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Electrolyte imbalance, or water-electrolyte imbalance, is an abnormality in the concentration of electrolytes in the body. Electrolytes play a vital role in maintaining homeostasis in the body. They help to regulate heart and neurological function, fluid balance, oxygen delivery, acid–base balance and much more. Electrolyte imbalances can develop by consuming too little or too much electrolyte as well as excreting too little or too much electrolyte.{{cn|date=June 2022}} Examples of electrolytes include calcium, chloride, magnesium, phosphate, potassium, and sodium.Electrolyte disturbances are involved in many disease processes and are an important part of patient management in medicine.JOURNAL, 3, Alfarouk, Khalid O., Ahmed, Samrein B. M., Ahmed, Ahmed, Elliott, Robert L., Ibrahim, Muntaser E., Ali, Heyam S., Wales, Christian C., Nourwali, Ibrahim, Aljarbou, Ahmed N., Bashir, Adil H. H., Alhoufie, Sari T. S., Alqahtani, Saad Saeed, Cardone, Rosa A., Fais, Stefano, Harguindey, Salvador, Reshkin, Stephan J., The Interplay of Dysregulated pH and Electrolyte Imbalance in Cancer, Cancers, 7 April 2020, 12, 4, 898, 10.3390/cancers12040898, 32272658, 7226178, free, JOURNAL, Balcı, Arif Kadri, Koksal, Ozlem, Kose, Ataman, Armagan, Erol, Ozdemir, Fatma, Inal, Taylan, Oner, Nuran, 2013, General characteristics of patients with electrolyte imbalance admitted to emergency department, World Journal of Emergency Medicine, 4, 2, 113–116, 10.5847/wjem.j.issn.1920-8642.2013.02.005, 1920-8642, 4129840, 25215103, The causes, severity, treatment, and outcomes of these disturbances can differ greatly depending on the implicated electrolyte.BOOK, Rosen's Emergency Medicine: Concepts and Clinical Practice, Walls, Ron M., Hockberger, Robert S., Gausche-Hill, Marianne, Elsevier, 2018, 978-0-323-35479-0, Philadelphia, PA, 1516–1532, The most serious electrolyte disturbances involve abnormalities in the levels of sodium, potassium or calcium. Other electrolyte imbalances are less common and often occur in conjunction with major electrolyte changes. The kidney is the most important organ in maintaining appropriate fluid and electrolyte balance, but other factors such as hormonal changes and physiological stress play a role.

Overview

Anions and cations

Calcium, magnesium, potassium, and sodium ions are cations (+), while chloride, and phosphate ions are anions (−).

Causes

Chronic laxative abuse or severe diarrhea or vomiting can lead to dehydration and electrolyte imbalance.{{cn|date=June 2022}}

Malnutrition

People with malnutrition are at especially high risk for an electrolyte imbalance. Severe electrolyte imbalances must be treated carefully as there are risks with overcorrecting too quickly, which can result in arrhythmias, brain herniation, or refeeding syndrome depending on the cause of imbalance.JOURNAL, Bockenhauer, D, Zieg, J, Electrolyte disorders., Clinics in Perinatology, September 2014, 41, 3, 575–90, 10.1016/j.clp.2014.05.007, 25155728, JOURNAL, Tisdall, M, Crocker, M, Watkiss, J, Smith, M, Disturbances of sodium in critically ill adult neurologic patients: a clinical review., Journal of Neurosurgical Anesthesiology, January 2006, 18, 1, 57–63, 16369141, 1513666, 10.1097/01.ana.0000191280.05170.0f, JOURNAL, Moritz, ML, Ayus, JC, 40511233, Disorders of water metabolism in children: hyponatremia and hypernatremia., Pediatrics in Review, November 2002, 23, 11, 371–80, 12415016, 10.1542/pir.23-11-371,

General function

Electrolytes are important because they are what cells (especially nerve, heart and muscle cells) use to maintain voltages across their cell membranes. Electrolytes have different functions, and an important one is to carry electrical impulses between cells.{{citation needed|date=November 2019}} Kidneys work to keep the electrolyte concentrations in blood constant despite changes in the body. For example, during heavy exercise, electrolytes are lost in sweat, particularly in the form of sodium and potassium. The kidneys can also generate dilute urine to balance sodium levels. These electrolytes must be replaced to keep the electrolyte concentrations of the body fluids constant. Hyponatremia, or low sodium, is the most commonly seen type of electrolyte imbalance.JOURNAL, Dineen, R, Thompson, CJ, Sherlock, M, Hyponatraemia – presentations and management., Clinical Medicine, June 2017, 17, 3, 263–69, 10.7861/clinmedicine.17-3-263, 28572229, 6297575, JOURNAL, Ályarez L, E, González C, E, [Pathophysiology of sodium disorders in children]., Revista chilena de pediatria, June 2014, 85, 3, 269–80, 10.4067/S0370-41062014000300002, 25697243, Review, free, Treatment of electrolyte imbalance depends on the specific electrolyte involved and whether the levels are too high or too low. The level of aggressiveness of treatment and choice of treatment may change depending on the severity of the disturbance. If the levels of an electrolyte are too low, a common response to electrolyte imbalance may be to prescribe supplementation. However, if the electrolyte involved is sodium, the issue is often water excess rather than sodium deficiency. Supplementation for these people may correct the electrolyte imbalance but at the expense of volume overload. For newborn children, this has serious risks. Because each individual electrolyte affects physiological function differently, they must be considered separately when discussing causes, treatment, and complications.{{cn|date=June 2022}}

Calcium

Though calcium is the most plentiful electrolyte in the body, a large percentage of it is used to form the bones. It is mainly absorbed and excreted through the GI system. The majority of calcium resides extracellularly, and it is crucial for the function of neurons, muscle cells, function of enzymes, and coagulation. The normal range for calcium concentration in the body is 8.5 - 10.5 mg/dL.{{Citation|last=Goldstein|first=David A.|title=Serum Calcium|date=1990|url=http://www.ncbi.nlm.nih.gov/books/NBK250/|work=Clinical Methods: The History, Physical, and Laboratory Examinations|editor-last=Walker|editor-first=H. Kenneth|edition=3rd|publisher=Butterworths|isbn=978-0-409-90077-4|pmid=21250094|access-date=2020-03-11|editor2-last=Hall|editor2-first=W. Dallas|editor3-last=Hurst|editor3-first=J. Willis}} The parathyroid gland is responsible for sensing changes in calcium concentration and regulating the electrolyte with parathyroid hormone.JOURNAL, Bove-Fenderson, Erin, Mannstadt, Michael, 2018-10-01, Hypocalcemic disorders, Best Practice & Research Clinical Endocrinology & Metabolism, SI: Metabolic bone disease, en, 32, 5, 639–656, 10.1016/j.beem.2018.05.006, 30449546, 53951967, 1521-690X,

Hypercalcemia

Hypercalcemia describes when the concentration of calcium in the blood is too high. This occurs above 10.5 mg/dL.

Causes

The most common causes of hypercalcemia are certain types of cancer, hyperparathyroidism, hyperthyroidism, pheochromocytoma, excessive ingestion of vitamin D, sarcoidosis, and tuberculosis. Hyperparathyroidism and malignancy are the predominant causes. It can also be caused by muscle cell breakdown, prolonged immobilization, dehydration.

Symptoms

The predominant symptoms of hypercalcemia are abdominal pain, constipation, extreme thirst, excessive urination, kidney stones, nausea and vomiting. In severe cases where the calcium concentration is >14 mg/dL, individuals may experience confusion, altered mental status, coma, and seizure.

Treatment

Primary treatment of hypercalcemia consists of administering IV fluids. If the hypercalcemia is severe and/or associated with cancer, it may be treated with bisphosphonates. For very severe cases, hemodialysis may be considered for rapid removal of calcium from the blood.

Hypocalcemia

Hypocalcemia describes when calcium levels are too low in the blood, usually less than 8.5 mg/dL.{{cn|date=June 2022}}

Causes

Hypoparathyroidism and vitamin D deficiency are common causes of hypocalcemia. It can also be caused by malnutrition, blood transfusion, ethylene glycol intoxication, and pancreatitis.

Symptoms

Neurological and cardiovascular symptoms are the most common manifestations of hypocalcemia. Patients may experience muscle cramping or twitching, and numbness around the mouth and fingers. They may also have shortness of breath, low blood pressure, and cardiac arrhythmias.

Treatment

Patients with hypocalcemia may be treated with either oral or IV calcium. Typically, IV calcium is reserved for patients with severe hypocalcemia. It is also important to check magnesium levels in patients with hypocalcemia and to replace magnesium if it is low.

Chloride

Chloride, after sodium, is the second most abundant electrolyte in the blood and most abundant in the extracellular fluid.JOURNAL, Nagami, Glenn T., 2016-07-01, Hyperchloremia – Why and how, Nefrología, en, 36, 4, 347–353, 10.1016/j.nefro.2016.04.001, 27267918, 0211-6995, free, Most of the chloride in the body is from salt (NaCl) in the diet.JOURNAL, Powers, F., September 1999, The role of chloride in acid-base balance, Journal of Intravenous Nursing, 22, 5, 286–291, 0896-5846, 10776193, Chloride is part of gastric acid (HCl), which plays a role in absorption of electrolytes, activating enzymes, and killing bacteria. The levels of chloride in the blood can help determine if there are underlying metabolic disorders.JOURNAL, Berend, Kenrick, van Hulsteijn, Leonard Hendrik, Gans, Rijk O. B., April 2012, Chloride: the queen of electrolytes?, European Journal of Internal Medicine, 23, 3, 203–211, 10.1016/j.ejim.2011.11.013, 1879-0828, 22385875, Generally, chloride has an inverse relationship with bicarbonate, an electrolyte that indicates acid-base status. Overall, treatment of chloride imbalances involve addressing the underlying cause rather than supplementing or avoiding chloride.{{cn|date=June 2022}}

Hyperchloremia

Causes

Hyperchloremia, or high chloride levels, is usually associated with excess chloride intake (e.g., saltwater drowning), fluid loss (e.g., diarrhea, sweating), and metabolic acidosis.

Symptoms

Patients are usually asymptomatic with mild hyperchloremia. Symptoms associated with hyperchloremia are usually caused by the underlying cause of this electrolyte imbalance.WEB,weblink Hyperchloremia (High Chloride) - Managing Side Effects - Chemocare, chemocare.com, 2020-03-27, 2020-03-27,weblink" title="web.archive.org/web/20200327163200weblink">weblink dead,

Treatment

Treat the underlying cause, which commonly includes increasing fluid intake.

Hypochloremia

Causes

Hypochloremia, or low chloride levels, are commonly associated with gastrointestinal (e.g., vomiting) and kidney (e.g., diuretics) losses. Greater water or sodium intake relative to chloride also can contribute to hypochloremia.

Symptoms

Patients are usually asymptomatic with mild hypochloremia. Symptoms associated with hypochloremia are usually caused by the underlying cause of this electrolyte imbalance.WEB,weblink Hypochloremia (Low Chloride) - Managing Side Effects - Chemocare, chemocare.com, 2020-03-27,

Treatment

Treat the underlying cause, which commonly includes increasing fluid intake.

Magnesium

Magnesium is mostly found in the bones and within cells. Approximately 1% of total magnesium in the body is found in the blood.{{Citation|last1=Glasdam|first1=Sidsel-Marie|title=Chapter Six - The Importance of Magnesium in the Human Body: A Systematic Literature Review|date=2016-01-01|journal=Advances in Clinical Chemistry|volume=73|pages=169–193|editor-last=Makowski|editor-first=Gregory S.|publisher=Elsevier|language=en|doi=10.1016/bs.acc.2015.10.002|last2=Glasdam|first2=Stinne|last3=Peters|first3=Günther H.|pmid=26975973}} Magnesium is important in control of metabolism and is involved in numerous enzyme reactions. A normal range is 0.70 - 1.10 mmol/L. The kidney is responsible for maintaining the magnesium levels in this narrow range.

Hypermagnesemia

Hypermagnesemia, or abnormally high levels of magnesium in the blood, is relatively rare in individuals with normal kidney function.JOURNAL, Van Laecke, Steven, 2019-01-02, Hypomagnesemia and hypermagnesemia, Acta Clinica Belgica, en, 74, 1, 41–47, 10.1080/17843286.2018.1516173, 30220246, 1784-3286, This is defined by a magnesium concentration >2.5 mg/dL.

Causes

Hypermagnesemia typically occurs in individuals with abnormal kidney function. This imbalance can also occur with use of antacids or laxatives that contain magnesium. Most cases of hypermagnesemia can be prevented by avoiding magnesium-containing medications.{{cn|date=June 2022}}

Symptoms

Mild symptoms include nausea, flushing, tiredness. Neurologic symptoms are seen most commonly including decreased deep tendon reflexes. Severe symptoms include paralysis, respiratory failure, and bradycardia progressing to cardiac arrest.{{cn|date=June 2022}}

Treatment

If kidney function is normal, stopping the source of magnesium intake is sufficient. Diuretics can help increase magnesium excretion in the urine. Severe symptoms may be treated with dialysis to directly remove magnesium from the blood.{{cn|date=June 2022}}

Hypomagnesemia

Hypomagnesemia, or low magnesium levels in the blood, can occur in up to 12% of hospitalized patients.JOURNAL, Wong, E. T., Rude, R. K., Singer, F. R., Shaw, S. T., March 1983, A high prevalence of hypomagnesemia and hypermagnesemia in hospitalized patients, American Journal of Clinical Pathology, 79, 3, 348–352, 10.1093/ajcp/79.3.348, 0002-9173, 6829504, free, Symptoms or effects of hypomagnesemia can occur after relatively small deficits.

Causes

Major causes of hypomagnesemia are from gastrointestinal losses such as vomiting and diarrhea. Another major cause is from kidney losses from diuretics, alcohol use, hypercalcemia, and genetic disorders. Low dietary intake can also contribute to magnesium deficiency.

Symptoms

Hypomagnesemia is typically associated with other electrolyte abnormalities, such as hypokalemia and hypocalcemia. For this reason, there may be overlap in symptoms seen in these other electrolyte deficiencies. Severe symptoms include arrhythmias, seizures, and tetany.

Treatment

The first step in treatment is determining whether the deficiency is caused by a gastrointestinal or kidney problem. People with no or minimal symptoms are given oral magnesium; however, many people experience diarrhea and other gastrointestinal discomfort. Those who cannot tolerate or receive magnesium, or those with severe symptoms can receive intravenous magnesium.Hypomagnesemia may prevent the normalization of other electrolyte deficiencies. If other electrolyte deficiencies are associated, normalizing magnesium levels may be necessary to treat the other deficiencies.

Phosphate

Hyperphosphatemia

Hypophosphatemia

Potassium

Potassium resides mainly inside the cells of the body, so its concentration in the blood can range anywhere from 3.5 mEq/L to 5 mEq/L. The kidneys are responsible for excreting the majority of potassium from the body. This means their function is crucial for maintaining a proper balance of potassium in the blood stream.

Hyperkalemia

Hyperkalemia means the concentration of potassium in the blood is too high. This occurs when the concentration of potassium is >5 mEq/L. It can lead to cardiac arrhythmias and even death. As such it is considered to be the most dangerous electrolyte disturbance.

Causes

Hyperkalemia is typically caused by decreased excretion by the kidneys, shift of potassium to the extracellular space, or increased consumption of potassium rich foods in patients with kidney failure. The most common cause of hyperkalemia is lab error due to potassium released as blood cells from the sample break down. Other common causes are kidney disease, cell death, acidosis, and drugs that affect kidney function.

Symptoms

Part of the danger of hyperkalemia is that it is often asymptomatic, and only detected during normal lab work done by primary care physicians. As potassium levels get higher, individuals may begin to experience nausea, vomiting, and diarrhea. Patients with severe hyperkalemia, defined by levels above 7 mEq/L, may experience muscle cramps, numbness, tingling, absence of reflexes, and paralysis. Patients may experience arrhythmias that can result in death.

Treatment

There are three mainstays of treatment of hyperkalemia. These are stabilization of cardiac cells, shift of potassium into the cells, and removal of potassium from the body. Stabilization of cardiac muscle cells is done by administering calcium intravenously. Shift of potassium into the cells is done using both insulin and albuterol inhalers. Excretion of potassium from the body is done using either hemodialysis, loop diuretics, or a resin that causes potassium to be excreted in the fecal matter.

Hypokalemia

The most common electrolyte disturbance, hypokalemia means that the concentration of potassium is