Case Report
Severe, refractory hyperkalemia often necessitates treatment with hemodialysis (HD). However,
in Malawi there are a limited number of HD machines and a large patient population that requires its
use thus requiring careful scrutiny when considering which patients are ultimately placed on therapy.
A 38 year old woman with a history of stage 3 CKD and HIV (on ART) presented to the short stay
unit with muscle pain/weakness, shortness of breath, and altered mental status. The patient was
referred from an outside clinic where her potassium was found to be elevated (exact number unknown).
Her creatinine was also found to be elevated above her usual baseline. Her guardian was able to
provide a limited history and informed the medical team that she had not been urinating for the past
couple days. Her condition deteriorated quickly to the point where the patient had generalized, severe
pain, shortness of breath, and was not responding appropriately to the guardian so she was taken to an
outside clinic and ultimately transferred to KCH. When the patient arrived at short stay in KCH she was
in severe distress and was not responding to questions. The patient was put on cardiac monitor that
showed T wave elevations secondary to hyperkalemia. It also showed widespread ST elevation and PR
depression thought to be uremic pericarditis from renal failure. Calcium gluconate was pushed
peripherally for myocardial stabilization. Oxygen therapy was initiated for the shortness of breath and
an insulin/dextrose drip was started to address the hyperkalemia. A foley catheter was placed to assess
urinary retention vs renal failure. Once the foley was placed, there was a minimal amount of urine
collected. The patient was not responding to therapies addressing her hyperkalemia as shown by the
cardiac monitor. A cardiac ultrasound was done given her EKG findings which showed a mild pericardial
effusion. At this point, the medical team discussed whether to put the patient on HD which was the
only solution given her refractory hyperkalemia, renal failure, and probable uremic pericardial
tamponade. However, given the limited resources for HD, criteria have been put in place to help
determine which patients will ultimately receive this therapy. The criteria include starting HD before the
age 60, social support system in place, good long term prognosis with HD, and exclude patients with
heart failure. This patient had a mild pericardial effusion and there was a discussion on whether this
excluded her from receiving HD because of the heart failure criterion. However, the final decision was
that her heart failure was likely reversible as it was attributed to her renal failure and thus qualified her
for receiving therapy. The patient had a temporary femoral hemodialysis catheter placed and she was
taken for emergent HD. After HD, the patient stabilized and was in the ICU before being discharged
after one week.
This case illustrates how health care in Malawi must be seen at both the macro and micro level
which is not usually the case in resource heavy countries like the US. Health care must be distributed in
a way that maximizes care for the population rather than just the individual because the lack of
resources prevents the ability for each individual to have the option of receiving full care. In the US,
patients are usually the deciding factor between the medical care they receive after all of the options
have been given to them. Many Malawians in need of care simply do not have this choice because
resources must be shared. More criteria are being implemented that helps health care workers decide
which patients will benefit most from care rather than somewhat arbitrarily choosing. In this case, the
patient was very close to death but in the end she was one of the lucky Malawians who were
determined to fit criteria for care.