American Journal of Emergency Medicine 33 (2015) 473.e3473.

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American Journal of Emergency Medicine

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Case Report

Treatment of life-threatening hyperkalemia with peritoneal dialysis in

the ED,
Abstract
Severe hyperkalemia (serum potassium N 7.0 mmol/L) is an
uncommon electrolyte abnormality in patients undergoing maintenance peritoneal dialysis (PD). Hemodialysis (HD) has been suggested
as the denitive therapy for severe hyperkalemia in this population,
although there is limited data regarding renal replacement options.
We report a case of life-threatening hyperkalemia with electrocardiogram changes in a nonadherent PD patient who was successfully
treated with standard medical therapy and manual exchanges
initiated by emergency department (ED) personnel. The patient did
not require HD. This case demonstrates the potential utility of PD as a
treatment option for severe hyperkalemia in established dialysis
patients when EDs are prepared to deliver exchanges. This report may
be particularly relevant due to the increasing prevalence rate of PD
and for centers with limited HD access.
The distribution of serum potassium values in patients undergoing
peritoneal dialysis (PD) is generally on the lower end of normal
compared with the high reference range observed in hemodialysis
(HD) patients [1-3]. In fact, severe hyperkalemia (serum potassium
N7.0 mmol/L) is an uncommon but potentially lethal condition in
patients performing maintenance PD. A large multicenter study of PD
patients in the United States (n = 10 468) reported a prevalence of
4.5% for time-averaged serum potassium values greater than or equal
to 5.5 mEq/L [1]. The prevalence of severe hyperkalemia in this
population is unknown but likely much lower. Dialysis is the
denitive therapy for PD patients at imminent risk for death due to
hyperkalemia. Hemodialysis has been suggested as the preferred
treatment modality in all dialysis-dependent patients, including PD,
because of the faster potassium elimination rates [4,5]. Emergency
departments (EDs) faced with this scenario must initiate rapid
therapy to avoid life-threatening cardiac complications. However,
there is no standard dialytic approach to the treatment of severe
hyperkalemia in established PD patients, and limited data exist
regarding the appropriate modality and dose.
Rapid initiation of PD exchanges by well-trained ED personnel
may be a viable treatment option for severe hyperkalemia. We report
an unusual presentation of life-threatening hyperkalemia manifested by electrocardiographic (ECG) changes in a PD patient who was
treated with manual exchanges initiated in the ED. We review the
literature regarding renal replacement options for severe hyperka-

D Roseman received funding from the National Institutes of Health (T32-DK-007053).

Part of this work was presented in abstract form at the 2013 Annual Meeting of the
American Society of Nephrology, Atlanta, GA.

0735-6757/ 2014 Elsevier Inc. All rights reserved.

lemia in PD patients and discuss its importance for centers providing

emergency care.
A 48-year-old man with a history of hypertension, cardiomyopathy, and end-stage renal disease with no residual renal function on
automated PD for 5 years using a exible Tenckhoff catheter
presented to the ED with 2 days of weakness, subjective fever, and
nonproductive cough immediately after returning from a 2-week
Caribbean vacation. The patient relied on a transient dialysis facility
for all supplies while traveling but discontinued PD after the rst
week due to concerns over sanitation and the potential risk of
infection such as peritonitis. On arrival, the patient was conversant
with a blood pressure of 160/105 mm Hg, a pulse rate of 108 beats per
minute, and an oxygen saturation of 96% on 4 L of supplemental
oxygen. The physical examination was notable for decreased
bibasilar breath sounds. A 12-lead ECG showed sinus tachycardia
with anterolateral ST and T wave abnormalities (Figure). Chest
radiography revealed clear lungs. Laboratory results included sodium
140 mmol/L, potassium 8.1 mmol/L, chloride 103 mmol/L, bicarbonate 13.2 mmol/L, blood urea nitrogen 179 mg/dL, creatinine 31.86
mg/dL, and glucose 95 mg/dL. The patient became progressively
lethargic requiring noninvasive ventilation. A repeat ECG showed
worsening tachycardia with a new incomplete right bundle-branch
block (Figure).
Standard medical therapy was administered including calcium
gluconate, insulin, dextrose, sodium bicarbonate, and albuterol. In
addition, a manual PD exchange with a 1.5% dextrose solution was
started by an ED nurse. The patient was monitored on telemetry and
stabilized with subsequent return of a sinus tachycardia before being
transferred to the intensive care unit. Intensive care unit staff
continued to perform 2-L manual exchanges every 2 hours. After 10
hours, the serum potassium decreased to 6.6 mmol/L and, by 16 hours,
had further improved to 5.4 mmol/L with no subsequent events on
telemetry. Exchanges were then extended to every 4 hours. The
patient was discharged after 3 days with complete resolution of
hyperkalemia and lethargy.
Early experiences with PD suggested that the modality could be
used as adjunct therapy for potassium intoxication until HD was
available [6,7]. More recently, HD was cited as the preferred modality
for potassium removal in dialysis patients due to faster clearance
rates when compared with PD [4,5]. The clearance of potassium
during extracorporeal dialysis can exceed 100 mL/min, whereas that
of PD averages approximately 17 mL/min [7]. However, HD
introduces potential risk due to insertion of central venous access
and use of low potassium dialysate that could provoke cardiac
arrhythmias [8]. Patients with marked hyperkalemia may also have a
rebound of plasma potassium after HD and require additional
treatments [9]. Finally, HD may involve logistical delays while

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D.A. Roseman et al. / American Journal of Emergency Medicine 33 (2015) 473.e3473.e5

Figure. A, Twelve-lead ECG in a patient on PD with life-threatening hyperkalemia at presentation revealing sinus tachycardia with anterolateral ST and T wave abnormalities. B,
Electrocardiogram 35 minutes after presentation showing worsening tachycardia with new incomplete right bundle-branch block.

waiting for support staff and setting up equipment. Peritoneal

dialysis supplies can be stored locally and made readily available.
Therefore, an ED prepared to deliver PD should consider starting
exchanges promptly because this can be initiated with minimal delay
using the indwelling catheter.
There is precedent for using PD alone to treat severe hyperkalemia. A 2008 report from a hospital without access to HD equipment
described 3 critically ill patients not previously on dialysis with
serum potassium values greater than 8.0 mEq/L who were successfully treated with acute PD. Emergency medicine residents were
trained to insert Tenckhoff catheters percutaneously, and nurses
were taught to use a PD cycler [10]. Our case extends the literature to
demonstrate that a patient already established on PD can be
effectively treated for severe hyperkalemia without HD if temporizing measures and exchanges alone are initiated early. Hemodialysis
may still remain the preferred modality, but the slower clearance
rates of potassium using PD should not preclude its consideration.
This observation may be particularly relevant for centers with limited
resources that care for PD patients. It is important to emphasize that
although our hospital has access to HD, our ED and intensive care unit
nurses are educated to perform manual PD exchanges. The
established coordination between nephrology and emergency
medicine departments resembles the earlier cases and was crucial
to this rapid lifesaving intervention.
Programs to train and educate emergency personnel on PD
techniques could be implemented that allow for more widespread
access and familiarity with PD. Currently, HD is the predominant

dialysis modality performed in the United States. However, the

incidence rate of HD declined for the rst time in over 30 years by
the end of 2011, whereas the incidence rate of PD increased for the
third consecutive year to 6.6% among all dialysis patients [11].
The increased utilization of PD is expected to continue due to
nancial incentives enacted by the US Congress and PD rst
initiatives meant to encourage greater adoption rates of home
therapies [12,13].
Peritoneal dialysis patients may also present to the ED with a
variety of mechanical, infectious, and metabolic emergencies that
are uniquely different from those associated with hemodialysis
[14,15]. Taken together, the rising number of patients choosing PD
and potential complications have considerable implications for
emergency staff encountering prevalent PD patients. These issues
further support the use of educational programs to help providers
develop the skills necessary for using PD equipment when
emergency care is indicated. Additional research is needed to
identify centers that may benet from learning new techniques as
the PD population expands.
Daniel A. Roseman, MD
Renal Section, Department of Medicine, Boston University Medical Center
Boston, MA, USA
Elissa M. Schechter-Perkins, MD, MPH
Department of Emergency Medicine, Boston University Medical Center
Boston, MA, USA

D.A. Roseman et al. / American Journal of Emergency Medicine 33 (2015) 473.e3473.e5

Jasvinder S. Bhatia, MD
Renal Section, Department of Medicine, Boston University Medical Center
Boston, MA, USA
E-mail address: jbhatia@bu.edu
http://dx.doi.org/10.1016/j.ajem.2014.08.041
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