What is the clinical significance of hyperkalemia and hypochloremia in a patient with normal renal function on Suboxone (buprenorphine)?

From the Guidelines

The patient's elevated potassium level (5.6 mmol/L) is the most concerning finding and should be addressed promptly by rechecking the potassium level to confirm the elevation and evaluating for potential causes of hyperkalemia, such as medication effects, kidney dysfunction, adrenal disorders, or excessive potassium intake, as suggested by the expert consensus document on the management of hyperkalaemia 1. The patient's lab results show mostly normal values, with a few abnormalities that require attention. The elevated potassium (hyperkalemia) is the primary issue, and the patient should be evaluated for causes of hyperkalemia. Some potential causes of hyperkalemia include:

• Medication effects: The patient should be evaluated for medications that may contribute to hyperkalemia, such as potassium-sparing diuretics, beta-blockers, NSAIDs, or renin-angiotensin-aldosterone inhibitors, as listed in Table 1 of the expert consensus document on the management of hyperkalaemia 1.
• Kidney dysfunction: Although the patient's kidney function appears normal based on creatinine and eGFR, kidney dysfunction can still contribute to hyperkalemia.
• Adrenal disorders: The patient should be evaluated for adrenal disorders, such as adrenal insufficiency, which can contribute to hyperkalemia.
• Excessive potassium intake: The patient should be advised to temporarily limit high-potassium foods and increase hydration to help manage hyperkalemia. The patient's slightly low chloride level (97 mmol/L) is less concerning but should be monitored. Overall, the patient's liver function, glucose, and other electrolytes appear normal, suggesting that the hyperkalemia is the primary issue requiring follow-up. The patient should be advised to temporarily limit high-potassium foods and increase hydration, and if potassium remains elevated on repeat testing, medication adjustments or specific treatments for hyperkalemia, such as loop diuretics or potassium binders, may be necessary, as suggested by the expert consensus document on the management of hyperkalaemia 1. The patient's potassium level should be monitored closely, and the patient should be evaluated for potential causes of hyperkalemia, as suggested by the guidelines for the diagnosis and treatment of chronic heart failure 1. The patient's medication regimen should be reviewed to ensure that it is not contributing to hyperkalemia, and adjustments should be made as necessary, as suggested by the renal function monitoring in heart failure narrative review 1. The patient's kidney function should be monitored closely, and the patient should be evaluated for potential kidney dysfunction, as suggested by the diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome practice guidance 1.

From the Research

Laboratory Results

• The patient's glucose level is 74 mg/dL, which is within the normal range of 65-99 mg/dL 2.
• The patient's urea nitrogen (BUN) level is 17 mg/dL, which is within the normal range of 7-25 mg/dL.
• The patient's creatinine level is 0.72 mg/dL, which is within the normal range of 0.60-1.29 mg/dL.
• The patient's eGFR is 116 mL/min/1.73m2, which is greater than or equal to 60 mL/min/1.73m2, indicating normal kidney function.
• The patient's BUN/creatinine ratio is within the normal range of 6-22 (calc).
• The patient's sodium level is 136 mmol/L, which is within the normal range of 135-146 mmol/L.
• The patient's potassium level is 5.6 mmol/L, which is higher than the normal range of 3.5-5.3 mmol/L, indicating hyperkalemia 3, 4.
• The patient's chloride level is 97 mmol/L, which is lower than the normal range of 98-110 mmol/L.
• The patient's carbon dioxide level is 25 mmol/L, which is within the normal range of 20-32 mmol/L.
• The patient's calcium level is 9.8 mg/dL, which is within the normal range of 8.6-10.3 mg/dL.
• The patient's total protein level is 7.5 g/dL, which is within the normal range of 6.1-8.1 g/dL.
• The patient's albumin level is 4.9 g/dL, which is within the normal range of 3.6-5.1 g/dL.
• The patient's globulin level is 2.6 g/dL, which is within the normal range of 1.9-3.7 g/dL (calc).
• The patient's albumin/globulin ratio is 1.9, which is within the normal range of 1.0-2.5 (calc).
• The patient's total bilirubin level is 0.4 mg/dL, which is within the normal range of 0.2-1.2 mg/dL.
• The patient's alkaline phosphatase level is 76 U/L, which is within the normal range of 36-130 U/L.
• The patient's AST level is 23 U/L, which is within the normal range of 10-40 U/L.
• The patient's ALT level is 19 U/L, which is within the normal range of 9-46 U/L.

Hyperkalemia

• The patient's potassium level is 5.6 mmol/L, which is higher than the normal range, indicating hyperkalemia 3, 4.
• Hyperkalemia can cause cardiac arrhythmias and muscle symptoms 3, 4.
• Management of hyperkalemia consists of intravenous calcium, intravenous insulin, and inhaled beta agonists for urgent cases, and renal elimination drugs or gastrointestinal elimination drugs for less severe cases 3, 4.
• The patient's hyperkalemia may be related to their medication regimen, and a review of their medications is necessary to identify potential causes 3, 4.

Diuretic Use

• Diuretics can cause electrolyte imbalances, including hypokalemia and hyperkalemia 5, 6.
• The patient's diuretic use should be carefully monitored to avoid diuretic resistance and electrolyte imbalances 5, 6.
• Aquaretics and high-saline solutions may be used to manage hyponatremia and hypochloremia in patients with diuretic resistance 5.