POCT errors can lead to false potassium results

Point-of-care-testing (POCT) facilitates rapid availability of results that allows prompt clinical decision making. These results must be reliable and the whole process must not compromise its quality. Blood gas analyzers are one of the most used methods for POCT tests in Emergency Departments (ED) and in critical patients. Whole blood is the preferred sample, and we must be aware that hemolysis can occur. These devices cannot detect the presence of hemolysis in the sample, and because of the characteristics of the sample, we cannot visually detect it either. Hemolysis can alter the result of different parameters, including potassium with abnormal high results or masking low levels (hypokalemia) when reporting normal concentrations. Severe hyperkalemia is associated with the risk of potentially fatal cardiac arrhythmia and demands emergency clinical intervention. Hemolysis can be considered the most frequent cause of pseudohyperkalemia (spurious hyperkalemia) or pseudonormokalemia and can be accompanied by a wrong diagnosis and an ensuing inappropriate clinical decision making. A complete review of the potential causes of falsely elevated potassium concentrations in blood is presented in this article. POCT programs properly led and organized by the clinical laboratory can help to prevent errors and their impact on patient care.

Effect of Angiotensin–Neprilysin Versus Renin–Angiotensin System Inhibition on Renal Outcomes: A Systematic Review and Meta-Analysis

Aims: We aim to perform a systematic review and meta-analysis examining randomized controlled trials assessing the efficacy and safety of sacubitril/valsartan in patients on renal outcomes, in comparison with the renin–angiotensin–aldosterone system inhibitor (RAASi).Methods: Eligible studies were retrieved on MEDLINE, EMBASE, and Cochrane until September 2021. The primary outcome was the incidence of renal impairment, which was defined as the composite of increases in serum creatinine by >0.3 mg/dl and/or a reduction in eGFR ≥25%, development of ESRD, or renal death. We pooled relative risks (RRs) with 95% confidence intervals (CIs) or the mean difference with 95% CIs for the variables.Results: Our search yielded 10 randomized controlled trials with a total of 18,362 patients. Compared with RAASi treatment, patients treated with sacubitril/valsartan had lower incidence of composite renal impairment (10 studies, 18,362 patients, RR 0.84; 95% CI 0.72–0.96, p = 0.01; I2 = 22%), ESRD development (3 studies, 13,609 patients, RR 0.53; 95% CI 0.30–0.96, p = 0.03; I2 = 0%), drug discontinuation due to renal events (4 studies, 9,995 patients, RR 0.58; 95% CI 0.40–0.83, p = 0.003; I2 = 47%), severe hyperkalemia (6 studies, 16,653 patients, RR 0.80; 95% CI 0.68–0.93, p = 0.01; I2 = 25%) and a slower eGFR decline (4 studies, 13,608 patients, WMD 0.56; 95% CI 0.36–0.76, p < 0.00001; I2 = 65%). Subgroup analysis demonstrated that sacubitril/valsartan was associated with a lower incidence of renal impairment in patients with heart failure and preserved ejection fraction (HFpEF), but not in those with heart failure and reduced ejection fraction (HFrEF). The superior renal function preservation of sacubitril/valsartan treatment was not associated with different baseline eGFR levels and follow-up duration. There was a smaller increase in the change in the urine albumin-to-creatinine ratio (UACR) (3 studies, 9,114 patients, SMD 0.06; 95% CI 0.02–0.10, p = 0.003; I2 = 14%) with sacubitril/valsartan treatment. However, patients with heart failure appeared to have increased microalbuminuria, not patients without HF (p = 0.80 for interaction).Conclusion: Sacubitril/valsartan was associated with a lower incidence of composite renal impairment especially in patients with HFpEF, but higher microalbuminuria in patients with heart failure (both HFrEF and HFpEF) compared with RAASi. The lower incidence of severe hyperkalemia and drug discontinuation due to renal events in patients with sacubitril/valsartan treatment demonstrated its superior safety compared with RAASi.

Levetiracetam Induced Hyperkalemia – A Rare Side Effect in Elderly with Pre-Existing Subclinical Renal Insufficiency Presenting with Bradyarrhythmia

Levetiracetam is a commonly used drug in today’s world for long term management of partial as well as generalized seizures mainly due its major advantage that is has so few and non-threatening side effects[1].In the following case scenario, we show how a 70 years old male presented with severe hyperkalemia and after no other common culprits were seen, it was thought to be a side effect therapy with levetiracetam and after discontinuing it and managing hyperkalemia, the patient’s condition improved from a very critical state. We also show a rare form ECG presentation of severe hyperkalemia in the form of bradyarrhythmia with absent P waves. Our experience shows that unpredictable and rare side effects of new anti-epileptic drugs should be given attention and such cases often go undiagnosed.

Successful Treatment of a Patient with Cardiac Arrest Due to Hyperkalemia by Prolonged Cardiopulmonary Resuscitation along with Hemodialysis: A Case Report and Review of the Literature

Severe hyperkalemia is a potentially life threatening cardiac emergency, especially in patients with renal failure, and can lead to fatal arrhythmias such as ventricular fibrillation or asystole, leading to cardiac arrest. We report a case of a 39-year-old woman who developed sudden cardiac arrest secondary to hyperkalemia (9.95 mEq/L) with renal insufficiency. Despite 20 min of cardiopulmonary resuscitation (CPR) and conventional treatment for hyperkalemia, the cardiac arrest persisted. Hemodialysis was then initiated via the right femoral vein during CPR, and the patient restored spontaneous heartbeat 40 min later. Hemodialysis should be considered in the course of CPR in severe hyperkalemia induced cardiac arrest if conventional therapies fail.

Hyperkalemic circulatory shock and cardiac arrest altered by therapeutic management: A case report

Hyperkalemia is one of the few potentially lethal electrolyte disturbances. Severe hyperkalemia (Serum potassium concentration > 6.5 mmol/L) occurs most commonly from renal failure or the release of potassium from cells and can cause circulatory shock, cardiac arrhythmias or cardiac arrest. Current BLS (Basic Life Support) and ACLS (Advanced Cardiovascular Life Support) protocol should be used to manage cardiac arrest associated with hyperkalemia. But early consideration should be given to using the selective method of therapeutic management in addition to standard ACLS protocols that can be provided rapidly, effectively in patients with cardiovascular instability. We describe here a case of chronic kidney disease and congestive heart failure who developed circulatory shock and eventually cardiac arrest due to hyperkalemia managed with Calcium Gluconate, Sodium Bicarbonate and Insulin along with standard advanced cardiovascular life support protocol. Keywords: Potassium, hyperkalemia, acidosis, calcium, insulin, cardiac arrest.

Patiromer in a Patient with Severe Hyperkalemia on Incremental Hemodialysis with 1 Session per Week: A Case Report and Literature Review

Hyperkalemia is common in patients with ESRD, undergoing hemodialysis (HD), and is associated with an increase in hospitalization and mortality. Residual kidney function in long-term dialysis patients is associated with lower morbidity and mortality in HD patients. Although the 2015 National Kidney Foundation-Kidney Disease Outcomes Quality Initiate (NKD-KDOQI) guidelines allow the reduction in the weekly HD dose for patients with a residual kidney urea clearance (Kur) >3 mL/min/1.73 m², very few centers adjust the dialysis dose based on these criteria. In our center, the pattern of incremental hemodialysis (iHD) with once-a-week schedule (1 HD/W) has been an option for a group of patients showing very good results. This pattern is maintained as long as residual diuresis is >1,000 mL/24 h, Kur is >4 mL/min, and there is no presence of edema or volume overload, as well as no analytical parameters persistently outside the advisable range (serum phosphorus >6 mg/dL or potassium [K⁺] >6.5 mmol/L). Management of hyperkalemia in HD patients includes reduction of dietary intake, dosing of medications that contribute to hyperkalemia, and use of cation-exchange resins such as calcium or sodium polystyrene sulfonate. Two newer potassium binders, patiromer sorbitex calcium and sodium zirconium cyclosilicate, have been safely used for potassium imbalance treatment in patients with ESRD in HD with a conventional regimen of thrice weekly, but has not yet been studied in 1 HD/W schedules. We present the case of a 76-year-old woman in iHD (1 HD/W) treated with patiromer for severe HK and describe her clinical characteristics and outcomes. In addition, we review the corresponding literature. Based on these data, it can be anticipated that the use of patiromer may overcome the risk of hyperkalemia in patients with incident ESRD treated with less-frequent HD regimens.

MO382POTASSIUM DISTURBANCES AND CHARACTERISTICS OF RENAL RECOVERY IN 1519 CONSECUTIVE PATIENTS WITH ACUTE KIDNEY INJURY

Background and Aims Acute kidney injury (AKI) is a common condition occurring in about 15% of hospitalized patients, often complicated by hyperkalemia causing increased risk for adverse cardiovascular events. The level of AKI (prerenal, renal or postrenal), is of importance as both pathophysiology and prognosis differ. Although early recovery from AKI is associated with less morbidity and mortality, patients with a history of AKI have a higher long-term risk of end-stage kidney disease and death. Most AKI studies include critically ill patients treated at intensive care units; less is known about AKI patients in general. The aim of this large single-center study was to report potassium disturbances and short-term hospital outcomes in 1519 consecutive patients with AKI admitted to a nephrology department. Methods All patients diagnosed with AKI between 2009 and 2018 and admitted to the nephrology department at Danderyd University Hospital, Stockholm, Sweden, were screened. Patients who fulfilled the KDIGO 2012 definition of AKI, a sCreatinine (sCr) >1.5 times baseline or increase by >0.3 mg/dL (>26.5 mmol/L), were included. Potassium levels at admission were classified into hypokalemia (<3.5 mmol/L), normokalemia (3.5-4.9 mmol/L), mild hyperkalemia (5-5.4 mmol/L), moderate (5.5-5.9 mmol/L) and severe hyperkalemia (≥6 mmol/L). Partial recovery was defined as an in-hospital sCr decrease by at least 30% while modest recovery was defined as s sCr decrease by at least 50%. Using logistic regression with conditional backward selection, we determined which variables that were associated with a partial recovery or a hyperkalemia (>5 mmol/L). Patients on dialysis treatment were excluded. Patients were followed until either discharge or death, whichever came first. Results In 1519 patients with AKI, the majority (n=687 (45%)) had prerenal AKI, followed by AKI on chronic (defined as chronic kidney disease combined with any type of AKI) (n=536 (35%)), renal (n=166 (11%)) and postrenal AKI (n=130 (9%)). At admission, 30% of patients had any hyperkalemia, whereas 7% had severe hyperkalemia. Normokalemia was seen in 60% of the patients while 10.5% had hypokalemia. The more hyperkalemia, the higher level of sCr at admission, the more acidosis and the less proteinuria. Proteinuria was most pronounced in patients with mild hyperkalemia and normokalemia. In-hospital partial renal recovery was seen in 63% of the patients, while 38% had a modest recovery. Mortality during hospitalization was 4%; most of these patients had normokalemia (58%), followed by mild (18%) and moderate hyperkalemia (15%). In the prerenal and postrenal groups, most patients had a partial renal recovery (76% and 73% respectively). In patients with renal and AKI on chronic the proportions were lower (40% and 51%, respectively). Conclusion This study provides data from a large, contemporary AKI patient cohort under nephrology care. Severe potassium disturbances are common and short-term outcomes differ substantially in patients of variable AKI level and etiology. These findings have important implications for prognostic evaluation upon admission and further resource planning.

Double Trouble of Severe Hyperkalemia: Syncope and No Significant ECG Changes

Potassium is an important ion capable to maintain intra-extracellular electric gradient. Hyperkalemia is a common and potential life-threatening electrolyte disorder in patients presenting to the emergency setting. Variations in the intra-extracellular ionic flow may alter cells functions, skeletal and smooth muscle contractility and electric activity of myocardial cells. Hyperkalemia can be difficult to diagnose clinically because symptoms may be vague. Patients may be asymptomatic or report non-specific symptoms such as generalized fatigue, weakness, paralysis or palpitations. Syncope is unusual neurological manifestation. An increase in serum potassium levels is followed by progressively severe electrophysiological derangements in cardiac impulse generation and conduction, which are reflected in the electrocardiogram (ECG).