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Abstract: PO2204

Should We Give the Green Light to Green Top Tube? Reverse Pseudohyperkalemia in Leukemia Patient

Session Information

  • Onco-Nephrology - 2
    October 22, 2020 | Location: On-Demand
    Abstract Time: 10:00 AM - 12:00 PM

Category: Onco-Nephrology

  • 1500 Onco-Nephrology


  • Chan, Ming-Jen, Cnang Gung Memorial Hospital, Taoyuan, Taiwan

Hewe we described a 69-year-old woman presented with hyperleukocytosis with reverse pseudohyperkalemia. This is also the first case of reverse pseudohyperkalemia in Philadelphia chromosome positive acute lymphoblastocytocytic leukemia.

Case Description

The 69-year-old woman was rushed to our emergency department due to progression of dyspnea for one week. Upon lab examination, hyperleukocytosis (> 500000/uL) with blasts that suggestive of acute leukemia. Notably, marked hyperkalemia (11.6 mEq/L) with normal renal function was noted but there is no typical electrocardiogram change. High LDH(3393 U/L) and low haptoglobin(<7.88 mg/dL) also noted. After clarification, the blood tube that had result of hyperkalemia is sodium heparin tube. We retested potassium by using serum separate tube with 5 minutes of 3000 revolutions per minute, revealing serum potassium level 3.8 mEq/L. Reverse pseudohyperkalemia was impressed. She recieved leukophresis and chemotherapy for leukostasis. The bone marrow biopsy later confirmed Philadelphia chromosome positive acute lymphoblastocytic leukemia. Reverse pseudohyperkalemia resolved after leukocyte return to normal level.


Pseudohyperkalemia is suspected when the measured potassium is high but the patient does not manifest signs of hyperkalemia, such as abnormal electrocardiogram. Pseudohyperkalaemia is falsely elevation of serum potassium levels without elevation of plasma potassium levels, commonly occurred in patients with hematological disease. Heparin anticoagulated plasma samples provide more accurate measurement of the true potassium level in these patients and sodium heparin (green top) tube is widely used. However, in reverse pseudohyperkalemia, serum potassium is within normal range, and plasma potassium is falsely elevated, such as in our patients. The heparin in the plasma collection tube causes damage to the cell membrane during processing and centrifugation in the context of fragile cells of hematologic malignancy. Reverse pseudohyperkalemia had been reported in chronic lymphocytic leukemia patient. To our knowledge, this is the first case report of reverse pseudohyperkalemia in Philadelphia chromosome positive acute lymphoblastocytocytic leukemia patient.This case reminds us that potassium obtained using heparin tube is not panacea to get accurate level, and reverse pseudohyperkalemia is a must-known phenomenon for clinicians.