Severe Hyperkalemic Type 4 Renal Tubular Acidosis After Kidney Transplantation: A Case Report

• Published in: Transplantation proceedings Vol. 38; no. 9; pp. 3112 - 3115
• Main Authors: Rangel, E.B., Gomes, S.A., Machado, P.G., Cardoso dos Santos, B.F., Medina Pestana, J.O., Pacheco-Silva, A., Heilberg, I.P.
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01.11.2006; Elsevier Science
• Subjects: Acidosis, Renal Tubular - diagnosis; Acidosis, Renal Tubular - drug therapy; Adolescent; Anti-Inflammatory Agents - therapeutic use; Bicarbonates - administration & dosage; Bicarbonates - therapeutic use; Biological and medical sciences; Cadaver; Dietary Supplements; Electrocardiography; Fludrocortisone - therapeutic use; Fundamental and applied biological sciences. Psychology; Fundamental immunology; Humans; Hyperkalemia - diagnosis; Hyperkalemia - drug therapy; Kidney Transplantation - adverse effects; Male; Medical sciences; Nephrology. Urinary tract diseases; Nephropathies. Renovascular diseases. Renal failure; Postoperative Complications; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the urinary system; Tissue Donors; Tissue, organ and graft immunology; Treatment Outcome; Tubulopathies; Kidney disease; Case study; Medicine; Type; Urinary system disease; Treatment; Surgery; Graft; Severe; Homotransplantation; Genetic disease; Kidney transplantation
• ISSN: 0041-1345; 1873-2623
• DOI: 10.1016/j.transproceed.2006.08.110

Hyperkalemia after transplantation is a common event, occurring in up to 70% of patients. It is usually asymptomatic but sometimes manifests as muscle weakness or cardiac arrhythmias. Case report. At 102 days after a second cadaveric kidney transplantation, a 15-year-old boy, was admitted to the emergency room with severe muscle weakness. His examinations showed a serum potassium of 9.8 mEq/L; blood pH 7.1; serum bicarbonate 7.6 mmol/L; and creatinine 2.5 mg/dL. He was initially treated with sodium bicarbonate, calcium gluconate, and furosemide. Subsequent investigation showed hyperchloremic metabolic acidosis, urinary pH <5.5, positive urinary anion gap, reduced transtubular potassium gradient (TTKG, 1.5) and low levels of aldosterone (0.7 ng/mL), suggesting the presence of type 4 renal tubular acidosis (RTA). Other causes of hyperkalemia were excluded in the present case. Serum levels of potassium returned to normal when fludrocortisone was added to the bicarbonate supplementation. This case of severe hyperkalemic secondary to type 4 RTA after kidney transplantation only responded to the combination of alkali and mineralocorticoid therapies.