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Kim M, Lee HY, Kim H. Impaired aldosterone response to potassium and hyperkalemia in patients receiving a renin-angiotensin-aldosterone system inhibitor. Korean J Intern Med 2025; 40:468-481. [PMID: 40360223 PMCID: PMC12081116 DOI: 10.3904/kjim.2024.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 10/30/2024] [Accepted: 11/04/2024] [Indexed: 05/15/2025] Open
Abstract
BACKGROUND/AIMS Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are associated with the development of hyperkalemia. We evaluated the relationship between the serum aldosterone-to-potassium ratio (APR) and the risk of developing hyperkalemia in patients with chronic kidney disease (CKD) receiving ACEIs or ARBs. METHODS One hundred eighty-six patients with stage 3-4 CKD receiving an ACEI or ARB for at least 3 months were evaluated. Serum aldosterone and potassium concentrations were measured simultaneously, and serum APR was calculated (ng/mL per mmol/L). Patients were divided into two groups for comparison according to the median value above or below 2.42. The primary outcome was the difference between the two groups in the development of hyperkalemia (defined as a serum potassium level > 5.5 mmol/L). Incidence rates and risk factors of hyperkalemia were assessed. RESULTS During the follow-up period, 144 hyperkalemic events in 81 patients (43.5%) were identified, yielding an incidence rate of 24.6 events/100 person-years. The incidence rate was significantly higher in patients with a low serum APR than in patients with a high APR (35.8 events/100 patient-years vs. 12.9 events/100 patient-years, p < 0.001). In addition, diabetes mellitus, history of hyperkalemia, CKD progression during the follow-up period, and low serum APR were predictors of the development of hyperkalemia. CONCLUSION Low serum APR was associated with the occurrence of hyperkalemia in patients with CKD receiving ACEIs or ARBs, suggesting that the identification of patients administered these drugs who are at high risk for hyperkalemia may be achieved using this index.
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Affiliation(s)
- Miyeon Kim
- Division of Nephrology, Department of Internal Medicine, Jeju National University Hospital, Jeju National University, School of Medicine, Jeju, Korea
| | - Hwa Young Lee
- Division of Nephrology, Department of Internal Medicine, Jeju National University Hospital, Jeju National University, School of Medicine, Jeju, Korea
| | - Hyunwoo Kim
- Division of Nephrology, Department of Internal Medicine, Jeju National University Hospital, Jeju National University, School of Medicine, Jeju, Korea
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Petras D, Marinaki S, Panagoutsos S, Stefanidis I, Stylianou K, Ntounousi E, Lionaki S, Tzanakis I, Griveas I, Xidakis D, Theodoropoulou E, Gourlis D, Andreadellis A, Goumenos D, Liakopoulos V. Spirit Interim Analysis: A Multicenter Prospective Observational Study of Outpatients with CKD and Decreased eGFR to Assess Therapeutic Algorithms, Disease Management and Quality of Life in Greece. J Clin Med 2025; 14:2079. [PMID: 40142886 PMCID: PMC11943387 DOI: 10.3390/jcm14062079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2025] [Revised: 03/11/2025] [Accepted: 03/14/2025] [Indexed: 03/28/2025] Open
Abstract
Background: Chronic Kidney Disease (CKD) affects 8-16% of the population worldwide and is characterized by an estimated Glomerular Filtration Rate (eGFR) of less than 60 mL/min/1.73 m2 for more than 3 months. The main purpose of the study is to record the treatment algorithms and disease management of patients presenting for the first time to hospital-based nephrologists with a reduced eGFR and CKD diagnosis, under real-world clinical practice in Greece. Methods: This is the 6-month interim analysis of an ongoing, multicenter, observational, prospective, national study, which included 178 patients, with an eGFR between <60 and 15 mL/min/1.73 m2, presenting for the first time to nephrologists at 15 public hospital units. Results: The median age of the patients was 71 years old, with 39.6% of them categorized as CKD stage G3b. Of these patients, 71.6% and 33.7% suffered from arterial hypertension and type 2 diabetes mellitus, respectively; 78.7% of patients received antihypertensive and 38.5% antidiabetic medications. Calcium channel blocker usage increased with disease progression (from 52.2% at G3a, to 67.9% and 67.6% at G3b and G4, respectively), while that of angiotensin II receptor antagonists decreased (from 78.3% at G3a, to 41.5% and 17.6% at G3b and G4, respectively). A decrease in metformin usage and an increase in Dipeptidyl peptidase-4 inhibitor (DPP4i) usage was also observed upon disease progression. Furthermore, 18.5%, 32.0% and 7.7% of patients received Sodium-glucose cotransporter-2 inhibitors (SGLT2i) at the G3a, G3b and G4 stages, respectively. Conclusions: The interim analysis results contributed to the collection of real-world data for the therapeutic patterns and the management of CKD in Greece.
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Affiliation(s)
- Dimitrios Petras
- Nephrology Department, Hippokration General Hospital, 11527 Athens, Greece
| | - Smaragdi Marinaki
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University School of Medicine, 11527 Athens, Greece;
| | - Stylianos Panagoutsos
- Department of Nephrology, University Hospital of Alexandroupolis, 68100 Alexandroupoli, Greece;
| | - Ioannis Stefanidis
- Department of Nephrology, University Hospital of Larissa, 41334 Larissa, Greece;
| | - Kostantinos Stylianou
- Department of Nephrology, University Hospital of Heraklion, 71500 Heraklion, Greece;
| | - Evangelia Ntounousi
- Department of Nephrology, School of Medicine, University of Ioannina, 45110 Ioannina, Greece;
| | - Sofia Lionaki
- Department of Nephrology, Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, 12462 Athens, Greece;
| | - Ioannis Tzanakis
- Department of Nephrology, General Hospital of Chania, 73300 Chania, Greece;
| | - Ioannis Griveas
- Nephrology Department, Army Share Fund Hospital of Athens, 417 NIMTS, 11521 Athens, Greece;
| | - Dimitrios Xidakis
- Department of Nephrology, Venizelio General Hospital of Heraklion, 71409 Heraklion, Greece;
| | | | - Dimitris Gourlis
- Medical Affairs Department, AstraZeneca, 15123 Athens, Greece; (D.G.); (A.A.)
| | | | - Dimitrios Goumenos
- Department of Nephrology, University Hospital of Patras, 26504 Patras, Greece;
| | - Vassilios Liakopoulos
- Department of Nephrology, AHEPA Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
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Yang C, Hu X, Ling X, Xiao C, Duan R, Qiu J, Li Q, Qin X, Zeng J, Zhang L, Hou H, Peng Y, Xu Y, Su J, Liu X, Lindholm B, Johnson DW, Lu F, Su G. Hypokalemia in Peritoneal Dialysis: A Systematic Review and Meta-analysis of Prevalence, Treatment, and Outcomes. Kidney Med 2024; 6:100923. [PMID: 39634334 PMCID: PMC11616037 DOI: 10.1016/j.xkme.2024.100923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2024] Open
Abstract
Rationale & Objective Hypokalemia is common and potentially life-threatening in patients undergoing peritoneal dialysis (PD). However, the current literature has produced varying results. This study aimed to evaluate the prevalence and adverse outcomes of hypokalemia and the role of potassium supplementation in patients receiving PD. Study Design Systematic review and meta-analysis of randomized controlled trials and observational studies. Setting & Study Populations Adults receiving maintenance PD. Selection Criteria for Studies Studies that investigated the prevalence and adverse outcomes of hypokalemia and the effect of potassium supplementation. Data Extraction Two independent reviewers evaluated studies for eligibility and extracted relevant data. Analytical Approach Random effects meta-analysis was conducted to pool hazard ratios (HRs) and 95% CIs for the outcomes of interest. The certainty of findings was rated according to the Grading of Recommendations Assessment, Development and Evaluation criteria. Results Of 3,632 reports identified, 24 studies involving 60,313 participants met the inclusion criteria. The prevalence of hypokalemia was 37.9% (95% CI, 27.2%-52.7%), 17.7% (95% CI, 12.0%-25.9%), and 4.4% (95% CI, 1.9%-10.2%) in patients with potassium level <4.0, 3.5, and 3.0 mmol/L, respectively. Hypokalemia, according to the study's definition, was associated with increased risks of all-cause mortality (HR, 1.49; 95% CI, 1.18-1.89), cardiovascular mortality (HR, 1.50; 95% CI, 1.19-1.88), and PD-associated peritonitis (HR, 1.42; 95% CI, 1.17-1.73). These associations were consistent but with low to very low certainty. The effect of correcting hypokalemia with potassium supplementation in patients undergoing PD remains uncertain. Limitations Heterogeneity persisted across most of the examined subgroups, and observational studies preclude causation. Conclusions Hypokalemia is common and portends poorer survival and a higher risk of peritonitis among patients undergoing PD. Further research into the optimal prevention and treatment strategies for hypokalemia is warranted to improve outcomes. Registration Registered at PROSPERO with registration number CRD42022358236.
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Affiliation(s)
- Changyuan Yang
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Xiaoxuan Hu
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xitao Ling
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Cuixia Xiao
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ruolan Duan
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jiamei Qiu
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qin Li
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xindong Qin
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jiahao Zeng
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - La Zhang
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Haijing Hou
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yu Peng
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yuan Xu
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jingxu Su
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xusheng Liu
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Bengt Lindholm
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - David W. Johnson
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Australia
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia
| | - Fuhua Lu
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Guobin Su
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Department of Nephrology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Guo Y, Qiu Y, Xue T, Yan P, Zhao W, Wang M, Liu C, Zhang N. Association between admission baseline blood potassium levels and all-cause mortality in patients with acute kidney injury combined with sepsis: A retrospective cohort study. PLoS One 2024; 19:e0309764. [PMID: 39565797 PMCID: PMC11578480 DOI: 10.1371/journal.pone.0309764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 08/17/2024] [Indexed: 11/22/2024] Open
Abstract
INTRODUCTION Imbalances in blood potassium (K) homeostasis is a significant contributor to the emergence of severe complications, especially among critically ill patients. Hypokalemia and hyperkalemia are both associated with an increased risk of adverse events. However, it is not known about the impact of blood K levels on risk of intensive care units (ICU) mortality for Acute kidney injury (AKI) combined with sepsis patients. This study aimed to explore the relationship between admission blood K levels and ICU 30-day mortality in patients with AKI combined with sepsis. METHODS We selected patients diagnosed with AKI and sepsis on their first ICU admission from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The first blood K levels within 24 hours of admission were categorized into three groups according to tertiles (T1 < 3.9 mmol/L, 3.9 ≤ T2 < 4.5 mmol/L, and T3 ≥ 4.5 mmol/L), with T2 serving as the reference. We examined the association between blood K levels and ICU 30-day mortality using accelerated failure time (AFT) models and survival analysis. RESULTS A total of 8,242 ICU patients with AKI combined with sepsis were included. In multivariate AFT models, each 1 mmol/L increase in blood K levels was associated with a 13% increase in the risk of ICU 30-day mortality (p < 0.001, 95% confidence interval (CI): 1.06-1.20). Extended multivariable AFT models showed that, compared to the middle category, patients with high blood K levels (≥ 4.5 mmol/L) were associated with all-cause mortality (p = 0.002, adjusted hazard ratio (HR) = 1.22, 95% CI: 1.08-1.38), whereas those with low blood K levels (< 3.9 mmol/L) showed no significant difference (p = 0.385, adjusted HR = 1.06, 95% CI: 0.93-1.21). Kaplan-Meier curves indicated that patients with high blood K levels had higher mortality, and those with middle blood potassium levels (3.9 ≤ K < 4.5 mmol/L) had the lowest mortality. CONCLUSION The admission baseline blood K levels were significantly associated with ICU 30-day mortality in intensive care patients suffering from AKI in conjunction with sepsis. Therefore, immediate and careful correction of blood potassium imbalances may prove to be a crucial approach in improving outcomes for these patients.
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Affiliation(s)
- Yifan Guo
- Department of Endocrinology and Nephropathy, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Yue Qiu
- Department of Endocrinology, Miyun Hospital District, The Third Affiliated Hospital of Beijing University of Chinese Medicine, Beijing, China
| | - Taiqi Xue
- Department of Endocrinology and Nephropathy, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Pu Yan
- Department of Endocrinology and Nephropathy, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Wenjing Zhao
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Mengdi Wang
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Cheng Liu
- Department of Human Anatomy, Program for Cancer and Cell Biology, Histology and Embryology, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China
| | - Ning Zhang
- Department of Endocrinology and Nephropathy, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
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Bogacka A, Olszewska M, Ciechanowski K. Effects of Diet and Supplements on Parameters of Oxidative Stress, Inflammation, and Antioxidant Mechanisms in Patients with Chronic Renal Failure Undergoing Hemodialysis. Int J Mol Sci 2024; 25:11036. [PMID: 39456817 PMCID: PMC11507481 DOI: 10.3390/ijms252011036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2024] [Revised: 10/07/2024] [Accepted: 10/12/2024] [Indexed: 10/28/2024] Open
Abstract
The prevalence of chronic kidney disease (CKD) worldwide increases as the population ages. The progression of the disease increases the risk of complications and death and leads to end-stage renal failure, requiring renal replacement therapy. Despite the positive effect of hemodialysis (HD), patients are at risk of developing malnutrition, inflammation, oxidative stress, or cardiovascular disease, which worsens quality of life and can lead to organ dysfunction. The occurrence of the mentioned disorders depends largely on the diet, so changes in diet composition are an important part of the treatment of kidney disease. This study aimed to evaluate the effects of a balanced diet on some parameters of oxidative stress, immune response, and nutritional status in patients. This study included 57 HD patients (19 women and 38 men). In all of them, nutritional status and diet were initially determined, and then, they were divided into six groups, which received different diets and supplements. Serum levels of albumin, total protein, MDA, and the cytokines Il-1, IL-6, IL-8, TNF-α, and IL-10 were determined, and the activity of the enzymes such as CAT, SOD, and GSH-Px were determined in erythrocytes by spectrophotometry. Based on the results of BMI, albumin, and total protein, it can be concluded that a well-balanced diet can reduce weight loss. This study shows that a well-balanced diet can reduce the secretion of pro-inflammatory cytokines, and ensure the normal activity of antioxidative enzymes in the blood of HD patients.
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Affiliation(s)
- Anna Bogacka
- Department of Commodity Science, Quality Assessment, Process Engineering, and Human Nutrition, West Pomeranian University of Technology in Szczecin, 71-459 Szczecin, Poland
| | - Maria Olszewska
- Departament of Medical Chemistry, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland
| | - Kazimierz Ciechanowski
- Clinical Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland;
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Wu P, Li ST, Shu TT, Mao ZH, Fu WJ, Yang YY, Pan SK, Liu DW, Liu ZS, Gao ZX. Impaired distal renal potassium handling in streptozotocin-induced diabetic mice. Am J Physiol Renal Physiol 2024; 327:F158-F170. [PMID: 38779755 DOI: 10.1152/ajprenal.00240.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 05/13/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024] Open
Abstract
Diabetes is closely associated with K+ disturbances during disease progression and treatment. However, it remains unclear whether K+ imbalance occurs in diabetes with normal kidney function. In this study, we examined the effects of dietary K+ intake on systemic K+ balance and renal K+ handling in streptozotocin (STZ)-induced diabetic mice. The control and STZ mice were fed low or high K+ diet for 7 days to investigate the role of dietary K+ intake in renal K+ excretion and K+ homeostasis and to explore the underlying mechanism by evaluating K+ secretion-related transport proteins in distal nephrons. K+-deficient diet caused excessive urinary K+ loss, decreased daily K+ balance, and led to severe hypokalemia in STZ mice compared with control mice. In contrast, STZ mice showed an increased daily K+ balance and elevated plasma K+ level under K+-loading conditions. Dysregulation of the NaCl cotransporter (NCC), epithelial Na+ channel (ENaC), and renal outer medullary K+ channel (ROMK) was observed in diabetic mice fed either low or high K+ diet. Moreover, amiloride treatment reduced urinary K+ excretion and corrected hypokalemia in K+-restricted STZ mice. On the other hand, inhibition of SGLT2 by dapagliflozin promoted urinary K+ excretion and normalized plasma K+ levels in K+-supplemented STZ mice, at least partly by increasing ENaC activity. We conclude that STZ mice exhibited abnormal K+ balance and impaired renal K+ handling under either low or high K+ diet, which could be primarily attributed to the dysfunction of ENaC-dependent renal K+ excretion pathway, despite the possible role of NCC.NEW & NOTEWORTHY Neither low dietary K+ intake nor high dietary K+ intake effectively modulates renal K+ excretion and K+ homeostasis in STZ mice, which is closely related to the abnormality of ENaC expression and activity. SGLT2 inhibitor increases urinary K+ excretion and reduces plasma K+ level in STZ mice under high dietary K+ intake, an effect that may be partly due to the upregulation of ENaC activity.
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Affiliation(s)
- Peng Wu
- Traditional Chinese Medicine Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
- Institute of Nephrology, Zhengzhou University, Zhengzhou, People's Republic of China
- Henan Province Research Center for Kidney Disease, Zhengzhou, People's Republic of China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, People's Republic of China
| | - Shu-Ting Li
- Traditional Chinese Medicine Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
- Institute of Nephrology, Zhengzhou University, Zhengzhou, People's Republic of China
- Henan Province Research Center for Kidney Disease, Zhengzhou, People's Republic of China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, People's Republic of China
| | - Ting-Ting Shu
- Traditional Chinese Medicine Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
- Institute of Nephrology, Zhengzhou University, Zhengzhou, People's Republic of China
- Henan Province Research Center for Kidney Disease, Zhengzhou, People's Republic of China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, People's Republic of China
| | - Zi-Hui Mao
- Traditional Chinese Medicine Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
- Institute of Nephrology, Zhengzhou University, Zhengzhou, People's Republic of China
- Henan Province Research Center for Kidney Disease, Zhengzhou, People's Republic of China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, People's Republic of China
| | - Wen-Jia Fu
- Traditional Chinese Medicine Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
- Institute of Nephrology, Zhengzhou University, Zhengzhou, People's Republic of China
- Henan Province Research Center for Kidney Disease, Zhengzhou, People's Republic of China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, People's Republic of China
| | - Yuan-Yuan Yang
- Traditional Chinese Medicine Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
- Institute of Nephrology, Zhengzhou University, Zhengzhou, People's Republic of China
- Henan Province Research Center for Kidney Disease, Zhengzhou, People's Republic of China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, People's Republic of China
| | - Shao-Kang Pan
- Traditional Chinese Medicine Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
- Institute of Nephrology, Zhengzhou University, Zhengzhou, People's Republic of China
- Henan Province Research Center for Kidney Disease, Zhengzhou, People's Republic of China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, People's Republic of China
| | - Dong-Wei Liu
- Traditional Chinese Medicine Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
- Institute of Nephrology, Zhengzhou University, Zhengzhou, People's Republic of China
- Henan Province Research Center for Kidney Disease, Zhengzhou, People's Republic of China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, People's Republic of China
| | - Zhang-Suo Liu
- Traditional Chinese Medicine Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
- Institute of Nephrology, Zhengzhou University, Zhengzhou, People's Republic of China
- Henan Province Research Center for Kidney Disease, Zhengzhou, People's Republic of China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, People's Republic of China
| | - Zhong-Xiuzi Gao
- Traditional Chinese Medicine Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
- Institute of Nephrology, Zhengzhou University, Zhengzhou, People's Republic of China
- Henan Province Research Center for Kidney Disease, Zhengzhou, People's Republic of China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, People's Republic of China
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Padoan F, Guarnaroli M, Brugnara M, Piacentini G, Pietrobelli A, Pecoraro L. Role of Nutrients in Pediatric Non-Dialysis Chronic Kidney Disease: From Pathogenesis to Correct Supplementation. Biomedicines 2024; 12:911. [PMID: 38672265 PMCID: PMC11048674 DOI: 10.3390/biomedicines12040911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 04/05/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
Nutrition management is fundamental for children with chronic kidney disease (CKD). Fluid balance and low-protein and low-sodium diets are the more stressed fields from a nutritional point of view. At the same time, the role of micronutrients is often underestimated. Starting from the causes that could lead to potential micronutrient deficiencies in these patients, this review considers all micronutrients that could be administered in CKD to improve the prognosis of this disease.
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Affiliation(s)
| | | | - Milena Brugnara
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, 37126 Verona, Italy (A.P.)
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8
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Shibagaki Y, Yamazaki H, Wakita T, Ware JE, Wang J, Onishi Y, Yajima T, Sada KE, Yamamoto Y, Fukuhara S. Impact of treatment of hyperkalaemia on quality of life: design of a prospective observational cohort study of long-term management of hyperkalaemia in patients with chronic kidney disease or chronic heart failure in Japan. BMJ Open 2023; 13:e074090. [PMID: 38101840 PMCID: PMC10728966 DOI: 10.1136/bmjopen-2023-074090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 11/30/2023] [Indexed: 12/17/2023] Open
Abstract
INTRODUCTION Hyperkalaemia (HK) is a frequent complication in patients with chronic kidney disease (CKD) and/or chronic heart failure (CHF). HK must be managed, both to protect patients from its direct clinical adverse outcomes and to enable treatment with disease-modifying therapies including renin-angiotensin-aldosterone system inhibitors. However, the experiences of patients undergoing treatment of HK are not clearly understood. Optimising treatment decisions and improving long-term patient management requires a better understanding of patients' quality of life (QOL). Thus, the aims of this research are: (1) to describe treatment patterns and the impact of treatment on a patient's QOL, (2) to study the relationships between treatment patterns and the impact of treatment on a patient's QOL and (3) to study the relationships between the control of serum potassium (S-K) and the impact of treatment on a patient's QOL, in patients with HK. METHODS AND ANALYSIS This is a prospective cohort study with 6 months of follow-up in 30-40 outpatient nephrology and cardiology clinics in Japan. The participants will be 350 patients with CKD or CHF who received their first potassium binders (PB) prescription to treat HK within the previous 6 months. Medical records will be used to obtain information on S-K, on treatment of HK with PBs and with diet, and on the patients' characteristics. To assess the impact of treatment on a patient's QOL, questionnaires will be used to obtain generic health-related QOL, CKD-specific and CHF-specific QOL, and PB-specific QOL. Multivariable regression models will be used to quantify how treatment patterns and S-K control are related to the impact of treatment on a patient's QOL. ETHICS AND DISSEMINATION Institutional review boards at all participating facilities review the study protocol. Patient consent will be obtained. The results will be published in international journals. TRIAL REGISTRATION NUMBER NCT05297409.
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Affiliation(s)
- Yugo Shibagaki
- Division of Nephrology and Hypertension, St Marianna University School of Medicine, Kawasaki, Japan
| | - Hajime Yamazaki
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - John E Ware
- Tufts University School of Medicine, Boston, Massachusetts, USA
- John Ware Research Group Inc, Watertown, Massachusetts, USA
| | - Jui Wang
- National Taiwan University College of Public Health, Taipei, Taiwan
- Institute for Health Outcomes & Process Evaluation Research, Kyoto, Japan
| | - Yoshihiro Onishi
- Institute for Health Outcomes & Process Evaluation Research, Kyoto, Japan
| | | | - Ken-Ei Sada
- Department of Clinical Epidemiology, Kochi Medical School, Nankoku, Japan
- Patient Driven Academic League (PeDAL), Tokyo, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, Kyoto University, Kyoto, Japan
| | - Shunichi Fukuhara
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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9
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Sun Z, Jiao J, Lu G, Liu R, Li Z, Sun Y, Chen Z. Overview of research progress on the association of dietary potassium intake with serum potassium and survival in hemodialysis patients, does dietary potassium restriction really benefit hemodialysis patients? Front Endocrinol (Lausanne) 2023; 14:1285929. [PMID: 38093955 PMCID: PMC10716210 DOI: 10.3389/fendo.2023.1285929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/13/2023] [Indexed: 12/18/2023] Open
Abstract
For the general population, increasing potassium intake can reduce the incidence of cardiovascular and cerebrovascular diseases. However, since hyperkalemia is a common and life-threatening complication in maintenance hemodialysis patients, which can increase the risk of malignant arrhythmia and sudden death, the current mainstream of management for hemodialysis patients is dietary potassium restriction in order to prevent hyperkalemia. Hemodialysis patients are usually advised to reduce dietary potassium intake and limit potassium-rich fruits and vegetables, but there is limited evidence to support this approach can reduce mortality and improve quality of life. There is still no consistent conclusion on the association between dietary potassium intake and serum potassium and survival in hemodialysis patients. According to the current small observational studies, there was little or even no association between dietary potassium intake and serum potassium in hemodialysis patients when assurance of adequate dialysis and specific dietary patterns (such as the plant-based diet mentioned in the article) are being followed, and excessive dietary potassium restriction may not benefit the survival of hemodialysis patients. Additionally, when assessing the effect of diet on serum potassium, researchers should not only focus on the potassium content of foods, but also consider the type of food and the content of other nutrients. However, more large-scale, multi-center clinical trials are required to provide high-quality evidence support. Besides, further research is also needed to determine the optimal daily potassium intake and beneficial dietary patterns for hemodialysis patients.
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Affiliation(s)
- Zuoya Sun
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Jian Jiao
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong First Medical University, Jinan, Shandong, China
| | - Gang Lu
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Ruihong Liu
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Zhuo Li
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yi Sun
- Department of Nephrology, Beijing Huairou Hospital of University of Chinese Academy of Sciences, Beijing, China
| | - Zhiyuan Chen
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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10
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Ashjian E, Clarke M, Pogue K. Pharmacotherapy considerations with finerenone in the treatment of chronic kidney disease associated with type 2 diabetes. Am J Health Syst Pharm 2023; 80:1708-1721. [PMID: 37632460 PMCID: PMC10664185 DOI: 10.1093/ajhp/zxad192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Indexed: 08/28/2023] Open
Abstract
PURPOSE This review provides an overview of the management of chronic kidney disease (CKD) associated with type 2 diabetes (T2D), how the novel treatment class of nonsteroidal mineralocorticoid receptor antagonists (MRAs) fits within the treatment landscape, and how pharmacists can contribute to the multidisciplinary care of patients with CKD associated with T2D. SUMMARY Optimizing pharmacotherapy for patients with CKD associated with T2D is critical to prevent or slow progression to end-stage kidney disease and reduce the incidence of cardiovascular events. However, many patients with CKD receive suboptimal treatment, in part because of the high complexity of care required, a lack of disease recognition among providers and patients, and a failure to utilize new kidney-protective therapies. Finerenone is the first nonsteroidal, selective MRA to be approved by the US Food and Drug Administration and the European Medicines Agency for the treatment of adult patients with CKD associated with T2D. Clinical trials have demonstrated that finerenone significantly reduces the risk of cardiorenal disease progression vs placebo and has a reduced risk of hyperkalemia compared to traditional steroidal MRAs. Initiation of finerenone should follow evaluation of baseline estimated glomerular filtration rate and serum potassium levels. Consideration of potential drug-drug interactions, follow-up monitoring of potassium levels, and coordination of changes in pharmacotherapy across the patient care team are also important. CONCLUSION Finerenone is a valuable addition to the treatment landscape for CKD associated with T2D. Through their expertise in -medication -management, transitions of care, and patient education, clinical pharmacists are well positioned to ensure patients receive safe and effective -treatment.
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Affiliation(s)
- Emily Ashjian
- Pharmacy Innovations & Partnerships, Michigan Medicine, Ann Arbor, MI
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Megan Clarke
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Kristen Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
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11
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Sumida K, Biruete A, Kistler BM, Khor BH, Ebrahim Z, Giannini R, Sussman-Dabach EJ, Avesani CM, Chan M, Lambert K, Yee-Moon Wang A, Clegg DJ, Burrowes JD, Palmer BF, Carrero JJ, Kovesdy CP. New Insights Into Dietary Approaches to Potassium Management in Chronic Kidney Disease. J Ren Nutr 2023; 33:S6-S12. [PMID: 37610407 PMCID: PMC10872890 DOI: 10.1053/j.jrn.2022.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/07/2022] [Accepted: 12/13/2022] [Indexed: 08/24/2023] Open
Abstract
Potassium disorders are one of the most common electrolyte abnormalities in patients with chronic kidney disease (CKD), contributing to poor clinical outcomes. Maintaining serum potassium levels within the physiologically normal range is critically important in these patients. Dietary potassium restriction has long been considered a core strategy for the management of chronic hyperkalemia in patients with CKD. However, this has been challenged by recent evidence suggesting a paradigm shift toward fostering more liberalized, plant-based dietary patterns. The advent of novel potassium binders and an improved understanding of gastrointestinal processes involved in potassium homeostasis (e.g., gastrointestinal potassium wasting) may facilitate a paradigm shift and incorporation of heart-healthy potassium-enriched food sources. Nevertheless, uncertainty regarding the risk-benefit of plant-based diets in the context of potassium management in CKD remains, requiring well-designed clinical trials to determine the efficacy of dietary potassium manipulation toward improvement of clinical outcomes in patients with CKD.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Annabel Biruete
- Department of Nutrition and Dietetics, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana; Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Department of Nutrition Science, Purdue University, West Lafayette, Indiana
| | - Brandon M Kistler
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana; Department of Nutrition and Health Science, Ball State University, Muncie, Indiana
| | - Ban-Hock Khor
- Faculty of Food Science and Nutrition, University Malaysia Sabah, Kota Kinabalu, Malaysia
| | - Zarina Ebrahim
- Division of Human Nutrition, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - Rossella Giannini
- Division of Metabolic Diseases and Clinical Nutrition, University Hospital of Modena, Modena, Italy
| | - Elizabeth J Sussman-Dabach
- Department of Family and Consumer Sciences, California State University, Northridge, Northridge, California
| | - Carla Maria Avesani
- Division of Renal Medicine, Baxter Novum. Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Maria Chan
- Departments of Nutrition and Dietetics and Renal Medicine, The St. George Hospital, Kogarah, New South Wales, Australia
| | - Kelly Lambert
- Faculty of Science, Medicine and Health, School of Medical, Indigenous and Health Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
| | - Deborah J Clegg
- Department of Internal Medicine, Paul Foster School of Medicine, Texas Tech Medical Center, El Paso, Texas
| | - Jerrilynn D Burrowes
- Department of Health Sciences and Administration, Program in Nutrition and Dietetics, Long Island University-Post, Greenvale, New York
| | - Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
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12
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Ni Z, Lu R, Xu X, Bian X, Zhou Z, Yang J, Luo Q, Chen M, Chen C, Sun X, Yu L, He Q, Jiang H, Yuan W, Li Y, Zhou R, Wang J, Zhang X, Zuo L, Meng X, Chang Z, Zhao J, Wessman P, Xiang P. DIALIZE China: A Phase IIIb, Randomized, Placebo-Controlled Study to Reduce Predialysis Hyperkalemia With Sodium Zirconium Cyclosilicate in Chinese Patients. Clin Ther 2023; 45:633-642. [PMID: 37385905 DOI: 10.1016/j.clinthera.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/18/2023] [Accepted: 04/23/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE The DIALIZE China study (Reduce Incidence of Pre-Dialysis Hyperkalaemia With Sodium Zirconium Cyclosilicate in Chinese Subjects) (NCT04217590) evaluated sodium zirconium cyclosilicate (SZC) for the management of hyperkalemia in Chinese patients undergoing hemodialysis. METHODS In the double-blind, Phase IIIb DIALIZE China study, Chinese adults with kidney failure and predialysis hyperkalemia (predialysis serum potassium [sK+] concentration >5.4 mmol/L after the long interdialytic interval [LIDI] and >5.0 mmol/L after ≥1 short interdialytic interval) who were receiving hemodialysis 3 times weekly were randomized to placebo or SZC 5 g once daily on nondialysis days. Doses were titrated towards maintaining normokalemia for 4 weeks (titration period) in 5-g increments up to 15 g. Primary efficacy was the proportion of responders during the 4-week evaluation period following the titration period (ie, those with a predialysis sK+ of 4.0-5.0 mmol/L for at least 3 of 4 hemodialysis visits following the LIDI) who did not require urgent rescue therapy. FINDINGS Overall, 134 adults (mean [SD] age, 55 [11.3] years) were randomized to SZC or placebo (n = 67 each). There were significantly more responders with SZC (37.3%) versus placebo (10.4%; estimated odds ratio [OR] = 5.10; 95% CI, 1.90-15.12; P < 0.001). The probability of all predialysis sK+ concentrations being 3.5 to 5.5 mmol/L was significantly higher with SZC versus placebo (estimated OR = 6.41; 95% CI, 2.71-15.12; P < 0.001). A greater proportion of patients achieved an sK+ of 3.5 to 5.5 mmol/L on at least 3 of 4 LIDI visits during evaluation with SZC (73.1%) versus placebo (29.9%). Serious adverse events occurred in 9.1% and 11.9% of patients in the SZC and placebo groups, respectively. IMPLICATIONS SZC treatment for predialysis hyperkalemia is effective and well tolerated in Chinese patients with kidney failure receiving hemodialysis. CLINICALTRIALS gov identifier: NCT04217590.
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Affiliation(s)
- Zhaohui Ni
- Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Renhua Lu
- Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xudong Xu
- Central Hospital of Minhang District, Shanghai, China
| | | | - Zhihong Zhou
- The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Junwei Yang
- The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qun Luo
- Ningbo Huamei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Menghua Chen
- General Hospital of Ningxia Medical University, Yinchuan, China
| | - Chaosheng Chen
- The First Affiliated Hospital of Wenzhou College, Wenzhou, China
| | - Xiuli Sun
- Baotou City Central Hospital, Baotou, China
| | - Lei Yu
- Inner Mongolia People's Hospital, Hohhot, China
| | - Qiang He
- Zhejiang Traditional Chinese Medicine Hospital, Hangzhou, China
| | - Hong Jiang
- People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, China
| | | | - Yi Li
- Dongguan People's Hospital, Dongguan, China
| | - Rong Zhou
- Shanghai Yangpu District Central Hospital, Shanghai, China
| | - Jianqin Wang
- Lanzhou University Second Hospital, Lanzhou, China
| | | | - Li Zuo
- Peking University People's Hospital, Beijing, China
| | | | | | - June Zhao
- BioPharmaceuticals Clinical, AstraZeneca R&D, Gaithersburg, Maryland
| | - Peter Wessman
- BioPharmaceuticals Clinical, AstraZeneca R&D, Gothenburg, Sweden
| | - Peng Xiang
- Global R&D (China), AstraZeneca, Shanghai, China
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13
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Hu A, Liu S, Montez-Rath ME, Khairallah P, Niu J, Turakhia MP, Chang TI, Winkelmayer WC. Associations of Serum and Dialysate Potassium Concentrations With Incident Atrial Fibrillation in a Cohort Study of Older US Persons Initiating Hemodialysis for Kidney Failure. Kidney Int Rep 2023; 8:305-316. [PMID: 36815107 PMCID: PMC9939356 DOI: 10.1016/j.ekir.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 09/27/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Atrial fibrillation (AF) disproportionally affects persons on maintenance hemodialysis (HD). Associations of serum and dialysate potassium concentrations [K+] with AF incidence are poorly understood. Methods We conducted a cohort study using Medicare claims merged with clinical data from a dialysis provider to determine whether serum-[K+] and/or dialysate-[K+] independently associated with AF incidence. Persons insured by fee-for-service Medicare aged ≥67 years at dialysis initiation and free from diagnosed AF prior to day 120 of dialysis were eligible. Serum-[K+] and dialysate-[K+] were assessed in 30-day intervals and patients were followed-up with for AF incidence in subsequent 30-day intervals. Results During 2006 to 2011, 15,190 persons (mean age = 76.3 years) initiating HD had no prior AF diagnosis. Mean serum-[K+] was 4.5 mEq/l; dialysate-[K+] was 3 mEq/l in 34% and 2 mEq/l in 52% of patients. Followed-up over 21,907 person-years, 2869 persons had incident AF (incidence/100 person-years, 13.1 [95% confidence interval [CI], 12.6-13.6]). The multivariable-adjusted association of serum-[K+] with incident AF was J-shaped as follows: relative to a serum-[K+] of 4.5 mEq/l, lower serum-[K+] associated with increased AF risk, whereas confidence bands for higher serum-[K+] indicated no association. Dialysis against a dialysate-[K+] of 3 mEq/l versus 2 mEq/l independently associated with a 14% (95% CI, 5%-24%) lower incidence of AF. No effect modification between serum-[K+] and dialysate-[K+] was detected (P = 0.34). Conclusion Lower serum-[K+] was independently associated with incident AF whereas elevated serum-[K+] was not. The findings support adoption of dialysate solutions with a dialysate-[K+] of 3 mEq/l, regardless of patients' serum-[K+], and elimination of lower dialysate-[K+] solutions from practice. Clinical trials randomizing patients to different dialysate-[K+] are warranted to establish causality.
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Affiliation(s)
- Austin Hu
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sai Liu
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Maria E. Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Pascale Khairallah
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jingbo Niu
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Mintu P. Turakhia
- Cardiovascular Division, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Tara I. Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Wolfgang C. Winkelmayer
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Muhlestein JB, Kammerer J, Bair TL, Knowlton KU, Le VT, Anderson JL, Lappé DL, May HT. Real-world clinical burden and economic assessment associated with hyperkalaemia in a large integrated healthcare system: a retrospective analysis. BMC PRIMARY CARE 2022; 23:65. [PMID: 35365076 PMCID: PMC8974122 DOI: 10.1186/s12875-022-01667-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 03/15/2022] [Indexed: 11/30/2022]
Abstract
Background Hyperkalaemia (HK) is a serious and potentially life-threatening condition. Both acute and chronic conditions may alter potassium homeostasis. Our aim is to describe HK incidence, clinical outcomes, and associated resource use within a large, integrated healthcare system. Methods Adult patients seen at Intermountain Healthcare facilities with a serum potassium (sK) result between January 1, 2003 and December 31, 2018 were retrospectively studied. Descriptive assessment of a population with detected HK, defined by any sK > 5.0 mmol/L and HK frequency and severity to associated resource use and characteristics of HK predictors were made. Multivariable Cox hazard regression was used to evaluate HK to outcomes. Results Of 1,208,815 patients included, 13% had HK. Compared to no-HK, HK patients were older (60 ± 18 vs 43 ± 18 years, P < 0.001), male (51% vs 41%, P < 0.001), and had greater disease burden (Charlson Comorbidity Index 3.5 ± 2.8 vs 1.7 ± 1.4, P < 0.001). At 3 years, more HK patients experienced major adverse cardiovascular events (MACEs) (19 vs 3%, P < 0.001), persisting post-adjustment (multivariable hazard ratio = 1.60, P < 0.001). They incurred higher costs for emergency department services ($552 ± 7,574 vs $207 ± 1,930, P < 0.001) and inpatient stays ($10,956 ± 93,026 vs $1,477 ± 21,423, P < 0.001). HyperK Risk Scores for the derivation and validation cohorts were: 44% low-risk, 45% moderate-risk, 11% high-risk. Strongest HK predictors were renal failure, dialysis, aldosterone blockers, diabetes, and smoking. Conclusion Within this large system, HK was associated with a large clinical burden, affecting over 1 in 10 patients; HK was also associated with increased 3-year MACE risk and higher medical costs. Although risk worsened with more severe or persistently recurring HK, even mild or intermittent HK episodes were associated with significantly greater adverse clinical outcomes and medical costs. The HyperK Score predicted patients who may benefit from closer management to reduce HK risk and associated costs. It should be remembered that our assumptions are valid only for detected HK and not HK per se.
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Fukuhara S, Yamazaki H, Wakita T, Ware Jr. JE, Wang J, Onishi Y, Yajima T, Sada K, Yamamoto Y, Shibagaki Y. Validation of a new instrument for measuring disease-specific quality of life: A pilot study among patients with chronic kidney disease and hyperkalemia. ANNALS OF CLINICAL EPIDEMIOLOGY 2022; 5:13-19. [PMID: 38505376 PMCID: PMC10760472 DOI: 10.37737/ace.23003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 09/04/2022] [Indexed: 03/21/2024]
Abstract
BACKGROUND To prepare for a longitudinal study of the effects of potassium-lowering treatment on quality of life (QOL), we quantified the validity of a new disease-specific instrument for measuring QOL, using data from patients who had hyperkalemia (HK) due to chronic kidney disease (CKD) or chronic heart failure, and were also being treated with potassium binders (PBs). METHODS In this cross-sectional study, the participants were 98 patients at five outpatient clinics in Japan. The outcome measures were the Medical Outcomes Study 36-item short-form (SF-36), a widely used generic measure of QOL, and the Quality of Life Disease-specific Impact Scale (QDIS-7), a recently-developed disease-specific measure of QOL. Internal-consistency reliability was quantified, and factor analysis was done to confirm hypothesized QOL dimensions. Validation tests used two external criteria: CKD stage, and PB formulation. PB formulation was used because different formulations are associated with different degrees of patients' burden. Using a previously-described method, we computed the relative validity (RV) of the two measures. RESULTS Two factor scoring of the SF-36 and one factor scoring of the QDIS-7, as standardized from previous studies, were confirmed. The RVs showed that the QDIS-7 was much more valid than the SF-36, for discriminating between groups defined clinically (by CKD stage), and also between groups defined by PB formulation. Reliability was satisfactory: 0.73-0.95 for the SF-36 and 0.86 for the QDIS-7. CONCLUSIONS The QDIS-7 with CKD or PB attributions was more valid than the SF-36 for measuring the effects of CKD and of PB formulation on QOL.
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Affiliation(s)
- Shunichi Fukuhara
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management
| | - Hajime Yamazaki
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University
| | | | | | - Jui Wang
- College of Public Health, National Taiwan University
- Institute for Health Outcomes & Process Evaluation Research (iHope International)
| | - Yoshihiro Onishi
- Institute for Health Outcomes & Process Evaluation Research (iHope International)
| | | | - Kenei Sada
- Department of Clinical Epidemiology, Kochi Medical School
- Patient Driven Academic League (PeDAL)
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, School of Public Health, Graduate School of Medicine, Kyoto University
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, St. Marianna University of Medicine
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First 24-Hour Potassium Concentration and Variability and Association with Mortality in Patients Requiring Continuous Renal Replacement Therapy in Intensive Care Units: A Hospital-Based Retrospective Cohort Study. J Clin Med 2022; 11:jcm11123383. [PMID: 35743452 PMCID: PMC9224685 DOI: 10.3390/jcm11123383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/06/2022] [Accepted: 06/11/2022] [Indexed: 02/04/2023] Open
Abstract
Serum potassium (K+) levels between 3.5 and 5.0 mmol/L are considered safe for patients. The optimal serum K+ level for critically ill patients with acute kidney injury undergoing continuous renal replacement therapy (CRRT) remains unclear. This retrospective study investigated the association between ICU mortality and K+ levels and their variability. Patients aged >20 years with a minimum of two serum K+ levels recorded during CRRT who were admitted to the ICU in a tertiary hospital in central Taiwan between January 01, 2010, and April 30, 2021 were eligible for inclusion. Patients were categorized into different groups based on their mean K+ levels: <3.0, 3.0 to <3.5, 3.5 to <4.0, 4.0 to <4.5, 4.5 to <5.0, and ≥5.0 mmol/L; K+ variability was divided by the quartiles of the average real variation. We analyzed the association between the particular groups and in-hospital mortality by using Cox proportional hazard models. We studied 1991 CRRT patients with 9891 serum K+ values recorded within 24 h after the initiation of CRRT. A J-shaped association was observed between serum K+ levels and mortality, and the lowest mortality was observed in the patients with mean K+ levels between 3.0 and 4.0 mmol/L. The risk of in-hospital death was significantly increased in those with the highest variability (HR and 95% CI = 1.61 [1.13−2.29] for 72 h mortality; 1.39 [1.06−1.82] for 28-day mortality; 1.43 [1.11−1.83] for 90-day mortality, and 1.31 [1.03−1.65] for in-hospital mortality, respectively). Patients receiving CRRT may benefit from a lower serum K+ level and its tighter control. During CRRT, progressively increased mortality was noted in the patients with increasing K+ variability. Thus, the careful and timely correction of dyskalemia among these patients is crucial.
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The association between serum glucose to potassium ratio on admission and short-term mortality in ischemic stroke patients. Sci Rep 2022; 12:8233. [PMID: 35581319 PMCID: PMC9114007 DOI: 10.1038/s41598-022-12393-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 05/09/2022] [Indexed: 11/19/2022] Open
Abstract
High serum glucose to potassium ratio (GPR) at admission is implicated for a poor outcome in acute brain injury, acute intracranial hemorrhage, and aneurysmal subarachnoid hemorrhage. However, the relationship between GPR and the outcome of ischemic stroke (IS) remains unknown. In all, 784 IS patients from a large emergency Norwegian cohort were included for secondary analysis. The exposure and outcome were GPR at baseline and all-cause mortality within 30 days after the first admission. Multivariable logistic regression analysis was performed to estimate the risk of 30-day mortality based on GPR levels. In addition, we examined whether there was a nonlinear relationship between admission GPR and 30-day mortality using two-piecewise linear regression with a smoothing function and threshold level analysis. The results of multivariable regression analysis showed that GPR at baseline was positively associated with the 30-day mortality (OR 2.01, 95% CI 1.12, 3.61) after adjusting for potential confounders (age, gender, department, serum sodium, serum albumin, serum-magnesium, hypertension, heart failure, chronic renal failure, and pneumonia). When GPR was translated to a categorical variable, the ORs and 95% CIs in the tertiles 2 to 3 versus the tertile 1 were 1.24 (0.60, 2.56) and 2.15 (1.09, 4.24), respectively (P for trend = 0.0188). Moreover, the results of the two-piecewise linear regression and curve fitting revealed a linear relationship between GPR and 30-day mortality. In IS patients, GPR is positively correlated with 30-day mortality, and the relationship between them is linear. The GPR at admission may be a promising predictor for the short-term outcome in IS patients.
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Garagarza C, Valente A, Caetano C, Ramos I, Sebastião J, Pinto M, Oliveira T, Ferreira A, Guerreiro CS. Potassium Intake-(Un)Expected Non-Predictor of Higher Serum Potassium Levels in Hemodialysis DASH Diet Consumers. Nutrients 2022; 14:nu14102071. [PMID: 35631212 PMCID: PMC9146185 DOI: 10.3390/nu14102071] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/05/2022] [Accepted: 05/11/2022] [Indexed: 02/01/2023] Open
Abstract
As high serum potassium levels can lead to adverse outcomes in hemodialysis (HD) patients, dietary potassium is frequently restricted in these patients. However, recent studies have questioned whether dietary potassium really affects serum potassium levels. The dietary approaches to stop hypertension (DASH) diet is considered a healthy dietary pattern that has been related to lower risk of developing end-stage kidney disease. The aim of this study was to analyze the association between a dietary pattern with high content of potassium-rich foods and serum potassium levels in HD patients. This was an observational, cross-sectional, multicenter study with 582 HD patients from 37 dialysis centers. Clinical and biochemical data were registered. Dietary intake was obtained using the Food Frequency Questionnaire. Adherence to the DASH dietary pattern was obtained from Fung’s DASH index. All statistical tests were performed using SPSS 26.0 software. A p-value lower than 0.05 was considered statistically significant. Patients’ mean age was 67.8 ± 17.7 years and median HD vintage was 65 (43−104) months. Mean serum potassium was 5.3 ± 0.67 mEq/L, dietary potassium intake was 2465 ± 1005 mg/day and mean Fung´s Dash Index was 23.9 ± 3.9. Compared to the lower adherence to the DASH dietary pattern, patients with a higher adherence to the DASH dietary pattern were older (p < 0.001); presented lower serum potassium (p = 0.021), serum sodium (p = 0.028), total fat intake (p = 0.001) and sodium intake (p < 0.001); and had higher carbohydrate intake (p < 0.001), fiber intake (p < 0.001), potassium intake (p < 0.001), phosphorus intake (p < 0.001) and body mass index (p = 0.002). A higher adherence to this dietary pattern was a predictor of lower serum potassium levels (p = 0.004), even in the adjusted model (p = 0.016). Following the DASH dietary pattern, which is rich in potassium, is not associated with increased serum potassium levels in HD patients. Furthermore, a higher adherence to the DASH dietary pattern predicts lower serum potassium levels. Therefore, generalized dietary potassium restrictions may not be adequate, at least for those with a DASH diet plan.
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Affiliation(s)
- Cristina Garagarza
- Nutrition Department, Nephrocare, 1250-191 Lisbon, Portugal; (A.V.); (C.C.); (I.R.); (J.S.); (M.P.); (T.O.)
- Nutrition Laboratory, Faculty of Medicine, Lisbon University, 1649-004 Lisbon, Portugal;
- Correspondence:
| | - Ana Valente
- Nutrition Department, Nephrocare, 1250-191 Lisbon, Portugal; (A.V.); (C.C.); (I.R.); (J.S.); (M.P.); (T.O.)
| | - Cristina Caetano
- Nutrition Department, Nephrocare, 1250-191 Lisbon, Portugal; (A.V.); (C.C.); (I.R.); (J.S.); (M.P.); (T.O.)
| | - Inês Ramos
- Nutrition Department, Nephrocare, 1250-191 Lisbon, Portugal; (A.V.); (C.C.); (I.R.); (J.S.); (M.P.); (T.O.)
| | - Joana Sebastião
- Nutrition Department, Nephrocare, 1250-191 Lisbon, Portugal; (A.V.); (C.C.); (I.R.); (J.S.); (M.P.); (T.O.)
| | - Mariana Pinto
- Nutrition Department, Nephrocare, 1250-191 Lisbon, Portugal; (A.V.); (C.C.); (I.R.); (J.S.); (M.P.); (T.O.)
| | - Telma Oliveira
- Nutrition Department, Nephrocare, 1250-191 Lisbon, Portugal; (A.V.); (C.C.); (I.R.); (J.S.); (M.P.); (T.O.)
| | - Aníbal Ferreira
- Nephrology Department, Dialysis Unit Vila Franca de Xira, 2600-076 Vila Franca de Xira, Portugal;
- Faculty of Medical Sciences, Nova Medical School, 1169-056 Lisbon, Portugal
| | - Catarina Sousa Guerreiro
- Nutrition Laboratory, Faculty of Medicine, Lisbon University, 1649-004 Lisbon, Portugal;
- Institute of Environmental Health, Faculty of Medicine, Lisbon University, 1649-004 Lisbon, Portugal
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Serum Aldosterone and Urine Electrolytes Dynamics in Response to DASH Diet Intervention – an Inpatient Mechanistic Study. J Clin Transl Sci 2022; 6:e84. [PMID: 35949658 PMCID: PMC9305085 DOI: 10.1017/cts.2022.394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/17/2022] [Accepted: 04/18/2022] [Indexed: 11/07/2022] Open
Abstract
Background: Methods: Results: Conclusion:
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OUP accepted manuscript. Nutr Rev 2022; 80:2198-2205. [DOI: 10.1093/nutrit/nuac026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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21
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Dashputre AA, Gatwood J, Sumida K, Thomas F, Akbilgic O, Potukuchi PK, Obi Y, Molnar MZ, Streja E, Kalantar-Zadeh K, Kovesdy CP. Association of dyskalemias with short-term health care utilization in patients with advanced CKD. J Manag Care Spec Pharm 2021; 27:1403-1415. [PMID: 34595956 PMCID: PMC10119640 DOI: 10.18553/jmcp.2021.27.10.1403] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Patients with advanced chronic kidney disease (CKD) are at high risk for dyskalemias, which may induce arrhythmias that require immediate emergent or hospital care. The association of dyskalemias with short-term hospital/emergency room (ER) visits in advanced CKD is understudied. OBJECTIVE: To assess the association of dyskalemias with short-term hospital/ER visits in an advanced CKD population. METHODS: From among 102,477 US veterans transitioning to dialysis from 2007 to 2015, we identified 21,366 patients with 2 predialysis outpatient eGFR < 30 ml/min/1.73m2 90-365 days apart (with the second eGFR serving as the index date) and at least 1 potassium (K) in the baseline period (1 year before index) and 1 outpatient K (oK) in the follow-up (1 year after the index but before dialysis initiation). We examined the association of time-varying hypokalemia (K < 3.5 mEq/L) and hyperkalemia (K > 5.5 mEq/L) vs referent (3.5-5.5 mEq/L) with separate hospital and ER visits within 2 calendar days following each oK value over the 1-year follow-up period from the index. We used generalized estimating equations with binary distribution and logit link to model the exposure-outcome relationship adjusted for various confounders. We conducted various subgroup and sensitivity analyses to test the robustness of our results. RESULTS: Over the 1-year follow-up, 125,266 oK measurements were observed, of which 6.8% and 3.7% were classified as hyper- and hypokalemia, respectively. In the multivariable-adjusted model, hyperkalemia (adjusted odds ratio [aOR] = 2.04; 95% CI = 1.88-2.21) and hypokalemia (aOR = 1.66; 95% CI = 1.48-1.86) were associated with significantly higher odds of hospital visits. Similarly, hyperkalemia (aOR = 1.83; 95% CI = 1.65-2.03) and hypokalemia (aOR = 1.24; 95% CI = 1.07-1.44) were associated with significantly higher odds of ER visits. Results were robust to subgroups and sensitivity analyses. CONCLUSIONS: In patients with advanced CKD, dyskalemias are associated with higher risk of hospital/ER visits. Interventions targeted at lowering the risk of dyskalemias might help in reducing the health care utilization and associated economic burden among patients with advanced CKD experiencing dyskalemias. DISCLOSURES: This study was supported by grant 5U01DK102163 from the National Institute of Health (NIH) to Kamyar Kalantar-Zadeh and Csaba P. Kovesdy and by resources from the US Department of Veterans Affairs. The data reported here have been supplied in part by the United States Renal Data System (USRDS). Support for VA/CMS data were provided by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development, VA Information Resource Center (project numbers SDR 02-237 and 98-004). Opinions expressed in this article are those of the authors and do not necessarily represent the opinion of the Department of Veterans Affairs or the funding institution. Kovesdy has received honoraria from Akebia, Ardelyx, Astra Zeneca, Bayer, Boehringer-Ingelheim, Cara Therapeutics, Reata, and Tricida unrelated to this study. Kalantar-Zadeh has received honoraria and/or support from Abbott, Abbvie, ACI Clinical (Cara Therapeutics), Akebia, Alexion, Amgen, American Society of Nephrology, Astra-Zeneca, Aveo, BBraun, Chugai, Cytokinetics, Daiichi, DaVita, Fresenius, Genentech, Haymarket Media, Hofstra Medical School, International Federation of Kidney Foundations, International Society of Hemodialysis, International Society of Renal Nutrition & Metabolism, Japanese Society of Dialysis Therapy, Hospira, Kabi, Keryx, Kissei, Novartis, OPKO, National Institutes of Health, National Kidney Foundations, Pfizer, Regulus, Relypsa, Resverlogix, Dr Schaer, Sandoz, Sanofi, Shire, Veterans Affairs, Vifor, UpToDate, and ZS-Pharma, unrelated to this study. Gatwood has received research support from AstraZeneca, Merck & Co., and GlaxoSmithKline unrelated to this study. Obi has received research support from Relypsa/Vifor Pharma Inc. The remaining authors declare that they have no relevant financial interests.
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Affiliation(s)
- Ankur A Dashputre
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis
| | - Justin Gatwood
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis
| | - Oguz Akbilgic
- Department of Health Informatics and Data Science, Parkinson School of Health Sciences and Public Health, Loyola University, Chicago, IL
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Miklos Z Molnar
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of CaliforniaIrvine, Orange, CA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of CaliforniaIrvine, Orange, CA
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Valdivielso JM, Balafa O, Ekart R, Ferro CJ, Mallamaci F, Mark PB, Rossignol P, Sarafidis P, Del Vecchio L, Ortiz A. Hyperkalemia in Chronic Kidney Disease in the New Era of Kidney Protection Therapies. Drugs 2021; 81:1467-1489. [PMID: 34313978 DOI: 10.1007/s40265-021-01555-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 12/20/2022]
Abstract
Despite recent therapeutic advances, chronic kidney disease (CKD) is one of the fastest growing global causes of death. This illustrates limitations of current therapeutic approaches and, potentially, unidentified knowledge gaps. For decades, renin-angiotensin-aldosterone system (RAAS) blockers have been the mainstay of therapy for CKD. However, they favor the development of hyperkalemia, which is already common in CKD patients due to the CKD-associated decrease in urinary potassium (K+) excretion and metabolic acidosis. Hyperkalemia may itself be life-threatening as it may trigger potentially lethal arrhythmia, and additionally may limit the prescription of RAAS blockers and lead to low-K+ diets associated to low dietary fiber intake. Indeed, hyperkalemia is associated with adverse kidney, cardiovascular, and survival outcomes. Recently, novel kidney protective therapies, ranging from sodium/glucose cotransporter 2 (SGLT2) inhibitors to new mineralocorticoid receptor antagonists have shown efficacy in clinical trials. Herein, we review K+ pathophysiology and the clinical impact and management of hyperkalemia considering these developments and the availability of the novel K+ binders patiromer and sodium zirconium cyclosilicate, recent results from clinical trials targeting metabolic acidosis (sodium bicarbonate, veverimer), and an increasing understanding of the role of the gut microbiota in health and disease.
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Affiliation(s)
- José M Valdivielso
- Vascular and Renal Translational Research Group, UDETMA, REDinREN del ISCIII, IRBLleida, Lleida, Spain.
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Robert Ekart
- Clinic for Internal Medicine, Department of Dialysis, University Medical Center Maribor, Maribor, Slovenia
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases, Ospedali Riuniti, 89124, Reggio Calabria, Italy
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Patrick Rossignol
- Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116 and FCRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Alberto Ortiz
- School of Medicine, IIS-Fundacion Jimenez Diaz, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
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Dashputre AA, Sumida K, Thomas F, Gatwood J, Akbilgic O, Potukuchi PK, Obi Y, Molnar MZ, Streja E, Kalantar Zadeh K, Kovesdy CP. Association of Dyskalemias with Ischemic Stroke in Advanced Chronic Kidney Disease Patients Transitioning to Dialysis. Am J Nephrol 2021; 52:539-547. [PMID: 34289468 DOI: 10.1159/000516902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/26/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hypo- and hyperkalemia are associated with a higher risk of ischemic stroke. However, this association has not been examined in an advanced chronic kidney disease (CKD) population. METHODS From among 102,477 US veterans transitioning to dialysis between 2007 and 2015, 21,357 patients with 2 pre-dialysis outpatient estimated glomerular filtration rates <30 mL/min/1.73 m2 90-365 days apart and at least 1 potassium (K) each in the baseline and follow-up period were identified. We separately examined the association of both baseline time-averaged K (chronic exposure) and time-updated K (acute exposure) treated as categorized (hypokalemia [K <3.5 mEq/L] and hyperkalemia [K >5.5 mEq/L] vs. referent [3.5-5.5 mEq/L]) and continuous exposure with time to the first ischemic stroke event prior to dialysis initiation using multivariable-adjusted Cox regression models. RESULTS A total of 2,638 (12.4%) ischemic stroke events (crude event rate 41.9 per 1,000 patient years; 95% confidence interval [CI] 40.4-43.6) over a median (Q1-Q3) follow-up time of 2.56 (1.59-3.89) years were observed. The baseline time-averaged K category of hypokalemia (adjusted hazard ratio [aHR], 95% CI: 1.35, 1.01-1.81) was marginally associated with a significantly higher risk of ischemic stroke. However, time-updated hyperkalemia was associated with a significantly lower risk of ischemic stroke (aHR, 95% CI: 0.82, 0.68-0.98). The exposure-outcome relationship remained consistent when using continuous K levels for both the exposures. DISCUSSION/CONCLUSION In patients with advanced CKD, hypokalemia (chronic exposure) was associated with a higher risk of ischemic stroke, whereas hyperkalemia (acute exposure) was associated with a lower risk of ischemic stroke. Further studies in this population are needed to explore the mechanisms underlying these associations.
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Affiliation(s)
- Ankur A Dashputre
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Justin Gatwood
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville, Tennessee, USA
| | - Oguz Akbilgic
- Department of Health Informatics and Data Science, Parkinson School of Health Sciences and Public Health, Loyola University, Chicago, Illinois, USA
| | - Praveen K Potukuchi
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Miklos Z Molnar
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Kamyar Kalantar Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
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Filipska I, Winiarska A, Knysak M, Stompór T. Contribution of Gut Microbiota-Derived Uremic Toxins to the Cardiovascular System Mineralization. Toxins (Basel) 2021; 13:toxins13040274. [PMID: 33920096 PMCID: PMC8070663 DOI: 10.3390/toxins13040274] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 02/07/2023] Open
Abstract
Chronic kidney disease (CKD) affects more than 10% of the world population and leads to excess morbidity and mortality (with cardiovascular disease as a leading cause of death). Vascular calcification (VC) is a phenomenon of disseminated deposition of mineral content within the media layer of arteries preceded by phenotypic changes in vascular smooth muscle cells (VSMC) and/or accumulation of mineral content within the atherosclerotic lesions. Medial VC results in vascular stiffness and significantly contributes to increased cardio-vascular (CV) morbidity, whereas VC of plaques may rather increase their stability. Mineral and bone disorders of CKD (CKD-MBD) contribute to VC, which is further aggravated by accumulation of uremic toxins. Both CKD-MBD and uremic toxin accumulation affect not only patients with advanced CKD (glomerular filtration rate (GFR) less than 15 mL/min/1.72 m2, end-stage kidney disease) but also those on earlier stages of a disease. The key uremic toxins that contribute to VC, i.e., p-cresyl sulphate (PCS), indoxyl sulphate (IS) and trimethylamine-N-oxide (TMAO) originate from bacterial metabolism of gut microbiota. All mentioned toxins promote VC by several mechanisms, including: Transdifferentiation and apoptosis of VSMC, dysfunction of endothelial cells, oxidative stress, interaction with local renin–angiotensin–aldosterone system or miRNA profile modification. Several attractive methods of gut microbiota manipulations have been proposed in order to modify their metabolism and to limit vascular damage (and VC) triggered by uremic toxins. Unfortunately, to date no such method was demonstrated to be effective at the level of “hard” patient-oriented or even clinically relevant surrogate endpoints.
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Sumida K, Dashputre AA, Potukuchi PK, Thomas F, Obi Y, Molnar MZ, Gatwood JD, Streja E, Kalantar-Zadeh K, Kovesdy CP. Laxative Use and Risk of Dyskalemia in Patients with Advanced CKD Transitioning to Dialysis. J Am Soc Nephrol 2021; 32:950-959. [PMID: 33547216 PMCID: PMC8017552 DOI: 10.1681/asn.2020081120] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/20/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Patients with advanced CKD experience increased intestinal potassium excretion. This compensatory mechanism may be enhanced by laxative use; however, little is known about the association of laxative use with risk of dyskalemia in advanced CKD. METHODS Our study population encompassed 36,116 United States veterans transitioning to ESKD from 2007 to 2015 with greater than or equal to one plasma potassium measurement during the last 1-year period before ESKD transition. Using generalized estimating equations with adjustment for potential confounders, we examined the association of time-varying laxative use with risk of dyskalemia (i.e., hypokalemia [potassium <3.5 mEq/L] or hyperkalemia [>5.5 mEq/L]) versus normokalemia (3.5-5.5 mEq/L) over the 1-year pre-ESKD period. To avoid potential overestimation of dyskalemia risk, potassium measurements within 7 days following a dyskalemia event were disregarded in the analyses. RESULTS Over the last 1-year pre-ESKD period, there were 319,219 repeated potassium measurements in the cohort. Of these, 12,787 (4.0%) represented hypokalemia, and 15,842 (5.0%) represented hyperkalemia; the time-averaged potassium measurement was 4.5 mEq/L. After multivariable adjustment, time-varying laxative use (compared with nonuse) was significantly associated with lower risk of hyperkalemia (adjusted odds ratio [aOR], 0.79; 95% confidence interval [95% CI], 0.76 to 0.84) but was not associated with risk of hypokalemia (aOR, 1.01; 95% CI, 0.95 to 1.07). The results were robust to several sensitivity analyses. CONCLUSIONS Laxative use was independently associated with lower risk of hyperkalemia during the last 1-year pre-ESKD period. Our findings support a putative role of constipation in potassium disarrays and also support (with a careful consideration for the risk-benefit profiles) the therapeutic potential of laxatives in hyperkalemia management in advanced CKD.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ankur A. Dashputre
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee,Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Praveen K. Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Miklos Z. Molnar
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Justin D. Gatwood
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville, Tennessee
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
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Dashputre AA, Sumida K, Potukuchi PK, Kar S, Obi Y, Thomas F, Molnar MZ, Streja E, Kalantar-Zadeh K, Kovesdy CP. Potassium Trajectories prior to Dialysis and Mortality following Dialysis Initiation in Patients with Advanced CKD. Nephron Clin Pract 2021; 145:265-274. [PMID: 33752200 DOI: 10.1159/000514294] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/04/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Patients with advanced non-dialysis-dependent CKD (NDD-CKD) have a reduced ability for maintaining plasma potassium (K) in normal range. Deviation from normal plasma K ranges is associated with increased mortality; however, the average trajectory of plasma K over time in patients with advanced NDD-CKD and the outcomes associated with plasma K trajectory are unknown. METHODS We identified 34,167 US veterans with advanced NDD-CKD transitioning to dialysis between October 2007 and March 2015 with at least 1 K measurement each year over a 3-year period prior to dialysis transition (3-year prelude). The K trajectory defined as the change in K (slope) per year over the entire 3-year prelude was estimated using linear mixed-effects models. The association between unadjusted (crude) K slope (categorized as stable [-0.09 to 0.09 mEq/L/year], decreasing [≤-0.10 mEq/L/year], and increasing [≥0.10 mEq/L/year]) and time to all-cause and cardiovascular mortality during the 6 months following dialysis initiation was assessed using multivariable-adjusted survival models. RESULTS The crude and multivariable-adjusted K slopes (mean, 95% CI) over the 3-year prelude were 0.008 (0.0059, 0.0110) and -0.15 mEq/L/year (-0.19, -0.11), respectively. Decreasing K slope was associated with higher multivariable-adjusted risk of all-cause mortality (adjusted hazard ratio [95% CI] vs. stable K slope: 1.08 [1.00-1.17]). No association was observed between K slope and cardiovascular mortality. DISCUSSION/CONCLUSION The average intraindividual plasma K trajectory is remarkably stable in patients with advanced NDD-CKD. A decreasing K slope is associated with higher all-cause mortality risk.
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Affiliation(s)
- Ankur A Dashputre
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Praveen K Potukuchi
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Suryatapa Kar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Miklos Z Molnar
- Division of Nephrology and Hypertension, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Elani Streja
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California-Irvine, Orange, California, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California-Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA, .,Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA,
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Palmer BF, Carrero JJ, Clegg DJ, Colbert GB, Emmett M, Fishbane S, Hain DJ, Lerma E, Onuigbo M, Rastogi A, Roger SD, Spinowitz BS, Weir MR. Clinical Management of Hyperkalemia. Mayo Clin Proc 2021; 96:744-762. [PMID: 33160639 DOI: 10.1016/j.mayocp.2020.06.014] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/18/2020] [Accepted: 06/10/2020] [Indexed: 12/26/2022]
Abstract
Hyperkalemia is an electrolyte abnormality with potentially life-threatening consequences. Despite various guidelines, no universally accepted consensus exists on best practices for hyperkalemia monitoring, with variations in precise potassium (K+) concentration thresholds or for the management of acute or chronic hyperkalemia. Based on the available evidence, this review identifies several critical issues and unmet needs with regard to the management of hyperkalemia. Real-world studies are needed for a better understanding of the prevalence of hyperkalemia outside the clinical trial setting. There is a need to improve effective management of hyperkalemia, including classification and K+ monitoring, when to reinitiate previously discontinued renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, and when to use oral K+-binding agents. Monitoring serum K+ should be individualized; however, increased frequency of monitoring should be considered for patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia and for those receiving RAASi therapy. Recent clinical studies suggest that the newer K+ binders (patiromer sorbitex calcium and sodium zirconium cyclosilicate) may facilitate optimization of RAASi therapy. Enhancing the knowledge of primary care physicians and internists with respect to the safety profiles of these newer K+ binders may increase confidence in managing patients with hyperkalemia. Lastly, the availability of newer K+-binding agents requires further study to establish whether stringent dietary K+ restrictions are needed in patients receiving K+-binder therapy. Individualized monitoring of serum K+ among patients with an increased risk of hyperkalemia and the use of newer K+-binding agents may allow for optimization of RAASi therapy and more effective management of hyperkalemia.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Deborah J Clegg
- Drexel University College of Nursing and Health Professions, Philadelphia, PA
| | | | | | - Steven Fishbane
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Debra J Hain
- Christine E. Lynn College of Nursing, Florida Atlantic University, and Cleveland Clinic Florida, Weston, FL
| | - Edgar Lerma
- Department of Medicine, University of Illinois at Chicago/Advocate Christ Medical Center, Oak Lawn
| | - Macaulay Onuigbo
- Robert Larner College of Medicine, University of Vermont Medical Center, Burlington
| | - Anjay Rastogi
- David Geffen School of Medicine, University of California, Los Angeles
| | - Simon D Roger
- Renal Research, Gosford Hospital, Gosford, Australia
| | | | - Matthew R Weir
- Department of Medicine, University of Maryland School of Medicine, Baltimore
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28
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Saglimbene VM, Su G, Wong G, Natale P, Ruospo M, Palmer SC, Craig JC, Carrero JJ, Strippoli GFM. Dietary intake in adults on hemodialysis compared with guideline recommendations. J Nephrol 2021; 34:1999-2007. [PMID: 33591554 PMCID: PMC8610942 DOI: 10.1007/s40620-020-00962-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/29/2020] [Indexed: 11/25/2022]
Abstract
Background Clinical practice guidelines of dietary management are designed to promote a balanced diet and maintain health in patients undergoing haemodialysis but they may not reflect patients’ preferences.
We aimed to investigate the consistency between the dietary intake of patients on maintenance haemodialysis and guideline recommendations. Methods Cross-sectional analysis of the DIET-HD study, which included 6,906 adults undergoing haemodialysis in 10 European countries. Dietary intake was determined using the Global Allergy and Asthma European Network (GA2LEN) Food Frequency Questionnaire (FFQ), and compared with the European Best Practice Guidelines. Consistency with guidelines was defined as achieving the minimum daily recommended intake for energy (≥ 30 kcal/kg) and protein (≥ 1.1 g/kg), and not exceeding the maximum recommended daily intake for phosphate (≤ 1000 mg), potassium (≤ 2730 mg), sodium (≤ 2300 mg) and calcium (≤ 800 mg). Results Overall, patients’ dietary intakes of phosphate and potassium were infrequently consistent with guidelines (consistent in 25% and 25% of patients, respectively). Almost half of the patients reported that energy (45%) and calcium intake (53%) was consistent with the guidelines, while the recommended intake of sodium and protein was consistent in 85% and 67% of patients, respectively. Results were similar across all participating countries. Intake was consistent with all six guideline recommendations in only 1% of patients. Conclusion Patients on maintenance haemodialysis usually have a dietary intake which is inconsistent with current recommendations, especially for phosphate and potassium. Supplementary Information The online version contains supplementary material available at 10.1007/s40620-020-00962-3.
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Affiliation(s)
- Valeria M Saglimbene
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio Cesare, 70124, Bari, Italy
| | - Guobin Su
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Department of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou City, Guangdong Province, China
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Germaine Wong
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia
- Department of Renal Medicine, Westmead Hospital, Westmead, Australia
| | - Patrizia Natale
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio Cesare, 70124, Bari, Italy
| | - Marinella Ruospo
- Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio Cesare, 70124, Bari, Italy
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Giovanni F M Strippoli
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia.
- Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio Cesare, 70124, Bari, Italy.
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29
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Kashihara N, Yamasaki Y, Osonoi T, Harada H, Shibagaki Y, Zhao J, Kim H, Yajima T, Sarai N. A phase 3 multicenter open-label maintenance study to investigate the long-term safety of sodium zirconium cyclosilicate in Japanese subjects with hyperkalemia. Clin Exp Nephrol 2021; 25:140-149. [PMID: 33098526 PMCID: PMC7880936 DOI: 10.1007/s10157-020-01972-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 09/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hyperkalemia is associated with many chronic diseases and renin-angiotensin-aldosterone system inhibitor therapy. Sodium zirconium cyclosilicate (SZC), an oral, highly selective cation-exchanger, is approved for the treatment of hyperkalemia. METHODS This phase 3, multicenter, open-label, single-arm, flexible-dose study assessed the safety and efficacy of SZC in Japanese patients with hyperkalemia during a correction phase of up to 3 days and long-term (1 year) maintenance phase (NCT03172702). RESULTS Overall, 150 patients received treatment during both study phases; the study population was generally representative of hyperkalemic Japanese patients in clinical practice. Most patients (78.7%) had three doses of SZC during the correction phase. All but one patient received SZC for ≤ 48 h before transitioning to the maintenance phase. In the maintenance phase, mean (standard deviation; SD) exposure to the study drug was 319.4 (98.1) days and mean (SD) dose was 7.38 (2.85) g/day. Adverse events (AEs) were reported in 131 patients (87.3%); most were mild. The most common treatment-related AEs as evaluated by investigators were constipation (6.7%), peripheral edema (4.0%), and hypertension (2.7%). In the correction phase, 78.7% of patients were normokalemic at 24 h and 98.7% within 48 h; ≥ 65.5% maintained normokalemia throughout the maintenance phase. CONCLUSION After a year of exposure, SZC treatment was well tolerated by Japanese patients and potassium levels were well controlled.
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Affiliation(s)
- Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Okayama, Japan
| | | | - Takeshi Osonoi
- Department of Internal Medicine, Nakakinen Clinic, Ibaraki, Japan
| | - Hiromasa Harada
- Departments of Internal Medicine, Yao Tokushukai General Hospital, Osaka, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, St. Marianna University School of Medicine Hospital, Kanagawa, Japan
| | - June Zhao
- CVRM Late-Stage Development, AstraZeneca Gaithersburg, Gaithersburg, USA
| | - Hyosung Kim
- Research and Development, AstraZeneca K.K, 1-8-3, Marunouchi, Chiyoda-ku, Tokyo, 100-0005, Japan
| | - Toshitaka Yajima
- Research and Development, AstraZeneca K.K, 1-8-3, Marunouchi, Chiyoda-ku, Tokyo, 100-0005, Japan
| | - Nobuaki Sarai
- Research and Development, AstraZeneca K.K, 1-8-3, Marunouchi, Chiyoda-ku, Tokyo, 100-0005, Japan.
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30
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Dashputre AA, Potukuchi PK, Sumida K, Kar S, Obi Y, Thomas F, Molnar MZ, Streja E, Kalantar-Zadeh K, Kovesdy CP. Predialysis Potassium Variability and Postdialysis Mortality in Patients With Advanced CKD. Kidney Int Rep 2021; 6:366-380. [PMID: 33615062 PMCID: PMC7879127 DOI: 10.1016/j.ekir.2020.11.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Patients with advanced non–dialysis-dependent chronic kidney disease (NDD-CKD) are prone to potassium (K) imbalances due to reduced kidney function. Both hypo- and hyperkalemia are associated with increased mortality; however, it is unclear if K variability before dialysis initiation is associated with outcomes after dialysis initiation. Methods We identified 34,167 US veterans with advanced NDD-CKD transitioning to dialysis between October 1, 2007, through March 31, 2015, who had at least 1 K measurement each year over a 3-year period before transition (3-year prelude). For each patient, a linear mixed-effects model was used to regress K over time (in years) over the 3-year prelude to derive K variability (square root of the average squared distance between the observed and estimated K). The main outcomes of interest were 6-month all-cause and cardiovascular mortality after dialysis initiation. Multivariable Cox and Fine-Gray competing risk regression adjusted for 3-year prelude K intercept, K slope (per year), demographics, smoking status, comorbidities, length of hospitalizations, body mass index, vascular access type, medications, average estimated glomerular filtration rate, and number of K measurements over the 3-year prelude were used to assess the association of K variability (expressed as quartiles) with all-cause and cardiovascular mortality, respectively. Results Higher prelude K variability was associated with higher multivariable-adjusted risk of all-cause mortality but not cardiovascular mortality (adjusted hazard/subhazard ratios [95% confidence interval] for highest quartile [vs. lowest] of K variability, 1.14 [1.03–1.25] and 0.99 [0.85–1.16] for all-cause and cardiovascular mortality, respectively). Conclusion Higher K variability is associated with higher all-cause mortality after dialysis initiation.
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Affiliation(s)
- Ankur A. Dashputre
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, TN, USA
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Praveen K. Potukuchi
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, TN, USA
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Suryatapa Kar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Miklos Z. Molnar
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
- Correspondence: Csaba P.Kovesdy, Nephrology Section, Memphis VA Medical Center, 1030 Jefferson Avenue, Memphis, Tennessee 38104, United States.
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31
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Overwyk KJ, Pfeiffer CM, Storandt RJ, Zhao L, Zhang Z, Campbell NRC, Wiltz JL, Merritt RK, Cogswell ME. Serum Sodium and Potassium Distribution and Characteristics in the US Population, National Health and Nutrition Examination Survey 2009-2016. J Appl Lab Med 2021; 6:63-78. [PMID: 33236098 DOI: 10.1093/jalm/jfaa127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 06/24/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Concern has been expressed by some that sodium reduction could lead to increased prevalence of hyponatremia and hyperkalemia for specific population subgroups. Current concentrations of serum sodium and potassium in the US population can help address this concern. METHODS We used data from the National Health and Nutrition Examination Survey 2009-2016 to examine mean and selected percentiles of serum sodium and potassium by sex and age group among 25 520 US participants aged 12 years or older. Logistic regression models with predicted residuals were used to examine the age-adjusted prevalence of low serum sodium and high serum potassium among adults aged 20 or older by selected sociodemographic characteristics and by health conditions or medication use. RESULTS The distributions of serum sodium and potassium concentrations were within normal reference intervals overall and across Dietary Reference Intake life-stage groups, with a few exceptions. Overall, 2% of US adults had low serum sodium (<135 mmol/L) and 0.6% had high serum potassium (>5 mmol/L). Prevalence of low serum sodium and high serum potassium was higher among adults aged 71 or older (4.7 and 2.0%, respectively) and among adults with chronic kidney disease (3.4 and 1.9%), diabetes (5.0 and 1.1%), or using certain medications (which varied by condition), adjusted for age; whereas, prevalence was <1% among adults without these conditions or medications. CONCLUSIONS Most of the US population has normal serum sodium and potassium concentrations; these data describe population subgroups at higher risk of low serum sodium and high serum potassium and can inform clinical care.
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Affiliation(s)
- Katherine J Overwyk
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA.,IHRC, Inc., Atlanta, GA
| | - Christine M Pfeiffer
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Renee J Storandt
- Division of Health and Nutrition Examination Surveys, National Center for Health Statistics, Centers for Disease Control and Prevention, Atlanta, GA
| | - Lixia Zhao
- Division of Health Informatics and Surveillance, Center for Surveillance Epidemiology and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, GA
| | - Zefeng Zhang
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Norm R C Campbell
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer L Wiltz
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA.,United States Public Health Service, Atlanta, GA
| | - Robert K Merritt
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Mary E Cogswell
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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32
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Laureati P, Xu Y, Trevisan M, Schalin L, Mariani I, Bellocco R, Sood MM, Barany P, Sjölander A, Evans M, Carrero JJ. Initiation of sodium polystyrene sulphonate and the risk of gastrointestinal adverse events in advanced chronic kidney disease: a nationwide study. Nephrol Dial Transplant 2020; 35:1518-1526. [PMID: 31377791 PMCID: PMC7473802 DOI: 10.1093/ndt/gfz150] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 06/27/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Despite long-standing clinical use of sodium polystyrene sulphonate (SPS) for hyperkalaemia management in chronic kidney disease (CKD), its safety profile remains poorly investigated. METHODS We undertook an observational analysis of nephrology-referred adults with incident CKD Stage 4+ in Sweden during 2006-16 and with no previous SPS use. We studied patterns of use and adverse events associated to SPS initiation during follow-up. Patterns of SPS use were defined by chronicity of treatment and by prescribed dose. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) associated with SPS initiation (time-varying exposure) for the risk of severe (intestinal ischaemia, thrombosis or ulceration/perforation) and minor (de novo dispensation of laxatives or anti-diarrheal drugs) gastrointestinal (GI) events. RESULTS Of 19 530 SPS-naïve patients with CKD, 3690 initiated SPS during follow-up. A total of 59% took SPS chronically, with an average of three dispensations/year. The majority (85%) were prescribed lower dosages than specified on the product label. During follow-up, 202 severe and 1149 minor GI events were recorded. SPS initiation was associated with a higher incidence of severe adverse events [adjusted HR 1.25 95% CI 1.05-1.49)], particularly in those receiving per label doses [1.54 (1.09-2.17)] and mainly attributed to ulcers and perforations. SPS initiation was also associated with higher incidence of minor GI events [adjusted HR 1.11 (95% CI 1.03-1.19)], regardless of dose, and mainly accounted for by de novo dispensation of laxatives. CONCLUSIONS Initiation of SPS in patients with advanced CKD is associated with a higher risk of severe GI complications as well as the initiation of GI-related medications, particularly when prescribed at per label doses.
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Affiliation(s)
- Paola Laureati
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- University of Milano-Bicocca, Milan, Italy
| | - Yang Xu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Marco Trevisan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | | | - Illaria Mariani
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- University of Milano-Bicocca, Milan, Italy
| | - Rino Bellocco
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- University of Milano-Bicocca, Milan, Italy
| | - Manish M Sood
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Peter Barany
- Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Arvid Sjölander
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Marie Evans
- Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Moore LW, Kalantar-Zadeh K. Global Approaches to Nutrition Assessment and Intervention for Patients With Kidney Disease. J Ren Nutr 2020; 30:271-273. [DOI: 10.1053/j.jrn.2020.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 05/31/2020] [Indexed: 12/19/2022] Open
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34
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Filippini T, Naska A, Kasdagli MI, Torres D, Lopes C, Carvalho C, Moreira P, Malavolti M, Orsini N, Whelton PK, Vinceti M. Potassium Intake and Blood Pressure: A Dose-Response Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc 2020; 9:e015719. [PMID: 32500831 PMCID: PMC7429027 DOI: 10.1161/jaha.119.015719] [Citation(s) in RCA: 147] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Epidemiologic studies, including trials, suggest an association between potassium intake and blood pressure (BP). However, the strength and shape of this relationship is uncertain. Methods and Results We performed a meta‐analysis to explore the dose‐response relationship between potassium supplementation and BP in randomized‐controlled trials with a duration ≥4 weeks using the recently developed 1‐stage cubic spline regression model. This model allows use of trials with at least 2 exposure categories. We identified 32 eligible trials. Most were conducted in adults with hypertension using a crossover design and potassium supplementation doses that ranged from 30 to 140 mmol/d. We observed a U‐shaped relationship between 24‐hour active and control arm differences in potassium excretion and BP levels, with weakening of the BP reduction effect above differences of 30 mmol/d and a BP increase above differences ≈80 mmol/d. Achieved potassium excretion analysis also identified a U‐shaped relationship. The BP‐lowering effects of potassium supplementation were stronger in participants with hypertension and at higher levels of sodium intake. The BP increase with high potassium excretion was noted in participants with antihypertensive drug‐treated hypertension but not in their untreated counterparts. Conclusions We identified a nonlinear relationship between potassium intake and both systolic and diastolic BP, although estimates for BP effects of high potassium intakes should be interpreted with caution because of limited availability of trials. Our findings indicate an adequate intake of potassium is desirable to achieve a lower BP level but suggest excessive potassium supplementation should be avoided, particularly in specific subgroups.
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Affiliation(s)
- Tommaso Filippini
- Environmental, Genetic and Nutritional Epidemiology Research Center Department of Biomedical, Metabolic and Neural Sciences University of Modena and Reggio Emilia Modena Italy
| | - Androniki Naska
- Department of Hygiene, Epidemiology and Medical Statistics School of Medicine National and Kapodistrian University of Athens Athens Greece
| | - Maria-Iosifina Kasdagli
- Department of Hygiene, Epidemiology and Medical Statistics School of Medicine National and Kapodistrian University of Athens Athens Greece
| | - Duarte Torres
- EPIUnit-Institute of Public Health University of Porto Portugal.,Faculty of Nutrition and Food Sciences University of Porto Portugal
| | - Carla Lopes
- EPIUnit-Institute of Public Health University of Porto Portugal.,Unit of Epidemiology Department of Public Health and Forensic Sciences, and Medical Education Faculty of Medicine University of Porto Portugal
| | - Catarina Carvalho
- EPIUnit-Institute of Public Health University of Porto Portugal.,Faculty of Nutrition and Food Sciences University of Porto Portugal
| | - Pedro Moreira
- EPIUnit-Institute of Public Health University of Porto Portugal.,Faculty of Nutrition and Food Sciences University of Porto Portugal
| | - Marcella Malavolti
- Environmental, Genetic and Nutritional Epidemiology Research Center Department of Biomedical, Metabolic and Neural Sciences University of Modena and Reggio Emilia Modena Italy
| | - Nicola Orsini
- Department of Global Public Health Karolinska Institute Stockholm Sweden
| | - Paul K Whelton
- Department of Epidemiology Tulane University School of Public Health and Tropical Medicine, and School of Medicine New Orleans LA
| | - Marco Vinceti
- Environmental, Genetic and Nutritional Epidemiology Research Center Department of Biomedical, Metabolic and Neural Sciences University of Modena and Reggio Emilia Modena Italy.,Department of Epidemiology Boston University School of Public Health Boston MA
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Urinary Sodium-to-Potassium Ratio and Blood Pressure in CKD. Kidney Int Rep 2020; 5:1240-1250. [PMID: 32775823 PMCID: PMC7403539 DOI: 10.1016/j.ekir.2020.05.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 05/11/2020] [Accepted: 05/18/2020] [Indexed: 12/11/2022] Open
Abstract
Introduction In the general population, urinary sodium-to-potassium (uNa/K) ratio associates more strongly with high blood pressure (BP) than either urinary sodium or potassium alone. Whether this is also the case among patients with chronic kidney disease (CKD) is unknown. Methods We studied the associations of spot urine sodium-to-creatinine (uNa/Cr), potassium-to-creatinine (uK/Cr), and uNa/K ratios with a single office BP reading in 1660 patients with moderate to severe CKD at inclusion in the CKD-REIN cohort. Results Patients' median age was 68 (interquartile range [IQR], 59-76) years; most were men (65%), had moderate CKD (57%), and albuminuria (72%). Mean systolic and diastolic BP was 142/78 mm Hg. Spot uNa/Cr and uNa/K ratios were positively associated with systolic, mean arterial, and pulse pressures. The mean adjusted difference in systolic BP between the highest and the lowest quartile (Q4 vs. Q1) was 4.24 (95% confidence interval [CI], 1.53-6.96) mm Hg for uNa/Cr and 4.79 (95% CI, 2.18-7.39) mm Hg for uNa/K. Quartiles of spot uK/Cr were not associated with any BP index. The higher the quartile of uNa/K, the higher the prevalence ratio of uncontrolled (Q4 vs. Q1, 1.43; 95% CI, 1.19-1.72) or apparently treatment-resistant hypertension (Q4 vs. Q1, 1.35; 95% CI, 1.14-1.60). Findings were consistent in a subset of 803 individuals with 2 BP readings. Conclusion In patients with CKD, higher urinary sodium excretion is associated with higher BP, but unlike in general population, lower potassium excretion is not. Urinary Na/K does not add significant value in assessing high BP risk, except perhaps for hypertension control assessment.
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Marklund M, Singh G, Greer R, Cudhea F, Matsushita K, Micha R, Brady T, Zhao D, Huang L, Tian M, Cobb L, Neal B, Appel LJ, Mozaffarian D, Wu JHY. Estimated population wide benefits and risks in China of lowering sodium through potassium enriched salt substitution: modelling study. BMJ 2020; 369:m824. [PMID: 32321724 PMCID: PMC7190075 DOI: 10.1136/bmj.m824] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To estimate the effects of nationwide replacement of discretionary salt (used at table or during cooking) with potassium enriched salt substitute on morbidity and death from cardiovascular disease in China. DESIGN Modelling study. SETTING China. POPULATION Adult population in China, and specifically individuals with chronic kidney disease (about 17 million people). INTERVENTIONS Comparative risk assessment models were used to estimate the effects of a nationwide intervention to replace discretionary dietary salt with potassium enriched salt substitutes (20-30% potassium chloride). The models incorporated existing data and corresponding uncertainties from randomised trials, the China National Survey of Chronic Kidney Disease, the Global Burden of Disease Study, and the Chronic Kidney Disease Prognosis Consortium. MAIN OUTCOME MEASURES Averted deaths from cardiovascular disease, non-fatal events, and disability adjusted life years from a reduction in blood pressure were estimated after implementation of potassium enriched salt substitution. In individuals with chronic kidney disease, additional deaths from cardiovascular disease related to hyperkalaemia from increased intake of potassium were calculated. The net effects on deaths from cardiovascular disease were estimated as the difference and ratio of averted and additional deaths from cardiovascular disease. RESULTS Nationwide implementation of potassium enriched salt substitution could prevent about 461 000 (95% uncertainty interval 196 339 to 704 438) deaths annually from cardiovascular disease, corresponding to 11.0% (4.7% to 16.8%) of annual deaths from cardiovascular disease in China; 743 000 (305 803 to 1 273 098) non-fatal cardiovascular events annually; and 7.9 (3.3 to 12.9) million disability adjusted life years related to cardiovascular disease annually. The intervention could potentially produce an estimated 11 000 (6422 to 16 562) additional deaths related to hyperkalaemia in individuals with chronic kidney disease. The net effect would be about 450 000 (183 699 to 697 084) fewer deaths annually from cardiovascular disease in the overall population and 21 000 (1928 to 42 926) fewer deaths in individuals with chronic kidney disease. In deterministic sensitivity analyses, with changes to key model inputs and assumptions, net benefits were consistent in the total population and in individuals with chronic kidney disease, with averted deaths outweighing additional deaths. CONCLUSIONS Nationwide potassium enriched salt substitution in China was estimated to result in a substantial net benefit, preventing around one in nine deaths from cardiovascular disease overall. Taking account of the risks of hyperkalaemia, a substantial net benefit was also estimated for individuals with chronic kidney disease.
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Affiliation(s)
- Matti Marklund
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, PO Box M201, Missenden Road, NSW 2050, Australia
- Friedman School of Nutrition Science and Policy at Tufts University, Boston, MA, USA
| | - Gitanjali Singh
- Friedman School of Nutrition Science and Policy at Tufts University, Boston, MA, USA
| | - Raquel Greer
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Frederick Cudhea
- Friedman School of Nutrition Science and Policy at Tufts University, Boston, MA, USA
| | | | - Renata Micha
- Friedman School of Nutrition Science and Policy at Tufts University, Boston, MA, USA
| | - Tammy Brady
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Di Zhao
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Liping Huang
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, PO Box M201, Missenden Road, NSW 2050, Australia
| | - Maoyi Tian
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, PO Box M201, Missenden Road, NSW 2050, Australia
- George Institute for Global Health at Peking University Health Science Centre, Beijing, China
| | - Laura Cobb
- Resolve to Save Lives, New York City, NY, USA
| | - Bruce Neal
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, PO Box M201, Missenden Road, NSW 2050, Australia
- Imperial College London, London, UK
| | - Lawrence J Appel
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dariush Mozaffarian
- Friedman School of Nutrition Science and Policy at Tufts University, Boston, MA, USA
| | - Jason H Y Wu
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, PO Box M201, Missenden Road, NSW 2050, Australia
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Gasparini A, Evans M, Barany P, Xu H, Jernberg T, Ärnlöv J, Lund LH, Carrero JJ. Plasma potassium ranges associated with mortality across stages of chronic kidney disease: the Stockholm CREAtinine Measurements (SCREAM) project. Nephrol Dial Transplant 2020; 34:1534-1541. [PMID: 30085251 PMCID: PMC6735645 DOI: 10.1093/ndt/gfy249] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Indexed: 12/16/2022] Open
Abstract
Background Small-scale studies suggest that hyperkalaemia is a less threatening condition in chronic kidney disease (CKD), arguing adaptation/tolerance to potassium (K+) retention. This study formally evaluates this hypothesis by estimating the distribution of plasma K+ and its association with mortality across CKD stages. Methods This observational study included all patients undergoing plasma K+ testing in Stockholm during 2006–11. We randomly selected one K+ measurement per patient and constructed a cross-sectional cohort with mortality follow-up. Covariates included demographics, comorbidities, medications and estimated glomerular filtration rate (eGFR). We estimated K+ distribution and defined K+ ranges associated with 90-, 180- and 365-day mortality. Results Included were 831 760 participants, of which 70 403 (8.5%) had CKD G3 (eGFR <60–30 mL/min) and 8594 (1.1%) had CKD G4–G5 (eGFR <30 mL/min). About 66 317 deaths occurred within a year. Adjusted plasma K+ increased across worse CKD stages: from median 3.98 (95% confidence interval 3.49–4.59) for eGFR >90 to 4.43 (3.22–5.65) mmol/L for eGFR ≤15 mL/min/1.73 m2. The association between K+ and mortality was U-shaped, but it flattened at lower eGFR strata and shifted upwards. For instance, the range where the 90-day mortality risk increased by no more than 100% was 3.45–4.94 mmol/L in eGFR >60 mL/min, but was 3.36–5.18 in G3 and 3.26–5.53 mmol/L in G4–G5. In conclusion, CKD stage modifies K+ distribution and the ranges that predict mortality in the community. Conclusion Although this study supports the view that hyperkalaemia is better tolerated with worse CKD, it challenges the current use of a single optimal K+ range for all patients.
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Affiliation(s)
| | - Marie Evans
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Barany
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | | | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Johan Ärnlöv
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Juan-Jesús Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Okuda N, Okayama A, Miura K, Yoshita K, Miyagawa N, Saitoh S, Nakagawa H, Sakata K, Chan Q, Elliott P, Ueshima H, Stamler J. Food Sources of Dietary Potassium in the Adult Japanese Population: The International Study of Macro-/Micronutrients and Blood Pressure (INTERMAP). Nutrients 2020; 12:nu12030787. [PMID: 32192157 PMCID: PMC7146396 DOI: 10.3390/nu12030787] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/11/2020] [Accepted: 03/16/2020] [Indexed: 02/06/2023] Open
Abstract
A lower-than-recommended potassium intake is a well-established risk factor for increased blood pressure. Although the Japanese diet is associated with higher sodium intake and lower potassium intake, few studies have examined the source foods quantitatively. Studies on dietary patterns in association with potassium intake will be useful to provide dietary advice to increase potassium intake. Twenty-four-hour (hr) dietary recall data and 24-hr urinary potassium excretion data from Japanese participants (574 men and 571 women) in the International Study of Macro/Micronutrients and Blood Pressure (INTERMAP) were used to calculate food sources of potassium and compare food consumption patterns among quartiles of participants categorized according to 24-hr urinary potassium excretion per unit of body weight (UK/BW). The average potassium intake was 2791 mg/day per participant, and the major sources were vegetables and fruits (1262 mg/day), fish (333 mg/day), coffee and tea (206 mg/day), and milk and dairy products (200 mg/day). Participants in the higher UK/BW quartile consumed significantly more vegetables and fruits, fish, and milk and dairy products, and ate less rice and noodles. Conclusion: Advice to increase the intake of vegetables and fruits, fish, and milk may be useful to increase potassium intake in Japan.
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Affiliation(s)
- Nagako Okuda
- Department of Health and Nutrition, University of Human Arts and Sciences, Saitama 339-8539, Japan
- Correspondence: ; Tel.: +81-48-749-6111; Fax: +81-48-6110
| | - Akira Okayama
- Department of Non-Communicable Diseases, Research Institute of Strategy for Prevention, Tokyo 104-0033, Japan;
| | - Katsuyuki Miura
- Department of Public Health, Shiga University of Medical Science, Otsu 520-2192, Japan; (K.M.); (H.U.)
- Center for Epidemiologic Research in Asia, Shiga University of Medical Science, Otsu 520-2192, Japan
| | - Katsushi Yoshita
- Department of Food Science and Nutrition, Graduate School of Human Life Science and Nutrition, Osaka City University, Osaka 558-8585, Japan;
| | - Naoko Miyagawa
- International Center for Nutrition and Information, National Institute of Biomedical Innovation, Health and Nutrition, Tokyo 162-8636, Japan;
| | - Shigeyuki Saitoh
- School of Health Sciences, Sapporo Medical University, Sapporo 060-8556, Japan;
| | - Hideaki Nakagawa
- Medical Research Institute, Kanazawa Medical University, Kanazawa 920-0265, Japan;
| | - Kiyomi Sakata
- Department of Hygiene and Public Health, Iwate Medical University, Yahaba 028-3694, Japan;
| | - Queenie Chan
- MRC-PHE Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London SW7 2AZ, UK; (Q.C.); (P.E.)
| | - Paul Elliott
- MRC-PHE Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London SW7 2AZ, UK; (Q.C.); (P.E.)
| | - Hirotsugu Ueshima
- Department of Public Health, Shiga University of Medical Science, Otsu 520-2192, Japan; (K.M.); (H.U.)
- Center for Epidemiologic Research in Asia, Shiga University of Medical Science, Otsu 520-2192, Japan
| | - Jeremiah Stamler
- Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA;
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Paik J. Sodium zirconium cyclosilicate in hyperkalaemia: a profile of its use. DRUGS & THERAPY PERSPECTIVES 2020. [DOI: 10.1007/s40267-020-00706-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Palmer BF. Potassium Binders for Hyperkalemia in Chronic Kidney Disease-Diet, Renin-Angiotensin-Aldosterone System Inhibitor Therapy, and Hemodialysis. Mayo Clin Proc 2020; 95:339-354. [PMID: 31668450 DOI: 10.1016/j.mayocp.2019.05.019] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/14/2019] [Accepted: 05/21/2019] [Indexed: 02/06/2023]
Abstract
Hyperkalemia is a potentially life-threatening complication of chronic kidney disease (CKD). The management of CKD requires balancing the benefits of specific treatments, which may exacerbate the potential for hyperkalemia, with the risks of hyperkalemia itself. Renin-angiotensin-aldosterone system (RAAS) inhibitors, which slow CKD progression and improve cardiovascular outcomes, are often discontinued if hyperkalemia develops. Patients with hyperkalemia are frequently advised to restrict dietary potassium (K+), depriving these patients of many heart-healthy foods. Patients receiving hemodialysis are particularly susceptible to hyperkalemia during long interdialytic intervals, and managing this risk without causing hypokalemia can be challenging. Recently, 2 K+-binding agents were approved for the treatment of hyperkalemia: sodium zirconium cyclosilicate and patiromer. These agents offer alternatives to sodium polystyrene sulfonate, which is associated with serious gastrointestinal adverse effects. For this review, PubMed was searched for English-language articles published in 2014-2018 using the terms patiromer, sodium zirconium cyclosilicate, sodium polystyrene sulfonate, hyperkalemia, renin-angiotensin-aldosterone, diet, and dialysis. In randomized controlled studies of patients with hyperkalemia, sodium zirconium cyclosilicate and patiromer effectively reduced serum K+ and were generally well tolerated. Furthermore, patients in these studies could maintain RAAS inhibitor therapy and, in some studies, were not required to limit dietary K+. There may also be a role for these agents in preventing hyperkalemia in patients receiving hemodialysis. Thus, K+-binding agents may allow patients with CKD at risk for hyperkalemia to optimize RAAS inhibitor therapy, receive benefits of a K+-rich diet, and experience improved hemodialysis outcomes. Additional long-term studies are necessary to confirm these effects.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.
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Palmer BF, Colbert G, Clegg DJ. Potassium Homeostasis, Chronic Kidney Disease, and the Plant-Enriched Diets. KIDNEY360 2020; 1:65-71. [PMID: 35372861 PMCID: PMC8808484 DOI: 10.34067/kid.0000222019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 11/25/2019] [Indexed: 11/27/2022]
Abstract
There are data demonstrating that ingestion of potassium-rich foods reduces the incidence of stroke, hypertension, nephrolithiasis, and osteoporosis. Dietary-consumption data indicate Westernized diets are high in processed foods, high in sodium content, and low in potassium. In fact, there are data suggesting individuals are not consuming enough potassium in their diet. Although consumption of diets high in plant proteins, fruits, and vegetables-which are excellent sources of potassium-is recognized as healthy and beneficial, individuals with decrements in their kidney function have been advised to avoid these foods. In reviewing the literature that provides the rationale for potassium restriction in patients with reductions in kidney function, it appears there is little direct evidence to support the levels of restriction which are now prescribed. Additionally, there are two new potassium-binding agents which are well tolerated and have been documented to be effective in controlling serum potassium. Therefore, with the new binding agents and the lack of empirical evidence supporting the stringent dietary potassium restrictions, the authors conclude by indicating the pressing need for further research focusing on dietary liberalization of potassium in patients with reductions in kidney function to enhance overall health and well being, to provide them cardiovascular benefits, and to reduce overall risk of mortality through the incorporation of potassium-enriched foods.
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Affiliation(s)
- Biff F. Palmer
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Gates Colbert
- Division of Nephrology, Department of Medicine, Texas A&M Health Science Center College of Medicine, Baylor University Medical Center, Dallas, Texas; and
| | - Deborah J. Clegg
- College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania
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Kovesdy CP, Gosmanova EO, Woods SD, Fogli JJ, Rowan CG, Hansen JL, Sauer BC. Real-world management of hyperkalemia with patiromer among United States Veterans. Postgrad Med 2020; 132:176-183. [DOI: 10.1080/00325481.2019.1706920] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Csaba P. Kovesdy
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Elvira O. Gosmanova
- Nephrology Section, Samuel S. Stratton VA Medical Center, Albany, NY, USA
- Division of Nephrology, Department of Medicine, Albany Medical College, Albany, NY, USA
| | - Steven D. Woods
- Managed Care and Health Outcomes, Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, CA, USA
| | - Jeanene J. Fogli
- Health Economics and Outcomes Research, Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, CA, USA
| | | | - Jared L. Hansen
- Division of Epidemiology, Salt Lake City VA Medical Center (IDEAS), University of Utah, Salt Lake City, UT, USA
| | - Brian C. Sauer
- Division of Epidemiology, Salt Lake City VA Medical Center (IDEAS), University of Utah, Salt Lake City, UT, USA
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Abstract
Hyperkalemia is a frequent finding in patients with chronic kidney disease (CKD). This increase in serum potassium levels is associated with decreased renal ion excretion, as well as the use of medications to reduce the progression of CKD or to control associated diseases such as diabetes mellitus and heart failure. Hyperkalemia increases the risk of cardiac arrhythmia episodes and sudden death. Thus, the control of potassium elevation is essential for reducing the mortality rate in this population. Initially, the management of hyperkalemia includes orientation of low potassium diets and monitoring of patients' adherence to this procedure. It is also important to know the medications in use and the presence of comorbidities to guide dose reduction or even temporary withdrawal of any of the potassium retention-related drugs. And finally, the use of potassium binders is indicated in both acute episodes and chronic hyperkalemia.
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Hoorn EJ, Gritter M, Cuevas CA, Fenton RA. Regulation of the Renal NaCl Cotransporter and Its Role in Potassium Homeostasis. Physiol Rev 2020; 100:321-356. [PMID: 31793845 DOI: 10.1152/physrev.00044.2018] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Daily dietary potassium (K+) intake may be as large as the extracellular K+ pool. To avoid acute hyperkalemia, rapid removal of K+ from the extracellular space is essential. This is achieved by translocating K+ into cells and increasing urinary K+ excretion. Emerging data now indicate that the renal thiazide-sensitive NaCl cotransporter (NCC) is critically involved in this homeostatic kaliuretic response. This suggests that the early distal convoluted tubule (DCT) is a K+ sensor that can modify sodium (Na+) delivery to downstream segments to promote or limit K+ secretion. K+ sensing is mediated by the basolateral K+ channels Kir4.1/5.1, a capacity that the DCT likely shares with other nephron segments. Thus, next to K+-induced aldosterone secretion, K+ sensing by renal epithelial cells represents a second feedback mechanism to control K+ balance. NCC’s role in K+ homeostasis has both physiological and pathophysiological implications. During hypovolemia, NCC activation by the renin-angiotensin system stimulates Na+ reabsorption while preventing K+ secretion. Conversely, NCC inactivation by high dietary K+ intake maximizes kaliuresis and limits Na+ retention, despite high aldosterone levels. NCC activation by a low-K+ diet contributes to salt-sensitive hypertension. K+-induced natriuresis through NCC offers a novel explanation for the antihypertensive effects of a high-K+ diet. A possible role for K+ in chronic kidney disease is also emerging, as epidemiological data reveal associations between higher urinary K+ excretion and improved renal outcomes. This comprehensive review will embed these novel insights on NCC regulation into existing concepts of K+ homeostasis in health and disease.
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Affiliation(s)
- Ewout J. Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands; and Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Martin Gritter
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands; and Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Catherina A. Cuevas
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands; and Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Robert A. Fenton
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands; and Department of Biomedicine, Aarhus University, Aarhus, Denmark
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Kovesdy CP. Fluctuations in plasma potassium in patients on dialysis. Nephrol Dial Transplant 2019; 34:iii19-iii25. [DOI: 10.1093/ndt/gfz209] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Indexed: 12/11/2022] Open
Abstract
Abstract
Plasma potassium concentration is maintained in a narrow range to avoid deleterious electrophysiologic consequences of both abnormally low and high levels. This is achieved by redundant physiologic mechanisms, with the kidneys playing a central role in maintaining both short-term plasma potassium stability and long-term total body potassium balance. In patients with end-stage renal disease, the lack of kidney function reduces the body’s ability to maintain normal physiologic potassium balance. Routine thrice-weekly dialysis therapy achieves long-term total body potassium mass balance, but the intermittent nature of dialytic therapy can result in wide fluctuations in plasma potassium concentration and consequently contribute to an increased risk of arrhythmogenicity. Various dialytic and nondialytic interventions can reduce the magnitude of these fluctuations, but the impact of such interventions on clinical outcomes remains unclear.
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Affiliation(s)
- Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
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46
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Roger SD, Spinowitz BS, Lerma EV, Singh B, Packham DK, Al-Shurbaji A, Kosiborod M. Efficacy and Safety of Sodium Zirconium Cyclosilicate for Treatment of Hyperkalemia: An 11-Month Open-Label Extension of HARMONIZE. Am J Nephrol 2019; 50:473-480. [PMID: 31658466 DOI: 10.1159/000504078] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/10/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Sodium zirconium cyclosilicate (SZC; formerly ZS-9) is a selective potassium (K+) binder for treatment of hyperkalemia. An open-label extension (OLE) of the -HARMONIZE study evaluated efficacy and safety of SZC for ≤11 months. METHODS Patients from HARMONIZE with point-of-care device i-STAT K+ 3.5-6.2 mmol/L received once-daily SZC 5-10 g for ≤337 days. End points included achievement of mean serum K+ ≤5.1 mmol/L (primary) or ≤5.5 mmol/L (secondary). RESULTS Of 123 patients who entered the extension (mean serum K+ 4.8 mmol/L), 79 (64.2%) completed the study. The median daily dose of SZC was 10 g (range 2.5-15 g). The primary end point was achieved by 88.3% of patients, and 100% achieved the secondary end point. SZC was well tolerated with no new safety concerns. CONCLUSION In the HARMONIZE OLE, most patients maintained mean serum K+ within the normokalemic range for ≤11 months during ongoing SZC treatment.
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Affiliation(s)
- Simon D Roger
- Renal Research, Gosford, New South Wales, Australia,
| | - Bruce S Spinowitz
- Division of Nephrology, Department of Medicine, NewYork-Presbyterian Queens, New York, New York, USA
| | - Edgar V Lerma
- Section of Nephrology, Advocate Christ Medical Center, University of Illinois at Chicago, Oak Lawn, Illinois, USA
| | - Bhupinder Singh
- ZS Pharma, Inc., Part of AstraZeneca, San Mateo, California, USA
- School of Medicine, University of California, Irvine, California, USA
| | - David K Packham
- Melbourne Renal Research Group and Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Mikhail Kosiborod
- Department of Cardiology, Saint Luke's Mid America Heart Institute and Department of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
- The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
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Editorial. Curr Opin Nephrol Hypertens 2019; 28:407-408. [DOI: 10.1097/mnh.0000000000000523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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48
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Noel JA, Bota SE, Petrcich W, Garg AX, Carrero JJ, Harel Z, Tangri N, Clark EG, Komenda P, Sood MM. Risk of Hospitalization for Serious Adverse Gastrointestinal Events Associated With Sodium Polystyrene Sulfonate Use in Patients of Advanced Age. JAMA Intern Med 2019; 179:1025-1033. [PMID: 31180477 PMCID: PMC6563537 DOI: 10.1001/jamainternmed.2019.0631] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
IMPORTANCE Sodium polystyrene sulfonate is commonly prescribed for the treatment of hyperkalemia. Case reports of intestinal injury after administration of sodium polystyrene sulfonate with sorbitol resulted in a US Food and Drug Administration warning and discontinuation of combined 70% sorbitol-sodium polystyrene sulfonate formulations. There are ongoing concerns about the gastrointestinal (GI) safety of sodium polystyrene sulfonate use. OBJECTIVE To assess the risk of hospitalization for adverse GI events associated with sodium polystyrene sulfonate use in patients of advanced age. DESIGN, SETTING, AND PARTICIPANTS Population-based, retrospective matched cohort study of eligible adults of advanced age (≥66 years) dispensed sodium polystyrene sulfonate from April 1, 2003, to September 30, 2015, in Ontario, Canada, with maximum follow-up to March 31, 2016. Initial data analysis was conducted from August 1, 2018, to October 3, 2018; revision analysis was conducted from February 25, 2019, to April 2, 2019. Cox proportional hazards regression models were used to examine the association of sodium polystyrene sulfonate use with a composite of GI adverse events compared with nonuse that was matched via a high-dimensional propensity score. Additional analyses were limited to a subpopulation with baseline laboratory values of estimated glomerular filtration rate and serum potassium level. EXPOSURE Dispensed sodium polystyrene sulfonate in an outpatient setting. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of adverse GI events (hospitalization or emergency department visit with intestinal ischemia/thrombosis, GI ulceration/perforation, or resection/ostomy) within 30 days of initial sodium polystyrene sulfonate prescription. RESULTS From a total of 1 853 866 eligible adults, 27 704 individuals were dispensed sodium polystyrene sulfonate (mean [SD] age, 78.5 [7.7] years; 54.7% male), and 20 020 sodium polystyrene sulfonate users were matched to 20 020 nonusers. Sodium polystyrene sulfonate use compared with nonuse was associated with a higher risk of an adverse GI event over the following 30 days (37 events [0.2%]; incidence rate, 22.97 per 1000 person-years vs 18 events [0.1%]; incidence rate, 11.01 per 1000 person-years) (hazard ratio, 1.94; 95% CI, 1.10-3.41). Results were consistent in additional analyses, including the subpopulation with baseline laboratory values (hazard ratio, 2.91; 95% CI, 1.38-6.12), and intestinal ischemia/thrombosis was the most common type of GI injury. CONCLUSIONS AND RELEVANCE The use of sodium polystyrene sulfonate is associated with a higher risk of hospitalization for serious adverse GI events. These findings require confirmation and suggest caution with the ongoing use of sodium polystyrene sulfonate.
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Affiliation(s)
- J Ariana Noel
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarah E Bota
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - William Petrcich
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, Health Sciences Centre, London, Ontario, Canada
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Ziv Harel
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Navdeep Tangri
- Division of Nephrology, Department of Medicine, Seven Oaks Hospital, Winnipeg, Manitoba, Canada
| | - Edward G Clark
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Paul Komenda
- Division of Nephrology, Department of Medicine, Seven Oaks Hospital, Winnipeg, Manitoba, Canada
| | - Manish M Sood
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
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Caravaca-Fontán F, Valladares J, Díaz-Campillejo R, Barroso S, Luna E, Caravaca F. Renal potassium handling in chronic kidney disease: Differences between patients with or wihtout hyperkalemia. Nefrologia 2019; 40:152-159. [PMID: 31353054 DOI: 10.1016/j.nefro.2019.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 03/09/2019] [Accepted: 04/11/2019] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Hyperkalemia (HK) is a common electrolyte disorder in chronic kidney disease (CKD), mainly in the advanced stages. A positive potassium balance due to reduced renal excretory capacity is likely the main pathogenic mechanism of HK. Research into the relative role of each pathogenic element in the development of HK in CKD may help to implement more suitable therapies. OBJECTIVE To investigate renal potassium handling in advanced CKD patients, and to determine the differences between patients with or without HK. MATERIAL AND METHODS Cross-sectional observational study in adult patients with stage 4-5 CKD pre-dialysis. Selection criteria included clinically stable patients and the ability to collect a 24hour urine sample correctly. Blood and urinary biochemical parameters were analysed including sodium and potassium (K). Fractional excretion of K (FEK) and K load relative to glomerular filtration (Ku/GFR) were calculated. HK was defined as a serum K concentration ≥5.5mmol/l. RESULTS The study group consisted of 212 patients (mean age 65±14 years, 92 females) with a mean GFR of 15.0±4.2ml/min/1.73m2. 63 patients (30%) had HK. Patients with HK had lower mean bicarbonate levels with respect to patients with normal K levels (NK) (20.3±3.1 vs. 22.8±3.2 mEq/l, P<.0001), but no differences were noted in total urinary sodium and K excretion. While mean FEK values were lower in patients with HK (32.1±12.1% vs. 36.4±14.3%, P=.038), Ku/GFR values were significantly greater with respect to the NK subgroup (4.2±1.5 vs. 3.7±1.4 mmol/ml/min, P=0,049). FEK showed a strong linear correlation with Ku/GFR (R2=0.74), and partial linear regressions demonstrated that at a similar Ku/GFR level, the FEK of patients with HK was lower than that of NK patients. By multivariate linear and logistic regression analyses, both FEK and Ku/GFR were shown to be the main determinants of K serum levels and HK. CONCLUSIONS Although the K load relative to glomerular filtration (Ku/GFR) is an important determinant of HK in advanced CKD, the most noteworthy characteristic associated with HK in these patients was the limitation of compensatory urinary K excretion, as indicated by lower FEK.
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Affiliation(s)
| | | | | | - Sergio Barroso
- Servicio Nefrología, Hospital Infanta Cristina, Badajoz, España
| | - Enrique Luna
- Servicio Nefrología, Hospital Infanta Cristina, Badajoz, España
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Fishbane S, Ford M, Fukagawa M, McCafferty K, Rastogi A, Spinowitz B, Staroselskiy K, Vishnevskiy K, Lisovskaja V, Al-Shurbaji A, Guzman N, Bhandari S. A Phase 3b, Randomized, Double-Blind, Placebo-Controlled Study of Sodium Zirconium Cyclosilicate for Reducing the Incidence of Predialysis Hyperkalemia. J Am Soc Nephrol 2019; 30:1723-1733. [PMID: 31201218 DOI: 10.1681/asn.2019050450] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/24/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Patients with ESRD have minimal renal potassium excretion and, despite hemodialysis, often have persistent predialysis hyperkalemia. The DIALIZE study (NCT03303521) evaluated sodium zirconium cyclosilicate (SZC) in the management of hyperkalemia in hemodialysis patients. METHODS In the DIALIZE study, a double-blind, placebo-controlled, phase 3b multicenter study, we randomized adults with ESRD who were managed by three-times weekly hemodialysis and had predialysis hyperkalemia to receive placebo or SZC 5 g once daily on non-dialysis days, and titrated towards maintaining normokalemia over 4 weeks, in 5 g increments to a maximum of 15 g. The primary efficacy outcome was proportion of patients during the 4-week stable-dose evaluation period who maintained predialysis serum potassium of 4.0-5.0 mmol/L during at least three of four hemodialysis treatments after the long interdialytic interval and did not require urgent rescue therapy to reduce serum potassium. RESULTS In total, 196 patients (mean [standard deviation (SD)] age =58.1 [13.7] years old) were randomized to sodium zirconium cyclosilicate or placebo. Of 97 patients receiving sodium zirconium cyclosilicate, 41.2% met the primary end point and were deemed treatment responders compared with 1.0% of 99 patients receiving placebo (P<0.001). Rescue therapy to reduce serum potassium during the treatment period was required by 2.1% of patients taking sodium zirconium cyclosilicate versus 5.1% taking placebo. Serious adverse events occurred in 7% and 8% of patients in sodium zirconium cyclosilicate and placebo groups, respectively. The two groups displayed comparable interdialytic weight gain. There were few episodes of hypokalemia. CONCLUSIONS Sodium zirconium cyclosilicate is an effective and well-tolerated treatment for predialysis hyperkalemia in patients with ESRD undergoing adequate hemodialysis.
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Affiliation(s)
- Steven Fishbane
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York;
| | - Martin Ford
- Department of Renal Medicine, King's College Hospital NHS Trust, London, United Kingdom
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Kieran McCafferty
- Department of Nephrology, Barts Health NHS Trust, London, United Kingdom
| | - Anjay Rastogi
- Department of Medicine, David Geffen School of Medicine, Los Angeles, California
| | - Bruce Spinowitz
- Department of Medicine, New York-Presbyterian Queens, Queens, New York
| | | | - Konstantin Vishnevskiy
- Propedeutics of Internal Diseases Chair, First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia
| | | | | | - Nicolas Guzman
- Global Medicines Development, AstraZeneca, Gaithersburg, Maryland; and
| | - Sunil Bhandari
- Department of Renal and Transplant Medicine, Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
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