Frequency of Hypokalemia and its influence on chronic liver

disease related complications

SYNOPSIS

By

Dr. Saba Izhar

Postgraduate Resident (FCPS-Internal Medicine)

RTMC no.MED-2015-150-10797

Department of Internal Medicine,

Allama Iqbal memorial teaching hospital, Sialkot

SUPERVISOR

Dr. Tauqeer Ahmad

Professor of Internal Medicine

Allama Iqbal memorial teaching hospital
Sialkot
Introduction
Serum potassium concentration ranges widely in patients with Chronic liver disease (CLD).Both
hypokalemia and hyperkalemia may occur, but usually normokalemia is observed. Although there
is increased secretion of aldosterone, which leads to sodium and potassium secretion, distal sodium
delivery is decreased, thereby counteracting the stimulatory effect of aldosterone on potassium
secretion.1

Early studies revealed a 40% prevalence of hypokalemia in cirrhotic patients, irrespective of the
disease stage.2 Patients may be hypokalemic owing to a variety of reasons including low dietary
intake of potassium-rich foods or intracellular shifting of extracellular potassium in the setting of
alkalemia. Alternatively, patients may become hypokalemic, commonly in the setting of potassium
loss with diuretic use, hyperaldosteronism, magnesium depletion (as in the case of chronic
alcoholic liver disease), or vomiting.3 When considering the classic characteristics of cirrhosis
such as vomiting, malnourishment, hypomagnesemia, diarrhea, and diuretic use, the perfect
scenario is set for the activation of renal and extrarenal mechanisms of potassium wasting.4

Recognizing hypokalemia is important in the setting of liver disease as it is a known precipitating

factor for hepatic encephalopathy.5 Hayat et al6 reported decrease in total body potassium level in
30% to 40% in patients with liver disease irrespective of the stage of liver disease and pointed out
that hypokalemia can exacerbate HE by increasing renal ammonia genesis and systemic ammonia
levels. Hypokalemia also can result in muscle weakness, myocardial irritability, polyuria,
polydipsia and ileus. Exacerbation of hypokalemia was reported in a patient given terlipressin, a
vasopressin analog used in the treatment of bleeding varices. The patient developed urinary
potassium wasting and it was postulated that perhaps terlipressin potentiated the effect of
aldosterone on potassium secretion.7Chronic liver disease patients often have esophageal varices
secondary to portal hypertension and are thus liable to this potential exacerbation of hypokalemia
if treated with terlipressin. In Pakistan burden of CLD is very high secondary to high HBV and
HCV prevalence. To date, various studies have been carried out covering varying aspects of CLD.
There are enough local studies regarding impact of hyponatremia in CLD patients however not a
single local study could be found detailing the prevalence of hypokalemia and discussing its
impact on the course of disease so we set out to conduct this study.
Objective:

To determine the frequency of hypokalemia in patients with chronic liver disease

To determine the correlation b/w Hypokalemia and the frequency of various complications
seen in chronic liver disease.

Operational definition:

Chronic liver disease

A patient will be labelled as having chronic liver disease if patient is child class A or B had
any of the following complications: Ascites, hepatic encephalopathy, hepatorenal
syndrome, esophageal varices along with Abdominal Ultrasound indicating liver cirrhosis
or raised serum bilirubin (more than 2.5 times the upper limit of normal) and prolonged
prothrombin time (prolonged by more than 3 s)

Complications

Ascites: Patient will be labelled as having ascites if he is positive for shifting dullness or fluid
thrill along with a confirmatory ultrasonography finding.

Hepatic encephalopathy: The presence of hepatic encephalopathy will be diagnosed on the

basis of speech, personality, intellectual disorders, and asterixis

Spontaneous Bacterial Peritonitis: For SBP diagnosis, the number of polymorphonuclear

leucocytes (PMN) from the ascitic fluid obtained by paracentesis, must exceed 250
cells/mm and or positive bacteriological cultures showing single organism.

Variceal Bleed: history of hematemesis along with confirmatory endoscopic evidence for
esophageal or gastric varices.

Hypokalemia

Defined as serum potassium concentration of <3.5 mmol/L

 Materials and Methods

Study design: Descriptive cross-sectional study

Study setting: Department of medicine, Allama Iqbal memorial teaching hospital (AIMTH), Sialkot

Study duration: 6 months after approval of synopsis

Sample size: To determine the sample size, we assumed a confidence level of 95%, with a
precision of 10%. Using a mean prevalence 40% hypokalemia6 in our group of cirrhotic
patients on the basis of previous data; the sample size comes out to be 120

Sampling technique Non probability consecutive sampling

Sample selection
Inclusion criteria
1. Both males and females
2. Patients aged 25-70 years of age
3. Diagnosis of cirrhosis confirmed by clinical, biochemical, and ultrasonographic findings
4. Patients having Hepatitis B or C

Exclusion criteria
1. Patients with hepatocellular carcinoma
2. Patients using diuretics within a 1-month period before admission
3. Patients with cholestatic liver diseases, namely primary biliary cirrhosis (PBC) and primary
sclerosing cholangitis (PSC)

Data Collection
After approval of synopsis, 250 consecutive cases of CLD presenting with complications in the
medicine ward will be offered to enroll in the study. The purpose of the study will be explained in
detail to all the patients and an informed consent will be taken in each case. Ultrasonography, LFTs
and other baseline investigations will be done to evaluate for hepatic decompensation. Serum
electrolytes (for hypokalemia) will be done in turn for every patient admitted. The relevant data
will be collected in a structured proforma containing background information like age, sex, serum
potassium, child class and frequency of different complications observed etc. The patients will be
followed on day to day basis to make sure all the complications that develop during their stay are
documented.
Data Analysis

Data will be analyzed using SPSS version 21.Mean with standard deviation will be calculated
for quantitative variables like Age and Serum potassium levels. In case of qualitative variables
like gender, presence of hypokalemia and different complications seen during liver cirrhosis;
frequency and percentages will be calculated. Data will be depicted in tables and graphs.
Regression analysis would be done and spearman pearson correlation coefficient will be
calculated to check for correlation between hypokalemia and frequency of various
complications seen in CLD.

References
1. Jimnez JV, Carrillo-Prez DL, Rosado-Canto R, Garca-Jurez I, Torre A, Kershenobich
D, Carrillo-Maravilla E. Electrolyte and AcidBase Disturbances in End-Stage Liver
Disease: A Physiopathological Approach. Digestive Diseases and Sciences. 2017 May
13:1-7.
2. Casey TH, Summerskill WH, Bickford RG, Rosevear JW. Body and serum potassium in
liver disease. II. Relationships to arterial ammonia, blood pH, and hepatic
coma.Gastroenterology.1965;48:208215.
3. Adewale A, Ifudu O. Kidney injury, fluid, electrolyte and acid-base abnormalities in
alcoholics. Nigerian medical journal: journal of the Nigeria Medical Association. 2014
Mar;55(2):93.
4. Unwin RJ, Luft FC, Shirley DG. Pathophysiology and management of hypokalemia: a
clinical perspective. Nat Rev Nephrol. 2011;7:7584.
5. Helmy A, Hussein M, Saleh SA, Mostafa AS, Abdella HM, Elaidy D. Serum Electrolytes:
a simple predictive test for grading severity of overt hepatic encephalopathy. International
Journal. 2015;3(7):1342-51.
6. Hayat A, Shaikh N, and Memon F. Identification of Precipitating Factors in Hepatic
Encephalopathy Patients at Liaquat University Hospital Jamshoro, World Applied
Sciences Journal 2010; 8 : 661-6
7. Stephan F, Paillard F: Terlipressin-exacerbated hypokalaemia. Lancet 351:1249-1250,
1998
 PROFORMA

Age: Serial no.

Sex: Child class:

Serum Potassium level: . High / Normal / Low

Hypokalemia: Yes / No

LFTs
ALT: AST: ALP: Serum Bilirubin:

Complications YES / NO

Ascites

Hepatic encephalopathy

Varix bleeding

Hepatorenal syndrome

Hepatic Hydrothorax

Esophageal varix

Spontaneous bacterial peritonitis

Intractable ascites
 CONSENT FORM

I Mr./Mrs. ____________________________ give consent to Dr. Saba Izhar (FCPS-Internal

Medicine Resident), Allama Iqbal memorial teaching hospital, Sialkot for my participation in the

study Frequency of Hypokalemia and its influence on chronic liver disease related

complications. He has explained me in detail the importance of this study.

Dated: _____________ Signature _______________

The Director, Research, Training and Monitoring cell,

College of Physicians and Surgeons, Pakistan,

7 Central Street Phase-II,

th

Defense Housing Authority, Karachi 75500.

Subject: SUBMISSION OF SYNOPSIS

Dear Sir/ Madam,

Enclosed is the research protocol entitled:

"Frequency of Hypokalemia and its influence on chronic
liver disease related complications"

Prepared by: Dr. Saba Izhar

RTMC Registration No: MED-2014-150-10797.

Department: Department of Internal Medicine

Name of Supervisor: Dr. Tauqeer Ahmad

Designation: Professor

Name of training institute: Allama Iqbal memorial teaching hospital, Sialkot

Date of submission:

The Director, Research, Training and Monitoring cell,

College of Physicians and Surgeons, Pakistan,

7 Central Street Phase-II,

th

Defense Housing Authority, Karachi 75500.

Subject: Non-duplication Certificate

Respected Madam/ Sir,

I want to submit the non-duplication Certificate for my synopsis titled:

"Frequency of Hypokalemia and its influence on chronic liver
disease related complications
Please note that this study has never been done before at Department of Internal Medicine,
Allama Iqbal memorial teaching hospital, Sialkot and it will be done for the first time in this
department as Department of Medicine Allama Iqbal memorial teaching hospital, Sialkot

is fully recognized for four years training by the CPSP.

My RTMC allocated registration number- MED-2015-150-10797.

Trainee's Signature

Name of Supervisor: Dr. Tauqeer Ahmad

Designation: Professor

Department: Department of Internal Medicine

Institution: Allama Iqbal memorial teaching hospital, Sialkot

Supervisors signature: