HYPERKALEMIAGroup A2

Case:

Salient Features

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

Blood TestResults 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?

Rule out:• Pseudohyperkalemia• Trancellular K+ shift• Oliguric Renal failure• Stop NSAIDS and ACEI

Assess K+ secretion

TTKG <5 TTKG > 10Inc. distal flow

• Decreased effective circulating volume• Low – protein diet (decreased urea)

Response to 9α – fludrocortisone

TTKG > 10 TTKG < 10

Primary or secondary hypoaldosteronism

Measure renin & aldosterone levels

Hypotension high renin and

aldosterone

Pseudohypoaldosteronism K+ sparing diuretics

Trimethoprim, pentamide

HypertensionLow renin and aldosterone

Gordon’s Syndrome(Cl- shunt)

CyclosporineDistal (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• 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• 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

• 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• Renal excretion

– 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