In DKA, how is potassium status typically described?

• A. Hyperkalemia is expected; if low or normal, there is a risk of profound hypokalemia
• B. Hypokalemia is always present and cannot change
• C. Potassium is not affected by DKA
• D. Potassium should be ignored during initial management

Answer: (A)

In DKA, potassium status is driven by shifts between the inside and outside of cells plus losses from the body. Insulin deficiency and metabolic acidosis push potassium out of cells into the bloodstream, so patients often present with a normal or even elevated serum potassium. At the same time, there is a real total body potassium deficit from osmotic diuresis, vomiting, and volume depletion, so the body’s potassium stores are low even if the blood level isn’t. When treatment begins with fluids and insulin, potassium shifts back into cells, which can cause the serum potassium to fall rapidly. If this isn’t anticipated and potassium isn’t replenished appropriately, profound hypokalemia can develop and lead to dangerous arrhythmias. Therefore, the typical description is that hyperkalemia or a normal potassium level is expected on presentation, but there is a total body potassium depletion, and initiating treatment can precipitate a significant drop in potassium.