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East Florida


HCA Florida Aventura Hospital


Emergency Medicine

Document Type


Publication Date



hyperkalemia, water-electrolyte imbalance


Emergency Medicine | Medicine and Health Sciences | Nutritional and Metabolic Diseases


Introduction: Hyperkalemia is a commonly presenting electrolyte derangement, usually secondary to chronic kidney disease or medication use. In one retrospective study by Singer et al of 100,260 Emergency Department (ED) patient visits it was found that 1 in 11 ED patients presented with a potassium derangement (1). Patients can present in various ways, from asymptomatic to life threatening arrhythmias. A less commonly recognized cause of hyperkalemia is dietary substitutions for everyday table salt. Ayach et al reported a patient with potassium of 9.8 mmol/L secondar to dietary substitutions but with acute kidney injury and ACE inhibitor use (2). Through a detailed literature review, we found that it is uncommon for patients to present with hyperkalemia with normal renal function and predisposing medications to hyperkalemia. The case we are presenting is that of a patient with normal kidney function, and no other known risk factors for hyperkalemia, presenting with an initial potassium of 9.0 mmol/L after the initiation of common table salt replacement.

Case Presentation: A 60-year-old female with no reported medical history presented to the emergency department for generalized weakness, nausea and 1 episode of emesis onset today, with diarrhea that started 3 days prior. During the evaluation in the ED, an EKG, chest x-ray, labs (CBC, CMP, Troponin, pro-BNP, Lipase, TSH w/ reflex T4, Urinalysis) were ordered. Initial CBC was un-remarkable, while initial CMP was significant for a hyperkalemia at 9.0 mmol/L with sodium at 133 mmol/L and creatinine of 0.70 mg/dL. A re-draw was immediately ordered and confirmed a potassium level of 8.9 mmol/L. All other lab draws were un-remarkable. EKG was significant for peaked T waves, with normal QRScomplexes. The patient was treated for hyperkalemia with 3 grams of calcium gluconate, 10mg of nebulized albuterol and 5 units Insulin with 25 mL of D50W. The intensive care team was consulted, and the patient was admitted to the intensive care unit for close monitoring of her potassium levels. The patient’s final potassium level upon discharge was 3.5 mmol/L Upon discussion with the patient of her lab results showing hyperkalemia, the patient revealed that she had recently started a table salt replacement called Nu-Salt because her primary care physician advised her to decrease her sodium intake. Nu-Salt is a popular salt substitute that if formulated with potassium chloride rather than sodium chloride. As there was no history of kidney disease, no evidence of acute kidney injury, or history of medication use linked to hyperkalemia, we attributed the use of large amounts of Nu-Salt to this patient’s acute hyperkalemia.

Discussion: Our case report demonstrates the importance of obtaining a thorough history, including recent changes to their diet, as well as the need to educate our patients on proper nutrition substitutions.


  1. Singer AJ, Thode HC Jr, Peacock WF. A retrospective study of emergency department potassium disturbances: severity, treatment, and outcomes. Clin Exp Emerg Med. 2017 Jun 30;4(2):73-79. doi: 10.15441/ceem.16.194. PMID: 28717776; PMCID: PMC5511959.
  2. Ayach T, Nappo RW, Paugh-Miller JL, Ross EA. Life-threatening hyperkalemia in a patient with normal renal function. Clin Kidney J. 2014 Feb;7(1):49-52. doi: 10.1093/ckj/sft151. Epub 2013 Dec 30. PMID: 25859350; PMCID: PMC4389164.

A Case of Hyperkalemia Secondary to Table Salt Alternative in a Patient with Normal Renal Function



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