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A 78-year-old man presented to the emergency department with a 10-day history of diarrhea and presyncope. His electrocardiogram showed a type-1 Brugada pattern but also a first-degree atrioventricular block, right bundle branch block, and peaked and symmetrical hyperacute T waves. A blood test revealed a potassium level of 9.3 mEq/L. After hemodialysis with normalization of serum potassium, the electrocardiographic abnormalities disappeared. An ajmaline challenge excluded the possibility of Brugada syndrome., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Overview: Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin-receptor blockers (ARB) are the most commonly prescribed anti-hypertensive medications in the United States, yet whether ACEI or ARB use is associated with a greater risk of hyperkalemia remains uncertain. Using real-world evidence from electronic health records, our study demonstrates that treatment with ACEI is associated with both a higher incidence and greater degree of hyperkalemia than treatment with ARB in adjusted models, especially in patients with chronic kidney disease. Providers should therefore consider this possible difference in hyperkalemia risk when choosing between ACEI and ARB therapy., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Objectives: Calcineurin inhibitors are the cornerstone of immunosuppression following solid-organ transplant. However, hyperkalemia may occur by multiple mechanisms affecting potassium in the distal tubule. Hyperkalemia is commonly observed in renal transplant recipients, and it is dose-dependent. Here, we evaluated the impact of fludrocortisone in the management of calcineurin inhibitor-induced hyperkalemia after renal transplant., Materials and Methods: We evaluated newly transplanted patients who developed hyperkalemia or those with hyperkalemia who attended our outpatient renal transplant clinic (Hamed Al-Essa Organ Transplant Center, Kuwait). Clinical and laboratory parameters were collected before starting fludrocortisone (baseline values) and then at 1, 2, 4, and 8 weeks. Drug history was assessed, with any drugs that could induce hyperkalemia being discontinued (such as spironolactone); otherwise, essential drugs like prophylactic agents (sulfamethoxazole-trimethoprim) were maintained. Oral anti-hyperkalemic doses (bicarbonate, resonium calcium, fludrocortisone) were noted., Results: Our study included 29 patients; most were men (aged 45.8 ± 15 years). Body weight did not significantly change after introduction of fludrocortisone (79.53 ± 24.31, 79.82 ± 23.85, 80.62 ± 24.24, 77.03 ± 20.7, and 79.21 ± 27.93 kg at baseline and at postdose week 1, 2, 4, and 8, respectively). Systolic and diastolic blood pressure levels were also similar at baseline versus postdose. Steroid doses (prednisolone) were significantly reduced over 1 month (15.7 ± 12.4, 14.1 ± 10.19, 12.6 ± 8.7, 9.5 ± 5.2, and 9.5 ± 5.2 mg/ day). Serum potassium levels significantly improved (5.18 ± 0.58, 4.9 ± 0.49, 4.8 ± 0.54, 4.8 ± 0.65, and 4.4 ± 0.72 mmol/L). Serum creatinine levels significantly improved by postdose week 8 (129.28 ± 48.9, 130.92 ± 52.2, 127.66 ± 50.9, 121.42 ± 41.7, and 124.1 ± 51.27 μmol/L). Serum bicarbonate levels remained similar., Conclusions: Fludrocortisone was a safe and effective option in management of calcineurin inhibitor-induced hyperkalemia among renal transplant recipients.

Two types of early childhood hyperkalemia had been recognized, according to the presence or absence of urinary salt wasting. This condition was attributed to a maturation disorder of aldosterone receptors and is characterized by sustained hyperkalemia, hyperchloremic metabolic acidosis (MA) due to reduced ammonium urinary excretion and bicarbonate loss, and normal creatinine with growth delay. We present 3 patients of the type without salt wasting, which we will call transient early-childhood hyperkalemia (TECHH) without salt wasting, and discuss its physiopathology according to new insights into sodium and potassium handling by the aldosterone in distal nephron. In 3 children from 30 to 120-day-old admitted with bronchiolitis and growth delay hyperkalemia was found in routine laboratory. Further studies revealed a normal creatinine with inappropriately normal or low fractional excretion (FE) of potassium, accompanied by inadequately normal serum aldosterone and plasma renin activity for their higher plasma potassium levels, but without urine salt wasting. They also presented hyperchloremic MA with FE of bicarbonate 0.58%-2.2%, positive urinary anion gap during MA and normal ability to acidify the urine. Based on these findings a diagnosis of TECHH without salt wasting was made and they were treated sodium bicarbonate and hydrochlorothiazide with favorable response. The condition was transient in all cases leading to treatment discontinuation. Given that TECCH without salt wasting is a tubular disorder of transient nature with mild symptoms; it must be keep in mind in the differential diagnosis of hyperkalemia in young children., (Copyright © 2022. Published by Elsevier España, S.L.U.)

Purpose: Hyperkalemia more commonly affects patients with a glomerular filtration rate of less than 60 mL/min. Using intravenous (IV) insulin to shift potassium intracellularly may cause hypoglycemia, requiring additional treatment or longer hospitalization. Literature on insulin dosing in this context is limited, with one previous study indicating that 5 units of IV insulin might be as effective and result in less hypoglycemia than the standard dose of 10 units of IV insulin. The hyperkalemia treatment pathway at our institution was revised in May 2018 to include a reduced-dose option (5 units of insulin) for patients with end-stage renal disease. This study aimed to compare the prevalence of hypoglycemia between patients who received standard-dose vs reduced-dose IV insulin., Methods: This single-center, retrospective, quasi-experimental study evaluated the impact of revision of the hyperkalemia treatment pathway by assessing rates of hypoglycemia during the 6 months before and after implementation of the revised pathway. The primary endpoint was prevalence of hypoglycemia, defined as a blood glucose level of less than or equal to 70 mg/dL., Results: There was no statistically significant difference in the occurrence of hypoglycemia when comparing the pre- and postimplementation groups (36 [17.7%] patients vs 34 [18.7%] patients; P = 0.7924). The postimplementation group had a statistically significant lower reduction in potassium levels after treatment than the preimplementation group (mean [interquartile range], -0.9 [-1.3, -0.5] mEq/L vs -0.6 [-1.2, -0.2] mEq/L; P = 0.0095). Baseline potassium levels were similar between the groups., Conclusion: Administration of reduced-dose IV insulin for treatment of hyperkalemia was significantly less effective in lowering serum potassium levels and did not decrease prevalence of hypoglycemia. When accounting for potential confounders, the only variable that was associated with hypoglycemia was pretreatment glucose level., (© American Society of Health-System Pharmacists 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Leukolysis-related pseudohyperkalemia due to preanalytical procedures may lead to erroneous (or absence of) treatment based on an invalid lab test result. We aimed to obtain a leukocyte threshold above which leukolysis-related pseudohyperkalemia becomes clinical relevant. Secondly, temporal dynamics of treatment-induced leukocyte decrease were studied to allow tailored implementation of laboratory information system (LIS) decision rules based on the leukocyte threshold to avoid leukolysis-related pseudohyperkalemia., Materials and Methods: Potassium results of AU5811 routine chemistry (Beckman Coulter, Brea, California, USA) and iStat point of care (POC) (Abbott Diagnostics, Chicago, Illinois, USA) analysers were compared, the latter method being insensitive to leukolysis caused by pre-analytical procedures. Potassium results were combined with leukocyte counts obtained using a Cell-Dyn Sapphire haematology analyser (Abbott Diagnostics, Santa Clara, California, USA), resulting in 132 unique data triplets. Regression analysis was performed to establish a leukocyte threshold. The Reference Change Value (√2 x Z x √(CV a 2 + CV i 2 )) was used to calculate maximum allowable difference between routine analyser and POC potassium results (delta max + 0.58 mmol/L). Temporal analysis on the treatment-induced leukocyte decrease was performed by plotting leukocyte counts in time for all patients above the threshold leukocyte count (N = 41)., Results: Established leukocyte threshold was 63 x10 9 /L. Temporal analysis showed leukocyte counts below the threshold within 8 days of treatment for all patients., Conclusions: Based on performed analyses we were able to implement LIS decision rules to reduce pseudohyperkalemia due to preanalytical procedures. This implementation can contribute to a reduction in erroneous (or absence of) treatments in the clinic., Competing Interests: Potential conflict of interest None declared., (Croatian Society of Medical Biochemistry and Laboratory Medicine.)

Background: Hyperkalemia is common among patients on maintenance hemodialysis (HD) and is associated with mortality. We hypothesized that clinical characteristics available at time of paramedic assessment before emergency department (ED) ambulance transport (ambulance-ED) would associate with severe hyperkalemia (K≥6 mmol/L). Rapid identification of patients who are at risk for hyperkalemia and thereby hyperkalemia-associated complications may allow paramedics to intervene in a timely fashion, including directing emergency transport to dialysis-capable facilities., Methods: Patients on maintenance HD from a single paramedic provider region, who had at least one ambulance-ED and subsequent ED potassium from 2014 to 2018, were examined using multivariable logistic regression to create risk prediction models inclusive of prehospital vital signs, days from last dialysis, and the presence of prehospital electrocardiogram (ECG) features of hyperkalemia. We used bootstrapping with replacement to validate each model internally, and performance was assessed by discrimination and calibration., Results: Among 704 ambulance-ED visits, severe hyperkalemia occurred in 75 (11%); 26 patients with ED hyperkalemia did not have a prehospital ECG. Younger age at transport, longer HD vintage, more days from last hemodialysis session (OR=49.84; 95% CI, 7.72 to 321.77 for ≥3 days versus HD the same day [before] ED transport), and prehospital ECG changes (OR=6.64; 95% CI, 2.31 to 19.12) were independently associated with severe ED hyperkalemia. A model incorporating these factors had good discrimination (c-statistic 0.82; 95% CI, 0.76 to 0.89) and, using a cutoff of 25% probability, correctly classified patients 89% of the time., Conclusions: Characteristics available at the time of ambulance-ED were associated with severe ED hyperkalemia. An awareness of these associations may allow health care providers to define novel care pathways to ensure timely diagnosis and management of hyperkalemia., Competing Interests: D.A. Clark reports research funding from Otsuka Canada Pharmaceutical, Inc., and honoraria from Baxter Canada. P.T. Fok reports ownership interest in Merck Pharmaceuticals and Moderna, Inc., but is no longer holding stocks of either company, and is on the Board of Directors of the Canadian Association of Emergency Physicians but receives no compensation for this. K.K. Tennankore reports consultancy for AstraZeneca, Baxter, Bayer, and Otsuka; research funding from Otsuka Canada; honoraria from Astra Zeneca, Baxter, Bayer, and Otsuka; being associate editor for the Canadian Journal of Kidney Health and Disease; and participating in a speakers’ bureau for AstraZeneca, Baxter, and Bayer. A.J. Vinson reports consultancy for Paladin Labs, Inc., and research funding from Paladin Labs, Inc. H. Wiemer reports research funding from Purdue Pharma (Canada). All remaining authors have nothing to disclose., (Copyright © 2022 by the American Society of Nephrology.)

Hyperkalaemia is an electrolyte abnormality that warrants urgent intervention and has well-recognised electrocardiographic changes. Peaking T wave is the most appreciated ECG sign, but hyperkalaemia manifesting electrocardiographically as acute ischemia with ST segment elevation is a very rare condition. We present a case of acute kidney injury, complicated by severe hyperkalaemia causing ST segment elevation changes in ECG simulating acute myocardial infarction. Rapid serum potassium level in arterial blood gases blood test guide treatment in this case saved the need for unnecessary activation of the catheterisation lab and more importantly, saved the patient from malignant dysthymia in case of treatment delay. Aggressive treatment of hyperkalaemia resulted in successful reduction of serum potassium level; ECG changes returned to baseline without any evidence of pseudoinfarction pattern. The medical staff should be aware of this condition in order to administer correct therapy and prevent unnecessary interventions and the associated risk of complications., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Flecainide is a commonly used IC antiarrhythmic. Clinical presentations of Flecainide toxicity are not commonly described., Case Report: A 62 year old man on dialysis presented for evaluation of outpatient bradycardia and hypotension. In the ED, patient had wide-complex rhythm with heart rates ranging from 76 to 127. The previous day, Flecainide and Metoprolol were discontinued and patient was dialyzed and discharged. The patient was treated empirically for possible hyperkalemia. No significant change in ECG was noted with administration of calcium. Sodium bicarbonate produced questionable benefit. Potassium level was 4.6 mmol/L. Cardiac rhythm fluctuated between sinus rhythm and wide complex tachycardia in the ED & ICU. Flecainide level was 2.1 μg/ml (normal <1 μg/ml). Toxicity developed despite previous discontinuation and dialysis prior to presentation because of Flecainide's large volume of distribution and lipopholicity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although Flecainide toxicity is uncommon, it has a high mortality rate, requiring early identification and treatment. Flecainide toxicity can develop in patients with hepatic or renal insufficiency, and can manifest with ventricular tachycardia or bradycardia. If suspicion of Flecainide toxicity arises, lidocaine and procainamide should be avoided to prevent further sodium channel blockade. Absence of response to calcium for a very wide complex QRS should raise clinicians' suspicion that WCT is not due to hyperkalemia, emphasizing the importance of reviewing patients' home medications. Sodium bicarbonate should be administered early to treat widened QRS. Amiodarone, intralipid emulsion therapy and ECMO may be considered in severe cases., Competing Interests: Declaration of Competing Interest The authors both declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Hyperkalemia represents a widespread and potentially lethal condition that affects millions of people across their lives. Despite the prevalence and severity of the condition, there are no consensus guidelines on the treatment of hyperkalemia or even a standard definition. Herein, we provide a succinct review of what we believe to be the most significant misconceptions encountered in the emergency care of hyperkalemia, examine current available literature, and discuss practical points on several modalities of hyperkalemia treatment. Additionally, we review the pathophysiology of the electrocardiographic effects of hyperkalemia and how intravenous calcium preparations can antagonize these effects. We conclude each section with recommendations to aid emergency physicians in making safe and efficacious choices for the treatment of acute hyperkalemia., Competing Interests: Declaration of Competing Interest Dr. Wardi has received funding from the National Institute of Health and the Gordon and Betty Moore Foundation, although unrelated to this work. The remaining authors have no conflicts of interest to disclose., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Renin-angiotensin-aldosterone system inhibitors (RAASi) have been shown to improve outcomes in chronic kidney disease (CKD) patients but are associated with an increased risk of hyperkalemia in this vulnerable population. Hyperkalemia often leads to patients' downtitrating or discontinuing RAASi which can result in sub-optimal health outcomes. The objective is to evaluate the cost and health benefits of maintaining normokalemia using patiromer, an oral potassium binder while optimizing RAASi therapy in CKD patients in the Kingdom of Saudi Arabia. The medium-to long-term costs and health outcomes of patients with CKD stage 3-4 and raised serum potassium levels (≥5.5 mmol/L) at baseline were estimated, from a Saudi Arabia payer perspective, using a Markov state-transition model simulating the natural progression of CKD depending on patients' serum potassium level and usage of RAASi at different dosages. The analysis demonstrated that appropriate management of hyperkalemia, enabling optimization of RAASi, leads to cost and health benefits. The cost of patiromer is offset by 68% due to a reduction in management costs associated with CKD progression, hyperkalemia-related hospitalization, and cardiovascular (CV) events. Over a 10-year time horizon, a pool of 300 patients treated with patiromer experience increased life-expectancy [+3.78 life-years (LYs)] and slower disease progression, with decreased time spent in end-stage renal disease (-9.59 LYs). Patiromer may deliver value to both CKD patients and payers in Saudi Arabia, leading to better health outcomes for the former and reduced cost of management of CKD progression and CV events at low additional costs for the latter.

Introduction: Hyperkalemia is often managed in the emergency department (ED) and it is important to understand how ED management and post-discharge outcomes vary by hyperkalemia severity. This study was conducted to characterize ED management and post-discharge outcomes across hyperkalemia severities., Methods: Adults with an ED visit with hyperkalemia (at least one serum potassium lab measure above 5.0 mEq/L) were selected from US electronic medical record data (2012-2018). Patient characteristics, potassium levels, treatments, and monitoring prior to and during the ED visit were compared by hyperkalemia severity (mild [> 5.0-5.5 mEq/L], moderate [> 5.5-6.0], severe [> 6.0]) using unadjusted analyses. Death, immediate inpatient admission, 30-day hyperkalemia recurrence, and 30-day inpatient admission were also assessed by severity., Results: Of 6222 patients included, 4432 (71.2%) had mild hyperkalemia, 1085 (17.4%) had moderate, and 705 (11.3%) had severe hyperkalemia. Chronic kidney disease (39.9-50.1%) and heart failure (21.6-24.3%) were common. In the ED, electrocardiograms (mild, 56.5%; moderate, 69.6%; severe, 81.0%) and patients with at least two potassium laboratory values increased with severity (15.0%; 40.4%; 75.5%). Among patients with at least two potassium laboratory values, over half of patients (60.4%) had potassium levels ≤ 5.0 mEq/L prior to discharge. Use of potassium-binding treatments (sodium polystyrene sulfonate: mild = 4.1%; moderate = 17.1%; severe = 27.4%), temporizing agents (5.6%; 15.5%; 31.6%), or dialysis (0.4%; 0.8%; 3.0%) increased with severity; treatment at discharge was not common. Death (1.1%; 3.7%; 10.6%), immediate admission to inpatient care (5.8%; 8.7%; 12.7%), 30-day hyperkalemia recurrence (2.9%; 19.0%; 32.5%), 30-day inpatient admission with hyperkalemia (6.5%; 7.9%; 9.3%) also increased with severity., Conclusion: Patients with moderate and severe hyperkalemia experienced elevated risk of hyperkalemia recurrence and hyperkalemia-related inpatient readmission following discharge from the ED from a descriptive analysis. Future research to assess strategies to reduce hyperkalemia recurrence and inpatient admission in this patient population would be beneficial., (© 2021. The Author(s).)

Competing Interests: Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none. Further details of The BMJ policy on financial interests are here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests

Pseudohypoaldosteronism type 1B is a rare autosomal recessive disorder caused by dysfunction of amiloride-sensitive epithelial sodium channels (ENaCs). We present the case of a neonate with cardiogenic shock after cardiac arrest due to profound hyperkalaemia. Genetic testing revealed a novel homozygous variant in SCNNIA We review diagnostic considerations including the molecular mechanisms of disease, discuss treatment approaches and highlight the possible significance of the diversity of pulmonary ENaCs., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Chon et al. suggested a high prevalence of severe hyperkalemia (serum potassium ≥ 6.0 mEq/L with electrocardiographic [ECG] changes) among patients with symptomatic or extreme bradycardia. Despite the urgent need to detect and treat severe hyperkalemia, serum potassium result may be available too late and is often spuriously high. Meanwhile, the traditional, descriptive ECG findings of severe hyperkalemia have shown unsatisfactory diagnostic powers. To overcome these diagnostic problems, they outlined the following quantitative rules to facilitate its early detection: Maximum precordial T wave ≥ 8.5 mV (2), atrial fibrillation/junctional bradycardia (1), heart rate (HR) ≤ 42/min (1) with (original rule)/without (ECG-only rule) diltiazem medication (2), and diabetes mellitus (1). Here we report on our external validation of these rules and the resulting updates., Methods: This retrospective, cross-sectional study included all adults with symptomatic (HR ≤ 50/min with syncope/pre-syncope/dizziness, altered mentality, chest pain, dyspnea, general weakness, oliguria, or shock) or extreme (HR ≤ 40/min) bradycardia who visited a university emergency department from 2014 to 2019. After validating the abovementioned rules externally, we selected risk factors of severe hyperkalemia among the ECG findings and easy-to-assess clinical variables by multiple logistic regression analysis. After modelling the updated 'ECG-only' and 'ECG-plus' indices, we internally validated the better of the two by bootstrapping with 1000 iterations., Results: Among 455 symptomatic/extreme bradycardia cases (70.3 ± 13.1 years; 213 females [46.8%]), 70 (15.4%) had severe hyperkalemia. The previous ECG-only rule showed a c-statistic of 0.765 (95% CI: 0.706-0.825), Hosmer-Lemeshow test of p < 0.001, and a calibration slope of 0.719 (95% CI: 0.401-1.04). On updating, the ECG-plus index summing junctional bradycardia/atrial fibrillation (1), maximum precordial T wave≥8.0 mV (2), general weakness as the chief complaint (2), oxygen demand (1), and dialysis (2) outperformed the ECG-only index (c-statistic, 0.832; 95% CI, 0.785-0.880 vs. 0.764; 95% CI, 0.700-0.828; p = 0.011). On bootstrapping, the c-statistic was 0.832 (95% CI: 0.786-0.878). For scores ≥ 3 (positive likelihood ratio ≥ 5.0), the sensitivity and specificity were 0.514 and 0.901, respectively. For scores ≤ 1, negative likelihood ratio was ≤0.2., Conclusions: Previous rules showed less satisfactory calibration but fair discrimination to detect severe hyperkalemia in patients with symptomatic or extreme bradycardia. We propose the ECG-plus index as the optimum tool to facilitate its early detection., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Finerenone reduced risk of cardiorenal outcomes in patients with CKD and type 2 diabetes in the FIDELIO-DKD trial. We report incidences and risk factors for hyperkalemia with finerenone and placebo in FIDELIO-DKD., Methods: This post hoc safety analysis defined hyperkalemia as ≥mild or ≥moderate based on serum potassium concentrations of >5.5 or >6.0 mmol/L, respectively, assessed at all regular visits. Cumulative incidences of hyperkalemia were based on the Aalen-Johansen estimator using death as competing risk. A multivariate Cox proportional hazards model identified significant independent predictors of hyperkalemia. Restricted cubic splines assessed relationships between short-term post-baseline changes in serum potassium or eGFR and subsequent hyperkalemia risk. During the study, serum potassium levels guided drug dosing. Patients in either group who experienced ≥mild hyperkalemia had the study drug withheld until serum potassium was ≤5.0 mmol/L; then the drug was restarted at the 10 mg daily dose. Placebo-treated patients underwent sham treatment interruption and downtitration., Results: Over 2.6 years' median follow-up, 597 of 2785 (21.4%) and 256 of 2775 (9.2%) patients treated with finerenone and placebo, respectively, experienced treatment-emergent ≥mild hyperkalemia; 126 of 2802 (4.5%) and 38 of 2796 (1.4%) patients, respectively, experienced moderate hyperkalemia. Independent risk factors for ≥mild hyperkalemia were higher serum potassium, lower eGFR, increased urine albumin-creatinine ratio, younger age, female sex, β -blocker use, and finerenone assignment. Diuretic or sodium-glucose cotransporter-2 inhibitor use reduced risk. In both groups, short-term increases in serum potassium and decreases in eGFR were associated with subsequent hyperkalemia. At month 4, the magnitude of increased hyperkalemia risk for any change from baseline was smaller with finerenone than with placebo., Conclusions: Finerenone was independently associated with hyperkalemia. However, routine potassium monitoring and hyperkalemia management strategies employed in FIDELIO-DKD minimized the impact of hyperkalemia, providing a basis for clinical use of finerenone., (Copyright © 2022 by the American Society of Nephrology.)

Background: Patients with chronic kidney disease, especially those receiving hemodialysis (HD), are at risk of hyperkalemia (HK). This systematic review aimed to evaluate the prevalence of HK in patients with renal disease receiving HD and collate evidence on the effect of HK and differing HD patterns (i.e., long vs. short inter-dialytic intervals [LIDI and SIDI, respectively] in a thrice weekly schedule) on mortality., Methods: Comprehensive searches were conducted across six databases and selected conference proceedings by two independent reviewers up to September 2020. A hundred and two studies reporting frequency of HK, mortality, or cardiovascular (CV) outcomes in adult patients with acute, chronic or end-stage renal disease in receipt of HD were included. Narrative synthesis of results was undertaken with key findings presented in tables and figures., Results: Median prevalence of HK in patients with renal disease receiving HD was 21.6% and increased in patients receiving concomitant medications - mainly renin-angiotensin-aldosterone system inhibitors and potassium-sparing diuretics. Associations between elevated potassium levels and increased risk of both all-cause and CV mortality in the HD population were consistent across the included studies. In addition, there was a rise in all-cause and CV mortality on the day following LIDI compared with the day after the two SIDIs in patients on HD., Conclusions: Evidence identified in this systematic review indicates a relationship between HK and LIDI with mortality in patients with renal disease receiving HD, emphasizing the need for effective monitoring and management to control potassium levels both in emergency and chronic HD settings.

Cholera is a well known cause of significant disease, particularly in resource-poor nations, but it is very rare in developed countries. The morbidity and mortality of cholera is resultant from large-volume diarrhea, hypovolemia, and electrolyte derangement. In the following case, a 60-year-old man with no recent travel history presented to the emergency department with muscle cramping, abdominal pain, and gastrointestinal distress. It was later confirmed that he was suffering from cholera. On presentation, he was hyperkalemic with ECG changes and soon went into a hypovolemic shock. After a complicated hospital course, he fortunately made a complete recovery. This case demonstrates that common complaints may result in uncommon diagnoses. It is important to pay attention to the clinical situation and intervene accordingly., (© The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: While severe hyperkalemia is commonly encountered, its manifestation in hospitalized patients and related outcomes are unclear. We aimed to examine development of hyperkalemia in hospitalized patients and associated outcomes., Methods: Data from a county hospital electronic health record were used to assess all inpatient admissions, 2012-2016, for non-dialysis-dependent patients with ≥1 K value for development of hyperkalemia. Unadjusted odds ratios (ORs) were calculated for associations of the maximum K value with in-hospital mortality and adjusted ORs were calculated for death associated with hyperkalemia., Results: In 47,018 individual patient hospitalizations, 1.3% had a maximum K ≥6.0 mEq/L and 4.2% <3.5 mEq/L. Fifth and 95th percentiles for maximum K values were 3.5 and 5.3 mEq/L. For high-K patients with a prior K value, the mean (SD) of the immediate pre-maximum K value was 5.0 ± 1.0 mEq/L, and the mean difference in K values (immediate pre-maximum to maximum) was 1.5 ± 1.1 mEq/L; mean duration between these two K tests was 10.7 ± 14.9 hours. Compared with maximum K values 3.5 to 4.0 mEq/L, ORs for death were 37.1 (95% confidence intervals, 25.8-53.3) for K 6.0 to <6.5, 88.6 (56.8-138.2) for K ≥7.0, and 18.9 (4.3-82.2) for K <3.0 mEq/L. In adjusted models, the OR for death for K ≥6.0 mEq/L was 4.9 (3.7-6.4)., Discussion/conclusions: Peak K values ≥6.0 mEq/L were associated with mortality. Values tended to increase rapidly, limiting opportunities for detection and treatment. Systems-based approaches to detect life-threatening hyperkalemia should be studied., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Severe toxicity from ingestions of oral sustained-release potassium is rare. While acute hyperkalaemia requires urgent intervention given the risk of cardiac toxicity, there is a lack of clinical consensus on optimal management. The aim of this study was to characterise the clinical manifestations of acute potassium overdose and its management approach., Methods: This is a retrospective case series of patients presenting following oral potassium overdose of ≥6000mg between January 2009 and December 2020 in Queensland, Australia as recorded in the state's Poisons Information Centre database and a tertiary Clinical Toxicology Unit database. Patients were identified from prospective databases maintained by both units and data were extracted from these in addition to medical records., Results: Thirteen presentations in eleven patients occurred in the twelve-year period. The median age was 35 years (range 14-55 years). The median dose ingested was 6.4 mmol/kg (range 0.9-30.8 mmol/kg). Severe hyperkalaemia >7mmol/L occurred in five patients, four with ingestions ≥60,000mg. All patients with hyperkalaemia received multiple modes of intracellular potassium shifting therapy. Four patients had endoscopic removal of pharmacobezoars. One also underwent whole bowel irrigation. Three presentations were managed with haemodialysis. All patients were discharged home with a median length of stay of 20 h., Conclusion: Aggressive medical therapy to shift potassium into cells appears to be the mainstay of treatment in patients with normal renal function. Early decontamination may limit peak potassium concentrations. It is unclear if haemodialysis provides significant additional benefit in patients with normal renal function.

Hyperkalaemia is a common biochemical finding that can allude to preanalytical or truly pathological causes. Here, we present a case of a 41-year-old female patient who has regularly presented with incidences of isolated hyperkalaemia since 2012, with otherwise normal renal function and no other associated symptoms. Investigations into the patient's family history revealed similar biochemical findings in her brother and eldest son. Familial causes of hyperkalaemia were investigated and an eventual diagnosis of pseudo-hypoaldosteronism type 2C was established. This is a rare congenital renal tubular disorder - also known as Gordon syndrome - that can cause a characteristic triad of symptoms that include hyperkalaemia, metabolic acidosis and hypertension. The presence and severity of each of these symptoms is dependent upon the disease-causing mutation that occurs in WNK4, WNK1, CUL3 or KLHL3 genes. These mutations alter the regulation of sodium/chloride co-transporter (NCC) expression on the luminal membrane of the principal cells of the distal convoluted tubule, disrupting normal homeostatic regulation of electrolyte reabsorption and excretion. The resolution for treating this condition is the administration of a thiazide diuretic, which directly counteracts the effects of NCC co-transporter overexpression and consequently aims to resolve the symptoms that arise as a result of this aberrant signalling. The case described here uniquely presents an extremely rare pathogenic variant in the conserved acidic motif of WNK1 resulting in a clear electrolyte phenotype with no hypertension.

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Background: Sodium zirconium cyclosilicate (SZC), a newly-developed selective potassium binder, has been clinically available to treat hyperkalemia. SZC might be a promising option to manage hyperkalemia, particularly in patients with heart failure, who often require potassium-sparing medications. However, the optimal initial dose of SZC therapy at a loading dose (30 g per day for the initial 2 days) versus a maintenance dose (5 g per day) remains unknown., Methods: Consecutive patients with heart failure and hyperkalemia who received 2-day SZC therapy were retrospectively included. Safety and efficacy of SZC therapy were compared between the two strategies (maintenance versus loading)., Results: We had 16 patients (76 years old, 11 men) who received 2-day SZC therapy (4 maintenance dose group and 12 loading dose group). Serum potassium decreased 0.7 mEqL/L by 2-day maintenance dose therapy and 1.3 mEq/L by 2-day loading dose therapy. Following 2-day SZC therapy, 25% of patients had hypokalemia, which was defined as serum potassium <4.0 mEq/L. Baseline lower serum potassium level was associated with the post-SZC hypokalemia., Conclusions: SZC immediately decreases approximately 1.0 mEq/L of serum potassium in patients with heart failure and hyperkalemia. However, caution should be exercised when utilizing SZC at a loading dose specifically in those with mild hyperkalemia to prevent iatrogenic hypokalemia., (© 2021 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Background: Hyperkalaemia is a potentially life-threatening condition. Furthermore, it is one of the main reasons for discontinuation and dose reduction of renin-angiotensin-aldosterone system inhibitors (RAASi) in clinical practice. However, exact data on the prevalence and consequences of occurrence of hyperkalaemia when taking RAASi in a dedicated heart failure care setting are scarce., Methods: Consecutive patients diagnosed with heart failure from a single tertiary hospital between August 2000 and May 2017 were retrospectively evaluated. Primary endpoint was the development of hyperkalaemia (≥5.5 mmol/L) at any moment during follow-up., Results: About 396 patients were included in the current analysis (mean follow-up 6.9 years). 26% ( n  = 104) and 12% ( n  = 46) of patients developed hyperkalaemia (≥5.5 mmol/L and ≥6.0 mmol/L, respectively). Diabetes mellitus (OR = 1.80, 95% CI = 1.03-3.19) and baseline creatinine (mg/dL) (OR = 2.37, 95% CI = 2.37-3.85) were independent risk factors for hyperkalaemia. Development of hyperkalaemia was associated with 6.5 higher odds for recurrence. Only 10% developed hyperkalaemia during up-titration of RAASi, while 90% developed during later follow-up on stable doses of RAASi. hyperkalaemia was not associated with worse outcome after multivariate adjustment for baseline co-morbidities. However, hyperkalaemia was associated with discontinuation and lower doses of MRAs during follow-up ( p  = 0.007). Discontinuation of MRA due to hyperkalaemia was associated with an increase in all-cause mortality in HFrEF patients (HR = 1.77, 95% CI = 1.05-2.99)., Conclusions: Approximately, one-fourth of patients developed hyperkalaemia during follow-up which was associated with a lower MRA dose during follow-up. Discontinuation of MRA, but not hyperkalaemia itself, was associated with an increased risk of all-cause mortality and heart failure admission in HFrEF patients.

BACKGROUND Brugada syndrome is a rare ion channelopathy that can lead to sudden cardiac death and lethal arrhythmias in patients without a structural cardiac defect, the most common of which being the gain-of-function mutation of the SCN5a sodium ion channel involving phase 0 of the cardiac action potential. In 2012, BrS electrocardiogram findings were redefined and classified as either congenital Brugada syndrome (BrS) or Brugada phenocopies (BrP). Several etiologies of BrP have been reported, such as metabolic derangements, electrolyte abnormalities, cardiovascular diseases, and pulmonary embolism. CASE REPORT A 28-year-old man presented to the Emergency Department unresponsive. An initial ECG taken by Emergency Medical Services (EMS) was interpreted as a STEMI. An initial ECG in the ED showed a Brugada type I ECG pattern in leads V1-V2 and hyperacute T wave abnormalities, among other findings. Additionally, the patient had a serum potassium level of 9 mmol/L, glucose level of 1375 mmol/L, and peak cardiac troponin-I of 20.452 μg/L. All underlying medical conditions were stabilized, electrolyte and metabolic abnormalities were corrected, and subsequent normalization of electrocardiographic findings was achieved. CONCLUSIONS Distinguishing congenital Brugada syndrome from Brugada phenocopies can be difficult, especially when patients present to the ED with severe underlying conditions. Several factors can be used to direct clinical suspicion towards one or the other; however, confirmation may require EP studies and further tests. In this case, the following findings were suggestive of BrP: presence of an identifiable underlying abnormality, correction of the underlying condition resolves the ECG pattern, and the absence of family history of sudden cardiac death.

[Figure: see text].

Aim: We evaluated the relationship between hyperkalemia and wide QRS complex in patients with pulseless electrical activity (PEA) cardiac arrest., Methods: This was a single-center, retrospective observational study of patients over the age of 18 treated for cardiac arrest at a tertiary referral hospital whose initial electrocardiogram rhythm was PEA from February 2010 to December 2019. Wide QRS PEA was defined as a QRS interval of 120 ms or more. Hyperkalemia was defined as serum potassium level > 5.5 mmol/L. The primary outcome was hyperkalemia. Multivariable logistic regression analysis was used to evaluate the relationship between wide QRS and hyperkalemia., Results: Among 617 patients, we analyzed 111 episodes in the wide QRS group and 506 episodes in the narrow QRS group. The potassium level in the wide QRS group was significantly higher than in the narrow QRS group (5.4 mmol/L, IQR 4.4-6.7 vs. 4.6 mmol/L, IQR 4.0-5.6, P < 0.001). Among all patients, 49.6% (n = 55/111) in the wide QRS group had hyperkalemia, which was significantly higher than the 26.7% (n = 135/506) in the narrow QRS group (P < 0.001). In multivariable logistic regression analysis, wide QRS PEA was significantly associated with hyperkalemia (odds ratio = 2.86, 95% confidence interval: 1.80-4.53, P < 0.001)., Conclusions: Wide QRS PEA as an initial cardiac rhythm was significantly associated with hyperkalemia in cardiac arrest patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Pseudohyperkalemia, a false elevation of potassium level in vitro, can be observed in chronic lymphocytic leukemia (CLL) patients due to fragility of leukocytes along with a high leukocyte count. This retrospective, observational study included all patients diagnosed with CLL at our hospital who had at least one leukocyte count ≥ 50.0 × 10 9 /L during the years 2008-2018. All hyperkalemic episodes (including when leukocyte count was below 50.0 × 10 9 /L) during this period were assessed. Pseudohyperkalemia was defined as when a normal potassium level was measured in a repeated blood test or when known risk factors and ECG changes typical of hyperkalemia were absent. Of the 119 episodes of hyperkalemia observed, 41.2% were considered as pseudohyperkalemia. Pseudohyperkalemia episodes were characterized by significantly higher leukocyte counts as well as higher potassium and LDH levels compared to true hyperkalemia. Pseudohyperkalemia was documented in medical charts only in a minority of cases (n = 4, 8.1%). Treatment was administered in 17 of 49 (34.7%) cases and caused significant hypokalemia in 6 of those cases. The incidence of pseudohyperkalemia in this study was rather high, suggesting that physicians should be more aware of this phenomenon in patients with CLL.

Introduction: Hyperkalemia is common in medicine and requires rapid management. Besides the easily evoked causes such as renal failure, adrenal insufficiency, cell lysis or iatrogenic causes, false or pseudo-hyperkalemia should not be forgotten., Observations: Three patients (1 man, 2 women, aged 78, 84, 88) were managed for thrombocytosis (between 1306 and 2404 G/L) and non-symptomatic hyperkalemia (between 6.1 and 7.7mmol/L) are reported. Kalemia on blood collected in heparin tube was normal (4.4-4.6mmol/L). Therefore, no specific treatment for this pseudohyperkalemia was required., Conclusion: The combination of thrombocytosis and non-symptomatic hyperkalemia should suggest the diagnosis of pseudohyperkalemia and should prompt for a control of kalemia on blood collected in heparin tube. The recognition of this diagnosis is important in order to avoid unnecessary and potentially deleterious treatment of hyperkalemia., (Copyright © 2021 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier Masson SAS. All rights reserved.)

Background: BRASH syndrome, a relatively new entity, has been described in the recent literature. It is defined as a combination of bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia. Although it is apparent that clinical symptomatology includes shock, it is still unclear whether all patients will initially present with all five components mentioned in the BRASH acronym., Case Report: An elderly woman presented to our Emergency Department (ED) with hyperkalemia, acute renal failure, and metabolic acidosis with bradycardia, which was refractory to antikalemic measures and atropine. The montage of clinical features put together showed a clear picture of BRASH syndrome, which helped us to streamline the management and achieve a better patient outcome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Renal failure with various metabolic derangements is commonly seen in the ED. We should be aware of this new clinical entity, as its incidence will certainly increase, and the management is a bit different. Prognosis is excellent with timely recognition and management of this rare clinical entity., (Copyright © 2021. Published by Elsevier Inc.)

Pseudohyperkalemia and pseudohyponatremia are phenomena in which hematologic disorders with high cell counts result in factitious electrolyte measurements that can result in inappropriate treatment. We describe 2 children with leukemia presenting with both disturbances to highlight the importance of correlating electrolyte results from plasma with those from whole blood before intervening., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Aims: Hyperkalemia is a potentially life-threatening condition associated with the use of heart failure (HF) medications, which can lead to increased morbidity and mortality. Novel approaches for hyperkalemia prevention are needed, especially in limited-resource settings. Despite multiple studies showing the beneficial impact of pharmaceutical-counseling in several outcomes, there is a knowledge-gap regarding its impact on hyperkalemia prevention., Methods: A case-control study was performed in patients from the Adult Heart Failure Clinic Registry in our institution. Cases were selected using a definition of serum potassium K+ ≥5.5 mmol/L. To study the association between hyperkalemia and relevant risk factors, we performed a multivariate logistic regression analysis using the Least Absolute Shrinkage and Selection Operator (LASSO) method for variable selection. We also fitted a Classification and Regression Tree (CART) to establish complex interactions and effect modifiers between the selected variables., Results: We matched 483 controls (eligible HF patients without hyperkalemia) to 132 cases (eligible HF patients with hyperkalemia based on age and calendar, yielding a total sample size of 615 patients (270 females) for this study. Cases had statistically significant lower odds of receiving a pharmacist-based multidimensional intervention (PBMI) (OR 0.57; 95% CI, 0.43-0.80) or having HF with reduced ejection fraction (OR 0.56; 95% CI, 0.18-0.72). On the other hand, patients who presented hyperkalemia had statistically significant higher odds of having a history of chronic kidney disease stage 4 (OR 4.97; 95% CI, 2.24-11.01) or 5 (OR 6.73; 95% CI, 1.69-26.84) and being on enalapril at doses =40 mg/day (OR, 9.90; 95% CI 5.81-16.87)., Conclusions: PBMI is a practical approach to prevent hyperkalemia in HF patients in a limited-resource setting. However, clinical trials are needed to assess its effectiveness., Competing Interests: Declaration of Competing Interest The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this manuscript., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Although dyskalemia is common, its management can be problematic for students and general practitioners, especially when it occurs in patients with heart and renal failure. The basic academic knowledge of general medicine students, who have often not yet encountered clinical situations of dyskalemia, remains unclear in this regard., Objectives: The purpose of this study was to evaluate the knowledge and reflexive practices of general medicine students in regard to dyskalemia., Methods: A cross-sectional survey, based on a self-questionnaire, of all of the students enrolled in general medicine studies at the Faculty of Medicine at the University of Nancy (France) at the end of their degree. The students were asked questions pertaining to specific clinical situations. The answers were compared to the information provided in the medical curriculum as well as to the relevant European guidelines., Results: We collected 290 of the questionnaires (participation rate: 81.2%). The hyper- and hypokalemia thresholds considered pathological (3.5-5.0 mmol/L) were known by 78% and 67% of the students, respectively. The perception of danger in case of severe hypokalemia was underestimated by 62.7% of them. In most cases, the proposed management of hyperkalemia in heart and renal failure did not comply with the relevant guidelines. The students tended to favor permanent discontinuation of the administration of converting enzyme inhibitors (ACE) and/or mineralocorticoid receptor antagonists (MRA) without considering the need for their reintroduction (51.6%). Sodium polystyrene sulfate was frequently seen as an appropriate first-line treatment for hyperkalemia (45%)., Conclusions: The knowledge and competence of general medicine students appear to be lacking for hyperkalemia in heart and renal failure, and they are long way from full compliance with the relevant European guidelines. Exposure to complex clinical situations as part of the medical curriculum, therefore, seems essential to improve the way dyskalemia is managed in France., (© 2020 Société Française de Pharmacologie et de Thérapeutique.)

Background: Serum potassium disorders, commonly observed in chronic kidney disease (CKD), are reportedly associated with higher mortality, but their impact on renal outcomes is still controversial., Methods: The present study used the longitudinal data of the Fukushima CKD cohort study to investigate the relationships between hypokalemia and hyperkalemia and adverse outcomes such as renal outcomes and all-cause mortality in Japanese patients with non-dialysis-dependent CKD. The study involved 1330 CKD patients followed-up for 2.8 years. The primary endpoint of the present study was a kidney event, defined as a combination of doubling of baseline serum creatinine and end-stage kidney disease., Results: Hyperkalemia (≥ 5.0 mmol/L) was noted in 10.6% and hypokalemia (< 4.0 mmol/L) in 16.4% of the study population. Significant U-shaped associations were observed between potassium levels and both kidney events and all-cause mortality on univariate Cox regression analyses. After adjustment for covariates, both hypokalemia and hyperkalemia were significantly associated with an increased risk of kidney events, with the lowest risk at a serum potassium of 4.0-4.4 mmol/L. Compared with a reference level of 4.0-4.4 mmol/L, the adjusted hazard ratio for kidney events was 2.49 (1.33-4.66) for serum potassium < 4.0 mmol/L, 1.72 (1.00-2.96) for 4.5-4.9 mmol/L, and 2.16 (1.15-4.06) for ≥ 5.0 mmol/L. There was no significant association between serum potassium levels and mortality after multivariate adjustment., Conclusion: Hypokalemia and hyperkalemia were associated with an increased risk of CKD progression, but not with mortality in Japanese patients with non-dialysis-dependent CKD.

Background: Hyperkalemia is a rare life-threatening complication of red blood cell (RBC) transfusion. Stored RBCs leak intracellular potassium (K+) into the supernatant; irradiation potentiates the K+ leak. As the characteristics of patients and implicated RBCs have not been studied systematically, a multicenter study of transfusion-associated hyperkalemia (TAH) in the pediatric population was conducted through the AABB Pediatric Transfusion Medicine Subsection., Study Design: The medical records of patients <18 years old were retrospectively queried for hyperkalemia occurrence during or ≤12 h after the completion of RBC transfusion in a 1-year period. Collected data included patient demographics, diagnosis, medical history, timing of hyperkalemia and transfusion, mortality, and RBC unit characteristics., Results/findings: A total of 3777 patients received 19,649 RBC units during the study period in four facilities. TAH was found in 35 patients (0.93%) in 37 occurrences. The patient median age and weight were 1.28 years and 9.80 kg, respectively. All patients had multiple serious comorbidities. There were 79 RBC units transfused in the TAH events; 62% were irradiated, and the median age of the units was 10 days. The median total RBC volume transfused ≤12 h before TAH was 24% of patient estimated total blood volume, and the median infusion rate (IR) was19.6 ml/kg/h. Mortality rate within 1 day after the TAH event was 20%., Conclusions: The prevalence of TAH in children was low; however, the 1-day mortality rate was 20%. Patients with multiple comorbidities may be at higher risk for TAH. The IR was higher for patients who had TAH than the IR threshold for safe transfusion., (© 2021 AABB.)

Background: Mineralocorticoid receptor antagonists (MRAs) and sodium glucose co-transporter 2 inhibitors favorably influence the clinical course of patients with heart failure and reduced ejection fraction., Objectives: This study sought to study the mutual influence of empagliflozin and MRAs in EMPEROR-Reduced (Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Reduced Ejection Fraction)., Methods: Secondary analysis that compared the effects of empagliflozin versus placebo in 3,730 patients with heart failure and a reduced ejection fraction, of whom 71% used MRAs at randomization., Results: The effects of empagliflozin on the primary endpoint, on most efficacy endpoints, and on safety were similar in patients receiving or not receiving an MRA (interaction p > 0.20). For cardiovascular death, the hazard ratios for the effect of empagliflozin versus placebo were 0.82 (95% confidence interval [CI]: 0.65 to 1.05) in MRA users and 1.19 (95% CI: 0.82 to 1.71) in MRA nonusers (interaction p = 0.10); a similar pattern was seen for all-cause mortality (interaction p = 0.098). Among MRA nonusers at baseline, patients in the empagliflozin group were 35% less likely than those in the placebo group to initiate treatment with an MRA following randomization (hazard ratio: 0.65; 95% CI: 0.49 to 0.85). Among MRA users at baseline, patients in the empagliflozin group were 22% less likely than those in the placebo group to discontinue treatment with an MRA following randomization (hazard ratio: 0.78; 95% CI: 0.64 to 0.96). Severe hyperkalemia was less common in the empagliflozin group., Conclusions: In EMPEROR-Reduced, the use of MRAs did not influence the effect of empagliflozin to reduce adverse heart failure and renal outcomes. Treatment with empagliflozin was associated with less discontinuation of MRAs. (Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Reduced Ejection Fraction [EMPEROR-Reduced]; NCT03057977)., Competing Interests: Funding Support and Author Disclosures EMPEROR-Reduced was funded by Boehringer Ingelheim and Eli Lilly. Dr. Ferreira has received consulting fees from Boehringer Ingelheim during the conduct of the study. Dr. Zannad has received personal fees from Boehringer Ingelheim during the conduct of the study; has received personal fees from Janssen, Novartis, Boston Scientific, Amgen, CVRx, AstraZeneca, Vifor Fresenius, Cardior, Cereno Pharmaceutical, Applied Therapeutics, Merck, Bayer, and Cellprothera outside the submitted work; and has received other support from CardioVascular Clinical Trialists and Cardiorenal, outside the submitted work. Dr. Pocock has received personal fees from Boehringer Ingelheim during the conduct of the study. Dr. Anker has received grants from Vifor; has received personal fees from Vifor, Bayer, Boehringer Ingelheim, Novartis, Servier, Impulse Dynamics, Cardiac Dimensions, and Thermo Fisher Scientific; and has received grants and personal fees from Abbott Vascular, outside the submitted work. Dr. Butler has received consultancy fees from Boehringer Ingelheim during the conduct of the study; and has received consultancy fees from Abbott, Adrenomed, Amgen, Applied Therapeutics, Array, AstraZeneca, Bayer, BerlinCures, Boehringer Ingelheim, Cardior, CVRx, Foundry, G3 Pharma, Imbria, Impulse Dynamics, Innolife, Janssen, LivaNova, Luitpold, Medtronic, Merck, Novartis, Novo Nordisk, Relypsa, Roche, Sanofi, Sequana Medical, V-Wave, and Vifor, outside the submitted work. Dr. Filippatos has received payment for being a trial committee member from Boehringer Ingelheim during the conduct of the study; and has received payment for being a trial committee member from Medtronic, Vifor, Servier, and Novartis, outside the submitted work. Dr. Brueckmann has received personal fees from Boehringer Ingelheim during the conduct of the study; and has received personal fees from AbbVie, Akcea, Amarin, AstraZeneca, Amgen, Boehringer Ingelheim, Cardiorentis, Daiichi-Sankyo, Johnson & Johnson, Lilly, Novartis, Pfizer, Relypsa, Sanofi, Synthetic Biologics, Theravance, and Novo Nordisk, outside the submitted work. Drs. Brueckmann, Steubl, Jamal, and Steubl are employees of Boehringer Ingelheim. Dr. Schueler is an employee of mainanalytics, contracted by Boehringer Ingelheim. Dr. Packer has reported that he has no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Potassium level is measured for patients with high risk of hyperkalemia in the emergency department (ED) using both blood gas analyser (BGA) and biochemistry analyser (BCA). The study was conducted to evaluate the correlation and agreement of potassium measurement between BGA and BCA., Materials and Methods: This is a prospective cross-sectional study on the data obtained from Hospital Universiti Sains Malaysia (Hospital USM) from Jun 2018 until May 2019. Blood samples were taken via a single prick from venous blood and sent separately using 1ml heparinised syringe and were analysed immediately in ED using BGA (Radiometer, ABL800 FLEX, Denmark) and another sample was sent to the central laboratory of Hospital USM and analysed by BCA (Architect, C8000, USA). Only patients who had potassium levels ≥5.0mmol/L on blood gas results were included. A total of 173 sample pairs were included. The correlation and agreement were evaluated using Passing and Bablok regression, Linear Regression and Bland-Altman test., Result: Of the 173 sample pairs, the median of potassium level based on BGA and BCA were 5.50mmol/L (IQR: 1.00) and 5.90mmol/L (IQR: 0.95) respectively. There was significant correlation between two measurements (p<0.001, r: 0.36). The agreement between the two measurements showed within acceptable mean difference which was 0.27 mmol/L with 95% limit of agreement were 1.21mmol/L to 1.73mmol/L., Conclusion: The result of blood gas can be used as a guide for initial treatment of hyperkalaemia in critical cases where time is of the essence. However, BCA result is still the definitive value.