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Hypovolaemic acute kidney injury with ECG-toxic hyperkalaemia — MSRA MCQ

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HardNephrologyHypovolaemic acute kidney injury with ECG-toxic hyperkalaemiaMSRA

A 74-year-old man with type 2 diabetes, heart failure and CKD G3b attends an urgent GP appointment. He has had 3 days of profuse diarrhoea and vomiting and is now passing very little urine. His regular medicines include ramipril, furosemide and dapagliflozin. He is alert but clinically dehydrated; BP is 92/56 mmHg and pulse 104 bpm. Blood tests taken this morning show creatinine 286 micromol/L (baseline 138 micromol/L), potassium 6.7 mmol/L and bicarbonate 17 mmol/L. A same-day ECG shows tall tented T waves. What is the most appropriate immediate management plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Arrange immediate hospital transfer for monitored emergency treatment of hyperkalaemia and acute kidney injury, while withholding ramipril and dapagliflozin

Explanation lettering: E = shown as A · D = shown as B · A = shown as D · B = shown as E

This man has hypovolaemic acute kidney injury, indicated by a greater than twofold rise in creatinine from baseline, in the setting of gastrointestinal fluid loss and drugs that can exacerbate AKI. His CKD, heart failure, ACE inhibitor use and diuretic exposure further increase risk. However, the priority is not simply medication sick-day management: potassium is 6.7 mmol/L and there are ECG changes consistent with cardiac toxicity. This is life-threatening acute hyperkalaemia requiring immediate monitored hospital treatment, including cardiac membrane stabilisation and potassium-lowering therapy as indicated. Ramipril should be withheld during vomiting, diarrhoea or sepsis until clinical recovery and stabilisation. Dapagliflozin should also be temporarily interrupted during volume depletion. A is inadequate because next-day reassessment delays emergency treatment. C is inappropriate because pseudo-hyperkalaemia should be considered, but confirmation must not delay treatment when potassium is severely raised with characteristic ECG changes. D may have a role in selected persistent hyperkalaemia but is not appropriate as sole community management of ECG-toxic hyperkalaemia. E wrongly continues dapagliflozin despite severe dehydration and fails to provide emergency escalation.

Reference: NICE NG148: Acute kidney injury: prevention, detection and management — Recommendations (Updated October 2024) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations NICE TA623: Patiromer for treating hyperkalaemia — Committee discussion, section 3.2 (2020) — https://www.nice.org.uk/guidance/ta623/chapter/3-Committee-discussion Empagliflozin 10 mg film-coated tablets — Summary of Product Characteristics (May 2026) — https://www.medicines.org.uk/emc/product/5441/smpc