Unspecified loop diuretics/zirconium silicate

Lack of efficacy: case report

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    An event is serious (based on the ICH definition) when the patient outcome is:

    • * death

    • * life-threatening

    • * hospitalisation

    • * disability

    • * congenital anomaly

    • * other medically important event

    “ ”

    A 44-year-old man developed lack of efficacy during treatment with zirconium silicate and unspecified loop diuretics for hyperkalaemia and azotaemia.

    The man presented to hospital with dyspnoea (oxygen saturation of 91% and RR of 24 breaths per minute), multifocal opacities on chest radiograph and a nasopharyngeal swab positive for severe respiratory syndrome coronavirus-2 (SARS‐CoV‐2). Seven years prior to the presentation, he had received a deceased donor kidney transplant. He had been receiving maintenance immunosuppressive therapy comprising tacrolimus, prednisone and mycophenolate sodium. On admission, his immunosuppressive therapy was maintained (tacrolimus target was lowered to 4 ng/mL) and he did not receive hydroxychloroquine due to prolonged QTc interval. He was not on renin–angiotensin system inhibitors. On admission, his serum creatinine, D‐Dimer, lactate dehydrogenase and ferritin levels were found to be elevated. However, arterial lactate remained within normal limits during the hospital course. His troponin level was 0.3 ng/mL on admission, and subsequently decreased. On day 2 of admission, he developed acute kidney injury. On day 10, he was intubated for respiratory failure and methylprednisolone was administered from day 11 through day 15, and then tapered to twice daily. He did not require vasopressor support. While intubated, tube feeds were administered. Additionally, the levels of serum creatinine, potassium and blood urea nitrogen were found to be elevated on day 11 necessitating haemodialysis. Between day 14 and day 17, he required daily haemodialysis for refractory hyperkalaemia and azotaemia, despite treatment with zirconium silicate [sodium zirconium cyclosilicate] 10g three times daily [route not stated] and loop diuretics [specific drug not stated].

    After four sessions of haemodialysis, the phosphorus level remained elevated. His urine output decreased from 4.1 L/24h on day 14 to 240 mL/24h on day 17. The intensity of dialysis was increased. On day 31, he remained both dialysis‐ and ventilator‐dependent. The persistent elevation in serum potassium, blood urea nitrogen and phosphorus levels with COVID‐19 infection was suggestive of a catabolic state in this patient.


    1. Billah M, et al. A catabolic state in a kidney transplant recipient with COVID-19. Transplant International 33: 1140-1141, No. 9, Sep 2020. Available from: URL: http://doi.org/10.1111/tri.13635

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    Unspecified loop diuretics/zirconium silicate. Reactions Weekly 1841, 230 (2021). https://doi.org/10.1007/s40278-021-90732-8

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