Case: HYPERKALEMIA Group A2

Salient Features 62 y/o Male Diabetic, Chronic Kidney Disease With proximal weakness Decreased skin turgor

Blood Test Results Normal Values Plasma Na 130 mEq/L K 8.5 mEq/L Chloride 98 mEq/L HCO3 17 mEq/L Creatinine 2.7 mEq/L pH 7.32 Capillary blood glucose 400 mmol/L Serum acetone +

2. Is this pseudohyperkalemia? Why or why not?

Pseudohyperkalemia An artificially elevated plasma K+ concentration due to K+ movement out of cells Factors: Prolonged use of torniquet (with or withour repeated clenched fist) Hemolysis Marked leukocytosis or thrombocytosis

Our patient is not in pseudohyperkalemia No leukocytosis No Hemolysis In Chronic Renal Failure

4. How would you manage this case?

Oliguric Renal failure Stop NSAIDS and ACEI Rule out: Pseudohyperkalemia Trancellular K+ shift Oliguric Renal failure Stop NSAIDS and ACEI Assess K+ secretion TTKG <5 TTKG > 10 Inc. distal flow Response to 9α – fludrocortisone Decreased effective circulating volume Low – protein diet (decreased urea) TTKG > 10 TTKG < 10 Primary or secondary hypoaldosteronism Hypotension high renin and aldosterone Hypertension Low renin and aldosterone Measure renin & aldosterone levels Pseudohypoaldosteronism K+ sparing diuretics Trimethoprim, pentamide Gordon’s Syndrome (Cl- shunt) Cyclosporine Distal (type 4) RTA

I. Evaluate Hyperkalemia Confirm the presence of hyperkalemia in patient

II. Determine Urgency Situation Emergent: if… Rapid and recent rise in Serum Potassium Renal insufficiency Metabolic Acidosis EKG changes consistent with Hyperkalemia (life – threatening & may be serious) Treatment: Individual Medications: Calcium gluconate Insulin and Glucose Kayexalate Bicarbonate Dialysis

Calcium gluconate Insulin and Glucose Stabilize myocardium Initial dose: 10 ml over 2-5 minutes Second dose after 5 minutes if no response Further calcium ineffective unless Hypocalcemia Insulin and Glucose Temporarily shift potassium into intracellular space Insulin Regular 10 units IV Glucose 50% (D50W) 50 ml (25 grams) Indicated with insulin if serum glucose <250 mg/dl Give 1 ampule IV over 5 minutes consider maintenance (e.g. D5 1/2NS 100 cc/h) Post initial bolus to cover further insulin

Nebulized Albuterol Bicarbonate 5 mg/ml Administer 10-20 mg over 10 minutes Serum potassium may increase briefly Bicarbonate no longer used unless Metabolic Acidosis Used before as adjunct to Calcium Consider in severe Metabolic Acidosis Sodium Bicarbonate 7.5% (44.6 meq) Give 1 ampule IV over 5 minutes May repeat every 10-15 min if EKG changes persists May also add to Glucose infusion Avoid bicarbonate until Hypocalcemia corrected Risk of Tetany and Seizures

Treatment: Enhance postassium excretion Non – Emergent: if… Emergent treatment criteria not met Serum Potassium <6.0 Treatment: Enhance postassium excretion Kayexalate gastrointestinal excretion: Sodium Polysterene Sulfonate (Kayexalate) Cation-Exchange Resin Dose: 50 grams Oral: Administer in 30 ml of Sorbitol Rectal: Enema activity is faster than oral Onset: Up to 4-6 hours for oral route Precautions: Avoid Sorbitol if bowel necrosis risk use caution if risk of CHF

Furosemide Dialysis Renal excretion Last option Dose: 20-40 mg IV Coadminister normal saline if dehydrated Dialysis Last option

III. Have a long – term plan For chronic hyperkalemia patients Treatment: Eliminate medication causes of elevated serum potassium Non-specific therapy Loop diuretics (Lasix) Oral Kayexalate chronically Specific Therapy Renal Failure (GFR < 10 ml/min) Restrict dietary Potassium to 40-60 meq/day

Renal Failure and ACE or ARB induced Hyperkalemia Indications: Metabolic Acidosis Sodium Bicarbonate Dose A: 8 meq tabs, 2 tabs twice daily Dose B: 0.5 to 1 tsp baking soda daily Hyporeninemic Hypoaldosteronism Loop diuretics ( Lasix) Fludrocortisone 0.1 mg daily Taper gradually as an outpatient Restart if Hyperkalemia recurs