Background. Chronic kidney disease (CKD) affects more than 20 million people in the USA, who have 30 times greater risk of cardiovascular mortality compared to the general population. Sudden cardiac death (SCD) is a leading cause of death in patients with ESRD, accounting for 20% to 30% of all deaths [1]. Hyperkalemia is the main cause of fatal arrhythmias in this group of patients. We present a case of multiple cardiac arrests related to acute hyperkalemia secondary to consumption of potassium rich diet in the patient with ESRD.
Case Presentation. A 64-year-old male with past medical history of diabetes mellitus, ESRD on hemodialysis (HD), coronary artery disease, and hypertension presented to ED after two syncopal episodes that lasted for a few seconds. As per the patient's family, the patient was in his usual state of health, was compliant with his medications and HD, however, was non-compliant with a low potassium diet. The patient started a religious fasting and was abstaining from any food or liquids for several days. However, he has been consuming one box of dates containing 26 dates every evening. When presenting to ED, the patient was found to be hypertensive and bradycardic with HR of 17 beats/min. He lost consciousness twice, was pulseless, thus, CPR was initiated. In 2 minutes, the patient regained his pulse without any medications. His BGCAP showed hyperkalemia of 6.7 mmol/l. EKG demonstrated junctional rhythm with bradycardia of 10 BMP and subsequent 5-second pause. The patient had the third episode of loss of pulse, and regained consciousness after 4 minutes of CPR. Patient was given atropine, calcium gluconate, and epinephrine with improvement of heart rate to the 50s beats/min. The patient was taken to HD emergently which improved his hyperkalemia and symptoms. Patient had an ICD placed on the same admission to prevent SCD in the future.
Discussion. Besides traditional risk factors (LVH, dyslipidemia, DM, CAD), there are additional factors for SCD in ESRD patients. They include: uremic state, dialysis-induced oxidative stress and myocardial stunning, diffuse myocardial fibrosis and vascular calcification, anemia, fluid overload, fluid and electrolyte shifts, sympathetic overactivity and mineral bone disease. These factors contribute to arrhythmias and sudden cardiac death. Hyperkalemia with potassium levels of more than 6.7 mmol/l are strongly associated with mortality and can be avoided, when patients are educated and compliant with HD, low potassium diet and regular follow-up visits.

Multiple cardiac arrests due to consumption of potassium rich fruit in the patient with end-stage renal disease

Background. Carotid artery dissection is a major cause of stroke in patients younger than 40 years old, accounting for up to 25% of ischemic cerebral events that lead to a long-term disability and a large economic burden. The clinical picture of this condition varies widely, thus, the disease may be easily misdiagnosed. We present a case of spontaneous left carotid artery dissection in a previously healthy 29-year-old female. Our aim is to stress on the presentation and a diagnostic approach of this condition, as prompt diagnosis and, thus, early treatment decrease the rate of a stroke and its consequences in this age population.
Case Presentation. A 29-year-old female presented to our clinic with the presumptive diagnosis of first manifestation of migraine, complaining of moderate unilateral headache, involving the left half of the head and neck, including periorbital region, exacerbated by physical activity. However, the clinical presentation of migraine was atypical, including the absence of aura, persistent character of pain, inadequate response to therapy. A decision to perform carotid artery ultrasound was made, revealing a hypoechoic thrombus, completely occluding the lumen of the left internal carotid artery, arising from posterior aspect of the left common carotid artery bifurcation. On color doppler, blood flow in the internal carotid artery was not visualized. MRA of the brain revealed dissection of the left carotid artery with the false lumen that has been completely clotted. A true lumen, 2 mm in diameter, also contained thrombus. The patient started anticoagulant therapy that lasted for 8 weeks. Our patient had a favorable outcome: symptoms were resolved and the blood flow was restored due to complete recanalization of the thrombus.
Discussion. In young adults, carotid artery dissection may occur spontaneously, thus, may be missed or misdiagnosed as other more common conditions, such as migraine, cluster or tension headache. Carotid artery dissection may cause serious complications (TIA, stroke, or one-sided blindness), so it should be included into the differential diagnosis of headache. Early diagnosis is imperative to initiate appropriate therapy that improves patients’ prognosis. More studies are needed to improve diagnostic approach and outcomes in this group of patients.


Spontaneous carotid artery dissection presenting with migraine-like headache in a young female: a case report.

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Multiple cardiac arrests due to consumption of potassium rich fruit in the patient with end-stage renal disease

Spontaneous carotid artery dissection presenting with migraine-like headache in a young female: a case report.

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