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1. Decreased renin: dysfunctional kidneys that do not release renin ("hyporeninemic hypoaldosteronism"); chronic interstitial nephritis; diabetes; exacerbated by NSAIDs

2. Decreased aldosterone:
- Potassium-sparing diuretics (Spironolactone blocks the aldosterone receptor; amiloride blocks the channel its action depends on)
- ACE inhibitors, angiotensin receptor antagonists, and renin inhibition
- Primary adrenal disease (Addison's), because it affects both the zona glomerulosa (site of aldosterone production) and fasciculata (site of cortisol production) - but not secondary adrenal insufficiency because lack of ACTH affects only the zona fasciculata
Heparins (Both unfractionated and low molecular weight are directly toxic to the zona glomerulosa)

3. Cellular shift: metabolic acidosis (K + /H + exchange), increased cell turnover (tumor lysis syndrome, rhabdomyolysis, acute leukemia)

4. Renal accumulation: Type 4 RTA

5. Drugs: Trimethoprim in TMP/SMX interferes with K + secretion in the late distal tubule and cortical collecting duct


1. Wilkinson, I. (2017). Oxford handbook of clinical medicine. Oxford: Oxford University Press.
2. Hannaman, R. A., Bullock, L., Hatchell, C. A., & Yoffe, M. (2016). Internal medicine review core curriculum, 2017-2018. CO Springs, CO: MedStudy.
3. Image: no reference available.

Ⓒ A. Manickam 2018

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