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Hyperkalemia – an emergency?

Hyperkalemia – an emergency?. Shaila Sukthankar Paediatric Nephrology Study Day 22.06.12 RMCH. Hyperkalemia. Overview Clinical cases Emergency Management. Hyperkalemia - causes. Spurious/ pseudohyperkalemia Increased intake Trans-cellular shift Decreased renal tubular excretion

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Hyperkalemia – an emergency?

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  1. Hyperkalemia – an emergency? Shaila Sukthankar Paediatric Nephrology Study Day 22.06.12 RMCH

  2. Hyperkalemia • Overview • Clinical cases • Emergency Management

  3. Hyperkalemia - causes • Spurious/ pseudohyperkalemia • Increased intake • Trans-cellular shift • Decreased renal tubular excretion • Renal • Endocrine • Drugs

  4. Investigations • Renal • U&Es, acid base balance, urinalysis • TTKG (urine K X P osmol/ plasma K X U osmol) • Endocrine • For another meeting! • Renin, aldosterone, urinary steroids, 17-OHP • Others • FBC, blood film, urate, CK, calcium, phosphate

  5. Case 1 • ER, 15 years old girl • Known to have IDDM for several years • Difficult family circumstances but ER very well engaged and compliant • Recent annual diabetes review 3 months before admission - good glycaemic control • Blood tests unremarkable, urine microalbumin/ creatinine ratio normal • Growth – weight and height 2nd to 9th and postpubertal

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

  7. Initial investigations • CBG: pH 7.2, BE –10, Bicarb 15 • Na 128, K 6.5, urea 23 • Hb 9.8, WCC 5.8

  8. Further investigations • Platelet 240 • Glucose 7.8 • Creatinine 210 • Ca 1.9, Pi 2.8 • Blood film – normal RBC and platelet morphology • Urine 2+ protein, 3+ blood with casts

  9. Immediate measures • Stop external sources of K • Stabilise myocardium • IV calcium gluconate • Enhance intracellular shift of K • Nebulised Salbutamol • Sodium Bicarbonate • Glucose Insulin infusion • Increase excretion • Ion exchange resin • Dialysis

  10. Calcium Gluconate • If K >7 mmol/ L or ECG changes • 10% solution • 0.5 ml/ Kg (maximum 20ml) over 10 minutes • With ECG control via large peripheral or central line • Protects myocardium from acute dysrhythmia, no effect on K levels

  11. Salbutamol • First line treatment – nebulised • 2.5mg up to 5 years age, 5mg there after • Can be repeated up to 3 times • Alternatively, if access available, IV salbutamol • 4mcg/ kg • diluted with normal saline or glucose • 50mcg/ml concentration • Over 5 min as slow bolus • Does not lower net K, shifts from ECF to ICF

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

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

  14. Calcium Resonium • Oral (not neonates) or rectal • 125-250 mg/ kg qds (maximum 15gm per dose) • If given orally, also use lactulose • Lowers total body K by excretion in stools

  15. Further management • Treatment of underlying cause – DKA management, endocrine, renal etc • Renal replacement modalities • Haemodialysis for rapid effective reduction in K levels • Peritoneal dialysis is as effective but over longer duration • Haemofiltration – if already on ICU

  16. After emergency treatment… • Recheck U&Es after 15 minutes of initial intervention to ensure • treatment is effective • Level is reaching safe range • Recheck after 1 – 2 hours to detect rebound hyperkalemia • Look for underlying cause

  17. ER - update • Required nebulised salbutamol and Ca gluconate at local DGH • Transferred to RMCH and started on dialysis the same day • Had immune work up and renal biopsy • GFR reduced to <10 (ESRD) – CKD5 management • On dialysis • Had living related donor kidney transplant

  18. Case 2 • 3 years, boy, previously well • Presented with fever and frequent URI • Growth, examination normal • 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

  19. Case 2 continues… • Plasma renin and aldosterone low • Synacthen test and 17-OHP normal • Diagnosis?? • Hyporeninemic hypoaldosteronism • Pseudohypoaldosteronism

  20. Gordon’s syndrome (PHA 2) • Tubulopathy affecting chloride channels, decreased potassium excretion (WNK1, WNK4 AR mutation) • Responded well to thiazide diuretics • Younger twin siblings also affected • All currently well with normal K levels on thiazide treatment

  21. Summary • Acute, severe, true hyperkalemia • is a medical emergency • requires prompt recognition and optimum treatment • Not all hyperkalemia is renal in origin • Specialist input required to establish etiology and long term management

  22. Specialist Input

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