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Aboghanem A, Prasad GVR. Disorders of potassium homeostasis after kidney transplantation. World J Transplant 2024; 14:95905. [PMID: 39295980 PMCID: PMC11317851 DOI: 10.5500/wjt.v14.i3.95905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 05/29/2024] [Accepted: 06/26/2024] [Indexed: 07/31/2024] Open
Abstract
Disturbances of potassium balance are often encountered when managing kidney transplant recipients (KTR). Both hyperkalemia and hypokalemia may present either as medical emergencies or chronic outpatient abnormalities. Despite the high incidence of hyperkalemia and its potential life-threatening implications, consensus on its management in KTR is lacking. Hypokalemia in KTR is also well-described, although it is given less attention by clinicians compared to hyperkalemia. This article discusses the etiology, pathophysiology and management of both types of potassium disorders in KTR. Once any emergent situation has been corrected, treatment approaches include correcting insulin deficiency if present, adjusting non-immunosuppressive and immunosuppressive medications, eliminating or supplementing potassium as needed, and dietary counselling. Although commonly of multifactorial etiology, ascertaining the specific cause in a particular patient will help guide successful management. Monitoring KTR through regular laboratory testing is essential to detect serious disturbances in potassium balance since patients are often asymptomatic.
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Affiliation(s)
| | - G V Ramesh Prasad
- School of Medicine, University of Toronto, Toronto M5C 2T2, Ontario, Canada
- Kidney Transplant Program, St. Michael's Hospital, Toronto M5C 2T2, Ontario, Canada
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Bakris G, Agiro A, Greatsinger A, Mu F, Cook EE, Sundar M, Louden E, Colman E, Desai P. Economic burden of recurrent hyperkalemia in patients with chronic kidney disease. J Manag Care Spec Pharm 2024:1-15. [PMID: 39102345 DOI: 10.18553/jmcp.2024.24114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
BACKGROUND Hyperkalemia is a common complication of chronic kidney disease (CKD) and can become recurrent in half of cases. However, the incremental economic burden associated with recurrent hyperkalemia is unknown. OBJECTIVE To evaluate all-cause health care resource utilization (HRU) and medical costs in patients with stage 3/4 CKD with recurrent hyperkalemia vs normokalaemia and vs nonrecurrent hyperkalemia. METHODS Data were from Optum's de-identified Market Clarity Data (January 1, 2016, to August 1, 2022). This retrospective observational cohort study compared patients with stage 3/4 CKD with recurrent hyperkalemia (≥2 hyperkalemia events within 1 year [hyperkalemia event: hyperkalemia diagnosis or potassium [K+]>5 mmol/l]; index was the first hyperkalemia event) with an exact- and propensity score-matched cohort of patients with normokalemia (K+ ≥3.5 to ≤5 mmol/l; random K+ as index) and separately with a matched cohort of patients with nonrecurrent hyperkalemia (1 hyperkalemia event within 1 year; index was hyperkalemia event). Patient characteristics, medication use, HRU, and medical costs were compared between cohorts using standardized mean differences during the 12-month baseline period. All-cause HRU and medical costs during the 12-month follow-up were compared using Wilcoxon rank sum tests for continuous variables and McNemar tests for categorical variables. Substudies of recurrent hyperkalemia vs normokalemia were conducted for patients with Medicare coverage and renin-angiotensin-aldosterone system inhibitor (RAASi) use. RESULTS The recurrent hyperkalemia vs normokalemia sample comprised 4,549 matched pairs (Medicare substudy: 3,151; RAASi substudy: 3,535) and the recurrent hyperkalemia vs nonrecurrent hyperkalemia sample comprised 1,599 matched pairs. Baseline characteristics, HRU, and medical costs of the cohorts were similar after matching. During follow-up, patients with recurrent hyperkalemia had a mean of 11.2 more health care encounters (0.5 more inpatient admissions, 0.3 more emergency department visits, and 7.2 more outpatient visits) than patients with normokalemia. Patients with recurrent hyperkalemia also had double the total annual medical costs vs normokalemia ($34,163 vs $15,175; P < 0.001), mainly driven by inpatient costs ($21,250 vs $7,392), which accounted for 62.2% and 48.7% of total costs, respectively. Results were similar in the RAASi and Medicare substudies. Recurrent hyperkalemia was associated with a mean 4.3 more all-cause health care encounters and $14,057 higher medical costs (both P < 0.001) than nonrecurrent hyperkalemia. CONCLUSIONS Recurrent hyperkalemia in patients with stage 3/4 CKD was associated with higher all-cause HRU and medical costs compared with normokalemia (including in patients with Medicare coverage and RAASi use) and nonrecurrent hyperkalemia. Research is needed to understand if long-term treatment strategies aimed at preventing hyperkalemia recurrence may alleviate this economic burden.
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Affiliation(s)
- George Bakris
- Comprehensive Hypertension Center, University of Chicago, IL
| | | | | | - Fan Mu
- Analysis Group, Inc, Boston, MA
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De Nicola L, Ferraro PM, Montagnani A, Pontremoli R, Dentali F, Sesti G. Recommendations for the management of hyperkalemia in patients receiving renin-angiotensin-aldosterone system inhibitors. Intern Emerg Med 2024; 19:295-306. [PMID: 37775712 PMCID: PMC10954964 DOI: 10.1007/s11739-023-03427-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/04/2023] [Indexed: 10/01/2023]
Abstract
Hyperkalemia is common in clinical practice and can be caused by medications used to treat cardiovascular diseases, particularly renin-angiotensin-aldosterone system inhibitors (RAASis). This narrative review discusses the epidemiology, etiology, and consequences of hyperkalemia, and recommends strategies for the prevention and management of hyperkalemia, mainly focusing on guideline recommendations, while recognizing the gaps or differences between the guidelines. Available evidence emphasizes the importance of healthcare professionals (HCPs) taking a proactive approach to hyperkalemia management by prioritizing patient identification and acknowledging that hyperkalemia is often a long-term condition requiring ongoing treatment. Given the risk of hyperkalemia during RAASi treatment, it is advisable to monitor serum potassium levels prior to initiating these treatments, and then regularly throughout treatment. If RAASi therapy is indicated in patients with cardiorenal disease, HCPs should first treat chronic hyperkalemia before reducing the dose or discontinuing RAASis, as reduction or interruption of RAASi treatment can increase the risk of adverse cardiovascular and renal outcomes or death. Moreover, management of hyperkalemia should involve the use of newer potassium binders, such as sodium zirconium cyclosilicate or patiromer, as these agents can effectively enable optimal RAASi treatment. Finally, patients should receive education regarding hyperkalemia, the risks of discontinuing their current treatments, and need to avoid excessive dietary potassium intake.
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Affiliation(s)
- Luca De Nicola
- Nephrology Unit, Advanced Medical and Surgical Sciences Department, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Pietro Manuel Ferraro
- U.O.S. Terapia Conservativa della Malattia Renale Cronica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy.
- Section of Nephrology, Department of Medicine, Università degli Studi di Verona, Verona, Italy.
| | - Andrea Montagnani
- Department of Internal Medicine, Hospital Misericordia, Grosseto, Italy
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, University of Rome-Sapienza, Rome, Italy
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Wheeler DC, Søndergaard H, Gwynn C, Hedman K, Hedberg J, Allum A, Chung HL, Någård M, Stjernlöf G, Wittbrodt E, Kim J, Morris J. Randomised, blinded, cross-over evaluation of the palatability of and preference for different potassium binders in participants with chronic hyperkalaemia in the USA, Canada and Europe: the APPETIZE study. BMJ Open 2024; 14:e074954. [PMID: 38387989 PMCID: PMC10882352 DOI: 10.1136/bmjopen-2023-074954] [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: 04/21/2023] [Accepted: 01/09/2024] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVES Traditional potassium (K+) binders for treating hyperkalaemia are unpalatable and poorly tolerated. Newer K+ binders are reportedly better tolerated; however, no published data describe their palatability, a determinant of long-term adherence. This study evaluated the palatability of and preference for three K+ binders: sodium and calcium polystyrene sulfonate (S/CPS), sodium zirconium cyclosilicate (SZC) and calcium patiromer sorbitex (patiromer). DESIGN Phase 4, randomised, participant-blinded, cross-over study. Participants were randomised to one of six taste sequences and, using a 'sip and spit' approach, tasted each K+ binder before completing a survey. SETTING 17 centres across the USA, Canada and European Union. PARTICIPANTS 144 participants with chronic kidney disease, hyperkalaemia and no recent use of K+ binders. MAIN OUTCOME MEASURES For the primary (USA) and key secondary (Canada and European Union) endpoints, participants rated palatability attributes (taste, texture, smell and mouthfeel) and willingness to take each K+ binder on a scale of 0-10 (rational evaluation). Feelings about each attribute, and the idea of taking the product once daily, were evaluated using a non-verbal, visual measure of emotional response. Finally, participants ranked the K+ binders according to palatability. RESULTS In each region, SZC and patiromer outperformed S/CPS on overall palatability (a composite of taste, texture, smell and mouthfeel), based on rational evaluation and emotional response. Taking the product once daily was more appealing for SZC and patiromer, creating greater receptivity than the idea of taking S/CPS. The emotional response to mouthfeel had the strongest influence on feelings about taking each product. In each region, a numerically greater proportion of participants ranked SZC as the most preferred K+ binder versus patiromer or S/CPS. CONCLUSIONS Preference for more palatable K+ binders such as SZC and patiromer may provide an opportunity to improve adherence to long-term treatment of hyperkalaemia. TRIAL REGISTRATION NUMBER NCT04566653.
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Affiliation(s)
- David C Wheeler
- Department of Renal Medicine, Centre for Nephrology, University College London, London, UK
| | | | | | | | - Jonatan Hedberg
- BioPharmaceuticals Medical Evidence and Observational Research, AstraZeneca, Gothenburg, Sweden
| | - Alaster Allum
- UK Global Medical Affairs, AstraZeneca, Cambridge, UK
| | - Hui-Lan Chung
- BioPharmaceuticals Medical Evidence, AstraZeneca, Taipei, Taiwan
| | - Mats Någård
- Clinical Pharmacology and Safety Sciences, AstraZeneca, Gaithersburg, Maryland, USA
| | | | - Eric Wittbrodt
- Global Medical Affairs, BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Maryland, USA
| | - Jennifer Kim
- Global Pricing and Market Access, AstraZeneca, Gaithersburg, Maryland, USA
| | - Jon Morris
- AdSAM, Gainesville, Florida, USA
- College of Journalism and Communications, University of Florida, Gainesville, Florida, USA
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Onogi C, Watanabe Y, Tanaka A, Furuhashi K, Maruyama S. Mortality and hyperkalaemia-associated hospitalisation in patients with chronic kidney disease: comparison of sodium zirconium cyclosilicate and sodium/calcium polystyrene sulfonate. Clin Kidney J 2024; 17:sfae021. [PMID: 38404365 PMCID: PMC10894033 DOI: 10.1093/ckj/sfae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Indexed: 02/27/2024] Open
Abstract
Background Sodium zirconium cyclosilicate (SZC), a novel drug used for treating hyperkalaemia, is effective in reducing serum potassium levels. The effects of potassium adsorbents on the mortality and hyperkalaemia-associated hospitalisation rates remain unclear. We aimed to examine how mortality and hyperkalaemia-associated hospitalisation rates vary with usage of various potassium adsorbents. Methods This retrospective study used patients' data between April 2008 and August 2021 obtained from a large-scale Japanese medical claims database. Consecutive patients with chronic kidney disease (CKD) prescribed potassium adsorbents were enrolled and divided into three groups according to the adsorbent type [SZC, calcium polystyrene sulfonate (CPS), and sodium polystyrene sulfonate (SPS)] and were observed for 1 year. The primary outcome was a composite of mortality and hyperkalaemia-associated hospitalisation. Results In total, 234, 54 183, and 18 692 patients were prescribed SZC, CPS, and SPS, respectively. The SZC group showed a higher event-free survival rate than the other two groups. The hazard ratio for the primary outcome in the CPS and SPS groups was similar in the analyses of the subgroups of patients who did not receive renal replacement therapy and those who received haemodialysis. The SZC group had a higher renin-angiotensin-aldosterone system inhibitors (RAASi) continuation rate compared to CPS and SPS groups, the difference being especially significant for SPS. Conclusions This real-world study demonstrated the therapeutic effect of SZC in reducing mortality and hyperkalaemia-associated hospitalisations. The high RAASi continuation rate in the SZC group might be a contributing factor for improvement of the primary outcome.
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Affiliation(s)
- Chikao Onogi
- Department of Nephrology, Nagoya University, Graduate School of Medicine, Nagoya, Japan
- Department of Cell Physiology, Nagoya University, Graduate School of Medicine, Nagoya, Japan
| | - Yu Watanabe
- Department of Nephrology, Nagoya University, Graduate School of Medicine, Nagoya, Japan
| | - Akihito Tanaka
- Department of Nephrology, Nagoya University Hospital, Nagoya, Japan
| | | | - Shoichi Maruyama
- Department of Nephrology, Nagoya University, Graduate School of Medicine, Nagoya, Japan
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Fan Y, Wu M, Li X, Zhao J, Shi J, Ding L, Jiang H, Li Z, Zhang W, Ma T, Wang D, Ma L. Potassium levels and the risk of all-cause and cardiovascular mortality among patients with cardiovascular diseases: a meta-analysis of cohort studies. Nutr J 2024; 23:8. [PMID: 38195532 PMCID: PMC10777575 DOI: 10.1186/s12937-023-00888-z] [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: 07/20/2023] [Accepted: 10/30/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Abnormal blood potassium levels are associated with an increased risk of cardiometabolic diseases and mortality in the general population; however, evidence regarding the association between dyskalemia and mortality among patients with cardiovascular disease (CVD) remains inconclusive. This study aimed to evaluate the association of potassium levels with all-cause and cardiovascular mortality among patients with CVD. METHODS PubMed, Embase, Web of Science, and Cochrane Library databases were searched up to August 2023 to identify relevant cohort studies among patients with CVD, such as myocardial infarction, stroke, and heart failure. Abnormal potassium levels were considered as hypokalemia or hyperkalemia. The primary outcomes were all-cause mortality based on follow-up length (including in-hospital, short-term and long-term mortality) and cardiovascular mortality. The methodological quality of included studies was assessed by using the Newcastle-Ottawa Scale. The pooled relative risks (RRs) and 95% confidence intervals (CIs) were calculated using random-effects models. Restricted cubic splines were applied to explore the dose-response relationship. RESULTS Thirty-one cohort studies involving 227,645 participants with an average age of 68.3 years were included in the meta-analysis, all of which achieved moderate to high quality. Hyperkalemia was significantly associated with an approximately 3.0-fold increased risk of all-cause in-hospital mortality (RR:2.78,95CI%:1.92,4.03), 1.8-fold of all-cause short-term mortality (RR:1.80, 95CI%:1.44,2.27), 1.3-fold of all-cause long-term mortality (RR:1.33, 95CI%:1.19,1.48) and 1.2-fold of cardiovascular mortality (RR:1.19, 95CI%:1.04,1.36). Similar positive associations were also observed between hypokalemia and risk of all-cause mortality and cardiovascular mortality. The RRs of all-cause in-hospital, short-term, long-term mortality and cardiovascular mortality with hyperkalemia were attenuated to 2.21 (95CI%:1.60,3.06), 1.46(95CI%:1.25,1.71), 1.23 (95CI%:1.09,1.39) and 1.13 (95CI%:1.00,1.27) when treating hypokalemia together with normokalemia as the reference group. A U-shaped association was observed between potassium levels and mortality, with the lowest risk at around 4.2 mmol/L. CONCLUSIONS Both hypokalemia and hyperkalemia were positively associated with the risk of mortality in patients with CVD. Our results support the importance of potassium homeostasis for improving the CVD management. REGISTRATION PROSPERO, CRD42022324337.
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Affiliation(s)
- Yahui Fan
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Min Wu
- The First Affiliated Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Xiaohui Li
- Department of Maternal and Child Health Management, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, 610045, China
| | - Jinping Zhao
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Jia Shi
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Lu Ding
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Hong Jiang
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Zhaofang Li
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Wei Zhang
- The First Affiliated Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Tianyou Ma
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China.
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi'an, 710061, China.
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education of China, Xi'an, 710061, China.
| | - Duolao Wang
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, Affiliated Hospital of Guangdong Medical University, Zhanjiang, 524013, China.
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK.
| | - Le Ma
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China.
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi'an, 710061, China.
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education of China, Xi'an, 710061, China.
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de Sequera P, Bover R, Ivanova-Markova Y, Ivanova A, González-Domínguez A, Valls M, Campos V. Economic impact of the use of patiromer in chronic kidney disease or heart failure for the treatment of chronic hyperkalemia in Spain. Nefrologia 2023; 43:721-730. [PMID: 38228463 DOI: 10.1016/j.nefroe.2024.01.002] [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: 04/22/2022] [Accepted: 08/25/2022] [Indexed: 01/18/2024] Open
Abstract
INTRODUCTION Chronic hyperkalemia has negative consequences in the medium and long term, and determines the suspension of nephro and cardioprotective drugs, such as renin-angiotensin-aldosterone system inhibitors (RAASi). There is an alternative to the suspension or dose reduction of these treatments: the administration of potassium chelators. The aim of this study is to estimate the economic impact of the use of patiromer in patients with chronic kidney disease (CKD) or heart failure (HF) and hyperkalemia in Spain. MATERIALS AND METHOD The annual economic impact of the use of patiromer has been estimated from the perspective of the Spanish society. Two scenarios were compared: patients with CKD or HF and hyperkalemia treated with and without patiromer. The costs have been updated to 2020 euros, using the Health Consumer Price Index. Direct healthcare costs related to the use of resources (treatment with RAASi, CKD progression, cardiovascular events and hospitalization due to hyperkalemia), direct non-healthcare costs (informal care: costs derived from time dedicated by patient's relatives), the indirect costs (productivity loss), as well as an intangible cost (due to premature mortality) were considered. A deterministic sensitivity analysis was performed to validate the robustness of the study results. RESULTS The mean annual cost per patient in the scenario without patiromer is €9,834.09 and €10,739.37 in CKD and HF, respectively. The use of patiromer would lead to cost savings of over 30% in both diseases. The greatest savings in CKD come from the delay in the progression of CKD. While in the case of HF, 80.1% of these savings come from premature mortality reduction. The sensitivity analyses carried out show the robustness of the results, obtaining savings in all cases. CONCLUSIONS The incorporation of patiromer allows better control of hyperkalemia and, as a consequence, maintain treatment with RAASi in patients with CKD or HF. This would generate a 32% of annual savings in Spain (€3,127 in CKD; €3,466 in HF). The results support the positive contribution of patiromer to health cost in patients with only CKD or in patients with only HF.
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Affiliation(s)
- Patricia de Sequera
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Ramón Bover
- Servicio de Cardiología, Hospital Universitario Clínico San Carlos, Madrid, Spain
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Ortiz A, Galán CDA, Carlos Fernández-García J, Cerezo JG, Ochoa RI, Núñez J, Gutiérrez FP, Navarro-González JF. Consensus document on the management of hyperkalemia. Nefrologia 2023; 43:765-782. [PMID: 38169239 DOI: 10.1016/j.nefroe.2023.12.002] [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: 05/03/2023] [Accepted: 05/08/2023] [Indexed: 01/05/2024] Open
Abstract
Hyperkalaemia is a common electrolyte imbalance with potentially serious short-, medium- and long-term consequences on morbidity and mortality rates and the use of national health service resources. The fact that different medical specialities can manage hyperkalaemia makes it important to have a unified approach, and the recent availability of new specific drug treatments means that the approach needs to be updated. This consensus document from the scientific societies most directly involved in the management of hyperkalaemia (Sociedad Española de Cardiología [Spanish Society of Cardiology], Sociedad Española de Endocrinología y Nutrición [Spanish Society of Endocrinology and Nutrition], Sociedad Española de Medicina Interna [Spanish Society of Internal Medicine], Sociedad Española de Medicina de Urgencias y Emergencias [Spanish Society of Accident and Emergency Medicine] and Sociedad Española de Nefrología [Spanish Society of Nephrology]) first of all reviews basic aspects of potassium balance and blood potassium. Then it goes on to focus on the concept, epidemiology, pathophysiology and diagnostic and therapeutic approaches to hyperkalaemia. The available evidence and the main published studies have been reviewed with the aim of providing a useful tool in the multidisciplinary approach to patients with hyperkalaemia.
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Affiliation(s)
| | | | | | | | - Rosa Ibán Ochoa
- Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), Spain
| | - Julio Núñez
- Sociedad Española de Cardiología (SEC), Spain
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Cohen DL, Wachtel H, Vaidya A, Hundemer GL, Tezuka Y, Davio A, Turcu AF, Cohen JB. Primary Aldosteronism in Chronic Kidney Disease: Blood Pressure Control and Kidney and Cardiovascular Outcomes After Surgical Versus Medical Management. Hypertension 2023; 80:2187-2195. [PMID: 37593884 DOI: 10.1161/hypertensionaha.123.21474] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/07/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Diagnosis and treatment of primary aldosteronism (PA) in chronic kidney disease (CKD) may be deferred due to limited evidence supporting safety and efficacy of treatment. Our goal was to assess clinical outcomes in patients with PA and CKD who received surgical or medical management. METHODS We conducted a multicenter, retrospective cohort study of patients with PA and CKD who underwent adrenal vein sampling from 2009-2019. We characterized clinical outcomes and evaluated differences by surgical versus medical management. Primary outcomes were systolic blood pressure and number of antihypertensive medications. Secondary outcomes were diastolic blood pressure, serum potassium, estimated glomerular filtration rate (eGFR), and kidney and cardiovascular events. Analyses were adjusted for age, sex, race, cardiovascular disease, diabetes, and eGFR. RESULTS Of 239 participants with PA and CKD, 158 (66%) underwent adrenalectomy, and 81 (34%) were treated medically. Mean age was 57±10 years, 67% were female, mean eGFR was 45±12 mL/min per 1.73 m2, and 49% were on potassium supplementation. At 5 years, mean blood pressure decreased from 149±22/85±14 to 131±28/78±16 mm Hg and mean number of antihypertensive medications decreased from 4.0±1.5 to 2.4±1.4. Adrenalectomy, compared to medical management, was associated with similar systolic blood pressure (-0.90 mm Hg [95% CI, -6.99 to 5.07]) but fewer medications (1.7 [95% CI, -2.24 to -1.10]), and no difference in potassium levels or kidney or cardiovascular outcomes. CONCLUSIONS Patients with PA and CKD are likely to benefit from either surgical adrenalectomy or medical management. Detection and treatment of PA may help to reduce blood pressure and medication burden in patients with CKD.
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Affiliation(s)
- Debbie L Cohen
- Renal-Electrolyte and Hypertension Division (D.L.C., J.B.C.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Heather Wachtel
- Department of Surgery (H.W.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Anand Vaidya
- Division of Endocrinology, Diabetes, and Hypertension, Center for Adrenal Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.V.)
| | - Gregory L Hundemer
- Division of Nephrology, Department of Medicine, Ottawa Hospital, University of Ottawa, ON, Canada (G.L.H.)
| | - Yuta Tezuka
- Division of Clinical Hypertension, Endocrinology and Metabolism (Y.T.), Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
- Division of Nephrology, Endocrinology and Vascular Medicine (Y.T.), Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Angela Davio
- Department of Medicine, University of Michigan, Ann Arbor (A.D., A.F.T.)
| | - Adina F Turcu
- Department of Medicine, University of Michigan, Ann Arbor (A.D., A.F.T.)
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division (D.L.C., J.B.C.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics (J.B.C.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Sampani E, Theodorakopoulou M, Iatridi F, Sarafidis P. Hyperkalemia in chronic kidney disease: a focus on potassium lowering pharmacotherapy. Expert Opin Pharmacother 2023; 24:1775-1789. [PMID: 37545002 DOI: 10.1080/14656566.2023.2245756] [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: 05/10/2023] [Revised: 08/01/2023] [Accepted: 08/04/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Hyperkalemia is one of the most common electrolyte disorders in chronic kidney disease (CKD) and is associated with serious adverse outcomes. Hyperkalemia risk is even greater when CKD patients also have additional predisposing conditions such as diabetes or heart failure. Renin-angiotensin-aldosterone-system blockers are first-line treatments for cardio- and nephroprotection, but their use is often limited due to K+ elevation, resulting in high rates of discontinuation. AREAS COVERED This article provides an overview of factors interfering with K+ homeostasis and discusses recent data on newer therapeutic agents used for the treatment of hyperkalemia. A detailed literature search was performed in two major databases (PubMed/MEDLINE and Scopus) up to April 2023. EXPERT OPINION Major clinical trials have tested new and promising kidney protective therapies such as sodium/glucose-cotransporter-2 inhibitors and mineralocorticoid-receptor-antagonists, with promising results. Until recently, the only treatment option for hyperkalemia was the cation-exchanging resin sodium-polystyrene-sulfonate. However, despite its common use, the efficacy and safety data of this drug in the long-term management of hyperkalemia are scarce. During the last decade, two novel orally administered K+-exchanging compounds (patiromer and sodium-zirconium-cyclosilicate) have been approved for the treatment of adults with hyperkalemia, as they both effectively reduce elevated serum K+ and maintain chronically K+ balance within the normal range with an excellent tolerability and no serious adverse events.
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Affiliation(s)
- Erasmia Sampani
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Marieta Theodorakopoulou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Fotini Iatridi
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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11
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Di Lullo L, Lavalle C, Scatena A, Mariani MV, Ronco C, Bellasi A. Finerenone: Questions and Answers-The Four Fundamental Arguments on the New-Born Promising Non-Steroidal Mineralocorticoid Receptor Antagonist. J Clin Med 2023; 12:3992. [PMID: 37373685 PMCID: PMC10299719 DOI: 10.3390/jcm12123992] [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: 05/16/2023] [Revised: 06/03/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Chronic kidney disease (CKD) is one of the most common complications of diabetes mellitus and an independent risk factor for cardiovascular disease. Despite guideline-directed therapy of CKD in patients with type 2 diabetes, the risk of renal failure and cardiovascular events still remains high, and diabetes remains the leading cause of end-stage kidney disease in affected patients. To date, current medications for CKD and type 2 diabetes mellitus have not reset residual risk in patients due to a high grade of inflammation and fibrosis contributing to kidney and heart disease. This question-and-answer-based review will discuss the pharmacological and clinical differences between finerenone and other mineralocorticoid receptor antagonists and then move on to the main evidence in the cardiovascular and renal fields, closing, finally, on the potential role of therapeutic combination with sodium-glucose cotransporter 2 inhibitors (SGLT2is).
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Affiliation(s)
- Luca Di Lullo
- Department of Nephrology and Dialysis, L. Parodi—Delfino Hospital, 00034 Colleferro, Italy
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (M.V.M.)
| | | | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (M.V.M.)
| | - Claudio Ronco
- International Renal Research Institute (IRRIV), S. Bortolo Hospital, 36100 Vicenza, Italy
| | - Antonio Bellasi
- Department of Medicine, Division of Nephrology, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland;
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12
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Hwang YJ, Muanda FT, McArthur E, Weir MA, Sontrop JM, Lam NN, Garg AX. Trimethoprim-sulfamethoxazole and the risk of a hospital encounter with hyperkalemia: a matched population-based cohort study. Nephrol Dial Transplant 2023; 38:1459-1468. [PMID: 36208171 PMCID: PMC10229280 DOI: 10.1093/ndt/gfac282] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Trimethoprim-sulfamethoxazole (TMP-SMX) can cause hyperkalemia by reducing renal potassium excretion. We assessed the risk of hyperkalemia after initiating TMP-SMX versus amoxicillin and determined if this risk is modified by a patient's baseline kidney function [estimated glomerular filtration rate (eGFR)]. METHODS We conducted a population-based cohort study in Ontario, Canada involving adults ≥66 years of age newly treated with TMP-SMX (n = 58 999) matched 1:1 with those newly treated with amoxicillin (2008-2020). The primary outcome was a hospital encounter with hyperkalemia defined by a laboratory serum potassium value ≥5.5 mmol/L within 14 days of antibiotic treatment. Secondary outcomes included a hospital encounter with acute kidney injury (AKI) and all-cause hospitalization. Risk ratios (RRs) were obtained using a modified Poisson regression. RESULTS A hospital encounter with hyperkalemia occurred in 269/58 999 (0.46%) patients treated with TMP-SMX versus 80/58 999 (0.14%) in those treated with amoxicillin {RR 3.36 [95% confidence interval (CI) 2.62-4.31]}. The absolute risk of hyperkalemia in patients treated with TMP-SMX versus amoxicillin increased progressively with decreasing eGFR (risk difference of 0.12% for an eGFR ≥60 ml/min/1.73 m2, 0.42% for eGFR 45-59, 0.85% for eGFR 30-44 and 1.45% for eGFR <30; additive interaction P < .001). TMP-SMX versus amoxicillin was associated with a higher risk of a hospital encounter with AKI [RR 3.15 (95% CI 2.82-3.51)] and all-cause hospitalization [RR 1.43 (95% CI 1.34-1.53)]. CONCLUSIONS The 14-day risk of a hospital encounter with hyperkalemia was higher in patients newly treated with TMP-SMX versus amoxicillin and the risk was highest in patients with a low eGFR.
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Affiliation(s)
- Y Joseph Hwang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Flory T Muanda
- ICES, Toronto, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | | | - Matthew A Weir
- ICES, Toronto, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Medicine, Western University, London, Ontario, Canada
| | - Jessica M Sontrop
- ICES, Toronto, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Ngan N Lam
- Division of Nephrology, University of Calgary, Calgary, Alberta, Canada
| | - Amit X Garg
- ICES, Toronto, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Medicine, Western University, London, Ontario, Canada
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Tian R, Li R, Zhou X. Recent Progresses in Non-Dialysis Chronic Kidney Disease Patients with Hyperkalemia: Outcomes and Therapeutic Strategies. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:353. [PMID: 36837554 PMCID: PMC9966910 DOI: 10.3390/medicina59020353] [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: 01/03/2023] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
Chronic kidney disease (CKD) affects about 10% of the world's population. Hyperkalemia is a life-threatening complication in patients with CKD, as it is associated with adverse cardiovascular and kidney outcomes. There are still many challenges and questions to address to improve the currently available therapeutic strategies to treat hyperkalemia, such as how to approach the emergency management of hyperkalemia. In recent years, in addition to novel oral potassium binders, great progress has been made in the application of novel kidney protective strategies, such as mineralocorticoid receptor antagonists and sodium-glucose cotransporter 2 inhibitors (SGLT2i) in hyperkalemia therapy. This review will discuss the recent advances from clinical trials in the effective management of hyperkalemia in non-dialysis CKD patients, enhancing the knowledge of physicians and internists concerning these newer agents and providing a helpful reference for clinical practice.
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Affiliation(s)
- Ruixue Tian
- The Fifth Clinical Medical College of Shanxi Medical University, Taiyuan 030012, China
| | - Rongshan Li
- Department of Nephrology, Shanxi Provincial People’s Hospital, The Fifth Clinical Medical College of Shanxi Medical University, Shanxi Kidney Disease Institute, 29 Shuang Ta East Street, Taiyuan 030012, China
| | - Xiaoshuang Zhou
- Department of Nephrology, Shanxi Provincial People’s Hospital, The Fifth Clinical Medical College of Shanxi Medical University, Shanxi Kidney Disease Institute, 29 Shuang Ta East Street, Taiyuan 030012, China
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14
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Henrysson J, Thunström E, Chen X, Fu M, Basic C. Hyperkalaemia as a cause of undertreatment with mineralocorticoid receptor antagonists in heart failure. ESC Heart Fail 2023; 10:66-79. [PMID: 36161782 PMCID: PMC9871699 DOI: 10.1002/ehf2.14137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 08/07/2022] [Accepted: 08/24/2022] [Indexed: 01/28/2023] Open
Abstract
AIMS To determine the incidence of hyperkalaemia in patients with heart failure with reduced ejection fraction (HFrEF) during up-titration of guideline-directed medical therapy (GDMT) in real-world settings. METHODS A retrospective review of medical records of all patients hospitalized for newly onset HFrEF at Sahlgrenska University Hospital, Sweden, between 1 January 2016 and 31 December 2019. Based on mineralocorticoid receptor antagonist (MRA) treatment within the first 6 months, patients were divided into four groups: (i) never received MRA, (ii) needed MRA dose reduction, (iii) needed discontinuation of MRA, and (iv) stable MRA treatment. Potassium levels were assessed at baseline and has the highest potassium level during the 6 months of up-titration. RESULTS Of 3456 patients hospitalized for heart failure, 630 (18%) were eligible (68.4% men, 66.8 years, mean EF of 29.4%). After up-titration of GDMT 48.4% of patients received MRAs. Patients without MRA treatment were older (P < 0.0001), had lower EF (P = 0.022), had higher NTproBNP (P = 0.017), had lower eGFR (P = 0.001), and were more often treated with angiotensin receptor inhibitors/angiotensin receptor blockers/angiotensin receptor neprilysin inhibitors (all P < 0.0001). In overall study population, hyperkalaemia increased from 5.9 to 24.4% after 6 months of up-titration of GDMT (P < 0.0001). Among four groups, the incidence of hyperkalaemia throughout up-titration of GDMT increased from 6.8 to 54.5% in patients with dose reduction of MRA, from 8.8 to 50.9% in those with discontinuation of MRA, from 5 to 10% in patients with stable MRA treatment, and from 6 to 28% in patients who were MRA naive (all P < 0.0001). In the MRA-naive group, normokalaemia/hypokalaemia occurred in 87.5% at baseline, and after 6 months of up-titration of GDMT, normokalaemia/hypokalaemia remained in 47.8%, whereas mild, moderate, and severe hyperkalaemia occurred in 22.4%, 5.7%, and 0.9%, respectively. CONCLUSIONS Hyperkalaemia increased significantly during up-titration of GDMT but with varying magnitudes in different clinical phenotypes, which might explain why physicians refrain from prescribing MRAs to patients with HFrEF.
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Affiliation(s)
- Josefin Henrysson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Department of Medicine, Geriatrics and Emergency Medicine, Västra Götaland RegionSahlgrenska University Hospital/ÖstraGothenburgSweden
| | - Erik Thunström
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Department of Medicine, Geriatrics and Emergency Medicine, Västra Götaland RegionSahlgrenska University Hospital/ÖstraGothenburgSweden
| | - Xiaojing Chen
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Michael Fu
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Department of Medicine, Geriatrics and Emergency Medicine, Västra Götaland RegionSahlgrenska University Hospital/ÖstraGothenburgSweden
| | - Carmen Basic
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Department of Medicine, Geriatrics and Emergency Medicine, Västra Götaland RegionSahlgrenska University Hospital/ÖstraGothenburgSweden
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Nakayama T, Yamaguchi S, Hayashi K, Uchiyama K, Tajima T, Azegami T, Morimoto K, Yoshida T, Yoshino J, Monkawa T, Kanda T, Itoh H. Compared effectiveness of sodium zirconium cyclosilicate and calcium polystyrene sulfonate on hyperkalemia in patients with chronic kidney disease. Front Med (Lausanne) 2023; 10:1137981. [PMID: 36950508 PMCID: PMC10025387 DOI: 10.3389/fmed.2023.1137981] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/20/2023] [Indexed: 03/08/2023] Open
Abstract
Hyperkalemia is a well-recognized electrolyte abnormality in patients with chronic kidney disease (CKD). Potassium binders are often used to prevent and treat hyperkalemia. However, few studies have evaluated the difference in serum potassium (K+) level-lowering effect during the post-acute phase between the novel potassium binder, sodium zirconium cyclosilicate (ZSC), and conventional agents. This retrospective study included patients who received potassium binders (either ZSC or calcium polystyrene sulfonate [CPS]) in our hospital between May 2020 and July 2022. The patients were divided into the ZSC and CPS groups. After propensity score matching, we compared changes from baseline to the first follow-up point, at least 4 weeks after initiating potassium binders, in electrolytes including K+ level between the two groups. Of the 132 patients, ZSC and CPS were administered in 48 and 84 patients, respectively. After matching, 38 patients were allocated to each group. The ZSC group showed greater reduction in K+ levels than did the CPS group (P < 0.05). Moreover, a significant increase in serum sodium minus chloride levels, a surrogate marker for metabolic acidosis, was observed in the ZSC group (P < 0.05). Our results demonstrated that ZSC could potentially improve hyperkalemia and metabolic acidosis in patients with CKD.
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Affiliation(s)
- Takashin Nakayama
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Yamaguchi
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
- *Correspondence: Shintaro Yamaguchi
| | - Kaori Hayashi
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kiyotaka Uchiyama
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takaya Tajima
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuhiko Azegami
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
- Keio University Health Center, Yokohama, Japan
| | - Kohkichi Morimoto
- Apheresis and Dialysis Center, Keio University School of Medicine, Tokyo, Japan
| | - Tadashi Yoshida
- Apheresis and Dialysis Center, Keio University School of Medicine, Tokyo, Japan
| | - Jun Yoshino
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Toshiaki Monkawa
- Medical Education Center, Keio University School of Medicine, Tokyo, Japan
| | - Takeshi Kanda
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Itoh
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Impacto económico del uso de patiromer en enfermedad renal crónica o insuficiencia cardíaca para el tratamiento de la hiperpotasemia crónica en España. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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17
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Kim K, Fagerström J, Chen G, Lagunova Z, Furuland H, McEwan P. Cost effectiveness of sodium zirconium cyclosilicate for the treatment of hyperkalaemia in patients with CKD in Norway and Sweden. BMC Nephrol 2022; 23:281. [PMID: 35953778 PMCID: PMC9373488 DOI: 10.1186/s12882-022-02903-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 07/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Hyperkalaemia is common in patients with chronic kidney disease (CKD) and is associated with a range of adverse outcomes. Historically, options for management of chronic hyperkalaemia in the outpatient setting have been limited. Novel oral potassium binders provide a safe, effective therapy for maintenance of normokalaemia in patients with CKD, but despite being approved for reimbursement in many countries, prescription data indicate uptake has been slower than anticipated. This analysis aimed to demonstrate the value to patients and the healthcare system of the potassium binder sodium zirconium cyclosilicate (SZC) for treatment of hyperkalaemia in patients with CKD in Norway and Sweden. Methods A published simulation model reflecting the natural history of CKD was adapted to the Norwegian and Swedish settings and used to predict long-term health economic outcomes of treating hyperkalaemia with SZC versus usual care. Results SZC was highly cost effective compared to usual care in Norway and Sweden, with incremental cost-effectiveness ratios of €14,838/QALY in Norway and €14,352/QALY in Sweden, over a lifetime horizon. The acquisition cost of SZC was largely offset by cost savings associated with reductions in hyperkalaemia events and hospitalisations; a modest overall increase in costs was predominantly attributable to costs associated with gains in life years compared with usual care. SZC remained cost effective in all scenarios examined. Conclusions SZC was estimated to be cost effective for treating hyperkalaemia. Consequently, improving access to a clinically effective, safe and cost-effective therapy, such as SZC, may result in considerable benefits for CKD patients with hyperkalaemia. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02903-7.
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Affiliation(s)
- Kun Kim
- AstraZeneca, Södertälje, Sweden.,Karolinska Institutet, Stockholm, Sweden
| | | | - Gengshi Chen
- AstraZeneca, Academy House, 136 Hills Road, Cambridge, CB2 8PA, UK.
| | | | - Hans Furuland
- Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
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Cost-Effectiveness of Treating Patients with Chronic Kidney Disease and Prior Hyperkalemia with Renin-Angiotensin-Aldosterone System Inhibitor and Patiromer: A Swiss Public Healthcare Perspective. Adv Ther 2022; 39:2717-2730. [PMID: 35416597 PMCID: PMC9122858 DOI: 10.1007/s12325-022-02123-3] [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: 01/20/2022] [Accepted: 03/10/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Hyperkalemia is associated with increased morbidity and mortality in patients with chronic kidney disease (CKD). Patiromer (Veltassa®) is an oral potassium binder indicated for the treatment of hyperkalemia in adults. We evaluated the impact of patiromer on the Swiss healthcare resources when used in patients with CKD and hyperkalemia who were on renin-angiotensin-aldosterone system inhibitor (RAASi) treatment. METHODS We built a decision tree and calculated the number needed to treat (NNT) to prevent hyperkalemia, hospitalization, and death based on published aggregated data. The decision tree was populated with available data from relevant patiromer clinical trials and data were applied to create a simple model showing the expected effectiveness of adding patiromer to the treatment of patients with medium-to-severe stage CKD on RAASi compared to RAASi only. Adapting the model to the Swiss healthcare system allowed us to estimate the impact of the new treatment on healthcare expenditures from a payer as well as a Swiss public healthcare perspective. RESULTS Patiromer reduced the absolute risk for recurrent hyperkalemia by 48% within 8 weeks, resulting in an NNT of 2.1 [95% CI 1.4, 3.7]. If one assumes that 90%, 50%, or 10% of all moderate-to-severe hyperkalemic events lead to hospitalization, the NNT to prevent one hospitalization would be 2.5, 4.4, and 22.2, respectively. On the basis of the death rate of patients with mild or moderate-to-severe hyperkalemia, and the prevalence of mild or moderate-to-severe hyperkalemia in the treatment and control groups, the NNT was 78.7 [95% CI 64.0, 99.3] to prevent one death. Patiromer resulted in expected cost offsets of CHF 303 (1 CHF = 0.95 EUR as of 2022) per patient over 8 weeks in Switzerland. CONCLUSION Patiromer used for the treatment of CKD reduces hyperkalemia recurrence leading to improved patient care. This results in substantial offset costs for the Swiss healthcare system.
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19
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Course of Hyperkalemia in Patients on Hemodialysis. Int J Nephrol 2022; 2022:6304571. [PMID: 35531468 PMCID: PMC9071981 DOI: 10.1155/2022/6304571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/29/2022] [Accepted: 04/07/2022] [Indexed: 11/22/2022] Open
Abstract
Background Evidence of longitudinal serum potassium (sK+) concentrations in hyperkalemic hemodialysis patients is sparse. Objective These post hoc analyses of the placebo arm of the phase 3b DIALIZE study (NCT03303521) explored the course of hyperkalemia in hemodialysis patients receiving placebo. Methods In DIALIZE, 196 patients receiving hemodialysis three times weekly were randomized to placebo or sodium zirconium cyclosilicate 5 g starting dose once daily on nondialysis days for 8 weeks. In these post hoc analyses of placebo patients overall (n = 86) and by predialysis sK+ subgroups at randomization <5.5 mmol/L, 5.5 to <6.0 mmol/L, 6.0 to <6.5 mmol/L, and ≥6.5 mmol/L, we assessed mean predialysis sK+ concentration by visit and the proportions of patients with mean predialysis sK+ ranges of 4.0–5.0 and 4.0–5.5 mmol/L by visit. Results In placebo patients, the mean predialysis sK+ concentration at randomization was 5.9 mmol/L, and 5.8 mmol/L at the end of the study (day 57). For placebo patients overall and across all predialysis sK+ subgroups, the mean predialysis sK+ concentration remained ≥5.0 mmol/L for all visits over 8 weeks. Overall, 7–21% and 27–62% of placebo patients had predialysis sK+ ranges of 4.0–5.0 and 4.0–5.5 mmol/L, respectively, at any visit. The proportions of placebo patients with either predialysis sK+ range were greatest for those who were least hyperkalemic (<5.5 mmol/L) and generally decreased with increasing predialysis sK+ concentration. Conclusions Patients receiving placebo and hemodialysis maintained high predialysis sK+ concentrations over 8 weeks following a hyperkalemic event. Most placebo patients remained hyperkalemic and may be at continued risk of adverse events.
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Su G, Qin X, Yang C, Sabatino A, Kelly JT, Avesani CM, Carrero JJ. Fiber intake and health in people with chronic kidney disease. Clin Kidney J 2022; 15:213-225. [PMID: 35145637 PMCID: PMC8825222 DOI: 10.1093/ckj/sfab169] [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] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 09/06/2021] [Indexed: 12/12/2022] Open
Abstract
Emerging evidence suggests that diet, particularly one that is rich in dietary fiber, may prevent the progression of chronic kidney disease (CKD) and its associated complications in people with established CKD. This narrative review summarizes the current evidence and discusses the opportunities for increasing fiber intake in people with CKD to improve health and reduce disease complications. A higher consumption of fiber exerts multiple health benefits, such as increasing stool output, promoting the growth of beneficial microbiota, improving the gut barrier and decreasing inflammation, as well decreasing uremic toxin production. Despite this, the majority of people with CKD consume less than the recommended dietary fiber intake, which may be due in part to the competing dietary potassium concern. Based on existing evidence, we see benefits from adopting a higher intake of fiber-rich food, and recommend cooperation with the dietitian to ensure an adequate diet plan. We also identify knowledge gaps for future research and suggest means to improve patient adherence to a high-fiber diet.
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Affiliation(s)
- Guobin Su
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Department of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital, The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Global Public Health, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden
| | - Xindong Qin
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital, The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Changyuan Yang
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital, The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Alice Sabatino
- Department of Nephrology, Parma University Hospital, Parma, Italy
| | - Jaimon T Kelly
- Centre for Online Health, The University of Queensland, Brisbane, Australia.,Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Carla Maria Avesani
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Medical Unit Clinical Nutrition, Karolinska University Hospital, Stockholm, Sweden
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Shaheen FAM, Meunier A, Altowaijri A, Faadhel TA, Al-Abdulkarim H, AlGabash A, Floros L. Cost Consequence Analysis of the Management of Hyperkalemia by Patiromer and Optimization of Renin-Angiotensin-Aldosterone System Inhibitors Therapy in Chronic Kidney Disease Patients in Saudi Arabia. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:S39-S52. [PMID: 37102523 DOI: 10.4103/1319-2442.374381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
Renin-angiotensin-aldosterone system inhibitors (RAASi) have been shown to improve outcomes in chronic kidney disease (CKD) patients but are associated with an increased risk of hyperkalemia in this vulnerable population. Hyperkalemia often leads to patients' downtitrating or discontinuing RAASi which can result in sub-optimal health outcomes. The objective is to evaluate the cost and health benefits of maintaining normokalemia using patiromer, an oral potassium binder while optimizing RAASi therapy in CKD patients in the Kingdom of Saudi Arabia. The medium-to long-term costs and health outcomes of patients with CKD stage 3-4 and raised serum potassium levels (≥5.5 mmol/L) at baseline were estimated, from a Saudi Arabia payer perspective, using a Markov state-transition model simulating the natural progression of CKD depending on patients' serum potassium level and usage of RAASi at different dosages. The analysis demonstrated that appropriate management of hyperkalemia, enabling optimization of RAASi, leads to cost and health benefits. The cost of patiromer is offset by 68% due to a reduction in management costs associated with CKD progression, hyperkalemia-related hospitalization, and cardiovascular (CV) events. Over a 10-year time horizon, a pool of 300 patients treated with patiromer experience increased life-expectancy [+3.78 life-years (LYs)] and slower disease progression, with decreased time spent in end-stage renal disease (-9.59 LYs). Patiromer may deliver value to both CKD patients and payers in Saudi Arabia, leading to better health outcomes for the former and reduced cost of management of CKD progression and CV events at low additional costs for the latter.
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Affiliation(s)
| | | | | | - Talal Al Faadhel
- Division of Nephrology, King Saud University, Riyadh, Saudi Arabia
| | - Hana Al-Abdulkarim
- Drug Policy and Economics Center, National Guard Health Affairs, Riyadh, Saudi Arabia
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22
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Panuccio V, Leonardis D, Tripepi R, Versace MC, Torino C, Tripepi G, D'Arrigo G, Mallamaci F, Zoccali C. Epidemiology of hyperkalemia in CKD patients under nephrological care: a longitudinal study. Intern Emerg Med 2021; 16:1803-1811. [PMID: 33575905 DOI: 10.1007/s11739-021-02653-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 01/22/2021] [Indexed: 12/17/2022]
Abstract
Hyperkalemia is a potential life-threatening condition among chronic kidney disease (CKD) patients. Available estimates of the burden of this alteration in CKD are mainly derived from large administrative databases. Since K measurements in patients in these databases are often dictated by clinical reasons, longitudinal studies including pre-planned measurements of potassium independently of clinical complication/symptoms may produce more reliable estimates of the frequency and the risk factors underlying hyperkalemia in CKD patients. We estimated the prevalence and the incidence of hyperkalemia in a longitudinal study in 752 stages 2-5 CKD patients lasting 3 years and including up to seven pre-planned assessment of key biochemical measurements including K. At baseline, 203 out of 752 patients (27%) had serum K > 5.0 mM/L and 33% had acidosis (HCO3 ≤ 22 mmol/L). Among those without hyperkalemia at baseline (n = 549), 284 patients developed this alteration across the 3-year follow-up. The point prevalence of hyperkalemia rose from 27% (baseline) to 30% (last visit) (P = 0.001). In a multivariate model, hyperkalemia at baseline [odds ratio (OR):7.29, 95% CI 5.65-9.41, P < 0.001], venous bicarbonate levels [OR (1 mmol/l): 0.92, 0.89-0.96, P < 0.001], eGFR [OR (1 ml/min/1.73m2): 0.98, 0.97-0.99, P < 0.001], use of ACE inhibitors (OR: 1.68, 1.28-2.19, P < 0.001) and angiotensin II antagonists (OR: 1.30, 1.01-1.68, P = 0.045) were related to hyperkalemia over time. Of note, venous bicarbonate levels emerged as an independent risk factor of hyperkalemia over time also in a separate analysis of patients with and without hyperkalemia at baseline. In a cohort of CKD patients including pre-planned measurements of K, 27% of patients had hyperkalemia. Metabolic acidosis and the use of drugs interfering with renin-angiotensin system were the strongest modifiable risk factors for this potentially life-threatening alteration in CKD in longitudinal analyses in the whole study cohort and in patients developing de novo hyperkalemia over time.
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Affiliation(s)
- Vincenzo Panuccio
- Nephrology, Dialysis and Transplantation Unit, Grande Ospedale Metropolitano BMM di Reggio Calabria, Reggio Calabria, Italy
| | - Daniela Leonardis
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-IFC of Reggio Calabria, Reggio Calabria, Italy
| | - Rocco Tripepi
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-IFC of Reggio Calabria, Reggio Calabria, Italy
| | - Maria Carmela Versace
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-IFC of Reggio Calabria, Reggio Calabria, Italy
| | - Claudia Torino
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-IFC of Reggio Calabria, Reggio Calabria, Italy
| | - Giovanni Tripepi
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-IFC of Reggio Calabria, Reggio Calabria, Italy
| | - Graziella D'Arrigo
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-IFC of Reggio Calabria, Reggio Calabria, Italy
| | - Francesca Mallamaci
- Nephrology, Dialysis and Transplantation Unit, Grande Ospedale Metropolitano BMM di Reggio Calabria, Reggio Calabria, Italy
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-IFC of Reggio Calabria, Reggio Calabria, Italy
| | - Carmine Zoccali
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-IFC of Reggio Calabria, Reggio Calabria, Italy.
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23
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Trevisan M, Clase CM, Evans M, Popov T, Ludvigsson JF, Sjölander A, Carrero JJ. Patterns of chronic and transient hyperkalaemia and clinically important outcomes in patients with chronic kidney disease. Clin Kidney J 2021; 15:153-161. [PMID: 35035946 PMCID: PMC8757415 DOI: 10.1093/ckj/sfab159] [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: 04/22/2021] [Indexed: 12/27/2022] Open
Abstract
Background Whether hyperkalaemia in CKD is chronic or transient, and whether this has different outcome implications, is not known. Methods This was an observational study of adults with CKD G3–5 from Stockholm, Sweden 2006–11. We examined individual trajectories of potassium from all measurements obtained through routine outpatient care. For each month of follow-up, we created a rolling assessment of the proportion of time in which potassium was abnormal during the previous 12 months. We defined patterns of hyperkalaemia as transient (≤50% of time during the previous year with potassium >5.0 mmol/L) and chronic (>50% of time with potassium >5.0 mmol/L), and examined whether previous hyperkalaemia pattern offers additional predictive value beyond that provided by the most recent (current) potassium value. Results We included 36 511 participants (56% women) with CKD G3–5 and median estimated glomerular filtration rate 46 mL/min/1.73 m2. Transient and chronic hyperkalaemia, respectively, were observed in 15% and 4% of patients with CKD G3a, and in 50% and 17% of patients with CKD G5. In fully adjusted models, transient (hazard ratio 1.36, 95% confidence interval 1.29–1.46) or chronic (1.16, 1.04–1.32) hyperkalaemia patterns, but not current hyperkalaemia, were associated with major adverse cardiovascular events (MACE), compared with normokalaemia. Transient hyperkalaemia (1.43, 1.35–1.52) and current potassium values, but not chronic hyperkalaemia, were associated with the risk of death. Conclusions Between 4% and 17% of patients with CKD G3–5 develop chronic hyperkalaemia. In general, hyperkalaemia predicted MACE and death; however, the lack of effect of current potassium on MACE when adjusted for the previous pattern, and the stronger effects on death than on MACE, lead us to question whether hyperkalaemia is causal in these relationships.
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Affiliation(s)
- Marco Trevisan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, ON, Hamilton, Canada
| | - Marie Evans
- Department of Clinical Science Intervention and Technology, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Tamara Popov
- Medical Affairs, Vifor Pharma Group, Glattbrugg, Switzerland
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
| | - Arvid Sjölander
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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24
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Georgianos PI, Agarwal R. Mineralocorticoid Receptor Antagonism in Chronic Kidney Disease. Kidney Int Rep 2021; 6:2281-2291. [PMID: 34514191 PMCID: PMC8418944 DOI: 10.1016/j.ekir.2021.05.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/18/2021] [Accepted: 05/24/2021] [Indexed: 12/25/2022] Open
Abstract
The overactivation of the mineralocorticoid receptor (MR) in animal models of chronic kidney disease (CKD) increases sodium retention and hypertension and provokes inflammation and fibrosis in the kidneys, blood vessels, and the heart; these processes play an important role in the progression of cardiorenal disease. Accordingly, blockade of the MR is an attractive therapeutic intervention to retard the progression of CKD and improve cardiovascular morbidity and mortality. Finerenone is a novel, nonsteroidal MR antagonist (MRA) with a unique mode of action that is distinct from currently available steroidal MRAs. In animal models of CKD, finerenone has a more favorable benefit/risk ratio as compared with the steroidal MRAs such as spironolactone and eplerenone. In patients with type 2 diabetes and heart and/or kidney disease, phase II trials have revealed that compared with spironolactone, eplerenone, or placebo, finerenone displays benefits that exceed the risks of MR antagonism. In patients with CKD and type 2 diabetes, a large phase III trial has shown that, compared with placebo, finerenone improved kidney failure and cardiovascular outcomes. In the first part of this article, we explore the safety and efficacy of spironolactone and eplerenone in early- and late-stage CKD. In the second part, we describe the mechanism of action of finerenone and discuss the promising role of this nonsteroidal MRA as a novel therapeutic opportunity to improve clinical outcomes in patients with CKD.
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Affiliation(s)
- Panagiotis I. Georgianos
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana, USA
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25
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Lou Arnal LM, Vercet Tormo A, Caverní Muñoz A, Medrano Villarroya C, Lou Calvo E, Munguía Navarro P, Sanz París A. Association between ultrapocessed food and chronic kidney disease. Nefrologia 2021; 41:489-501. [PMID: 36165132 DOI: 10.1016/j.nefroe.2021.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 11/19/2020] [Indexed: 06/16/2023] Open
Abstract
The modern diet is closely linked to the consumption of processed foods, causing an increase in the intake of salt, simple sugars, phosphorus and added potassium. This excess intake is associated with an increased risk of obesity, diabetes, hypertension and chronic kidney disease (CKD). CKD, which according to data from the ENRICA study affects 15% of the population, magnifies its impact due to the higher prevalence of diabetes and hypertension and due to limitations in the management of sodium and phosphorus. The intake of these products far exceeds the established recommendations, assuming 72% of total sodium, 25%-35% of phosphorus, 12%-18% of potassium and exceeding 10% of the caloric intake in simple sugars. Measures are necessary to reduce their contribution through nutritional advice, labeling review, education campaigns on healthy habits, fees and institutional actions that involve food safety agencies, industry, distribution and scientific societies.
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Affiliation(s)
| | - Antonio Vercet Tormo
- Departamento de tecnología de los alimentos, Facultad de las Ciencias de la Salud y el Deporte, Universidad de Zaragoza, Zaragoza, Spain
| | - Alberto Caverní Muñoz
- Grupo de Nutrición de la SEN, España; Servicio de Dietética, Asociación de Enfermos Renales Alcer Ebro, Zaragoza, Spain
| | | | - Elena Lou Calvo
- Medicina Familiar y Comunitaria, Centro de Salud Torrero-La Paz, Zaragoza, Spain
| | | | - Alejandro Sanz París
- Servicio de Endocrinología y Nutrición, Hospital Universitario Miguel Servet, Zaragoza, Spain
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26
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Mclean A, Nath M, Sawhney S. Population Epidemiology of Hyperkalemia: Cardiac and Kidney Long-term Health Outcomes. Am J Kidney Dis 2021; 79:527-538.e1. [PMID: 34419518 DOI: 10.1053/j.ajkd.2021.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/05/2021] [Indexed: 12/21/2022]
Abstract
RATIONALE & OBJECTIVE The population burden and long-term implications of hyperkalemia have not been comprehensively studied. We studied how often and where hyperkalemia occurs as well as its independent association with survival and long-term cardiac and kidney health. STUDY DESIGN Population-based cohort study of adult residents of Grampian, United Kingdom. SETTING & PARTICIPANTS Among the 468,594 adult residents (2012-2014), 302,630 people with at least 1 blood test were followed until 2019. EXPOSURE Hyperkalemia was defined as serum potassium ≥ 5.5 mmol/L. Adjustment for comorbidities, demographics, measures of acute and chronic kidney function, and medications prescribed before measurement of serum potassium. OUTCOME All-cause mortality, cardiac events, and kidney failure. ANALYTICAL APPROACH Description of the annual incidence of hyperkalemia and the characteristics associated with its occurrence, and adjusted Cox proportional hazards (PH) analysis to evaluate the independent long-term association of hyperkalemia with all-cause mortality among people who survived ≥90 days after blood testing. Cause-specific PH models were fit to evaluate the association of hyperkalemia with cardiac events/death, noncardiac death, and kidney failure. Effect modification by level of estimated glomerular filtration rate (eGFR) at the time of blood testing was explored. RESULTS The annual population incidence of hyperkalemia was 0.96 per 100 person-years. This represented 2.3%, 2.1%, and 1.9% of people with at least one blood test in 2012, 2013, and 2014, respectively. Two-thirds of episodes of hyperkalemia occurred in the community. The hyperkalemia rate was 2-fold higher for each 10-year greater age. Those with hyperkalemia were 20 times more likely to have concurrent acute kidney injury (AKI), and 17 times more likely to have an eGFR of <30 mL/min/1.73 m2. Throughout 5 years of follow-up evaluation (2,483,452 person-years), hyperkalemia was associated with poorer health outcomes. This association held across all levels of kidney function and was irrespective of concurrent AKI, but was stronger among those with a baseline eGFR of ≥60 mL/min/1.73 m2 (P for interaction < 0.001). The adjusted HRs (hyperkalemia vs no hyperkalemia) for people with eGFR ≥60 mL/min/1.73 m2 and eGFR <30 mL/min/1.73 m2 were 2.3 (95% CI, 2.2-2.5) and 1.5 (95% CI, 1.3-1.6) for mortality; 1.8 (95% CI, 1.6-1.9) and 1.4 (95% CI, 1.2-1.6) for cardiac events; and 17.0 (95% CI, 9.3-31.1) and 2.0 (95% CI, 1.5-2.8) for kidney failure, respectively. LIMITATIONS The observational nature of this study limits evaluation of causal relationships. CONCLUSIONS There is a substantial burden of hyperkalemia in the general population. Hyperkalemia is associated with poorer long-term health outcomes, especially kidney outcomes, that are independent of other established risk factors.
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Affiliation(s)
- Andrew Mclean
- Aberdeen Centre for Health Data Sciences, University of Aberdeen, Aberdeen, United Kingdom; National Health Service Grampian, Aberdeen, United Kingdom
| | - Mintu Nath
- Aberdeen Centre for Health Data Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Simon Sawhney
- Aberdeen Centre for Health Data Sciences, University of Aberdeen, Aberdeen, United Kingdom; National Health Service Grampian, Aberdeen, United Kingdom.
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27
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Shibata S, Uchida S. Hyperkalemia in patients undergoing hemodialysis: its pathophysiology and management. Ther Apher Dial 2021; 26:3-14. [PMID: 34378859 PMCID: PMC9291487 DOI: 10.1111/1744-9987.13721] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/01/2021] [Accepted: 08/09/2021] [Indexed: 11/28/2022]
Abstract
Potassium is a major intracellular cation in the body, regulating membrane potential of excitable cells, such as cardiomyocytes and skeletal muscle cells. Because the kidney plays a critical role in controlling potassium balance, the elevation in serum potassium levels is one of the most common complications in patients with maintenance hemodialysis (MHD). In addition to reduced renal potassium excretion, the alteration in body potassium distribution owing to comorbid conditions may also contribute to dyskalemia. Besides potassium elimination through hemodialysis in MHD patients, accumulating data indicate the potential importance of extra‐renal elimination involving the gastrointestinal system, which can be affected by the inhibitors of the renin‐angiotensin‐aldosterone system. In this article, the literature on potassium physiology in MHD patients is reviewed with an emphasis on the changes from individuals with normal kidney function. This article also summarizes the findings of recent studies on dietary control, dialysate prescription, and pharmacological therapy.
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Affiliation(s)
- Shigeru Shibata
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Shunya Uchida
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan.,Department of Health Care, Teikyo Heisei University, Tokyo, Japan
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28
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Valdivielso JM, Balafa O, Ekart R, Ferro CJ, Mallamaci F, Mark PB, Rossignol P, Sarafidis P, Del Vecchio L, Ortiz A. Hyperkalemia in Chronic Kidney Disease in the New Era of Kidney Protection Therapies. Drugs 2021; 81:1467-1489. [PMID: 34313978 DOI: 10.1007/s40265-021-01555-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 12/20/2022]
Abstract
Despite recent therapeutic advances, chronic kidney disease (CKD) is one of the fastest growing global causes of death. This illustrates limitations of current therapeutic approaches and, potentially, unidentified knowledge gaps. For decades, renin-angiotensin-aldosterone system (RAAS) blockers have been the mainstay of therapy for CKD. However, they favor the development of hyperkalemia, which is already common in CKD patients due to the CKD-associated decrease in urinary potassium (K+) excretion and metabolic acidosis. Hyperkalemia may itself be life-threatening as it may trigger potentially lethal arrhythmia, and additionally may limit the prescription of RAAS blockers and lead to low-K+ diets associated to low dietary fiber intake. Indeed, hyperkalemia is associated with adverse kidney, cardiovascular, and survival outcomes. Recently, novel kidney protective therapies, ranging from sodium/glucose cotransporter 2 (SGLT2) inhibitors to new mineralocorticoid receptor antagonists have shown efficacy in clinical trials. Herein, we review K+ pathophysiology and the clinical impact and management of hyperkalemia considering these developments and the availability of the novel K+ binders patiromer and sodium zirconium cyclosilicate, recent results from clinical trials targeting metabolic acidosis (sodium bicarbonate, veverimer), and an increasing understanding of the role of the gut microbiota in health and disease.
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Affiliation(s)
- José M Valdivielso
- Vascular and Renal Translational Research Group, UDETMA, REDinREN del ISCIII, IRBLleida, Lleida, Spain.
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Robert Ekart
- Clinic for Internal Medicine, Department of Dialysis, University Medical Center Maribor, Maribor, Slovenia
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases, Ospedali Riuniti, 89124, Reggio Calabria, Italy
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Patrick Rossignol
- Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116 and FCRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Alberto Ortiz
- School of Medicine, IIS-Fundacion Jimenez Diaz, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
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29
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Vestergaard SV, Christiansen CF, Thomsen RW, Birn H, Heide-Jørgensen U. Identification of Patients with CKD in Medical Databases: A Comparison of Different Algorithms. Clin J Am Soc Nephrol 2021; 16:543-551. [PMID: 33707181 PMCID: PMC8092062 DOI: 10.2215/cjn.15691020] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 01/18/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite CKD consensus definitions, epidemiologic studies use multiple different algorithms to identify CKD. We aimed to elucidate if this affects the patient characteristics and the estimated prevalence and prognosis of CKD by applying six different algorithms to identify CKD in population-based medical databases and compare the cohorts. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients with CKD in Northern Denmark (2009-2016) were identified using six different algorithms: five were laboratory based defined by (1) one measured outpatient eGFR <60 ml/min per 1.73 m2 (single test, n=103,435), (2) two such findings ≥90 days apart (Kidney Disease Improving Global Outcomes, n=84,688), (3) two such findings ≥90 days apart with no eGFR >60 ml/min per 1.73 m2 observed in-between (Kidney Disease Improving Global Outcomes, persistent, n=68,994), (4) two such findings ≥90 and <365 days apart (Kidney Disease Improving Global Outcomes, time limited, n=75,031), and (5) two eGFRs <60 ml/min per 1.73 m2 or two urine albumin-creatinine ratios >30 mg/g ≥90 days apart (Kidney Disease Improving Global Outcomes, eGFR/albuminuria, n=100,957). The sixth included patients identified by reported in- and outpatient hospital International Classification of Diseases diagnoses of CKD (hospital-diagnosed, n=27,947). For each cohort, we estimated baseline eGFR, CKD prevalence, and 1-year mortality using the Kaplan-Meier method. RESULTS The five different laboratory-based algorithms resulted in large differences in the estimated prevalence of CKD from 4637-8327 per 100,000 population. In contrast, 1-year mortality varied only slightly (7%-9%). Baseline eGFR levels at diagnosis were comparable (53-56 ml/min per 1.73 m2), whereas median time since first recorded eGFR <60 ml/min per 1.73 m2 varied from 0 months (single-test) to 17 months (Kidney Disease Improving Global Outcomes, persistent). The hospital-diagnosed algorithm yielded markedly lower CKD prevalence (775 per 100,000 population), a lower baseline eGFR (47 ml/min per 1.73 m2), longer time since first eGFR <60 ml/min per 1.73 m2 (median 70 months), and much higher 1-year mortality (22%). CONCLUSIONS Population prevalence of CKD identified in medical databases greatly depends on the applied algorithm to define CKD. Despite these differences, laboratory-based algorithms produce cohorts with similar prognosis. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_03_11_CJN15691020_final.mp3.
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Affiliation(s)
| | | | | | - Henrik Birn
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Uffe Heide-Jørgensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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30
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Dashputre AA, Sumida K, Potukuchi PK, Kar S, Obi Y, Thomas F, Molnar MZ, Streja E, Kalantar-Zadeh K, Kovesdy CP. Potassium Trajectories prior to Dialysis and Mortality following Dialysis Initiation in Patients with Advanced CKD. Nephron Clin Pract 2021; 145:265-274. [PMID: 33752200 DOI: 10.1159/000514294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/04/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Patients with advanced non-dialysis-dependent CKD (NDD-CKD) have a reduced ability for maintaining plasma potassium (K) in normal range. Deviation from normal plasma K ranges is associated with increased mortality; however, the average trajectory of plasma K over time in patients with advanced NDD-CKD and the outcomes associated with plasma K trajectory are unknown. METHODS We identified 34,167 US veterans with advanced NDD-CKD transitioning to dialysis between October 2007 and March 2015 with at least 1 K measurement each year over a 3-year period prior to dialysis transition (3-year prelude). The K trajectory defined as the change in K (slope) per year over the entire 3-year prelude was estimated using linear mixed-effects models. The association between unadjusted (crude) K slope (categorized as stable [-0.09 to 0.09 mEq/L/year], decreasing [≤-0.10 mEq/L/year], and increasing [≥0.10 mEq/L/year]) and time to all-cause and cardiovascular mortality during the 6 months following dialysis initiation was assessed using multivariable-adjusted survival models. RESULTS The crude and multivariable-adjusted K slopes (mean, 95% CI) over the 3-year prelude were 0.008 (0.0059, 0.0110) and -0.15 mEq/L/year (-0.19, -0.11), respectively. Decreasing K slope was associated with higher multivariable-adjusted risk of all-cause mortality (adjusted hazard ratio [95% CI] vs. stable K slope: 1.08 [1.00-1.17]). No association was observed between K slope and cardiovascular mortality. DISCUSSION/CONCLUSION The average intraindividual plasma K trajectory is remarkably stable in patients with advanced NDD-CKD. A decreasing K slope is associated with higher all-cause mortality risk.
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Affiliation(s)
- Ankur A Dashputre
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Praveen K Potukuchi
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Suryatapa Kar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Miklos Z Molnar
- Division of Nephrology and Hypertension, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Elani Streja
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California-Irvine, Orange, California, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California-Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA, .,Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA,
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31
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Almalki B, Cunningham K, Kapugi M, Kane C, Agrawal A. Management of hyperkalemia: A focus on kidney transplant recipients. Transplant Rev (Orlando) 2021; 35:100611. [PMID: 33711778 DOI: 10.1016/j.trre.2021.100611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 11/15/2022]
Abstract
Hyperkalemia is a frequent complication among kidney transplant recipients that can lead to fatal arrhythmias. The causes of hyperkalemia post kidney transplant are multifactorial and often are drug-induced, and include decreased glomerular filtration rate, tubular dysfunction, and impaired sodium delivery in the distal nephron. This review will discuss pathophysiology and recent updates in the management of both acute and chronic hyperkalemia with a focus on kidney transplant recipients.
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Affiliation(s)
- Bassem Almalki
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, United States.
| | - Kathleen Cunningham
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Michelle Kapugi
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Clare Kane
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Akansha Agrawal
- Department of Nephrology, Northwestern Memorial Hospital, Chicago, IL, United States
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32
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Lou Arnal LM, Vercet Tormo A, Caverní Muñoz A, Medrano Villarroya C, Lou Calvo E, Munguía Navarro P, Sanz París A. Association between ultrapocessed food and chronic kidney disease. Nefrologia 2021. [PMID: 33714628 DOI: 10.1016/j.nefro.2020.11.013] [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: 10/21/2022] Open
Abstract
The modern diet is closely linked to the consumption of processed foods, causing an increase in the intake of salt, simple sugars, phosphorus and added potassium. This excess intake is associated with an increased risk of obesity, diabetes, hypertension and chronic kidney disease (CKD). CKD, which according to data from the ENRICA study affects 15% of the population, magnifies its impact due to the higher prevalence of diabetes and hypertension and due to limitations in the management of sodium and phosphorus. The intake of these products far exceeds the established recommendations, assuming 72% of total sodium, 25-35% of phosphorus, 12-18% of potassium and exceeding 10% of the caloric intake in simple sugars. Measures are necessary to reduce their contribution through nutritional advice, labeling review, education campaigns on healthy habits, fees and institutional actions that involve food safety agencies, industry, distribution and scientific societies.
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Affiliation(s)
| | - Antonio Vercet Tormo
- Departamento de tecnología de los alimentos, Facultad de las Ciencias de la Salud y el Deporte, Universidad de Zaragoza, Zaragoza, España
| | - Alberto Caverní Muñoz
- Grupo de Nutrición de la SEN, España; Servicio de Dietética, Asociación de Enfermos Renales Alcer Ebro, Zaragoza, España
| | | | - Elena Lou Calvo
- Medicina Familiar y Comunitaria, Centro de Salud Torrero-La Paz, Zaragoza, España
| | | | - Alejandro Sanz París
- Servicio de Endocrinología y Nutrición, Hospital Universitario Miguel Servet, Zaragoza, España
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33
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Funck KL, Knudsen JS, Hansen TK, Thomsen RW, Grove EL. Real-world use of cardioprotective glucose-lowering drugs in patients with type 2 diabetes and cardiovascular disease: A Danish nationwide cohort study, 2012 to 2019. Diabetes Obes Metab 2021; 23:520-529. [PMID: 33140907 PMCID: PMC7839758 DOI: 10.1111/dom.14245] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/05/2020] [Accepted: 10/25/2020] [Indexed: 12/13/2022]
Abstract
AIMS To investigate temporal trends in time to initiation of sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide 1 analogues (cardioprotective glucose-lowering drugs [GLDs]) in patients with a new dual diagnosis of type 2 diabetes (T2DM) and cardiovascular disease (CVD). MATERIALS AND METHODS In a cohort study, we identified patients with a new dual diagnosis of T2DM and CVD using linked healthcare data from nationwide registries on drug prescriptions and diagnosis codes. For each calendar year between 2012 and 2018, we examined time to initiation and cumulative user proportions (CUPs) for cardioprotective GLD use 1 and 2 years after the dual diagnosis. RESULTS Among all individuals living in Denmark in the period 2012 to 2018, 41 733 patients with a new dual diagnosis of T2DM and CVD were identified (median [interquartile range] age 71 [64-79] years, 61% male, and 57% with CVD as the latest diagnosis). Incidence curve slopes and 1- and 2-year CUPs for cardioprotective GLDs increased during the study period (1-year CUP 4.0%, 95% confidence interval [CI] 3.6-4.5) in 2012 to 14.7, 95% CI 13.7-15.7, in 2018; 2-year CUP 5.5, 95% CI 5.0-6.1, in 2012 to 16.7, 95% CI 15.8-17.7, in 2017). T2DM patients with CVD as the second (latest) diagnosis had higher 1-year CUPs than CVD patients with T2DM as the latest diagnosis: 2012: 7.0 (95% CI 6.2-8.0) versus 1.4 (95% CI 1.0-1.8); 2018: 18.1 (95% CI 16.8-19.6) versus 10.0 (95% CI 8.8-11.3). CONCLUSIONS In patients with T2DM and CVD, the incidence of cardioprotective GLD initiation increased between 2012 and 2018, however, within 2 years of dual diagnosis, it remained low.
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Affiliation(s)
- Kristian L. Funck
- Steno Diabetes Center Aarhus, Aarhus University HospitalAarhusDenmark
- Diagnostic Center, Regional Hospital Central JutlandSilkeborgDenmark
| | - Jakob S. Knudsen
- Department of Clinical EpidemiologyAarhus University HospitalAarhusDenmark
| | - Troels K. Hansen
- Steno Diabetes Center Aarhus, Aarhus University HospitalAarhusDenmark
| | - Reimar W. Thomsen
- Department of Clinical EpidemiologyAarhus University HospitalAarhusDenmark
| | - Erik L. Grove
- Department of CardiologyAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineHealth, Aarhus UniversityAarhusDenmark
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34
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Sasaki O, Uriuda Y, Shinkai M, Sasaki H. Atypical electrocardiographic findings in severe hyperkalemia with slow clinical course. J Gen Fam Med 2021; 22:43-46. [PMID: 33457155 PMCID: PMC7796785 DOI: 10.1002/jgf2.381] [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: 02/20/2020] [Revised: 05/22/2020] [Accepted: 08/13/2020] [Indexed: 11/19/2022] Open
Abstract
A 77-year-old woman walked into the emergency department with an episode of syncope and vomiting. She had visited at an orthopedic clinic with weakness of the lower extremities 6 weeks before, but cervical and lumbar MRI findings were unremarkable. Thereafter, she developed fingertip numbness and appetite loss at 7 and 3 days, respectively, before admission. She had been prescribed with RAS inhibitors for years. Electrocardiography while in the emergency department revealed bradycardia with normal QRS and a tented T wave. Laboratory findings revealed serum potassium 9.2 mEq/L. We discontinued RAS inhibitors and β-blockers and added glucose-insulin therapy. Thereafter, her general condition gradually recovered, and her symptoms completely disappeared. Elderly patients with chronic kidney disease treated with RAS inhibitors might develop slowly progressive symptoms of hyperkalemia. Electrocardiographic findings could be atypical and inconsistent with serum potassium values.
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Affiliation(s)
- Osamu Sasaki
- Division of Internal MedicineTokyo‐Shinagawa HospitalTokyoJapan
| | - Yozo Uriuda
- Division of Internal MedicineTokyo‐Shinagawa HospitalTokyoJapan
| | | | - Hideki Sasaki
- Department of Cardiovascular SurgeryTokyo Women's Medical University HospitalTokyoJapan
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35
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Jin A, Zhao M, Sun Y, Feng X, Zhang R, Qiao Q, Wang H, Yuan J, Wang Y, Cheng L, Zhang H, Li HJ, Wu Y. Normal range of serum potassium, prevalence of dyskalaemia and associated factors in Chinese older adults: a cross-sectional study. BMJ Open 2020; 10:e039472. [PMID: 33127634 PMCID: PMC7604839 DOI: 10.1136/bmjopen-2020-039472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To investigate the normal range of serum potassium, the prevalence of dyskalaemia and the associated factors in Chinese older adults. DESIGN A cross-sectional study conducted from September 2017 to March 2018. SETTING Forty-eight community elderly care facilities in four regions in northern China. PARTICIPANTS A total of 1266 (308 apparently healthy and 958 unhealthy) participants 55 years or older and with fasting serum potassium measured. MAIN OUTCOME MEASURES AND METHODS Serum potassium <3.5 mEq/L and >5.5 mEq/L (guidelines definition) and <2.5th and >97.5th percentiles of the distribution among healthy participants (our study definition) were both used to define hypokalaemia and hyperkalaemia, respectively. Multivariable generalised estimating equation models were used to adjust for clustering effect in the analyses of factors associated with risk of dyskalaemia and with variations in serum potassium. RESULTS The study participants had a mean age of 70 (8.8) years. Among apparently healthy participants, the 2.5th and 97.5th percentiles of serum potassium distribution were 3.7 mEq/L and 5.3 mEq/L, respectively. Using the study definition, the prevalence of hyperkalaemia was 4.3% (95% CI 3.2% to 5.4%) and of hypokalaemia was 4.0% (95% CI 2.9% to 5.1%). Multivariable analyses showed that risk of hyperkalaemia was associated with unhealthy conditions (OR=2.21; 95% CI 1.17 to 4.18); risk of hypokalaemia was associated with unhealthy conditions (OR=2.56; 95% CI 1.05 to 6.23), older age (OR=1.70 per 10-year increase; 95% CI 1.04 to 2.79) and region (OR=16.87; 95% CI 6.41 to 44.38); and higher serum potassium was associated with male gender (mean difference (MD)=0.12; 95% CI 0.05 to 0.19) and estimated glomerular filtration rate <60 mL/min/1.73 m2 (MD=0.29; 95% CI 0.12 to 0.46). Using the guidelines definition, hyperkalaemia accounted for 2.7% (1.8%, 3.6%) and hypokalaemia 1.8% (1.1%, 2.5%). Analyses of the associated factors showed similar trends. CONCLUSIONS The study suggested a narrower normal range of serum potassium for defining dyskalaemia, which was common in older Chinese and more prevalent in unhealthy ones. TRIAL REGISTRATION NUMBER NCT03290716; Pre-results.
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Affiliation(s)
- Aoming Jin
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Minghui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Yihong Sun
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Xiangxian Feng
- Department of Preventive Medicine, Changzhi Medical College, Changzhi, Shanxi, China
| | - Ruijuan Zhang
- School of Public Health, Xian Jiaotong University, Xi'an, Shaanxi, China
| | - Qianku Qiao
- Yangcheng Ophthalmology Hospital, Jincheng, Shanxi, China
| | - Hongxia Wang
- Department of Nutrition and Food Safety, Hohhot Center for Disease Control and Prevention, Hohhot, Inner Mongolia, China
| | - Jianhui Yuan
- Department of Preventive Medicine, Changzhi Medical College, Changzhi, Shanxi, China
| | - Yuqi Wang
- School of Public Health, Xian Jiaotong University, Xi'an, Shaanxi, China
| | - Lili Cheng
- Yangcheng Ophthalmology Hospital, Jincheng, Shanxi, China
| | - Hui Zhang
- Department of Nutrition and Food Safety, Hohhot Center for Disease Control and Prevention, Hohhot, Inner Mongolia, China
| | - Hui-Juan Li
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Yangfeng Wu
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
- Department of Epidemiology and Biostatistics, Peking University School of Public Health, Beijing, China
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36
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Haynes R, Zhu D, Judge PK, Herrington WG, Kalra PA, Baigent C. Chronic kidney disease, heart failure and neprilysin inhibition. Nephrol Dial Transplant 2020; 35:558-564. [PMID: 31028383 PMCID: PMC7139204 DOI: 10.1093/ndt/gfz058] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 03/07/2019] [Indexed: 12/11/2022] Open
Abstract
Patients with chronic kidney disease are at increased risk of cardiovascular disease and this often manifests clinically like heart failure. Conversely, patients with heart failure frequently have reduced kidney function. The links between the kidneys and cardiovascular system are being elucidated, with blood pressure being a key risk factor. Patients with heart failure have benefitted from many trials which have now established a strong evidence based on which to base management. However, patients with advanced kidney disease have often been excluded from these trials. Nevertheless, there is little evidence that the benefits of such treatments are modified by the presence or absence of kidney disease, but more direct evidence among patients with advanced kidney disease is required. Neprilysin inhibition is the most recent treatment to be shown to improve outcomes among patients with heart failure. The UK HARP-III trial assessed whether neprilysin inhibition improved kidney function in the short- to medium-term and its effects on cardiovascular biomarkers. Although no effect (compared to irbesartan control) was found on kidney function, allocation to neprilysin inhibition (sacubitril/valsartan) did reduce cardiac biomarkers more than irbesartan, suggesting that this treatment might improve cardiovascular outcomes in this population. Larger clinical outcomes trials are needed to test this hypothesis.
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Affiliation(s)
- Richard Haynes
- Medical Research Council Population Health Research Unit, University of Oxford, Headington, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Headington, Oxford, UK
| | - Doreen Zhu
- Clinical Trial Service Unit and Epidemiological Studies Unit, Headington, Oxford, UK
| | - Parminder K Judge
- Medical Research Council Population Health Research Unit, University of Oxford, Headington, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Headington, Oxford, UK
| | - William G Herrington
- Medical Research Council Population Health Research Unit, University of Oxford, Headington, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Headington, Oxford, UK
| | - Philip A Kalra
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK
| | - Colin Baigent
- Medical Research Council Population Health Research Unit, University of Oxford, Headington, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Headington, Oxford, UK
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37
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Ronksley PE, Wick JP, Elliott MJ, Weaver RG, Hemmelgarn BR, McRae A, James MT, Harrison TG, MacRae JM. Derivation and Internal Validation of a Clinical Risk Prediction Tool for Hyperkalemia-Related Emergency Department Encounters Among Hemodialysis Patients. Can J Kidney Health Dis 2020; 7:2054358120953287. [PMID: 32953128 PMCID: PMC7485157 DOI: 10.1177/2054358120953287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/16/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Approximately 10% of emergency department (ED) visits among dialysis patients are for conditions that could potentially be managed in outpatient settings, such as hyperkalemia. OBJECTIVE Using population-based data, we derived and internally validated a risk score to identify hemodialysis patients at increased risk of hyperkalemia-related ED events. DESIGN Retrospective cohort study. SETTING Ten in-center hemodialysis sites in southern Alberta, Canada. PATIENTS All maintenance hemodialysis patients (≥18 years) between March 2009 and March 2017. MEASUREMENTS Predictors of hyperkalemia-related ED events included patient demographics, comorbidities, health-system use, laboratory measurements, and dialysis information. The outcome of interest (hyperkalemia-related ED events) was defined by International Classification of Diseases (10th Revision; ICD-10) codes and/or serum potassium [K+] ≥6 mmol/L. METHODS Bootstrapped logistic regression was used to derive and internally validate a model of important predictors of hyperkalemia-related ED events. A point system was created based on regression coefficients. Model discrimination was assessed by an optimism-adjusted C-statistic and calibration by deciles of risk and calibration slope. RESULTS Of the 1533 maintenance hemodialysis patients in our cohort, 331 (21.6%) presented to the ED with 615 hyperkalemia-related ED events. A 9-point scale for risk of a hyperkalemia-related ED event was created with points assigned to 5 strong predictors based on their regression coefficients: ≥1 laboratory measurement of serum K+ ≥6 mmol/L in the prior 6 months (3 points); ≥1 Hemoglobin A1C [HbA1C] measurement ≥8% in the prior 12 months (1 point); mean ultrafiltration of ≥10 mL/kg/h over the preceding 2 weeks (2 points); ≥25 hours of cumulative time dialyzing over the preceding 2 weeks (1 point); and dialysis vintage of ≥2 years (2 points). Model discrimination (C-statistic: 0.75) and calibration were good. LIMITATIONS Measures related to health behaviors, social determinants of health, and residual kidney function were not available for inclusion as potential predictors. CONCLUSIONS While this tool requires external validation, it may help identify high-risk patients and allow for preventative strategies to avoid unnecessary ED visits and improve patient quality of life. TRIAL REGISTRATION Not applicable-observational study design.
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Affiliation(s)
- Paul E. Ronksley
- Department of Community Health Sciences,
Cumming School of Medicine, University of Calgary, AB, Canada
| | - James P. Wick
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Meghan J. Elliott
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Robert G. Weaver
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Brenda R. Hemmelgarn
- Department of Community Health Sciences,
Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Andrew McRae
- Department of Emergency Medicine,
Cumming School of Medicine, University of Calgary, AB, Canada
| | - Matthew T. James
- Department of Community Health Sciences,
Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Tyrone G. Harrison
- Department of Community Health Sciences,
Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Jennifer M. MacRae
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
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38
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Bakris G, Yang YF, Pitt B. Mineralocorticoid Receptor Antagonists for Hypertension Management in Advanced Chronic Kidney Disease: BLOCK-CKD Trial. Hypertension 2020; 76:144-149. [PMID: 32520623 DOI: 10.1161/hypertensionaha.120.15199] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Spironolactone, a steroidal mineralocorticoid receptor antagonist, is recommended as add-on therapy for treatment-resistant/uncontrolled hypertension. However, caution is advised in patients with advanced chronic kidney disease (CKD) due to an increased risk for hyperkalemia. KBP-5074 is a nonsteroidal mineralocorticoid receptor antagonist under investigation for the treatment of treatment-resistant and uncontrolled hypertension in patients with moderate-to-severe CKD. BLOCK-CKD is a phase 2, international, multicenter, randomized, double-blind, placebo-controlled, parallel-group study to evaluate the efficacy and safety of KBP-5074, on top of current therapy, in patients with stage 3B/4 CKD (estimated glomerular filtration rate ≥15 and ≤44 mL/[min·1.73 m2]) and resistant hypertension (trough cuff seated systolic blood pressure ≥140 mm Hg, despite treatment with maximally tolerated doses of 2 or more antihypertensive medicines with complementary mechanisms). Patients (n=240) will be randomized 1:1:1 to once-daily treatment with KBP-5074 0.25 mg, KBP-5074 0.5 mg, or placebo, stratified by estimated glomerular filtration rate (≥30 versus <30 mL/[min·1.73 m2]) and systolic blood pressure (≥160 versus <160 mm Hg). Approximately 30% of enrolled patients should have an estimated glomerular filtration rate of 15 to 29 mL/(min·1.73 m2). The primary efficacy analysis is the change in trough cuff seated systolic blood pressure from baseline to day 84 for the KBP-5074 doses compared with placebo. Changes in urinary albumin-creatinine ratio will be assessed along with changes in serum potassium/incidence of hyperkalemia and changes in estimated glomerular filtration rate and serum creatinine. BLOCK-CKD will determine whether the addition of KBP-5074 will effectively lower blood pressure without an increased risk of hyperkalemia in patients who are not candidates for steroidal mineralocorticoid receptor antagonists due to advanced CKD. Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT03574363.
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Affiliation(s)
- George Bakris
- From the Department of Medicine, American Heart Association Comprehensive Hypertension Center, The University of Chicago Medicine, IL (G.B.)
| | | | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.)
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39
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Arendt JFH, Hansen AT, Ladefoged SA, Sørensen HT, Pedersen L, Adelborg K. Existing Data Sources in Clinical Epidemiology: Laboratory Information System Databases in Denmark. Clin Epidemiol 2020; 12:469-475. [PMID: 32547238 PMCID: PMC7244445 DOI: 10.2147/clep.s245060] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/26/2020] [Indexed: 11/23/2022] Open
Abstract
Routine biomarker results from hospital laboratory information systems, covering hospitals and general practitioners, in Denmark are available to researchers through access to the regional Clinical Laboratory Information System Research Database at Aarhus University and the nationwide Register of Laboratory Results for Research. This review describes these two data sources. The laboratory databases have different geographical and temporal coverage. They both include individual-level biomarker results that are electronically transferred from laboratory information systems. The biomarker results can be linked to all other Danish registries at the individual level, using the unique identifier, the CPR number. The databases include variables such as the CPR number, date and time (hour and minute) of sampling, NPU code, and name of the biomarker, identification code for the laboratory and the requisitioner, the test result with the corresponding unit, and the lower and upper reference limits. Access to the two databases differs since they are hosted by two different institutions. Data cannot be transferred outside Denmark, and direct access is provided only to Danish institutions. It is concluded that access to data on routine biomarkers expands the detailed biological and clinical information available on patients in the Danish healthcare system. The full potential is enabled through linkage to other Danish healthcare registries.
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Affiliation(s)
- Johan Frederik Håkonsen Arendt
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Anette Tarp Hansen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
| | | | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Kasper Adelborg
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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40
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Knudsen JS, Baggesen LM, Lajer M, Nurkanovic L, Ustyugova A, Sørensen HT, Thomsen RW. Changes in SGLT2i and GLP-1RA real-world initiator profiles following cardiovascular outcome trials: A Danish nationwide population-based study. PLoS One 2020; 15:e0229621. [PMID: 32130249 PMCID: PMC7055862 DOI: 10.1371/journal.pone.0229621] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/10/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND We investigated changes in clinical characteristics of SGLT2i and GLP-1RA real-world initiators in Denmark before/after landmark cardiovascular outcome trials. METHODS We compared first-time SGLT2i (25,070) and GLP-1RA (14,671) initiators to initiators of DPP-4i (n = 34,079), a class without proven cardiovascular benefits. We used linked population-based healthcare data to examine initiation incidence, medication patterns, and pre-existing atherosclerotic cardiovascular disease (ASCVD) during 2014-2017. RESULTS Nationwide incidence of SGLT2i initiators increased 3.6-fold (53/100,000 to 172/100,000 per year) vs. a 1.5-fold increase for GLP-1RA. DPP-4i initiation remained stable. From the end of 2015, SGLT2i was increasingly used as 2nd-line therapy, while medication patterns were much more stable for GLP-1RA. Among SGLT2i users, ASCVD increased slightly from 28% to 30%; age- and gender-adj. prevalence ratio (aPR) = 1.03 (95% CI:0.97-1.10). In contrast, among GLP-1RA initiators, baseline ASCVD declined from 29% to 27% (aPR: 0.90 (95% CI:0.84-0.97)), and in DPP-4i initiators from 31% to 29% (aPR: 0.91 (95% CI:0.88-0.96)). CONCLUSIONS Following the EMPA-REG OUTCOME trial in 2015, SGLT2i have become increasingly used as 2nd-line treatment in everyday clinical practice, with only minor increases in patient proportions with ASCVD. For GLP-1RA, we observed more stable therapy lines and slightly decreasing ASCVD in new users despite the LEADER trial.
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Affiliation(s)
- Jakob S. Knudsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Lisbeth M. Baggesen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | | | - Henrik T. Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Reimar W. Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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41
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Palmer BF. Potassium Binders for Hyperkalemia in Chronic Kidney Disease-Diet, Renin-Angiotensin-Aldosterone System Inhibitor Therapy, and Hemodialysis. Mayo Clin Proc 2020; 95:339-354. [PMID: 31668450 DOI: 10.1016/j.mayocp.2019.05.019] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/14/2019] [Accepted: 05/21/2019] [Indexed: 02/06/2023]
Abstract
Hyperkalemia is a potentially life-threatening complication of chronic kidney disease (CKD). The management of CKD requires balancing the benefits of specific treatments, which may exacerbate the potential for hyperkalemia, with the risks of hyperkalemia itself. Renin-angiotensin-aldosterone system (RAAS) inhibitors, which slow CKD progression and improve cardiovascular outcomes, are often discontinued if hyperkalemia develops. Patients with hyperkalemia are frequently advised to restrict dietary potassium (K+), depriving these patients of many heart-healthy foods. Patients receiving hemodialysis are particularly susceptible to hyperkalemia during long interdialytic intervals, and managing this risk without causing hypokalemia can be challenging. Recently, 2 K+-binding agents were approved for the treatment of hyperkalemia: sodium zirconium cyclosilicate and patiromer. These agents offer alternatives to sodium polystyrene sulfonate, which is associated with serious gastrointestinal adverse effects. For this review, PubMed was searched for English-language articles published in 2014-2018 using the terms patiromer, sodium zirconium cyclosilicate, sodium polystyrene sulfonate, hyperkalemia, renin-angiotensin-aldosterone, diet, and dialysis. In randomized controlled studies of patients with hyperkalemia, sodium zirconium cyclosilicate and patiromer effectively reduced serum K+ and were generally well tolerated. Furthermore, patients in these studies could maintain RAAS inhibitor therapy and, in some studies, were not required to limit dietary K+. There may also be a role for these agents in preventing hyperkalemia in patients receiving hemodialysis. Thus, K+-binding agents may allow patients with CKD at risk for hyperkalemia to optimize RAAS inhibitor therapy, receive benefits of a K+-rich diet, and experience improved hemodialysis outcomes. Additional long-term studies are necessary to confirm these effects.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.
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Abstract
Hyperkalemia is a frequent finding in patients with chronic kidney disease (CKD). This increase in serum potassium levels is associated with decreased renal ion excretion, as well as the use of medications to reduce the progression of CKD or to control associated diseases such as diabetes mellitus and heart failure. Hyperkalemia increases the risk of cardiac arrhythmia episodes and sudden death. Thus, the control of potassium elevation is essential for reducing the mortality rate in this population. Initially, the management of hyperkalemia includes orientation of low potassium diets and monitoring of patients' adherence to this procedure. It is also important to know the medications in use and the presence of comorbidities to guide dose reduction or even temporary withdrawal of any of the potassium retention-related drugs. And finally, the use of potassium binders is indicated in both acute episodes and chronic hyperkalemia.
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Palaka E, Grandy S, Darlington O, McEwan P, van Doornewaard A. Associations between serum potassium and adverse clinical outcomes: A systematic literature review. Int J Clin Pract 2020; 74:e13421. [PMID: 31532067 DOI: 10.1111/ijcp.13421] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/30/2019] [Accepted: 09/13/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Despite the growing body of evidence characterising the association between serum potassium levels and adverse clinical outcomes, a contemporary summary of available evidence is currently lacking. The objective of this study, therefore, was to undertake a systematic literature review to identify all relevant evidence assessing risk factors associated with the incidence of hyperkalaemia (HK) and also quantifying the effect of serum potassium levels on risk of adverse clinical outcomes. METHODS PubMed (Medline and Medline In-Process), Embase and the Cochrane Library were searched for studies published between January 2002 and November 2018. Search inclusion criteria included studies describing either the incidence of HK events and any associated risk factors, or associations between HK or serum potassium concentration and adverse clinical outcomes including mortality, hospitalisation, major adverse cardiac events (MACE) and renin-angiotensin-aldosterone system inhibitors (RAASi) discontinuation in adult patients with chronic kidney disease (CKD), heart failure (HF), type 2 diabetes (T2DM) or hypertension. RESULTS The search identified 1,897 publications. From these, a total of 123 studies met the inclusion criteria and were included in the review. The most commonly identified risk factors associated with HK events were the presence of CKD or renal impairment, T2DM, HF, hypertension, RAASi use and mineralocorticoid receptor antagonist use. Potassium levels both above and below the normal range were consistently associated with adverse clinical outcomes, with relative and absolute risks of outcomes increasing with severity of hyper- or hypokalaemia. These associations were consistently reported across a broad range of patient population types and study types. CONCLUSION The current body of published evidence is compelling in its confirmation of the associations between serum potassium levels and adverse clinical outcomes. This review further highlights the importance of avoiding both hyper- and hypokalaemia, in order to reduce risk of mortality, hospitalisation, MACE and RAASi discontinuation or down-titration.
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Affiliation(s)
| | - Susan Grandy
- Global Pricing and Market Access, AstraZeneca, Gaithersburg, MD, USA
| | | | - Phil McEwan
- Health Economics and Outcomes Research Ltd, Cardiff, UK
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Greer RC, Marklund M, Anderson CAM, Cobb LK, Dalcin AT, Henry M, Appel LJ. Potassium-Enriched Salt Substitutes as a Means to Lower Blood Pressure: Benefits and Risks. Hypertension 2019; 75:266-274. [PMID: 31838902 DOI: 10.1161/hypertensionaha.119.13241] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Use of salt substitutes containing potassium chloride is a potential strategy to reduce sodium intake, increase potassium intake, and thereby lower blood pressure and prevent the adverse consequences of high blood pressure. In this review, we describe the rationale for using potassium-enriched salt substitutes, summarize current evidence on the benefits and risks of potassium-enriched salt substitutes and discuss the implications of using potassium-enriched salt substitutes as a strategy to lower blood pressure. A benefit of salt substitutes that contain potassium chloride is the expected reduction in dietary sodium intake at the population level because of reformulation of manufactured foods or replacement of sodium chloride added to food during home cooking or at the dining table. There is empirical evidence that replacement of sodium chloride with potassium-enriched salt substitutes lowers systolic and diastolic blood pressure (average net Δ [95% CI] in mm Hg: -5.58 [-7.08 to -4.09] and -2.88 [-3.93 to -1.83], respectively). The risks of potassium-enriched salt substitutes include a possible increased risk of hyperkalemia and its principal adverse consequences: arrhythmias and sudden cardiac death, especially in people with conditions that impair potassium excretion such as chronic kidney disease. There is insufficient evidence regarding the effects of potassium-enriched salt substitutes on the occurrence of hyperkalemia. There is a need for additional empirical research on the effect of increasing dietary potassium and potassium-enriched salt substitutes on serum potassium levels and the risk of hyperkalemia, as well as for robust estimation of the population-wide impact of replacing sodium chloride with potassium-enriched salt substitutes.
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Affiliation(s)
- Raquel C Greer
- From the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (R.C.G., C.A.M.A., M.H., L.J.A.).,Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (R.C.G., A.T.D., L.J.A.)
| | | | - Cheryl A M Anderson
- From the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (R.C.G., C.A.M.A., M.H., L.J.A.).,Department of Family Medicine and Public Health, University of California San Diego School of Medicine (C.A.M.A.)
| | | | - Arlene T Dalcin
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (R.C.G., A.T.D., L.J.A.)
| | - Megan Henry
- From the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (R.C.G., C.A.M.A., M.H., L.J.A.)
| | - Lawrence J Appel
- From the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (R.C.G., C.A.M.A., M.H., L.J.A.).,Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (R.C.G., A.T.D., L.J.A.)
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Houzé P, Baud FJ, Raphalen JH, Winchenne A, Moreira S, Gault P, Carli P, Lamhaut L. Continuous renal replacement therapy in the treatment of severe hyperkalemia: An in vitro study. Int J Artif Organs 2019; 43:87-93. [DOI: 10.1177/0391398819865748] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Continuous renal replacement therapy is not presently recommended in the treatment of life-threatening hyperkalemia. There are no specific recommendations in hemodialysis to treat hyperkalemia. We hypothesized an in vitro model may provide valuable information on the usefulness of continuous renal replacement therapy to treat severe hyperkalemia. Methods: A potassium-free solute was used instead of diluted blood for continuous renal replacement therapy with a simulated blood flowrate set at 200 mL/min. The mode of elimination included continuous filtration, continuous dialysis, and continuous diafiltration using a flowrate of 4000 mL/min for continuous filtration and continuous dialysis modes, and a ratio of 2500/1500 in the continuous diafiltration mode. Results: The mean initial potassium in the central compartment was 10.1 ± 0.4 mmol/L. The clearances in the continuous diafiltration, continuous filtration, and continuous dialysis were 3.4 ± 0.5, 3.6 ± 0.1, and 3.7 ± 0.1 L/h, respectively, not significantly different. Continuous dialysis resulted in the lowest workload for staff. Increasing the continuous dialysis flowrates from 2000 to 8000 mL/h increased clearance from 2.3 ± 0.3 to 6.2 ± 0.8 L/h. The delays in decreasing the potassium concentration to 5.5 mmol/L dropped from 120 to 45 min, respectively. Potassium eliminated in the first hour increased from 18 to 38 mmol that compared favorably with hemodialysis. Decrease in simulated blood flowrate from 200 to 50 mL/min moderately but significantly decreased the clearance from 3.7 to 3.0 L/h. Conclusion: Hyperkalemia is efficiently treated by continuous renal replacement therapy using the dialysis mode. Caution is needed to prevent the onset of severe hypokalemia within 40 min after initiation of the session.
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Affiliation(s)
- Pascal Houzé
- Laboratoire de Biochimie, Hôpital Universitaire Necker–Enfants Malades, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris, France
- Unité de Technologies Chimiques et Biologiques pour la Santé (UTCBS), CNRS UMR8258, Inserm U1022, Faculté de Pharmacie Paris Descartes, Université Paris Descartes, Paris, France
| | - Frédéric Joseph Baud
- Département d’Anesthésie et de Réanimation, Adult Intensive Care Unit, Hôpital Universitaire Necker–Enfants Malades, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris, France
- EA7323 Evaluation of Therapeutics and Pharmacology in Perinatality and Pediatrics, Hôpitaux Universitaires Cochin—Broca—Hôtel Dieu, Site Tarnier, Université Paris Descartes, Paris, France
- Paris Diderot University, Paris, France
| | - Jean-Herlé Raphalen
- Département d’Anesthésie et de Réanimation, Adult Intensive Care Unit, Hôpital Universitaire Necker–Enfants Malades, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris, France
| | - Anaïs Winchenne
- Département d’Anesthésie et de Réanimation, Adult Intensive Care Unit, Hôpital Universitaire Necker–Enfants Malades, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris, France
| | - Sonia Moreira
- Département d’Anesthésie et de Réanimation, Adult Intensive Care Unit, Hôpital Universitaire Necker–Enfants Malades, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris, France
| | - Philippe Gault
- Département d’Anesthésie et de Réanimation, Adult Intensive Care Unit, Hôpital Universitaire Necker–Enfants Malades, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris, France
| | - Pierre Carli
- Département d’Anesthésie et de Réanimation, Adult Intensive Care Unit, Hôpital Universitaire Necker–Enfants Malades, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris, France
- Université Paris Descartes, Paris, France
| | - Lionel Lamhaut
- Département d’Anesthésie et de Réanimation, Adult Intensive Care Unit, Hôpital Universitaire Necker–Enfants Malades, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris, France
- Université Paris Descartes, Paris, France
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Caravaca-Fontán F, Valladares J, Díaz-Campillejo R, Barroso S, Luna E, Caravaca F. Renal potassium handling in chronic kidney disease: Differences between patients with or wihtout hyperkalemia. Nefrologia 2019; 40:152-159. [PMID: 31353054 DOI: 10.1016/j.nefro.2019.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 03/09/2019] [Accepted: 04/11/2019] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Hyperkalemia (HK) is a common electrolyte disorder in chronic kidney disease (CKD), mainly in the advanced stages. A positive potassium balance due to reduced renal excretory capacity is likely the main pathogenic mechanism of HK. Research into the relative role of each pathogenic element in the development of HK in CKD may help to implement more suitable therapies. OBJECTIVE To investigate renal potassium handling in advanced CKD patients, and to determine the differences between patients with or without HK. MATERIAL AND METHODS Cross-sectional observational study in adult patients with stage 4-5 CKD pre-dialysis. Selection criteria included clinically stable patients and the ability to collect a 24hour urine sample correctly. Blood and urinary biochemical parameters were analysed including sodium and potassium (K). Fractional excretion of K (FEK) and K load relative to glomerular filtration (Ku/GFR) were calculated. HK was defined as a serum K concentration ≥5.5mmol/l. RESULTS The study group consisted of 212 patients (mean age 65±14 years, 92 females) with a mean GFR of 15.0±4.2ml/min/1.73m2. 63 patients (30%) had HK. Patients with HK had lower mean bicarbonate levels with respect to patients with normal K levels (NK) (20.3±3.1 vs. 22.8±3.2 mEq/l, P<.0001), but no differences were noted in total urinary sodium and K excretion. While mean FEK values were lower in patients with HK (32.1±12.1% vs. 36.4±14.3%, P=.038), Ku/GFR values were significantly greater with respect to the NK subgroup (4.2±1.5 vs. 3.7±1.4 mmol/ml/min, P=0,049). FEK showed a strong linear correlation with Ku/GFR (R2=0.74), and partial linear regressions demonstrated that at a similar Ku/GFR level, the FEK of patients with HK was lower than that of NK patients. By multivariate linear and logistic regression analyses, both FEK and Ku/GFR were shown to be the main determinants of K serum levels and HK. CONCLUSIONS Although the K load relative to glomerular filtration (Ku/GFR) is an important determinant of HK in advanced CKD, the most noteworthy characteristic associated with HK in these patients was the limitation of compensatory urinary K excretion, as indicated by lower FEK.
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Affiliation(s)
| | | | | | - Sergio Barroso
- Servicio Nefrología, Hospital Infanta Cristina, Badajoz, España
| | - Enrique Luna
- Servicio Nefrología, Hospital Infanta Cristina, Badajoz, España
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Adelborg K, Nicolaisen SK, Hasvold P, Palaka E, Pedersen L, Thomsen RW. Predictors for repeated hyperkalemia and potassium trajectories in high-risk patients - A population-based cohort study. PLoS One 2019; 14:e0218739. [PMID: 31226134 PMCID: PMC6588240 DOI: 10.1371/journal.pone.0218739] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 06/07/2019] [Indexed: 01/29/2023] Open
Abstract
Understanding predictors and trajectories of increased potassium may inform testing and treatment of hyperkalemia. We examined predictors for repeated hyperkalemia among patients after first-time renin angiotensin system inhibitor (RASi) prescription, chronic kidney disease (CKD), or chronic heart failure (CHF); and we also examined potassium trajectories in these patients after their first hyperkalemia event. We used Danish population-based registries to identify all patients with first-time RASi prescription, incident CKD, or incident CHF (2000–2012). For patients with a first hyperkalemia event, potassium trajectories over the following 6 months were examined. The predictors associated with repeated hyperkalemia were assessed, with repeated hyperkalemia defined as a potassium test >5.0 mmol/L after the first event within 6 months. Overall 262,375 first-time RASi users, 157,283 incident CKD patients, and 14,600 incident CHF patients were included. Of patients with a first hyperkalemia event, repeated hyperkalemia within 6 months occurred in 37% of RASi users, 40% with CKD, and 49% of patients with CHF. Predictors included severe hyperkalemia, low eGFR, diabetes, and spironolactone use. In all cohorts, the median potassium levels declined over 2–4 weeks after a hyperkalemia event for the first time, but reverted to levels higher than before the initial hyperkalemia event in those who had repeated hyperkalemia. Following hyperkalemia, discontinuation of RASi and spironolactone was common in the RASi and CHF cohorts. Repeated hyperkalemia was common among the explored cohorts. The first hyperkalemia event was an indicator of increased median potassium levels. Predictors may identify patients likely to benefit from intensified monitoring and intervention.
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Affiliation(s)
- Kasper Adelborg
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- * E-mail:
| | | | - Pål Hasvold
- AstraZeneca Nordic, Medical Department, Etterstad, Oslo, Norway
| | - Eirini Palaka
- AstraZeneca, Global Payer Evidence, Cambridge, United Kingdom
| | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Kashihara N, Kohsaka S, Kanda E, Okami S, Yajima T. Hyperkalemia in Real-World Patients Under Continuous Medical Care in Japan. Kidney Int Rep 2019; 4:1248-1260. [PMID: 31517144 PMCID: PMC6734103 DOI: 10.1016/j.ekir.2019.05.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 05/16/2019] [Accepted: 05/20/2019] [Indexed: 12/12/2022] Open
Abstract
Introduction An abnormal serum potassium (S-K) level is an important electrolyte disturbance. However, its relation to clinical outcomes in real-world patients, particularly hyperkalemia burden, is not extensively studied. Methods An observational retrospective cohort study using a Japanese hospital claims database was done (April 2008–September 2017; N = 1,022,087). Associations between index S-K level and 3-year survival were modeled using cubic spline regression. Cox regression model was applied to estimate the time to death according to different S-K levels. Prevalence, patient characteristics, treatment patterns, and management of patients with hyperkalemia from first episode were assessed. Results Hyperkalemia prevalence was 67.9 (95% confidence interval [CI]: 67.1–68.8) per 1000 and increased in patients with chronic kidney disease (CKD) (227.9; 95% CI: 224.3–231.5), heart failure (134.0; 95% CI: 131.2–136.8), and renin-angiotensin-aldosterone system inhibitor (RAASi) use (142.2; 95% CI: 139.6–144.7). U-shaped associations between S-K level and 3-year survival were observed with nadir 4.0 mEq/l. The risk of death was increased at S-K 5.1–5.4 mEq with hazard ratio of 7.6 (95% CI: 7.2–8.0). The 3-year mortality rate in patients with CKD stages 3a, 3b, 4, and 5 with normokalemia were 1.51%, 3.93%, 10.86%, and 12.09%, whereas that in patients with CKD stage 3a at S-K 5.1–5.4, 5.5–5.9, and ≥6.0 mEq/l increased to 10.31%, 11.43%, and 22.64%, respectively. Despite treatment with loop diuretics (18.5%) and potassium binders (5.8%), >30% of patients had persistently high S-K (≥5.1 mEq/l). Conclusion This study provides real-world insight on hyperkalemia based on a large number of patients with various medical backgrounds.
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Affiliation(s)
- Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Okayama, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Eiichiro Kanda
- Medical Science, Kawasaki Medical School, Okayama, Japan
| | - Suguru Okami
- Cardiovascular, Renal, and Metabolism, Medical Affairs, AstraZeneca K.K., Osaka, Japan
| | - Toshitaka Yajima
- Cardiovascular, Renal, and Metabolism, Medical Affairs, AstraZeneca K.K., Osaka, Japan
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Kim K, Thomsen RW, Nicolaisen SK, Hasvold LP, Palaka E, Sørensen HT. Healthcare resource utilisation and cost associated with elevated potassium levels: a Danish population-based cohort study. BMJ Open 2019; 9:e026465. [PMID: 30940761 PMCID: PMC6500209 DOI: 10.1136/bmjopen-2018-026465] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 02/08/2019] [Accepted: 02/15/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To investigate healthcare costs associated with hyperkalaemia (HK) among patients with chronic kidney disease (CKD), heart failure (HF) or diabetes. DESIGN Before-after cohort study of patients with HK and matched patients without HK. SETTING Population-based databases covering primary and secondary care for the entire of Northern Denmark. PARTICIPANTS Patients with a first incident record of CKD (n=78 372), HF (n=14 233) or diabetes (n=37 479) during 2005-2011. Among all patients experiencing a first HK event (potassium level >5.0 mmol/L), healthcare costs were compared during 6 months before and 6 months after the HK event. The same cost assessment was conducted 6 months before and after a matched index date in a comparison cohort of patients without HK. PRIMARY AND SECONDARY OUTCOME MEASURES Mean costs of hospital care, general practice and dispensed drugs converted to 2018 Euros. RESULTS Overall, 17 747 (23%) CKD patients, 5141 (36%) HF patients and 4183 (11%) diabetes patients with a first HK event were identified. More than 40% of all HK patients across the patient groups had subsequent HK events with successively shorter times between the events. In CKD patients, overall mean costs were €5518 higher 6 months after versus before first HK, while €441 higher in matched CKD patients without HK, yielding HK-associated costs of €5077. Corresponding costs associated with a HK event were €6018 in HF patients, and €4862 in diabetes patients. CONCLUSIONS Among CKD, HF and diabetes patients, an incident HK event was common, and a large proportion of the patients experienced recurrent HK events. Substantial increase in healthcare costs associated with a HK event was observed in the HK patients compared with non-HK patients. These results are important to better understand the potential economic impact of HK among high-risk comorbid patients in a real-wold setting and help inform decision-making for clinicians and healthcare providers.
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Affiliation(s)
- Kun Kim
- Health Economics, AstraZeneca Nordic-Baltic, Södertälje, Sweden, Södertälje, Sweden
| | | | | | | | - Eirini Palaka
- Global Health Economics, AstraZeneca, Cambridge, Cambridge, UK
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
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Jun M, Jardine MJ, Perkovic V, Pilard Q, Billot L, Rodgers A, Rogers K, Gallagher M. Hyperkalemia and renin-angiotensin aldosterone system inhibitor therapy in chronic kidney disease: A general practice-based, observational study. PLoS One 2019; 14:e0213192. [PMID: 30845156 PMCID: PMC6405190 DOI: 10.1371/journal.pone.0213192] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 02/18/2019] [Indexed: 12/13/2022] Open
Abstract
Data on hyperkalemia frequency among chronic kidney disease (CKD) patients receiving renin-angiotensin aldosterone system inhibitors (RAASis) and its impact on subsequent RAASi treatment are limited. This population-based cohort study sought to assess the incidence of clinically significant hyperkalemia among adult CKD patients who were prescribed a RAASi and the proportion of patients with RAASi medication change after experiencing incident hyperkalemia. We conducted a retrospective, population-based cohort study (1 January 2013–30 June 2017) using Australian national general practice data from the NPS MedicineWise’s MedicineInsight program. The study included adults aged ≥18 years who received ≥1 RAASi prescription during the study period and had CKD (estimated glomerular filtration rate [eGFR] <60 ml/min/1.73m2). Study outcomes included incident clinically significant hyperkalemia (serum potassium >6 mmol/L or a record of hyperkalemia diagnosis) and among patients who experienced incident hyperkalemia, the proportion who had RAASi medication changes (cessation or dose reduction during the 210-day period after the incident hyperkalemia event). Among 20,184 CKD patients with a median follow-up of 3.9 years, 1,992 (9.9%) patients experienced an episode of hyperkalemia. The overall incidence rate was 3.1 (95% CI: 2.9–3.2) per 100 person-years. Rates progressively increased with worsening eGFR (e.g. 3.5-fold increase in patients with eGFR <15 vs. 45–59 ml/min/1.73m2). Among patients who experienced incident hyperkalemia, 46.6% had changes made to their RAASi treatment regimen following the first occurrence of hyperkalemia (discontinuation: 36.6% and dose reduction: 10.0%). In this analysis of adult RAASi users with CKD, hyperkalemia and subsequent RAASi treatment changes were common. Further assessment of strategies for hyperkalemia management and optimal RAASi use among people with CKD are warranted.
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Affiliation(s)
- Min Jun
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- * E-mail:
| | - Meg J. Jardine
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Quentin Pilard
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Laurent Billot
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Kris Rogers
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Martin Gallagher
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
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