Severe Hyperkalemia without Electrocardiographic Changes

A 73-year-old man was admitted to the emergency service with generalized pain, bad health, nausea and vertigo; with a week history of mild chest pain. His medical history included chronic renal failure (from 8 years ago) and hypertension (from 20 years ago) and type 2 diabetes mellitus. Usual medications at the time of admission cluded: aspirin, triamterene, amlodipine and atorvastatin. The patient’s history of smokingwas 45 pack/ year. His physical examination was notable for mild weakness and decreased sensitivity in the calf. Vital signs showed a blood pressure of 190/140 mmHg and arterial blood gas (ABG) analysis revealed PH 7.25 that indicates acidosis. The admission ECG revealed heart rate 80 /min ,ST elevation in inferior leads (ɪ ,ɪɪ ,avF) and ST depression in avL.(Fig.1) .The patient hospitalized in CCU unit with diagnosis of acute coronary syndrome (ACS) and got treatment with anti-anginas and anti-platelets. His renal and urinary tract’s sonography showed normal kidney dimensions and no sign of hydronephrosis was shown. The serum potassium was 9 mEq/L and other investigations revealed hemoglobin mg/dl, sodium 135 mEq/L, calcium 9.1 mg/dl, keratinize 2.3 mg/dl, urea 84 mg/dl, and troponin 467 ng/ml. Considering pseudohyperkalemia; the serum potassium was rechecked. Repeated serum potassium confirmed the same level. Therefore he immediately treated with calcium gluconate, k. oxalate and sorbitol with the diagnosis of hyperkalemia and high potassium diet was limited for him. His serum potassium level gradually returned to normal level.Finally, with hospital treatments, the patient was discharged from hospital with creatinine 1.5 mg/dl and stable potassium level of 3.5 mmol/L. The important point in this case is normal ECG in the presence ofsevere hyperkalemia. (No defused tall and tent T wave was seen.