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Abstract: PO1463

Lethal Refractory Hyperkalemia and Metabolic Acidosis in a Patient with Secondary Hemophagocytic Lymphohistiocytosis (HLH)

Session Information

Category: Trainee Case Report

  • 902 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

  • Grand, David, Yeshiva University Albert Einstein College of Medicine, Bronx, New York, United States
  • Sourial, Mina, Montefiore Medical Center, Bronx, New York, United States
  • Brogan, Maureen E., Montefiore Medical Center, Bronx, New York, United States
  • Thakkar, Jyotsana, Montefiore Medical Center, Bronx, New York, United States
Introduction

Renal replacement therapy (RRT) is used as an adjuvant therapy to treat severe electrolyte and acid-base abnormalities. We describe a case of severe metabolic acidosis (lactic acidosis) and hyperkalemia which was refractory to treatment with simultaneous continuous renal replacement therapy (CRRT) and hemodialysis (HD) in a patient with HLH.

Case Description

A 63-year-old female with a history of diabetes mellitus, warm antibody autoimmune hemolytic anemia was admitted to the hospital with hyponatremia and hyperglycemia diagnosed on outpatient labs. Her hospital course was complicated with fevers, severe lactic acidosis, worsening thrombocytopenia and anemia. Infectious and rheumatologic workup was negative. Presumed diagnosis of secondary HLH was made with elevated serum ferritin (100,000 ng/ml), elevated triglyceride levels (346 mg/dl), low fibrinogen levels (70 mg/dl), fevers, bicytopenia and elevated soluble IL-2 receptor levels (34177 units/ml). She was treated with etoposide and dexamethasone for secondary HLH. Nephrology was consulted for hyperkalemia, metabolic acidosis and elevated lactate in our patient with normal renal function. Hyperkalemia was thought to be due to ongoing hemolysis.
Despite medical management with intravenous bicarbonate, albuterol and insulin, the hyperkalemia persisted so RRT was initiated. Her potassium levels did not improve despite her serum pH increasing to 7.33. Serum lactate remained persistently elevated to 21 mmol/L. Neither high dialysate flow rates (DFR) up to 7.5 liters per hour with a 2 meq/ dl potassium bath nor hemodialysis which followed, using a zero potassium dialysate bath, lowered the potassium level. The patient continued to have a wide complex QRS interval on her ECG and episodes of ventricular tachycardia and suffered from a cardiac arrest when her potassium was 6.9 meq/dl. Suspected malignancy associated secondary HLH was thought to be the possible etiology of her refractory lethal metabolic problems.

Discussion

HLH has been associated with severe type B lactic acidosis from excessive cytokine overproduction. Often, CRRT with higher DFR than recommended have been used in the past to achieve solute clearance. Our case was unique as the patient continued to have refractory hyperkalemia and elevated lactate despite receiving CRRT and HD and had poor outcomes.