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Artefactual Serum Hyperkalaemia and Hypercalcaemia in Essential Thrombocythaemia J Clin Pathol: First Published As 10.1136/Jcp.53.2.105 on 1 February 2000

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Artefactual Serum Hyperkalaemia and Hypercalcaemia in Essential Thrombocythaemia J Clin Pathol: First Published As 10.1136/Jcp.53.2.105 on 1 February 2000 J Clin Pathol 2000;53:105–109 105 Artefactual serum hyperkalaemia and hypercalcaemia in essential thrombocythaemia J Clin Pathol: first published as 10.1136/jcp.53.2.105 on 1 February 2000. Downloaded from M R Howard, S Ashwell, L R Bond, I Holbrook Abstract the release of potassium ions from platelets Aim—To investigate possible abnormali- which are entrapped within the clot in a serum ties of serum potassium and calcium sample. This phenomenon generally occurs levels in patients with essential thrombo- with platelet counts in excess of 600 × 109/litre, cythaemia and significant thrombocyto- with a roughly predictable increment in serum sis. potassium for every further increase in platelet Methods—24 cases of essential thrombo- count. The potassium level is normalised if the cythaemia with significant thrombocyto- estimation is made using plasma rather than sis (platelet count > 700 × 109/litre) had serum.45 serum potassium and calcium estimations Abnormalities of other ions have not been performed at the time of maximum well described in essential thrombocythaemia. thrombocytosis before treatment, and at Despite the presence of calcium in platelet- the time of low platelet count after dense granules and its secretion from platelets treatment with cytoreductive drugs. Se- during activation, there has been no systematic lected patients were further investigated study of serum calcium levels in patients with with plasma sampling and estimation of essential thrombocythaemia and significantly ionised calcium and parathyroid hor- increased platelet counts. There has been a mone. single case report of serum hypercalcaemia Results—At the time of maximum throm- associated with essential thrombocythaemia. In bocytosis six patients had serum hyperka- this case the hypercalcaemia rapidly resolved laemia (> 5.5 mmol/litre) and five had following reduction of the platelet count.6 We serum hypercalcaemia (> 2.6 mmol/litre). have investigated a group of patients with Following treatment and reduction of the essential thrombocythaemia and significant platelet count, hyperkalaemia resolved in thrombocytosis to further characterise the all cases and hypercalcaemia in four of the nature of pseudohyperkalaemia and also to five cases. Mean serum potassium and establish whether there are similar alterations calcium concentrations were raised in serum calcium levels. (p < 0.0001) at maximum thrombocytosis compared with the values when the plate- let count was low. Serum potassium and Methods http://jcp.bmj.com/ calcium values were significantly corre- PATIENTS lated at all stages. Measurements on Thirty three patients with essential thrombo- plasma consistently corrected the hyper- cythaemia were identified from clinical records kalaemia but not the hypercalcaemia. and 24 were eligible for the study. To be eligi- Serum hypercalcaemia was associated ble, patients had to have a presentation platelet with raised ionised calcium and normal count in excess of 700 × 109/litre and measure- parathyroid hormone concentrations. ments of serum calcium and serum potassium on October 2, 2021 by guest. Protected copyright. Conclusions—Essential thrombocythae- made at the time of maximum platelet count mia with significant thrombocytosis is before treatment and at the time of a low plate- associated with serum hyperkalaemia and let count after appropriate treatment of throm- hypercalcaemia. The probable mech- bocytosis. Where relevant biochemical tests anism of hypercalcaemia is the secretion were available at more than one normal platelet of calcium in vitro from an excessive count after treatment, the lowest platelet count number of abnormally activated platelets. was used. Department of It is thus likely that the hypercalcaemia is The mean age of the patients was 66 years Haematology, York an artefact, as is the hyperkalaemia. (range 17–84 years). The male:female ratio was District Hospital, (J Clin Pathol 2000;53:105–109) 11:13. The mean pretreatment platelet count Wigginton Road, York × 9 YO31 8HE, UK was 1144 10 /litre (range 736–2291). The Keywords: thrombocythaemia; hypercalcaemia; patients were treated with either oral hydroxy- MRHoward hyperkalaemia S Ashwell urea (n = 20) or busulphan, anagrelide, or L R Bond interferon alfa (n = 4). Essential thrombocythaemia is a chronic my- Following cytoreductive treatment the Department of eloproliferative disorder characterised by a platelet count fell to a mean level of 288 × 109/ Biochemistry, York 1 District Hospital persistently raised platelet count. It has litre (range 61–526). Two patients with poor I Holbrook previously been reported that the marked compliance with treatment and fluctuating thrombocytosis that is often associated with levels of severe thrombocytosis (cases 1 and 2) Correspondence to: essential thrombocythaemia may lead to associated with serum hyperkalaemia and Dr Howard. spurious laboratory abnormalities including hypercalcaemia had serial monitoring of 2 3 Accepted for publication pseudohyperkalaemia and pseudohypoxaemia. serum potassium and serum calcium during 8 July 1999 Serum hyperkalaemia appears to result from their clinical course, and also the following 106 Howard, Ashwell, Bond, et al 8 Serum and plasma potassium estimation Potassium was measured on a Hitachi 917 J Clin Pathol: first published as 10.1136/jcp.53.2.105 on 1 February 2000. Downloaded from analyser (Roche Diagnostics, Lewes, E Sussex, 6.5 UK) using an indirect ion selective electrode method. The reference range was 3.5–5.5 6 mmol/litre. ULk Serum and plasma calcium estimation 5.5 Calcium was measured on a Hitachi 917 analyser using an o-cresolphthalein complex- 5 one method. The reference range was 2.10– 2.60 mmol/litre. 4.5 Serum phosphate estimation Serum potassium (mmol/l) Phosphate was measured on a Hitachi 917 4 analyser using an ammonium molybdate method, the reaction being monitored at an ULp LLp ultraviolet wavelength. The reference range 3.5 was 0.8–1.4 mmol/litre. 1400 1200 1000 800 600 400 200 0 1500 1300 1100 900 700 500 300 100 × 9 Ionised calcium estimation Platelet count ( 10 /l) Serum ionised calcium was measured on a Figure 1 Platelet count and serum potassium Ciba Corning 634 Ca2+/pH analyser (Beckman concentrations in 24 patients with essential Instruments, High Wycombe, Buckingham- thrombocythaemia. Serum potassium values are shown at the highest (C) and low (x) platelet counts. Broken lines shire, UK) using a calcium ion selective and indicate the upper limit (UL) and lower limit (LL) of pH electrodes. The reference range was normal reference ranges for potassium (k) and platelet 1.18–1.38 mmol/lire. count (p). Parathyroid hormone (PTH) estimation investigations: plasma sampling in addition to Intact PTH was analysed on a Nichols Advan- serum sampling for potassium and calcium tage analyser (Nichols Institute Diagnostics, concentrations, and measurement of serum Newport, Gwent, UK) using a chemilumines- phosphate, ionised calcium, and parathyroid cent immunoassay method. The reference hormone. range was 10–60 ng/litre. LABORATORY METHODS STATISTICAL METHODS Blood count Possible diVerences in the mean serum calcium All blood counts were performed using a and serum potassium levels at the time of Sysmex automated cell counter. The normal maximum thrombocytosis and low platelet http://jcp.bmj.com/ platelet reference range was defined as 150– count were analysed using the paired t test. 400 × 109/litre. Blood films were routinely Possible correlations between serum calcium inspected to confirm the degree of thrombocy- and serum potassium levels were detected tosis. using the Pearson correlation coeYcient test. Case 1 Case 2 7 7 on October 2, 2021 by guest. Protected copyright. 6 6 5 5 4 4 (mmol/l) 3 3 Serum potassium 3.0 3.0 2.8 2.8 2.6 2.6 2.4 2.4 (mmol/l) 2.2 2.2 2000 2000 /l) Serum calcium 9 1000 1000 10 700 700 × 500 500 300 300 200 200 100 100 Platelets ( 321 45 910876 14 15131211 19 20181716 21 321 45 9876 Time (months) Time (months) Figure 2 Platelet count, serum potassium concentration, and serum calcium concentration in two patients with poorly controlled essential thrombocythaemia (cases 1 and 2). Broken lines indicate the upper limits of the normal range. Hyperkalaemia and hypercalcaemia in thrombocythaemia 107 3 patients developed clinical symptoms of hyper- 2.9 calcaemia. The mean serum calcium was J Clin Pathol: first published as 10.1136/jcp.53.2.105 on 1 February 2000. Downloaded from significantly raised at the time of maximum 2.8 thrombocytosis compared with the value when 2.7 the platelet count was low (2.52 2.33 mmol/ UL v 2.6 c litre; p < 0.0001). 2.5 2.4 Plasma calcium In two patients with coexisting serum hyperka- 2.3 laemia and hypercalcaemia (cases 1 and 2), the 2.2 LL degree of hypercalcaemia was not significantly 2.1 c altered by the collection and analysis of a 2 plasma sample in case 1, but there appeared to Serum calcium (mmol/l) 1.9 be a small correction in the plasma sample in case 2 (case 1: serum calcium 2.79 mmol/litre, 1.8 plasma calcium 2.72 mmol/litre; case 2: serum 1.7 calcium 2.64 mmol/litre, plasma calcium 2.51 1.6 ULp LLp mmol/litre). 1.5 1400 1200 1000 800 600 400 200 0 1500 1300 1100 900 700 500 300 100 Correlation of serum calcium with the platelet count in two patients with poorly controlled 9 Platelet count (×10 /l) thrombocythaemia Figure 3 Platelet count and serum calcium concentration In these patients (cases 1 and 2) there was a in 24 patients with essential thrombocythaemia. Serum close correlation between the degree of serum calcium is shown at the time of highest (C) and low (x) hypercalcaemia and the degree of thrombocy- platelet counts. Broken lines indicate the upper limit (UL) and lower limit (LL) of normal reference ranges for calcium tosis (fig 2). (c) and platelet count (p). CORRELATION BETWEEN SERUM CALCIUM AND Results SERUM POTASSIUM SERUM AND PLASMA POTASSIUM ESTIMATIONS There was a significant correlation between Serum potassium serum potassium and serum calcium, both at Serum hyperkalaemia (> 5.5 mmol/litre) was the time of maximum thrombocytosis observed in six patients at the time of (p = 0.02) and at the time of low platelet count maximum thrombocytosis and in no patients at (p = 0.02) (fig 4).
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