1
|
Pollock C, Moon JY, Ngoc Ha LP, Gojaseni P, Ching CH, Gomez L, Chan TM, Wu MJ, Yeo SC, Nugroho P, Bhalla AK. Framework of Guidelines for Management of CKD in Asia. Kidney Int Rep 2024; 9:752-790. [PMID: 38765566 PMCID: PMC11101746 DOI: 10.1016/j.ekir.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/29/2023] [Accepted: 12/11/2023] [Indexed: 05/22/2024] Open
Affiliation(s)
- Carol Pollock
- Kolling Institute of Medical Research, University of Sydney, St Leonards, New South Wales, Australia
| | - Ju-young Moon
- Kyung Hee University School of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Le Pham Ngoc Ha
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | | | | | - Lynn Gomez
- Asian Hospital and Medical Center, Muntinlupa City, Metro Manila, Philippines
| | - Tak Mao Chan
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Ming-Ju Wu
- Taichung Veterans General Hospital, Taichung City, Taiwan
| | | | | | - Anil Kumar Bhalla
- Department of Nephrology-Sir Ganga Ram Hospital Marg, New Delhi, Delhi, India
| |
Collapse
|
2
|
Fu EL, Mastrorilli J, Bykov K, Wexler DJ, Cervone A, Lin KJ, Patorno E, Paik JM. A population-based cohort defined risk of hyperkalemia after initiating SGLT-2 inhibitors, GLP1 receptor agonists or DPP-4 inhibitors to patients with chronic kidney disease and type 2 diabetes. Kidney Int 2024; 105:618-628. [PMID: 38101515 PMCID: PMC10922914 DOI: 10.1016/j.kint.2023.11.025] [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: 05/24/2023] [Revised: 11/02/2023] [Accepted: 11/10/2023] [Indexed: 12/17/2023]
Abstract
Hyperkalemia is a common adverse event in patients with chronic kidney disease (CKD) and type 2 diabetes and limits the use of guideline-recommended therapies such as renin-angiotensin system inhibitors. Here, we evaluated the comparative effects of sodium-glucose cotransporter-2 inhibitors (SGLT-2i), glucagon-like peptide-1 receptor agonists (GLP-1RA) and dipeptidyl peptidase-4 inhibitors (DPP-4i) on the risk of hyperkalemia. We conducted a population-based active-comparator, new-user cohort study using claims data from Medicare and two large United States commercial insurance databases (April 2013-April 2022). People with CKD stages 3-4 and type 2 diabetes who newly initiated SGLT-2i vs. DPP-4i (141671 patients), GLP-1RA vs. DPP-4i (159545 patients) and SGLT-2i vs. GLP-1RA (93033 patients) were included. The primary outcome was hyperkalemia diagnosed in inpatient or outpatient settings. Secondary outcomes included hyperkalemia diagnosed in inpatient or emergency department setting, and serum potassium levels of 5.5 mmol/L or more. Pooled hazard ratios and rate differences were estimated after propensity score matching to adjust for over 140 potential confounders. Initiation of SGLT-2i was associated with a lower risk of hyperkalemia compared with DPP-4i (hazard ratio 0.74; 95% confidence interval 0.68-0.80) and contrasted to GLP-1RA (0.92; 0.86-0.99). Compared with DPP-4i, GLP-1RA were also associated with a lower risk of hyperkalemia (0.80; 0.75-0.86). Corresponding absolute rate differences/1000 person-years were -24.8 (95% confidence interval -31.8 to -17.7), -5.0 (-10.9 to 0.8), and -17.7 (-23.4 to -12.1), respectively. Similar findings were observed for the secondary outcomes, among subgroups, and across single agents within the SGLT-2i and GLP-1RA classes. Thus, SGLT-2i and GLP-1RA are associated with a lower risk of hyperkalemia than DPP-4i in patients with CKD and type 2 diabetes, further supporting the use of these drugs in this population.
Collapse
Affiliation(s)
- Edouard L Fu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Julianna Mastrorilli
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Katsiaryna Bykov
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah J Wexler
- Diabetes Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander Cervone
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Julie M Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Renal (Kidney) Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts, USA.
| |
Collapse
|
3
|
Calderón-Juárez M, Samejima S, Rempel L, Sachdeva R, Krassioukov A. Autonomic dysreflexia in urological practice: pathophysiology, prevention and treatment considerations. World J Urol 2024; 42:80. [PMID: 38358540 DOI: 10.1007/s00345-024-04781-0] [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: 10/13/2023] [Accepted: 01/09/2024] [Indexed: 02/16/2024] Open
Abstract
PURPOSE Spinal cord injury (SCI) leads to sensorimotor impairments; however, it can also be complicated by significant autonomic dysfunction, including cardiovascular and lower urinary tract (LUT) dysfunctions. Autonomic dysreflexia (AD) is a dangerous cardiovascular complication of SCI often overlooked by healthcare professionals. AD is characterized by a sudden increase in blood pressure (BP) that can result in severe cardiovascular and cerebrovascular complications. In this review, we provide an overview on the clinical manifestations, risk factors, underlying mechanisms, and current approaches in prevention and management of AD. METHODS After conducting a literature research, we summarized relevant information regarding the clinical and pathophysiological aspects in the context of urological clinical practice CONCLUSIONS: The most common triggers of AD are those arising from LUT, such as bladder distention and urinary tract infections. Furthermore, AD is commonly observed in individuals with SCI during urological procedures, including catheterization, cystoscopy and urodynamics. Although significant progress in the clinical assessment of AD has been made in recent decades, effective approaches for its prevention and treatment are currently lacking.
Collapse
Affiliation(s)
- Martín Calderón-Juárez
- International Collaboration On Repair Discoveries, Faculty of Medicine, The University of British Columbia, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Soshi Samejima
- International Collaboration On Repair Discoveries, Faculty of Medicine, The University of British Columbia, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Lucas Rempel
- International Collaboration On Repair Discoveries, Faculty of Medicine, The University of British Columbia, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
- Faculty of Medicine, The University of British Columbia, Vancouver, Canada
| | - Rahul Sachdeva
- International Collaboration On Repair Discoveries, Faculty of Medicine, The University of British Columbia, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Andrei Krassioukov
- International Collaboration On Repair Discoveries, Faculty of Medicine, The University of British Columbia, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.
- Division of Physical Medicine and Rehabilitation, Department of Medicine, The University of British Columbia, Vancouver, Canada.
- GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, BC, Canada.
| |
Collapse
|
4
|
Riccio E, D'Ercole A, Sannino A, Hamzeh S, De Marco O, Capuano I, Buonanno P, Rizzo M, Pisani A. Real-world management of chronic and postprandial hyperkalemia in CKD patients treated with patiromer: a single-center retrospective study. J Nephrol 2024:10.1007/s40620-024-01897-9. [PMID: 38319545 DOI: 10.1007/s40620-024-01897-9] [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: 10/20/2023] [Accepted: 01/07/2024] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Hyperkalemia, one of the most important electrolyte abnormalities of chronic kidney disease (CKD), often limits the use of renin-angiotensin-aldosterone system inhibitors and can increase in the postprandial period. In this study we report a real-world experience with the new non-adsorbed potassium binder patiromer in stage 3b-4 CKD patients. Moreover, we performed a cross-sectional analysis to evaluate, for the first time, the efficacy of patiromer in the control of postprandial potassium concentrations. METHODS We retrospectively collected data of 40 patients at the time of patiromer initiation (T0), and after 2 (T2), 6 (T6) and 12 (T12) months of treatment. For cross sectional analysis, a blood sample was collected 2 h after the main meal for the evaluation of postprandial potassium concentrations. RESULTS Eighty-two point five percent of patients (33/40) reached normal potassium concentrations at T2. Serum potassium significantly decreased at T2 compared to T0 (5.13 ± 0.48 vs 5.77 ± 0.41 mmol/L, respectively; p < 0.001) and the reduction remained significant during the follow-up (5.06 ± 0.36 at T6 and 5.77 ± 0.41 at T12; p < 0.001 vs T0). Renin-angiotensin-aldosterone system inhibitors were continued by 93% of patients (27/29). Adverse events were reported in 27.5% of patients and were all mild-to-moderate. Postprandial potassium concentrations did not significantly change compared to fasting state potassium measured at T12 (4.53 ± 0.33 vs 5.06 ± 0.36 mmol/L; p = 0.15). CONCLUSIONS In a real-world setting of advanced CKD patients, patiromer is a useful treatment for hyperkalemia, since it significantly reduces serum potassium levels over the long term and is able to maintain potassium concentrations in the normal range even in the post-prandial period.
Collapse
Affiliation(s)
- Eleonora Riccio
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy.
| | - Anna D'Ercole
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Anna Sannino
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Sarah Hamzeh
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Oriana De Marco
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Ivana Capuano
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Pasquale Buonanno
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Manuela Rizzo
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Antonio Pisani
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| |
Collapse
|
5
|
Sevamontree C, Jintajirapan S, Phakdeekitcharoen P, Phakdeekitcharoen B. The Prevalence and Risk Factors of Hyperkalemia in the Outpatient Setting. Int J Nephrol 2024; 2024:5694131. [PMID: 38292832 PMCID: PMC10824579 DOI: 10.1155/2024/5694131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/06/2023] [Accepted: 11/20/2023] [Indexed: 02/01/2024] Open
Abstract
Background Hyperkalemia is a life-threatening condition in outpatient and emergency departments. Hyperkalemia is associated with more events of major adverse cardiovascular diseases, hospitalization, and death. The aim of this study is to study and assess the prevalence and risk factors for developing hyperkalemia within the Thai population. Method A cross-sectional observational study of 3,299 unique adult patients (≥18 years) in one calendar year (2021) with at least 1 valid serum potassium (SK) test was conducted in the outpatient department of medicine. Hyperkalemia was determined as SK ≥5.8 mmol/L without hemolysis or technical error. Clinical data and laboratory tests were collected for analysis of risk factors. Result 2,971 patients (131 hyperkalemia and 2,840 control) were eligible. The annual prevalence of hyperkalemia was 4.41%. The mean ages of patients were 66.5 years in the hyperkalemia group and 55.9 years in the control group. Increasing age had a positive association (r = 0.220, p < 0.001) to risk of hyperkalemia, whereas the estimated glomerular filtration rate (eGFR) had an inverse association with SK level (r = -0.398, p < 0.001). The risk factors for hyperkalemia were patients with age ≥65 years (odds ratio, 2.106; 95% CI, 1.399, 3.171; p < 0.001), presence of diabetes mellitus (DM, odds ratio, 1.541; 95% CI, 1.030, 2.306; p = 0.036), chronic kidney disease (CKD) stage ≥3 (odds ratio, 14.885; 95% CI, 8.112, 27.313; p < 0.001), hemodialysis treatment (odds ratio, 10.170; 95% CI, 5.858, 17.657; p < 0.001), and usage of renin-angiotensin-aldosterone system inhibitors (RAASi, odds ratio, 2.256; 95% CI, 1.440, 3.536; p < 0.001). Conclusion The risk factors contributing to hyperkalemia were patients with older age, DM, CKD, hemodialysis treatment, and usage of RAASi. Although the usage of RAASi is proven to be a cardiovascular advantage in the elderly, DM, and CKD patients, careful monitoring of SK is strongly advised to optimize patient care.
Collapse
Affiliation(s)
- Chadapa Sevamontree
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Supreeya Jintajirapan
- Outpatient Intervention and Urgency Care, Department of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Bunyong Phakdeekitcharoen
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
6
|
Obi Y, Thomas F, Dashputre AA, Goedecke P, Kovesdy CP. Long-term Patiromer Use and Outcomes Among US Veterans With Hyperkalemia and CKD: A Propensity-Matched Cohort Study. Kidney Med 2024; 6:100757. [PMID: 38192434 PMCID: PMC10772292 DOI: 10.1016/j.xkme.2023.100757] [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] [Indexed: 01/10/2024] Open
Abstract
Rationale & Objective Patiromer is a potassium binder approved for the long-term management of hyperkalemia. Although patiromer use among patients with advanced chronic kidney disease (CKD) has been shown to reduce the discontinuation of renin-angiotensin-aldosterone system inhibition therapy, it remains unclear whether patiromer can improve clinical outcomes. The aim of this study was to examine the association of long-term patiromer use with clinical outcomes among hyperkalemic patients with CKD. Study Design This was a longitudinal observational study. Setting & Participants We evaluated a national cohort of 854,217 US Veterans who had at least 1 serum potassium measurement of ≥5.1 mEq/L and were treated at US Department of Veterans Affairs health care facilities between January 2016 and September 2019. Exposure The exposure was long-term patiromer use. Outcomes The outcomes were as follows: (1) composite endpoint of kidney failure with replacement therapy (KFRT) or all-cause death and (2) all-cause death including the post-KFRT period. Analytical Approach Cox proportional Fine-Gray subdistribution hazard models were used in a propensity-matched cohort. Results Among 2,004 patients who ever used patiromer during the study period (0.2% of the cohort), 666 met the criteria for long-term patiromer use. We matched 308 long-term patiromer users to 308 nonusers based on propensity scores. The median estimated glomerular filtration rate was 23.5 mL/min/1.73m2, and the median potassium level was 5.2 mEq/L. Approximately 45% were on renin-angiotensin system inhibitor(s) at baseline. During follow-up, 93 patients developed KFRT, and 134 patients died. Long-term patiromer users, when compared to nonusers, experienced a 26% lower risk of the composite outcome (HR, 0.74; 95% CI, 0.53-1.01; P = 0.06) and a 41% lower risk of all-cause mortality (HR, 0.59; 95% CI, 0.41-0.84; P = 0.003). Limitations The study cohort included mostly male veterans with relatively short follow-up periods. Conclusions Long-term patiromer use was associated with a lower risk of all-cause mortality among patients with CKD and hyperkalemia. Long-term potassium binder use for hyperkalemia may improve clinical outcomes in CKD. Plain-Language Summary Hyperkalemia is a common complication of chronic kidney disease (CKD) and can result in the discontinuation of renin-angiotensin-aldosterone system inhibition therapy, a cornerstone of CKD management. Patiromer is a new potassium binder approved for the long-term management of hyperkalemia, but it remains unclear whether patiromer can improve clinical outcomes. We examined a cohort of US Veterans with hyperkalemia between January 2016 and September 2019 and found that patiromer use was uncommon for treating hyperkalemia during this study period. We then matched 308 long-term patiromer users and 308 nonusers based on propensity scores. Long-term patiromer users, when compared to nonusers, experienced a 26% lower risk of the composite outcome and a 41% lower risk of all-cause mortality. These findings indicate that long-term potassium binder use for hyperkalemia may improve clinical outcomes in CKD.
Collapse
Affiliation(s)
- Yoshitsugu Obi
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Fridtjof Thomas
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Ankur A. Dashputre
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
- Health Economics & Outcomes Research, Bausch Health US LLC, Bridgewater, NJ
| | - Patricia Goedecke
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
- Nephrology Section, Veterans Memphis Affairs Medical Center, Memphis, TN
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Palmer BF, Clegg DJ. Pathophysiology and clinical management of hyperkalemia in chronic kidney disease. Minerva Med 2023; 114:719-735. [PMID: 36912858 DOI: 10.23736/s0026-4806.23.08465-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Adaptive increases in kidney and gastrointestinal excretion of K+ help to prevent hyperkalemia in patients with chronic kidney disease (CKD) as long as the glomerular filtration rate (GFR) remains >15-20 mL/min. K+ balance is maintained by increased secretion per functioning nephron, which is mediated by elevated plasma K+ concentration, aldosterone, increased flow rate, and enhanced Na+-K+-ATPase activity. Fecal losses of potassium also increase in CKD. These mechanisms are effective in preventing hyperkalemia if urine output is in excess of 600 mL/day and the GFR exceeds 15 mL/min. Development of hyperkalemia with only mild to moderate reductions in GFR should prompt a search for intrinsic disease of the collecting duct, disturbances in mineralocorticoid activity, and/or decreased delivery of sodium to the distal nephron. The initial approach to treatment is to review the patient's medication profile and whenever possible discontinue drugs that impair kidney K+ excretion. Patients should be educated on sources of K+ in the diet and should be strongly encouraged to avoid the use of K+ containing salt substitutes as well as herbal remedies since herbs may be a hidden source of dietary K+. Effective diuretic therapy and correction of metabolic acidosis are effective strategies to minimize the potential for hyperkalemia. Discontinuation or use of submaximal doses of renin-angiotensin blockers should be discouraged given the cardiovascular protective effect these drugs provide. Potassium binding drugs can be useful to enable use of these drugs and potentially allow liberalization of the diet in CKD patients.
Collapse
Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA -
| | - Deborah J Clegg
- Department of Internal Medicine, Texas Tech Health Sciences Center, El Paso, TX, USA
| |
Collapse
|
9
|
Dockery S, Dupré A, Deflorio P, Murray BP. Emergency Department Presentation of Life-threatening Symptomatic Hyperkalemia From an Angiotensin Receptor Blocker in a Low-risk Individual. Mil Med 2023; 188:3242-3247. [PMID: 36454619 DOI: 10.1093/milmed/usac376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/22/2022] [Accepted: 11/14/2022] [Indexed: 08/31/2023] Open
Abstract
Hyperkalemia is a common electrolyte abnormality with characteristic electrocardiogram changes. Both angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) increase the risk of developing hyperkalemia. This case highlights a rare life-threatening episode of hyperkalemia in an individual whose only risk factor was an ARB. A 58-year-old female presented with sudden-onset chest pressure, light-headedness, and diaphoresis. Her initial electrocardiogram showed a nearly sinusoidal rhythm with a widened ventricular depolarization (QRS) and prolonged QT-interval (QTc). Life-threatening hyperkalemia of 9.1 mmol/L was confirmed with a rapid point-of-care electrolyte panel. She was rapidly treated with calcium, potassium-shifting and eliminating medications, and emergent hemodialysis. After stabilization, a thorough workup found that the patient's only risk factor for hyperkalemia was her use of an ARB. While both ARBs and ACEIs are commonly associated with mild hyperkalemia, life-threatening hyperkalemia is rare, particularly in patients without concomitant renal failure, diabetes mellitus, adrenal disease, or potassium-sparing diuretic use. However, this case illustrates that life-threatening hyperkalemia is possible in patients solely taking an ARB without prior significant risk factors. Despite normal renal function in an individual without heart failure or diabetes, this patient developed life-threatening hyperkalemia.
Collapse
Affiliation(s)
- Samuel Dockery
- Wright State University Boonshoft School of Medicine, Dayton, OH 45435, USA
| | - Alan Dupré
- Wright State University Boonshoft School of Medicine, Dayton, OH 45435, USA
| | - Paul Deflorio
- Wright State University Boonshoft School of Medicine, Dayton, OH 45435, USA
| | | |
Collapse
|
10
|
Paraskevaidis I, Xanthopoulos A, Karamichalakis N, Triposkiadis F, Tsougos E. Medical Treatment in Heart Failure with Reduced Ejection Fraction: A Proposed Algorithm Based on the Patient's Electrolytes and Congestion Status. Med Sci (Basel) 2023; 11:38. [PMID: 37367737 PMCID: PMC10302950 DOI: 10.3390/medsci11020038] [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: 04/25/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
In heart failure (HF) with reduced ejection fraction (HFrEF), four classes of drugs (β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor neprilysin inhibitors, mineralocorticoid receptor antagonists, and the most recent Sodium-Glucose Co-Transporters 2 Inhibitors) have demonstrated positive results in randomized controlled trials (RCTs). Nevertheless, the latest RCTs are not proper for comparison since they were carried out at various times with dissimilar background therapies and the patients enrolled did not have the same characteristics. The difficulty of extrapolating from these trials and proposing a common framework appropriate for all cases is thus obvious. Despite the fact that these four agents are now the fundamental pillars of HFrEF treatment, the built-up algorithm of initiation and titration is a matter of debate. Electrolyte disturbances are common in HFrEF patients and can be attributed to several factors, such as the use of diuretics, renal impairment, and neurohormonal activation. We have identified several HFrEF phenotypes according to their sodium (Na+) and potassium (K+) status in a "real world" setting and suggest an algorithm on how to introduce the most appropriate drug and set up therapy based on the patients' electrolytes and the existence of congestion.
Collapse
Affiliation(s)
| | - Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
| | | | | | - Elias Tsougos
- 6th Department of Cardiology, Hygeia Hospital, 15123 Athens, Greece
| |
Collapse
|
11
|
Lu JC, Lee P, Ierino F, MacIsaac RJ, Ekinci E, O'Neal D. Challenges of Glycemic Control in People With Diabetes and Advanced Kidney Disease and the Potential of Automated Insulin Delivery. J Diabetes Sci Technol 2023:19322968231174040. [PMID: 37162092 DOI: 10.1177/19322968231174040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Diabetes is the leading cause of chronic kidney disease (CKD) and end-stage kidney disease in the world. It is known that maintaining optimal glycemic control can slow the progression of CKD. However, the failing kidney impacts glucose and insulin metabolism and contributes to increased glucose variability. Conventional methods of insulin delivery are not well equipped to adapt to this increased glycemic lability. Automated insulin delivery (AID) has been established as an effective treatment in patients with type 1 diabetes mellitus, and there is emerging evidence for their use in type 2 diabetes mellitus. However, few studies have examined their role in diabetes with concurrent advanced CKD. We discuss the potential benefits and challenges of AID use in patients with diabetes and advanced CKD, including those on dialysis.
Collapse
Affiliation(s)
- Jean C Lu
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Parkville, VIC, Australia
| | - Petrova Lee
- Department of Nephrology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Francesco Ierino
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
- Department of Nephrology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
- St Vincent's Institute of Medical Research, Fitzroy, VIC, Australia
| | - Richard J MacIsaac
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Parkville, VIC, Australia
| | - Elif Ekinci
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Parkville, VIC, Australia
- Department of Endocrinology and Diabetes, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine, Austin Hospital, The University of Melbourne, Heidelberg, VIC, Australia
| | - David O'Neal
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Parkville, VIC, Australia
| |
Collapse
|
12
|
Chen HT, Yu BH, Yeh MH, Hung SK, Chen YC. Dose- and time-dependent renoprotection of Angelica sinensis in patients with chronic kidney disease: A longitudinal cohort study. Front Pharmacol 2023; 14:1153583. [PMID: 37180720 PMCID: PMC10166798 DOI: 10.3389/fphar.2023.1153583] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/05/2023] [Indexed: 05/16/2023] Open
Abstract
Background: Based on their anti-oxidative and anti-fibrotic properties, Angelica sinensis (Oliv.) Diels roots [Apiaceae; Radix Angelicae sinensis] (Danggui [abbreviated as S in the context]), Astragalus membranaceus (Fisch.) Bunge [Fabaceae; Astragalus membranaceus] (Huangqi [A]), Rheum palmatum L. [Polygonaceae; Rheum palmatum] (Dahuang [R]), and Salvia miltiorrhiza Bunge [Lamiaceae; Salvia miltiorrhiza Bunge radix et rhizoma] (Danshen [D]) are potential renoprotective Chinese herbal medicines (CHMs). Renoprotection using ARD alone for the treatment of chronic kidney disease (CKD) has been documented in pre-clinical, clinical, and meta-analysis research; however, only pre-clinical data are available for the use of S alone. Moreover, with an increasing number of CKD patients taking prescribed CHMs, hyperkalemia risk remains unclear. Methods: This study retrospectively analyzed national health insurance claims data in 2001-2017. Propensity score matching was used to analyze renal and survival outcomes and the dose-response effects of S without ARD use in 18,348 new S users, 9,174 new ARD users, and 36,696 non-users. Cox proportional hazard regression was used to investigate adjusted hazard ratios (aHRs) for end-stage renal disease (ESRD) in the presence of competing mortality and death. The additive effect of the S herb in single form to compounds was also analyzed. Additionally, to analyze hyperkalemia risk, an exact match on each covariate was used to include 42,265 new CHM users and non-users, while Poisson regression was used to estimate adjusted incidence rate ratios (aIRRs) of hyperkalemia of prescribed CHMs. Results: S users and ARD users were associated with aHRs of 0.77 (95% confidence interval; 0.69-0.86) and 1.04 (0.91-1.19), respectively, for ESRD and 0.55 (0.53-0.57) and 0.71 (0.67-0.75), respectively, for death. The renal and survival benefits of S use were consistent in several sensitivity analyses. The dose- and time-dependent renoprotection and dose-dependent survival benefits were observed for S use. The top two additive renoprotective collocations of the S herb in compounds were Xue-Fu-Zhu-Yu-Tang and Shen-Tong-Zhu-Yu-Tang, followed by Shu-Jing-Huo-Xue-Tang and Shen-Tong-Zhu-Yu-Tang. Moreover, CHM users were associated with aIRRs of 0.34 (0.31-0.37) for hyperkalemia. Conclusion: This study suggests dose- and time-dependent renoprotection and dose-dependent survival benefits of the S herb in compounds and no increased hyperkalemia risk of the prescribed CHMs in CKD patients.
Collapse
Affiliation(s)
- Hsiao-Tien Chen
- Department of Chinese Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Ben-Hui Yu
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Ming-Hsien Yeh
- Department of Chinese Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
| | - Shih-Kai Hung
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yi-Chun Chen
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Nephrology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| |
Collapse
|
13
|
Habas E, Akbar R, Farfar K, Arrayes N, Habas A, Rayani A, Alfitori G, Habas E, Magassabi Y, Ghazouani H, Aladab A, Elzouki AN. Malignancy diseases and kidneys: A nephrologist prospect and updated review. Medicine (Baltimore) 2023; 102:e33505. [PMID: 37058030 PMCID: PMC10101313 DOI: 10.1097/md.0000000000033505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/21/2023] [Indexed: 04/15/2023] Open
Abstract
Acute kidney injury (AKI), chronic renal failure, and tubular abnormalities represent the kidney disease spectrum of malignancy. Prompt diagnosis and treatment may prevent or reverse these complications. The pathogenesis of AKI in cancer is multifactorial. AKI affects outcomes in cancer, oncological therapy withdrawal, increased hospitalization rate, and hospital stay. Renal function derangement can be recovered with early detection and targeted therapy of cancers. Identifying patients at higher risk of renal damage and implementing preventive measures without sacrificing the benefits of oncological therapy improve survival. Multidisciplinary approaches, such as relieving obstruction, hydration, etc., are required to minimize the kidney injury rate. Different keywords, texts, and phrases were used to search Google, EMBASE, PubMed, Scopus, and Google Scholar for related original and review articles that serve the article's aim well. In this nonsystematic article, we aimed to review the published data on cancer-associated kidney complications, their pathogenesis, management, prevention, and the latest updates. Kidney involvement in cancer occurs due to tumor therapy, direct kidney invasion by tumor, or tumor complications. Early diagnosis and therapy improve the survival rate. Pathogenesis of cancer-related kidney involvement is different and complicated. Clinicians' awareness of all the potential causes of cancer-related complications is essential, and a kidney biopsy should be conducted to confirm the kidney pathologies. Chronic kidney disease is a known complication in malignancy and therapies. Hence, avoiding nephrotoxic drugs, dose standardization, and early cancer detection are mandatory measures to prevent renal involvement.
Collapse
Affiliation(s)
- Elmukhtar Habas
- Facharzt Internal Medicine, Facharzt Nephrology, Medical Department, Hamad General Hospital, Doha, Qatar
| | - Raza Akbar
- Medical Department, Hamad General Hospital, Doha, Qatar
| | - Kalifa Farfar
- Facharzt Internal Medicine, Medical Department, Alwakra General Hospital, Alwakra, Qatar
| | - Nada Arrayes
- Medical Education Fellow, Lincoln Medical School, University of Lincoln, Lincoln, UK
| | - Aml Habas
- Hematology-Oncology Department, Tripoli Children Hospital, Tripoli, Libya
| | - Amnna Rayani
- Facharzt Pediatric, Facharzt Hemotoncology, Hematology-Oncology Department, Tripoli Children Hospital, Tripoli, Libya
| | | | - Eshrak Habas
- Medical Department, Tripoli Central Hospital, University of Tripoli, Tripoli, Libya
| | | | - Hafidh Ghazouani
- Quality Department, Senior Epidemiologist, Hamad Medical Corporation, Doha, Qatar
| | | | | |
Collapse
|
14
|
Cañas AE, Troutt HR, Jiang L, Tonthat S, Darwish O, Ferrey A, Lotfipour S, Kalantar-Zadeh K, Hanna R, Lau WL. A randomized study to compare oral potassium binders in the treatment of acute hyperkalemia. BMC Nephrol 2023; 24:89. [PMID: 37016309 PMCID: PMC10074796 DOI: 10.1186/s12882-023-03145-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/28/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND The KBindER (K+ Binders in Emergency Room and hospitalized patients) clinical trial is the first head-to-head evaluation of oral potassium binders (cation-exchange resins) for acute hyperkalemia therapy. METHODS Emergency room and hospitalized patients with a blood potassium level ≥ 5.5 mEq/L are randomized to one of four study groups: potassium binder drug (sodium polystyrene sulfonate, patiromer, or sodium zirconium cyclosilicate) or nonspecific laxative (polyethylene glycol). Exclusion criteria include recent bowel surgery, ileus, diabetic ketoacidosis, or anticipated dialysis treatment within 4 h of treatment drug. Primary endpoints include change in potassium level at 2 and 4 h after treatment drug. Length of hospital stay, next-morning potassium level, gastrointestinal side effects and palatability will also be analyzed. We are aiming for a final cohort of 80 patients with complete data endpoints (20 per group) for comparative statistics including multivariate adjustment for kidney function, diabetes mellitus, congestive heart failure, metabolic acidosis, renin-angiotensin-aldosterone system inhibitor prescription, and treatment with other agents to lower potassium (insulin, albuterol, loop diuretics). DISCUSSION The findings from our study will inform decision-making guidelines on the role of oral potassium binders in the treatment of acute hyperkalemia. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04585542 . Registered 14 October 2020.
Collapse
Affiliation(s)
- Alejandro E Cañas
- Division of Nephrology, Department of Medicine, University of California-Irvine, 101 The City Drive South, City Tower, Suite 400, Orange, CA, 92868, USA
| | - Hayden R Troutt
- Division of Nephrology, Department of Medicine, University of California-Irvine, 101 The City Drive South, City Tower, Suite 400, Orange, CA, 92868, USA
| | - Luohua Jiang
- Department of Epidemiology & Biostatistics, Program in Public Health, University of California-Irvine, Irvine, USA
| | - Sam Tonthat
- Division of Nephrology, Department of Medicine, University of California-Irvine, 101 The City Drive South, City Tower, Suite 400, Orange, CA, 92868, USA
| | - Omar Darwish
- Department of Medicine, University of California-Irvine, Orange, USA
| | - Antoney Ferrey
- Division of Nephrology, Department of Medicine, University of California-Irvine, 101 The City Drive South, City Tower, Suite 400, Orange, CA, 92868, USA
| | - Shahram Lotfipour
- Department of Emergency Medicine, University of California-Irvine, Orange, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Department of Medicine, University of California-Irvine, 101 The City Drive South, City Tower, Suite 400, Orange, CA, 92868, USA
| | - Ramy Hanna
- Division of Nephrology, Department of Medicine, University of California-Irvine, 101 The City Drive South, City Tower, Suite 400, Orange, CA, 92868, USA
| | - Wei Ling Lau
- Division of Nephrology, Department of Medicine, University of California-Irvine, 101 The City Drive South, City Tower, Suite 400, Orange, CA, 92868, USA.
| |
Collapse
|
15
|
Johnson M, Morrison FJ, McMahon G, Su M, Turchin A. Outcomes in patients with cardiometabolic disease who develop hyperkalemia while treated with a renin-angiotensin-aldosterone system inhibitor. Am Heart J 2023; 258:49-59. [PMID: 36642227 DOI: 10.1016/j.ahj.2023.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 01/06/2023] [Accepted: 01/07/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Many patients with indications for renin-angiotensin-aldosterone system inhibitor (RAASi) therapy are not receiving these medications. Concern about hyperkalemia is thought to contribute to this lack of evidence-based therapy. METHODS A retrospective cohort study included adult patients in primary care practices affiliated with an integrated health care delivery system treated with RAASi between 2000 and 2019 for any of the following indications: (a) coronary artery disease (CAD); (b) heart failure (HF) with a left ventricle ejection fraction ≤ 40%; (c) diabetes mellitus (DM) with proteinuria; or (d) chronic kidney disease (CKD) with proteinuria. Relationship between hyperkalemia (K > 5.0 mEg/L) over the first 12 months of follow-up and a composite end point of cardiovascular events, renal dysfunction, and all-cause mortality was evaluated. RESULTS Among 82,732 study patients, 7,727 (9.34%) developed hyperkalemia. Patients with hyperkalemia were older (69.0 vs 64.6) and more likely to have CAD (57.8 vs 53.7%), CKD (57.3 vs 51.1%), HF (19.3 vs 9.7%), and DM (45.3 vs 33.3%) (P < .001 for all). Five-year cumulative risk of the primary outcome was higher in patients who did (63.9%; 95% CI: 62.8%-65.1%) versus did not (37.2%; 95% CI: 36.8%-37.6%) develop hyperkalemia. Five-year cumulative risk of ED visit or hospitalization for hyperkalemia was 15.6% (14.7%-16.6%) for patients with versus 2.7% (95% CI: 2.6-2.9) for patients without hyperkalemia, rising to 25.9% (95% CI: 22.4-29.9) for patients with severe (K > 6.0 mEq/dL) hyperkalemia. Patients who experienced hyperkalemia were more likely (34.4%) than patients who did not (29.2%) to deintensify RAASi therapy (P < .001). Five-year cumulative risk of the primary outcome was higher in patients who lowered RAASi dose (50.4%; 95% CI: 48.5%-52.4%) or stopped RAASi therapy completely (49.3%; 95% CI: 48.5%-50.1%), compared to patients who continued RAASi therapy (36.1%; 95% CI: 25.7-36.5). Similar findings were observed in multivariable analyses and for individual components of the primary outcome. CONCLUSIONS Hyperkalemia is a common complication of RAASi therapy and is associated with an increased risk of multiple adverse outcomes. Patients who have their RAASi medications deintensified after a hyperkalemic event have higher incidence of cardiovascular events, renal dysfunction and death.
Collapse
Affiliation(s)
- Matthew Johnson
- Division of Endocrinology, Brigham and Women's Hospital, Boston, MA; Columbia University College of Physicians and Surgeons, New York, NY
| | | | - Gearoid McMahon
- Division of Endocrinology, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Maxwell Su
- Harvard School of Public Health, Boston, MA; Phase V, Wellesley Hills, MA
| | - Alexander Turchin
- Division of Endocrinology, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| |
Collapse
|
16
|
Hirai T, Ueda S, Ogura T, Katayama K, Dohi K, Hosohata K, Aoyama T, Matsumoto Y, Iwamoto T. Hyperkalemia by eplerenone or esaxerenone in the presence or absence of clarithromycin in hypertensive patients: a retrospective observational cohort study. J Hypertens 2023; 41:580-586. [PMID: 36655800 DOI: 10.1097/hjh.0000000000003372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Mineralocorticoid receptor antagonists (MRAs), eplerenone and esaxerenone, cause hyperkalemia dose-dependently. We investigated the cytochrome P450 3A4-mediated drug-drug interaction between the MRAs and clarithromycin. METHODS This retrospective observational study included adult hypertensive patients with MRA plus clarithromycin or MRA alone with a propensity score matching (1:1). The difference in serum potassium level (ΔK, maximum level - baseline level) between groups was compared using the Mann-Whitney U -test. Linear regression analysis was used to detect variables that correlated with ΔK in patients with MRA plus clarithromycin. RESULTS After propensity score matching (each nine patients), serum potassium level was elevated after treatment with MRA plus clarithromycin [4.3 (3.5 to 5.1) meq/l to 4.9 (4.0 to 5.5) meq/l, P = 0.0234] and MRA alone [4.3 (4.0 to 4.7) meq/l to 4.6 (4.4 to 5.2) meq/l, P = 0.0469]. Although there was no significant difference in ΔK between groups [MRA plus clarithromycin: 0.5 (0.1 to 1.1) meq/l vs. MRA alone: 0.3 (0.1 to 1.2) meq/l, P = 0.7231], ΔK was significantly higher in esaxerenone plus clarithromycin than in esaxerenone alone [0.6 (0.5 to 1.1) meq/l vs. 0.1 (0.1 to 0.2) meq/l, P = 0.0495]. Conversely, clarithromycin did not show a significant effect on ΔK in patients with eplerenone [0.4 (-0.2 to 1.2) meq/l vs. 0.8 (0.1 to 1.3) meq/l, P = 0.5745]. A positive correlation was found between ΔK and age in patients with MRA plus clarithromycin ( y = 0.03 × x - 1.38, r = 0.71, P = 0.0336). CONCLUSION The drug-drug interaction between MRAs and clarithromycin was evident, particularly in esaxerenone. Serum potassium levels should be closely monitored in older patients.
Collapse
Affiliation(s)
| | - Shun Ueda
- Department of Pharmacy, Faculty of Medicine
| | | | | | - Kaoru Dohi
- Department of Cardiology, Faculty of Medicine, Mie University Hospital, Mie University, Edobashi, Tsu, Mie
| | - Keiko Hosohata
- Education and Research Center for Clinical Pharmacy, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka
| | - Takahiko Aoyama
- Laboratory of Clinical Pharmacokinetics, School of Pharmacy, Nihon University, Funabashi, Chiba, Japan
| | - Yoshiaki Matsumoto
- Laboratory of Clinical Pharmacokinetics, School of Pharmacy, Nihon University, Funabashi, Chiba, Japan
| | | |
Collapse
|
17
|
Ni J, Khalid A, Lin YC, Barakat MT, Wang J, Tsai CY, Azar PRS, Ding Y, Murayi JA, Jayaraman T, Poropatich R, Bottino R, Wen L, Papachristou GI, Swaminathan G, Yu M, Husain SZ. Preclinical safety evaluation of calcineurin inhibitors delivered through an intraductal route to prevent post-ERCP pancreatitis demonstrates endocrine and systemic safety. Pancreatology 2023:S1424-3903(23)00073-X. [PMID: 37031049 DOI: 10.1016/j.pan.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/24/2023] [Accepted: 03/26/2023] [Indexed: 04/10/2023]
Abstract
OBJECTIVE There is an urgent need for safe and targeted interventions to mitigate post-ERCP pancreatitis (PEP). Calcineurin inhibitors (CnIs) offer therapeutic promise as calcineurin signaling within acinar cells is a key initiating event in PEP. In previous proof-of-concept studies using experimental models, we showed that concurrent intra-pancreatic ductal administration of the CnIs, tacrolimus (Tac) or cyclosporine A (CsA) with the ERCP radiocontrast agent (RC) prevented PEP. To translate this finding clinically, we investigated potential toxic effects of intraductal delivery of a single-dose RC-CnI formulation on endocrine pancreas function and systemic toxicities in a preclinical PEP model. METHODS C57BL/6J mice underwent ductal cannulation and received a single, intra-pancreatic ductal infusion of RC or RC with Tac or CsA (treatment groups) or underwent ductal cannulation without infusion ('sham' group). To assess endocrine function, intraperitoneal glucose tolerance test (IPGTT) was performed at two days before infusion and on day 2 and 14 post-surgery. To evaluate off-target tissue toxicities, renal and hepatic function-related parameters including blood urea nitrogen, plasma creatinine, potassium, aspartate aminotransferase, alanine aminotransferase, and total bilirubin were measured at the same time-points as IPGTT. Histological and biochemical indicators of pancreas injury and inflammation were also evaluated. RESULTS No abnormalities in glucose metabolism, hepatic or renal function were observed on day 2 or 14 in mice administered with intraductal RC or RC with Tac or CsA. CONCLUSION Intraductal delivery of RC-CnI formulation was safe and well-tolerated with no significant acute or subacute endocrine or systemic toxicities, underscoring its clinical utility to prevent PEP.
Collapse
Affiliation(s)
- Jianbo Ni
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA; Department of Gastroenterology and Shanghai Key Laboratory of Pancreatic Disease, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Asna Khalid
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Yu-Chu Lin
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Monique T Barakat
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA; Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jing Wang
- Department of Radiology and Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Cheng-Yu Tsai
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Pasha Reza Shams Azar
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Ying Ding
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Judy-April Murayi
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Thottala Jayaraman
- Department of Oral and Craniofacial Sciences, School of Dental Medicine, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Rita Bottino
- Imagine Islet Center, Imagine Pharma, 1401 Forbes Avenue, Pittsburgh, PA, USA
| | - Li Wen
- Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | | | - Gayathri Swaminathan
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Mang Yu
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
| | - Sohail Z Husain
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
| |
Collapse
|
18
|
Thanabalasingam S, Popa C, Arora N, Hiremath S, Teakell J. Renin-Angiotensin System Inhibitors in Advanced CKD: a #NephJC Editorial on STOP-ACEi. Kidney Med 2023; 5:100633. [DOI: 10.1016/j.xkme.2023.100633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
|
19
|
Ogata S, Akashi Y, Kato S, Oka Y, Suda A, Yoshizaki S, Maeda Y, Nishimura K, Maeda K, Nakai S. Association Between Dietary Potassium Intake Estimated From Multiple 24-Hour Urine Collections and Serum Potassium in Patients With CKD. Kidney Int Rep 2023; 8:584-595. [PMID: 36938093 PMCID: PMC10014441 DOI: 10.1016/j.ekir.2022.12.005] [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: 11/01/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
Abstract
Introduction Limited and inconclusive evidence for the association of dietary potassium intake with serum potassium in chronic kidney disease (CKD) patients have been shown, though restricting dietary potassium has been recommended for CKD patients to prevent hyperkalemia. Multiple 24-hour urine collections are necessary to adequately assess potassium intake. We investigated associations of 24-hour urinary potassium excretion (UKV) with serum potassium in CKD outpatients based on multiple 24-hour urine collections. Methods This retrospective cohort study was based on outpatients with CKD stages G3 to G5, median age of 72.0 years; and median follow-up of 3.9 months and 8.9 months, respectively, for analyses using 3-time measurement (N = 290 and 870 observations) and 7-time measurements (N = 220 and 1540 observations). The outcome was serum potassium. Results Multivariable-adjusted mean difference in serum potassium (mEq/l) and odds ratio of hyperkalemia per 10 mEq/d increase in UKV were, respectively, 0.12 (95% confidence interval [CI]: 0.09-0.15) and 2.15 (1.70-2.73) in generalized estimating equations (GEEs) with 3-time measurements. The mean difference became more pronounced as CKD stages progressed: 0.08 (0.05-0.12), 0.12 (0.08-0.16), and 0.16 (0.12-0.20) for CKD G3, G4, and G5. Similar results were obtained from analyses using 7-time measurements and hierarchical Bayesian measurement error models treating measurement error of UKV adequately. Conclusion We suggest significant but weak associations (R2: 0.08, 0.14, and 0.18 for CKD G3, G4, and G5) between serum potassium and dietary potassium intake estimated by multiple 24-hour urine collections in CKD patients. Further studies are needed to validate nutritional and clinical aspects of the associations.
Collapse
Affiliation(s)
- Soshiro Ogata
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yuumi Akashi
- Faculty of Nursing, Fujita Health University School of Health Sciences, Toyoake, Aichi, Japan
| | - Satoshi Kato
- HU Group Research Institute GK, Akiruno, Tokyo, Japan
| | - Yuma Oka
- HU Group Research Institute GK, Akiruno, Tokyo, Japan
| | - Akari Suda
- HU Group Research Institute GK, Akiruno, Tokyo, Japan
| | | | - Yuko Maeda
- Daiko-Sunadabashi Clinic, Nagoya, Aichi, Japan
| | - Kunihiro Nishimura
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kenji Maeda
- Daiko-Sunadabashi Clinic, Nagoya, Aichi, Japan
| | - Shigeru Nakai
- Faculty of Nursing, Fujita Health University School of Health Sciences, Toyoake, Aichi, Japan
- Correspondence: Shigeru Nakai, Faculty of Nursing, Fujita Health University School of Health Sciences, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192, Japan.
| |
Collapse
|
20
|
Adomako EA, Maalouf NM. Type 4 renal tubular acidosis and uric acid nephrolithiasis: two faces of the same coin? Curr Opin Nephrol Hypertens 2023; 32:145-152. [PMID: 36683539 PMCID: PMC9881823 DOI: 10.1097/mnh.0000000000000859] [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] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW The present review summarizes findings of recent studies examining the epidemiology, pathophysiology, and treatment of type 4 renal tubular acidosis (RTA) and uric acid nephrolithiasis, two conditions characterized by an abnormally acidic urine. RECENT FINDINGS Both type 4 RTA and uric acid nephrolithiasis disproportionately occur in patients with type 2 diabetes and/or chronic kidney disease. Biochemically, both conditions are associated with reduced renal ammonium excretion resulting in impaired urinary buffering and low urine pH. Reduced ammoniagenesis is postulated to result from hyperkalemia in type 4 RTA and from insulin resistance and fat accumulation in the renal proximal tubule in uric acid nephrolithiasis. The typical biochemical findings of hyperkalemia and systemic acidosis of type 4 RTA are rarely reported in uric acid stone formers. Additional clinical differences between the two conditions include findings of higher urinary uric acid excretion and consequent urinary uric acid supersaturation in uric acid stone formers but not in type 4 RTA. SUMMARY Type 4 RTA and uric acid nephrolithiasis share several epidemiological, clinical, and biochemical features. Although both conditions may be manifestations of diabetes mellitus and thus have a large at-risk population, the means to the shared biochemical finding of overly acidic urine are different. This difference in pathophysiology may explain the dissimilarity in the prevalence of kidney stone formation.
Collapse
Affiliation(s)
- Emmanuel A. Adomako
- Department of Internal Medicine, Division of Nephrology and Hypertension, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Naim M. Maalouf
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, and Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
21
|
Emektar E. Acute hyperkalemia in adults. Turk J Emerg Med 2023; 23:75-81. [PMID: 37169032 PMCID: PMC10166290 DOI: 10.4103/tjem.tjem_288_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 03/06/2023] Open
Abstract
Hyperkalemia is a common, life-threatening medical situation in chronic renal disease patients in the emergency department (ED). Since hyperkalemia does not present with any specific symptom, it is difficult to diagnose clinically. Hyperkalemia causes broad and dramatic medical presentations including cardiac arrhythmia and sudden death. Hyperkalemia is generally determined through serum measurement in the laboratory. Treatment includes precautions to stabilize cardiac membranes, shift potassium from the extracellular to the intracellular, and increase potassium excretion. The present article discusses the management of hyperkalemia in the ED in the light of current evidence.
Collapse
|
22
|
Bjune T, Bøe TB, Kjellevold SA, Heldal K, Abedini S. Hyperkalemia and the Use of New Potassium Binders a Single Center Experience from Vestfold Norway (The PotBind Study). Int J Nephrol Renovasc Dis 2023; 16:73-82. [PMID: 36960344 PMCID: PMC10027611 DOI: 10.2147/ijnrd.s401623] [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: 12/22/2022] [Accepted: 03/03/2023] [Indexed: 03/17/2023] Open
Abstract
Purpose Hyperkalemia is a common metabolic complication of chronic kidney disease (CKD) and is associated with several serious adverse events. We aimed to treat/prevent hyperkalemia using the new of potassium-binders, allowing maintained renin-angiotensin-aldosterone system inhibitors (RAASi) treatment in proteinuric CKD and/or congestive heart failure (CHF) patients. Patients and Methods We conducted a retrospective cohort study in long-term users of potassium binders for chronic hyperkalemia. Patients aged 18 years and older, treated with potassium-binders and who met the reimbursement criteria and indication for RAASi treatment were included. Results Fifty-seven percent of the patients were males and mean age was 65 years. During the study period, no patients were admitted to hospital due to hyperkalemia after initiation of potassium binders. Potassium maximum values were significantly lower after treatment. Few patients reported major side effects, and discontinuation was mostly due to normokalemia. We found no significant changes in bicarbonate, serum creatinine or GFR stage after starting potassium binder treatment. All patients on RAASi treatment before initiating potassium-binders were retained on RAASi treatment. Conclusion New potassium binders in clinical practice are an easy and safe treatment with few side effects and good tolerance, that significantly lowers the risk of hyperkalemia. Furthermore, and most importantly, patients can be maintained on RAASi treatment.
Collapse
Affiliation(s)
- Thea Bjune
- Vear General Practitioner Group, Vear, Vestfold, Norway
- Correspondence: Thea Bjune, Vear General Practitioner group, Steinbruddveien 8, Vear, 3173, Norway, Tel +47 33362700, Email
| | | | - Stig Arne Kjellevold
- Vestfold Hospital Trust, Medical Clinic, Section for Kidney Disease, Toensberg, Vestfold, Norway
| | - Kristian Heldal
- Department of Transplantation Medicine, Oslo University Hospital and Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Sadollah Abedini
- Vestfold Hospital Trust, Medical Clinic, Section for Kidney Disease, Toensberg, Vestfold, Norway
| |
Collapse
|
23
|
Association of Potassium Level at Discharge with Long-Term Mortality in Hospitalized Patients with Heart Failure. J Clin Med 2022; 11:jcm11247358. [PMID: 36555973 PMCID: PMC9782550 DOI: 10.3390/jcm11247358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 11/26/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
Dyskalemia (hypokalemia and hyperkalemia) is a common comorbidity of heart failure (HF). Although dyskalemia is associated with poor prognosis, different prognostic impacts of hypo- and hyperkalemia remain vastly unclear. This study investigated the association of dyskalemia with prognosis in HF patients, especially the mode of death and left ventricular ejection fraction (LVEF). The multicenter study included 3398 patients hospitalized for HF. Patients were divided into three groups based on serum potassium levels at discharge: hypokalemia (<3.5 mEq/L; n = 115 (3.4%)), normokalemia (3.5−5.0 mEq/L; n = 2960 (87.1%)), and hyperkalemia (≥5.0 mEq/L; n = 323 (9.5%)). Two-year all-cause, cardiac, and non-cardiac mortality was evaluated. Association of serum potassium with two-year mortality demonstrated a U-shaped curve, with a worse prognosis for patients with hypokalemia. All-cause mortality at two-years did not differ among the three groups. Hypokalemia was associated with 2-year cardiac death (adjusted hazard ratio (HR), 2.60; 95% confidence interval (CI), 1.20−5.64) in HF with reduced ejection fraction (HFrEF; LVEF < 40%), but not in non-HFrEF. Regardless of LVEF, hyperkalemia was not independently associated with any mortality. Hypokalemia was independently associated with cardiac death, particularly in HFrEF patients. Such an association was not observed in hyperkalemia regardless of LVEF.
Collapse
|
24
|
Rafique Z, Hoang B, Mesbah H, Pappal R, Peacock FW, Juarez-Vela R, Szarpak L, Kuo DC. Hyperkalemia and Electrocardiogram Manifestations in End-Stage Renal Disease. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16140. [PMID: 36498212 PMCID: PMC9736513 DOI: 10.3390/ijerph192316140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/29/2022] [Accepted: 12/01/2022] [Indexed: 06/17/2023]
Abstract
Hyperkalemia is one of the more common acute life-threatening metabolic emergencies. The aim of our study is to determine the correlation and accuracy of abnormal ECG parameters as a function of serum potassium concentration in the end-stage renal disease (ESRD) population. We performed a retrospective chart review of emergency department patients presenting with ESRD and receiving emergent hemodialysis treatment. A total of 96 patients, each with five independent ED visits, provided 480 sets of ECGs and electrolytes. Of these, four ECGs were excluded for inability to interpret, leaving a total of 476 patient encounters that met all inclusion criteria. Linear regression analysis on the limited data set for serum potassium versus T/R in V2, V3, and V4, PR, and QRS found weak correlations (r2 = 0.02 to 0.12) with statistical significance <0.05 level for T/R in V2, V3, and V4. In summary, we found that a QRS duration of 120 ms or greater is most predictive of hyperkalemia in the ESRD population. On the other hand, T/R ratio, PR interval and QRS duration have poor correlations with serum potassium and are not predictive of hyperkalemia in patients with ESRD.
Collapse
Affiliation(s)
- Zubaid Rafique
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Bryan Hoang
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77004, USA
| | - Heba Mesbah
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Ryan Pappal
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Frank W. Peacock
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Raul Juarez-Vela
- Group in Research in Care (GRUPAC), Department of Nursing, University of La Rioja, 93-103 Logrono, Spain
| | - Lukasz Szarpak
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Dick C. Kuo
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| |
Collapse
|
25
|
Machine Learning Models Predicting Cardiovascular and Renal Outcomes and Mortality in Patients with Hyperkalemia. Nutrients 2022; 14:nu14214614. [PMID: 36364890 PMCID: PMC9658112 DOI: 10.3390/nu14214614] [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: 08/31/2022] [Revised: 10/20/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022] Open
Abstract
Hyperkalemia is associated with increased risks of mortality and adverse clinical outcomes. The treatment of hyperkalemia often leads to the discontinuation or restriction of beneficial but potassium-increasing therapy such as renin-angiotensin-aldosterone inhibitors (RAASi) and high-potassium diet including fruits and vegetables. To date, limited evidence is available for personalized risk evaluation in this heterogeneous and multifactorial pathophysiological condition. We developed risk prediction models using extreme gradient boosting (XGB), multiple logistic regression (LR), and deep neural network. Models were derived from a retrospective cohort of hyperkalemic patients with either heart failure or chronic kidney disease stage ≥3a from a Japanese nationwide database (1 April 2008−30 September 2018). Studied outcomes included all-cause death, renal replacement therapy introduction (RRT), hospitalization for heart failure (HHF), and cardiovascular events within three years after hyperkalemic episodes. The best performing model was further validated using an external cohort. A total of 24,949 adult hyperkalemic patients were selected for model derivation and internal validation. A total of 1452 deaths (16.6%), 887 RRT (10.1%), 1,345 HHF (15.4%), and 621 cardiovascular events (7.1%) were observed. XGB outperformed other models. The area under receiver operator characteristic curves (AUROCs) of XGB vs. LR (95% CIs) for death, RRT, HHF, and cardiovascular events were 0.823 (0.805−0.841) vs. 0.809 (0.791−0.828), 0.957 (0.947−0.967) vs. 0.947 (0.936−0.959), 0.863 (0.846−0.880) vs. 0.838 (0.820−0.856), and 0.809 (0.784−0.834) vs. 0.798 (0.772−0.823), respectively. In the external dataset including 86,279 patients, AUROCs (95% CIs) for XGB were: death, 0.747 (0.742−0.753); RRT, 0.888 (0.882−0.894); HHF, 0.673 (0.666−0.679); and cardiovascular events, 0.585 (0.578−0.591). Kaplan−Meier curves of the high-risk predicted group showed a statistically significant difference from that of the low-risk predicted groups for all outcomes (p < 0.005; log-rank test). These findings suggest possible use of machine learning models for real-world risk assessment as a guide for observation and/or treatment decision making that may potentially lead to improved outcomes in hyperkalemic patients while retaining the benefit of life-saving therapies.
Collapse
|
26
|
Rossing P, Caramori ML, Chan JC, Heerspink HJ, Hurst C, Khunti K, Liew A, Michos ED, Navaneethan SD, Olowu WA, Sadusky T, Tandon N, Tuttle KR, Wanner C, Wilkens KG, Zoungas S, de Boer IH. KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int 2022; 102:S1-S127. [PMID: 36272764 DOI: 10.1016/j.kint.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 02/07/2023]
|
27
|
Zhang H, Xiu X, Yang Y, Yang Y, Zhao H. Identification of Putative Causal Relationships Between Type 2 Diabetes and Blood-Based Biomarkers in East Asians by Mendelian Randomization. Am J Epidemiol 2022; 191:1867-1876. [PMID: 35801869 DOI: 10.1093/aje/kwac118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 04/22/2022] [Accepted: 06/29/2022] [Indexed: 02/01/2023] Open
Abstract
Observational studies have revealed phenotypic associations between type 2 diabetes (T2D) and many biomarkers. However, causality between these conditions in East Asians is unclear. We leveraged genome-wide association study (GWAS) summary statistics on T2D (n = 77,418 cases; n = 356,122 controls) from the Asian Genetic Epidemiology Network (sample recruited during 2001-2011) and GWAS summary statistics on 42 biomarkers (n = 12,303-143,658) from BioBank Japan (sample recruited during 2003-2008) to investigate causal relationships between T2D and biomarkers. Applications of Mendelian randomization approaches consistently revealed genetically instrumented associations of T2D with increased serum potassium levels (liability-scale β = 0.04-0.10; P = 6.41 × 10-17-9.85 × 10-5) and decreased serum chloride levels (liability-scale β = -0.16 to -0.06; P = 5.22 × 10-27-3.14 × 10-5), whereas these 2 biomarkers showed no causal effects on T2D. Heritability Estimation Using Summary Statistics (ρ-HESS) and summary-data-based Mendelian randomization highlighted 27 genomic regions and 3 genes (α-1,3-mannosyl-glycoprotein 2-β-N-acetylglucosaminyltransferase (MGAT1), transducing-like enhancer (TLE) family member 1, transcriptional corepressor (TLE1), and 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR)) that interactively associated with the shared genetics underlying T2D and the 2 biomarkers. Thus, T2D may causally affect serum potassium and chloride levels among East Asians. In contrast, the relationships of potassium and chloride with T2D are not causal, suggesting the importance of monitoring electrolyte disorders for T2D patients.
Collapse
|
28
|
Pecoits-Filho R, McCullough K, Muenz D, Quinn CM, Budden J, Golden J, de Arellano AR, Tillmann FP, Duttlinger J, Calice-Silva V, Massy ZA, Bieber B, Robinson BM, Fliser D, Reichel H. Patiromer utilization in patients with advanced chronic kidney disease under nephrology care in Germany. Clin Kidney J 2022; 16:176-183. [PMID: 36726438 PMCID: PMC9871846 DOI: 10.1093/ckj/sfac209] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Indexed: 02/04/2023] Open
Abstract
Background Hyperkalemia (HK) is a frequent condition in patients with chronic kidney disease (CKD) that is associated with high morbidity and mortality. Patiromer has recently been introduced as a potassium binder. Data on patiromer use in patients with CKD in the real-world setting in Europe are lacking. We describe time to discontinuation and changes in serum potassium levels among German CKD stage 3-5 patients starting patiromer. Methods Duration of patiromer use was estimated by Kaplan-Meier curve, starting at patiromer initiation and censoring for death, dialysis, transplant or loss to follow-up. Serum potassium levels and renin-angiotensin-aldosterone system inhibitor (RAASi) use are described at baseline and during follow-up, restricted to patients remaining on patiromer. Results We identified 140 patiromer users within our analysis sample [81% CKD stage 4/5, 83% receiving RAASi, and median K+ 5.7 (5.4, 6.3) mmol/L]. Thirty percent of patiromer users had prior history of polystyrene sulfonate use. Overall, 95% of patiromer users stayed on treatment past 1 month, with 53% continuing for over a year. Mean serum potassium levels decreased after patiromer initiation and remained stable under treatment during follow-up (up to 180 days). Among these patients, 73%-82% used RAASis during the time periods before and after patiromer initiation, with no obvious trend indicating discontinuation. Conclusion Real-world evidence of patiromer use in Germany shows that, in line with what has been observed in clinical trials, patients on patiromer have a reduction in serum potassium when used long-term. Moreover, most patients on patiromer do not discontinue treatment prior to 1 year after initiation.
Collapse
Affiliation(s)
| | | | - Daniel Muenz
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | | | | | | | - Frank-Peter Tillmann
- Department of Medicine I – Nephrology, Transplantation & Medical Intensive Care, University Witten/Herdecke, Medical Center Cologne-Merheim, Cologne, Germany
| | | | | | - Ziad A Massy
- Department of Nephrology, CHU Ambroise Paré, APHP, Boulogne, France,Center for Research in Epidemiology and Population Health (CESP), University Paris Saclay, University Versailles Saint-Quentin en Yvelines, National Institute of Health, Clinical Epidemiology Team, Villejuif, France,Division of Nephrology, Ambroise Paré Universitry Hospital, APHP, Paris, France
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Danilo Fliser
- Saarland University Medical Centre, Homburg, Germany
| | - Helmut Reichel
- Nephrological Center, Villingen-Schwenningen, Baden-Württemberg, Germany
| | | |
Collapse
|
29
|
Kohsaka S, Okami S, Morita N, Yajima T. Risk-Benefit Balance of Renin-Angiotensin-Aldosterone Inhibitor Cessation in Heart Failure Patients with Hyperkalemia. J Clin Med 2022; 11:5828. [PMID: 36233692 PMCID: PMC9572691 DOI: 10.3390/jcm11195828] [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: 08/31/2022] [Revised: 09/24/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022] Open
Abstract
Background: Whether to continue renin−angiotensin−aldosterone system inhibitor (RAASi) therapy in patients with hyperkalemia remains a clinical challenge, particularly in patients with heart failure (HF), where RAASis remain the cornerstone of treatment. We investigated the incidence of dose reduction or the cessation of RAASis and evaluated the threshold of serum potassium at which cessation alters the risk−benefit balance. Methods: This retrospective analysis of a Japanese nationwide claims database investigated treatment patterns of RAASis over 12 months after the initial hyperkalemic episode. The incidences of the clinical outcomes of patients with RAASi (all ACEi/ARB/MRA) or MRA-only cessation (vs. non-cessation) were compared via propensity score-matched patients. A cubic spline regression analysis assessed the hazard of death resulting from treatment cessation vs. no cessation at each potassium level. Results: A total of 5059 hyperkalemic HF patients were identified; most received low to moderate doses of ACEis and ARBs (86.9% and 71.5%, respectively) and low doses of MRAs (76.2%). The RAASi and MRA cessation rates were 34.7% and 52.8% at 1 year post-diagnosis, while the dose reduction rates were 8.4% and 6.5%, respectively. During the mean follow-up of 2.8 years, patients who ceased RAASi or MRA therapies were at higher risk for adverse outcomes; cubic spline analysis found that serum potassium levels of <5.9 and <5.7 mmol/L conferred an increased mortality risk for RAASi and MRA cessation, respectively. Conclusions: Treatment cessation/dose reduction of RAASis are common among HF patients. The risks of RAASi/MRA cessation may outweigh the benefits in patients with mild to moderate hyperkalemia.
Collapse
Affiliation(s)
- Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan;
| | - Suguru Okami
- Cardiovascular, Renal, and Metabolism, Medical Affairs, AstraZeneca K.K., Osaka 530-0011, Japan; (S.O.); (N.M.)
| | - Naru Morita
- Cardiovascular, Renal, and Metabolism, Medical Affairs, AstraZeneca K.K., Osaka 530-0011, Japan; (S.O.); (N.M.)
| | - Toshitaka Yajima
- Cardiovascular, Renal, and Metabolism, Medical Affairs, AstraZeneca K.K., Osaka 530-0011, Japan; (S.O.); (N.M.)
| |
Collapse
|
30
|
Palmer BF, Clegg DJ. Managing Hyperkalemia to Enable Guideline-Recommended Dosing of Renin-Angiotensin-Aldosterone System Inhibitors. Am J Kidney Dis 2022; 80:158-160. [PMID: 35461743 DOI: 10.1053/j.ajkd.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/15/2022] [Indexed: 01/27/2023]
Affiliation(s)
- Biff F Palmer
- Department of Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas.
| | | |
Collapse
|
31
|
Butler J, Anker SD, Lund LH, Coats AJS, Filippatos G, Siddiqi TJ, Friede T, Fabien V, Kosiborod M, Metra M, Piña IL, Pinto F, Rossignol P, van der Meer P, Bahit C, Belohlavek J, Böhm M, Brugts JJ, Cleland JG, Ezekowitz J, Bayes-Genis A, Gotsman I, Goudev A, Khintibidze I, Lindenfeld J, Mentz RJ, Merkely B, Montes EC, Mullens W, Nicolau JC, Parkhomenko A, Ponikowski P, Seferovic PM, Senni M, Shlyakhto E, Cohen-Solal A, Szecsödy P, Jensen K, Dorigotti F, Weir MR, Pitt B. Patiromer for the management of hyperkalemia in heart failure with reduced ejection fraction: the DIAMOND trial. Eur Heart J 2022; 43:4362-4373. [PMID: 35900838 DOI: 10.1093/eurheartj/ehac401] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/01/2022] [Accepted: 07/12/2022] [Indexed: 11/12/2022] Open
Abstract
AIMS To investigate the impact of patiromer on serum potassium level and its ability to enable specified target doses of renin-angiotensin-aldosterone system inhibitor (RAASi) use in patients with heart failure and reduced ejection fraction (HFrEF). METHODS AND RESULTS A total of 1642 patients with HFrEF and current or a history of RAASi-related hyperkalemia were screened and 1195 were enrolled in the run-in phase with patiromer and optimization of RAASi therapy (≥50% recommended dose of angiotensin-converting-enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, and 50 mg of mineralocorticoid receptor antagonist [MRA] spironolactone or eplerenone). Specified target doses of RAASi therapy were achieved in 878 (84.6%) patients; 439 were randomized to patiromer and 439 to placebo. All patients, physicians, and outcome assessors were blinded to treatment assignment. The primary endpoint was between-group difference in adjusted mean change in serum potassium. Five hierarchical secondary endpoints were assessed. At the end of treatment, the median (interquartile range) duration of follow-up was 27 (13, 43) weeks, the adjusted mean change in potassium was +0.03 mmol/L in the patiromer group and +0.13 mmol/L in the placebo group (difference in adjusted mean change between patiromer and placebo: -0.10 [95% confidence interval, CI -0.13, -0.07] mmol/L, P<0.001). Risk of hyperkalemia >5.5 mmol/L (hazard ratio [HR] 0.63; 95% CI 0.45, 0.87; P=0.006), reduction of MRA dose (HR 0.62; 95% CI 0.45, 0.87; P=0.006), and total adjusted hyperkalemia events/100 person-years (77.7 vs. 118.2; HR 0.66; 95% CI 0.53, 0.81; P<0.001) were lower with patiromer. Hyperkalemia-related morbidity-adjusted events (win ratio 1.53, P<0.001) and total RAASi use score (win ratio 1.25, P=0.048) favored the patiromer arm. Adverse events were similar between groups. CONCLUSION Concurrent use of patiromer and high-dose MRAs reduces the risk of recurrent hyperkalemia (ClinicalTrials.gov: NCT03888066).
Collapse
Affiliation(s)
- Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Center for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | - Lars H Lund
- Department of Medicine, Unit of Cardiology, Karolinska Institutet, Solna, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Tariq Jamal Siddiqi
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Tim Friede
- University Medical Center Göttingen, Göttingen, Germany; DZHK (German Center for Cardiovascular Research), Göttingen partner site, Göttingen, Germany
| | | | - Mikhail Kosiborod
- Department of Cardiovascular Disease, Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri
| | - Marco Metra
- Cardiology, ASST Spedali Civili and University, Brescia, Italy
| | - Ileana L Piña
- Central Michigan University College of Medicine, Mount Pleasant, Michigan, USA
| | - Fausto Pinto
- Santa Maria University Hospital, CAML, CCUL, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Patrick Rossignol
- X Université de Lorraine, INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM Unit 1116, Centre Hospitalier Régional Universitaire (CHRU) de Nancy, and F-CRIN INI-CRCT, Nancy, France
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, Groningen, Netherlands
| | - Cecilia Bahit
- INECO Neurociencias Oroño, Rosario, Santa Fe, New Mexico, USA
| | - Jan Belohlavek
- Clinic of Cardiology and Angiology, General University Hospital Prague, Prague, Czech Republic
| | - Michael Böhm
- Klinik für Innere Medizin III, Saarland University, Homburg/Saar, Germany
| | - Jasper J Brugts
- Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - John Gf Cleland
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Justin Ezekowitz
- Faculty of Medicine & Dentistry, University of Alberta, Alberta, Canada
| | - Antoni Bayes-Genis
- Cardiology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, CIBERCV, Spain
| | | | - Assen Goudev
- Department of Emergency Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Irakli Khintibidze
- Alexandre Aladashvili Clinic, Tbilisi State Medical University, Tbilisi, Georgia
| | - Joann Lindenfeld
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Bela Merkely
- Semmelweis University Heart and Vascular Center, Budapest, Hungary
| | | | | | - Jose C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | | | - Piotr Ponikowski
- Insitute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Petar M Seferovic
- Faculty of Medicine Belgrade, Serbia, and Serbian Academy of Sciences and Arts
| | - Michele Senni
- University of Milano - Bicocca, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Evgeny Shlyakhto
- Almazov Federal Heart, Blood and Endocrinology Centre, Saint-Petersburg, Russia
| | - Alain Cohen-Solal
- Université de Paris, INSERM U942, APHP, Hospital Lariboisiere, Paris, France
| | | | | | | | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, USA
| | - Bertram Pitt
- Division of Cardiology, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
32
|
Scicchitano P, Iacoviello M, Massari F, De Palo M, Caldarola P, Mannarini A, Passantino A, Ciccone MM, Magnesa M. Optimizing Therapies in Heart Failure: The Role of Potassium Binders. Biomedicines 2022; 10:biomedicines10071721. [PMID: 35885026 PMCID: PMC9313061 DOI: 10.3390/biomedicines10071721] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/12/2022] [Accepted: 07/15/2022] [Indexed: 11/21/2022] Open
Abstract
Heart failure (HF) is a worrisome cardiac pandemic with a negative prognostic impact on the overall survival of individuals. International guidelines recommend up-titration of standardized therapies in order to reduce symptoms, hospitalization rates, and cardiac death. Hyperkalemia (HK) has been identified in 3–18% of HF patients from randomized controlled trials and over 25% of HF patients in the “real world” setting. Pharmacological treatments and/or cardio-renal syndrome, as well as chronic kidney disease may be responsible for HK in HF patients. These conditions can prevent the upgrade of pharmacological treatments, thus, negatively impacting on the overall prognosis of patients. Potassium binders may be the best option in patients with HK in order to reduce serum concentrations of K+ and to promote correct upgrades of therapies. In addition to the well-established use of sodium polystyrene sulfonate (SPS), two novel drugs have been recently introduced: sodium zirconium cyclosilicate (SZC) and patiromer. SZC and patiromer are gaining a central role for the treatment of chronic HK. SZC has been shown to reduce K+ levels within 48 h, with guaranteed maintenance of normokalemia for up to12 months. Patiromer has resulted in a statistically significant decrease in serum potassium for up to 52 weeks. Therefore, long-term results seemed to positively promote the implementation of these compounds in clinical practice due to their low rate side effects. The aim of this narrative review is to delineate the impact of new potassium binders in the treatment of patients with HF by providing a critical reappraisal for daily application of novel therapies for hyperkalemia in the HF setting.
Collapse
Affiliation(s)
- Pietro Scicchitano
- Cardiology Section, Hospital “F. Perinei” Altamura (BA), 70022 Altamura, Italy;
- Correspondence: ; Tel.: +39-0803108286
| | - Massimo Iacoviello
- Cardiology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (M.I.); (M.M.)
| | - Francesco Massari
- Cardiology Section, Hospital “F. Perinei” Altamura (BA), 70022 Altamura, Italy;
| | - Micaela De Palo
- Cardiac Surgery Unit, Azienda Ospedaliero-Universitaria Policlinico Bari, 70124 Bari, Italy;
| | | | - Antonia Mannarini
- Division of University Cardiology, Cardiothoracic Department, Policlinic University Hospital, 70124 Bari, Italy;
| | - Andrea Passantino
- Division of Cardiology and Cardiac Rehabilitation, Scientific Clinical Institutes Maugeri, IRCCS Institute of Bari, 70124 Bari, Italy;
| | - Marco Matteo Ciccone
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, 70124 Bari, Italy;
| | - Michele Magnesa
- Cardiology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (M.I.); (M.M.)
| |
Collapse
|
33
|
Ferreira JP, Zannad F, Butler J, Filipattos G, Ritter I, Schüler E, Kraus BJ, Pocock SJ, Anker SD, Packer M. Empagliflozin and serum potassium in heart failure: an analysis from EMPEROR-Pooled. Eur Heart J 2022; 43:2984-2993. [PMID: 35687107 PMCID: PMC9375711 DOI: 10.1093/eurheartj/ehac306] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/09/2022] [Accepted: 05/24/2022] [Indexed: 12/21/2022] Open
Abstract
AIMS Hyperkalaemia frequently leads to interruption and discontinuation of neurohormonal antagonists, which may worsen heart failure prognosis. Some studies suggested that sodium-glucose cotransporter 2 inhibitors reduce hyperkalaemia, an effect that may have important clinical implications. This analysis evaluates the effect of empagliflozin on the occurrence of hyper- and hypokalaemia in HF. METHODS AND RESULTS EMPEROR-Pooled (i.e. EMPEROR-Reduced and EMPEROR-Preserved combined) included 9583 patients with available serum potassium levels at baseline (98.6% of the total EMPEROR-Pooled population, n = 9718). Hyperkalaemia was identified by investigators' reports of adverse events, and by a laboratory serum potassium value above 5.5 mmol/L and 6.0 mmol/L. The main outcome was a composite of investigator-reported hyperkalaemia or initiation of potassium binders. Patients with high potassium at baseline were more frequently diagnosed with diabetes and ischaemic HF aetiology and had lower left ventricular ejection fraction and estimated glomerular filtration rate but were more frequently treated with sacubitril/valsartan or mineralocorticoid receptor antagonists. Empagliflozin (compared with placebo) reduced the composite of investigator-reported hyperkalaemia or initiation of potassium binders [6.5% vs. 7.7%, hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.71-0.95, P = 0.01]. Empagliflozin reduced hyperkalaemia rates regardless of the definition used (serum potassium >5.5 mmol/l: 8.6% vs. 9.9%, HR 0.85, 95% CI 0.74-0.97, P = 0.017; serum potassium >6.0 mmol/l: 1.9% vs. 2.9%, HR 0.62, 95% CI 0.48-0.81, P < 0.001). The incidence of hypokalaemia (investigator-reported or serum potassium <3.0 mmol/l) was not significantly increased with empagliflozin. CONCLUSIONS Empagliflozin reduced the incidence of hyperkalaemia without significant increase in hypokalaemia.
Collapse
Affiliation(s)
- João Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques Plurithématique 1433, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France.,Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Faiez Zannad
- Baylor Heart and Vascular Institute Dallas, TX, USA.,Imperial College, London, UK
| | - Javed Butler
- University of Mississippi Medical Center, Jackson, MS, USA
| | - Gerasimos Filipattos
- National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Ivana Ritter
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | | | - Bettina J Kraus
- Boehringer Ingelheim International GmbH, Ingelheim, Germany.,Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany
| | | | - Stefan D Anker
- Department of Cardiology (CVK) Berlin Institute of Health Center for Regenerative Therapies (BCRT) German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Milton Packer
- Baylor Heart and Vascular Institute Dallas, TX, USA.,Imperial College, London, UK
| |
Collapse
|
34
|
Raffee LA, Alawneh KZ, Ababneh MJ, Hijazi HH, Al Abdi RM, Aboozour MM, Alghzawi FA, Al-Mistarehi AH. Clinical and electrocardiogram presentations of patients with high serum potassium concentrations within emergency settings: a prospective study. Int J Emerg Med 2022; 15:23. [PMID: 35619089 PMCID: PMC9137132 DOI: 10.1186/s12245-022-00422-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Elevated potassium level is a common and reversible peri-arrest condition. Diagnosis and management of hyperkalemia in a short time is critical, where electrocardiogram (ECG) alterations might be helpful. We aimed to investigate the role of clinical features and ECGs in early diagnosing and treating hyperkalemia. METHODS Prospectively, adult patients who presented to the emergency department (ED) from July 2019 to March 2020 with hyperkalemia (serum potassium ≥5.5mmol/L) were included. History was obtained, and laboratory investigations and ECGs were performed at the presentation and before initiating hyperkalemia therapy. Hyperkalemia severity was divided into mild (5.5-5.9mmol/L), moderate (6.0-6.4mmol/L), and severe (≥6.5mmol/L). A cardiologist and emergency physician blinded to laboratory values, study design, and patients' diagnoses interpreted ECGs and presenting symptoms independently to predict hyperkalemia. RESULTS Sixty-seven hyperkalemic patients with a mean (±SD) serum potassium level of 6.5±0.7mmol/L were included in this study. The mean age was 63.9±15.1, and 58.2% were females. Hyperkalemia was mild in 10.4%, moderate in 40.3%, and severe in 49.3%. Almost two thirds of patients (71.6%) had hypertension, 67.2% diabetes, and 64.2% chronic kidney disease. About one-quarter of patients (22.4%) were asymptomatic, while fatigue (46.3%), dyspnea (28.4%), and nausea/vomiting (20.9%) were the most common presenting symptoms. Normal ECGs were observed in 25.4% of patients, while alterations in 74.6%. Atrial fibrillation (13.4%), peaked T wave (11.9%), widened QRS (11.9%), prolonged PR interval (10.5%), and flattening P wave (10.5%) were the most common. Peaked T wave was significantly more common in severe hyperkalemia (87.5%) than in mild and moderate hyperkalemia (12.5%, 0.0%, respectively) (p=0.041). The physicians' sensitivities for predicting hyperkalemia were 35.8% and 28.4%, improved to 51.5% and 42.4%, respectively, when limiting the analyses to severe hyperkalemia. The mean (±SD) time to initial hyperkalemia treatment was 63.8±31.5 min. Potassium levels were positively correlated with PR interval (r=0.283, p=0.038), QRS duration (r=0.361, p=0.003), peaked T wave (r=0.242, p=0.041), and serum levels of creatinine (r=0.347, p=0.004), BUN (r=0.312, p=0.008), and CK (r=0.373, p=0.039). CONCLUSIONS The physicians' abilities to predict hyperkalemia based on ECG and symptoms were poor. ECG could not be solely relied on, and serum potassium tests should be conducted for accurate diagnosis.
Collapse
Affiliation(s)
- Liqaa A Raffee
- Department of Accident and Emergency Medicine, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 630001, Irbid, 22110, Jordan.
| | - Khaled Z Alawneh
- Department of Diagnostic Radiology and Nuclear Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Muhannad J Ababneh
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Heba H Hijazi
- Chair of Department of Health Services Administration, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates.,Department of Health Management and Policy, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Rabah M Al Abdi
- Department of Biomedical Engineering, Faculty of Engineering, Jordan University of Science and Technology, Irbid, Jordan
| | - Mahmoud M Aboozour
- Department of Accident and Emergency Medicine, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 630001, Irbid, 22110, Jordan
| | - Fadi A Alghzawi
- Department of Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 630001, Irbid, 22110, Jordan
| | - Abdel-Hameed Al-Mistarehi
- Department of Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 630001, Irbid, 22110, Jordan.
| |
Collapse
|
35
|
Arif Y, Wenziger C, Hsiung JT, Edward A, Lau WL, Hanna RM, Lee Y, Obi Y, Kovesdy CP, Kalantar-Zadeh K, Streja E. Association of serum potassium with decline in residual kidney function in incident hemodialysis patients. Nephrol Dial Transplant 2022; 37:2234-2240. [PMID: 35561740 PMCID: PMC9585465 DOI: 10.1093/ndt/gfac181] [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: 01/20/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hyperkalemia is associated with kidney function decline in patients with non-dialysis dependent chronic kidney disease, but this relationship is unclear for residual kidney function among hemodialysis (HD) patients. METHODS We conducted a retrospective cohort study of 6655 patients who started HD from January 2007 to December 2011 and who had data on renal urea clearance (KRU). Serum potassium levels were stratified into four groups (i.e. ≤4.0, >4.0 to ≤ 4.5, >4.5 to ≤ 5.0, >5.0 mEq/L) and 1-year KRU slope for each group was estimated by a linear mixed-effects model. RESULTS Higher serum potassium was associated with greater decline in KRU, and the greatest decrease in KRU (-0.20, 95% CI -0.50, -0.06) was observed for baseline potassium > 5.0 mEq/L in the fully adjusted model. Mediation analysis showed that KRU slope mediated 1.78% of the association between serum potassium and mortality. CONCLUSIONS In conclusion, hyperkalemia is associated with decline in residual kidney function amongst incident HD patients. These findings may have important clinical implications in the management of hyperkalemia in advanced CKD if confirmed in additional studies including clinical trials.
Collapse
Affiliation(s)
- Yousif Arif
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Cachet Wenziger
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Jui Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Amanda Edward
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Wei Ling Lau
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Ramy M Hanna
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Yuji Lee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Kam Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, VA Long Beach Healthcare System, Long Beach, CA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, VA Long Beach Healthcare System, Long Beach, CA
| |
Collapse
|
36
|
Clozel M. Aprocitentan and the endothelin system in resistant hypertension. Can J Physiol Pharmacol 2022; 100:573-583. [PMID: 35245103 DOI: 10.1139/cjpp-2022-0010] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Endothelin has emerged as a target for therapeutic intervention in systemic hypertension. As a vasoconstrictor, co-mitogenic agent, linking pulse pressure and vascular remodeling, and mediator of aldosterone and catecholamine release, endothelin is a key player in hypertension and end-organ damage. In 10-20% of the hypertensive population, the high blood pressure is resistant to administration of antihypertensive drugs of different classes in combination. Because endothelin is not targeted by the current antihypertensive drugs this may suggest that this resistance is due, in part at least, to a dependence on endothelin. This hypothesis is supported by the observation that this form of hypertension is often salt-sensitive, and that the endothelin system is stimulated by salt. In addition, the endothelin system is activated in subjects at risk of developing resistant hypertension, such as African-Americans or patients with obesity or obstructive sleep apnea. Aprocitentan is a novel, potent, dual endothelin receptor antagonist (ERA) currently in phase 3 development for the treatment of difficult-to-treat hypertension. This article discusses the research which underpinned the discovery of this ERA and the choice of its first clinical indication for patients with forms of hypertension which cannot be well controlled with classical antihypertensive drugs.
Collapse
Affiliation(s)
- Martine Clozel
- Idorsia Pharmaceuticals Ltd, 510456, Allschwil, Basel-Landschaft, Switzerland;
| |
Collapse
|
37
|
Babich JS, Kalantar-Zadeh K, Joshi S. Taking the Kale out of Hyperkalemia: Plant Foods and Serum Potassium in Patients with Kidney Disease. J Ren Nutr 2022; 32:641-649. [DOI: 10.1053/j.jrn.2022.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/26/2022] [Accepted: 01/30/2022] [Indexed: 11/11/2022] Open
|
38
|
Banerjee D, Winocour P, Chowdhury TA, De P, Wahba M, Montero R, Fogarty D, Frankel AH, Karalliedde J, Mark PB, Patel DC, Pokrajac A, Sharif A, Zac-Varghese S, Bain S, Dasgupta I. Management of hypertension and renin-angiotensin-aldosterone system blockade in adults with diabetic kidney disease: Association of British Clinical Diabetologists and the Renal Association UK guideline update 2021. BMC Nephrol 2022; 23:9. [PMID: 34979961 PMCID: PMC8722287 DOI: 10.1186/s12882-021-02587-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 10/28/2021] [Indexed: 12/31/2022] Open
Abstract
People with type 1 and type 2 diabetes are at risk of developing progressive chronic kidney disease (CKD) and end-stage kidney failure. Hypertension is a major, reversible risk factor in people with diabetes for development of albuminuria, impaired kidney function, end-stage kidney disease and cardiovascular disease. Blood pressure control has been shown to be beneficial in people with diabetes in slowing progression of kidney disease and reducing cardiovascular events. However, randomised controlled trial evidence differs in type 1 and type 2 diabetes and different stages of CKD in terms of target blood pressure. Activation of the renin-angiotensin-aldosterone system (RAAS) is an important mechanism for the development and progression of CKD and cardiovascular disease. Randomised trials demonstrate that RAAS blockade is effective in preventing/ slowing progression of CKD and reducing cardiovascular events in people with type 1 and type 2 diabetes, albeit differently according to the stage of CKD. Emerging therapy with sodium glucose cotransporter-2 (SGLT-2) inhibitors, non-steroidal selective mineralocorticoid antagonists and endothelin-A receptor antagonists have been shown in randomised trials to lower blood pressure and further reduce the risk of progression of CKD and cardiovascular disease in people with type 2 diabetes. This guideline reviews the current evidence and makes recommendations about blood pressure control and the use of RAAS-blocking agents in different stages of CKD in people with both type 1 and type 2 diabetes.
Collapse
Affiliation(s)
- D Banerjee
- St George's Hospitals NHS Foundation Trust, London, UK
| | - P Winocour
- ENHIDE, East and North Herts NHS Trust, Stevenage, UK
| | | | - P De
- City Hospital, Birmingham, UK
| | - M Wahba
- St Helier Hospital, Carshalton, UK
| | | | - D Fogarty
- Belfast Health and Social Care Trust, Belfast, UK
| | - A H Frankel
- Imperial College Healthcare NHS Trust, London, UK
| | | | - P B Mark
- University of Glasgow, Glasgow, UK
| | - D C Patel
- Royal Free London NHS Foundation Trust, London, UK
| | - A Pokrajac
- West Hertfordshire Hospitals, London, UK
| | - A Sharif
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - S Bain
- Swansea University, Swansea, UK
| | - I Dasgupta
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| |
Collapse
|
39
|
Sane AH, Mekonnen MS, Tsegaw MG, Zewde WC, Mesfin EG, Beyene HA, Ashine TM, Tiruneh KG, Mengistie MA. New Onset of Diabetes Mellitus and Associated Factors among COVID-19 Patients in COVID-19 Care Centers, Addis Ababa, Ethiopia 2022. J Diabetes Res 2022; 2022:9652940. [PMID: 36420090 PMCID: PMC9678479 DOI: 10.1155/2022/9652940] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/22/2022] [Accepted: 11/01/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION New onset of diabetes mellitus was noted as the commonest comorbidity in the COVID-19 pandemic, which contributed to a worse prognosis. Existing evidence showed that new-onset diabetes is associated with increased mortality compared to nondiabetic and known diabetic patients in the COVID-19 era. SARS-CoV-2 virus can worsen existing diabetes; at the same time, it can trigger new-onset diabetes that eventually worsens patient outcomes. Thus, this study is aimed at determining the prevalence and factors associated with new onset of diabetes mellitus among COVID-19 patients. METHODS Institution-based retrospective cross-sectional study design was conducted by reviewing 244 patient's records in the Addis Ababa COVID-19 care center. Descriptive statistics and binary logistic regression were used. During bivariate analysis, variables with p ≤ 0.25 were transferred into multivariate analysis. Adjusted odds ratios to determine the strength and presence of the association with a 95% confidence interval and p value ≤ 0.05 were considered, respectively. RESULTS The mean age of the study participants was 53.2 years with (SD = 13.35). The study findings showed that 31.1% (CI: 25.4-37.4) of COVID-19 patients had new onset of diabetes mellitus; of those, 11.8% had type 1 and 88.2% had type 2 diabetes. Being male (aOR = 2.9; 95% CI: 1.2, 7.1), family history of hypertension (aOR = 3.7; 95% CI: 1.3, 10.5), obesity (aOR = 3.1; 95% CI: 1.01, 8.9), having pulmonary embolism (aOR = 0.2; 95% CI: 0.06, 0.04), and hyperkalemia (aOR = 9.3; 95% CI: 1.8, 47.3) showed statistically significant association with new onset of diabetes mellitus. CONCLUSION A significant proportion of COVID-19 patients had been diagnosed with new onset of diabetes mellitus, and new-onset type 2 diabetes mellitus is the most common diabetes mellitus type. Being male, obesity, having a pulmonary embolism, family history of hypertension, and hyperkalemia were independently associated with new onset of diabetes mellitus among COVID-19 patients. Therefore, focused interventions need to be strengthened towards the identified factors.
Collapse
Affiliation(s)
| | - Migbar Sibhat Mekonnen
- Department of Nursing, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Melsew Getnet Tsegaw
- Millennium COVID-19 Care Center, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Wuletaw Chane Zewde
- Millennium COVID-19 Care Center, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Edmialem Getahun Mesfin
- Millennium COVID-19 Care Center, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Hailu Asmare Beyene
- School of Nursing, College of Health Science and Medicine, Wolaita Sodo University, Sodo, Ethiopia
| | - Taye Mezgebu Ashine
- Schools of Nursing, College of Health Science and Medicine, Wachemo University, Hosaena, Ethiopia
| | - Kasie Gebeyehu Tiruneh
- Department of Nursing, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | | |
Collapse
|
40
|
Humphrey T, Davids MR, Chothia MY, Pecoits-Filho R, Pollock C, James G. How common is hyperkalaemia? A systematic review and meta-analysis of the prevalence and incidence of hyperkalaemia reported in observational studies. Clin Kidney J 2021; 15:727-737. [PMID: 35371465 PMCID: PMC8967676 DOI: 10.1093/ckj/sfab243] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Indexed: 01/29/2023] Open
Abstract
Background The prevalence and incidence of hyperkalaemia, a potassium abnormality that can potentially have life-threatening consequences, are unclear. Methods The objective was to provide the most comprehensive overview of the epidemiology of hyperkalaemia to date within the general population, across different continents, in different healthcare settings and within pre-specified subgroups. Embase and MEDLINE were searched from database inception to 2 February 2021 using the Ovid SP platform. Relevant congress proceedings from 2018 to 2020 were also reviewed for inclusion. There was no language constraint applied. Observational studies from any time period and language reporting prevalence or incidence of hyperkalaemia within both adult and paediatric populations. Four investigators independently screened abstracts and assessed study quality of those meeting the pre-determined inclusion/exclusion criteria. Data extraction was conducted by the lead author with oversight from the senior author and data were pooled using a random-effects model. The measures assessed were the prevalence and incidence of hyperkalaemia. Prevalence was reported as a percentage, whilst incidence was reported as the rate per 100 person years. Results In total, 542 articles were included from an initial search of 14 112 articles. Across all adult studies, we report a prevalence of hyperkalaemia (by any definition/threshold) of 6.3% [95% confidence interval (CI): 5.8–6.8%], with an incidence of hyperkalaemia in the adult population of 2.8 (2.3–3.3) cases per 100 person years. Prevalence within the general population was 1.3% (1.0–1.8%), whilst incidence was 0.4 (0.2–0.8) cases per 100 person years. There was a variation by sex with a prevalence of 6.3% (4.9–8.0%) in males and 5.1% (4.0–6.6%) in females. Prevalence also varied according to the definition/threshold of hyperkalaemia used: >5 mmol/L—8.0% (7.2–8.9), ≥5.5 mmol/L—5.9% (3.5–10.0) and ≥6.0 mmol/L—1.0% (0.8–1.4); hyperkalaemia (by any definition/threshold) was highest amongst patients with end-stage kidney disease (21.5%; 18.3–25.3), kidney transplant patients (21.8%; 16.1–29.5) and patients with acute kidney injury (24.3%; 19.3–30.7). Conclusions This novel review provides a comprehensive and valuable resource on the prevalence and incidence of hyperkalaemia to better inform clinicians, healthcare providers and health policy makers on the burden of hyperkalaemia across different healthcare settings, patient populations and continents.
Collapse
Affiliation(s)
- Toby Humphrey
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mogamat Razeen Davids
- Department of Medicine, Stellenbosch University, Stellenbosch, South Africa
- Division of Nephrology, Tygerberg Hospital, Cape Town, South Africa
| | - Mogamat-Yazied Chothia
- Department of Medicine, Stellenbosch University, Stellenbosch, South Africa
- Division of Nephrology, Tygerberg Hospital, Cape Town, South Africa
| | - Roberto Pecoits-Filho
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
- Arbor Research Collaborative, Ann Arbor, MI, USA
| | - Carol Pollock
- Kolling Institute, Royal North Shore Hospital, University of Sydney, Camperdown, NSW, Australia
| | - Glen James
- BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| |
Collapse
|
41
|
Bussalino E, Panaro L, Marsano L, Bellino D, Ravera M, Paoletti E. Prevalence and clinical correlates of hyperkalemia in stable kidney transplant recipients. Intern Emerg Med 2021; 16:1787-1792. [PMID: 33544373 DOI: 10.1007/s11739-021-02649-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 01/19/2021] [Indexed: 12/28/2022]
Abstract
Although hyperkalemia (HK) is often associated with adverse clinical outcomes in renal patients, few studies are available in the setting of kidney transplantation. Therefore, we evaluated prevalence and clinical correlates of HK in stable kidney transplant recipients (KTRs) on standard of care immunosuppressive therapy. We studied 160 stable KTRs (post-transplant vintage 46.6 ± 16.6 months), most of whom (96.2%) on calcineurin inhibitor (CNI)-based immunosuppressive therapy. HK was defined as plasma potassium levels above 5 mEq/L, confirmed in two consecutive samples. Office blood pressure was measured, and renal graft function was expressed by estimated glomerular filtration rate (eGFR), calculated according to the CKD-EPI formula. HK prevalence was 8.8%, and plasma K above 5.5 mEq/L was found in 2.5% of all KTRs. In the univariate logistic regression analysis HK was significantly associated with serum urea concentration (OR 1.03, 95% CI 1.01-1.05 for each 1 mg/dL increase), tCO2 (OR 0.77, 95% CI 0.66-0.90 for each 1 mmol/L increase), the presence of arterial hypertension (OR 4.01, 95% CI 1.3-12.64), the use of RAAS inhibitors (OR 5.26, 95% CI 1.6-17.7), and eGFR less than 30 ml/min/1.73 m2 (OR 7.51, 95% CI 2.37-23.77). By multivariable backward stepwise regression analysis, the presence of metabolic acidosis (OR 0.83, 95% CI 0.69-0.99, P = 0.04), arterial hypertension (OR 4.65 95% CI 1.01-17.46 P = 0.03), and to be administered RAAS inhibitors (OR 6.11, 95% CI 1.03-25.96 P = 0.03) remained significantly associated with HK. We conclude that in stable KTRs the prevalence of HK is about 9%, slightly lower than previously reported. Moreover, it is not associated with eGFR, but with metabolic acidosis, arterial hypertension, and the use of RAAS inhibitors.
Collapse
Affiliation(s)
- Elisabetta Bussalino
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Laura Panaro
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Luigina Marsano
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Diego Bellino
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Maura Ravera
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Ernesto Paoletti
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy.
| |
Collapse
|
42
|
Sorraya N, Farrokhzad A, Hassani B, Talebi S. Association between serum potassium and risk of all-cause mortality among chronic kidney diseases patients: A systematic review and dose-response meta-analysis of more than one million participants. Food Sci Nutr 2021; 9:5312-5323. [PMID: 34532036 PMCID: PMC8441339 DOI: 10.1002/fsn3.2478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 07/02/2021] [Accepted: 07/06/2021] [Indexed: 11/10/2022] Open
Abstract
We aimed to perform a meta-analysis, using prospective cohort studies, to test the association between serum potassium and all-cause mortality among chronic kidney diseases (CKD) patients. A systematic search was performed using PubMed-MEDLINE and Scopus, up to July 2020. Prospective cohort studies which reported risk estimates of all-cause mortality in CKD patients with different serum potassium levels were included in the present meta-analysis. Thirteen studies were included in the analysis. A nonlinear dose-response meta-analysis suggested that there is a J-shaped association between serum potassium levels and the risk of all-cause mortality, with a nadir at serum potassium of 4.5 mmol/L. Subgroup analyses indicated that the strength and shape of the association between serum potassium and all-cause mortality may be influenced by age. Our meta-analysis provides supportive evidence that there is a J-shape association between serum potassium and all-cause mortality among CKD patients.
Collapse
Affiliation(s)
- Nasim Sorraya
- Department of Community NutritionSchool of Nutrition and Food ScienceFood Security Research CenterIsfahan University of Medical SciencesIsfahanIran
| | | | - Bahar Hassani
- Department of NutritionAhvaz Jundishapur University of Medical SciencesAhvazIran
- Department of Health Safety and Environment (HSE)Razi Petrochemical CompanyMahshahrIran
| | - Shokoofeh Talebi
- Department of Clinical NutritionSchool of Nutrition and Food ScienceFood Security Research CenterIsfahan University of Medical SciencesIsfahanIran
| |
Collapse
|
43
|
Chertow GM, Vart P, Jongs N, Toto RD, Gorriz JL, Hou FF, McMurray JJ, Correa-Rotter R, Rossing P, Sjöström CD, Stefánsson BV, Langkilde AM, Wheeler DC, Heerspink HJ. Effects of Dapagliflozin in Stage 4 Chronic Kidney Disease. J Am Soc Nephrol 2021; 32:2352-2361. [PMID: 34272327 PMCID: PMC8729835 DOI: 10.1681/asn.2021020167] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/06/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND In the Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease (DAPA-CKD) randomized, placebo-controlled trial, the sodium-glucose cotransporter 2 inhibitor dapagliflozin significantly reduced risk of kidney failure and prolonged survival in patients with CKD with or without type 2 diabetes. METHODS Adults with eGFR of 25-75 ml/min per 1.73 m2 and urinary albumin-to-creatinine ratio of 200-5000 mg/g had been randomized to receive dapagliflozin 10 mg/d or placebo. Here, we conducted a prespecified analysis of dapagliflozin's effects in patients with stage 4 CKD (eGFR,30 ml/min per 1.73 m2) at baseline. The primary end point was a composite of time to ≥50% sustained decline in eGFR, ESKD, or kidney or cardiovascular death. Secondary end points were a kidney composite (same as the primary end point but without cardiovascular death), a composite of cardiovascular death or heart failure hospitalization, and all-cause death. RESULTS A total of 293 participants with stage 4 CKD received dapagliflozin and 331 received placebo. Patients with stage 4 CKD randomized to dapagliflozin experienced a 27% (95% confidence interval [95% CI]: -2 to 47%) reduction in the primary composite endpoint, and 29% (-2 to 51%), 17% (-53 to 55%), and 32% (-21 to 61%) reductions in the kidney, cardiovascular and mortality endpoints, respectively, relative to placebo. Interaction P-values were 0.22, 0.13, 0.63, and 0.95, respectively, comparing CKD stages 4 versus 2/3. The eGFR slope declined by 2.15 and 3.38 ml/min per 1.73 m2 per year in the dapagliflozin and placebo groups, respectively (P=0.005). Patients treated with dapagliflozin or placebo had similar rates of serious adverse events and adverse events of interest. CONCLUSIONS Among patients with stage 4 CKD and albuminuria, the effects of dapagliflozin were consistent with those observed in the DAPA-CKD trial overall, with no evidence of increased risks.
Collapse
Affiliation(s)
- Glenn M. Chertow
- Departments of Medicine and Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
| | - Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Robert D. Toto
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jose Luis Gorriz
- Hospital Clinico Universitario de Valencia, University of Valencia, Valencia, Spain
| | - Fan Fan Hou
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, Guangzhou, China
| | - John J.V. McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Ricardo Correa-Rotter
- National Medical Science and Nutrition Institute Salvador Zubirán, Mexico City, Mexico
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - C. David Sjöström
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Bergur V. Stefánsson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - David C. Wheeler
- Department of Renal Medicine, University College London, United Kingdom,The George Institute for Global Health, Sydney, Australia
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | |
Collapse
|
44
|
Hundemer GL, Sood MM. Hyperkalemia with RAAS inhibition: Mechanism, clinical significance, and management. Pharmacol Res 2021; 172:105835. [PMID: 34438065 DOI: 10.1016/j.phrs.2021.105835] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/09/2021] [Accepted: 08/16/2021] [Indexed: 12/30/2022]
Abstract
Renin-angiotensin-aldosterone system (RAAS) inhibitors are evidence-based treatments for a number of conditions including hypertension, diabetes mellitus, chronic kidney disease, and congestive heart failure. Among the most common adverse effects of RAAS inhibitors is hyperkalemia which results from either reduced secretion of aldosterone or increased resistance to aldosterone. Many of the conditions for which RAAS inhibitors are recommended further amplify the risk for hyperkalemia in and of themselves. RAAS inhibitor-related hyperkalemia is associated with an increased risk for cardiovascular events, hospitalizations, and death. Yet discontinuation of RAAS inhibitors for patients with chronic kidney disease and congestive heart failure is also associated with an increased risk for cardiovascular events, hospitalizations, and death. Therefore, clinicians are often left to struggle with the dilemma of the best management approach to RAAS inhibitor-related hyperkalemia. The ideal solution involves pharmacotherapies that are safe and effective in mitigating hyperkalemia and allow patients to continue to receive the beneficial effects from RAAS inhibitors. In this regard, modern pharmacologic agents such as patiromer and zirconium cyclosilicate are providing a mechanism whereby physicians are better equipped to maintain their patients on RAAS inhibitors.
Collapse
Affiliation(s)
- Gregory L Hundemer
- Department of Medicine (Division of Nephrology) and The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
| | - Manish M Sood
- Department of Medicine (Division of Nephrology) and The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Institute for Clinical Evaluative Sciences, Ottawa, Canada
| |
Collapse
|
45
|
Laymito-Quispe RDP, López-Vilella R, Sánchez-Lázaro I, Donoso-Trenado V, Lozano-Edo S, Martínez-Dolz L, Almenar-Bonet L. Prognostic implications of hypo and hyperkalaemia in acute heart failure with reduced ejection fraction. Analysis of cardiovascular mortality and hospital readmissions. Med Clin (Barc) 2021; 158:211-217. [PMID: 34229884 DOI: 10.1016/j.medcli.2021.03.037] [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: 11/25/2020] [Revised: 03/14/2021] [Accepted: 03/18/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Potassium alterations constitute a major clinical problem in decompensated heart failure (HF). This study aims to assess the prognostic implications of hypo and hyperkalaemia on admission for acute HF in cardiovascular mortality and hospital readmissions. MATERIAL AND METHOD From January 2016 to June 2020, 1,397 cases with a diagnosis of acute HF were admitted. Admission programmed for study, elective therapies, and patients with LVEF> 40% were excluded. The study was carried out on 689 patients, 45 with K+ <3.5 mmol/L, 49K +>5.0 mmol/L and 595K+3.5-5.0 mmol/L. Medical history, baseline clinical profile, drug therapy, and potassium levels obtained upon admission were analysed. RESULTS Annual mortality due to hypokalaemia (K+<3.5mmol/L) was 37.8% (HR 2.4; 95% CI: 1.3-4.7; P<.007); for hyperkalaemia 40.8% (HR: 1.9; 95% CI: 0.98-3.51; P<.055). Creatinine level and age were variables associated with mortality in both the hyperkalaemic and hypokalaemic cohorts. Hospital readmissions did not show statistical association with these electrolyte disorders. CONCLUSIONS In patients admitted for decompensated HF, both hyperkalaemia and hypokalaemia determined at admission have a negative prognostic impact on survival. Creatinine and age are other independent factors associated with mortality. The effect on the probability of hospital readmission at one year is not demonstrated in this study.
Collapse
Affiliation(s)
- Rocío Del Pilar Laymito-Quispe
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, España; Servicio de Cardiología, Hospital Universitari i Politècnic La Fe. Valencia, España.
| | - Raquel López-Vilella
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, España; Servicio de Cardiología, Hospital Universitari i Politècnic La Fe. Valencia, España
| | - Ignacio Sánchez-Lázaro
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, España; Servicio de Cardiología, Hospital Universitari i Politècnic La Fe. Valencia, España; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Valencia, España
| | - Víctor Donoso-Trenado
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, España; Servicio de Cardiología, Hospital Universitari i Politècnic La Fe. Valencia, España
| | - Silvia Lozano-Edo
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, España; Servicio de Cardiología, Hospital Universitari i Politècnic La Fe. Valencia, España
| | - Luis Martínez-Dolz
- Servicio de Cardiología, Hospital Universitari i Politècnic La Fe. Valencia, España; Facultad de Medicina, Universidad de Valencia, Valencia, España
| | - Luis Almenar-Bonet
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, España; Servicio de Cardiología, Hospital Universitari i Politècnic La Fe. Valencia, España; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Valencia, España; Facultad de Medicina, Universidad de Valencia, Valencia, España
| |
Collapse
|
46
|
Britto DT, Coskun D, Kronzucker HJ. Potassium physiology from Archean to Holocene: A higher-plant perspective. JOURNAL OF PLANT PHYSIOLOGY 2021; 262:153432. [PMID: 34034042 DOI: 10.1016/j.jplph.2021.153432] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 05/27/2023]
Abstract
In this paper, we discuss biological potassium acquisition and utilization processes over an evolutionary timescale, with emphasis on modern vascular plants. The quintessential osmotic and electrical functions of the K+ ion are shown to be intimately tied to K+-transport systems and membrane energization. Several prominent themes in plant K+-transport physiology are explored in greater detail, including: (1) channel mediated K+ acquisition by roots at low external [K+]; (2) K+ loading of root xylem elements by active transport; (3) variations on the theme of K+ efflux from root cells to the extracellular environment; (4) the veracity and utility of the "affinity" concept in relation to transport systems. We close with a discussion of the importance of plant-potassium relations to our human world, and current trends in potassium nutrition from farm to table.
Collapse
Affiliation(s)
- Dev T Britto
- Faculty of Land and Food Systems, University of British Columbia, Vancouver, BC, V6T 1Z4, Canada; School of BioSciences, The University of Melbourne, Parkville, Victoria, 3010, Australia
| | - Devrim Coskun
- Département de Phytologie, Faculté des Sciences de l'Agriculture et de l'Alimentation (FSAA), Université Laval, Québec, QC, G1V 0A6, Canada
| | - Herbert J Kronzucker
- Faculty of Land and Food Systems, University of British Columbia, Vancouver, BC, V6T 1Z4, Canada; School of BioSciences, The University of Melbourne, Parkville, Victoria, 3010, Australia.
| |
Collapse
|
47
|
Jaisser F, Tan X, Chi S, Liu J, Wang P, Bush M, Benn V, Yang YF, Zhang J. The Non-Steroidal Mineralocorticoid Receptor Antagonist KBP-5074 Limits Albuminuria and has Improved Therapeutic Index Compared With Eplerenone in a Rat Model With Mineralocorticoid-Induced Renal Injury. Front Pharmacol 2021; 12:604928. [PMID: 34248613 PMCID: PMC8264204 DOI: 10.3389/fphar.2021.604928] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 05/31/2021] [Indexed: 12/15/2022] Open
Abstract
The therapeutic indices (TIs) and efficacy of the non-steroidal mineralocorticoid receptor antagonist (MRA) KBP-5074 and steroidal MRA eplerenone were evaluated in a uninephrectomized Sprague Dawley rat model of aldosterone-mediated renal disease. In two parallel studies, rats were placed on a high-salt diet and received aldosterone by osmotic mini-pump infusion over the course of 27 days. The urinary albumin-to-creatinine ratio (UACR) was evaluated after 7, 14, and 26 days of treatment. Serum K+ was evaluated after 14 and 27 days of treatment. Urinary Na+, urinary K+, and urinary Na+/K+ ratio were evaluated after 7, 14, and 26 days of treatment. The TI was calculated for each drug as the ratio of the concentration of drug producing 50% of maximum effect (EC50) for increasing serum K+ to the EC50 for lowering UACR. The TIs were 24.5 for KBP-5074 and 0.620 for eplerenone, resulting in a 39-fold improved TI for KBP-5074 compared with eplerenone. Aldosterone treatment increased UACR, decreased serum K+, and decreased urinary Na+ relative to sham-operated controls that did not receive aldosterone infusion in both studies, validating the aldosterone/salt renal injury model. KBP-5074 prevented the increase in UACR at 0.5, 1.5, and 5 mg/kg BID while eplerenone did so only at the two highest doses of 50 and 450 mg/kg BID. Both KBP-5074 and eplerenone blunted the reduction in serum K+ seen in the aldosterone treatment group, with significant increases in serum K+ at the high doses only (5 mg/kg and 450 mg/kg BID, respectively). Additionally, the urinary Na+ and Na+/K+ ratio significantly increased at the middle and high doses of KBP-5074, but only at the highest dose of eplerenone. These results showed increased TI and efficacy for KBP-5074 compared with eplerenone over a wider therapeutic window.
Collapse
Affiliation(s)
- Frédéric Jaisser
- INSERM UMRS1138, Sorbonne Université, Université de Paris, Centre de Recherche des Cordeliers, Paris, France
| | | | | | | | - Ping Wang
- KBP BioSciences Co., Ltd., Shandong, China
| | - Mark Bush
- Nuventra Inc., Durham, NC, United States
| | - Vincent Benn
- KBP BioSciences USA Inc., Princeton, NJ, United States
| | - Y Fred Yang
- KBP BioSciences USA Inc., Princeton, NJ, United States
| | - Jay Zhang
- KBP BioSciences USA Inc., Princeton, NJ, United States
| |
Collapse
|
48
|
Potassium Metabolism and Management in Patients with CKD. Nutrients 2021; 13:nu13061751. [PMID: 34063969 PMCID: PMC8224083 DOI: 10.3390/nu13061751] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 01/20/2023] Open
Abstract
Potassium (K), the main cation inside cells, plays roles in maintaining cellular osmolarity and acid–base equilibrium, as well as nerve stimulation transmission, and regulation of cardiac and muscle functions. It has also recently been shown that K has an antihypertensive effect by promoting sodium excretion, while it is also attracting attention as an important component that can suppress hypertension associated with excessive sodium intake. Since most ingested K is excreted through the kidneys, decreased renal function is a major factor in increased serum levels, and target values for its intake according to the degree of renal dysfunction have been established. In older individuals with impaired renal function, not only hyperkalemia but also hypokalemia due to anorexia, K loss by dialysis, and effects of various drugs are likely to develop. Thus, it is necessary to pay attention to K management tailored to individual conditions. Since abnormalities in K metabolism can also cause lethal arrhythmia or sudden cardiac death, it is extremely important to monitor patients with a high risk of hyper- or hypokalemia and attempt to provide early and appropriate intervention.
Collapse
|
49
|
Hu J, Xu Y, Bachmann S, Mutig K. Angiotensin II receptor blockade alleviates calcineurin inhibitor nephrotoxicity by restoring cyclooxygenase 2 expression in kidney cortex. Acta Physiol (Oxf) 2021; 232:e13612. [PMID: 33377278 DOI: 10.1111/apha.13612] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 12/27/2022]
Abstract
AIM The use of calcineurin inhibitors such as cyclosporine A (CsA) for immunosuppression after solid organ transplantation is commonly limited by renal side effects. CsA-induced deterioration of glomerular filtration rate and sodium retention may be related to juxtaglomerular dysregulation as a result of suppressed cyclooxygenase 2 (COX-2) and stimulated renin biosynthesis. We tested whether CsA-induced COX-2 suppression is caused by hyperactive renin-angiotensin system (RAS) and whether RAS inhibition may alleviate the related side effects. METHODS Rats received CsA, the RAS inhibitor candesartan, or the COX-2 inhibitor celecoxib acutely (3 days) or chronically (3 weeks). Molecular pathways mediating effects of CsA and RAS on COX-2 were studied in cultured macula densa cells. RESULTS Pharmacological or siRNA-mediated calcineurin inhibition in cultured cells enhanced COX-2 expression via p38 mitogen-activated protein kinase and NF-kB signalling, whereas angiotensin II abolished these effects. Acute and chronic CsA administration to rats led to RAS activation along with reduced cortical COX-2 expression, creatinine clearance and fractional sodium excretion. Evaluation of major distal salt transporters, NKCC2 and NCC, showed increased levels of their activating phosphorylation upon CsA. Concomitant candesartan treatment blunted these effects acutely and completely normalized the COX-2 expression and renal functional parameters at long term. Celecoxib prevented the candesartan-induced improvements of creatinine clearance and sodium excretion. CONCLUSION Suppression of juxtaglomerular COX-2 upon CsA results from RAS activation, which overrides the cell-autonomous, COX-2-stimulatory effects of calcineurin inhibition. Angiotensin II antagonism alleviates CsA nephrotoxicity via the COX-2-dependent normalization of creatinine clearance and sodium excretion.
Collapse
Affiliation(s)
- Junda Hu
- Department of Anatomy Charité‐Universitätsmedizin Berlin Berlin Germany
| | - Yan Xu
- Department of Anatomy Charité‐Universitätsmedizin Berlin Berlin Germany
| | | | - Kerim Mutig
- Department of Anatomy Charité‐Universitätsmedizin Berlin Berlin Germany
- Department of Pharmacology I.M. Sechenov First Moscow State Medical University (Sechenov University) Moscow Russian Federation
| |
Collapse
|
50
|
Campbell P, McKeveney P, Donegan K, Ataliotis C, Patton C, Mullan R. Practical guidance for the use of potassium binders in the management of hyperkalaemia in patients with heart failure and/or chronic kidney disease. Br J Hosp Med (Lond) 2021; 82:1-11. [PMID: 33914625 DOI: 10.12968/hmed.2021.0215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Given the critical physiological role of potassium, it is understandable that the development of severe hyperkalaemia requires effective management to reduce its effects, which include muscle weakness, paralysis and cardiac arrhythmias. Hyperkalaemia most often results from the failure of renal adaptation to potassium imbalance. Patients who are most susceptible to the development of hyperkalaemia include those with chronic kidney disease and those with heart failure. These patients are often treated with renin-angiotensin-aldosterone system (RAAS) inhibitors, such as angiotensin-converting enzyme inhibitors and angiotensin II-receptor blockers, but the development of hyperkalaemia can require down-titration or cessation of RAAS inhibitors. This presents a significant challenge to nephrologists, cardiologists and healthcare professionals treating these patients as this can prevent them from receiving maximum guideline-directed RAAS inhibitor therapy. Panellists in this roundtable discussion shared their clinical experiences of using potassium binders to manage hyperkalaemia in patients with chronic kidney disease and patients with heart failure (illustrated with case studies) in Northern Ireland and considered recommendations for the implementation and maintenance of chronic potassium-lowering treatment.
Collapse
Affiliation(s)
| | | | | | | | - Carol Patton
- Craigavon Hospital, Southern HSC Trust, Portadown, Craigavon
| | | |
Collapse
|