Managing Hyperkalemia to Enable Guideline-Recommended Dosing of Renin-Angiotensin-Aldosterone System Inhibitors

Knowledge, attitudes and practices among patients with end-stage kidney disease towards hyperkalaemia management in Shenzhen, China: a cross-sectional study

OBJECTIVES

To investigate the knowledge, attitudes and practices (KAP) among patients with end-stage kidney disease (ESKD) towards hyperkalaemia.

DESIGN

A cross-sectional study.

SETTING

This study was conducted between September and November 2023 at the Department of Nephrology, Shenzhen Third People's Hospital and the Second Affiliated Hospital of Southern University of Science and Technology.

PARTICIPANTS

The study included 568 patients with ESKD who were undergoing haemodialysis, peritoneal dialysis or both, recruited through convenience sampling.

PRIMARY AND SECONDARY OUTCOME MEASURES

This study was conducted using a self-administered questionnaire, which assessed participants' KAP towards hyperkalaemia management. The questionnaire comprised four sections: demographic information, knowledge (13 items), attitudes (9 items) and practices (9 items), with responses evaluated using a 5-point Likert scale. A cut-off value of 70% of the total score was applied, with thresholds for sufficient knowledge, favourable attitudes and proactive practices set at 6.3, 31.5 and 31.5 points, respectively. The higher the KAP scores, the better the levels of knowledge, attitude and practice. A structural equation model (SEM) was constructed to analyse the effects of demographic characteristics on KAP dimensions. Path coefficients (standardised estimates) were used to assess the strength of relationships between variables, with coefficients>0.2 generally considered moderate effects and >0.5 strong effects.

RESULTS

A total of 568 participants were enrolled in this study, including 369 (64.69%) males, and 249 (43.84%) have been diagnosed with ESKD for more than 5 years. The median (IQR) KAP scores of the participants were 9 (3-9) (possible range: 0-9), 34 (24-45) (possible range: 9-45) and 32 (10-45) (possible range: 9-45), respectively. SEM demonstrated that the frequency of dialysis had direct effects on knowledge (coefficient=0.113, p=0.039), education had direct effects on attitudes (coefficient=0.257, p<0.001), knowledge had direct effects on practices (coefficient=-0.130, p=0.016), attitudes had direct effects on practices (coefficient=0.549, p<0.001) and education had direct effects on practices (coefficient=0.112, p=0.007).

CONCLUSION

Patients with ESKD enrolled in this study have sufficient knowledge, favourable attitudes and proactive practices towards the hyperkalaemia. Nevertheless, it is still recommended to enhance clinical practice in hyperkalaemia management among patients with ESKD by tailoring education for those with lower education levels, emphasising the importance of regular dialysis and implementing strategies to bridge the knowledge-practice gap.

Albuminuria in Cardiovascular, Kidney, and Metabolic Disorders: A State-of-the-Art Review

Albuminuria-increased urine albumin excretion-is associated with cardiovascular mortality among patients with diabetes, hypertension, chronic kidney disease, or heart failure, as well as among adults with few cardiovascular risk factors. Many authors have hypothesized that albuminuria reflects widespread endothelial dysfunction, but additional work is needed to uncover whether albuminuria is directly pathologic or causative of cardiovascular disease. Urinary albumin-to-creatinine ratio is an attractive, unifying biomarker of cardiovascular, kidney, and metabolic conditions that may be useful for identifying and monitoring disease trajectory. However, albuminuria may develop through unique mechanisms across these distinct clinical phenotypes. This state-of-the-art review discusses the role of albuminuria in cardiovascular, kidney, and metabolic conditions; identifies potential pathways linking albuminuria to adverse outcomes; and provides practical approaches to screening and managing albuminuria for clinical cardiologists. Future research is needed to determine how broadly and how frequently to screen patients for albuminuria, whether it is cost-effective to treat low-grade albuminuria (10-30 mg/g), and how to equitably offer newer antiproteinuric therapies across the spectrum of cardiovascular-kidney-metabolic diseases.

Consensus statement on the management of hyperkalaemia-An Asia-Pacific perspective

Hyperkalaemia is an electrolyte imbalance that impairs muscle function and myocardial excitability, and can potentially lead to fatal arrhythmias and sudden cardiac death. The prevalence of hyperkalaemia is estimated to be 6%-7% worldwide and 7%-10% in Asia. Hyperkalaemia frequently affects patients with chronic kidney disease, heart failure, and diabetes mellitus, particularly those receiving treatment with renin-angiotensin-aldosterone system (RAAS) inhibitors. Both hyperkalaemia and interruption of RAAS inhibitor therapy are associated with increased risks for cardiovascular events, hospitalisations, and death, highlighting a clinical dilemma in high-risk patients. Conventional potassium-binding resins are widely used for the treatment of hyperkalaemia; however, caveats such as the unpalatable taste and the risk of gastrointestinal side effects limit their chronic use. Recent evidence suggests that, with a rapid onset of action and improved gastrointestinal tolerability, novel oral potassium binders (e.g., patiromer and sodium zirconium cyclosilicate) are alternative treatment options for both acute and chronic hyperkalaemia. To optimise the care for patients with hyperkalaemia in the Asia-Pacific region, a multidisciplinary expert panel was convened to review published literature, share clinical experiences, and ultimately formulate 25 consensus statements, covering three clinical areas: (i) risk factors of hyperkalaemia and risk stratification in susceptible patients; (ii) prevention of hyperkalaemia for at-risk individuals; and (iii) correction of hyperkalaemia for at-risk individuals with cardiorenal disease. These statements were expected to serve as useful guidance in the management of hyperkalaemia for health care providers in the region.

Hyperkalemia in pediatric chronic kidney disease

BACKGROUND

While hyperkalemia is well described in adult chronic kidney disease (CKD), large studies evaluating potassium trends and risk factors for hyperkalemia in pediatric CKD are lacking. This study aimed to characterize hyperkalemia prevalence and risk factors in pediatric CKD.

METHODS

Cross-sectional analysis of Chronic Kidney Disease in Children (CKiD) study data evaluated median potassium levels and percentage of visits with hyperkalemia (K ≥5.5 mmoL/L) in relation to demographics, CKD stage, etiology, proteinuria, and acid-base status. Multiple logistic regression was used to identify risk factors for hyperkalemia.

RESULTS

One thousand and fifty CKiD participants with 5183 visits were included (mean age 13.1 years, 62.7% male, 32.9% self-identifying as African American or Hispanic). A percentage of 76.6% had non-glomerular disease, 18.7% had CKD stage 4/5, 25.8% had low CO2, and 54.2% were receiving ACEi/ARB therapy. Unadjusted analysis identified a median serum potassium level of 4.5 mmol/L (IQR 4.1-5.0, p <0.001) and hyperkalemia in 6.6% of participants with CKD stage 4/5. Hyperkalemia was present in 14.3% of visits with CKD stage 4/5 and glomerular disease. Hyperkalemia was associated with low CO2 (OR 7.72, 95%CI 3.05-19.54), CKD stage 4/5 (OR 9.17, 95%CI 4.02-20.89), and use of ACEi/ARB therapy (OR 2.14, 95%CI 1.36-3.37). Those with non-glomerular disease were less frequently hyperkalemic (OR 0.52, 95%CI 0.34-0.80). Age, sex, and race/ethnicity were not associated with hyperkalemia.

CONCLUSIONS

Hyperkalemia was observed more frequently in children with advanced stage CKD, glomerular disease, low CO2, and ACEi/ARB use. These data can help clinicians identify high-risk patients who may benefit from earlier initiation of potassium-lowering therapies. A higher resolution version of the Graphical abstract is available as Supplementary information.