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Habib et al.| Life threatening arrhythmia secondary to hyperkalemia in a patient with chronic kidney disease
INTERNATIONAL JOURNAL OF ADVANCES IN
PHARMACY MEDICINE AND BIOALLIED SCIENCES
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Life threatening arrhythmia secondary to hyperkalemia in a patient with chronic
kidney disease
Anwar Habib1, Mohd Aslam2, Muhammad Uwais Ashraf2*, Shadab A Khan2
1Department
2Department
of Medicine, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard. New Delhi, India.
of Medicine, JN Medical College, AMU, Aligarh, UP, India.
CASE REPORT
ABSTRACT
ARTICLE INFORMATION
Article history
Received: 15 March 2015
Revised: 25 March 2015
Accepted: 15 April 2015
Early view: 20 April 2015
*Author for correspondence
E-mail: [email protected]
Q
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C
o
d
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Hyperkalemia is a common clinical condition associated with serious
cardiac arrhythmias and at times may lead to death. Timely detection of
hyperkalemia in a susceptible patient is crucial for patient survival. The
emergence of new medications that specifically target hyperkalaemia could
lead to new therapeutic horizons. Also, the prevention of severe episodes
of hyperkalemia in high-risk patients requires measures aimed at the longterm normalization of potassium homeostasis. We present here an
interesting case of Chronic Kidney Disease presenting with life threatening
arrhythmia secondary to hyperkalemia. Prompt treatment of hyperkalemia
reverted the arrhythmia in our patient and saved the life of a patient.
Keywords: Chronic Kidney Disease, Hyperkalemia.
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INTRODUCTION
Hyperkalemia is a common clinical condition associated
with serious cardiac arrhythmias and at times may lead to
death. Timely detection of hyperkalemia in a susceptible
patient is crucial for patient survival. Hyperkalaemia is
common in patients with chronic kidney disease (CKD), in
part because of the effects of kidney dysfunction on
potassium homeostasis and in part because of the cluster
of comorbidities (and their associated treatments) that
occur in CKD. Due to its electrophysiological effects,
hyperkalemia stands out as a medical emergency that
should be treated promptly. Also, the prevention of
severe episodes of hyperkalemia in high-risk patients
requires measures aimed at the long-term normalization
of potassium homeostasis (An et al., 2012). The effective
and safe medical interventions for restoring chronic
potassium balance are very few, and the management of
hyperkalaemia on a long-term basis is primarily limited to
the correction of modifiable exacerbating factors (Yelena
Mushiyakh et al., 2011). The emergence of new
medications that specifically target hyperkalaemia could
Int J Adv Pharmacy Med Bioallied Sci. 3, 1, 2015.
lead to new therapeutic horizons, and the preventive
aspects as well as the management of incidentally
discovered elevations in serum potassium levels cannot
be over-emphasised (Ahee et al., 2000).
CASE REPORT
A 55 year old male, known diabetic, CKD patient on
maintenance haemodialysis for the last two years was
brought to emergency department with complaints of
vomitings and extreme weakness since morning. He had
undergone haemodialysis two days before. On
examination he was conscious but confused, his pulse was
feeble and blood pressure was unrecordable. His JVP was
not raised, there was no jaundice, pallor, sweating or
breathlessness. His chest was clear. Respiratory rate was
22/mt. Cardiac auscultation revealed feeble heart
sounds. Per Abdomen examination was normal and there
was no organomegaly. There was no cyanosis or
peripheral oedema. His nurological examination was
normal with depressed reflexes. His ECG (Fig. 1) showed
broad QRS complexes (224 mseconds) coming at wide
intervals. He was immediately shifted to ICCU where
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Habib et al.| Life threatening arrhythmia secondary to hyperkalemia in a patient with chronic kidney disease
cardiac monitor showed a heart rate of 15-20/min.
Suspecting hyperkalemia we gave him 20 ml of Calcium
gluconate, 50 ml of sodium bicarbonate, 100 ml of 25%
dextrose with insulin and 0.6 mg of atropine. He
responded a little to this regime and his heart rate went
up to 45/min, his radial pulse became palpable, his BP
was recordable at 100/50 and he also became oriented
and alert. By this time his lab report had come which
showed serum potassium of 9.4meq/l. He was subjected
to Haemodialysis with potassium free dialysate. After
haemodialysis the patient fully improved and his
potassium came down to 5.8 meq/l. His ECG also
improved, HR became 60/min and QRS became 120 ms.
His cardiac enzymes were found to be within normal
limits and echocardiographic examination also revealed
normal Left Ventricular functions. He was discharged in a
stable condition and is coming for regular haemodialysis.
We could not ascertain the cause for his hyperkalemia.
Neither drugs (he is on amlodipine, calcitriol, sevelamer,
calcium carbonate and pantoprazole) nor dietary history
indicated anything significant. It is possible that in his
previous dialysis he may have been dialysed with
inappropriate potassium concentration in the dialysate.
Figure 1. ECG at the time of presentation.
RESULTS
Hyperkalemia is a common cause of the cardiac
arrhythmias seen in clinical practice. The challenge in
managing hyperkalemia is that it can be difficult, and at
times, impossible, to identify the condition solely on the
basis of electrocardiographic information. Patients who
present with hyperkalemia may have a normal
electrocardiogram or have changes that are so subtle that
physicians frequently have difficulty attributing these
changes to increased potassium levels. In a study
conducted at the University of Pittsburgh Medical Center,
it was seen that, 46% of patients who had potassium
levels greater than 6.0 mEq/L had electro-cardiographic
changes, and only 55% of patients with potassium levels
greater than 6.8 mEq/L had changes consistent with
hyperkalemia (Martinez-Vea et al., 1999). In fact, there
have been several reports in the literature of patients
who had potassium levels greater than 7.5 mEq/L with no
electrocardiographic manifestations of hyperkalemia
(Ettinger et al., 1974). It has been seen that, even if
there is some evidence of hyperkalemia on a patient's
electrocardiogram, physicians often tend to miss the
diagnosis. Wrenn and colleagues conducted a study to
ascertain the ability of physicians to predict the presence
of hyperkalemia solely on the basis of their patients'
electrocardiograms (Fisch, 1973). In this study, the
physicians were able to predict hyperkalemia with a
sensitivity of 35% to 43% and a specificity of 85% to 86%.
This study emphasizes how difficult it can be to diagnose
hyperkalemia. Still, hyperkalemia can manifest with
classical electrocardiographic changes which directly
point to the diagnosis.
Int J Adv Pharmacy Med Bioallied Sci. 3, 1, 2015.
Figure 2. ECG before discharge.
CONCLUSION
As our case illustrates, at times it may be difficult to
diagnose hyperkalemia. Patients presenting with severe
hyperkalemia
may
at
times
have
normal
electrocardiograms or electrocardiographic abnormalities
that are difficult to attribute to hyperkalemia. The
diagnosis of hyperkalemia may be suspected in any
patient with clinical risk factors that would predispose
them. More often, patients with hyperkalemia have
underlying renal dysfunction or are taking a medication
known to increase serum potassium concentrations. The
treatment of hyperkalemia must be prompt and
immediate to prevent the development of fatal cardiac
arrhythmias. If a patient has electrocardiographic
manifestations of hyperkalemia, or his serum potassium
level is greater than 6.5 mEq/L, the first drug to be
administered should be calcium. The reason behind this is
that calcium has rapid onset of action and it has ability to
stabilize myocyte electrical activity. Insulin with dextrose
infusion, and β2 agonists should then be quickly
administered to decrease extracellular potassium levels.
Hemodialysis is the most effective tool to decrease
systemic potassium levels. Sodium bicarbonate therapy
has limited role in the routine treatment of hyperkalemia
unless severe metabolic acidosis is present. It is therefore
suggested that physicians should perform a thorough
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Habib et al.| Life threatening arrhythmia secondary to hyperkalemia in a patient with chronic kidney disease
search to identify the cause of the hyperkalemia in order
to prevent a recurrence.
CONFLICT OF INTEREST
None declared.
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