#2585 Life-threatening hyperkalemia and metabolic acidosis after positively charged amino acid infusion for renal protection during Peptide receptor radionuclide therapy for metastatic neuroendocrine tumor: a case report and proposed mechanisms
Abstract
Peptide receptor radionuclide therapy (PRRT) is a systemic radiotherapy with targeted radioligands used for the treatment of metastatic neuroendocrine tumors (NETs). Tubular uptake of the radioligands exposes kidney cells to radiation, with a potential risk for nephrotoxicity. Co-administration of positively charged amino acid (AA) solutions is a standard renoprotective regimen for patients at high risk of kidney injury.
Method:
We report a case of a 69-year-old man with a medical history of type 2 diabetes mellitus, hypertension, and CKD3b, admitted for administration of PRRT for metastatic NET. The patient received a renoprotective regimen with positively charged AA lysine and arginine solution at a dose three times higher than the recommended protocol, administered at a rapid infusion rate.
Three hours after therapy completion, the patient developed cardiogenic shock secondary to extreme hyperkalemia (9 mmol/L), severe metabolic acidosis (pH 7.07, HCO3⁻ 9.1 mmHg, lactate 7 mmol/L, with an anion gap of 4), and anuric acute kidney injury (AKI) on CKD. Possible mechanisms for hyperkalemia included movement of potassium from cells into extracellular fluid due to cationic AA (lysine and arginine) entering muscle cells in exchange for potassium, hyperosmolarity of the AA solution causing water to diffuse out of cells (carrying potassium as “solvent drag”), and metabolic acidosis resulting from H⁺ shifts out of cells in exchange for cationic AA, AA metabolism in the liver…
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