Too much of a good thing: hyperkalemia from overconsumption of mangoes

Jonathan S. Zipursky MD1,2 , Umberin Najeeb MD1,2

1Department

BACKGROUND

Potassium is the major intracellular cation in

the human body.
The adequate intake (AI) of potassium for a
normal male or female adult is 4700 mg/day
(120 mmol/day)1.
Most normal humans can adequately maintain
potassium balance even if the daily intake of
potassium is slowly increased to upwards of
19500 mg (500 mmol/day)2,3.
Potassium adaptation: increased aldosterone
secretion secondary to elevations in plasma
renin activity2,3.
Hyperkalemia in the setting of dietary
indiscretion is rare in people with normal renal
function4.
Hyperkalemia is more common in patients with
acute kidney injury or chronic kidney disease
and in those patients taking medications that
can exacerbate or contribute to hyperkalemia.
PURPOSE

To describe an interesting case of a patient with

a large dietary intake of mangoes who
presented with hyperkalemia.
To highlight the importance of dietary history in
patients with chronic kidney disease who take
medications such as angiotensin converting
enzyme (ACE) inhibitors and beta-blockers that
can contribute to and exacerbate hyperkalemia.

CASE

A 70-year-old male presented to the ER with

lightheadedness, severe forehead pain, and
hypotension. In the week leading up to admission
the patient reported lightheadedness and
dizziness on exertion. Prior to coming to hospital
he measured his blood pressure at home and it
was 60/40. He immediately sought care with his
family physician who advised him to come to the
emergency room for further evaluation.

of Medicine, Sunnybrook Health Sciences Centre; 2Faculty of Medicine, University of Toronto;

The patient had a history of type II diabetes

mellitus, BPH, coronary artery disease and a CABG
in 1998 with two subsequent angioplasties. He
also has a diagnosis of NYHA III congestive heart
failure with a left ventricular ejection fracture of <
35% and had an ICD with dual chamber pacer
inserted in 2011. Medications were as follows:
lisinopril (20 mg daily), furosemide (160 mg daily),
and metoprolol (75 mg daily), and alfuzosin (10
mg daily). Upon reviewing his dietary history, the
patient revealed that he was consuming four
mangoes per day for the past two months. He
reported no other unusual dietary habits and was
not taking any additional salt, salt alternatives or
potassium supplements.
In the emergency room his blood pressure was
91/50. He appeared euvolemic with a jugular
venous pressure of 2 cm above the sternal angle.
The remainder of the physical exam was
unremarkable. Electrocardiogram showed a paced
rhythm with low voltage, occasional PVCs, but no
peaked T waves, and no prolonged ECG intervals.
Chest X-ray did not show any acute
cardiopulmonary process.
Table 1. Laboratory values at admission to hospital

TREATMENT AND OUTCOME

Table 3. Literature Review: Cases of diet associated hyperkalemia

The patient was given isotonic fluids, calcium

gluconate, Dextrose-50 solution, insulin,
salbutamol, furosemide, and Kayexelate. Lisinopril
was held. Several hours later, potassium was 5.0
mmol/L. The next day potassium was 3.5 mmol/L
and the Creatinine was 102 umol/L (eGFR = 76.7
umol/L). Prior to discharge, the patient was seen
by one of the hospital dieticians. He was
counseled regarding potassium-rich foods and
advised to reduce his intake of mangoes.

Reference

Table 2. Potassium content of fruit

Fruit

K+ content (mg)
per 100 g of fruit

Size of one whole

fruit (g)

K+ content (mg)
per one whole fruit

Watermelon

112

4518

5060

Honeydew melon

228

1000

2280

Cantaloupe

267

814

2173

Papaya

182

781

1421

Mango

168

336

564

Banana

358

118

422

Tomato

237

123

292

Orange

181

131

237

Grapefruit

139

166

231

Apple

107

182

195

Data taken from the USDA Nutrient Data Laboratory.

http://ndb.nal.usda.gov/ndb/foods/list

K+ associated with ACEi in normal renal

function = 0% to 6%; in renal insufficiency = 5% to
50% or patients5.
Risk factors: Urea > 6.4 mmol/L, Creat > 136
umol/L, CHF, age > 70, and long acting ACEi5.
Protective factors: use of a loop or thiazide
diuretic5.
K+ associated with non-selective > selective
beta blockers (4-17% of hospitalized patients): 1)
reduction in catecholamine-induced renin release
and aldosterone synthesis, and 2) prevents
potassium uptake by cells by inhibiting the
function of the Na-K-ATPase6.

Case

Javed RA, Marrero K,

Rafique M, Khan MU,
Jamarai D, Vieira J.
Singapore Med J.
2007. 48(11):e293-5.

Orange juice 51 year old male who presented with weakness and
paralysis. K = 9 mEq/L, Creatinine 177 umol/L (baseline
normal renal function), and characteristic ECG changes.
He had been drinking 2.5 L of orange juice for the past 3
weeks.

Berk DR, Conti PM,

Sommer BR. Int J
Psychiatry Med. 2004;
34(1)79-82.

Orange juice 66 year old female with schizophrenia and psychogenic

polydipsia and baseline normal renal function presented
with hyperkalemia (K = 5.9 mEq/L). She was consuming
excessive amounts of orange juice while hospitalized as
an inpatient.

Fan K, Leehey DJ.

Diabetes Care. 1996;
19(12): 1457-8.

Orange juice 50 year old male with diabetic nephropathy (Creat 400
530 umol/L) with normal K at admission (4.2 - 5.1
mEq/L) who developed hypoglycemia in hospital. He was
given orange juice and proceeded to consumed almost 4
L in the next 24 hrs and K = 6.2 mEq/L.

Tazoe M, Narita M,
Sakuta R, Nagai T,
Narita N. Brain Dev.
2007; 29(6)369-72.

DISCUSSION
Hyperkalemia was related to three factors:
Acute kidney injury
Medications (ACEi, -blocker)
Increased potassium in diet

Fruit

Banana

15 year old female with anorexia nervosa who over the

course of two years only consumed mineral water and
between 5 20 bananas per day. Serum potassium rose
from 4.7 mEq/L to 6.1 mEq/L.

Pavletic A.
Psychosomatics. 2011.
52(5): 494-495.

Dried fruit

36 year old female who was asymptomatic, but found on

routine labs to have a potassium of 6.4 mEq/L. She was
consuming large amounts of dried fruit.

Williams E, Fulop M.
The Lancet. 2001.
357(9263):1176

Apple juice

70 year old male with insulin-treated diabetes, mild CKD,

coronary and peripheral vascular disease, and chronic
bronchitis presented to hospital with a K = 8.6 mEq/L. He
was taking lisinopril. He had been consuming 2.3 to 4.5 L
of apple juice per day for several months.

CONCLUSIONS

First reported case of hyperkalemia caused by

over consumption of mangoes.
Diet can exacerbate hyperkalemia in the setting
of acute kidney injury and the use of
medications (ACEi, -blocker) that can
contribute to hyperkalemia.
It is important to take a complete medication
and dietary history in any patient who presents
with hyperkalemia and especially those with
concomitant acute or chronic kidney injury.
REFERENCES
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uncommon or undiagnosed. Am J Emerg Med. 2011; 29(9)e1-2.
Nyirenda MJ, Tang JI, Padfield PL, Seckl JR. Hyperkalaemia. BMJ. 2009; 339:1019-24.
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Inhibitors-How Much Should We Worry? Arch Int Med. 1998. 158: 26-32.
Perazella M. Drug-induced Hyperkalemia: Old Culprits and New Offenders. Am. J. Med. 2000. 109: 307314.
Javed RA, Marrero K, Rafique M, Khan MU, Jamarai D, Vieira J. Life-threatening hyperkalaemia
developing following excessive ingestion of orange juice in a patient with baseline normal renal
function. Singapore Med J. 2007. 48(11):e293-5.
Berk DR, Conti PM, Sommer BR. Orange juice-induced hyperkalemia in schizophrenia. Int J Psychiatry
Med. 2004; 34(1)79-82.
Fan K, Leehey DJ. Orange juice-induced hyperkalemia in a diabetic patient with chronic renal failure.
Diabetes Care. 1996; 19(12): 1457-8.
Tazoe M, Narita M, Sakuta R, Nagai T, Narita N. Hyperkalemia and hyperdopaminemia induced by an
obsessive eating of banana in an anorexia nervosa adolescent. Brain Dev. 2007; 29(6)369-72.
Pavletic A. Hyperkalemia induced by excessive consumption of dried fruits manifestation of an
undiagnosed eating disorder? Psychosomatics. 2011. 52(5): 494-495.
Williams E, Fulop M. A puzzling case of hyperkalemia. The Lancet. 2001. 357(9263):1176