Blood Potassium Levels Research Articles

Relationship between blood electrolytes and prognosis of patients with severe coronavirus disease 2019

To analyze the relationship between blood electrolytes and the prognosis of patients with severe coronavirus disease 2019 (COVID-19) and to provide assistance for clinical decision-making. The clinical data of patients with severe COVID-19 admitted to intensive care unit (ICU) of the Wuhan Third Hospital by the Shanghai aid-Hubei medical team from January 21 to March 4, 2020 were collected. Excluding ineligible patients, 110 patients were finally enrolled. The patients' gender, age, temperature, heart rate, systolic and diastolic blood pressure, clinical symptoms at admission, time of symptom onset, duration of fever, and relevant indicators at admission to ICU (including blood potassium, chloride, sodium, calcium, phosphorus, and magnesium, etc.) and prognosis were analyzed. The patients were grouped by blood potassium or calcium levels or blood potassium/calcium ratio. The Kaplan-Meier survival curves were used to analyze the survival of patients in each group. The relationship between the potassium/calcium ratio and the prognosis was analyzed using restricted cubic spline plots. The relationship between each index in the different models and the prognosis was analyzed using Cox regression models. Among 110 severe COVID-19 patients, 78 cases survived, and 32 cases died. Compared with the surviving group, patients in the death group had higher blood potassium levels [mmol/L: 4.25 (3.80, 4.65) vs. 3.90 (3.60, 4.20), P < 0.05] and lower blood calcium levels (mmol/L: 2.00±0.14 vs. 2.19±0.18, P < 0.05). The Kaplan-Meier survival curves showed that patients in the potassium > 4.2 mmol/L group had a worse prognosis than the potassium < 3.8 mmol/L group and the potassium 3.8-4.2 mmol/L group (P = 0.011), patients in the calcium > 2.23 mmol/L group had a better prognosis than the calcium < 2.03 mmol/L group and the calcium 2.03-2.23 mmol/L group, and the lower calcium group had a worse prognosis (P = 0.000 15). Cox regression analysis showed that the hazard ratio (HR) of blood potassium and calcium were 2.08 and 0.01, respectively, in model 1 (single blood potassium or calcium) and in model 2 (model 1 plus age and gender), the HR of blood potassium and calcium were 1.98 and 0.01 respectively, which were significantly associated with patient prognosis (all P < 0.05). Patients in the group with the potassium/calcium ratio > 1.9 had higher blood potassium levels and a higher proportion of mechanical ventilation, lower calcium levels and lower proportion of survival, and longer time of ICU admission compared with the groups with the potassium/calcium ratio < 1.7 and 1.7-1.9. The Kaplan-Meier survival curves showed that the survival rate of the potassium/calcium ratio > 1.9 group was the lowest (P < 0.000 1), and there was no statistically significant difference in survival between the potassium/calcium ratio < 1.7 group and the potassium/calcium ratio 1.7-1.9 group. A restricted cubic spline plot corrected for age and gender showed that patients in the potassium/calcium ratio > 1.8 group had HR values > 1. Cox regression analysis corrected for other indicators showed that the potassium/calcium ratio was still associated with patient prognosis (HR = 4.85, P = 0.033). Blood potassium, calcium, and the potassium/calcium ratio at ICU admission are related to the prognosis of patients with severe COVID-19, and the potassium/calcium ratio is an independent risk factor for the death of patients. The higher the potassium/calcium ratio, the worse the prognosis of patients.

Capecitabine-induced severe diabetes and hypokalemia: a case report

BackgroundCapecitabine is widely used in chemotherapy for breast, colorectal, and gastric cancers. The frequent adverse reactions of capecitabine mainly include gastrointestinal side effects, anemia, and cardiovascular toxicity. Here, we report a rare case of severe hyperglycemia and hypokalemia during long-term treatment with capecitabine.Case presentationA 48-year-old Chinese female was hospitalized with the complaint of breathlessness and weakness after activity, for 1 month. Her past history is significant for a diagnosis of right-sided breast cancer 7 years ago. She underwent right mastectomy, following which capecitabine was started 1.5 years prior to the current admission as part of her primary treatment at the discovery of systemic osseous metastasis. Her fasting plasma glucose and hemoglobin A1c levels were quite normal 7 months ago but increased to 15.3 mmol/L and 11.2%, respectively, at the present admission. Her serum potassium level was as low as 2.5 mmol/L. Plasma autoantibodies related to islets and insulin were all negative. Capecitabine was discontinued, and an insulin pump and potassium supplement were given after admission. Her blood sugar and potassium levels returned to their normal ranges soon. Self-injection of insulin was withdrawn completely at 2 months after discharge, and no oral hypoglycemic agents were added. Her plasma glucose and electrolyte levels were at normal levels at her 1-year follow-up.ConclusionGlucose intolerance and hypokalemia may be rare but serious adverse effects during long-term chemotherapy with capecitabine.

Declining Levels and Bioavailability of IGF-I in Cardiovascular Aging Associate With QT Prolongation-Results From the 1946 British Birth Cohort.

BackgroundAs people age, circulating levels of insulin-like growth factors (IGFs) and IGF binding protein 3 (IGFBP-3) decline. In rat cardiomyocytes, IGF-I has been shown to regulate sarcolemmal potassium channel activity and late sodium current thus impacting cardiac repolarization and the heart rate-corrected QT (QTc). However, the relationship between IGFs and IGFBP-3 with the QTc interval in humans, is unknown.ObjectivesTo examine the association of IGFs and IGFBP-3 with QTc interval in an older age population-based cohort.MethodsParticipants were from the 1946 Medical Research Council (MRC) National Survey of Health and Development (NSHD) British birth cohort. Biomarkers from blood samples at age 53 and 60–64 years (y, exposures) included IGF-I/II, IGFBP-3, IGF-I/IGFBP-3 ratio and the change (Δ) in marker levels between the 60–64 and 53y sampled timepoints. QTc (outcome) was recorded from electrocardiograms at the 60–64y timepoint. Generalized linear multivariable models with adjustments for relevant demographic and clinical factors, were used for complete-cases and repeated after multiple imputation.ResultsOne thousand four hundred forty-eight participants were included (48.3% men; QTc mean 414 ms interquartile range 26 ms). Univariate analysis revealed an association between low IGF-I and IGF-I/IGFBP-3 ratio at 60–64y with QTc prolongation [respectively: β −0.30 ms/nmol/L, (95% confidence intervals −0.44, −0.17), p < 0.001; β−28.9 ms/unit (-41.93, −15.50), p < 0.001], but not with IGF-II or IGFBP-3. No association with QTc was found for IGF biomarkers sampled at 53y, however both ΔIGF-I and ΔIGF-I/IGFBP-3 ratio were negatively associated with QTc [β −0.04 ms/nmol/L (−0.08, −0.008), p = 0.019; β −2.44 ms/unit (-4.17, −0.67), p = 0.007] while ΔIGF-II and ΔIGFBP-3 showed no association. In fully adjusted complete case and imputed models (reporting latter) low IGF-I and IGF-I/IGFBP-3 ratio at 60–64y [β −0.21 ms/nmol/L (−0.39, −0.04), p = 0.017; β −20.14 ms/unit (−36.28, −3.99), p = 0.015], steeper decline in ΔIGF-I [β −0.05 ms/nmol/L/10 years (−0.10, −0.002), p = 0.042] and shallower rise in ΔIGF-I/IGFBP-3 ratio over a decade [β −2.16 ms/unit/10 years (−4.23, −0.09), p = 0.041], were all independently associated with QTc prolongation. Independent associations with QTc were also confirmed for other previously known covariates: female sex [β 9.65 ms (6.65, 12.65), p < 0.001], increased left ventricular mass [β 0.04 ms/g (0.02, 0.06), p < 0.001] and blood potassium levels [β −5.70 ms/mmol/L (−10.23, −1.18) p = 0.014].ConclusionOver a decade, in an older age population-based cohort, declining levels and bioavailability of IGF-I associate with prolongation of the QTc interval. As QTc prolongation associates with increased risk for sudden death even in apparently healthy people, further research into the antiarrhythmic effects of IGF-I on cardiomyocytes is warranted.

The Effects Of Race On Guideline-Directed Medical Therapy Prescribing In Patients With Heart Failure With Reduced Ejection Fraction At A Large Academic Medical Center

The Effects Of Race On Guideline-Directed Medical Therapy Prescribing In Patients With Heart Failure With Reduced Ejection Fraction At A Large Academic Medical Center

Predictors of hyperkalemia after total parathyroidectomy in patients with drug-refractory secondary hyperparathyroidism.

The purpose of this retrospective study was to explore the primary possible risk factors for the development of postoperative hyperkalemia after total parathyroidectomy with autotransplantation (TPTX + AT) in patients with drug-refractory secondary hyperparathyroidism (SHPT). The clinical data of 149 patients receiving maintenance dialysis for drug-refractory SHPT, who underwent TPTX + AT, were reviewed and analyzed. Demographic data, dialysis status, and laboratory test indices were collected from enrolled patients. According to the postoperative serum potassium level >5.3 mmol/L or not, they were divided into hyperkalemia group and non-hyperkalemia group. The differences in general clinical data and laboratory indicators between the two groups were compared; logistic regression analysis was performed to analyze the risk factors affecting the development of postoperative hyperkalemia in patients; receiver operating characteristic (ROC) subject workup curves were analyzed for the threshold values of postoperative hyperkalemia. Of the 149 participants, 25 (16.78%) developed postoperative hyperkalemia after TPTX + AT. Univariate analysis suggested that dialysis duration, SHPT duration, dialysis modality, and preoperative alkaline phosphatase, blood potassium, and blood calcium levels were independently associated with the development of hyperkalemia after TPTX + AT. Univariate logistic analysis suggested that dialysis duration [odds ratio (OR) 1.18, 95% confidence interval (CI): 1.03, 1.35, P=0.014], preoperative blood potassium (OR 4.95, 95% CI: 2.05, 11.96, P<0.001), and preoperative blood calcium (OR 16.17, 95% CI: 1.36, 191.58, P=0.027) were 3 factors that predicted hyperkalemia after TPTX + AT. According to ROC curve analysis, the optimal cutoff point for dialysis duration was 8.5 years, the optimal cutoff level for preoperative blood potassium was 4.57 mmol/L, and the optimal cutoff level for preoperative blood calcium was 2.31 mmol/L. Of these 3 factors, preoperative blood potassium had a more balanced sensitivity, specificity, and optimal diagnostic efficacy. Patients with drug-refractory SHPT are prone to hyperkalemia after TPTX + AT. Duration of dialysis and preoperative blood potassium and blood calcium levels can help predict the development of postoperative hyperkalemia.

Prevalence of Hyperkalaemia in Chronic Haemodialysis Patients

Haemodialysis patients are more likely to suffer from hyperkalaemia than the general population. It puts them at danger of a fatal accident. In haemodialysis, it is not part of the standard examinations. The purpose of our study was to find out how common it was among individuals on long-term dialysis. Our research was cross-sectional in nature. Participants had to have been on haemodialysis for at least two months and be willing to participate in the research. Before the start of their first and second weekly dialysis sessions, we did a clinical examination, blood potassium, sodium, and ionized calcium tests, and an electrocardiogram in each of them. 88 patients were chosen for the study. Before the first dialysis session began, 38.7 percent of patients had hyperkalaemia, and 17 percent had it before the second. In three cases, the blood potassium level was determined to be at least 7.5 mEq / l, indicating that the patient was suffering from a condition known as paresis. Hyperkalaemia is associated with a tall T wave on the ECG in two circumstances. Although hyperkalaemia is widespread in our dialysis patients, its clinical and electrocardiographic symptoms are less so.

Ejection fraction and blood pressure variabilities in acute myocardial infarction patients and its relationship with serum electrolytes

Background: In patients with acute myocardial infarction, age, BMI, blood pressure, and electrolytes all influence ejection fraction improvement following percutaneous coronary intervention (PCI) . Many studies have looked into the long-term consequences of these factors, but none have found evidence that they have an impact on PCI efficacy. Aim: To evaluate the effectiveness of percutaneous coronary intervention (PCI) and predict prognosis in AMI patients by measuring blood pressure and serum electrolytes. Methods: It is a study that will last for a lengthy period of time. Before and after angioplasty, the EF of 40 patients with acute myocardial infarction (AMI) was measured in this research. The data were analysed using the SPSS 23 statistical package. Results:The effects of age (P = 0.34) and BMI (P = 0.49) on EF improvement are not well understood. The difference between those with initial high blood pressure and those without (P = 0.12), although not significantly different. Although serum calcium levels (P = 0.74) were normal, elevated sodium and potassium levels (P = 0.05) were shown to be associated with lower EF improvement. The concentrations of sodium and potassium in the blood were found to have a P value of 0.07. Conclusion: After PCI, patients with AMI have a better prognosis if they are older and have a normal BMI; nonetheless, greater blood sodium and potassium levels have a worse prognosis. Key words: Acute Myocardial Infarction; Percutaneous Intervention; Ejection Fraction; Serum Electrolytes

Thyrotoxic Hypokalemic Periodic Paralysis: Case Report

Introduction: &#x0D; Thyrotoxic Hypokalemic Periodic Paralysis (THPP) is a rare hereditary disorder which is characterized by thyroid hormone elevation, low blood potassium level and recurrent acute muscle weakness. Basic pathology is thought to be the increase in activity in the sodium-potassium pump (Na+/K+ATPase). &#x0D; &#x0D; Case report: &#x0D; Here we report the case of a 31-year-old male that presented with weakness in his legs, and inability to walk. The patient had elevated thyroid hormone levels (FT3 and FT4) and lower TSH levels, lower serum potassium levels, and recurrent acute muscle weakness. The diagnosis was made to be Thyrotoxic Hypokalemic Periodic Paralysis precipitated after intense physical activity. &#x0D; &#x0D; Conclusion: &#x0D; THPP is a reversible medical emergency. Early diagnosis, and rapid treatment is lifesaving. Although rare, THPP must be considered as a differential diagnosis in patients presenting with hypokalemia and paralysis.

Adrenal glands and diabetes

Adrenal glands and diabetes

Serum copeptin as a biomarker of hypertension in children with obesity

Hypertension (HT) in obesity has been reported frequently in children in recent years. The role of copeptin and uric acid here are not well known. We aimed to investigate the relationship between HT and serum copeptin and uric acid levels in children with obesity. We included 80 children with obesity who were admitted to our hospital between April 2018 and September 2018. The patients were separated into two groups: hypertensive and non-hypertensive. Serum copeptin levels were measured using the enzyme-linked immunosorbent assay. Copeptin levels were significantly higher in patients with HT than in those without (p= 0.0001). In addition, serum uric acid levels in patients with HT were significantly higher, while the serum potassium levels were significantly lower (p= 0.01) than in those without HT (p= 0.001). In correlation analyses, a positive correlation was detected between blood sodium and copeptin levels (p= 0.037). Hypertensive children with obesity had higher serum copeptin and uric acid and lower blood potassium levels. Moreover, copeptin levels were positively correlated with blood sodium levels. Thus, in addition to copeptin, serum uric acid, potassium, and sodium levels may be important in the diagnosis and follow-up of children with HT.

Changes in Blood Potassium after Reperfusion during Living-Donor Liver Transplantation: An Exploratory Study.

The incidence of hyperkalemia (>5.5 mEq/L) or high blood potassium (5–5.5 mEq/L) during living-donor liver transplantation (LDLT) is reported to be more than 10%. It occurs more frequently in the early post-reperfusion period and is a major cause of post-reperfusion arrhythmia and cardiac arrest. Unlike deceased-donor liver transplantation, the pattern of blood potassium changes immediately after reperfusion has not been described in LDLT. From January 2021 to March 2021, fifteen consecutive patients were enrolled. Baseline blood potassium was measured from blood samples obtained 10-min (T-10) and immediately before (T0) reperfusion. During the first 5 min after reperfusion, blood potassium measurements were conducted every one minute (T1–T5). The blood potassium levels at T-10 and T0 were 3.8 ± 0.4 and 3.9 ± 0.4 mEq/L, respectively. After reperfusion, mean increases (95% CI) in blood potassium from T-10 and T0 were 0.5 (0.4–0.6) and 0.4 (0.3–0.5) mEq/L, respectively. Blood potassium peaked at T1, returned to baseline at T3, and fell below the baseline at T5. Peak blood potassium after reperfusion showed strong correlations with blood potassium measured at T-10 (p < 0.001) and T0 (p < 0.0001). These findings can support the establishment of future research plans and perioperative management of blood potassium in LDLT.

The effect of imatinib and nilotinib on blood calcium and blood potassium levels in chronic myeloid leukemia patients: a literature review.

Imatinib and nilotinib are first-line treatments for chronic myeloid leukemia (CML) patients, which act specifically against target cells. However, these drugs may cause side effects, such as electrolyte disturbances. This literature review aimed to provide a comparison of the effects of imatinib and nilotinib on blood potassium and calcium levels. It also summarized their hypothetical mechanism. A comprehensive electronic search of the different databases was conducted using ‘chronic myeloid leukemia’, ‘tyrosine kinase inhibitors’, ‘imatinib’, ‘nilotinib’, ‘potassium’, ‘calcium’, ‘electrolytes’ as keywords. This review used PubMed- MEDLINE, Cochrane Library, and Google Scholar as the source databases. Sixteen articles published from 2006 to 2020 were reviewed. Changes in blood potassium levels range from increased to decreased levels, while changes in blood calcium levels range from the lower normal values to below normal values (hypocalcemia). Tyrosine kinase inhibitors (TKIs), including imatinib and nilotinib, have a non-specific target, namely plateletderived growth factor receptor (PDGFR), which indirectly affects blood potassium and calcium levels in CML patients. The clinical manifestations of these changes vary from being visible only in laboratory tests to displaying a variety of clinical signs and symptoms.

Prevalence and related factors of hyperkalemia in patients with diabetic kidney disease

Objective: To explore the prevalence and related factors of hyperkalemia in patients with diabetic kidney disease (DKD). Methods: DKD patients from the Department of Nephrology of the First Affiliated Hospital of Zhengzhou University from January 2012 to December 2020 were selected, and the clinical data of the patients were retrospectively collected. The prevalence of hyperkalemia in DKD patients and the prevalence of hyperkalemia in patients with different age, gender and different stages of chronic kidney disease (CKD) were studied, and the related factors of hyperkalemia were further explored. Results: A total of 1 721 patients with DKD were included, with 1 117 males (64.9%) [mean age: (56±12) years] and 604 females (35.1%) [mean age: (59±12) years]. The blood potassium level of the study population was (4.93±0.77) mmol/L, in which the serum potassium level of male and female was (4.92±0.77) mmol/L and (4.93±0.76) mmol/L, respectively, and the difference was not statistically significant (P=0.752). Further grouping by CKD stage, the serum potassium levels of CKD stage 1-5 patients were (4.58±0.52), (4.65±0.47), (4.86±0.59), (5.21±0.79) and (5.61±0.88) mmol/L, respectively, and the difference was statistically significant (F=170.701, P<0.001). The prevalence of hyperkalemia was 37.0% (636/1 721). The prevalence of mild, moderate and severe hyperkalemia was 17.4%, 10.5% and 9.1%, respectively. There was no significant difference in the prevalence of hyperkalemia between men and women (36.8% vs 37.3%, χ²=0.035, P=0.851). The prevalence of hyperkalemia in CKD stage 1-5 patients was 16.3%, 21.2%, 37.6%, 55.2%, 72.5%, respectively, which increased with the severity of CKD (χ²=365.721, P<0.001). Multivariate logistic regression showed that estimated glomerular filtration rate (OR=0.975, 95%CI: 0.972-0.979), diastolic blood pressure (OR=0.985, 95%CI: 0.975-0.994) and serum sodium concentration (OR=0.972, 95%CI: 0.945-1.000) were the influencing factors of hyperkalemia in DKD patients. Conclusions: The prevalence of hyperkalemia in DKD patients was 37.0%. Glomerular filtration rate, diastolic blood pressure and serum sodium concentration were the influencing factors. The serum potassium level and the prevalence of hyperkalemia increased with the deterioration of renal function.

Assessment of Omecamtiv Mecarbil for the Treatment of Patients With Severe Heart Failure

Heart failure with reduced ejection fraction is a progressive clinical syndrome, and many patients' condition worsen over time despite treatment. Patients with more severe disease are often intolerant of available medical therapies. To evaluate the efficacy and safety of omecamtiv mecarbil for the treatment of patients with severe heart failure (HF) enrolled in the Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure (GALACTIC-HF) randomized clinical trial. The GALACTIC-HF study was a global double-blind, placebo-controlled phase 3 randomized clinical trial that was conducted at multiple centers between January 2017 and August 2020. A total of 8232 patients with symptomatic HF (defined as New York Heart Association symptom class II-IV) and left ventricular ejection fraction of 35% or less were randomized to receive omecamtiv mecarbil or placebo and followed up for a median of 21.8 months (range, 15.4-28.6 months). The current post hoc analysis evaluated the efficacy and safety of omecamtiv mecarbil therapy among patients classified as having severe HF compared with patients without severe HF. Severe HF was defined as the presence of all of the following criteria: New York Heart Association symptom class III to IV, left ventricular ejection fraction of 30% or less, and hospitalization for HF within the previous 6 months. Participants were randomized at a 1:1 ratio to receive either omecamtiv mecarbil or placebo. The primary end point was time to first HF event or cardiovascular (CV) death. Secondary end points included time to CV death and safety and tolerability. Among 8232 patients enrolled in the GALACTIC-HF clinical trial, 2258 patients (27.4%; mean [SD] age, 64.5 [11.6] years; 1781 men [78.9%]) met the specified criteria for severe HF. Of those, 1106 patients were randomized to the omecamtiv mecarbil group and 1152 to the placebo group. Patients with severe HF who received omecamtiv mecarbil experienced a significant treatment benefit for the primary end point (hazard ratio [HR], 0.80; 95% CI, 0.71-0.90), whereas patients without severe HF had no significant treatment benefit (HR, 0.99; 95% CI, 0.91-1.08; P = .005 for interaction). For CV death, the results were similar (HR for patients with vs without severe HF: 0.88 [95% CI, 0.75-1.03] vs 1.10 [95% CI, 0.97-1.25]; P = .03 for interaction). Omecamtiv mecarbil therapy was well tolerated in patients with severe HF, with no significant changes in blood pressure, kidney function, or potassium level compared with placebo. In this post hoc analysis of data from the GALACTIC-HF clinical trial, omecamtiv mecarbil therapy may have provided a clinically meaningful reduction in the composite end point of time to first HF event or CV death among patients with severe HF. These data support a potential role of omecamtiv mecarbil therapy among patients for whom current treatment options are limited. ClinicalTrials.gov Identifier: NCT02929329.

LABORATORY RISK INDICATOR FOR NECROTIZING FASCIITIS (LRINEC) SCORE FOR THE ASSESSMENT OF NECROTIZING FASCIITIS IN HIMALAYAN REGION.

Background: The LRINEC score (laboratory risk indicators for necrotizing fasciitis) was established in 2004 to aid in the differentiation of necrotizing fasciitis from severe soft tissue infections. Methods: The study included all patients hospitalized to the department of general surgery at Dr. Rajendra Prasad Govt. Medical College &amp; Hospital, Kangra, Tanda, H.P. India with a diagnosis of necrotizing fasciitis for a period of one year, from June 2018 to May 2019. At the time of admission, the patient’s hemoglobin, white blood cell count, C-reactive protein, blood glucose level, urea, sodium, potassium and creatinine levels (LIRNEC Score) were calculated. Results: In all the patients LRINEC Score was &gt; 6. Out of 60 patients, 14(23%) patients had LRINEC Score in between 6 to 7 and 46 (76%) patients had LRINEC score &gt;8. Conclusion: The LRINEC score of 6 and above suggest NF and therefore aiding in the early recognition of NSTI and its management.

Comparison of Biochemical and Pathological Parameters and Parenteral Nutrition of ICU Patients Under Supervision of Dietitians and Surgeons.

Background: Nutrient imbalance can frequently occur in patients with indications for parenteral nutrition (PN) after gastrointestinal surgery. This study aimed to compare the recommendations of a surgeon to those of a dietitian in the field of parenteral nutrition.Methods: This study was performed on 256 patients undergoing gastrointestinal surgery who received PN, which included 120 patients who received PN based on recommendations of the surgeons and 136 patients who were referred to receive PN under the supervision of a dietitian in Razi Hospital in Rasht, Iran. Data on PN and clinical outcomes of the patients were collected.Results: Patients under the supervision of dietitians received higher vitamin B complex and lipids and lower vitamin A and vitamin E than the surgeon-supervised patients (all P < 0.001). In the group receiving PN under the supervision of a surgeon, the level of blood glucose (207 vs. 182, P < 0.01), sodium (138 vs. 136, P = 0.01), potassium (3.97 vs. 3.53, P < 0.01), and white blood cell count (9.83 vs. 9.28, P < 0.01) increased significantly at the end of the PN compared to baseline. In the group receiving PN under the supervision of a dietician, the level of serum Cr (1.23 vs. 1.32, P = 0.04), Mg (2.07 vs. 1.84, P < 0.01), and pH (7.45 vs. 7.5, P = 0.03) significantly improved after receiving parenteral nutrition compared to baseline.Conclusion: The amounts of nutrients recommended for PN by the surgeon and dietitian were different. Implementation of dietitian recommendations in critically ill patients under PN can improve patients' clinical parameters.

MIRACLE DRUG UNDER FIRE: HYDROXYCHLOROQUINE OVERDOSE TOXICOKINETICS EXPLORED

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Hydroxychloroquine (HCQ) is a medication used in the treatment of malaria, lupus and rheumatoid arthritis. The drug gained popularity during the early stage of the Coronavirus Disease 2019 (COVID-19) pandemic as an emergency use therapy. It has since been shown in numerous studies that HCQ can actually cause more harm than good. However, its media attention has led to an increase in overdose cases, which can be fatal due to cardiac complications. We present a case of a patient with access to HCQ for COVID-19 prophylaxis who overdosed in a suicide attempt with a favorable outcome. CASE PRESENTATION: A 38-year old Asian American female with no significant history was found 4-6 hours after ingesting approximately 27 grams of oral HCQ. She was admitted to the intensive care for shock and severe hypokalemia (1.7 mmol/L). The pills were obtained from an overseas third party vendor for COVID-19 prophylaxis. Vitals on arrival were BP 60/30 mmHg, HR 66 bpm, temperature 94.9 fahrenheit. Based on previous case reports and studies on chloroquine, the patient was started on an epinephrine and versed drip, including 2 doses of 60mg diazepam. A single dose of activated charcoal was administered. Initial electrocardiogram revealed conduction abnormalities with QT interval of 549ms (629ms with Bazett's correction). The patient received 240 meq of potassium in a span of 25 hour and began to develop hyperkalemia of up to 6.4 mmol/L. After 48 hours, the patient's blood pressure and potassium levels normalized. On hospital day 4, she was successfully extubated with a favorable remaining hospital course. DISCUSSION: The most life threatening sequelae seen in HCQ overdoses are cardiac arrhythmias due to electrolyte imbalances, mainly potassium. Hyperkalemia after initial severe hypokalemia has been observed in numerous case reports of HCQ overdose and thought to be intracellular shifts rather than relative depletion. Thus, caution should be taken in the correction of initial hypokalemia. A review of previous cases shows an inverse relationship between potassium and HCQ levels, as with our case. Reported toxicity half-life ranges between 11.6 and 31 hours. Our case had an approximate peak concentration of 27 µg/ml after 4-6 hours after ingestion with an estimated observed half-life of 27 hours based on recorded concentrations over 45 hours, assuming 1st order elimination. Our patient's hypokalemia began to reverse during the 2nd half-life period which is also consistent with other reported cases. CONCLUSIONS: We believe that during the 2nd half-life, when more than 50% of the drug is eliminated, is the period when correction of hypokalemia should be taken with more caution. While these are only observations based on a few case reports, they can provide more insight on how to better manage electrolyte imbalances which can avoid fatal arrhythmias and circulatory arrest. REFERENCE #1: de Olano, J., Howland, M. A., Su, M. K., Hoffman, R. S., & Biary, R. (2019). Toxicokinetics of hydroxychloroquine following a massive overdose. The American journal of emergency medicine, 37(12), 2264-e5. REFERENCE #2: Jordan, P., Brookes, J. G., Nikolic, G., Le Couteur, D. G., & Le Couteur, D. (1999). Hydroxychloroquine overdose: toxicokinetics and management. Journal of Toxicology: Clinical Toxicology, 37(7), 861-864. REFERENCE #3: Palatnick, W., Meatherall, R., Sitar, D., & Tenenbein, M. (1997). Hydroxychloroquine kinetics after overdose. J Toxicol Clin Toxicol, 35, 496.Miller, D., & Fiechtner, J. (1989). Hydroxychloroquine overdosage. The Journal of rheumatology, 16(1), 142-143. DISCLOSURES: No relevant relationships by Fatima Anjum, source=Web Response No relevant relationships by James Kang, source=Web Response No relevant relationships by Hyfaa Mashaal, source=Web Response No relevant relationships by James Pellegrini, source=Web Response

Effect of Angiotensin Receptor Blocker and Angiotensin Converting Enzyme Inhibitor on Kidney Function and Blood Potassium Level in Indonesian Type 2 Diabetes Mellitus with Hypertension: A Three-Month Cohort Study.

PurposeNational formulary restrictions in Indonesia (2019) require estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73 m2 to be able to prescribe telmisartan and valsartan and ACE-I intolerance to be able to prescribe irbesartan and candesartan. These restrictions are based on economic considerations and differ from American Diabetes Association (ADA) (2020) guidelines which allow equal use of angiotensin II receptor blockers (ARB) and angiotensin-converting enzyme inhibitors (ACE-I) without restriction. Since there is a need to evaluate the different effects of ACE-I and ARB in the Indonesian hypertensive type 2 diabetes mellitus (T2DM) population, we compare their effects on urine albumin-to-creatinine ratio (UACR), estimated glomerular filtration rate (eGFR), and blood potassium level.Patients and MethodsA prospective cohort study at RSUPN Dr. Cipto Mangunkusumo Hospital was conducted in 123 T2DM patients. We followed the study subjects prospectively for three months using a validated questionnaire, health record, and laboratory data.ResultsAfter 3 months of observation, there were no significant changes, except increased BMI values (p = 0.046) in the ACE-I group, and decreased LDL value (p = 0.016) and HDL value (p = 0.004) in the ARB group. Multivariate analysis showed that the consumption of ACE-I or ARB was not associated with a decrease/constant of UACR or increase potassium level, even after adjusting by confounding variables. Interestingly, we found ARB was more likely to increase eGFR, but the significance was lost once the duration of ACE-I/ARB use was entered into the model. In addition, BMI >25 kg/m2 was a significant factor associated with decreased/constant UACR, maleness was significant for increased eGFR, and declining systolic blood pressure for increase in potassium level.ConclusionACE-I and ARB have a similar effect on UACR and blood potassium level, but ARB slightly increased eGFR compared to ACE-I within three months of consumption.

Safety and Efficacy of Sacubitril/Valsartan Early Initiation in Hospitalized Patients with Heart Failure and Reduced Ejection Fraction

Abstract Background: Current guidelines approved Sacubitril/ valsartan as replacement therapy to angiotensin-converting-enzyme inhibitors or angiotensin-receptor-blockers for treat-ment of heart failure patients with reduced ejection fraction. Aim of Study: The study was conducted to evaluate the safety, efficacy, and tolerability of sacubitril/valsartan (S/V) initiation in hospitalized patients. Patients and Methods: This is a Prospective observational cohort study that included 191 patients who were hospitalized due to heart failure with reduced Ejection fraction (HFrEF) from March 2019 till June 2020. Sacubitril/valsartan was initiated during hospitalization and after hemodynamic stabi-lization. The study evaluated the following: Incidence of hypotensive events, the incidence of inpatient acute kidney injury and hyperkalemia, rate of discontinuation, and change in ejection fraction (EF), Brain natriuretic peptide (BNP), and N-terminal Pro-B-type natriuretic peptide (NT-pro-BNP) from baseline and after one and three months from initiation. Results: The mean age was 60.4±12.4 years and 73.8% of patients were males. Of the studied group, 92.1 % continued to take S/V, while 3.1% stopped medicine due to symptomatic hypotension, 2.6% due to financial issues, 1% due to AKI, and 1% due to hyperkalemia. After three months, only 5.8% of the patients tolerated the maximum dose (97-103) bid. For patients who continued to take S/V, there was a significant increase in EF at one- and three-month post-initiation, 28.4% vs. 33.8% & 28.4% vs. 39.4% respectively, (p < 0.001). On the other hand, there was a significant decrease in both BNP and NT-pro-BNP, (p < 0.001). Conclusions: Early initiation of sacubitril/valsartan during hospitalization is safe and tolerable with good efficacy and minimal adverse effects. Key Messages: Most hospitalized patients due to acute decompensated heart failure and reduced ejection fraction can tolerate initiation of sacubitril/valsartan after hemodynamic stabilization guided by strict blood pressure, creatinine, and potassium level monitoring.

Sacubitril/Valsartan for heart failure in adults with systemic right ventricle: A single center safety and efficacy experience

Heart failure in adult with congenital heart disease is an important cause of morbi-mortality. Sacubitril/Valsartan has been validated for the treatment of heart failure in adults with left ventricular dysfunction. The aim of this study was to assess safety and efficacy of Sacubitril/Valsartan in symptomatic adults with systemic right ventricle dysfunction. This is a retrospective and single center study (Quebec Heart and Lung Institute, Quebec City, Canada). Eight patients (mean age 41 ± 9.2 years, 5 males) with a significant systemic right ventricle dysfunction in New York functional class II–III despite optimal heart failure medication were included. Sacubitril/Valsartan was up titrated at the maximal dosage tolerated. The mean dosage reached was 85 ± 22 mg/90 ± 24 mg. During a median follow-up of 248 (213–430) days, systolic (121 ± 13 vs. 116 ± 13 mmHg, P = 0.238) and diastolic (76 ± 6 mmHg vs. 72 ± 5 mmHg, P = 0.105) blood pressure, potassium (4.1 ± 0.4 mmol/L vs. 3.9 ± 0.2 mmol/L, P = 0.111) and creatinine (71.7 ± 14.5 μmol/L vs. 68.9 ± 14.7 μmol/L, P = 0.516) levels remained stable. No discontinuation, reduction in dose or side effects were noted. A significant improvement in functional status was observed ( P = 0.03): 6 patients had a New York Heart Association class improvement and 2 remained in the same class ( Fig. 1 ). Maximal oxygen uptake, NTproBNP levels and echocardiographic data did not reach significant improvement. Sacubitril/Valsartan titration in a population of patients with congenital heart disease and significant right ventricle dysfunction was well tolerated and associated with significant improvement in functional status class. Whether Sacubitril/Valsartan improved right ventricle remodeling or decrease heart failure hospitalization or mortality in that population remained to determined.