Life-threatening Electrolyte Abnormalities Research Articles

Comparison of the efficacy and tolerability of different repetitive transcranial magnetic stimulation modalities for post-stroke dysphagia: a systematic review and Bayesian network meta-analysis protocol

IntroductionUp to 78% of patients who had a stroke develop post-stroke dysphagia (PSD), a significant consequence. Life-threatening aspiration pneumonia, starvation, and water and electrolyte abnormalities can result. Several meta-analyses have...

Variations in intravenous fluid management for paediatric hypernatraemia in South Africa: A survey of junior and senior South African paediatric doctors

Background. Paediatric hypernatraemia is a severe and life-threatening electrolyte abnormality that is associated with considerable morbidity and mortality. Although intravenous (IV) fluid therapy is a crucial component of management, there are no management guidelines, and varying approaches to IV fluid therapy are commonplace in clinical practice. Objectives. To determine the variance in IV fluid therapy in the management of paediatric hypernatraemia among paediatric registrars and consultants in South Africa. Methods. A self-administered online survey was conducted from November 2020 to February 2021. The survey assessed paediatricians’ management of three typical clinical scenarios of community-acquired hypernatraemia seen in South Africa. Descriptive results were presented as proportions, frequencies and medians with interquartile ranges. Comparisons were done using contingency tables. Results. Responses from 119 participants were analysed. Most respondents worked in the state sector (69.8%), and were based mainly in Gauteng (46.2%) or Western Cape (25.2%) province. Most (60.2%) respondents considered a serum sodium level ≥146 mmol/L indicative of hypernatraemia, and 43.6% (n=51/117) reported seeing >10 cases of paediatric hypernatraemia in 2019. For all three cases, at least eight different types of infusate (of varying sodium concentrations) were chosen as maintenance fluids. Fluid deficits were calculated using either the free water method or based on the perceived degree/percentage of clinical dehydration. Conclusion. There is considerable variability in the management of hypernatraemia among paediatricians in South Africa. There is an urgent need to develop a standardised guideline for the treatment of paediatric hypernatraemia.

Hyperkalemia in Patients with Type 2 Diabetes Mellitus: Risk Factors and Clinical Outcomes

Hyperkalemia is one of life-threatening electrolyte abnormalities. Diabetes mellitus (DM) is among the diseases in which patients can commonly develop hyperkalemia due to various factors. This study aimed to determine the occurrence of hyperkalemia and potential risk factors that contribute to development of hyperkalemia among type 2 diabetes mellitus (T2DM) patients. This is a single centered retrospective study in all deceased diabetic patients who were previously admitted to Sultan Ismail Petra Hospital, Kelantan state of Malaysia from January 2017 to December 2017 with or without hyperkalemia. A total of 132 patients were studied after screening for eligibility from medical records. Hyperkalemia was defined as potassium level ≥5.5 mEq/L. Univariate and multiple logistic regression analysis were used to identify potential risk factors associated with hyperkalemia. The occurrence of hyperkalemia among T2DM patients was 54.5%. In multivariable analysis, stage 4 CKD (eGFR: 15-29 ml/min/1.73m2) (AOR=0.154, 95%CI=0.003,0.763), use of ARB (AOR=26.269, 95%CI=1.25,548.50) and length of stay (AOR=1.007, 95%CI=1.001,1.013) were the significant risk factors for hyperkalemia. No significant difference between diabetes patients with hyperkalemia (DMHK) group with diabetes patients without hyperkalemia (DMWOHK) group in terms of clinical outcomes. Among diabetic patients with hyperkalemia, the mean time from development of hyperkalemia until death was 99.92±119.07 hours. In conclusion, this study shows that hyperkalemia is common among T2DM patient in our study setting. Although a number of factors may contribute to the high occurrence of hyperkalemia, the use of ARB, advanced CKD at stage 4 and length of stay are major determinants of hyperkalemia occurrence. Aggressive management of hyperkalemia may be beneficial as to prevent significant clinical outcomes requiring intensive care management and cardiac problem lead to death.

Distal renal tubular acidosis and nephrocalcinosis as initial manifestation of primary sjögren's syndrome.

There is a well-established association between primary Sjögren's syndrome and distal renal tubular acidosis (dRTA). dRTA is a relatively infrequent manifestation of primary Sjögren's syndrome which can present with life-threatening electrolyte abnormalities while, in some patients, it could be the first manifestation of the syndrome. We report the case of a 35-year-old woman who presented with unexplained episodes of generalized weakness, severe hypokalemia, nephrocalcinosis, and normal anion gap metabolic acidosis. Subsequent evaluation revealed primary Sjögren's syndrome as her underlying condition. The patient responded well to potassium supplementation, sodium bicarbonate, and oral prednisolone. After four years of follow-up, there were no other extraglandular manifestations, the renal function remained stable and the acidosis was partially improved without the need for oral bicarbonate. This case demonstrates that dRTA could be the initial manifestation of primary Sjögren's syndrome and highlights the necessity for increased vigilance for patients presenting with persistent hypokalemia or nephrocalcinosis so that an early diagnosis can be made allowing for better control and prevention of disease progression.

HYPOKALEMIA – INDUCED OUT-OF-HOSPITAL CARDIAC ARREST – CASE STUDY

Life-threatening electrolyte abnormalities, such as sudden changes in serum potassium, cause or contribute to fatal cardiac consequences, including cardiac arrest. Here we present a case of a 57-year-old man with unrecognized hypokalaemia who experienced exercise-related out-of-hospital cardiac arrest (OHCA). Successful CPR was initiated immediately; however, he remained in a coma for four days. The patient had no other comorbidities except a history of mild hypertension treated with low doses of angiotensin receptor blocker (ARB) combined with thiazide. On admission: sinus heart rhythm 80 bpm, potassium level 2.8 mmol/l, Glasgow Coma Scale 3, blood pressure normal. Coronary angiography did not show any coronary occlusion. Other additional tests were nonspecific. Upon awakening, he had major confusion with severe memory deficits. A week later, he was able to walk and was discharged from the hospital. Seventeen months later, the patient still struggles with severe cognitive impairment, lack of motivation, muscle weakness, and fatigue. He requires special care, including supervision and help with activities of daily living. Although the exact cause of hypokalaemia remained unrecognized, several probable mechanisms were taken into consideration.

Junctional Bradikardia pada Pasien Hiperkalemia

Hyperkalemia is a life-threatening electrolyte abnormality resulting in cardiac arrhythmia. Hyperkalemia may also cause bradycardia with junctional rhythm. However, the prevalence of hyperkalemia accompanying symptomatic bradycardia has only been explored in a few case reports. Thus we present a case of hyperkalemia with uncommon ECG findings. It has been reported that a 76 years old woman with type 2 diabetes mellitus, hyperkalemia and suspected coronary artery disease complaining about palpitation. Electrocardiography (ECG) showed junctional bradycardia with tall T wave and laboratory examination showed mild hyperkalemia (5.8 mmol/L). After one day of observation, severe hypotension was detected. Unexpectedly the cardiac rhythm was returned into the sinus after correction of hyperkalemia using calcium gluconate, insulin, dextrose, and salbutamol. As serum potassium level rises, sinoatrial and atrioventricular conduction was blocked, causing escape rhythm (junctional escape rhythm). In hyperkalemia, cardiotoxicity can be caused by an increase in resting membrane potential, decreased depolarization and duration of depolarization. When detected on ECG, hyperkalemia should be treated urgently and important to identify underlying causes or precipitating factors of hyperkalemia. Sinus node dysfunction is not excluded in this case. Hyperkalemia can present a bradycardia junctional rhythm. Although the increasing serum potassium levels were low, hyperkalemia may have affected the conduction system leading to the ECG changes.Keywords: hyperkalemia, junctional bradycardia, symptomatic bradycardia

Prevalence, clinical impact and costs of hyperkalaemia: Special focus on heart failure

BackgroundHyperkalaemia is a potential life‐threatening electrolyte abnormality. Although renin‐angiotensin‐aldosterone system inhibitors (RAASi) are potentially life‐saving, they may contribute to hyperkalaemia.MethodsThe prevalence, comorbidities, comedications and 1‐year outcomes of patients admitted or treated for hyperkalaemia were investigated in a large healthcare administrative database including 12 533 230 general population inhabitants. A similar analysis was performed in the Italian Network on Heart Failure (IN‐HF), a cardiology registry of 1726 acute and 7589 chronic HF patients, stratified by serum potassium. General practice healthcare costs related to hyperkalaemia were also assessed. Hyperkalaemia was defined by hospital coding, potassium‐binder prescription or serum levels (mild: 5‐5.4, moderate‐severe: ≥5.5 mmol/L).ResultsIn the general population, the prevalence of hyperkalaemia was 0.035%. After excluding patients on haemodialysis, hyperkalaemia in the community (n = 2314) was significantly and directly associated with diabetes, chronic kidney disease, HF, RAASi prescriptions, 1‐year hospitalisations and threefold annual healthcare costs, compared to age‐ and sex‐matched non‐hyperkalaemic subjects (n = 2314). In the IN‐HF registry, hyperkalaemia affected 4.3% of acute and 3.6% of chronic patients and was significantly associated with diabetes, kidney disease and lesser use of RAASi, compared to normokalaemic patients. Among patients hospitalised for acute HF, those with hyperkalaemia at entry had significantly higher 1‐year all‐cause mortality compared with normokalaemic patients, even after adjustment for available confounders.ConclusionsHyperkalaemia in the general population, although uncommon, was associated with increased hospitalisations and tripling of healthcare costs. Among HF patients, hyperkalaemia was common and associated with underuse of RAASi; in acutely decompensated patients, it remained independently associated with 1‐year all‐cause mortality.

Reverse pseudohyperkalemia is more than leukocytosis: a retrospective study.

BackgroundHyperkalemia is a potentially life-threatening electrolyte abnormality that often requires urgent treatment. Clinicians should distinguish true hyperkalemia from pseudohyperkalemia and reverse pseudohyperkalemia (RPK). RPK has exclusively been described in case reports of patients with hematologic malignancies (HMs) and extreme leukocytosis [white blood cell (WBC) count >200 × 103/mL].MethodsThis single-center retrospective study analyzed laboratory data from the Mount Sinai Data Warehouse between 1 January 2010 and 31 December 2016 for plasma potassium and serum potassium samples drawn within 1 h of each other, with plasma potassium ≥1 mEq/L of the serum potassium. Only plasma potassium ≥5 mEq/L were included. Samples that were documented to be hemolyzed or contaminated were excluded. Clinical history and laboratory data were collected from the identified cases.ResultsAfter applying the inclusion/exclusion criteria to 485 potential cases, the final cohort included 45 cases from 41 patients. There were 24 men and 17 women with a mean age of 52 years. The median plasma potassium was 6.1 mEq/L and serum potassium was 4.4 mEq/L. The median WBC count was 9.35 × 103/mL (interquartile range 6.5–19.7 × 103/mL). Only 44% of the samples had leukocytosis, defined as WBC >11 × 103/mL.Seven patients had a HM and comprised 11 of the cases (24%) with a median WBC of 181.8 × 103µL. There was no difference in their plasma and serum potassium levels when compared with the total cohort, despite a higher median WBC count. Thirty-eight percent of the cases required medical management.ConclusionsThe literature on RPK is limited to case reports and series associated with extreme leukocytosis. This is the first study characterizing RPK predominantly associated with normal leukocyte counts. Further investigation is required to more precisely characterize factors associated with RPK and to elucidate RPK mechanisms.

P0800PROFILING HYPOKALAEMIC AND HYPERKALAEMIC STATES IN THE IRISH HEALTH SYSTEM: TESTING RATES, INCIDENCE AND DETERMINANTS

Abstract Background and Aims Hypo- and hyperkalaemia are potentially life-threatening electrolyte abnormalities often associated with severe adverse clinical outcomes. Real-world incidence and determinants of hypo- and hyperkalaemia in clinical settings are poorly characterised. We studied incidence and determinants of these abnormalities in the Irish healthcare system Method Data from the Irish National Kidney Disease Surveillance and Quality Assurance Programme were used to construct a retrospective observational study. We identified all adult individuals (age > 18 years) who accessed health care from 2006 and 2010 in a regional health system (n = 205,334). Cumulative incidence of hypokalaemia (K+ < 3.5 mmol/L), hyperkalaemia (K+> 5 mmol/L), and moderate/severe hyperkalaemia (K+> 5.5 mmol/L) was estimated over a 3-year period. Kidney function was assessed by estimated glomerular filtration rate (eGFR). Multinomial logistic regression explored associations of baseline patient characteristics with dyskalaemia states. Results Of 205,334 participants, 85.2% had 1–2 potassium tests, 5.8% had 2–3 tests, 2.7% had 3-4 tests and the remaining 6.4% had > 4 potassium tests/year. Hypokalaemia occurred in 17,145 (8.35%) individuals, of these 43.8% had recurrent hypokalaemia (>1 event). Hyperkalaemia occurred in 44,283 (21.6%) individuals, with 29.7% recurrence. Moderate/severe hyperkalaemia occurred in 9,672 (4.71%) with 18.0% recurrence. The frequency of potassium testing was an important determinant of dyskalaemia risk. In adjusted analyses, advancing age profile, women, inpatients, outpatients and emergency department patients (vs general practice), and frequency of tests had significantly higher risks of hypokalaemia. Additionally, advancing age, men, poorer kidney function, and frequency of potassium testing, and general practice were associated with significantly higher risk of hyperkalaemia. Conclusion Both hypo- and hyperkalaemic states are common in the Irish healthcare system with high rates of recurrence. Surveillance strategies should be put in place to allow timely detection and treatment of potassium disturbances in these high-risk groups.

SUN-157 Delayed Diagnosis of Cushings Syndrome: Hiding in Plain Sight!

BACKGROUND: Endogenous Cushing’s syndrome (CS) is rare, with an incidence of 0.7-2.4/million people/year.1 It should be considered in individuals with diabetes (DM), hypertension (HTN), osteoporosis or electrolyte abnormalities.2 We present a patient with DM2 and persistent hypokalemia for 10 years found to have ACTH-independent Cushing’s disease as the cause of metabolic syndrome. Case: 62 y.o. M admitted with abdominal pain, a history of DM2 (2012) on Metformin 500 mg BID, HTN (2010) and on ramipril 10 mg qd, with chronic lymphedema on furosemide 20 mg qd. He reported 3-inch height loss. On exam, had facial plethora, moon facies, supraclavicular fullness, thick violaceous abdominal striae and kyphosis. Past history was significant for abdominal/leg cellulitis, muscle weakness, difficult to heal wounds, easy bruising and recurrent hospitalizations for hypokalemia, despite being on KCl up to 80 mEq/d for 10 years. Labs showed AM cortisol at 22.6 ug/dL, ACTH <5 pg/mL, 24-hour urine free cortisol of 523 ug/d (normal < 60 ug/d). AM cortisol after 1 mg overnight dexamethasone suppression was 36.8 g/dL, ACTH <5 pg/mL. CT abdomen showed right adrenal nodule, 4.0 x 3.5 cm with density of 22 HU. MRI showed lipid-poor adenoma measuring 3.9 x 3.5 cm, raising concern for adrenocortical malignancy. Patient underwent right adrenalectomy. Pathology was consistent with benign adenoma showing no nuclear pleomorphism, lipid rich cells containing eosnophillic cytoplasm. Mib-1 stain <1% cells and positive inhibin. He was maintained on steroids post op due to concern about adrenal insufficiency. Hypokalemia, DM and lymphedema resolved completely 4 months post op with weight loss of ~30 pounds. HbA1c improved to 5.1%, metformin was stopped and he was maintained on Carvedilol 6.125 mg BID for HTN. He was diagnosed with osteoporosis with T score -4.0 at mean femoral neck, -2.9 for mean total hip with non-diagnostic spine. He had multi-level chronic compression fractures of the mid-thoracic spine. Conclusion: Delayed diagnosis of CS, as occurred in our patient, can result in detrimental consequences such as life threatening electrolyte abnormalities, cardiovascular events, fractures and premature death.1 Identifying CS can be challenging as clinical presentation is variable. 2,3 Early recognition, diagnosis and control of CS is crucial to decrease morbidity and mortality. Our patient demonstrated rapid resolution of DM, hypokalemia and lymphedema after surgery; however, prolonged exposure to endogenous cortisol resulted in compression fractures and osteoporosis requiring follow up treatment.

PDB59 THE IMPACT OF HYPERKALAEMIA AND ITS CONCURRENCE WITH CARDIORENAL COMORBIDITIES ON HEALTHCARE RESOURCE USE IN THE UK

Hyperkalaemia (HK) is a potentially life-threatening electrolyte abnormality characterized by elevated serum potassium concentrations above 5.0mmol/L. The clinical and economic burden of HK is of concern for patients with cardiovascular and renal comorbidities. However, there is limited data on the impact of HK and its concurrence with comorbidities on healthcare resource use (HRU) in the UK. In this study we aimed to characterise HRU associated with HK hospitalisations in patients with different cardiovascular and renal comorbidities in the UK.

Polysulfonate Resins in Hyperkalemia: A Systematic Review.

Background:Hyperkalemia is a potentially life-threatening electrolyte abnormality defined as a serum potassium above the lab reference range (usually >5.0-5.5 mEq/L). Polystyrene resins, including sodium polystyrene sulfonate (SPS) and calcium polystyrene sulfonate (CPS), have long been used to treat hyperkalemia. Sodium polystyrene sulfonate/calcium polystyrene sulfonate act by exchanging a cation for potassium within the intestinal lumen. While SPS and CPS have been available since the 1960s, there are rising concerns about the validity of the data supporting its use and about serious adverse gastrointestinal effects.Objective:The objective of this systematic review was to quantify the efficacy and safety of polystyrene sulfonate resins (SPS/CPS) in the treatment of adults with hyperkalemia. This review focuses on the randomized control trial (RCT), interventional non-RCT, and observational data available on SPS/CPS use.Design:Systematic review.Setting:Any country of origin. Both inpatient and outpatient settings.Patients:Adults with hyperkalemia treated with polystyrene sulfonate resins.Measurements:The primary outcome was change in serum potassium. The secondary outcomes included adverse effects of SPS/CPS and prevention of recurrent hyperkalemia.Methods:We conducted a systematic review using Cochrane Library, EMBASE (1947-2019), and Medline (1946-2019) databases. Literature reviews, systematic reviews, case studies, case series, and editorial pieces were excluded. Included studies were assessed for risk of bias.Results:Four RCTs, 21 observational studies, and 5 quasi-experimental trials were included. A total of 212 351 patients were included. Two thousand and fifty-eight patients were studied for the primary outcome and 210 293 patients were studied for the secondary outcomes. Study designs were heterogeneous and not amenable to meta-analysis. Most studies included nonhemodialysis outpatients older than 65 years. Of the included studies, 22/25 (88%) demonstrated a reduction of serum potassium >0.5 mEq/L over the study period. The magnitude of reduction in serum potassium of potassium resin compared with placebo or matched controls in the 3 low-risk studies identified was 0.14 to 1.04 mEq/L. However, each study used different dosing regimens. Ten of 22 studies reported the effects of polystyrene resins on serum potassium within 24 hours. A few high-quality observational studies suggest an increased risk of serious adverse gastrointestinal events with a relative risk of 2.10 and a hazard ratio of 1.25 to 1.94; however, the absolute risk remains low. The incidence of adverse gastrointestinal events is 16 to 23 events per 1000 person-years.Limitations:We acknowledge several limitations in this study. Case studies and case series were excluded from the search results. Large case series may have been excluded despite having comparable sample sizes to studies included due to lack of a comparator and calculated estimates. Due to the heterogeneity of the studies, the data were unable to be meta-analyzed and as such the potassium-lowering effect of polystyrene sulfonate resins remains founded on small studies with potential confounders.Conclusions:This systematic review demonstrates a continued lack of high-quality evidence for the use of SPS/CPS in hyperkalemia. Studies investigated highly variable timelines and the most robust evidence for SPS/CPS use is in chronic hyperkalemia. While the absence of high-quality evidence does not exclude the possibility of benefit, prescribers must understand that the use of SPS/CPS in acute hyperkalemia is not supported by high-quality evidence.Trial registration:The protocol for this systematic review was not registered.

Rhabdomyolysis in Intensive Care Unit: More than One Cause.

ABSTRACTRhabdomyolysis is a serious medical condition, encountered in the intensive care unit (ICU). The etiology of rhabdomyolysis is often multifactorial. It leads to complications like acute kidney injury and life-threatening electrolyte abnormalities. A high index of suspicion and early institution of therapy is required to prevent complications and improve patient outcomes. Herein, we present the case of a young man with alcohol dependence who presented with fever and altered sensorium. He was found to have rhabdomyolysis and was managed successfully. We also discuss the common causes of rhabdomyolysis and a bedside approach to its management in the ICU.How to cite this article: Saxena P, Dhooria S, Agarwal R, Prasad KT, Sehgal IS. Rhabdomyolysis in Intensive Care Unit: More than One Cause. Indian J Crit Care Med 2019;23(9):427–429.

A Case of Celiac Crisis in an Elderly Male

Celiac disease (CD) has many faces and can present in many ways. Celiac crisis is one such rare manifestation of the disease. Celiac crisis is characterized by watery diarrhea and life-threatening electrolyte abnormalities requiring hospitalization. We present a case of the diagnostic dilemma in an elderly male, who presented with anemia and was diagnosed with celiac disease only after developing so-called celiac crisis. A 76-year-old male with a history of alcoholism, chronic pancreatitis and rheumatoid arthritis was admitted to our hospital with anorexia and significant weight loss. Initial work-up revealed marked microcytic anemia with a hemoglobin of 6g/dl. History did not suggest gastrointestinal bleeding, however patient reported lifetime constipation. Other laboratory work-up showed a low iron level, ferritin >2000, and an elevated ESR and CRP. A subsequent upper endoscopy and colonoscopy was unremarkable with no identifiable bleeding source. There were no mucosal changes noted and no biopsies were performed. The patient underwent extensive testing in the hospital looking for the etiology of the anemia and weight loss. At the end of two weeks, he developed profuse watery diarrhea with severe electrolyte derangements. Infectious work-up including a stool Clostridium difficile toxin was negative. Stool studies were consistent with secretory diarrhea. Patient underwent repeat upper endoscopy and colonoscopy, which showed cobblestoning of duodenal mucosa and mucosal edema throughout the colon. TTG of the serum was positive for celiac disease. Histopathology of the biopsy showed villous blunting of the duodenum consistent with celiac disease. The patient received parenteral fluid and nutrition replacement and his diarrhea resolved with a gluten free diet. CD is known for its atypical presentations and it still remains under-diagnosed. Celiac crisis is a rare life-threatening syndrome where celiac disease causes acute diarrhea and severe metabolic derangements. General immune stimuli such as infection, surgery or pregnancy have been known to precipitate celiac crisis. It is unknown why a small subset of patients with CD develops celiac crisis.2581_A Figure 1. Normal appearing duodenal mucosa on Endoscopy #12581_B Figure 2. Cobblestoning apperance of Duodenal mucosa on endoscopy #2, 2 weeks later.2581_C Figure 3. Histopathology of Duodenal Biopsy showing Villous blunting and lymphocytesOur case is an example of the heterogeneous clinical course of CD and emphasizes the need to consider it in the differential diagnosis in elderly presenting with anemia and weight loss. Delay in diagnosis can lead to complication such as celiac crisis. Treatment for Celiac crisis is gluten free diet and steroids.

Causes, Clinical Features and Treatment of Rhabdomyolysis: A Retrospective Analysis

Background: RM is a condition of skeletal muscle breakdown which ranges from an asymptomatic illness with elevation in CK level to a life-threatening condition associated with extreme elevation in CK, electrolyte imbalance, AKI, and disseminated intravascular coagulation. In this study, the author analyzed the causes, clinical features, and treatments of RM. Methods: The study collected the records of 48 patients in the First Affiliated Hospital of Jinan University who were diagnosed RM from June 2012 to August 2016. By using SPSS to analyse the data, the study draw a clear chart about the distribution of patients’ age, etiologies and clinical symptoms respectively. The statistic analysis also reveals dramatically change on CK and other indicators after treatment. Results: A total of 48 patients were eligible for the study (mean age = 29.7 ± 12.3 years; 36 males and 12 females). Strenuous exercises and infections took the greatest percent amount the causes of RM. Muscular weakness and muscle aches were the two most common symptoms. Among the patients, 42 received intravenous (IV) fluid therapy, and none developed acute kidney injury (AKI). The other six patients accepted CRRT, five of whom had an alleviation of their symptoms. One patient was transferred to another hospital for further treatment since the primary disease was dermatomyositis and it was non-responsive to immunotherapy. Discussion and conclusions: RM is treatable if early diagnosis, comprehensive therapy, active prevention, and the timely elimination of complications are put into effect. Its main symptoms such as muscle aches, muscular weakness, and dark urine may not presented at the same time. In this study, Strenuous exercise is the most common cause of RM and IV fluid therapy is the cornerstone of RM treatment. CRRT should also be considered when life-threatening electrolyte abnormalities emerge as complications of AKI, or when the RM is non-responsive to initial therapy.

Patiromer: The First Potassium Binder Approved in Over 50 Years.

For over 50 years, there have been limited options for the management of hyperkalemia, especially among patients with chronic kidney disease (CKD), diabetic nephropathy, hypertension, and heart failure, who were receiving concomitant renin-angiotensin-aldosterone system (RAAS) inhibitor therapy. Hyperkalemia is a potential, life-threatening electrolyte abnormality that frequently challenges clinicians from maximizing the mortality benefit and organ-protective properties of RAAS inhibitors especially in CKD and heart failure populations. Patiromer is a novel nonabsorbed, cation-exchange polymer that binds and exchanges potassium for calcium, predominantly in the gastrointestinal tract. It has demonstrated potassium-lowering effects in normo- or hyperkalemic patients on concomitant RAAS inhibitors with heart failure, diabetic nephropathy, and CKD, in the PEARL-HF, AMETHYST-DN, and OPAL-HK studies, respectively. Across all studies, it appears to be generally effective and well tolerated, with adverse events predominantly gastrointestinal in nature. Additional investigational studies are needed to explore its use for an extended duration of treatment and in larger patient populations, as well as exploring drug-drug interactions. Overall, patiromer demonstrates a promising role in the chronic management of hyperkalemia that will allow optimization of RAAS inhibitor therapy, thus delaying progression of CKD and improving the mortality benefit in heart failure patients.

Sodium Zirconium Cyclosilicate (ZS-9): A Novel Agent for the Treatment of Hyperkalemia.

Hyperkalemia is a potentially life-threatening electrolyte abnormality that may be caused by select medications, underlying organ dysfunction, or alterations in potassium homeostasis. Treatment for this condition has remained largely unchanged since the release of sodium polystyrene sulfonate (SPS) in 1958. Despite its widespread use, the safety and efficacy of SPS remains controversial. Two novel potassium-binding resins have emerged in recent years. Patiromer was the first of these to receive U.S. Food and Drug Administration approval for the treatment of hyperkalemia in October 2015. A second potassium-binding resin, a zirconium cyclosilicate currently known as ZS-9, may provide yet another alternative to the archetypal treatment with SPS. ZS-9 is an orally administered nonabsorbed inorganic compound that selectively binds potassium ions in vivo. Two phase III multicenter, randomized, placebo-controlled, double-blind trials have evaluated ZS-9 for the treatment of acute hyperkalemia. In this review, we discuss the pharmacology, clinical efficacy, safety, and potential place in therapy of ZS-9 for the enhanced elimination of potassium in the setting of hyperkalemia.

Periodic paralysis: An unusual presentation of drug-induced hyperkalemia

Hyperkalemia is a life-threatening electrolyte abnormality. The most common cause of hyperkalemia includes renal disease and ingestion of medications. Drug-induced hyperkalemia may develop in patients with underlying renal impairment, disturbed cellular uptake of potassium load, excessive ingestion or infusion of potassium-containing substances. We report a case of “drug-induced severe hyperkalemia” presenting as periodic paralysis. A 67-year-old diabetic and hypertensive woman presented to emergency department with the complaint of intermittent episode of inability to walk for the past 5 days. Each episode lasted for 15-20 minutes and was associated with breathlessness and restlessness. There was no family history of periodic paralysis and drug history revealed that the patient was onolmesartan 20 mg per day (for past 2 years), perindopril 4 mg per day (for past 16 months), and torsemide 10 mg/day. On examination patient was found to be conscious, alert, and afebrile. Vitals were normal. Examination of cardiovascular and respiratory system did not reveal any significant finding. Blood report of the patient showed serum K+ level 8.6 mmol/l. All other investigations were within normal limits. A diagnosis of drug-induced hyperkalemia was made. Patient responded well to the symptomatic treatment. To the best of the author's knowledge, this is the first case report of drug-induced hyperkalemia presenting as periodic paralysis.

Endoscopic Removal of Pharmacobezoar in Case of Intentional Potassium Overdose

BackgroundHyperkalemia is a potentially life-threatening electrolyte abnormality commonly seen in the emergency department (ED). Intentional overdose of potassium supplements is an uncommon occurrence. ObjectiveThis case illustrates a novel approach to treatment of pharmacobezoar with esophagogastroduodenoscopy (EGD) and demonstrates its effectiveness in the setting of extended-release potassium chloride overdose. Case ReportA 44-year-old female presented to the ED with intentional ingestion of an unknown amount of extended-release potassium chloride (K-Dur®) tablets and alprazolam (Xanax®). The patient's serum potassium was initially 7.3 mmol/L and she was treated with standard treatments, including albuterol, calcium gluconate, insulin, dextrose, and sodium bicarbonate. Radiographic investigation showed a pharmacobezoar in the gastric fundus. Treatment was then augmented with whole bowel irrigation (WBI) using polyethylene glycol solution via nasogastric tube. Patient did not tolerate the nasogastric tube, became combative with increasing alteration in her level of consciousness, and WBI therapy was stopped. After discussion with the gastroenterologist, the patient was treated with EGD to remove the pharmacobezoar. The EGD was successful in the removal of the pharmacobezoar and the patient's potassium normalized without complications. ConclusionsWe recommend that in cases of suspected or confirmed potassium drug bezoar in the stomach, physicians consider EGD for removal. This allows for normalization of potassium level while preventing adverse sequelae.

Akutes Nierenversagen - Evidenzbasierte Therapie mit Nierenersatzverfahren - intermittierend vs. CRRT

Continuous and intermittent renal replacement procedures are equally adequate therapies for acute kidney injury. The choice of modality should be made individually and on the basis of the specific clinical situation which may include switching between modalities during the course of treatment. In patients with haemodynamic instability or at risk of disequilibrium and cerebral edema CRRT or prolonged intermittent treatment may offer advantages whilst IHD should be preferred for the acute treatment of life-threatening electrolyte abnormalities or metabolic acidosis. Overall, the different modalities should be viewed as complementary.