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Hypokalaemia and paralysis
Abstract
It is not uncommon for patients to present to the emergency room with severe weakness and a markedly low plasma potassium concentration. We attempted to identify useful clues to the diagnosis of hypokalaemic periodic paralysis (HPP), because its acute treatment aims are unique. We retrospectively reviewed charts over a 10-year period: HPP was the initial diagnosis in 97 patients. Mean patient age was 29+/-1.1 and the male:female ratio was 77:20. When the final diagnosis was HPP (n=73), the acid-base state was normal, the urine K(+) concentration was low, and the transtubular K(+) concentration gradient (TTKG) was <3. In patients with thyrotoxic periodic paralysis (TPP) (n=39), hypokalaemia was very commonly accompanied by hypophosphataemia (1.9+/-0.1 mg/dl). A clinical diagnosis of sporadic periodic paralysis (SPP) was made if hyperthyroidism and a family history of HPP were both absent (n=29). One subgroup of patients with HPP had a severe degree of hypernatraemia (167+/-5.0 mmol/l, n=3). There were only two patients with familial periodic paralysis (FPP). In 24 patients, the initial diagnosis was HPP, but subsequent studies failed to confirm this diagnosis. Each of these patients had an acid-base disorder, a high rate of renal K(+) excretion in the presence of hypokalaemia, and a TTKG of close to 7. With respect to therapy, much less K(+) was given to patients with HPP, yet 1:3 subsequently had a plasma K(+) concentration that eventually exceeded 5.0 mmol/l. Using plasma acid-base status, phosphate and K(+) excretion parameters allows a presumptive diagnosis of HPP with more confidence in the emergency room.
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“In one series, tachycardia (mean heart rate = 105 bpm) was noted at presentation and distinguished these patients from those with familial hypokalemic periodic paralysis [22].”
From Thyrotoxic Periodic Paralysis: Clinical Challenges (2014) · cites this paper as [22]
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“The hypokalemia of thyrotoxicosis is caused in part by increased catecholamine sensitivity and also by a direct effect of thyroxine on Na + ,K + -ATPase activity; patients with the thyrotoxic form of HPP are sometimes also hypophosphatemic and can respond to nonselective β-blockade”
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Self-citationLaboratory Tests to Determine the Cause of Hypokalemia and Paralysis
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BackgroundEffects of potassium supplementation on the recovery of thyrotoxic periodic paralysis
Lu, K.-C., Hsu, Y.-J., Chiu, J.-S., Hsu, Y.-D., & Lin, S.-H. (2004) · The American Journal of Emergency Medicine · doi:10.1016/j.ajem.2004.09.016 · Cited by 134
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“In one series, tachycardia (mean heart rate = 105 bpm) was noted at presentation and distinguished these patients from those with familial hypokalemic periodic paralysis [22].”
RetractedNovel etiopathophysiological aspects of thyrotoxic periodic paralysis
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Hsieh, M. ‐., Lyu, R. ‐., Chang, W. ‐., Chang, K. ‐., Chen, C. ‐., Chang, H. ‐., Wu, Y. ‐., Chen, S. ‐., & Ro, L. ‐. (2008) · European Journal of Neurology · doi:10.1111/j.1468-1331.2008.02132.x · Cited by 78
Electrocardiographic Manifestations in Patients with Thyrotoxic Periodic Paralysis
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Self-citationAcute Hypercapnic Respiratory Failure due to Thyrotoxic Periodic Paralysis
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“Of note, paralytic attacks can be induced in THypoKPP patients only during thyrotoxicosis, not after reaching euthyroidism. In the present case, treatment for thyrotoxicosis had been started 2 weeks earlier at another hospital, but the patient was still hyperthyroid. He received additional treatment for ophthalmopathy…”
MethodInfluentialTherapeutic analysis in Chinese patients with thyrotoxic periodic paralysis over 6 years
Shiang, J.-C., Cheng, C.-J., Tsai, M.-K., Hung, Y.-J., Hsu, Y.-J., Yang, S.-S., Chu, S.-J., & Lin, S.-H. (2009) · European Journal of Endocrinology · doi:10.1530/eje-09-0553 · Cited by 56
Self-citationEarly diagnosis of thyrotoxic periodic paralysis: Spot urine calcium to phosphate ratio*
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Self-citationAn Unusual Cause of Hypokalemic Paralysis: Chronic Licorice Ingestion
Lin, S., Yang, S.-S., Chau, T., & Halperin, M. L. (2003) · The American Journal of the Medical Sciences · doi:10.1097/00000441-200303000-00008 · Cited by 48
Self-citationRao, N. K., John, M., Thomas, N., Rajaratnam, S., & Seshadri, M. S. (2006) · PubMed · Cited by 46
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Groeneveld, J. H. M., Sijpkens, Y. W. J., Lin, S.-H., Davids, M. R., & Halperin, M. L. (2005) · QJM · doi:10.1093/qjmed/hci046 · Cited by 46
“The helpful laboratory data suggestive of HPP are a low rate of excretion of Kþ and the absence of an acid-base disorder.(6) More detailed information is provided in Table 3.”
BackgroundSelf-citationKamel, K. S., & Halperin, M. L. (2021) · Kidney International Reports · doi:10.1016/j.ekir.2021.02.003 · Cited by 49
Aristolochic acid-induced Fanconi's syndrome and nephropathy presenting as hypokalemic paralysis
Yang, S.-S., Chu, P., Lin, Y., Chen, A., & Lin, S. (2002) · American Journal of Kidney Diseases · doi:10.1053/ajkd.2002.31425 · Cited by 45
Self-citationAlam, S., Kandasamy, D., Goyal, A., Vishnubhatla, S., Singh, S., Karthikeyan, G., & Khadgawat, R. (2021) · Clinical Endocrinology · doi:10.1111/cen.14409 · Cited by 44
A simple and rapid approach to hypokalemic paralysis
Lin, S., Chiu, J.-S., Hsu, C.-W., & Chau, T. (2003) · The American Journal of Emergency Medicine · doi:10.1016/s0735-6757(03)00159-1 · Cited by 44
Self-citationRhee, E. P., Scott, J. A., & Dighe, A. S. (2012) · New England Journal of Medicine · doi:10.1056/nejmcpc1110051 · Cited by 43
Spectrum of hypokalaemic periodic paralysis in a tertiary care centre in India
Maurya, P. K., Kalita, J., & Misra, U. K. (2010) · Postgraduate Medical Journal · doi:10.1136/pgmj.2010.104026 · Cited by 39
“Thyrotoxic hypokalaemic paralysis is common in the Asian (oriental) population.(4) The aetiology of hypokalaemic paralysis is likely to depend on ethnicity, vigour of the investigation, and the setting of the medical practice.”
BackgroundInfluentialThyrotoxic hypokalemic periodic paralysis: An overlooked pathology in western countries
Pompeo, A., Nepa, A., Maddestra, M., Feliziani, V., & Genovesi, N. (2007) · European Journal of Internal Medicine · doi:10.1016/j.ejim.2007.03.003 · Cited by 40
“Indeed, with THPP, the symptoms and classic signs of hyperthyroidism are often absent [3,35], and the motor slackness, pains, and muscular contractions can mislead the diagnostic decision [10].”
BackgroundInfluentialDias-da-Silva, M. R., Chiamolera, M. I., Kasamatsu, T. S., Cerutti, J. M., & Maciel, R. M. B. (2004) · Arquivos Brasileiros de Endocrinologia & Metabologia · doi:10.1590/s0004-27302004000100022 · Cited by 39
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Self-citationMutation screening in Chinese hypokalemic periodic paralysis patients
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Glucocorticoids may trigger attacks in several types of periodic paralysis
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“During attacks of paralysis in HypoPP patients, plasma potassium concentration is low, however their urine potassium concentration is also low [7] indicating an altered potassium distribution across the muscle membrane.”
BackgroundHypokalaemia and paralysis in the Thai population
Phakdeekitcharoen, B., Ruang-Raksa, C., & Radinahamed, P. (2004) · Nephrology Dialysis Transplantation · doi:10.1093/ndt/gfh328 · Cited by 33
“In Taiwan, most cases of HypoPP are sporadic [ 7 ].”
BackgroundResultInfluentialThyrotoxic periodic paralysis: an overview
Hsieh, C., Kuo, S., Pei, D., Hung, Y.-J., Fan, S. C., Wu, L.-I., He, C., Yang, T., Lian, W., & Lee, C.-H. (2004) · Annals of Saudi Medicine · doi:10.5144/0256-4947.2004.418 · Cited by 31
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Self-citationAbbasi, B., Sharif, Z. I., Sprabery, L. R., & Lopez, F. A. (2010) · The American Journal of the Medical Sciences · doi:10.1097/maj.0b013e3181cbf567 · Cited by 30
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“Some presenting features frequently associated with TPP include: (1) usually male gender of Asian descent greater than 20 years of age; (2) no family history of periodic paralysis; (3) history of hyperthyroidism or related symptoms; (4) usually normal acid-base balance and low K excretion5 and (5) accompanying hypopho…”
BackgroundSelf-citationLin, S., Cheng, N.-L., Hsu, Y., & Kao, M. (2005) · The American Journal of the Medical Sciences · doi:10.1097/00000441-200502000-00003 · Cited by 29
Self-citationClinical and Molecular Analysis of Chinese Patients with Thyrotoxic Periodic Paralysis
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Self-citationWu, C., Wu, Y., Lin, J., & Kuo, S. (2008) · Thyroid · doi:10.1089/thy.2008.0232 · Cited by 26
“TTP should be distinguished from hypokalemic periodic paralysis, familial hypokalemic paralysis, idiopathic or sporadic periodic paralysis, and barium intoxication (5).”
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Self-citationEtiologic and Therapeutic Analysis in Patients with Hypokalemic Nonperiodic Paralysis
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Self-citationGenotype and Phenotype Analysis of Patients With Sporadic Periodic Paralysis
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Self-citationThyrotoxic Periodic Paralysis: An Underdiagnosed and Underrecognized Condition
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Assessment of Urine Biochemistry
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Self-citationUnusual causes of hypokalaemia and paralysis
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“In TPP, the paralysis results from hypokalaemia due to a rapid and massive transcellular shift of potassium from extracellular to intracellular compartments rather than net potassium loss.(6,7) In addition to hypokalaemia, mild to moderate hypophosphataemia may also occur secondary to intracellular shift due to increa…”
Weakness in the intensive care unit
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Treatment of Hypokalemia and Hyperkalemia
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Self-citationThyrotoxic periodic paralysis and anesthesia report of a case and literature review
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“Attacks can occur during hypokalemia [35,36], normokalemia [37], or hyperkalemia [38], indicating that potassium flux is not the sole factor in paralysis.”
BackgroundGug, C., Mihăescu, A., & Mozos, I. M. (2018) · Therapeutics and Clinical Risk Management · doi:10.2147/tcrm.s150483 · Cited by 14
Spectrum of hypokalemic paralysis from a tertiary care center in India
Dineshkumar, T., Chandramohan, G., Arul, R., Seenivasan, M., Dhanapriya, J., Sakthirajan, R., Balasubramaniyan, T., & Gopalakrishnan, N. (2018) · Indian Journal of Nephrology · doi:10.4103/ijn.ijn_225_17 · Cited by 17
“The presence of a positive family history and recurrent episodes in a patient can be helpful in making a diagnosis of periodic paralysis, but periodic and non‐periodic forms cannot be distinguished on clinical features alone.[7,8]”
BackgroundSevere hypokalaemia in a Chinese male
LIN, Y.-F. (2002) · QJM · doi:10.1093/qjmed/95.10.695 · Cited by 14
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A Case of Trigger-Point Injection-Induced Hypokalemic Paralysis
Soriano, P. K., Bhattarai, M., Vogler, C. N., & Hudali, T. H. (2017) · American Journal of Case Reports · doi:10.12659/ajcr.903139 · Cited by 13
Etiology of Hypokalemic Paralysis in Korea: Data from a Single Center
Wi, J. K., Lee, H. J., Kim, E. Y., Cho, J. H., Chin, S. O., Rhee, S. Y., Moon, J.-Y., Lee, S.-H., Jeong, K. H., Ihm, C., et al. (2012) · Electrolytes & Blood Pressure · doi:10.5049/ebp.2012.10.1.18 · Cited by 14
Hypokalaemic Periodic Paralysis– A Prospective Study of the Underlying Etiologies
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Hypokalemic paralysis is not just a hypokalemic paralysis
Cesur, M., ILGIN, S. D., Başkal, N., & Güllü, S. (2008) · European Journal of Emergency Medicine · doi:10.1097/mej.0b013e3282bf6ee3 · Cited by 12
Sandhya, P. (2022) · International Journal of Rheumatic Diseases · doi:10.1111/1756-185x.14483 · Cited by 11
CHANDRAN, S. R., Balakrishnan, R., Thirumalnesan, G., & Doraisamy, N. (2011) · Indian Journal of Endocrinology and Metabolism · doi:10.4103/2230-8210.83360 · Cited by 11
“[4] There is an overwhelming male predominance, with a male-tofemale ratio of 77:20.[5] The condition has been reported worldwide, including United Kingdom, United States (in whites and African Americans), and South America.”
BackgroundHypokalemic paralysis due to thyrotoxicosis accompanied by Gitelman′s syndrome
Baldane, S., İpekçi, S. H., Celik, S., Gündoğdu, A., & Kebapçılar, L. (2015) · Indian Journal of Nephrology · doi:10.4103/0971-4065.140719 · Cited by 10
“…and the TRAb level was normalized; however, serum potassium levels were below 4 mEq/L. Investigations were performed to reveal the etiology of the hypokalemia, and metabolic alkalosis, hypokalemia, hypomagnesemia, hypocalciuria, and elevated renin and aldosterone levels were recorded [Table 1].”
BackgroundThyrotoxic periodic paralysis triggered by β2- adrenergic bronchodilators
Yeh, F., Chiang, W., Wang, C.-C., & Lin, S. (2014) · Canadian Journal of Emergency Medicine · doi:10.2310/8000.2013.130867 · Cited by 10
Self-citationSevere Hypokalemia, Paralysis, and AIDS-Associated Isospora Belli Diarrhea
Williams, D. T., Smith, R. S., & Mallon, W. K. (2008) · Journal of Emergency Medicine · doi:10.1016/j.jemermed.2008.05.001 · Cited by 10
Garcia, E. A., Nakhleh, N., Simmons, D., & Ramsay, C. (2008) · Pediatric Emergency Care · doi:10.1097/pec.0b013e318166868e · Cited by 10
Sporadic hypothyroidism-related hypokalemic paralysis: Diagnosis in a resource-poor setting
Viswanathan, S., Kadeeja, N., Senthilnathan, N., & Aghoram, R. (2017) · Journal of Family Medicine and Primary Care · doi:10.4103/jfmpc.jfmpc_215_17 · Cited by 9
“Potassium losses in urine (diabetes, toluene) and stools (diarrhea), insulin lack (DKA) and defects in renal acidification (DRTA) lead to hypokalemia and its manifestations.[3] Only the last cause was relevant in Case 1.”
BackgroundInfluentialLin, H.-W., Chau, T., Lin, C., & Lin, S. (2009) · BMJ Case Reports · doi:10.1136/bcr.07.2008.0577 · Cited by 9
Self-citationInterpretation of Electrolyte and Acid-Base Parameters in Blood and Urine
Kamel, K. S., Davids, M. R., Lin, S., & Halperin, M. L. (2012) · Elsevier eBooks · doi:10.1016/b978-1-4160-6193-9.10026-0 · Cited by 9
Self-citationAggarwal, A., Wadhwa, R., Pande, A. K., Sahu, M., Kapoor, D., & Khanna, R. (2019) · Indian Journal of Endocrinology and Metabolism · doi:10.4103/ijem.ijem_619_18 · Cited by 9
Hsiao, Y., Fang, Y., Leu, J., & Tsai, M. (2017) · American Journal of Case Reports · doi:10.12659/ajcr.901793 · Cited by 8
Case of Thyrotoxic Periodic Paralysis in a Caucasian Male and Review of Literature
Thethi, T. K., Parks, R., Katalenich, B., Chhabra, P. T., McCaw, J. M., Syu, S., Nguyen, T., Larrazolo, J., Munshi, K., Waddadar, J., et al. (2014) · Case Reports in Medicine · doi:10.1155/2014/314262 · Cited by 8
A single-center retrospective study on the clinical features of thyrotoxic periodic paralysis
Yamada, K., Tanabe, A., Hashimoto, M., Ohsugi, M., Ueki, K., & Kajio, H. (2024) · PLoS ONE · doi:10.1371/journal.pone.0308076 · Cited by 7
“These findings were similar to reports from Taiwan in the 1990s and the 2000s [2,10].”
ResultCase report: Hyperthyroid hypokalemic periodic paralysis
Jaishi, P. P., Neupane, S. K., & Neupane, P. K. (2022) · Annals of Medicine and Surgery · doi:10.1016/j.amsu.2022.103759 · Cited by 8
“The clinical features of hyperthyroidism can appear months or even years before the onset of periodic paralysis, but they can also appear concurrently or after the onset of periodic paralysis [28,29].”
BackgroundA Practical and Pathophysiologic Approach to Hypokalemia
Lin, S. (2008) · Hong Kong Journal of Nephrology · doi:10.1016/s1561-5413(08)60014-9 · Cited by 7
Self-citationRyan, E. T., Cronin, C. G., & Branda, J. A. (2011) · New England Journal of Medicine · doi:10.1056/nejmcpc1011322 · Cited by 7
Chakraborty, P., Patra, S., Biswas, S. N., & Barman, H. (2018) · Indian Journal of Endocrinology and Metabolism · doi:10.4103/ijem.ijem_633_17 · Cited by 7
A 20-year-old Chinese man with recurrent hypokalemic periodic paralysis and delayed diagnosis
Naqi, M., Bhatt, V. R., Pant, S., Shrestha, R., Tadros, M., Murukutla, S., & Rothman, J. (2012) · BMJ Case Reports · doi:10.1136/bcr.01.2012.5541 · Cited by 7
A rare case of thyrotoxic periodic paralysis precipitated by hydrocortisone
Chakrabarti, S. (2015) · Journal of Natural Science Biology and Medicine · doi:10.4103/0976-9668.149236 · Cited by 6
Sporadic hypokalemic paralysis caused by osmotic diuresis in diabetes mellitus
Vishnu, V. Y., Kattadimmal, A., Rao, S. A., & Kadhiravan, T. (2014) · Journal of Clinical Neuroscience · doi:10.1016/j.jocn.2013.10.024 · Cited by 6
“Urinary potassium excretion is the key parameter to distinguish between these two mechanisms [2,3].”
Hypokalemic paralysis in a young obese female
Chiang, W., Hsu, Y., Chang, C.-C., & Lin, S. (2012) · Clinica Chimica Acta · doi:10.1016/j.cca.2012.04.005 · Cited by 6
Self-citationClinical and biochemical features of hypokalemic paralysis: a study from rural Eastern India
Ganie, H. A., Dar, W., Bhattacharya, A. P., & Yaqoob, A. (2023) · The Egyptian Journal of Neurology Psychiatry and Neurosurgery · doi:10.1186/s41983-023-00622-w · Cited by 6
“Although some studies have reported markedly lower serum potassium concentrations in secondary hypokalemic paralysis, not all studies support this finding [20, 21].”
ResultRecurrent hypokalemic paralysis in hypothyroidism
Singh, J., Dinkar, A., Kumar, N., & Kumar, K. (2023) · The American Journal of the Medical Sciences · doi:10.1016/j.amjms.2023.01.009 · Cited by 6
Peripheral nervous system and neuromuscular disorders in the emergency department: A review
Sivadasan, A., Cortel-LeBlanc, M., Cortel‐LeBlanc, A., & Katzberg, H. D. (2024) · Academic Emergency Medicine · doi:10.1111/acem.14861 · Cited by 5
Ebrahimi, P., Taheri, H., Mousavinejad, S. A., & Nazari, P. (2024) · Clinical Case Reports · doi:10.1002/ccr3.8923 · Cited by 5
Zonisamide-induced distal renal tubular acidosis and critical hypokalaemia
MacMahon, T., & Kelly, Y. P. (2023) · BMJ Case Reports · doi:10.1136/bcr-2023-254615 · Cited by 5
Electrolyte Emergencies and Acute Renal Failure in Pediatric Critical Care
Galloway, E., & Doughty, L. (2007) · Clinical Pediatric Emergency Medicine · doi:10.1016/j.cpem.2007.08.012 · Cited by 5
“Organ systems primarily affected are cardiovascular, skeletal muscle, gastrointestinal, and renal [12].”
BackgroundHypokaliämische Lähmung bei Hyperthyreose
Brandenburg, V. M., Knackstedt, C., Gobbelé, R., Graf, J., Schröder, J., Westerhuis, R., & Kosinski, C. M. (2004) · Der Nervenarzt · doi:10.1007/s00115-004-1707-6 · Cited by 5
An unusual complication of quadriparesis after trigger point injection: a case report
Sangondimath, G. M., Kalidindi, K. K. V., Pandrakula, P., Kumar, V., & Krishan, M. H. (2020) · Pain · doi:10.1097/j.pain.0000000000002094 · Cited by 5
“Thyrotoxic periodic paralysis is established when the hypokalemic paralysis is associated with hyperthyroidism.(5) In our case, a negative family history of HPP and an association with hyperthyroidism suggest that TPP can also be a possible cause.”
Background
Metadata
- Authors
- Lin, S.-H.
- Affiliations
- Tri-Service General Hospital (TW)
- Corresponding author
- Lin, S.-H.
- ORCID
- Lin, S.-H.
- Venue
- QJM
- Publisher
- Oxford University Press (OUP)
- Published
- 2001-03-01
- Volume
- 94
- Issue
- 3
- Pages
- 133-139
- ISSN
- 0033-5622 (ISSN-L)
- 1460-2393
- OpenAlex
- W2159477041
- Cited by
- 173
- References
- 50
- Citations by year
- 2026: 1 · 2025: 4 · 2024: 5 · 2023: 5 · 2022: 6 · 2021: 4 · 2020: 5 · 2019: 5 · 2018: 6 · 2017: 9 · 2016: 4 · 2015: 10 · 2014: 7 · 2013: 3 · 2012: 11
- FWCI
- 7.63
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- QJM (publishedVersion)
- PubMed (publishedVersion)
- HighWire Press Open Archive (submittedVersion)
- Topics
- Health Sciences › Medicine › Nephrology › Potassium and Related Disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Ion Transport and Channel Regulation
- Keywords
- hypokalemic periodic paralysis, thyrotoxic periodic paralysis, familial periodic paralysis, hypokalemia, paralysis, hypophosphatemia, hypernatremia, acid-base status, renal potassium excretion, potassium replacement therapy, emergency diagnosis
- MeSH terms
- Acid-Base Equilibrium, Adolescent, Adult, Aged, Analysis of Variance, Diagnosis, Differential, Female, Humans, Hypernatremia, Hypokalemia, Male, Middle Aged, Paralysis, Potassium, Retrospective Studies, Thyrotoxicosis, Hypophosphatemia, Genetic Predisposition to Disease
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