Can electrolyte imbalance cause acute kidney injury?

Can Electrolyte Imbalance Cause Acute Kidney Injury?

Yes, severe electrolyte imbalances—particularly hyperkalemia and hyperchloremia—can directly cause or contribute to acute kidney injury (AKI), though the relationship is bidirectional with AKI more commonly causing electrolyte disturbances than the reverse.

Direct Causative Mechanisms

Hyperkalemia and AKI

• Severe hyperkalemia (>6.5 mmol/L) most commonly occurs from renal failure itself, but acute kidney injury was present in all documented cases of hyperkalemia-induced cardiac arrest in one retrospective study of 29,063 patients 1
• The relationship is typically that AKI causes hyperkalemia rather than hyperkalemia causing AKI, though the two conditions exacerbate each other in a dangerous cycle 1

Hyperchloremia as a Direct Cause

• Hyperchloremia from 0.9% saline administration can directly cause AKI through decreased kidney perfusion, reduced urine output, and increased extravascular fluid accumulation 1
• The World Journal of Emergency Surgery specifically identifies hyperchloremia as capable of causing acute kidney injury, particularly when associated with high-chloride fluid resuscitation 2
• The SMART trial demonstrated that patients receiving 0.9% saline had significantly higher incidence of major adverse kidney events (15.4% vs 14.3%) compared to balanced crystalloids 1

Electrolyte Disturbances as Risk Factors

Common Precipitants

• Electrolyte disorders are recognized precipitating factors for AKI development, particularly in patients with underlying liver disease, sepsis, or critical illness 1
• In COVID-19 patients specifically, AKI may be associated with both increased and decreased serum sodium and potassium levels 1

Predictive Value

• Risk scoring systems incorporating electrolyte disorders have been validated to predict both AKI occurrence (AUC 0.738-0.758) and severe AKI (AUC 0.733-0.853) in hospitalized patients 3
• Hyperphosphatemia before dialysis initiation conferred a 2.2-fold increased risk of 28-day mortality and 2.6-fold increased risk of 90-day mortality in septic AKI patients 4

Clinical Monitoring Requirements

Assessment Frequency

• Measure serum urea, creatinine, and electrolytes (sodium, potassium, bicarbonate) at least every 48 hours in patients at increased risk of AKI, or more frequently if clinically indicated 1
• The European Society of Clinical Nutrition recommends electrolyte monitoring every 6-12 hours in critically ill patients with AKI or chronic kidney disease 2

Specific Electrolytes to Monitor

• Hyponatremia, hyperkalemia, hyperphosphatemia, and hypocalcemia are the most commonly reported electrolyte disturbances in kidney disease 2
• Patients undergoing emergency laparotomy are especially susceptible to hypo- and hypernatremia, hypo- and hyperkalemia, hypophosphatemia, hypocalcemia, and hypomagnesemia 1

Prevention Strategies

Fluid Selection

• Use balanced crystalloids instead of 0.9% normal saline for resuscitation to reduce AKI risk 1
• Limit 0.9% saline use especially in higher-risk patients with existing electrolyte derangements such as acidosis or hyperchloremia 1
• The SALT trial showed patients receiving balanced crystalloids had lower 30-day mortality and reduced incidence of renal replacement therapy 1

High-Risk Populations

• Avoid potassium-containing solutions in patients with severe renal impairment, acute dehydration, extensive tissue injury, or congestive heart failure 5
• Patients with cirrhosis require careful volume status assessment and electrolyte monitoring to prevent AKI from dehydration or electrolyte disturbances 1

Common Pitfalls

• Do not aggressively correct post-dialysis electrolyte abnormalities, as overcorrection (particularly hypokalemia and hypophosphatemia) commonly occurs after CRRT initiation and can cause dangerous fluctuations 6, 4
• Rule out pseudohyperkalemia from hemolysis or inadequate phlebotomy technique before aggressive treatment 2
• Recognize that rapid correction of chronic hyponatremia risks osmotic demyelination syndrome; monitor sodium concentrations closely during correction 5
• Be aware that electrolyte disturbances can trigger cardiac dysrhythmias, particularly atrial fibrillation, which may further compromise renal perfusion 1