DRUG INDUCED HYPERKALEMIA

Yazhini¹, Ramu², Arivarasan³

MEM Resident, Kauvery Hospital, Cantonment, Trichy

Consultant, Emergency Department, Kauvery Hospital, Cantonment, Trichy

Consultant, Medical Gastroenterology, Kauvery Hospital, Cantonment, Trichy

Introduction

Hyperkalemia is a potentially life-threatening metabolic problem caused by inability of the kidneys to excrete potassium, impairment of the mechanisms that move potassium from the circulation into the cells, or a combination of these factors. Hyperkalemia is defined as a serum or plasma potassium level above the upper limits of normal, usually greater than 5.0 mEq/L.

Case presentation

A 59-year gentleman with a known history of Decompensated chronic liver disease with Portal hypertension diagnosed in May 2023. Coronary artery disease S/P CABG (2012). Type 2 diabetes mellitus. Severe peripheral neuropathy now presented to ER with complaints of breathing difficulty since 3 am on 12/12/23 (NYHA – 4) and decreased urine output since the same morning. Patient had passed normal stools and flatus. Patient had no complaints of melena, hematemesis or hematochezia. No complaints of chest pain, palpitations, abdominal pain, fever or any associated symptoms.

Past medication History

T. Lasilactone 20/50 1-0-0 (Furosemide and Sporonolactone)
T. Cardivas 3.125mg 1-0-1 (Carvedolol)
T.Reclimet 1-1-1 (Gliclazide 80mg/Metformon 500 mg)
Human Actrapid 15-15-0 s/c (Regular Insulin)

On Examination

On arrival to ER his vitals were as follows

BP – 200/110 mmHg,

HR – 72 bpm,

SpO2 – 77% @ RA,

RR – 28/min,

Temperature – 98.5 F,

GCS – 15/15,

GRBS – 482mg/dl,

On Auscultation bilateral wheeze and crepitation’s were heard.

ECG Result

Impression

ECG showed acute Tall peaked T waves, with PR, QRS and QTc prolongation, and ST depression in LI and aVL

Lab Investigations

Na+ – 121mmol/L

K+ – >9 mmol/L

BUN – 42 mg/dl,

Creatinine – 2.2 mg/dl

Glucose – 469 mg/dl

Cl- – 104 mmol/L

Ca – 1.40 mmol/L

Hct – 32%,

Hb – 10.9 g/dl

TCO2 – 14 mmol/L

Primary Management

Patient was started on Noninvasive ventilation in view of acute pulmonary edema. All of the following were given simultaneously in view of aggressive Hyperkalemia.

Drug	Dose	Frequency
Inj Calcium gluconate	10% 30 cc	IV stat
Inj Lasix	40mg	Infusion 2ml/hr.
Human Actrapid	8 units s/c	Infusion according to GRBS
K bind		Q6H.
Neb. Salbutamaol	3 cycles	Q6H.
IV fluids		According to volume status.

ABG Analysis

Arterial blood gas analysis was obtained which revealed High Anion Gap metabolic acidosis.
Cardiologist, Nephrologist and Medical gastroenterology opinion were obtained and followed as per orders.
All present medications were withheld and present management was being continued along with monitoring of urine output, blood sugars and vitals.
After 2 hr, patient’s monitor showed Bradyarrythmmia (HR – 42 bpm) with variable heart rate. ABG was repeated which still showed persistent Hyperkalemia (7.7) with metabolic acidosis.

ECG Before hemodialysis

ECG still showed persistent Tall peaked T waves.
Inj Calcium gluconate 10% 30cc IV stat was again given and correction for hyperkalemia was continued.
Despite aggressive corrections patient had persistent Hyperkalemia and hence one cycle of rescue Hemodialysis was done.

ECG after hemodialysis

Repeat ECG following hemodialysis showed T waves returning to baseline with PR, QRS and QTc interval normalization.

ABG after dialysis

Repeat ABG following dialysis showed pH returning to normal limits & hyperkalemia corrected with serum potassium: 4.9 mmol/L.
Patient was then weaned from Noninvasive ventilation and continued on Oxygen support via face mask and shifted to ICU for further monitoring.
Patient was also diagnosed with Heart failure with preserved ejection fraction
He was placed on T. Dytor – 10mg – 1-0-0) and T. Clopitab CV – 71/20 – 0-0-1.

Serum potassium levels and renal function tests were as follows

vitals	13/12/23	14/12/23	15/12/23
K+	8.2	4	4.8
Urea	8.9	5.99	7.90
Creatinine	2.2	1.8	1.59

Patient progressively showed clinical improvement and became hemodynamically stable and hence was discharged with following medications.

Discharge medication

Drug	Dose	Frequency
T. Carvedilol	3.125 mg	BD
T. clopidogrel/atorvastatin CV	75/20 mg	OD
T. Sodium bicarbonate	500 mg	BD
T N taurine		BD
T. Pioglitazone	7.5 mg	OD
Inj insulin glargine s/c	30 units	OD
Inj human actrapid s/c	20 units	TDS
T. Vildagliptin	50 mg	OD
T. Dapagliflozin	10 mg	OD
Syp lactulose	30 ml	OD

Discussion

1. Acute episodes of hyperkalemia are commonly triggered by the introduction of a medication affecting potassium homeostasis. Illness or dehydration also can be triggers.
2. Prescribed medications, over-the-counter drugs, and nutritional supplements are used by many patients.
3. Although most of these products are well tolerated, drug – induced hyperkalemia may develop in patients with underlying renal impairment or other abnormalities in potassium homeostasis.
4. The presence of typical electrocardiographic changes or a rapid rise in serum potassium indicates hyperkalemia which is potentially life threatening.
5. The initial diagnostic approach begins with the clinical history, review of medications, and physical examination.
6. Symptoms and signs include muscular weakness or flaccid paralysis, ileus, and characteristic electrocardiograph (ECG) changes.
7. The first test that should be ordered in a patient with suspected hyperkalemia is an ECG since the most lethal complication of hyperkalemia is cardiac condition abnormalities which can lead to dysrhythmias and death.
8. Elevated potassium causes ECG changes in a dose – dependent manner:a. 5.5 to 6.5 mEq/L ECG will show tall, peaked t- waves
  b. K = 6.5 to 7.5 mEq/L ECG will show loss of p- waves
  
  c. K = 7 to 8 ECG mEq/L will show widening of the QRS complex
  
  d. K = 8 to 10 mEq/L will produce cardiac arrhythmias, sine wave pattern, and asystole.
9. ECG features of hyperkalemia include:a. Prolonged PR interval
  b. Augmented R wave
  
  c. Wide QRS and prolonged QTC
  
  d. Peaked T waves.
  
  e. Small or absent P wave
  1. Additional laboratory testing should include serum blood urea nitrogen and creatinine to assess renal function and urinalysis to screen for renal disease. A complete blood count to screen for leukocytosis or thrombocytosis may also be helpful. Serum glucose and blood gas analysis should be ordered in patients with diabetes and patients with suspected acidosis. Lactate dehydrogenase should be ordered in patients with suspected hemolysis. Since pseudo hyperkalemia is so common, confirmation should be obtained in asymptomatic patients without typical ECG changes before initiating aggressive therapy.

Conclusion

Most probable cause for severe intractable hyperkalemia in this patient would have been due to Spironolactone and Carvedilol with super added renal failure. Serial monitoring of serum potassium levels in patients on drugs with such Potassium retaining potentials is thus highly recommended. Several commonly used drugs can disrupt potassium balance in these patients and precipitate frank hyperkalemia. The high rate of polypharmacy also contributes to hyperkalemia. In addition, many patients ingest over-the-counter medications, nutritional supplements, and unknown herbal remedies in an unregulated fashion, which can further increase the risk of serious hyperkalemia. Clinicians must recognize patients at risk of hyperkalemia and avoid medications or drug combinations that may exacerbate the problem. Patients should also be educated to avoid nonprescription sources of excess potassium.

Dr. Yazhini. N

MEM Resident

Dr. V. Ramu

Consultant Emergency Physician

Dr. K. Arivarasan

Consultant Medical Gastroenterologist

DRUG INDUCED HYPERKALEMIA