The prevalence of predialysis hyperkalemia and associated characteristics among hemodialysis patients: The RE-UTILIZE study

Associations between serum potassium variability and mortality in patients undergoing maintenance hemodialysis: a retrospective study

Dyskalemia are associated with an increased risk of mortality in patients undergoing maintenance hemodialysis (MHD). However, studies evaluating the impact of serum potassium variability on mortality in MHD patients are scarce. To investigate serum potassium variability and its association with prognosis in MHD patients, we conducted a retrospective study on maintenance hemodialysis patients from three campus of Renji Hospital between June 2018 and December 2022. The exposure of interest was serum potassium variability defined as the coefficient of variation of serum potassium levels (CVSP). Cox regression models and Kaplan-Meier survival analysis were used to assess the prognostic significance of serum potassium variability. In a subgroup analysis, the association between serum potassium variability and prognosis was investigated in patients within normal serum potassium concentration range. Total of 588 maintenance hemodialysis patients were included. During a median follow-up of 45 months (24, 54), 121 patients (20.6%) died. The survival analysis suggested significantly higher survival rates for both all-cause (p < 0.01) and cardiovascular (p < 0.01) death in patients in the highest group of CVSP (H-CVSP) compared with those in the the lowest group (L-CVSP). After adjustment, the all-cause mortality hazard ratio compared to L-CVSP was 2.17 [95% confidence interval (CI) 1.18, 3.97] for H-CVSP (p < 0.05) and was 2.53 [95%CI 1.03, 6.22] for cardiovascular mortality (p < 0.05). In the subgroup analysis, 493 patients (83.8%) presented normokalemia (the mean of serum potassium levels ≥ 3.5mmol/L and ≤ 5.0mmol/L) were included. Similar association was found between serum potassium variability and accumulated survival rates, and higher serum potassium variablity was remained an independent risk factor for cardiovascular mortality (2.69, 95% CI 1.07-6.78, p < 0.05) in patients within normal serum potassium concentration range. In conclusion, a higher serum potassium variability was associated with all-cause and cardiovascular mortality in maintenance haemodialysis patients, even in the normal range.

Hyperkalemia burden and treatment patterns in Chinese patients on hemodialysis: final analysis of a prospective multicenter cohort study (PRECEDE-K)

OBJECTIVES

Patients with end-stage renal disease (ESRD) on hemodialysis (HD) are at risk for hyperkalemia (HK), associated with cardiac arrhythmia and sudden death. Data on the burden of HK and management techniques among HD patients in China are still scarce. This study assessed the treatment modalities, recurrence, and prevalence of HK in Chinese HD patients.

METHODS

In this prospective cohort study conducted from May 2021 to July 2022, patients aged ≥18 years who had ESRD and were on HD were enrolled from 15 centers in China (up to 6 months).

RESULTS

Overall, 600 patients were enrolled. At the baseline visit, mean (± standard deviation) urea reduction ratio was 68.0% ± 9.70 and Kt/V was 1.45 ± 0.496. Over 6 months, 453 (75.5%) patients experienced HK, of whom 356 (78.6%) recurred. Within 1, 2, 3, 4, 5, and 6 months, 203 (44.8%), 262 (57.8%), 300 (66.2%), 326 (72.0%), 347 (76.6%), and 356 (78.6%) patients had at least one HK recurrence event, respectively. The proportions of patients with ≥1, 2, 3, 4, 5, or 6 HK recurrence events were 356 (78.6%), 306 (67.5%), 250 (55.2%), 208 (45.9%), 161 (35.5%), and 110 (24.3%), respectively. Among the 453 patients who experienced HK, only 24 (5.3%) were treated with potassium binders: seven (1.5%) with sodium polystyrene sulfonate, 13 (2.9%) with calcium polystyrene sulfonate, and six (1.3%) with sodium zirconium cyclosilicate.

CONCLUSION

Since HK is a chronic illness, long-term care is necessary. Patients on HD should have effective potassium management on non-dialysis days, yet our real-world population rarely used potassium binders.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT04799067.

Cost-Utility of Real-Time Potassium Monitoring in United States Patients Receiving Hemodialysis

Introduction

Patients with kidney failure requiring hemodialysis are at high risk for hyperkalemia between treatments, which is associated with increased cardiovascular morbidity and mortality. Early detection of hyperkalemic events may be useful to prevent adverse outcomes and their associated costs. We performed a cost-utility analysis comparing an intervention where a real-time potassium monitoring device is administered in patients on hemodialysis in comparison to usual care.

Methods

We developed a cost-utility model with microsimulation from the perspective of the United States health care payer. Primary outcomes included the monthly cost-effectiveness threshold cost and break-even cost per patient attributable to the intervention and the incremental cost-effectiveness ratio comparing the intervention to usual care. A 25% reduction in hyperkalemic events was applied as a baseline device effectiveness estimate. Concurrent first and second order microsimulations were performed using 10%, 25%, and 50% effectiveness estimates as sensitivity analyses. Results are presented over a 10-year time horizon in 2022 United States dollars and a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY) was considered.

Results

Over 10 years, threshold and break-even analysis yielded maximum monthly costs of $201.10 and $144.15 per patient, respectively. The intervention was associated with reduced mean costs ($6381.21) and increased mean QALYs (0.03) per patient; therefore, was considered dominant. In sensitivity analysis, the intervention was dominant in 99% of simulations performed at all effectiveness rates.

Conclusion

Implementing a real-time potassium monitoring device in patients on hemodialysis has the potential for cost savings and improved outcomes from the perspective of the United States health care payer.

Evaluating the Effectiveness of a Generative Pretrained Transformer-Based Dietary Recommendation System in Managing Potassium Intake for Hemodialysis Patients

OBJECTIVE

Despite adequate dialysis, the prevalence of hyperkalemia in Chinese hemodialysis (HD) patients remains elevated. This study aims to evaluate the effectiveness of a dietary recommendation system driven by generative pretrained transformers (GPTs) in managing potassium levels in HD patients.

METHODS

We implemented a bespoke dietary guidance tool utilizing GPT technology. Patients undergoing HD at our center were enrolled in the study from October 2023 to November 2023. The intervention comprised of two distinct phases. Initially, patients were provided with conventional dietary education focused on potassium management in HD. Subsequently, in the second phase, they were introduced to a novel GPT-based dietary guidance tool. This artificial intelligence (AI)-powered tool offered real-time insights into the potassium content of various foods and personalized dietary suggestions. The effectiveness of the AI tool was evaluated by assessing the precision of its dietary recommendations. Additionally, we compared predialysis serum potassium levels and the proportion of patients with hyperkalemia among patients before and after the implementation of the GPT-based dietary guidance system.

RESULTS

In our analysis of 324 food photographs uploaded by 88 HD patients, the GPTs system evaluated potassium content with an overall accuracy of 65%. Notably, the accuracy was higher for high-potassium foods at 85%, while it stood at 48% for low-potassium foods. Furthermore, the study examined the effect of GPT-based dietary advice on patients' serum potassium levels, revealing a significant reduction in those adhering to GPTs recommendations compared to recipients of traditional dietary guidance (4.57 ± 0.76 mmol/L vs. 4.84 ± 0.94 mmol/L, P = .004). Importantly, compared to traditional dietary education, dietary education based on the GPTs tool reduced the proportion of hyperkalemia in HD patients from 39.8% to 25% (P = .036).

CONCLUSION

These results underscore the promising role of AI in improving dietary management for HD patients. Nonetheless, the study also points out the need for enhanced accuracy in identifying low potassium foods. It paves the way for future research, suggesting the incorporation of extensive nutritional databases and the assessment of long-term outcomes. This could potentially lead to more refined and effective dietary management strategies in HD care.

Personalizing electrolytes in the dialysis prescription: what, why and how?

Maintenance hemodialysis patients suffer from multiple comorbidities and treatment-related complications. A personalized approach to hemodialysis prescription could reduce some of these burdens by preventing complications such as excessive changes in blood pressure, arrhythmias, post-dialysis fatigue and decreased quality of life. A patient-centered approach to dialysate electrolyte concentrations represents one such opportunity. In addition to modifications in dialysate electrolyte concentrations, consideration of individual factors such as patients' serum concentrations, medication profiles, nutritional status and comorbidities is critical to tailoring hemodialysis prescriptions to optimize patient outcomes. The development of personalized dialysis treatment depends on the collection of comprehensive patient data, advances in technology, resource allocation and patient involvement in decision-making. This review discusses how the treatment of maintenance hemodialysis patients could benefit from individualized changes in certain dialysis fluid components.

Hyperkalaemia prevalence and dialysis patterns in Chinese patients on haemodialysis: an interim analysis of a prospective cohort study (PRECEDE-K)

BACKGROUND

Hyperkalaemia is a known risk factor for cardiac arrhythmia and mortality in patients on haemodialysis. Despite standard adequate haemodialysis, hyperkalaemia is common in patients with end-stage renal disease (ESRD) at interdialytic intervals. Data on hyperkalaemia burden and its effects on dialysis patterns and serum potassium (sK) fluctuations in patients on haemodialysis in China remain limited. The prospective, observational cohort study (PRECEDE-K; NCT04799067) investigated the prevalence, recurrence, and treatment patterns of hyperkalaemia in Chinese patients with ESRD on haemodialysis.

METHODS

Six hundred adult patients were consecutively enrolled from 15 secondary and tertiary hospitals in China. In this interim analysis, we report the baseline characteristics of the cohort, the prevalence of predialysis hyperkalaemia (sK > 5.0 mmol/L), and the trends in serum-dialysate potassium gradient and intradialytic sK shift at Visit 1 (following a long interdialytic interval [LIDI]).

RESULTS

At baseline, most patients (85.6%) received three-times weekly dialysis; mean duration was 4.0 h. Mean urea reduction ratio was 68.0% and Kt/V was 1.45; 60.0% of patients had prior hyperkalaemia (previous 6 months). At Visit 1, mean predialysis sK was 4.83 mmol/L, and 39.6% of patients had hyperkalaemia. Most patients (97.7%) received a dialysate potassium concentration of 2.0 mmol/L. The serum-dialysate potassium gradient was greater than 3 mmol/L for over 40% of the cohort (1- < 2, 2- < 3, 3- < 4, and ≥ 4 mmol/L in 13.6%, 45.1%, 35.7%, and 5.2% of patients, respectively; mean: 2.8 mmol/L). The intradialytic sK reduction was 1- < 3 mmol/L for most patients (0- < 1, 1- < 2, 2- < 3, and ≥ 3 mmol/L in 24.2%, 62.2%, 12.8%, and 0.9% of patients, respectively; mean: 1.4 mmol/L).

CONCLUSIONS

Hyperkalaemia after a LIDI was common in this real-world cohort of Chinese patients despite standard adequate haemodialysis, and led to large serum-dialysate potassium gradients and intradialytic sK shifts. Previous studies have shown hyperkalaemia and sK fluctuations are highly correlated with poor prognosis. Effective potassium-lowering treatments should be evaluated for the improvement of long-term prognosis through the control of hyperkalaemia and sK fluctuations.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04799067.

A nomogram to predict hyperkalemia in patients with hemodialysis: a retrospective cohort study

BACKGROUND

Hyperkalemia increases the risk of mortality and cardiovascular-related hospitalizations in patients with hemodialysis. Predictors of hyperkalemia are yet to be identified. We aimed at developing a nomogram able to predict hyperkalemia in patients with hemodialysis.

METHODS

We retrospectively screened patients with end-stage renal disease (ESRD) who had regularly received hemodialysis between Jan 1, 2017, and Aug 31, 2021, at Lishui municipal central hospital in China. The outcome for the nomogram was hyperkalemia, defined as serum potassium [K⁺] ≥ 5.5 mmol/L. Data were collected from hemodialysis management system. Least Absolute Shrinkage Selection Operator (LASSO) analysis selected predictors preliminarily. A prediction model was constructed by multivariate logistic regression and presented as a nomogram. The performance of nomogram was measured by the receiver operating characteristic (ROC) curve, calibration diagram, and decision curve analysis (DCA). This model was validated internally by calculating the performance on a validation cohort.

RESULTS

A total of 401 patients were enrolled in this study. 159 (39.65%) patients were hyperkalemia. All participants were divided into development (n = 256) and validation (n = 145) cohorts randomly. Predictors in this nomogram were the number of hemodialysis session, blood urea nitrogen (BUN), serum sodium, serum calcium, serum phosphorus, and diabetes. The ROC curve of the training set was 0.82 (95%CI 0.77, 0.88). Similar ROC curve was achieved at validation set 0.81 (0.74, 0.88). The calibration curve demonstrated that the prediction outcome was correlated with the observed outcome.

CONCLUSION

This nomogram helps clinicians in predicting the risk of PEW and managing serum potassium in the patients with hemodialysis.