Renal failure, acute hyperkalemia

Complications. The earliest complication of acute renal failure is hyperkalemia (see p 38) this may be more pronounced if the cause of the renal failure is rhabdomyolysis or hemolysis, both of which release large amounts of Intracellular potassium into the circulation. Later complications include metabolic acidosis, delirium, and coma. 

A 78-year-old woman with a history of heart problems developed bradycardia, acute renal failure with hyperkalemia, and coagulopathy after 3 days of consuming a decoction made from rue. Each dose was made from 50 g of fresh rue in 1000 ml of water, made into 250 ml of decoction... 

Venzin RM, Cohen CD, Maggiorini M, Wuthrich RP. Aliskiren-associated acute renal failure with hyperkalemia. Clin Nephrol 2009 71(3) 326-8. 

Potassium is contraindicated in patients who are at risk for experiencing hyperkalemia, such as those with renal failure, oliguria, or azotemia (file presence of nitrogen-containing compounds in the blood), anuria, severe hemolytic reactions, untreated Addison s disease (see Chap. 50), acute dehydration, heat cramps, and any form of hyperkalemia Potassium is used cautiously in patients with renal impairment or adrenal insufficiency, heart disease, metabolic acidosis, or prolonged or severe diarrhea. Concurrent use of potassium with... 

Besides hypotension, the most frequent adverse reaction to an ACE inhibitor is cough, which may occur in up to 30% of patients. Patients with an ACE inhibitor cough and either clinical signs of heart failure or LVEF less than 40% may be prescribed an ARB.3 Other, less common but more serious adverse effects to ACE inhibitors and ARBs include acute renal failure, hyperkalemia, and angioedema. 

IV Diseases where high potassium levels may be encountered hyperkalemia renal failure and conditions in which potassium retention is present oliguria or azotemia anuria crush syndrome severe hemolytic reactions adrenocortical insufficiency (untreated Addison disease) adynamica episodica hereditaria acute dehydration heat cramps hyperkalemia from any cause early postoperative oliguria except during Gl drainage. 

Severe hypotension can occur after initial doses of any ACE inhibitor in patients who are hypovolemic as a result of diuretics, salt restriction, or gastrointestinal fluid loss. Other adverse effects common to all ACE inhibitors include acute renal failure (particularly in patients with bilateral renal artery stenosis or stenosis of the renal artery of a solitary kidney), hyperkalemia, dry cough sometimes accompanied by wheezing, and angioedema. Hyperkalemia is more likely to occur in patients with renal insufficiency or diabetes. Bradykinin and substance P seem to be responsible for the cough and angioedema seen with ACE inhibition. 

The most important indications for the use of the loop diuretics include acute pulmonary edema, other edematous conditions, and acute hypercalcemia. The use of loop diuretics in these conditions is discussed in Clinical Pharmacology. Other indications for loop diuretics include hyperkalemia, acute renal failure, and anion overdose. 

Na/K/2CI transporter in the ascending limb of Henle s loop excretion, some wasting, hypokalemic metabolic alkalosis, increased urine Ca and Mg peripheral edema, hypertension, acute hypercalcemia or hyperkalemia, acute renal failure, anion overdose duration of action 2-4 h Toxicitiy Ototoxicity, hypovolemia, wasting, hyperuricemia, hypomagnesemia... 

NSAID-induced acute renal decompensation is a pharmacologically predictable phenomenon that possesses a dose-dependent component. In a triplecrossover study of 12 females with mild renal failure, ibuprofen (800 mg three times daily) was discontinued in 3 pahents after 8 days because of worsening renal function (> 133 pmol/L - > 1.5 mg/dl increase in serum creahnine) or hyperkalemia (potassium > 6 mmol/ml). When these 3 pahents were rechallenged at a 50% lower dose of ibuprofen, two developed evidence of acute renal deteriorahon [45]. 

Angiotensin-converting enzyme (ACE) inhibitors Group toxicitv hyperkalemia, acute renal failure, anaioedema, rash, couah anemia, and liver toxicitv ... 

Triamterene 25 mg b.i.d. 50 mg b.i.d. 5%-10% q.12hr q.12hr Avoid Active metabolite with long half-life in ESRD hyperkalemia common when GFR < 30 ml/min, especially In diabetics may cause acute renal failure acts as folic acid antagonist may cause urolithiasis or crys-talluria in acid urine Avoid Avoid Avoid... 

Acute decreases in renal function and hyperkalemia usually resolve over several days after ACEl or ARB therapy is discontinued. Occasional patients will require management of severe hyperkalemia, usually with sodium polystyrene sulfate (see Chap. 50). ACEl or ARB therapy may frequently be reinitiated, particularly for patients with congestive heart failure, after intravascular volume depletion has been corrected or the diuretic doses reduced. The development of mild renal insufficiency (serum creatinine concentration of 2 to 3 mg/dL) may be an acceptable trade-off for hemodynamic improvement in certain patients with severe congestive heart failure or renovascular disease not amenable to invasive management. Congestive heart failure patients with greater renal insufficiency may be best treated by substitution of hydralazine and nitrates for afterload reduction. 

The kidneys excrete 80% of the daily potassium intake. Therefore when the kidney is unable to excrete potassium appropriately, as in acute renal failure and CKD, potassium is retained and often results in hyperkalemia. Moreover, many drugs can inhibit the kidney s ability to excrete potassium by inhibiting aldosterone and thus contribute to an increase in serum potassium levels. 

Adverse effects hypotension, hypovolemia, dry cough (30% incidence with ACEIs, much less with AT-1 antagonists), hyperkalemia, acute renal failure (especially in renal artery stenosis), angioedema. 

ACE-INHIBITORS Hyperkalemia, acute renal failure, angioed-... 

Cough hypotension, particularly with a diuretic or volume depletion loss of taste with anorexia skin rash bronchospasm acute renal failure with bilateral renal artery stenosis or stenosis of the artery to a solitary kidney cholestatic jaundice angioedema hyperkalemia if also on potassium supplements or potassium-retaining diuretics blood dyscrasias and renal damage are rare except in patients with renal dysfunction, and particularly in patients with collagen-vascular disease may increase fetal mortahty and should not be used during pregnancy... 

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