Thread by @kidney_boy

It started with some snark,

https://twitter.com/kidney_boy/status/1187109447199612929?s=20

Now the rest of the story

Here are the initial labs

AKI, hyperkalemia, acidosis, hypernnatremia. This is a mess...

What are you thinking?

I hope you are thinking "All of the above." These are life threatening labs and though medical management can be remarkable effective (see pbfluids.com/2019/10/medica…) this could go sideways fast.

But you should make sure the potassium is really bad before you start calling the nephrology fellow and vascular resident.

Repeat labs:

Oh shit.

Here are the labs if you don't speak skeleton key

EKG is normal.
Hmmm.

Check the CBC.
The smear shows smudge cells.
The patient has leukemia, CLL specifically.

CLL is famous for causing pseudohyperkalemia. The lymphocytes are incredibly fragile and when the blood clots in the gold top tube (red top for us Gen Xers), the lymphocytes rupture and release the intracellular potassium.

The cells are so fragile that transporting the sample by vacume tube breaks the lymphocytes. When transported by medical student they stay intact and the pseudohyperkalemia goes away. ncbi.nlm.nih.gov/pubmed/20040925

The key to the diagnosis is checking the potassium on the blood gas machine. The samples for blood gases are heparinized so they don't clot. No clot, no pseudohyperkalemia.

You need to rule out pseudohyperkalemia if the WBC is over 100,000 or the platelets are over 1,000,000.

Don't start dialysis on a zero K bath like happened here: ajkd.org/article/S0272-…

You might suck all of the potassium out of your patient and get fired like Izzy did on Grey's Anatomy

What other disease should be on your mind with AKI, lymphoma, and hyperkalemia?

Lots of good choices there, but I would worry about tumor lysis syndrome. Patient's uric acid was 18. So TLS is a reasonable diagnosis to consider, however the K on the ABG was 3.4, locking in the diagnosis of pseudohyperkalemia.