Current Management of Hyperkalemia in Patients on Dialysis

Abstract

Patients with end-stage renal disease (ESRD) on maintenance dialysis have a high risk of developing hyperkalemia, generally defined as serum potassium (K þ) concentrations of >5.0 mmol/l, particularly those undergoing maintenance hemodialysis. Currently, the key approaches to the management of hyperkalemia in patients with ESRD are dialysis, dietary K þ restriction, and avoidance of medications that increase hyperkalemia risk. In this review, we highlight the issues and challenges associated with effective management of hyperkalemia in patients undergoing maintenance dialysis using an illustrative case presentation. In addition, we examine the potential nondialysis options for the management of these patients, including use of the newer K þ binder agents patiromer and sodium zirconium cyclosilicate, which may reduce the need for the highly restrictive dialysis diet, with its own implication on nutritional status in patients with ESRD, as well as reducing the risk of potentially life-threatening hyperkalemia.

Brazilian dialysis survey 2019

“…Hyperkalemia in dialysis patients can reach figures of up to 37% of patients, increasing the potential risk of sudden death in the interdialytic period. 24 In a metaanalysis that evaluated observational studies, having hyperkalemia increased the risk of cardiac mortality by 1.4 times. 25 About 11% of the patients had 25-OH vitamin D <20 ng/mL, indicating that the vast majority of patients have an adequate serum level of this vitamin.…”

Consensus-Based Recommendations for the Management of Hyperkalemia in the Hemodialysis Setting

“…The safety of low-K 1 dialysate (,2.0 mmol/L) has been a focus of concern as the rapid lowering of K 1 during dialysis may potentially provoke cardiac arrhythmias and cardiac mortality. 6,39,40 A prospective multicenter study found that patients with a high predialysis serum K 1 concentration ($5 mmol/L) prescribed a dialysate K 1 concentration of 1 mmol/L were at higher risk of mortality than patients prescribed 2 mmol/L or 3 mmol/L dialysate. 41 In a large-scale global study, no clinically meaningful difference in mortality or arrhythmias was detected among patients on 3.0 mmol/L or 2.0 mmol/L dialysate at any level of predialysis serum K 1 .…”

“…Hyperkalemia is associated with increased risk of arrhythmias and cardiac arrest and is prevalent in patients undergoing hemodialysis. 6 However, there is limited evidence on how best to manage these risks. Even at the initial stages of hyperkalemia management, there are no clear guidelines on what level of K 1 constitutes a concern, specifically in patients receiving maintenance hemodialysis, and what frequency of monitoring would most meaningfully capture fluctuations in patient serum K 1 .…”

“…5,6 Each month, nearly two-third of patients undergoing hemodialysis experience an episode of hyperkalemia (K 1 .5.5 mmol/L) after the long interdialytic interval. 6,7 Currently, key approaches to managing hyperkalemia in patients with end-stage kidney disease (ESKD) include changing the dialysis prescription (time, blood flow rate, dialysate flow rate, dialyzer, dialysate K 1 concentration), dietary counseling on K 1 intake, additional dialysis sessions, and, particularly for patients with residual kidney function, adjustment of medications that increase serum K 1 such as nonsteroidal anti-inflammatories, b blockers, and renin-angiotensin-aldosterone system (RAAS) inhibitors. 6,8 However, RAAS inhibitors reduce cardiovascular risk, are efficacious in managing resistant hypertension, and in patients receiving maintenance dialysis, may preserve residual renal function.…”

“…6,7 Currently, key approaches to managing hyperkalemia in patients with end-stage kidney disease (ESKD) include changing the dialysis prescription (time, blood flow rate, dialysate flow rate, dialyzer, dialysate K 1 concentration), dietary counseling on K 1 intake, additional dialysis sessions, and, particularly for patients with residual kidney function, adjustment of medications that increase serum K 1 such as nonsteroidal anti-inflammatories, b blockers, and renin-angiotensin-aldosterone system (RAAS) inhibitors. 6,8 However, RAAS inhibitors reduce cardiovascular risk, are efficacious in managing resistant hypertension, and in patients receiving maintenance dialysis, may preserve residual renal function. 9,10 Given the interplay among these many factors influencing serum K 1 concentrations, nephrologists are faced with a difficult decision when considering whether to manage hyperkalemia by reducing or discontinuing their patients' RAAS inhibitor dose.…”