Pharmacologic Treatment of Chronic Hyperkalemia in Patients with Chronic Kidney Disease

Kim, Gheun-Ho

doi:10.5049/ebp.2019.17.1.1

Cited by 24 publications

(26 citation statements)

References 23 publications

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“…Large cohort studies have demonstrated an elevated risk of adverse events in HD patients with serum K levels >5.5 or >6.0 mEq/L [ 19–22 ]. These studies utilized a variety of methodological strategies, including capturing short-term risk within 96 h of K measurement [ 19 ], assessing long-term risk following a single K measurement over multiple years [ 20 ] and investigating 3-month time-averaged serum K [ 21 , 22 ]. Serial K measurements may be more informative than a single K measure by being more sensitive to day-to-day fluctuations in serum K [ 23 , 24 ] and may be aligned with the concept that K excursions may lead to events such as arrhythmias and sudden cardiac death.…”

Section: Introductionmentioning

confidence: 99%

Hyperkalemia excursions are associated with an increased risk of mortality and hospitalizations in hemodialysis patients

Karaboyas

Robinson

James

et al. 2020

Clinical Kidney Journal

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Background Hyperkalemia is common among hemodialysis (HD) patients and has been associated with adverse clinical outcomes. Previous studies considered a single serum potassium (K) measurement or time-averaged values, but serum K excursions out of the target range may be more reflective of true hyperkalemia events. We assessed whether hyperkalemia excursions lead to an elevated risk of adverse clinical outcomes. Methods Using data from 21 countries in Phases 4–6 (2009–18) of the Dialysis Outcomes and Practice Patterns Study (DOPPS), we investigated the associations between peak serum K level, measured monthly predialysis, over a 4-month period (‘peak K’) and clinical outcomes over the subsequent 4 months using Cox regression, adjusted for potential confounders. Results The analysis included 62 070 patients contributing a median of 3 (interquartile range 2–6) 4-month periods. The prevalence of hyperkalemia based on peak K was 58% for >5.0, 30% for >5.5 and 12% for >6.0 mEq/L. The all-cause mortality hazard ratio for peak K (reference ≤5.0 mEq/L) was 1.15 [95% confidence interval (CI) 1.09, 1.21] for 5.1–5.5 mEq/L, 1.19 (1.12, 1.26) for 5.6–6.0 mEq/L and 1.33 (1.23, 1.43) for >6.0 mEq/L. Results were qualitatively consistent when analyzing hospitalizations and a cardiovascular composite outcome. Conclusions Among HD patients, we identified a lower K threshold (peak K 5.1–5.5 mEq/L) than previously reported for increased risk of hospitalization and mortality, with the implication that a greater proportion (>50%) of the HD population may be at risk. A reassessment of hyperkalemia severity ranges is needed, as well as an exploration of new strategies for effective management of chronic hyperkalemia.

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Section: Introductionmentioning

confidence: 99%

Hyperkalemia excursions are associated with an increased risk of mortality and hospitalizations in hemodialysis patients

Karaboyas

Robinson

James

et al. 2020

Clinical Kidney Journal

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“…However, it is not clear if it had played a major role in her presentation with hyperkalemia. CKD is associated with hyperkalemia as kidneys play a more role in potassium clearance [8]. In this particular case, the role of CKD in the patient's acute presentation is unclear as the progression of underlying CKD was not massive, and the patient was not in a state of end-stage renal disease (ESRD) given the good UOP and her estimated glomerular filtration rate (eGFR) was 15 ml/min/1.73m2.…”

Section: Discussionmentioning

confidence: 93%

Severe Persistent Hyperkalemia with Electrocardiogram Changes in a Patient with Hyperaldosteronism

Elmoheen

Mishreky

Albeiruti

et al. 2020

Cureus

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A 62-year-old female presented to the emergency department (ED) with fatigue and generalized body weakness for the last three days. Upon arrival, initial ECG showed wide complex tachycardia with sine waves and a heart rate (HR) ranging between 100-170 bpm. She was otherwise vitally stable. The patient had a past medical history of hyperaldosteronism, type 2 diabetes mellitus (DM), chronic kidney disease (CKD) with microalbuminuria, and hypertension. She also had a history of cerebrovascular accident (CVA) and residual left-sided weakness more pronounced in the upper limb. Initial venous blood gas (VBG) analysis showed a potassium level of more than 10 mmol/L, chloride 114 mmol/L, bicarbonate 9 mmol/L, sodium 135 mmol/L, and pH of 7.1. Treatment for hyperkalemia was started immediately with calcium gluconate 1 gm that effectively narrowed her QRS complex and normalized her ECG. Salbutamol nebulization, glucose/insulin infusion, and calcium polystyrene syrup were given. Later, she was started on 100 mg sodium bicarbonate infusion, and Foley's catheter was inserted to follow urine output (UOP) strictly. However, she did not show a decrease in serum potassium levels. Then the patient underwent hemodialysis for two hours. Her first potassium reading after hemodialysis was 5.2 mmol/L. The purpose of this case report is to emphasize the importance of hemodialysis in patients with persistent severe life-threatening hyperkalemia.

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“…Until now, the long-term pharmacological management of hyperkalaemia in patients with CKD has depended upon low potassium diets, sodium polystyrene sulfonate (SPS), which is a resin that exchanges potassium for sodium within the gastrointestinal tract [9], and the optimisation of metabolic acidosis in patients with more advanced CKD [10]. Using SPS continues to be controversial from its safety and e cacy pro le and remains poorly adhered to from its gastrointestinal side effects [11]. Poor compliance to low potassium diets is likewise a challenge [12].…”

Section: Hyperkalaemia Can Be a Potentially Life-threatening Complicamentioning

confidence: 99%

Analysing the impact of a guideline for the use of new potassium binders for treatment of chronic hyperkalaemia to maximise inhibition of renin–angiotensin–aldosterone system (RAAS) within the general nephrology clinic?

Patel

Frankel

2020

Preprint

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Background Renin–angiotensin–aldosterone system (RAAS) inhibitors provide significant cardiorenal benefits with improved long-term outcomes for patients. This is most significant for patients receiving maximal RAAS inhibition, but some patients are unable to tolerate this therapy because of hyperkalaemia. Recently published National Institute for Health and Care Excellence (NICE) technology appraisal guidance recommended using sodium zirconium cyclosilicate (SZC) and patiromer for patients with chronic kidney disease (CKD) stage 3b to 5 or heart failure with reduced ejection fraction, who are not taking an optimised dosage of RAAS inhibitor because of hyperkalaemia. Objective Determine the impact of a locally produced guideline on effective implementation of NICE recommendation for use of SZC or patiromer to help maximise inhibition of the renin–angiotensin–aldosterone system within the general nephrology clinic. Methods A local guideline to practically support the implementation of recommendations made by NICE in the chronic use of new potassium binders was produced. One hundred sequential patients in a general nephrology clinic with non-immune chronic kidney disease (CKD 3 to 5) had their electronic records reviewed. Those with an indication for RAAS inhibition were identified. Results Of the 100 consecutive patients audited, 46 were female and 54 were male. The mean age of these patients was 64 and the mean estimated glomerular filtration rate (eGFR) was 33. Sixty-eight patients had an indication for being on RAAS inhibition with only 10 on maximal doses. Of the remaining 58 patients, 26 (45%) were limited by hyperkalaemia. Of these 26 patients, 12 of these patients (46%) had hyperkalaemia associated with an episode of acute kidney injury (AKI). Therefore, 14% of patients attending a general nephrology clinic were identified suitable for SZC and patiromer. Conclusions A significant proportion (14%) of unselected patients attending a general nephrology clinic were not on optimum RAAS inhibition due to hyperkalaemia. These patients would meet the criteria established within a working guideline for the implementation of the chronic use of SZC or patiromer and are likely to attain prognostic long-term benefit by using these new potassium binders to maximise RAAS inhibition. This analysis has implications for renal centres across the UK.

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Pharmacologic Treatment of Chronic Hyperkalemia in Patients with Chronic Kidney Disease

Cited by 24 publications

References 23 publications

Hyperkalemia excursions are associated with an increased risk of mortality and hospitalizations in hemodialysis patients

Hyperkalemia excursions are associated with an increased risk of mortality and hospitalizations in hemodialysis patients

Severe Persistent Hyperkalemia with Electrocardiogram Changes in a Patient with Hyperaldosteronism

Analysing the impact of a guideline for the use of new potassium binders for treatment of chronic hyperkalaemia to maximise inhibition of renin–angiotensin–aldosterone system (RAAS) within the general nephrology clinic?

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