Salbutamol to facilitate management of acute hyperkalemia in liver transplantation: a case report

Acute hyperkalemia is a frequent, potentially life-threatening complication in orthotopic liver transplantation (OLT). We describe a case of acute hyperkalemia during the pre-anhepatic stage that remained persistent despite conventional treatment, including calcium salts, insulin and glucose, sodium bicarbonate, and furosemide. A 50-yr-old man with end-stage hepatitis B liver cirrhosis underwent living donor liver transplantation, receiving a right lobe graft donated by his son. The initial serum potassium concentration was 4.6 mEq l(-1). Despite conventional management, the serum potassium concentration increased to 6.6 mEq l(-1), intraoperatively. Since about 90 min elapsed from the division of the hepatic artery and the portal vein to the clamping of the suprahepatic inferior vena cava, the persistent hyperkalemia may have resulted from loss of potassium from ischemic liver cells into the systemic circulation. After incorporating nebulized salbutamol, a selective beta(2)-agonist, into the combined therapeutic regimen (sodium bicarbonate and insulin with glucose), the serum potassium concentrations rapidly normalized. This case suggests that acute and relatively refractory hyperkalemia can develop when surgical interruption of hepatic inflow is prolonged during hepatectomy in patients undergoing OLT using the piggyback technique. In such situations, incorporating nebulized salbutamol with a conventional anti-hyperkalemia strategy can provide an effective therapeutic option to treat hyperkalemia, even during the anhepatic stage.