Hypokalemia (Low Potassium Blood Level)

What Is Hypokalemia?

[dropcap]H[/dropcap]ypokalemia means the level of potassium in the bloodstream is too low to meet metabolic needs of the body for this mineral and is characterized by metabolic acidosis, altered nerve conduction and muscle contraction.

Rapid potassium loss can result in life-threatening hypokalemic rhabdomyolysis which is destruction of muscle tissue that results in kidney damage.¹

Q: What are metabolic needs of the body for potassium?

A: The metabolic needs of the body for potassium are great because this mineral is crucial for life and especially for normal nerve and muscle function.

Most potassium is intracellular, meaning it is found within cells while sodium, its opposing mineral (both electrolytes), is found in the fluid surrounding cells. In muscle contraction, exchange of potassium and sodium takes place so that potassium moves out of muscle cells and sodium moves into them. With muscle relaxation, potassium moves back into the cells and sodium moves out.

What Is Hypokalemia In Celiac Disease and/or Gluten Sensitivity?

• Relationship between hypokalemia and celiac disease. Hypokalemia is a classic feature of untreated celiac disease.
• Relationship between hypokalemia and malabsorption in celiac disease. It is now known that the main routes for water and potassium absorption are deficient in celiac disease and may play a role in the onset of malabsorption symptoms.²

How Prevalent is Hypokalemia In Celiac Disease and/or Gluten Sensitivity?

Hypokalemia is a significantly abnormal serology result in all study patients at diagnosis of celiac disease.³

What Are The Symptoms of Hypokalemia?

Hypokalemia is marked by these symptoms:

• Muscle weakness, especially of the lower extremities progressing to paralysis without treatment.
• Muscle wasting when chronic.
• Hypotension (low blood pressure).
• Dizziness.
• Drowsiness.
• Confusion.
• Depression.
• Anorexia.
• Thirst.
• Vomiting.
• Tremor.
• Muscle spasm.
• Drowsiness.
• Anxiety.
• Confusion.
• Personality changes.
• Depression.
• Bone pain.
• Cardiac disturbance (premature ventricular and atrial contractions).
• Contributes to osteoporosis.

Acute severe deficiency causes rhabdomyolysis (muscle destruction) and paralysis which can include the lungs, and can lead to serious heart rhythm problems that can be fatal.

Late symptoms include tetany, myoclonic jerks, convulsions, and kidney damage (hypokalemic nephropathy).⁴

How Does Hypokalemia Develop In Celiac Disease and/or Gluten Sensitivity?

• Hypokalemia results from malabsorption in celiac disease and depletion associated with loss from diarrhea and steatorrhea when these conditions are present in celiac disease.⁵
• Research shows that the main routes for water and solute absorption are deficient in celiac disease and may play a role in the onset of malabsorption symptoms.²
• Duodenal biopsies from untreated celiacs, treated celiacs, healthy controls and disease were examined. The expression of transcripts was virtually absent in duodenal biopsies of untreated celiac disease patients. In healthy controls, immunohistochemistry revealed a labelling in the apical membrane of surface epithelial cells of the duodenum. The immunolabelling was heavily reduced or absent in untreated celiac patients, while it was normal in patients consuming a gluten-free diet for at least 12 months.²

Does Hypokalemia Respond To Gluten-Free Diet?

Yes. Celiac disease-related hypokalemia normalizes on gluten free diet and in patients with diarrhea who have resolution. Rhabdomyolysis requires medical treatment with potassium therapy that may need to be given intravenously.⁶

6 Steps To Improve Hypokalemia In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both potassium levels and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁷
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.⁸
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁸
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁸.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁸
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁸
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁸[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4[/dropcap] Manage Your Medications Safely:

[box type=”shadow” ]

Certain medications deplete potassium which promotes hypokalemia. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

This is not a complete listing.

ANTACIDS / ULCER MEDICATIONS

• Pepcid®, Tagamet®, Zantac® deplete Potassium.
• Magnesium and Aluminum Antacid preparations deplete Potassium.
• Alka Seltzer®, Baking Soda deplete Potassium.

ANTIVIRAL AGENTS

• Foscanet depletes Potassium. 

DIURETICS

• Thiazide Diuretics (Hydrochlorothiazide, Enduron®, Diuril®, Lozol®, Zaroxolyn®, Hygroton® and others) deplete Potassium.
• Loop Diuretics (Lasix®, Bumex®, Edecrin®) deplete Potassium. [/box]

• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Potassium only as prescribed following blood test for status. Too much is as dangerous as too little.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Hypokalemia In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Solute transporters and aquaporins are impaired in celiac disease.” This study investigating the possible alteration in the expression and localization of water channels and some solute transporters in duodenal mucosa of celiac disease patients show that the main routes for water and solute absorption like potassium are deficient in celiac disease and may play a role in the onset of malabsorption symptoms.

Duodenal biopsies from untreated celiacs, treated celiacs, healthy controls and disease were examined. The expression of transcripts was virtually absent in duodenal biopsies of untreated celiac disease patients. In healthy controls, immunohistochemistry revealed a labelling in the apical membrane of surface epithelial cells of the duodenum. The immunolabelling was heavily reduced or absent in untreated celiac patients, while it was normal in patients consuming a gluten-free diet for at least 12 months.⁹

CASE REPORT SUMMARIES

“A case of periodic hypokalemic paralysis in a patient with celiac disease.” This case report describes recurrent hypokalemic paralysis with previously unsuspected celiac disease in a 4-year-old male child who was not in celiac crisis. The patient presented with recurrent episodes of diarrhea for 6-months. He had loose movements for 6 days ( 4-5 times/day, semisolid, non-foul smelling, no abnormal character of stools) and acute, non- progressive weakness of both upper and lower limb since last four days. Both the upper and lower limbs were affected simultaneously, with more involvement of lower limbs and proximal portion. There was no associated difficulty in breathing, difficulty in swallowing, altered sensorium, seizures, visual problem or bulbar weakness. Each episode of diarrhea was associated with weakness of all four limbs and documented hypokalemia. On examination the child had some pallor, short stature, flaccid quadriparesis with absent DTR (deep tendon reflexes). ECG was showing hypokalemic changes.

The patient responded clinically and biochemically to potassium supplement. TTG antibody testing and intestinal biopsy confirmed celiac disease. The patient was put on gluten free diet and is doing well with no recurrence.¹⁰

“Celiac crisis with quadriplegia due to potassium depletion as presenting feature of celiac disease.” This case report describes a 26-year-old who woman presented with a suddenly developed weakness of all four limbs and a severe diarrhea. Authors emphasize celiac crisis, which is a presenting feature of coeliac disease, characterized by acute diarrhea with life-threatening acid base and electrolyte abnormalities. The patient improved with correction of hypokalemia (low blood potassium) and gluten-free diet. A severe acute diarrhea with metabolic and systemic complications, the so-called coeliac crisis, is a possible presenting clinical feature due to potassium depletion of a previously undiagnosed adult celiac disease.¹¹

“Carpopedal spasm in an elderly man: an unusual presentation of celiac disease.” This case report describes diagnosis of celiac disease in a 68-year-old single Caucasian man admitted to the hospital with a 24-hour history of carpopedal spasm of both hands. Apart from generalized weakness, he reported no other symptoms. Physical examination revealed carpopedal spasm, clubbing of fingers and cachexia (body mass index 14 kg/m2). This patient was found to have several unusual features of celiac disease, including the advanced age at presentation, severe hypocalcemia and electrolyte disturbances including low potassium as the initial manifestations, minimal gastrointestinal symptoms, and negative tTG-antibodies.

Blood tests showed severe hypocalcemia, with a total serum calcium of 1.06 mmol/L (normal range [NR] 2.05-2.55 mmol/L). He also had low serum potassium (2.8 mmol/L; NR 3.5-5.5 mmol/L) and magnesium (0.36 mmol/L; NR 0.65-1.05 mmol/L). Other significant results included hemoglobin 10.6 g/dL (NR 13-18 g/dL), mean corpuscular volume 98.1 fl (NR 82-98 fl), vitamin B12 157 ng/L (NR > 165 ng/L), folate 2.8 g/L (NR 3.1-17.5 μg/L), ferritin 252 μg/L (NR 30-250 μg/L), prothrombin time 20 s (NR 11-14 s), thyroid stimulating hormone 0.87 mu/L (NR 0.35-4.5 mu/L), phosphate 0.57 mmol/L (NR 0.8-1.45 mmol/L), albumin 32 g/L (NR 34-48 g/L) and alkaline phosphatase 313 IU/L (NR 47-141 IU/L).  Subsequent results revealed vitamin D deficiency with a low serum 25-OH vitamin D of < 7 μg/L (NR 7-40 μg/L), a low 24-hour urinary calcium excretion of 0.9 mmol (NR 2.5-7.5 mmol) and a raised serum parathyroid hormone of 22.7 pmol/L (NR 1.6-6.9 pmol/L).

Serology for tissue transglutaminase (tTG) antibodies was negative, and a serum IgA level of 4.95 g/L (NR 0.8-4.0 g/L) excluded selective IgA deficiency.

Barium meal and follow through showed dilated proximal bowel loops and absence of normal feathery pattern of the jejunum, features suggestive of a malabsorptive state. Upper gastroscopic examination was normal; however, the duodenal biopsy showed partial and subtotal villous atrophy with increased intra-epithelial lymphocyte infiltration, consistent with the diagnosis of celiac disease.¹²

“Hypokalaemic rhabdomyolsis: an unusual presentation of celiac disease.” This case report describes a 60 year old man presenting with weakness describes hypokalemic rhabdomyolysis caused by celiac disease. The patient’s myopathy (impaired muscles) responded to potassium supplements, his diarrhea and histological changes resolved while on gluten free diet.¹³

Sources:

1. Williams SG, Davison AG, Glynn MJ. Hypokalaemic rhabdomyolsis: an unusual presentation of celiac disease. European Journal of Gastroenterology and Hepatology. Feb 1995;7(2):183-4. [↩]
2. Laforenza U, Miceli E, Gastaldi G, Scaffino MF, Ventura U, Fontana JM, Orsenigo MN, Corazza GR. Solute transporters and aquaporins are impaired in celiac disease. Biol Cell. 2010 May 26;102(8):457-67. doi: 10.1042/BC20100023. [↩] [↩] [↩]
3. Molteni N, Bardella MT, Vezzoli G, Pozzoli E, Bianchi P. Intestinal calcium absorption as shown by stable strontium test in celiac disease before and after gluten-free diet. American Journal of Gastroenterology. Nov 1995;90(11):2025-8. [↩]
4. Kathleen Mahan and Sylvia Escott-Stump, ed. Krause’s Food, Nutrition & Diet Therapy, 10th Edition. Philadelphia, PA. USA: W.B. Saunders Company, 2000. [↩]
5. Williams SG, Davison AG, Glynn MJ. Hypokalaemic rhabdomyolsis: an unusual presentation of celiac disease. European Journal of Gastroenterology and Hepatology. Feb 1995;7(2):183-4. [↩]
6. Williams SG, Davison AG, Glynn MJ. Hypokalaemic rhabdomyolsis: an unusual presentation of celiac disease. European Journal of Gastroenterology and Hepatology. Feb 1995;7(2):183-4. [↩]
7. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
8. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
9. Laforenza U, Miceli E, Gastaldi G, Scaffino MF, Ventura U, Fontana JM, Orsenigo MN, Corazza GR. Solute transporters and aquaporins are impaired in celiac disease. Biol Cell. 2010 May 26;102(8):457-67. doi: 10.1042/BC20100023. [↩]
10. Ranjan A, Debata PK. A case of periodic hypokalemic paralysis in a patient with celiac disease. J Clin Diagn Res. 2014 Jun;8(6):PD03-4. doi: 10.7860/JCDR/2014/8372.4483. [↩]
11. Atikou A, Rabhi M, Hidani H, El Alaoui Faris M, Toloune F. Celiac crisis with quadriplegia due to potassium depletion as presenting feature of celiac disease. Rev Med Interne. 2009 Jun;30(6):516-8. doi: 10.1016/j.revmed.2008.11.012. [↩]
12. Schmidt K, Powari M, Shirazi T, Vaidya B. Carpopedal spasm in an elderly man: an unusual presentation of coeliac disease. J R Soc Med. 2007 Nov;100(11):524-5. [↩]
13. Williams SG, Davison AG, Glynn MJ. Hypokalaemic rhabdomyolsis: an unusual presentation of celiac disease. European Journal of Gastroenterology and Hepatology. Feb 1995;7(2):183-4. [↩]