27 year-old female • Primi gravida. • Delivered by C.S-spinal anasethia> full term baby • 10 hours later, the patient returned to home, she complained from headache. • The obstetrician ordered to give fluids
Day 1 • Severe Headache, malaise, lethargy and dizziness. • The family called the physician . • No bleeding • Fluids, analgesics, assurance
Day 2 • The patient became dyspneic . • The obstetrician asked the family to consult chest physician. The chest physician ordered CBC which revealed leukocytosis and HB 9 g/dl. • Blood pressure : 100/70 mmHg ---- • He called the obstetrician and started broad spectrum antibiotic
Day 3 • The patient became feverish • The obstetrician accompanied the patient to the emergency hospital . • They spent 10 hours in the hospital . • CBC revealed leukocytosis.us revealed small collection 5*5 • The patient returned to her locality Diagnosis :infected collection Treatment: iv antibiotics
Day 4 Her level of consciousness is deteriorating. She was referred to ICU Oliguric …..90/60 mmhg Creatinine 5 mg/dl K 6.5 m.mol/l PH 7.1 HCO3 15…. Nephrology consultation.

Hyperkalemia is a potentially serious medical condition in which elevated serum potassium levels can increase the risk of severe cardiac electrophysiology abnormalities (e.g., cardiac arrhythmias) and sudden death. Modulation of renin-angiotensin-aldosterone system (RAAS) in reducing disease progression and in improving the outcome in heart failure and chronic kidney disease is very well documented and is recommended in respective guidelines. Unfortunately, patients with heart failure and chronic kidney disease are at greater risk of hyperkalemia with RAAS inhibitors than those without these conditions. Prescribing of renin–angiotensin inhibitors and mineralocorticoid antagonists is often limited by occurrence of hyperkalemia and further, underutilization of these potentially beneficial medications in consistent with established guidelines is common due to perceived risk of hyperkalemia. Although, there are effective management strategies in the treatment of acute hyperkalemia, the long-term management of hyperkalemia often requires withdrawing or reducing the doses of drugs proven to improve the outcome in heart failure and chronic kidney disease and/or implementing severe and sometimes intolerable dietary potassium restrictions. Withdrawal of RAAS inhibitors leads to increased morbidity and mortality consequent to rapid disease progression resulting in incremental healthcare cost. On the contrary, hyperkalemia itself is associated with significant adverse clinical outcome and incremental financial burden. The presence of hyperkalemia is a big risk factor for all-cause mortality regardless of the kidney function and results in increased emergency department visits and hospitalizations with economic consequences. There is unmet need of long-term treatment strategies of hyperkalemia. The new potassium binders (patiromer and zirconium cyclosilicate) have extended novel treatment options of chronic hyperkalemia allowing the use of RAAS inhibitors.