Refractory Hyperkalemia Research Articles

Severe respiratory acidosis contributing to refractory hyperkalemia: a case series of COVID-19 patients with renal failure

Introduction: Respiratory acidosis (RA) is not known to cause severe hyperkalemia. However, an exception to this general rule was observed in three patients with severe COVID-19 complicated with renal failure in our center. Objectives: The current study investigated the explanation for hyperkalemia refractory to renal replacement therapy in patients with severe COVID-19 with hypercarbia and renal failure in a tertiary care center. Patients and Methods: In this study, we present a case series of three patients with severe COVID-19 with hypercarbia and dialysis-requiring renal failure who developed persistent hyperkalemia refractory to renal replacement therapy. We studied various causes of persistent hyperkalemia, such as acid‒base disorder, a high turnover state, exogenous administration, rhabdomyolysis, and hypoaldosteronism. Results: All three patients initially presented with episodes of severe hyperkalemia, which were ameliorated after RA was corrected. All of these patients had worsening pulmonary function, after which the hyperkalemia could not be corrected, corresponding to persistent RA. The evidence that there was a contribution of RA to hyperkalemia was further strengthened by the observations of patient 1, in whom the hyperkalemia was only corrected after changing ventilator settings and who was unresponsive to dialysis. We studied the dialysate effluent in patient 3, and the results showed satisfactory removal of potassium with no improvement in the high serum potassium levels. Another interesting finding was that although the dialysate sodium concentration was greater than the serum sodium concentration, there was a decrease in the serum sodium concentration, indicating a reduced movement of sodium into the extracellular space. Conclusion: In our study, metabolic acidosis alone could not explain the high serum potassium levels. Moreover, hyperkalemia was corrected after RA was corrected, indicating that the latter might have been the predominant cause of hyperkalemia in these scenarios. The presence of renal failure and low serum bicarbonate levels might have been the factors contributing to decreased Na+-K+-ATPase activity in the setting of RA, which contributed to severe hyperkalemia in all three patients.

Indications and Complications of Emergency Hemodialysis Among Patients with Acute Kidney Injury Admitted in Hemodialysis Center at Bahri Teaching Hospital, Khartoum State, Sudan 2021 - 2022

BACKGROUND: AKI is defined as abrupt decline in renal functions either due to structural damage or loss of function , associated with poor clinical outcomes for hospitalized patients. In the context of Sudan, highlighting the most common indications and complications that may occur during emergency hemodialysis and describing their presentation , may offer measures to minimize them by provide specific interventions to prevent the consequences when such emergencies arise. AIMS: To study the indications, and complications of emergency haemodialysis among patients admitted in haemodialysis center at Bahry teaching hospital, Khartoum state, Sudan . The study also aimed to describes the pattern of presentation in term of symptoms and signs reported among patients. METHODS: It’s an observational descriptive cross sectional, hospital based study that was conducted at the renal haemodialysis center within the period from September 2021 to October 2022 and covered 149 patients with AKI who underwent emergency hemodialysis,this sample size was calculated using Epi calculator and then adjusted using the hospital records that described the frequency of admission of patients with AKI in the preceding 6 months and excluded obstetric AKI . Data was collected, prepared, entered and analyzed using SPSS version 25.0 in term of descriptive statistics and Bi-variable analysis to determine the associations between some relevant factors (demographic characteristics, indications and complications) with the occurrence of complications using Chi square test (for categorical variables) and t-test (quantitative variables). RESULTS: This study covered 149 participants. Nearly half of them 40.9% of the study participants were in the age group 30-60 years with male: female ratio of 2.3:1 and 44 % of the participants had co morbid illnesses with diabetes , hypertension and liver disease being the most common. Regarding the history of renal disease only 4.7 % had previous history and 10% had family history of renal disease .The most common indication for emergency haemodialysis was uremia 44%, followed by fluid overload that cannot be managed by diuretics 30%,worsening sever metabolic acidosis 10% and refractory hyperkalemia 4.7 % . Complications on the other hand occurred among 20% of the patients such as hypotension 8.7%, and hypoglycaemia 8.7%. There was significant association between certain social habits like smoking , middle age group as well as past history of renal disease with the development of complications (p value = 0.01 , 0.005 and 0.05 respectively). CONCLUSION: nearly half of the study participants were in the age group 30-60 years old with male: female ratio of 2.3:1. The most common indication for emergency haemodialysis was uremic gastropathy followed by Volume overload . Complications occurred among 20% of the participants such as hypotension and hypoglycaemia. Recommendation, Training of health care provider on how to deal with patient with AKI and when to include nephrologist in management to avoid dialysis and training of dialysis staff on early recognition and management of complication.

Ventricular fibrillation in a dog with refractory hyperkalaemia due to uroabdomen following extradural anaesthesia

AbstractA young adult, crossbreed dog was presented to a referral small animal veterinary hospital with uroabdomen causing a severe hyperkalaemia. Stabilisation of the condition consisted of abdominocentesis and intravenous administration of calcium gluconate, insulin, glucose and crystalloids. The patient was then anaesthetised for diagnostic and therapeutic procedures. An epidural was performed with levobupivacaine due to nociception and requirement for exploratory surgery. Marked bradycardia ensued and was treated with anticholinergics and terbutaline, among other repeated efforts to resolve a pharmaceutically resistant hyperkalaemia. However, cardiorespiratory arrest followed, characterised by ventricular fibrillation. Cardiopulmonary resuscitation utilised cardioversion to achieve return of spontaneous circulation within 16 minutes. After return of spontaneous circulation, serum potassium levels only decreased and remained below 7 mmol/L after repeat abdominocentesis, alongside continued medical therapy. Unfortunately, despite successful recovery from general anaesthesia, the patient later developed surgical wound dehiscence and was euthanased as a result.

SP4.2 Saving inpatient beds: Are day-case total parathyroidectomies possible and safe?

Abstract Introduction Total parathyroidectomy on patients with hyperparathyroidism traditionally required an inpatient hospital stay to monitor patients for postoperative hypocalcaemia. Our centre developed a safe protocol in 2015 which enables total parathyroidectomies to be carried out as a day-case procedure. This protocol, developed in conjunction with the renal physicians, involves giving the patient oral alfacalcidol preoperatively for 5 days and close monitoring of the calcium levels postoperatively to permit safe same day discharge. Methods A single centre retrospective study was carried out on all patients who underwent a total parathyroidectomy for hyperparathyroidism between 2005 and 2022. A comparison study was done before and after the protocol was introduced in 2015. Data were collected regarding the patient comorbidities, peri-operative calcium level, post-operative calcium, potassium and parathyroid levels, length of hospital stay, operative procedure details, hospital readmission, and 30-day morbidity. Results 57 patients underwent total parathyroidectomy during the study period (22 before protocol and 35 after the protocol). After introduction of the protocol, 40% of patients were discharged on the same day, compared to only 4.54% previously. The duration of inpatient hospital stay was reduced from 0-13 days to 0-3 days. Reasons for prolonged hospital stay in the remaining patients included refractory hyperkalaemia requiring dialysis, complications secondary to anaesthesia, as well as hypocalcaemia in a few cases. No patient required readmission during the 30-day post-operative period. Conclusions Day-case surgery for total parathyroidectomy can be achieved safely in patients with a preoperative regimen of alfacalcidol and close monitoring of calcium levels post-operatively, emulating a virtual ward round.

Mortality and Recovery of Kidney Function in Kidney Replacement TherapyRequiring AKI: Data from All Affected In-Hospital Subjects

Acute kidney injury (AKI) affects increasing numbers of hospitalized patients in Central Europe and in the US. Kidney replacement therapy (KRT) becomes mandatory if other strategies fail to prevent patients from systemic intoxication, resistant hyperhydration, or refractory hyperkalemia. The majority of data related to survival rates of AKI subjects that require KRT have been acquired under intensive care conditions. In the current letter to the editor we provide outcome data of all patients with in-hospital diagnosed AKI that received KRT at least once. We retrospectively assessed subjects receiving one or more individual sessions of KRT due to AKI of various etiology. Subjects were partly treated in the ICU or under non-ICU conditions. The in-hospital mortality was 35.4% complete recovery of kidney function occurred in 48.8%. In summary, the mortality of all inhospital AKI subjects is comparable to the mortality of AKI patients in the ICU. In addition, more than 50% do not recovery completely. Therefore, subjects with hospital-acquired AKI and an incident or prolonged need for KRT require the highest attention of nephrologists in general, no matter whether they received intensive care treatment or not.

Abstract 10735: Brash Syndrome: Frequently Under-Recognized and Often Confused With Simple Hyperkalemia

Introduction: BRASH syndrome is a relatively newly recognized and under-reported clinical entity characterized by bradycardia, renal dysfunction, atrioventricular node blockade (AVNB), shock, and hyperkalemia. We report a case of BRASH syndrome that was refractory to medical therapy alone, requiring transvenous pacing, hemodialysis, and vasopressor support. Case presentation: An 82-year-old female with hypertension, diabetes, and paroxysmal atrial fibrillation (on metoprolol and verapamil) was found unresponsive at a nursing home. She had refractory shock (99/34 mmHg) and symptomatic bradycardia with heart rate (HR) of 33 BPM. EKG showed atrial fibrillation rhythm with ventricular rate of 31 BMP and peaked T-waves. Labs revealed creatinine of 1.98 mg/dL, potassium of 6.8 mmol/L, and TSH of 2.90 ulU/ml. She had no signs of infection and echocardiogram showed normal left ventricular systolic function. She was intubated for airway protection. AVNB agents were immediately held. Potassium-lowering agents and vasoactive drugs were administered. Temporary transvenous pacemaker was placed due to persistent bradycardia with hemodynamic instability even after transcutaneous pacing. Temporary hemodialysis was started for worsening renal failure and refractory hyperkalemia. She was weaned off vasopressor support, mechanical ventilation, hemodialysis and temporary pacing over the next few days. Renal function improved and HR stabilized at 70 BPM. Discussion: In our case, AVNB agent overdose caused bradycardia which in turn led to decreased cardiac output and renal hypoperfusion. Resultant acute kidney injury led to decreased clearance of renally excreted metoprolol and verapamil and worsening hyperkalemia, which locked the patient in a vicious cycle of BRASH syndrome leading to hemodynamic compromise. Therefore, rapid diagnosis and correct management with transvenous pacemaker and renal replacement therapy are crucial to reduce mortality.

STOP GOES MY HEART: PERMANENT PACEMAKER IMPLANTATION FOR BRASH SYNDROME-RELATED COMPLETE HEART BLOCK

STOP GOES MY HEART: PERMANENT PACEMAKER IMPLANTATION FOR BRASH SYNDROME-RELATED COMPLETE HEART BLOCK

TH8.4 The potential for day case total parathyroidectomy in patients with secondary hyperparathyroidism

Abstract Aims Hypocalcaemia is a common complication after parathyroidectomy for secondary hyperparathyroidism (SHPT) and is often the cause of a prolonged hospital stay post operatively. Although there is no current guidance on targets for total parathyroidectomy for SHPT, current guidance recommends a day-case rate of 90% for patients undergoing surgery for primary hyperparathyroidism. Our centre has developed a safe protocol which allows us to perform total parathyroidectomies as a day-case procedure in patients with SHPT. This protocol, developed in conjunction with the renal physicians, involves giving the patients alpha calcidol pre-operatively for 5 days, to minimise the incidence of hypocalcaemia, and close monitoring of the calcium levels post operatively, to permit safe discharge. Methods We carried out a single centre retrospective study on all patients who underwent a total parathyroidectomy for SHPT between February 2005 and May 2021. All the patients received the alpha calcidol regimen pre-operatively. Data on patient baseline characteristics, peri-operative calcium, potassium and PTH levels, length of hospital stay, operative procedure details, hospital readmission and 30-day morbidity were collected. Results 49 patients underwent a total parathyroidectomy during the study period. 67% of patients were discharged on day 0 or on day 1 post-operatively. Reasons for prolonged hospital stay in the remaining patients included refractory hyperkalaemia requiring dialysis, complications secondary to anaesthesia, as well as hypocalcaemia in a few cases. No patients required readmission during the 30-day post-operative period. Conclusion Day-case surgery for SHPT can be achieved safely with a pre-operative regimen of alpha calcidol and close monitoring of calcium levels post-operatively.

Spontaneous tumor lysis syndrome in hyperaggressive mantle cell lymphoma.

An otherwise well 61-year-old male presented to his primary care practitioner with drenching sweats, weight loss, massive splenomegaly (30 cm as measured by computed tomography [CT], Figure 1A) and a lymphocytosis (white blood cell [WBC] at diagnosis 150 × 109/L). The peripheral smear was notable for the presence of pleomorphic abnormal lymphocytes, with clumped chromatin, high nuclear:cytoplasm ratio and irregular nuclei (Figure 1B). Peripheral blood flow cytometry revealed a kappa light chain restricted population of mature B-cells which co-expressed CD20 and CD5 (Figure 1C). CD23 and CD10 were negative. Fluorescent in situ hybridization revealed a CCND1/IGH rearrangement, consistent with a diagnosis of advanced stage mantle cell lymphoma (MCL). Approximately 3 weeks after diagnosis, he was admitted electively for chemotherapy. On admission to the unit he was well, with normal vital signs and a normal baseline tumor lysis profile (K, Phos, Ca, urate and creatinine all within institution limits). His WBC was noted to have increased modestly to 264 × 109/L. Unfortunately, over the course of the next 12 h, prior to the administration of any systemic anti–cancer therapy (including steroids), he developed spontaneous tumor lysis syndrome and died of catastrophic metabolic derangement, despite aggressive supportive care. He developed severe, refractory hyperkalemia (7.5 mmol/L), severe hyperphosphatemia (3.83 mmol/L) and profound metabolic acidosis (pH <6.9, HCO3– 3 mmol/L, lactate 17 mmol/L). His WBC had also climbed explosively to 695 × 109/L (Figure 1D), putting him at significant risk of leukostasis. I postulate that, via clonal evolution, his disease acquired a hyperproliferative phenotype, resulting in fulminant, spontaneous tumor lysis syndrome. There are limited reports of secondary translocations involving the MYC proto-oncogene in patients with MCL. This is associated with aggressive clinical course and short overall survival; however there are no reports of MCL behaving this aggressively in the literature. Practitioners should be aware of this rare but potentially devastating complication of MCL. James Wilson wrote the manuscript and took pictures. The author declares they have no conflicts of interest. The author received no specific funding for this work. No research on human was performed on this study. Data sharing not applicable—no new data generated.

A Novel Predictive Model for Hospital Survival in Patients who are Critically Ill with Dialysis-Dependent AKI: A Retrospective Single-Center Exploratory Study.

Mortality of patients who are critically ill with AKI initiated on RRT is very high. Identifying modifiable and unmodifiable clinical variables at dialysis start that are associated with hospital survival can help, not only in prognostication, but also in clinical triaging. A retrospective observational study was conducted on patients with AKI-D who were initiated on RRT in the medical and surgical intensive care units (ICUs) of a high-acuity academic medical center from January 2010 through December 2015. We excluded patients with suspected poisoning, ESKD, stage 5 CKD not on dialysis, or patients with AKI-D initiated on RRT outside of the ICU setting. The primary outcome was in-hospital mortality. Of the 416 patients who were critically ill with AKI-D admitted to the medical (38%), surgical (41%), and cardiac (21%) ICUs, with nearly 75% on artificial organ support, the mean age 62.1±14.8 years, mean SOFA score was 11.8±4.3, dialysis was initiated using continuous RRT in 261 (63%) and intermittent hemodialysis in 155 (37%) patients. Incidence of survival to hospital discharge was 48%. Using multivariable logistic regression with stepwise backward elimination, a prognostic model was created that included the variables age, CKD, COPD, admission, and within 24 hours of the start SOFA score, refractory hyperkalemia and uremic encephalopathy as dialysis indications, BUN >100 mg/dl, serum creatinine, serum lactate, serum albumin, CRRT as initial modality, severe volume overload, and abdominal surgery. The model exhibited good calibration (goodness of fit test, P=0.83) and excellent discrimination (optimism-corrected C statistic 0.93). In this single-center, diverse, critically ill AKI-D population, a novel prognostic model that combined widely used ICU scores, clinical and biochemical data at dialysis start, and dialysis indication and modality, robustly predicted short-term survival. External validation is needed to prove the generalizability of the study findings.

Relapsed Nocardiosis Presenting as Acute Vision Loss

<h3>Introduction</h3> Opportunistic infections with Nocardia spp. can be morbid in lung transplant recipients (LTxRs). Nocardia is most commonly acquired by inhalation, and most patients present with respiratory involvement. Treatment strategies vary, but typically include 2 antimicrobials initially, followed by a prolonged course with a single agent. Although treatment is often curative, relapses can occur. We describe a case of relapsed nocardiosis presenting with acute vision loss in an LTxR. <h3>Case Report</h3> A 68-year-old woman presented with a left lower lobe mass-like consolidation 7 months after bilateral LTx for sarcoidosis. <i>Nocardia cyriacigeogica</i> was isolated from bronchoalveolar lavage (BAL) and she was treated with ceftriaxone (CTX), linezolid, and inhaled amikacin. Trimethoprim-sulfamethoxazole (TMX-SM) was not administered due to a history of hives with sulfa derivatives. Brain MRI and abdomen/pelvis CT showed no evidence of disseminated disease. Her antimicrobials were changed to CTX, minocycline, and inhaled amikacin based on sensitivities, and she completed a 6-month course with radiographic improvement and 2 negative BAL cultures. Six months after stopping nocardia-directed treatment, she presented with left-sided vision loss. MRI of the orbits revealed soft tissue thickening in the posterior left globe, and brain MRI showed rim enhancing lesions in the right frontal lobe. CT of the chest, abdomen, and pelvis showed a slight interval worsening of multifocal tree-in-bud nodules in bilateral lower lobes of the lungs, but no evidence of abdominopelvic infection, and BAL grew acremonium spp. Retinal exam showed vitritis and retinal detachment. She was treated with intravitreal amikacin and was restarted on systemic CTX and linezolid for presumed Nocardia relapse. A trial of TMX-SM showed no evidence of drug allergy, thus CTX and linezolid were replaced with TMX-SM—2 DS tablets BID. After a year, the TMX-SM dose was reduced to 1 DS tablet BID to refractory leukopenia and hyperkalemia. Nearly 3 years after relapse, she remains on this regimen with no evidence of recurrent disease or drug intolerance and resolution of vision loss and MRI abnormalities. <h3>Summary</h3> Nocardiosis can relapse despite prolonged antimicrobial therapy, particularly in immunocompromised patients, and clinical presentation can be extra-pulmonary. Ongoing administration of TMX-SM may prevent relapse in high-risk patients.

C16. BRASH (Bradycardia, Renal Failure, AV Nodal Blocker, Shock, and Hyperkalemia) Syndrome: Lost in Plain Sight

Abstract Background Bradycardia, Renal failure, AV-Nodal blockers, Shock, Hyperkalemia (BRASH) Syndrome new clinical entities due to a vicious cycle in which hyperkalemia from renal failure synergizes with AV-nodal blockers, consequently between the clinical condition of patients with the degree of hyperkalemia and bradycardia are inappropriate, Furthermore, the symptoms may be refractory to typical positive chronotropic interventions or overdose antidotes. Case Illustration A hypertensive 70-years old female with history of heart failure with routinely consume spironolactone, diltiazem, and beta blocker admitted with bradycardia and shock after watery diarrhea and vomit 3 days before. The electrocardiogram showed junctional rhythm 40 beats per minutes. Laboratory findings Hyperkalemia (6.8 mEq/L) and acute kidney injury (urea 58.6 mg/dL, creatinine 3.13 mg/dL, eGFR 16.23) was presented. Refractory hyperkalemia occured, but by using pacemaker, providing adequate fluids, and the return of renal perfusion, hyperkalemia can be overcome. Discussion BRASH syndrome usually triggered by hypotension in the elderly due to hypovolemia or an overdose of antihypertensive drugs. The natural compensation response for hypotension is to increase heart rate, but AV-nodal blockers blunt this response, which causes a decrease in renal perfusion. This ultimately results in hyperkalemia and accumulation of AV-nodal blockers which produce a synergistic effect causes bradycardia and decreased renal perfusion. Treatment involves supportive care including hemodynamic support with fluids and management of bradycardia, and also avoid trigger factor.

C16. BRASH (Bradycardia, Renal Failure, AV Nodal Blocker, Shock, and Hyperkalemia) Syndrome: Lost in Plain Sight

Abstract Background Bradycardia, Renal failure, AV-Nodal blockers, Shock, Hyperkalemia (BRASH) Syndrome new clinical entities due to a vicious cycle in which hyperkalemia from renal failure synergizes with AV-nodal blockers, consequently between the clinical condition of patients with the degree of hyperkalemia and bradycardia are inappropriate, Furthermore, the symptoms may be refractory to typical positive chronotropic interventions or overdose antidotes. Case Illustration A hypertensive 70-years old female with history of heart failure with routinely consume spironolactone, diltiazem, and beta blocker admitted with bradycardia and shock after watery diarrhea and vomit 3 days before. The electrocardiogram showed junctional rhythm 40 beats per minutes. Laboratory findings Hyperkalemia (6.8 mEq/L) and acute kidney injury (urea 58.6 mg/dL, creatinine 3.13 mg/dL, eGFR 16.23) was presented. Refractory hyperkalemia occured, but by using pacemaker, providing adequate fluids, and the return of renal perfusion, hyperkalemia can be overcome. Discussion BRASH syndrome usually triggered by hypotension in the elderly due to hypovolemia or an overdose of antihypertensive drugs. The natural compensation response for hypotension is to increase heart rate, but AV-nodal blockers blunt this response, which causes a decrease in renal perfusion. This ultimately results in hyperkalemia and accumulation of AV-nodal blockers which produce a synergistic effect causes bradycardia and decreased renal perfusion. Treatment involves supportive care including hemodynamic support with fluids and management of bradycardia, and also avoid trigger factor.

NO WATER, NO PROBLEM: USING CRRT FOR HEMODIALYSIS PATIENTS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Each dialysis session uses approximately 150 to 200 L of water [1]. While this was an issue discussed by policymakers and environmentalists, the winter storm that swept across the southwest United States in February 2021 made the bedside physician keenly aware of the problem. The region saw an unprecedented disruption of water and power supplies which put end-stage renal disease (ESRD) patients in jeopardy. Intermittent hemodialysis (IHD) could not be performed due to lack of running water, low water pressures, and unsanitary water conditions. We present 4 cases when continuous renal replacement therapy (CRRT) was utilized to provide urgent hemodialysis in hemodynamically stable, non-critically ill ESRD patients during this time of water supply crisis. CASE PRESENTATION: Our patients were between the ages 47-62 years old, mostly male. All patients were ESRD patients on IHD three days per week. Shortness of breath was the presenting complaint in 3 of 4 patients, each of whom had missed their last scheduled HD session due to inclement weather. 1 of 4 patients presented with altered mental status. Indications for hemodialysis included volume overload with pulmonary edema and respiratory distress, hypertensive crisis, refractory hyperkalemia, and uremic encephalopathy. The CRRT equipment used included the PRISMAX system for CRRT with M150 filters. Renal replacement solution containing 32 mEq/L bicarbonate, 4 mEq/L potassium, and 2.5 mEq/L calcium was used as dialysate fluid. Continuous veno-venous hemodialysis (CVVHD) more was used with a dialysate flow rate of 6L /hour and a blood flow rate of 200/per hour with calculated urea clearance of 100 ml/min. The duration of treatment was 8 hours to achieve the target Kt/V of 1.15, comparable to the recommended 1.2 provided by IHD. 9-10 bags of dialysate were used per each session. Fluid removal ranged from 150-500 ml/hr. 1 patient required a repeat session on a subsequent day due to incomplete treatment due to filter clotting. All patients tolerated the procedure well with the resolution of their acute conditions and normalization of blood pressure and electrolytes. 1 patient developed brief hypotension which resolved with fluid administration. No other adverse events were seen. DISCUSSION: CRRT has typically been used for renal replacement therapy in critically ill patients. It requires specialized equipment and a higher nurse: patient ratio as compared to IHD but can be used to manage volume overload and electrolyte derangements in ESRD patients without the substantial water requirements of IHD. CONCLUSIONS: We demonstrate limited CRRT as an alternative to safely manage ESRD patients needing urgent hemodialysis in the scenario of a natural disaster resulting in a water outage. REFERENCE #1: Hoenich NA, Levin R, Ronco C: Water for haemodialysis and related therapies: recent standards and emerging issues. Blood Purif 2010;29:81–8 DISCLOSURES: No relevant relationships by Sukhmani Boparai, source=Web Response Scientific Medical Advisor relationship with ALung Technologies, Inc. Please note: $5001 - $20000 by Steven Conrad, source=Web Response, value=Consulting fee No relevant relationships by Rajkamal Hansra, source=Web Response No relevant relationships by Prathik Krishnan, source=Web Response No relevant relationships by Audrey Netzel, source=Web Response

LEGIONNAIRES' DISEASE: A FATAL FORM OF COMMUNITY-ACQUIRED PNEUMONIA

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Legionella pneumophila is gram-negative bacilli known to cause community-acquired pneumonia (CAP), also termed Legionnaires' disease. While pneumonia is the most common manifestation, extrapulmonary infections include renal injury and rhabdomyolysis. Age, immunosuppression and multi-system infection increase mortality, even with early initiation of therapy. CASE PRESENTATION: A 30-year-old male with history of bipolar disease, alcohol and tobacco abuse presented with diarrhea, fever and confusion for three days. He was found to be febrile, tachycardic, encephalopathic and hypoxic requiring high-flow nasal cannula. Initial evaluation revealed leukocytosis, acute liver injury, acute renal injury, respiratory alkalosis, lactic acidosis, and elevated troponin and creatine kinase levels. Chest x-ray (CXR) showed a dense left upper lobe consolidation. Sepsis was worked up and he was given intravenous fluids and antibiotics (Vancomycin, Cefepime, Metronidazole, Azithromycin). Over several hours, he became oliguric, tachypnic and hypotensive requiring vasopressors, continuous renal replacement therapy (CRRT) and mechanical ventilation. Urinary legionella antigen returned positive so Levofloxacin was added. Despite antibiotics and CRRT, his shock worsened and he ultimately had pulseless electrical activity arrest with demise. DISCUSSION: The presence of acute renal injury in Legionnaires' disease increases mortality up to 51% so early diagnosis is crucial to guide management. The urinary antigen test for L. pneumophila only identifies serogroup 1, which is the most common type. When prevalence is high, specificity of this test is >99%. Severe cases of CAP should be tested for Legionella as half of patients with Legionnaires' disease will require intensive care. Rhabdomyolysis occurs due to direct toxin invasion and renal injury occurs subsequently or due to sepsis. Levofloxacin or Azithromycin are the antibiotics of choice as they are bactericidal and reach high intracellular concentrations. There are twenty-two known cases of Legionnaires' disease with rhabdomyolysis and acute renal injury. Nearly all patients with this triad survived and of those who did, all received antibiotics and about half required hemodialysis (HD). To our knowledge, there is only one other case where the outcome was death despite several days of HD. In comparison, presentation to death occurred in less than twenty-four hours in our case. Cause of death was refractory hyperkalemia due to rhabdomyolysis-induced renal injury despite CRRT. CONCLUSIONS: Even with timely diagnosis and treatment of Legionnaires' disease, renal involvement portends a high mortality rate. At the earliest evidence of renal injury in Legionnaires' disease complicated by rhabdomyolysis, immediate placement of central venous catheters and early initiation of CRRT is mandatory and may be life saving. REFERENCE #1: Soni AJ, Peter A. Established association of legionella with rhabdomyolysis and renal failure: A review of the literature. Respir Med Case Rep. 2019 Oct 28;28:100962. REFERENCE #2: Mercante, J. W., & Winchell, J. M. (2015). Current and emerging Legionella diagnostics for laboratory and outbreak investigations. Clinical microbiology reviews, 28(1), 95–133. REFERENCE #3: Straus W.L., Plouffe J.F., File T.M. Risk factors for domestic acquisition of Legionnaires' disease. Ohio Legionnaires Disease group. Arch. Intern. Med. 1996;156(15):1685–1692. DISCLOSURES: No relevant relationships by Allen Roberts, source=Web Response No relevant relationships by Jigna Solanki, source=Web Response

Saved by Insulin! Continuous Intravenous Insulin Infusion as an Adjunctive Treatment for Refractory Hyperkalaemia

Intravenous insulin infusion which is used in treatment of hyperglycaemic emergencies can cause hypokalemia. We report a case of how this disadvantage was utilised to save a patient with life threatening hyperkalaemia. A 46-year-old lady with diabetes mellitus and chronic kidney disease (CKD) presented with breathlessness for 3 days. She had been taking excessive durian for 5 days before admission. Her medications included atenolol. On examination, she was severely bradycardic with pulse rate of 35 beats per minute. She had clinical features of fluid overload. Her renal profile showed elevated urea (17.5 mmol/l) potassium (7.8 mmol/l) and creatinine (322 umol/l). Electrocardiograph (ECG) showed junctional bradycardia. Despite counselling, she declined renal replacement therapy. Various potassium lowering therapies were given including regular nebulised salbutamol, calcium polystyrene sulfonate, intravenous furosemide, and regular insulin chase. After 5 rounds of insulin chases, potassium level remained markedly elevated at 8.2 mmol/l. When she finally consented, haemodialysis was performed. 9 hours post haemodialysis, potassium level was 7.6 mmol/l. While waiting for a next session of haemodialysis, fixed rate intravenous insulin infusion (0.1 unit/kg/hour) was given with concurrent dextrose fluids. Blood glucose was monitored hourly. 15 hours later potassium dropped to 5 mmol/l. ECG changes resolved with resolution of hyperkalemia. She did not require further haemodialysis. Patients with CKD should be cautious with durian intake as it is rich in potassium and may lead to severe hyperkalemia. This case highlights a novel use of continuous fixed-rate insulin infusion for treatment of refractory hyperkalemia when all else fails.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S8

The indications for and timing of haemodialysis in critically ill patients with acute kidney injury in Johannesburg, South Africa.

Background Acute kidney injury (AKI) is common among patients admitted to the intensive care unit (ICU). It is an independent risk factor for morbidity and mortality. The optimal timing of renal replacement therapy (RRT) remains unknown, resulting in a wide variation in observed current practices. There is a paucity of data on current practices within ICUs in South Africa. Objectives To describe current practices in the timing of RRT in patients with AKI admitted to the ICU. The secondary objectives were to describe the patient characteristics, severity of illness scores, staging at initiation of RRT, outcome at ICU discharge, and to estimate and describe delays in the initiation of RRT. Methods A retrospective, descriptive study was conducted in an adult academic ICU in Soweto from 1 January 2014 to 31 December 2015. Results There were 2 152 ICU admissions over the 2 years. Less than a tenth of the patients (3.5%; n=76) required RRT and the majority had sepsis (83%). The most common indication for RRT was oliguria/anuria (50%; n=38), followed by worsening urea/creatinine (29%; n=22), metabolic acidosis (11.8%; n=9), refractory hyperkalaemia (5.3%; n=4), fluid overload (2.6%; n=2) and other (1.3%; n=1). More than half of the patients (55%; n=42) had RRT instituted on admission day (D0 ), while 45% (n=34) had RRT initiated after D0 (D1-21). RRT was initiated at stage 3 AKI in 90% and 94% of D0 RRT group and D1-21 RRT group, respectively. The median (interquartile range (IQR)) time to starting RRT was 4 (4) hours once the decision to initiate RRT was made. The composite outcome of death, RRT dependence and diuretic dependence at ICU discharge was 21% and there was no difference between the two groups (p=0.22). The ICU mortality was 3%. Conclusion The sampled population was young, predominantly male and had post emergency surgery with a high burden of sepsis and HIV. The observed current threshold for RRT was late (stage 3 AKI with classic/emergent indications) with outcomes comparable with the reviewed literature. Contributions of the studyThe present study adds insight into the practice of initiating RRT in patients admitted to the ICU with AKI. These data have previously not been described in the South African context. The patient population differed from the literature in that they were young, predominantly male and had post-emergency surgery with a high burden of sepsis and HIV.

Refractory hyperkalemia caused by ACE gene mutation in a 3-year-old girl with kidney transplantation: a case report

Refractory hyperkalemia caused by ACE gene mutation in a 3-year-old girl with kidney transplantation: a case report

Bi-atrial thrombosis in a patient with SARS-CoV-2 infection: a case report.

BackgroundCoronavirus disease 2019 (COVID-19) is a rapidly spreading pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It is a multisystemic disease associated with micro- and macrovascular thrombo-embolic complications, including intracardiac thrombosis, which has not been previously reported in the literature.Case summaryWe report a case of a 68-year-old woman with COVID-19 admitted to our intensive care unit with acute respiratory distress, undifferentiated shock, hyperkalaemia, acute kidney injury, and coagulopathy. She received crystalloid infusion, broad-spectrum antibiotics, hydroxychloroquine, insulin–dextrose, calcium gluconate, sodium bicarbonate, and i.v. vasopressors. Continuous renal replacement therapy (CRRT) was started for refractory hyperkalaemia and metabolic acidosis. Transthoracic echocardiogram obtained for concern of pulmonary embolism found bi-atrial thrombosis with normal bi-ventricular dimensions and function. Systemic anticoagulation was provided, but this was stopped soon afterwards due to worsening coagulopathy and bleeding. Despite intensive measures and supportive therapy, the patient developed worsening hypoxia, refractory shock, and multiorgan failure. After discussion of goals of care with her family, a decision was made to initiate hospice care. The patient died within 72 h of hospital admission.DiscussionInfection with SARS-CoV-2 is a multisystemic disease that primarily affects the lungs, but also predisposes to rare thrombo-embolic phenomena such as intracardiac thrombosis.

SUN-332 POST TRANSPLANT GRAFT ABSCESS IN HEPATITIS-B POSITIVE RECIPIENT

Graft-site candidiasis is a rare manifestation of invasive fungal infections, with a risk of 1.3% in kidney transplants. The incidence of graft-site candidiasis is 0.1% in renal transplant recipients. Preservation of the renal graft is rarely possible when candidiasis is accompanied by vascular complications. A 24 year old male, with end-stage renal disease due to right solitary kidney with grade-3 vesicoureteric reflux, underwent left live-related donor kidney transplant with 2/6 HLA mismatch. He tested positive for Hepatitis B surface antigen, prior to continuation of maintenance hemodialysis at our center, and underwent hemodialysis for 1 year prior to transplant, hemodialysis access being left IJV cuffed hemodialysis catheter. The donor being his mother, was 45 years old, without any comorbidities. The recipient underwent right laparoscopic nephroureterectomy, on the same day, prior to transplantation. The patient received induction with Inj Grafalon, (an anti-human T-lymphocyte immunoglobulin from rabbits), intraoperatively, followed by triple-drug therapy with Tacrolimus, Prednisone, and Mycophenolate sodium. Urinary catheter, abdominal drain, left IJV cuffed hemodialysis catheter were removed prior to discharge. on day 9 he was discharged with DJ stent insitu and a baseline creatinine of 1.6 mg/dL. 19 days post transplant, he presented with facial puffiness, 4-6 loose stools, vomiting, 9 kg weight gain, oliguria and azotemia. There was no history of fever, vomiting, dysuria, bleeding manifestation, abdominal pain. He was hemodynamically stable with a hemoglobin of 7.4g%, TLC 5200/µL, Platelet 95000/ µL, serum urea and creatinine of 156 mg/dL, 6.6 mg/dL respectively. His spot UPCR was 8.3 and urine had 3+ proteinuria, 80 – 90 RBC / hpf, 15 – 20 Pus cells / hpf. His abdominal sonography was suggestive of pyelonephritis of the transplanted kidney & graft vessel doppler was normal. Urine culture was suggestive of Klebsiella pneumoniae and was treated as per antibiotic sensitivity. Due to persistent anuria, and a rising trend of serum creatinine with severe metabolic acidosis and refractory hyperkalemia, he underwent hemodialysis, via left femoral uncuffed hemodialysis catheter. DJ stent was removed. Repeat urine and blood cultures showed no growth. Stool culture also showed no growth. Repeat abdominal ultrasonography & CT-KUB were suggestive of pyonephrosis of transplanted kidney. He underwent right IJV cuffed hemodialysis catheter insertion and was put on thrice weekly maintenance hemodialysis. Post-transplant day-70, he underwent graft nephrectomy. Histopathology of multiple sections of the graft showed focal areas of abscess with non-septate fungal hyphae, numerous foreign body and langhan’s giant cells mixed with lymphohistiocytic inflammatory cells with epitheloid cells. There was evidence of tubulitis, glomerulonephritis with vessels showing hyaline arteriolar sclerosis with areas of infarcts. Sections from the ureter showed inflammatory cell infiltration of transitional epithelium and the walls showed candida, conclusive with Pyelonephritis due to candidiasis (Banff category 6). Diagnosis of fungal infection in transplant recipients can be perplex due to vague patient symptoms and lack of specificity of blood test or radiologic findings. The paucity of data regarding their management poses a challenge to transplant physicians.