ia

he modality could be

American Journal of Emergency Medicine 33 (2015) 473.e3473.e5

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American Journal of E

j ourna l homepage: www.eRapid initiation of PD exchanges by well-trained ED personnelmay be a viable treatment option for severe hyperkalemia.We reportan unusual presentation of life-threatening hyperkalemia manifest-ed by electrocardiographic (ECG) changes in a PD patient who was

used as adjunct therapy for potassium intoxication until HD wasavailable [6,7]. More recently, HDwas cited as the preferredmodalityfor potassium removal in dialysis patients due to faster clearancerates when compared with PD [4,5]. The clearance of potassiumregarding the appropriate modality and dose. Early experiences with PD suggested that tthere is no standard dialytic approach to the treatment of severehyperkalemia in established PD patients, and limited data exist

patient was discharged after 3 days with complete resolution ofhyperkalemia and lethargy.Case Report

Treatment of life-threatening hyperkalemthe ED,

Abstract

Severe hyperkalemia (serum potassium N 7.0 mmol/L) is anuncommon electrolyte abnormality in patients undergoing mainte-nance peritoneal dialysis (PD). Hemodialysis (HD) has been suggestedas the denitive 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 successfullytreated with standard medical therapy and manual exchangesinitiated by emergency department (ED) personnel. The patient didnot require HD. This case demonstrates the potential utility of PD as atreatment option for severe hyperkalemia in established dialysispatients when EDs are prepared to deliver exchanges. This report maybe particularly relevant due to the increasing prevalence rate of PDand for centers with limited HD access.

The distribution of serum potassium values in patients undergoingperitoneal dialysis (PD) is generally on the lower end of normalcompared with the high reference range observed in hemodialysis(HD) patients [1-3]. In fact, severe hyperkalemia (serum potassiumN7.0 mmol/L) is an uncommon but potentially lethal condition inpatients performing maintenance PD. A large multicenter study of PDpatients in the United States (n = 10468) reported a prevalence of4.5% for time-averaged serum potassium values greater than or equalto 5.5 mEq/L [1]. The prevalence of severe hyperkalemia in thispopulation is unknown but likely much lower. Dialysis is thedenitive therapy for PD patients at imminent risk for death due tohyperkalemia. Hemodialysis has been suggested as the preferredtreatment modality in all dialysis-dependent patients, including PD,because of the faster potassium elimination rates [4,5]. Emergencydepartments (EDs) faced with this scenario must initiate rapidtherapy to avoid life-threatening cardiac complications. However,treated with manual exchanges initiated in the ED. We review theliterature regarding renal replacement options for severe hyperka-

DRosemanreceived funding fromtheNational InstitutesofHealth (T32-DK-007053). Part of this work was presented in abstract form at the 2013 Annual Meeting of theAmerican Society of Nephrology, Atlanta, GA.

0735-6757/ 2014 Elsevier Inc. All rights reserved.with peritoneal dialysis in

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

A 48-year-old man with a history of hypertension, cardiomyop-athy, and end-stage renal disease with no residual renal function onautomated PD for 5 years using a exible Tenckhoff catheterpresented to the ED with 2 days of weakness, subjective fever, andnonproductive cough immediately after returning from a 2-weekCaribbean vacation. The patient relied on a transient dialysis facilityfor all supplies while traveling but discontinued PD after the rstweek due to concerns over sanitation and the potential risk ofinfection such as peritonitis. On arrival, the patient was conversantwith a blood pressure of 160/105mmHg, a pulse rate of 108 beats perminute, and an oxygen saturation of 96% on 4 L of supplementaloxygen. The physical examination was notable for decreasedbibasilar breath sounds. A 12-lead ECG showed sinus tachycardiawith anterolateral ST and T wave abnormalities (Figure). Chestradiography revealed clear lungs. Laboratory results included sodium140 mmol/L, potassium 8.1 mmol/L, chloride 103 mmol/L, bicarbon-ate 13.2 mmol/L, blood urea nitrogen 179 mg/dL, creatinine 31.86mg/dL, and glucose 95 mg/dL. The patient became progressivelylethargic requiring noninvasive ventilation. A repeat ECG showedworsening tachycardia with a new incomplete right bundle-branchblock (Figure).

Standard medical therapy was administered including calciumgluconate, insulin, dextrose, sodium bicarbonate, and albuterol. Inaddition, a manual PD exchange with a 1.5% dextrose solution wasstarted by an ED nurse. The patient was monitored on telemetry andstabilized with subsequent return of a sinus tachycardia before beingtransferred to the intensive care unit. Intensive care unit staffcontinued to perform 2-L manual exchanges every 2 hours. After 10hours, the serum potassium decreased to 6.6mmol/L and, by 16 hours,had further improved to 5.4 mmol/L with no subsequent events ontelemetry. Exchanges were then extended to every 4 hours. The

mergency Medicine

l sev ie r .com/ locate /a jemduring extracorporeal dialysis can exceed 100 mL/min, whereas thatof PD averages approximately 17 mL/min [7]. However, HDintroduces potential risk due to insertion of central venous accessand use of low potassium dialysate that could provoke cardiacarrhythmias [8]. Patients with marked hyperkalemia may also have arebound of plasma potassium after HD and require additionaltreatments [9]. Finally, HD may involve logistical delays while

473.e4 D.A. Roseman et al. / American Journal of Emergency Medicine 33 (2015) 473.e3473.e5waiting for support staff and setting up equipment. Peritonealdialysis supplies can be stored locally and made readily available.Therefore, an ED prepared to deliver PD should consider startingexchanges promptly because this can be initiatedwithminimal delayusing 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 equipmentdescribed 3 critically ill patients not previously on dialysis withserum potassium values greater than 8.0 mEq/L who were success-fully treated with acute PD. Emergency medicine residents weretrained to insert Tenckhoff catheters percutaneously, and nurseswere taught to use a PD cycler [10]. Our case extends the literature todemonstrate that a patient already established on PD can beeffectively treated for severe hyperkalemia without HD if temporiz-ing measures and exchanges alone are initiated early. Hemodialysismay still remain the preferred modality, but the slower clearancerates of potassium using PD should not preclude its consideration.This observationmay be particularly relevant for centerswith limitedresources that care for PD patients. It is important to emphasize thatalthough our hospital has access to HD, our ED and intensive care unitnurses are educated to perform manual PD exchanges. Theestablished coordination between nephrology and emergencymedicine departments resembles the earlier cases and was crucialto this rapid lifesaving intervention.

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

Figure. A, Twelve-lead ECG in a patient on PD with life-threatening hyperkalemia at preseElectrocardiogram 35 minutes after presentation showing worsening tachycardia with newdialysis modality performed in the United States. However, theincidence rate of HD declined for the rst time in over 30 years bythe end of 2011, whereas the incidence rate of PD increased for thethird consecutive year to 6.6% among all dialysis patients [11].The increased utilization of PD is expected to continue due tonancial incentives enacted by the US Congress and PD rstinitiatives meant to encourage greater adoption rates of hometherapies [12,13].

Peritoneal dialysis patients may also present to the ED with avariety of mechanical, infectious, and metabolic emergencies thatare uniquely different from those associated with hemodialysis[14,15]. Taken together, the rising number of patients choosing PDand potential complications have considerable implications foremergency staff encountering prevalent PD patients. These issuesfurther support the use of educational programs to help providersdevelop the skills necessary for using PD equipment whenemergency care is indicated. Additional research is needed toidentify centers that may benet from learning new techniques asthe PD population expands.

Daniel A. Roseman, MDRenal Section, Department of Medicine, Boston University Medical Center

Boston, MA, USA

Elissa M. Schechter-Perkins, MD, MPHDepartment of Emergency Medicine, Boston University Medical Center

Boston, MA, USA

ntation revealing sinus tachycardia with anterolateral ST and T wave abnormalities. B,incomplete right bundle-branch block.

Jasvinder S. Bhatia, MDRenal Section, Department of Medicine, Boston University Medical Center

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

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

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