Hyperkalemia – a renal emergency_ by hcj


   – an emergency?

 Shaila Sukthankar
 Paediatric Nephrology Study Day

n Overview

n Clinical   cases

n Emergency     Management
Hyperkalemia - causes

n Spurious/ pseudohyperkalemia
n Increased intake
n Trans-cellular shift
n Decreased renal tubular excretion
  – Renal
  – Endocrine
  – Drugs

n   Renal
    – U&Es, acid base balance, urinalysis
    – TTKG (urine K X P osmol/ plasma K X U osmol)
n   Endocrine
    – For another meeting!
    – Renin, aldosterone, urinary steroids, 17-OHP
n   Others
    – FBC, blood film, urate, CK, calcium, phosphate
Case 1
n   ER, 15 years old girl
n   Known to have IDDM for several years
n   Difficult family circumstances but ER very well
    engaged and compliant
n   Recent annual diabetes review 3 months before
    admission - good glycaemic control
n   Blood tests unremarkable, urine microalbumin/
    creatinine ratio normal
n   Growth – weight and height 2nd to 9th and
Clinical Presentation

n   Diarrhoeal illness for 1 week – mucus, no
    blood. Initially polyuric and nocturic, now
    decreased urine output
n   Parents noticed her to be pale and tired lately
n   Examination – pale, BP 130/ 86, hydration
    and perfusion normal
n   Urine 3+ glucose, ketones ++
Initial investigations

n   CBG: pH 7.2, BE –10, Bicarb 15
n   Na 128, K 6.5, urea 23
n   Hb 9.8, WCC 5.8
Further investigations

n   Platelet 240
n   Glucose 7.8
n   Creatinine 210
n   Ca 1.9, Pi 2.8
n   Blood film – normal RBC and platelet
n   Urine 2+ protein, 3+ blood with casts
Immediate measures
n   Stop external sources of K
n   Stabilise myocardium
    – IV calcium gluconate
n   Enhance intracellular shift of K
    – Nebulised Salbutamol
    – Sodium Bicarbonate
    – Glucose Insulin infusion
n   Increase excretion
    – Ion exchange resin
    – Dialysis
Calcium Gluconate

n   If K >7 mmol/ L or ECG changes
n   10% solution
n   0.5 ml/ Kg (maximum 20ml) over 10 minutes
n   With ECG control via large peripheral or
    central line
n   Protects myocardium from acute dysrhythmia,
    no effect on K levels
n   First line treatment – nebulised
n   2.5mg up to 5 years age, 5mg there after
n   Can be repeated up to 3 times
n   Alternatively, if access available, IV
    –   4mcg/ kg
    –   diluted with normal saline or glucose
    –   50mcg/ml concentration
    –   Over 5 min as slow bolus
n   Does not lower net K, shifts from ECF to ICF
Sodium Bicarbonate

n   In presence of acidosis
n   8.4% solution
n   1ml (1mmol)/ Kg
n   Diluted to minimum 1:10 with normal saline/
    glucose for peripheral venous use (1:5 for
    central access)
n   Infusion over 30 minutes
n   Shifts K from ECF to ICF
Glucose Insulin infusion

n   Soluble short acting insulin (0.1 U/ Kg)
n   Mixed in 5 – 10 ml/ Kg of 10% dextrose for
    peripheral use (2.5 to 5 ml of 20% dextrose
    for central access)
n   Infused over 30 minutes
n   Check BM every 15 minutes by POCT – until
    15 minutes after infusion
Calcium Resonium

n   Oral (not neonates) or rectal
n   125-250 mg/ kg qds (maximum 15gm per
n   If given orally, also use lactulose
n   Lowers total body K by excretion in stools
Further management

n   Treatment of underlying cause – DKA
    management, endocrine, renal etc
n   Renal replacement modalities
    – Haemodialysis for rapid effective reduction in K
    – Peritoneal dialysis is as effective but over longer
    – Haemofiltration – if already on ICU
After emergency treatment…

n   Recheck U&Es after 15 minutes of initial
    intervention to ensure
    – treatment is effective
    – Level is reaching safe range
n   Recheck after 1 – 2 hours to detect rebound
n   Look for underlying cause
ER - update
n   Required nebulised salbutamol and Ca
    gluconate at local DGH
n   Transferred to RMCH and started on dialysis
    the same day
n   Had immune work up and renal biopsy
n   GFR reduced to <10 (ESRD) – CKD5
n   On dialysis
n   Had living related donor kidney transplant
Case 2

n   3 years, boy, previously well
n   Presented with fever and frequent URI
n   Growth, examination normal
n   Blood tests
    –   FBC normal, mild iron deficiency
    –   Na 135, K 6.8, U 4.5, Creatinine 35
    –   pH 7.3 BE – 8, sugar 4.8, urine NAD
    –   ECG nSR
Case 2 continues…

n   Plasma renin and aldosterone low
n   Synacthen test and 17-OHP normal
n   Diagnosis??
    – Hyporeninemic hypoaldosteronism
    – Pseudohypoaldosteronism
Gordon’s syndrome (PHA 2)

n   Tubulopathy affecting chloride channels,
    decreased potassium excretion (WNK1, WNK4
    AR mutation)
n   Responded well to thiazide diuretics
n   Younger twin siblings also affected
n   All currently well with normal K levels on
    thiazide treatment

n   Acute, severe, true hyperkalemia
     – is a medical emergency
    – requires prompt recognition and optimum
n   Not all hyperkalemia is renal in origin
n   Specialist input required to establish etiology
    and long term management
Specialist Input
Assessment                Action

Abnormal renal function   D/w Nephrology

Massive hemolysis/        D/w Nephrology
rhabdomyolysis or tumor   (+ hemato-oncology)
Normal renal function     D/w Endocrinology (+/-
Uncertain                 D/w All

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