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Abstract: PO0815

Hemodialysis Refractory Hyperkalemia in a Case of SARS-CoV-2 Infection

Session Information

Category: Trainee Case Report

  • 000 Coronavirus (COVID-19)

Authors

  • Mehta, Siddharth, Trumbull Regional Medical Center, Warren, Ohio, United States
  • Parikh, Rohan, Trumbull Regional Medical Center, Warren, Ohio, United States
  • Solanki, Shantanu, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, United States
  • Singh, Jagmeet, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, United States
  • Patel, Rajvee, Trumbull Regional Medical Center, Warren, Ohio, United States
Introduction

Severe acute respiratory syndrome coronavirus- 2 (SARS-CoV-2) is a newly identified virus that affects respiratory tract with varying severity. Renal disease is not uncommon, but the etiology is multifactorial and still not well understood. We present a case of hemodialysis refractory hyperkalemia in a patient with SARS-CoV-2 infection.

Case Description

56-year-old African American male with past medical history of hypertension presented with cough, dyspnea and fever. On admission, he had a temperature of 104F, BP of 149/90 mmHg, HR of 104 bpm, and oxygen saturation of 92%. Physical examination was remarkable for diminished and diffuse coarse breath sounds. Lab work-up showed serum creatinine of 2.99 mg/dl (baseline 1.19 mg/dl) with an estimated GFR of 26 ml/min. Urinalysis revealed protein > 500 mg/dl, RBC 25, and presence of coarse granular casts. Urine protein-creatinine ratio was 3.2. Serology was negative for ANA, ANCA, and anti-proteinase antibodies, as well as hepatitis and HIV panels. Serum C3 and C4 levels were within normal limits. Viral PCR of nasopharyngeal aspirate was positive for SARS- CoV-2. Home medications lisinopril and hydrochlorothiazide were held on admission, and he was started on intravenous fluids, azithromycin, and hydroxychloroquine. On day 4, serum creatinine trended up to 3.29 mg/dl and potassium was 4 mmol/L but since the patient was oliguric, hemodialysis (HD) was started. Serum creatinine then trended to a high of 15 mg/dl, urea nitrogen to 102 mg/dl and serum potassium level to 6.9 mmol/L despite multiple HD sessions. Meanwhile, his oxygen requirement also increased to 15L. After 10 days of daily HD sessions, serum potassium came down to 4.3 mmol/L but he ultimately required HD post discharge.

Discussion

Previous literature has discussed SARS-CoV-2 association with effects on ACE2 of RAS and proximal tubular cells causing hypokalemia. To the best of our knowledge this would be the first documented case of hemodialysis refractory hyperkalemia seen with SARS-CoV-2 infection. One of the mechanisms for kidney injury is a direct viral induced cytopathic effect, which we believe held true for our patient. As viremia cleared, the kidney function improved though it did not return to baseline. In our case, development of hyperkalemia despite hemodialysis makes it more interesting, but it remains unclear how.