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      Acute Kidney Injury and Hyperkalemia With Precarious Electrocardiographic Changes Caused by Concurrent Use of Telmisartan and Diclofenac

      case-report
      Author(s): 1 , 1 , , 1 , 1
      Editor(s): ,
      Publication date (Electronic, pub):
      Publication date (Electronic, collection):
      Journal: Cureus
      Publisher: Cureus
      Keywords: aki, acute kidney injury, telmisartan, diclofenac, drug induced, dialysis, hyperkalemia, ecg

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          Abstract

          A 70-year-old hypertensive man was prescribed telmisartan for control of blood pressure. He concurrently took over-the-counter diclofenac for back pain. Few days later, he presented to the casualty after syncopal episodes. He was found to have acute kidney injury and elevated potassium of 6.6 mmol/L with junctional bradycardia on electrocardiogram (ECG). Medical measures were instituted for hyperkalemia and sinus rhythm was restored, but peaked T waves were still present in the precordial leads. Hemodialysis was done, and antihypertensive therapy was changed on discharge.

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          Pathophysiological aspects of nephropathy caused by non-steroidal anti-inflammatory drugs

          Guillherme Nobre Cavalcanti Lucas, Ana Carla Carneiro Leitão, Renan Lima Alencar … (2018)
          Abstract Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used medications associated with nephrotoxicity, especially when used chronically. Factors such as advanced age and comorbidities, which in themselves already lead to a decrease in glomerular filtration rate, increase the risk of NSAID-related nephrotoxicity. The main mechanism of NSAID action is cyclooxygenase (COX) enzyme inhibition, interfering on arachidonic acid conversion into E2 prostaglandins E2, prostacyclins and thromboxanes. Within the kidneys, prostaglandins act as vasodilators, increasing renal perfusion. This vasodilatation is a counter regulation of mechanisms, such as the renin-angiotensin-aldosterone system works and that of the sympathetic nervous system, culminating with compensation to ensure adequate flow to the organ. NSAIDs inhibit this mechanism and can lead to acute kidney injury (AKI). High doses of NSAIDs have been implicated as causes of AKI, especially in the elderly. The main form of AKI by NSAIDs is hemodynamically mediated. The second form of NSAID-induced AKI is acute interstitial nephritis, which may manifest as nephrotic proteinuria. Long-term NSAID use can lead to chronic kidney disease (CKD). In patients without renal diseases, young and without comorbidities, NSAIDs are not greatly harmful. However, because of its dose-dependent effect, caution should be exercised in chronic use, since it increases the risk of developing nephrotoxicity.
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            Albuterol and insulin for treatment of hyperkalemia in hemodialysis patients.

            Michael Allon, Charles Copkney (1990)
            We evaluated in maintenance hemodialysis patients the potassium lowering effects of intravenous insulin with glucose, nebulized albuterol, and a regimen combining both modalities. There was a similar decrease in plasma potassium following either insulin with glucose (0.65 +/- 0.09 mmol/liter) or albuterol (0.66 +/- 0.12 mmol/liter), and a substantially greater fall with the combined regimen (1.21 +/- 0.19 mmol/liter, P less than 0.02 vs. either drug alone). Baseline plasma glucose concentrations were similar (about 4.8 mmol/liter) prior to all three treatments. Following insulin with glucose, plasma glucose increased transiently. but then fell to 2.8 +/- 0.3 mmol/liter at one hour, with concentrations below 3 mmol/liter in 9 of 12 patients. None of the patients had symptoms of hypoglycemia. Plasma glucose increased to 6.8 +/- 0.5 mmol/liter with albuterol. After the combined drug regimen plasma glucose rose transiently and was back to baseline (4.7 +/- 0.7 mmol/liter) at one hour. Treatment with insulin or albuterol produced trivial increases in heart rate, whereas the combined drug regimen was associated with a significant rise (15.1 +/- 6.0 min-1). These observations suggest that albuterol and insulin with glucose are equally efficacious in lowering plasma potassium in uremic patients, and that the hypokalemic effects of the two drugs is additive. The hypoglycemic effect of insulin is attenuated by coadministration albuterol. Combined therapy with insulin, glucose and albuterol is efficacious and safe for the acute treatment of hyperkalemia in hemodialysis patients.
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              Hyperkalemia, cardiac conduction, and the electrocardiogram: a review.

              Philip Ettinger, Timothy Regan, Henry Oldewurtel (1974)
              Article 0 comments Cited 27 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cureus
                Journal ID (iso-abbrev): Cureus
                Journal ID (issn): 2168-8184
                Title: Cureus
                Publisher: Cureus (Palo Alto (CA) )
                ISSN (Electronic): 2168-8184
                Publication date (Electronic, pub): 18 August 2020
                Publication date (Electronic, collection): August 2020
                Volume: 12
                Issue: 8
                Electronic Location Identifier: e9858
                Affiliations
                [1 ] General Medicine, Government Medical College and Hospital, Chandigarh, IND
                Author notes
                Article
                DOI: 10.7759/cureus.9858
                PMC ID: 7500713
                PubMed ID: 32963900
                SO-VID: 6095623b-b396-4415-8e86-da60b9cce6f7
                Copyright © Copyright © 2020, Gaba et al.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 10 August 2020
                Date accepted : 18 August 2020
                Categories
                Subject: Cardiology
                Subject: Emergency Medicine
                Subject: Internal Medicine

                Keywords: aki,acute kidney injury,telmisartan,diclofenac,drug induced,dialysis,hyperkalemia,ecg
                Data availability:
                Keywords: aki, acute kidney injury, telmisartan, diclofenac, drug induced, dialysis, hyperkalemia, ecg

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