Question of the Week # 316

316)  A 72-year-old man was admitted to the hospital with right leg deep vein thrombosis. He has a history of prostate cancer, well-controlled diabetes and mild renal insufficiency. His baseline creatinine is usually between 1.4 to 1.6mg%. His laboratory investigations at admission were normal except for increased creatinine at 1.4mg% . Venous doppler showed leg femoral deep vein thrombosis in femoral vein. He was started on Heparin drip and oral warfarin.  Three days after admission, the patient develops persistent hyperkalemia (6.5 to 7.0 mEq/l). Rest of his electrolytes are normal and renal function is at his baseline. His INR ( International Normalized Ratio) is 1.4. There are no EKG abnormalities. His Urine Osmolality is 300mOsm/kg, Urine K 20 mmol/L and Serum Osmolality 280 mOsm/kg.  He is given insulin and dextrose therapy however, hyperkalemia persists. Which of the following is the most appropriate next step in management?

A) Start Kayexalate

B) Discontinue Heparin and Start Enoxaparin

C) Discontinue Heparin and place Green field filter

D) Hemodilaysis

E) Intravenous Sodium bicarbonate

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