American Journal of Emergency Medicine 33 (2015) 473.e3-473.e5

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American Journal of Emergency Medicine

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Case Report

Treatment of life-threatening hyperkalemia with Peritoneal dialysis in the ED?,??

Abstract

Severe hyperkalemia (serum potassium N 7.0 mmol/L) is an uncommon electrolyte abnormality in patients undergoing mainte- nance peritoneal dialysis (PD). Hemodialysis (HD) has been suggested as the definitive therapy for severe hyperkalemia in this population, although there is limited data regarding renal replacement options. We report a case of life-threatening hyperkalemia with electrocar- diogram changes in a nonadherent PD patient who was successfully treated with standard medical therapy and manual exchanges initiated by emergency department (ED) personnel. The patient did not require HD. This case demonstrates the potential utility of PD as a treatment option for severe hyperkalemia in established dialysis patients when EDs are prepared to deliver exchanges. This report may be particularly relevant due to the increasing prevalence rate of PD and for centers with limited HD access.

The distribution of serum potassium values in patients undergoing peritoneal dialysis (PD) is generally on the lower end of normal compared with the high reference range observed in hemodialysis (HD) patients [1-3]. In fact, severe hyperkalemia (serum potassium N 7.0 mmol/L) is an uncommon but potentially lethal condition in patients performing maintenance PD. A large multicenter study of PD patients in the United States (n = 10468) reported a prevalence of 4.5% for time-averaged serum potassium values greater than or equal to 5.5 mEq/L [1]. The prevalence of severe hyperkalemia in this population is unknown but likely much lower. Dialysis is the definitive therapy for PD patients at imminent risk for death due to hyperkalemia. Hemodialysis has been suggested as the preferred Treatment modality in all dialysis-dependent patients, including PD, because of the faster potassium elimination rates [4,5]. Emergency departments (EDs) faced with this scenario must initiate rapid therapy to avoid life-threatening cardiac complications. However, there is no standard dialytic approach to the treatment of severe hyperkalemia in established PD patients, and limited data exist regarding the appropriate modality and dose.

Rapid initiation of PD exchanges by well-trained ED personnel may be a viable treatment option for severe hyperkalemia. We report an Unusual presentation of life-threatening hyperkalemia manifest- ed by electrocardiographic changes in a PD patient who was treated with manual exchanges initiated in the ED. We review the literature regarding renal replacement options for severe hyperka-

? D Roseman received funding from the National Institutes of Health (T32-DK-007053).

?? Part of this work was presented in abstract form at the 2013 Annual Meeting of the American Society of Nephrology, Atlanta, GA.

lemia in PD patients and discuss its importance for centers providing emergency care.

A 48-year-old man with a history of hypertension, cardiomyop- athy, and end-stage renal disease with no residual renal function on automated PD for 5 years using a flexible Tenckhoff catheter presented to the ED with 2 days of weakness, subjective fever, and nonproductive cough immediately after returning from a 2-week Caribbean vacation. The patient relied on a transient dialysis facility for all supplies while traveling but discontinued PD after the first week due to concerns over sanitation and the potential risk of infection such as peritonitis. On arrival, the patient was conversant with a blood pressure of 160/105 mm Hg, a pulse rate of 108 beats per minute, and an oxygen saturation of 96% on 4 L of supplemental oxygen. The physical examination was notable for decreased bibasilar breath sounds. A 12-lead ECG showed sinus tachycardia with anterolateral ST and T wave abnormalities (Figure). Chest radiography revealed clear lungs. Laboratory results included sodium 140 mmol/L, potassium 8.1 mmol/L, chloride 103 mmol/L, bicarbon- ate 13.2 mmol/L, blood urea nitrogen 179 mg/dL, creatinine 31.86 mg/dL, and glucose 95 mg/dL. The patient became progressively lethargic requiring noninvasive ventilation. A repeat ECG showed worsening tachycardia with a new incomplete right bundle-branch block (Figure).

Standard medical therapy was administered including Calcium gluconate, insulin, dextrose, sodium bicarbonate, and albuterol. In addition, a manual PD exchange with a 1.5% dextrose solution was started by an ED nurse. The patient was monitored on telemetry and stabilized with subsequent return of a sinus tachycardia before being transferred to the intensive care unit. Intensive care unit staff continued to perform 2-L manual exchanges every 2 hours. After 10 hours, the serum potassium decreased to 6.6 mmol/L and, by 16 hours, had further improved to 5.4 mmol/L with no subsequent events on telemetry. Exchanges were then extended to every 4 hours. The patient was discharged after 3 days with complete resolution of hyperkalemia and lethargy.

Early experiences with PD suggested that the modality could be used as adjunct therapy for potassium intoxication until HD was available [6,7]. More recently, HD was cited as the preferred modality for potassium removal in dialysis patients due to faster clearance rates when compared with PD [4,5]. The clearance of potassium during extracorporeal dialysis can exceed 100 mL/min, whereas that of PD averages approximately 17 mL/min [7]. However, HD introduces potential risk due to insertion of central venous access and use of low potassium dialysate that could provoke cardiac arrhythmias [8]. Patients with marked hyperkalemia may also have a rebound of plasma potassium after HD and require additional treatments [9]. Finally, HD may involve logistical delays while

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473.e4 D.A. Roseman et al. / American Journal of Emergency Medicine 33 (2015) 473.e3–473.e5

Figure. A, Twelve-lead ECG in a patient on PD with life-threatening hyperkalemia at presentation revealing sinus tachycardia with anterolateral ST and T wave abnormalities. B, Electrocardiogram 35 minutes after presentation showing worsening tachycardia with new incomplete right bundle-branch block.

waiting for support staff and setting up equipment. Peritoneal dialysis supplies can be stored locally and made readily available. Therefore, an ED prepared to deliver PD should consider starting exchanges promptly because this can be initiated with minimal delay using the indwelling catheter.

There is precedent for using PD alone to treat severe hyperkale- mia. A 2008 report from a hospital without access to HD equipment described 3 critically ill patients not previously on dialysis with serum potassium values greater than 8.0 mEq/L who were success- fully treated with acute PD. Emergency medicine residents were trained to insert Tenckhoff catheters percutaneously, and nurses were taught to use a PD cycler [10]. Our case extends the literature to demonstrate that a patient already established on PD can be effectively treated for severe hyperkalemia without HD if temporiz- ing measures and exchanges alone are initiated early. Hemodialysis may still remain the preferred modality, but the slower clearance rates of potassium using PD should not preclude its consideration. This observation may be particularly relevant for centers with limited resources that care for PD patients. It is important to emphasize that although our hospital has access to HD, our ED and intensive care unit nurses are educated to perform manual PD exchanges. The established coordination between nephrology and emergency medicine departments resembles the earlier cases and was crucial to this rapid lifesaving intervention.

Programs to train and educate emergency personnel on PD techniques could be implemented that allow for more widespread access and familiarity with PD. Currently, HD is the predominant

dialysis modality performed in the United States. However, the incidence rate of HD declined for the first time in over 30 years by the end of 2011, whereas the incidence rate of PD increased for the third consecutive year to 6.6% among all dialysis patients [11]. The increased utilization of PD is expected to continue due to financial incentives enacted by the US Congress and “PD first” initiatives meant to encourage greater Adoption rates of home therapies [12,13].

Peritoneal dialysis patients may also present to the ED with a variety of mechanical, infectious, and metabolic emergencies that are uniquely different from those associated with hemodialysis [14,15]. Taken together, the rising number of patients choosing PD and potential complications have considerable implications for emergency staff encountering prevalent PD patients. These issues further support the use of educational programs to help providers develop the skills necessary for using PD equipment when emergency care is indicated. Additional research is needed to identify centers that may benefit from learning new techniques as the PD population expands.

Daniel A. Roseman, MD

Renal Section, Department of Medicine, Boston University Medical Center

Boston, MA, USA

Elissa M. Schechter-Perkins, MD, MPH

Department of Emergency Medicine, Boston University Medical Center

Boston, MA, USA

D.A. Roseman et al. / American Journal of Emergency Medicine 33 (2015) 473.e3–473.e5 473.e5

Jasvinder S. Bhatia, MD

Renal Section, Department of Medicine, Boston University Medical Center

Boston, MA, USA E-mail address: jbhatia@bu.edu

http://dx.doi.org/10.1016/j.ajem.2014.08.041

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