive tissue damage (eg, rhabdomyolysis, reperfusion injury after thromboembolic event, gastric torsion)

  • Trichuris vulpis infection 

  • Severe malabsorption

  • Salmonellosis

  • Perforated duodenal ulcer 

  • Chylous effusions following drainage

  • Peritoneal effusion (cats)

  • Hyporeninemic hypoaldosteronism 

  • Late pregnancy (greyhounds) 

  • Acute tumor lysis syndrome

  • Strenuous exercise 

  • Hyperkalemic periodic paralysis

  • Increased intake

    • Excessive potassium supplementation in IV fluids

    • High-dose potassium penicillin

*Order of likelihood is based on the author’s personal experience.