A Case of Severe Hyperkalemia.

Case Description

A 46-year-old female with HTN and DM who presents to the emergency room with abdominal pain and found to have AKI with creatinine 8.9 mg/dl, BUN 75 mg/dl, CO2 9 mmol/L and severe hyperkalemia K 10 meq/L. There was no available baseline creatinine or history of prior CKD. Initial ECG at 22:07 showed QRS widening which was near a sinusoidal wave pattern. Patient was temporized with calcium gluconate, insulin/D50, fluids and received loop diuretic and zirconium. Dialysis access was quickly obtained, and dialysis initiated with 2K bath for the first hour followed by 1K bath for the second hour. Follow up ECG at 22:25 showed improvement of QRS after temporization and ECG had complete resolution with normal sinus rhythm and narrow QRS complex post dialysis. Etiology of AKI was presumed due to severe hypovolemia from poor oral intake in setting of Covid infection. There was no evidence of rhabdomyolysis, hemolysis, or urinary obstruction. Patient only required 1 dialysis session and creatinine improved to 3.4 on discharge 3 days later and 1.9 mg//dl 10 days after.

Discussion

Patients with advanced CKD and especially those on dialysis can usually tolerate higher levels of serum potassium due to higher intracellular stores and consequently a lower degree of membrane potential differential. In contrast patients with AKI usually do not have that buffer and have a higher likelihood of morbidity and mortality with severe hyperkalemia. ECG is a valuable tool to assess, confirm and monitor hyperkalemia in order to avoid delays in treatment and prevent cardiac arrest.