Hiponatremia e hiperpotasemia persistente inducida por enoxaparina y revertida con hidrocortisona en paciente con metástasis lumbares / Low molecular weight heparin-induced hyperkalemia and hyponatremia: report of one case

Low molecular weight heparin-induced hyperkalemia is not an uncommon side effect. The development of hyponatremia is well described although it is less common. We report a 72-year-old woman with lumbar metastases who developed hyponatremia and hyperkalemia on the tenth day of hospitalization. Hyponatremia, with limited criteria for syndrome of inappropriate secretion of antidiuretic hormone, did not resolve with vigorous volume restriction. Hyperkalemia without an acid-base disorder or baseline renal failure, did not resolve after losartan was stopped. Enoxaparin-induced hypoaldosteronism was proposed and the drug was discontinued. After four days' persistence of the electrolyte disturbance, dexamethasone was changed to Hydrocortisone, and parameters normalized in 24 hours. The patient remained well until discharge and during outpatient control.

Cotrimoxazol en infecciones óseas: toxicidad e impacto clínico y económico / Cotrimoxazole in bone-related infections: toxicity and clinical and economic impact

Background: Cotrimoxazole is a therapeutic option for bone-related infections but is associated to hyperkalemia and renal failure. Tolerance to this drug may reduce length of stay (LOS) and hospital charges. Aims: To evaluate renal, potassium toxicity, clinical outcome, and use of hospital resources in patients treated with cotrimoxazole for bone-related infections. Methods: Retrospective analysis of adult patients with bone-related infections confirmed by culture and treated with this drug. Serum potassium and creatinine levels were analyzed during follow-up and risk factors for hyperkalemia were searched. Length of stay (LOS) and hospital charges were compared. Clinical outcome was evaluated as a secondary endpoint. Results: From 2011 to 2014, 23 patients were identified (mean age 64.7 years). Diabetes mellitus, peripheral vascular disease, and previous amputations prevalence were high (82.6%, 47.8%, and 43.5%, respectively). Median serum potassium concentration increased significantly at first control (4.35 mEq/L to 4.9 mEq/L; p < 0.001), and also creatinine serum concentration (0.9 to 1.1 mg/dL; p < 0.05). Seven patients developed hyperkalemia. Cotrimoxazole was discontinued in 10 patients (43.5%), and in 6, discharge was postponed. Drugs active against the renin-angiotensin system (DAARAS) were associated with kyperkalemia (OR 10.8 IC95 1.37-85; p < 0.05). LOS was higher among patients with cotrimoxazole toxicity (median LOS 56 versus 30 days, p < 0.05). Patients with no cotrimoxazole interruption had less drug-related hospital charges (median values of 563 versus 2820 USD, respectively; p < 0.01). Conclusions: Cotrimoxazole use must be monitored in order to detect hyperkalemia or renal toxicity and suspend its prescription. Patients that use DAARAS have a higher risk of kyperkalemia. LOS and drug-related hospital charges are reduced when patients can tolerate cotrimoxazole.

Antecedentes: Cotrimoxazol es una alternativa en infecciones óseas pero se ha asociado al desarrollo de falla renal e hiperkalemia. Objetivo: Evaluar toxicidad renal, hiperkalemia, estadía y gastos hospitalarios y evolución clínica en un grupo de pacientes con infecciones óseas tratados con este compuesto. Pacientes y Métodos: Estudio retrospectivo-descriptivo de pacientes adultos con infecciones óseas confirmadas con cultivos y tratados con este compuesto. Seguimiento de creatinina y kalemia y búsqueda de factores de riesgo para hiperkalemia, comparación de gastos y estadía hospitalaria y análisis de eficacia clínica. Resultados: Desde el año 2011 al 2014 se identificaron 23 pacientes (promedio de edad 64,7 años). La prevalencia de diabetes mellitus tipo 2 (82,6%), enfermedad vascular periférica (47,8%) y amputaciones previas (43,5%) fue elevada. La mediana de la kalemia basal aumentó significativamente al primer control (4,35 a 4,9 mEq/L) al igual que la creatinina plasmática (0,9 a 1,1 mg/dL). Siete pacientes desarrollaron hiperkalemia (30,4%). Se suspendió cotrimoxazol en 10 casos (43,5%) y en 6 casos se postergó el alta. El uso de fármacos activos contra el sistema renina-angiotensina (FASRA) se asoció a hiperkalemia (OR 10,8 IC95 1,37-85; p < 0,05). La estadía hospitalaria fue mayor en el grupo con toxicidad a cotrimoxazol (mediana de 56 versus 30 días; p < 0,05) y los pacientes sin suspensión de terapia tuvieron menos gastos por fármacos (medianas de 563 vs 2.820 USD, p < 0,01). Conclusiones: El uso de cotrimoxazol debe ser monitorizado para detectar hiperkalemia o toxicidad renal y suspender su prescripción. Los pacientes que usan FASRA tienen mayor riesgo de hiperkalemia. La estadía y gastos hospitalarios por fármacos son menores en pacientes que toleran el cotrimoxazol.

Hiperpotasemia extrema no fatal en un caso de acidosis láctica por sobreingesta de metformina / Non-fatal hyperkalemia in lactic acidosis due to metformin overdose. Report of one case

We report a 74-year-old man with diabetes mellitus type 2 and hypertension, who recently underwent coronary bypass surgery due to severe triple vessel disease receiving cardiological and combined antidiabetic therapy, including metformin 4 g/day. He was admitted with abdominal pain, nausea, vomiting, diarrhea and loss of consciousness. At admission, he was disoriented and agitated with signs of poor perfusion. His blood pressure was 80/70 mmHg, pulse rate 40 beats/min, respiratory rate 20-breaths/min, and axillary temperature 35°C. Biochemical profile revealed an extreme hyperkalemia of 15.4 mEq/L (double checked), elevated creatinine, uremia and brain natriuretic peptide; hypoglycemia (blood glucose 68 mg/dl) and normal C Reactive Protein. Arterial blood gases revealed severe lactic acidemia. The electrocardiogram showed sinus bradycardia, simple AV block, widened QRS with prominent T wave and prolonged QT. He was admitted to the Intensive Care Unit (ICU) with the suspicion of lactic acidosis associated with metformin, receiving fluid management, intravenous hypertonic glucose plus insulin and sodium bicarbonate, mechanical ventilation, vasopressor therapy, a temporary pacemaker lead, in addition to continuous venovenous hemodiafiltration. Two days later, the patient experienced a significant clinical improvement with normalization of the acid-base status, plasma lactate and potassium levels. On day 9, diuresis was recovered, creatinine and uremia returned to normal levels and the patient was discharged from the ICU.

Bloqueo AV completo, reversible, en relación a hiperkalemia grave por enalapril y espironolactona: caso clínico / Complete atrioventricular block, reversible, related to serious hyperkalemia due to enalapril and spironolactone: case report

La hiperkalemia es una de las principales complicaciones potenciales del uso de drogas del tipo IECA, bloqueadores ARAII y antagonistas del receptor de aldosterona, en relación a su dosis, su eventual uso combinado y la función renal del paciente. A continuación se reporta el caso de un paciente de 71 años de edad, hipertenso y diabético que se encontraba en tratamiento con Enalapril 10 mg c/12 h y Furosemida 40 mg a/ 12 h, que sufre una bloqueo aurículo ventricular de 3º grado, secundario a una hiperkalemia de 8.53 mEq/l.

Hiperpotassemia na vigência de espironolactona em pacientes com insuficiência cardíaca descompensada / Hyperkalemia during spironolactone use in patients with decompensated heart failure

FUNDAMENTO: A incidência de hiperpotassemia relacionada à espironolactona é baixa na insuficiência cardíaca estável, entretanto não foi estudada durante a descompensação. OBJETIVO: Avaliar a influência da espironolactona na insuficiência cardíaca descompensada sobre o potássio sérico. MÉTODOS: Em um estudo de coorte, selecionamos pacientes hospitalizados por descompensação da insuficiência cardíaca, FEVE < 0,45 e potássio sérico entre 3,5 e 5,5 mEq/l. Os pacientes foram divididos segundo o uso da espironolactona (grupo E) ou não (grupo C). O desfecho foi aumento do potássio (> 6,0 mEq/l) e uso de poliestireno de cálcio. Realizou-se a análise multivariada pela regressão logística, e p < 0,05 foi considerado significante. RESULTADOS: Foram estudados 186 pacientes (grupo E: 56; grupo C: 130), FEVE 0,25, idade 55,5 anos e 65,2 por cento de homens. A incidência de hiperpotassemia foi de 10,7 por cento no grupo E e de 5,4 por cento no grupo C (p = 0,862). A análise multivariada mostrou que a uréia sérica > 60,5 mg/dl, durante a internação, apresenta risco relativo de 9,6 (IC 95 por cento 8,03 - 11,20; p = 0,005) para a ocorrência de hiperpotassemia. CONCLUSÃO: A incidência de hiperpotassemia foi duas vezes maior com espironolactona, mas não estatisticamente significante. Elevação da uréia foi associada à hiperpotassemia. Estudos randomizados são necessários para esclarecer o assunto.

BACKGROUND: The incidence of hyperkalemia related to spironolactone use is low in stable heart failure; however, it has not been studied during decompensation. OBJECTIVE: To evaluate the influence of spironolactone on serum potassium in decompensated heart failure (HF). METHODS: In a cohort study, patients that had been hospitalized due to decompensated HF, with left ventricular ejection fraction (LVEF) < 0.45 and serum potassium between 3.5 and 5.5 mEq/l were selected. The patients were divided according to spironolactone use (Group S) or no use (Group C). The outcome was potassium increase (> 6.0 mEq/l) and the use of calcium polystyrene. A multivariate analysis through logistic regression was carried out and values of p < 0.05 were considered significant. RESULTS: A total of 186 patients (group S: 56; group C: 130) were studied; LVEF of 0.25, aged 55.5 years and 65.2 percent of them males. The incidence of hyperkalemia was 10.7 percent in group S and 5.4 percent in group C (p = 0.862). The multivariate analysis showed that serum urea > 60.5 mg/dl during the hospitalization presents a relative risk of 9.6 (95 percentCI 8.03 - 11.20; p = 0.005) for the occurrence of hyperkalemia. CONCLUSION: The incidence of hyperkalemia was two-fold higher with spironolactone use, but it was not statistically significant. The increase in urea levels was associated to the hyperkalemia. Randomized studies are necessary to clarify this issue.

Approach to hyperkalemia.

Hyperkalemia is commonly found in hospitalized patients. Given the fact that untreated hyperkalemia is associated with high morbidity and mortality, it is critical to recognize and treat this disorder promptly. Patients at greatest risk for hyperkalemia include those with diabetes or impaired renal function, those with advanced age and those receiving drugs which interfere with renal potassium excretion. Hyperkalemia is likely to become an even more common clinical event, since ACE inhibitors, angiotensin-receptor blockers and aldosterone antagonists are increasingly being used in higher doses and in combination, in the belief that these measures provide additional cardiovascular and renal protection. The urgency of hyperkalemia treatment is dictated by change in electrocardiogram. Treatment of hyperkalemia includes calcium gluconate, insulin, beta agonists, sodium bicarbonate, cation exchange resin, diuretics and/or dialysis.

Refractory hyperkalaemia due to trimethoprim, successfully treated with fludrocortisone.

We report a case of intractable hyperkalaemia in an elderly patient with myeloma, who received conventional dose of trimethoprim-sulfamethoxazole and hyperkalaemia resolved following therapy with fludrocortisone. We recommend monitoring of serum potassium in high-risk patients receiving conventional doses of trimethoprim-sulfamethoxazole for 5 or more days.

Hiperkalemia grave asociada a drogas que actúan sobre el sistema renina, angiotensina, aldosterona: Un problema que requiere atención: Caso clínico / Severe hyperkalemia associated to the use of losartan and spironolactone: Case report

Hyperkalemia is a complications of the use of angiotensin converting enzyme inhibitors, angiotensin receptor antagonists and aldosterone antagonists. These drugs are commonly used for the treatment of hypertension and cardiac failure. We report a 84 year-old female treated with losartan 50 mg/day and spironolactone 25 mg/day that presented with a hyperkalemia of 8.4 mEq/l and bradicardia, drowsiness and respiratory depression. She required hemodialysis and ventilatory assistance. She was discharged in good conditions five days after admission.

Factors predicting hyperkalemia in patients with cirrhosis receiving spironolactone

To evaluate the factors leading to hyperkalemia in patients with cirrhosis receiving spironolactone. Design: An observational, analytical, case control study. Place and Duration of Study: The Aga Khan University Hospital. Six months. Subjects and One hundred and fifty consecutive patients [100 males, 50 females] with cirrhosis of liver, hospitalized for decompensated disease and receiving spironolactone for at least two weeks before admission, were included in this study. Patients with hyperkalemia [n=67] having potassium level >5 mmol/l were compared with patients who had normal potassium level 5 mmol/l [n=83]. The parameters taken into account were age, gender of the patients, type and dose of diuretics along with concomitant medicines, diastolic blood pressure, edema, ascites, blood urea nitrogen, serum creatinine, electrolytes, bilirubin, albumin, prothrombin time, Child class, and Child Pugh score. Patients with hyperkalemia [K > 5 mmol/l] had higher blood urea nitrogen, serum creatinine and bilirubin levels [p= 0.004, 0.001 and 0.044 respectively]. Their serum sodium and albumin levels were lower [p= 0.000 and 0.017 respectively]. They had advanced cirrhosis with high Pugh score [p= 0.003]. These patients were on higher dose of spironolactone [p =0.001]. Multivariate analysis showed that dose of spironolactone >100 mg /day, serum creatinine >1.3 mg/dl, persistence of ascites and edema, and female gender were important predictors of development of hyperkalemia. Patients with cirrhosis receiving high dose of the diuretic, having edema, ascites and high serum creatinine are at the greater risk of developing hyperkalemia during spironolactone therapy

Effects of Thyroxine on Hyperkalemia and Renal Cortical Na(+), K(+) - ATPase Activity Induced by Cyclosporin A

Cyclosporin A (CsA)-induced hyperkalemia is caused by alterations in transepithelial K(+) secretion resulting from the inhibition of renal tubular Na(+), K(+) -ATPase activity. Thyroxine enhances renal cortical Na(+), K(+) -ATPase activity. This study investigated the effect of thyroxine on CsA-induced hyperkalemia. Sprague-Dawley rats were treated with either CsA, thyroxine, CsA and thyroxine, or olive-oil vehicle. CsA resulted in an increase in BUN and serum K(+), along with a decrease in creatinine clearance, fractional excretion of potassium, and renal cortical Na(+), K(+) -ATPase activity, as compared with oil vehicle administration. Histochemical study showed reduced Na(+), K(+) -ATPase activity in the proximal tubular epithelial cells of the CsA-treated compared with the oil-treated rats. Histologically, isometric intracytoplasmic vacuolation, disruption of the arrangement and swelling of the mitochondria, and a large number of lysosomes in the tubular epithelium were characteristic of the CsA-treated rats. Co-administration of thyroxine prevented CsA-induced hyperkalemia and reduced creatinine clearance, Na(+), K(+) -ATPase activity, and severity of the histologic changes in the renal tubular cells when compared with the CsA-treated rats. Thyroxine increased the fractional excretion of potassium via the preservation of Na(+), K(+) -ATPase activity in the renal tubular cells. Thus, the beneficial effects of thyroxine may be suited to treatment modalities for CsA-induced hyperkalemia.

Diclofenac induced renal dysfunction presenting as cardiac arrhythmia.

A fifty year old male presented on the sixteenth post-operative day after leg surgery with abdominal pain and distension, difficulty to breathe and oliguria. He had bradycardia and hypotension. Electrocardiography (ECG) revealed junctional rhythm and there was biochemical evidence of hyperkalemia. This was attributed to non-steroidal anti inflammatory drug diclofenac sodium induced renal dysfunction.

Variation of serum potassium and creatinine phosphokinase levels in suxamethonium-induced muscle relaxation.

Popular depolarising muscle relaxant, suxamethonium (succinylcholine chloride), produces fasciculation in group of muscles and 'after pain'. Mode of its action is neuromuscular blockage. It also may be associated with muscle fibre injury and altered membrane permeability. These may cause rise of serum K+ and creatinine phosphokinase (CPK) levels. But use of diazepam either during or as pretreatment may reduce the fasciculation, 'after pain' and rise of K+ and CPK levels. Present study was undertaken to show whether any correlation of the degree of fasciculation and postsuxamethonium myalgia is present or not and whether diazepam has any role in reducing muscle injury and in turn reducing the levels of serum K+ and CPK.

Hipercalemia induzida pelo trimetoprim em pacientes com SIDA / Hyperkalemia induced by trimethoprin in patients with AIDS

A hipercalemia tem sido descrita com elevada prevalência ((17 por cento) em pacientes com a síndrome de imunodeficiência adquirida (SIDA). Recentemente, sugeriu-se que o uso de sulfametoxazol-trimetoprim (SMT) seja um importante fator causal de hipercalemia nestes pacientes. Com o objetivo de estudar a prevalência de hipercalemia (definida por K+ > 5,1 Eq/l) em pacientes com SIDA e a influência do uso de SMT sobre a freqüência daquela complicaçäo, realizamos estudo retrospectivo entre 218 pacientes internados com SIDA no H.U.G.G. Observamos 34 casos (l5,6 por cento) de hipercalemia. Em apenas 6 casos (2,5 por cento do total de pacientes, 17,7 por cento dos casos de hipercalemia) a calemia excedeu 6,0 mEq/l. Insuficiência renal (definida por creatininemia > 1,4mg por cento) estava presente em 27 pacientes (79,4 por cento) que desenvolveram hipercalemia, incluindo 5 dos 6 casos com K+ > 6,0 mEq/l. Dos 145 pacientes que näo apresentavam insuficiência renal, 61 estavam em uso de SMT, 84 näo usavam SMT. Entre eles, seis pacientes (9,8 por cento) em uso de SMT e l (l,2 por cento) dos que näo usaram SMT desenvolveram hipercalemia (p = O,042, razäo dos produtos cruzados = 9,1, intervalo de confiança de 95 por cento =1,04 a 421,4). Concluímos que a freqüência de hipercalemia na populaçäo estudada aproximou-se da descrita na literatura. Na maior parte dos casos a hipercalemia foi branda e associou-se à insuficiência renal. O uso de SMT relacionou-se a um maior risco de desenvolvimento de hipercalemia nos pacientes sem insuficiência renal.

Comparative study of diazepam with D-tubocurarine on suxamethonium induced hyperkalemia in burns

Effectiveness of diazepam in preventing suxamethonium induced hyperkalemia was studied and compared with the same action of D-tubecurarine [d.Tc]. in 51 burn patients. These patients were studied under four groups and the hyperkalemic response was related to the degree, extent [percent of body surface area burned] and duration. No significant difference was seen between diazepam [0.1 mg/kg] and d.Tc. [0.05 mg/kg] in preventing the hyperkalemia following suxamethonium in burn patients. No direct relation to the extent of burns was seen, however relation to duration of the burns was very significant as dangerous hyperkalemic response was seen in the patients between the twentieth to seventieth post-burn days