Abbreviations
ACE
angiotensin‐converting enzyme
ACT
activated clotting time
ACTH
adrenocorticotropic hormone
BUN
blood urea nitrogen
CBC
complete blood count
CKD
chronic kidney disease
CRI
constant rate infusion
CRRT
continuous renal replacement treatment
CVVHDF
continuous venovenous hemodiafiltration
ECF
extracellular fluid
HIH
heparin‐induced hyperkalemia
ICF
intracellular fluid
LMWH
low‐molecular‐weight heparin
RER
resting energy requirement
RI
reference interval
SCr
serum creatinine
UFH
unfractionated heparin
UOP
urine output
UPC
urine protein:creatinine
Case Summary
An 11‐year‐old, male castrated Australian shepherd dog presented for evaluation of
acute exacerbation of chronic kidney disease (CKD). The dog had a history of stage
III CKD1 (borderline proteinuric, blood pressure unknown) that had been stable for
4 years. The dog had last been evaluated 5 months earlier. At that time, blood urea
nitrogen (BUN) concentration was 57 mg/dL, serum creatinine (SCr) concentration was
3.3 mg/dL, and serum potassium concentration was 5.5 mEq/L. The dog had been treated
chronically with enalapril (0.56 mg/kg PO q24h), calcitriol (2.7 ng/kg PO q24h), omega
fatty acids (unknown dose), aspirin (1.1 mg/kg PO q24h), and a prescription renal
diet2. According to the owner, the dog had been doing well since its last evaluation
with no changes in appetite, activity, or urinations.
A week before presentation, the dog's appetite and activity decreased markedly. It
began having diarrhea, and water intake was decreased. No definitive toxin exposure
had occurred but there was possible ingestion of raisin bread within 10 days of presentation.
The dog weighed 17.8 kg and was markedly azotemic (SCr concentration: 12.6 mg/dL;
BUN concentration: >130 mg/dL) with a urine protein:creatinine (UPC) ratio of 1.49.
The dog was hospitalized and treated with antimicrobials, antacids, antiemetics, IV
fluids, antihypertensive treatment, enteral nutrition (50% resting energy requirement
[RER] for 2 days before referral), and 1 dose of epoetin alfa (101 U/kg SC). After
a week of treatment, the dog was referred for continuous renal replacement treatment
(CRRT) to manage refractory azotemia (SCr concentration: 8.2 mg/dL) and resolve fluid
overload evidenced by peripheral edema and net weight gain (approximately 1.1 kg)
although the dog had lost 1.2 kg in the 48 hours before referral.
On presentation, the dog was quiet but responsive. Its mucous membranes were pale
pink, vital signs were within normal limits, and body weight was 18.3 kg. The dog
was mildly uncomfortable on abdominal palpation. Mentation was normal but occasional
focal facial seizures were noted. A serum biochemistry profile and complete blood
count (CBC) were obtained before initiating CRRT. Results indicated marked azotemia
(BUN, 107 mg/dL; reference interval [RI], 7–27 mg/dL; SCr concentration, 7.9 mg/dL;
RI, 0.4–1.8 mg/dL), hyperphosphatemia (serum phosphorus concentration, 11.6 mg/dL;
RI, 2.2–7.9 mg/dL), hypoalbuminemia (serum albumin concentration, 1.9 g/dL; RI, 2.3–3.9
g/dL), hypernatremia (serum sodium concentration, 153 mEq/L; RI, 141–150 mEq/L), with
normal serum chloride (112 mEq/L; RI, 109–119 mEq/L), and serum potassium (5.0 mEq/L;
RI, 3.9–5.3 mEq/L) concentrations. The CBC results were consistent with a stress leukogram
and disclosed a normocytic, hypochromic anemia (hematocrit, 19%). A dialysis catheter3
was placed in the left jugular vein under anesthesia. The jugular sampling catheter
on the contralateral side, nasogastric feeding tube, and urinary catheter placed before
referral were evaluated for patency, cleaned, and maintained in place.
Continuous venovenous hemodiafiltration (CVVHDF) was initiated using an automated
renal replacement treatment and continuous fluid management unit4. Before use, the
hemofilter5 and blood access lines were primed with heparinized saline (10 units/mL
heparin in 0.9% saline). A commercial, electrolyte‐balanced solution6 was used as
the dialysate and replacement solutions. A constant rate infusion (CRI) of unfractionated
heparin (UFH) was utilized for anticoagulantion; dosages ranged from 22 to 38.5 U/kg/h
to achieve an activated clotting time (ACT) between 180 and 220 seconds. During the
initial CRRT session, extracorporeal blood flow rate was approximately 40 mL/min (2.2
mL/kg/min). Dialysate flow rates of 0–300 mL/h (0–16.5 mL/kg/h) and replacement rates
of 300–350 mL/h (16.4–19 mL/kg/h) were utilized, with 200 mL/h predialyzer and 100–150
mL/h postdialyzer. A filtration fraction of 14–17% and a measured Kt/V7 of 1.32–1.34
was achieved during the session. A commercial, electrolyte‐balanced fluid8 was administered
through the jugular sampling catheter at a rate determined by urine output (UOP).
There was no net fluid removal during the session. A packed red blood cell transfusion
(450 mL total; 24.7 mL/kg) was administered on the first day of CRRT.
Medications administered during CRRT included ampicillin/sulbactam (24.7 mg/kg IV
q8h), enrofloxacin (11 mg/kg IV q24h), diazepam (0.25–0.5 mg/kg IV as needed for seizure
activity), levetiracetam (22 mg/kg IV q8h) for focal seizures, pantoprazole (0.9 mg/kg
IV q24h), maropitant (1 mg/kg SC q24h), amlodipine (0.27 mg/kg PO q24h), and enteral
nutrition (increased to 100% RER). The dog became tachycardic during CRRT and a fentanyl
CRI was initiated (2–3 μg/kg/h) for analgesia. Because of decreasing UOP (2.8 mL/kg/h)
which occurred 12 hour after beginning the first CRRT session, and concurrent weight
gain (0.5 kg), furosemide (1 mg/kg IV) was administered followed by a fenoldopam CRI
(0.5 μg/kg/min). After 46 hour of CRRT, SCr concentration was 1.9 mg/dL, well below
the patient's baseline SCr concentration. In addition, UOP appeared stable, with no
evidence of fluid overload, and the session was discontinued. Serum potassium concentration
(4.6 mEq/L) was normal at that time. After cessation of CRRT, the dog was continued
on IV fluids to match UOP plus estimated insensible losses. Because of the risk of
thromboembolism (given the presence of bilateral jugular catheters, recent extracorporeal
treatment, and proteinuria), UFH CRI (22–30 U/kg/h) was continued. Fentanyl was discontinued
after CRRT. Fenoldopam was discontinued because UOP had increased (>4.0 mL/kg/h).
The patient's demeanor, UOP and weight appeared stable with fluid treatment alone
despite gradual worsening of azotemia. Two days later, SCr concentration had increased
to 4.2 mg/dL and hyperkalemia (6.2 mEq/L) was noted. A limited renal replacement session
of 10 hours was performed in an attempt to managed worsening azotemia and hyperkalemia.
A shorter session was elected because of owner constraints. Similar fluid flow parameters
were used during this second session. Despite improvement of SCr concentration (2.2
mg/dL), minimal improvement of hyperkalemia (5.7 mEq/L) occurred and hyponatremia
(138 mEq/L) and hypochloremia (106 mEq/L) developed. At this point, nutritional support
had been occurring for 5 days, including 3 days of 100% RER. On day 5 of hospitalization,
heparin‐induced hyperkalemia (HIH) was considered as a differential diagnosis for
the persistent hyperkalemia, and heparin was discontinued. Before cessation of the
heparin CRI, blood was collected for measurement of plasma aldosterone concentration
(0 pmol/L; RI, 14–957 pmol/L). Fludrocortisone (0.01 mg/kg PO q12h) was initiated
3 days later because of persistent hyperkalemia. Hyperkalemia resolved (4.9 mEq/L)
within 2 days of starting fludrocortisone. SCr concentration stabilized between 4.2
and 4.7 mg/dL, and the dog was discharged with the following medications: benazepril
(0.19 mg/kg PO q24h), aluminum hydroxide (8.8 mg/kg PO q6h), amlodipine (0.27 mg/kg
PO q24h), levetiracetam (6.9 mg/kg PO q8h), metoclopramide (0.1 mg/kg PO q8h), maropitant
(1.6 mg/kg PO q24h), and fludrocortisone (0.005 mg/kg PO q12h). A prescription renal
diet2 was administered via an esophagostomy tube placed 24 hours before discharge
in preparation for home care.
Three days after discharge, the patient was reevaluated. Fludrocortisone administration
had undergone planned dose reduction and was discontinued the morning of reevaluation.
The serum potassium concentration was 5.3 mEq/L at that time and SCr concentration
level had increased to 4.9 mg/dL. Benazepril, amlodipine, and aluminum hydroxide were
continued. Several days later, the dog was evaluated at an emergency clinic after
an episode of vomiting. Serum cortisol and plasma aldosterone concentrations were
measured before and after ACTH administration, 2 days after discontinuing fludrocortisone.
The baseline serum cortisol concentration was 5.9 μg/dL (RI, 1.0–5.0 μg/dL) and post‐stimulation
was 24.8 μg/dL (RI, 8.0–17.0 μg/dL). The baseline plasma aldosterone concentration
was 92 pmol/L, and the post‐stimulation concentration was 376 pmol/L (RI, 197–2,103
pmol/L). At reevaluation 3 days later, serum potassium concentration was 4.5 mEq/L,
and SCr concentration was 6.4 mg/dL. A month later, because of declining quality of
life, the dog was euthanized.
This case report is consistent with a unique clinical syndrome, HIH. The associated
aldosterone concentrations and resolution of hyperkalemia upon cessation of heparin
treatment are documented, and support HIH as a cause of the hyperkalemia. HIH has
not previously been described previously in veterinary medicine.
Hyperkalemia has been reported as an uncommon adverse effect in humans treated with
heparin.1, 2, 3, 4, 5 Hyperkalemia has been attributed to transient suppression of
aldosterone synthesis that resolves with cessation of heparin administration.4, 5,
6 This phenomenon has been reported in humans receiving UFH as well as those treated
with low‐molecular‐weight heparins (LMWH).4, 7, 8, 9 Reports suggest that 7–8% of
human patients receiving heparin treatment may experience some degree of HIH.5, 6
Heparin is used frequently in both human and veterinary medicine, but HIH is reported
uncommonly in humans and has not been reported previously in veterinary patients.
Clinically relevant HIH in humans has been associated primarily with concurrent renal
insufficiency, diabetes mellitus, metabolic acidosis, or concurrent use of other drugs
(eg, angiotensin‐converting enzyme [ACE] inhibitors) that can contribute to hyperkalemia.4,
6 These concurrent conditions are thought to impede compensation for aldosterone suppression.6
In HIH in humans, hyperkalemia often is detectable within 2–3 days and becomes marked
by days 4–6 of heparin treatment.5, 6 Concurrent hyponatremia is reported in 6–50%
of cases.5, 6 Studies from humans and rats identified subclinical decreases in plasma
aldosterone concentration associated with heparin administration.3, 5 Heparin does
not alter metabolic clearance of aldosterone but instead decreases its production
in a dose‐dependent manner.3, 5, 6 In HIH, aldosterone suppression may be mediated
through inhibition of the adrenal response to angiotensin II, because both the number
and affinity of angiotensin II receptors are decreased.5, 6 In addition, there is
evidence of a direct inhibitory effect on adrenal aldosterone production; steroidogenesis
is inhibited at the 18‐hydroxylase step.6, 9 Aldosterone synthase (18‐hydroxylase)
is the final step in aldosterone synthesis, which converts corticosterone to aldosterone.
Evidence of adrenal zona glomerulosa atrophy from chronic heparin treatment also has
been reported on necropsy.5, 6, 9
Our patient had confirmed hypoaldosteronism during heparin treatment that resolved
after cessation of heparin treatment. At that time, no other inhibitors of aldosterone
had been administered and the dog was hyperkalemic and hyponatremic. Hyperkalemia
normally stimulates aldosterone secretion,5, 10 thus making this patient's hypoaldosteronism
inappropriate. In addition to hyperkalemia, the other major stimulus for aldosterone
secretion is the renin‐angiotensin system, in response to hypovolemia.10 At the time
of aldosterone sample collection, the patient showed no evidence of volume overload,
and body weight had remained stable. It is unlikely that a subclinical change in volume
status would suppress aldosterone to this extent, particularly in the face of clinically
relevant hyperkalemia. Furthermore, hypoadrenocorticism was later ruled out by ACTH
stimulation testing. Primary hypoaldosteronism without hypocortisolism has been reported
in dogs11, 12 but in this patient hypoaldosteronism and hyperkalemia resolved after
discontinuation of heparin treatment.
In veterinary medicine, hyperkalemia has been associated with a variety of different
conditions resulting in a shift of potassium to the extracellular fluid (ECF) or decreased
renal excretion. The majority of body potassium is stored intracellularly and translocation
of potassium from the intracellular fluid (ICF) to the ECF, as seen in patients with
acute hyperchloremic acidosis, insulin deficiency, and hyperosmolality, can result
in hyperkalemia.10, 13 None of these conditions were present in this patient. Hyperkalemia
also has been associated with renal injury, but occurs uncommonly unless oliguria,
anuria or urinary tract obstruction is present.13 Our patient's OUP reached a nadir
of 1.7 mL/kg/h, and the dog was normokalemic (4.3 mEq/L) at that time. For the majority
of hospitalization, UOP averaged between 3.0 and 4.5 mL/kg/h concurrent during periods
of hyperkalemia. Based on this finding, the cause of hyperkalemia was not consistent
with oliguric renal failure. Additionally, an abdominal ultrasound examination disclosed
no evidence of postrenal obstruction.
Excessive dietary potassium intake is another potential cause for hyperkalemia. This
patient received a balanced critical care diet9 via a nasogastric tube during the
majority of hospitalization. The dog received a total of 894 mg of potassium per day
using this diet, which contained 1.3 g potassium per 1,000 kcal of metabolizable energy,
and received the same volume of food consistently. Because the dog had a poor appetite
in the hospital, an esophagostomy tube was placed to facilitate adequate caloric intake.
The dog was transitioned to a prescription renal diet2 after esophagostomy tube placement.
The dog received a total of 494 mg of potassium per day in this diet (0.8 g potassium/1,000
kcal of ME), with minimal supplemental PO feeding. The suggested dietary potassium
intake for dogs with CKD is 0.8–1.2 g/1,000 kcal of ME.14 Although slightly above
the suggested intake for a CKD patient, the potassium intake in the hospital was well
below the minimum for normal dogs (1.7 g/1,000 kcal of ME14) and unlikely to be excessive.
Although subsequent reduction in dietary potassium intake may have contributed to
the eventual normalization of the dog's serum potassium concentration, improvement
in hyperkalemia preceded the dietary transition. Furthermore, diet‐induced hyperkalemia
should stimulate, rather than suppress, production of aldosterone,13 and is therefore
inconsistent with the hyperkalemia in this patient.
The patient previously had been treated with an ACE inhibitor, but it was discontinued
because of inappetence. Hyperkalemia was not observed at the time of presentation
and developed several days after ACE inhibitor treatment was suspended. Furthermore,
benazepril was initiated before discharge, and hyperkalemia continued to improve despite
re‐administration of an ACE inhibitor.
Fludrocortisone, a steroid with potent mineralocorticoid activity, was used to promote
potassium excretion and sodium retention.2, 6 This drug has been used previously in
human patients with HIH, resulting in rapid correction of hyperkalemia.2, 6 In our
patient, hyperkalemia improved substantially within 24 hours of fludrocortisone administration.
Hyperkalemia may have resolved spontaneously, however, after cessation of heparin
treatment, based on the clinical course observed in human patients. The time from
cessation of heparin treatment to resolution of hyperkalemia varied from 1 to 30 days
in humans, but was ≤5 days in 9 of 11 patients.5, 6
In patients with HIH, fluid diuresis and loop or thiazide diuretics to manage hyperkalemia
may be considered if cessation of heparin is not an option.13 Hyperkalemia also can
be managed by promoting potassium shifts from ECF to ICF by administration of glucose
alone or glucose with insulin, or with sodium bicarbonate.13 Gastrointestinal absorption
of potassium also can be decreased by administration of oral potassium binders such
as polystyrene sulfonate10.13 In addition, although LMWH also has been associated
with hyperkalemia, it may pose a lower risk and therefore may be preferable in patients
potentially at risk for HIH.4
In conclusion, the laboratory changes in this patient were consistent with HIH, a
condition that has not been described previously in a veterinary patient. HIH does
not appear to be of prognostic relevance, but could be easily misinterpreted as indication
of declining renal function. Clinicians should be aware of this syndrome in veterinary
patients receiving heparin that have unexplained or unexpected hyperkalemia.