1
|
Ahdoot RS, Hsiung JT, Agiro A, Brahmbhatt YG, Cooper K, Fawaz S, Westfall L, Norris KC, Kalantar-Zadeh K, Streja E. Hyperkalemia Recurrence and Its Association With Race and Ethnicity in United States Veterans: A Retrospective Cohort Study. Cureus 2024; 16:e59003. [PMID: 38800332 PMCID: PMC11127698 DOI: 10.7759/cureus.59003] [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] [Accepted: 04/22/2024] [Indexed: 05/29/2024] Open
Abstract
INTRODUCTION Information on whether race and ethnicity are associated with a greater risk of recurrent hyperkalemia is limited. The aim of this study was to examine the association between race or ethnicity and recurrent hyperkalemia in a population of US veterans. METHODS This retrospective study used the US Veterans Affairs database to identify adults (aged ≥18 years) with at least one serum potassium measurement during the study period who ever experienced hyperkalemia (serum potassium > 5.0 mmol/L). The proportion of patients with hyperkalemia recurrence (≥1 subsequent event) within one year was determined for different race and ethnicity groups. The association between patient race and ethnicity and the risk of hyperkalemia recurrence within one year after the index hyperkalemia event was analyzed using competing risk regression. RESULTS Among a total of 1,493,539 veterans with incident hyperkalemia (median age (interquartile range): 61.0 years (54.0, 71.0)), recurrence within one year occurred in 19.1% of Black, 16.0% of Native Hawaiian/other Pacific Islander, 15.1% of White, 14.9% of American Indian/Alaska Native, and 13.1% of Asian patient groups. Recurrent hyperkalemia occurred in 18.1% of Hispanic and 15.6% of non-Hispanic patient groups. In a fully-adjusted regression model, recurrent hyperkalemia risk was significantly higher in Black versus White patient groups (subhazard ratio (sHR), 1.17; 95% confidence interval (CI), 1.16-1.19; p< 0.0001) and in Hispanic versus non-Hispanic patient groups (sHR, 1.30; 95% CI, 1.28-1.33; p< 0.0001). DISCUSSION/CONCLUSION Among US veterans with incident hyperkalemia, the risk of recurrent hyperkalemia was higher in Black and Hispanic patient groups. This information may be useful for health system screenings to risk stratify patient groups and both guide the frequency of serum potassium monitoring and better understand the root causes of group differences.
Collapse
Affiliation(s)
- Rebecca S Ahdoot
- Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, USA
| | - Jui-Ting Hsiung
- Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, USA
- Department of Research, Tibor Rubin VA Medical Center, Long Beach, USA
| | - Abiy Agiro
- Department of Medical Affairs, AstraZeneca, Wilmington, USA
| | | | - Kerry Cooper
- Department of Medical Affairs, AstraZeneca, Wilmington, USA
| | - Souhiela Fawaz
- Department of Medical Affairs, AstraZeneca, Wilmington, USA
| | - Laura Westfall
- Department of Medical Affairs, AstraZeneca, Wilmington, USA
| | - Keith C Norris
- Department of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Kamyar Kalantar-Zadeh
- Department of Research, Tibor Rubin VA Medical Center, Long Beach, USA
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, USA
| | - Elani Streja
- Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, USA
- Department of Research, Tibor Rubin VA Medical Center, Long Beach, USA
| |
Collapse
|
2
|
Wieërs MLAJ, Mulder J, Rotmans JI, Hoorn EJ. Potassium and the kidney: a reciprocal relationship with clinical relevance. Pediatr Nephrol 2022; 37:2245-2254. [PMID: 35195759 PMCID: PMC9395506 DOI: 10.1007/s00467-022-05494-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/02/2022] [Accepted: 02/02/2022] [Indexed: 10/26/2022]
Abstract
By controlling urinary potassium excretion, the kidneys play a key role in maintaining whole-body potassium homeostasis. Conversely, low urinary potassium excretion (as a proxy for insufficient dietary intake) is increasingly recognized as a risk factor for the progression of kidney disease. Thus, there is a reciprocal relationship between potassium and the kidney: the kidney regulates potassium balance but potassium also affects kidney function. This review explores this relationship by discussing new insights into kidney potassium handling derived from recently characterized tubulopathies and studies on sexual dimorphism. These insights reveal a central but non-exclusive role for the distal convoluted tubule in sensing potassium and subsequently modifying the activity of the sodium-chloride cotransporter. This is another example of reciprocity: activation of the sodium-chloride cotransporter not only reduces distal sodium delivery and therefore potassium secretion but also increases salt sensitivity. This mechanism helps explain the well-known relationship between dietary potassium and blood pressure. Remarkably, in children, blood pressure is related to dietary potassium but not sodium intake. To explore how potassium deficiency can cause kidney injury, we review the mechanisms of hypokalemic nephropathy and discuss if these mechanisms may explain the association between low dietary potassium intake and adverse kidney outcomes. We discuss if potassium should be repleted in patients with kidney disease and what role dietary potassium plays in the risk of hyperkalemia. Supported by data and physiology, we reach the conclusion that we should view potassium not only as a potentially dangerous cation but also as a companion in the battle against kidney disease.
Collapse
Affiliation(s)
- Michiel L. A. J. Wieërs
- grid.5645.2000000040459992XDepartment of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Room Ns403, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Jaap Mulder
- grid.5645.2000000040459992XDepartment of Pediatrics, Division of Pediatric Nephrology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands ,grid.10419.3d0000000089452978Department of Pediatrics, Division of Pediatric Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joris I. Rotmans
- grid.10419.3d0000000089452978Department of Internal Medicine, Division of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ewout J. Hoorn
- grid.5645.2000000040459992XDepartment of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Room Ns403, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| |
Collapse
|
3
|
Lin Z, Wong LYF, Cheung BMY. Diuretic-induced hypokalaemia: an updated review. Postgrad Med J 2021; 98:477-482. [PMID: 33688065 DOI: 10.1136/postgradmedj-2020-139701] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/29/2021] [Accepted: 01/31/2021] [Indexed: 12/24/2022]
Abstract
Diuretic-induced hypokalaemia is a common and potentially life-threatening adverse drug reaction in clinical practice. Previous studies revealed a prevalence of 7%-56% of hypokalaemia in patients taking thiazide diuretics. The clinical manifestations of hypokalaemia due to diuretics are non-specific, varying from asymptomatic to fatal arrhythmia. Diagnosis of hypokalaemia is based on the level of serum potassium. ECG is useful in identifying the more severe consequences. A high dosage of diuretics and concomitant use of other drugs that increase the risk of potassium depletion or cardiac arrhythmias can increase the risk of cardiovascular events and mortality. Thiazide-induced potassium depletion may cause dysglycaemia. The risk of thiazide-induced hypokalaemia is higher in women and in black people. Reducing diuretic dose and potassium supplementation are the most direct and effective therapies for hypokalaemia. Combining with a potassium-sparing diuretic or blocker of the renin-angiotensin system also reduces the risk of hypokalaemia. Lowering salt intake and increasing intake of vegetables and fruits help to reduce blood pressure as well as prevent hypokalaemia.
Collapse
Affiliation(s)
- Ziying Lin
- Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Louisa Y F Wong
- Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Bernard M Y Cheung
- Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong .,State Key Laboratory of Pharmaceutical Biotechnology, University of Hong Kong, Hong Kong, Hong Kong
| |
Collapse
|
4
|
Eriguchi R, Obi Y, Soohoo M, Rhee CM, Kovesdy CP, Kalantar-Zadeh K, Streja E. Racial and Ethnic Differences in Mortality Associated with Serum Potassium in Incident Peritoneal Dialysis Patients. Am J Nephrol 2019; 50:361-369. [PMID: 31522173 PMCID: PMC6856395 DOI: 10.1159/000502998] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/25/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Abnormalities in serum potassium are risk factors for sudden cardiac death and arrhythmias among dialysis patients. Although a previous study in hemodialysis patients has shown that race/ethnicity may impact the relationship between serum potassium and mortality, the relationship remains unclear among peritoneal dialysis (PD) patients where the dynamics of serum potassium is more stable. METHODS Among 17,664 patients who started PD between January 1, 2007 and December 31, 2011 in a large US dialysis organization, we evaluated the association of serum potassium levels with all-cause and arrhythmia-related deaths across race/ethnicity using time-dependent Cox models with adjustments for demographics. We also used restricted cubic spline functions for serum potassium levels to explore non-linear associations. RESULTS Baseline serum potassium levels were the highest among Hispanics (4.2 ± 0.7 mEq/L) and lowest among non-Hispanic blacks (4.0 ± 0.7 mEq/L). Among 2,949 deaths during the follow-up of median 2.2 (interquartile ranges 1.3-3.2) years, 683 (23%) were arrhythmia-related deaths. Overall, both hyperkalemia and hypokalemia (i.e., serum potassium levels >5.0 and <3.5 mEq/L, respectively) were associated with higher all-cause and arrhythmia-related mortality. In a stratified analysis according to race/ethnicity, the association of hypokalemia with all-cause and arrhythmia-related mortality was consistent with an attenuation for arrhythmia-related mortality in non-Hispanic blacks. Hyperkalemia was associated with all-cause and arrhythmia-related mortality in non-Hispanic whites and non-Hispanic blacks, but no association was observed in Hispanics. CONCLUSION Among incident PD patients, hypokalemia was consistently associated with all-cause and arrhythmia-related deaths irrespective of race/ethnicity. However, while hyperkalemia was associated with both death outcomes in non-Hispanic blacks and whites, it was not associated with either death outcome in Hispanic patients. Further studies are needed to demonstrate whether different strategies should be followed for the management of serum potassium levels according to race/ethnicity.
Collapse
Affiliation(s)
- Rieko Eriguchi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
- Long Beach Veterans Affairs Healthcare System, Long Beach, California, USA
- Department Epidemiology, UCLA Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA,
- Long Beach Veterans Affairs Healthcare System, Long Beach, California, USA,
| |
Collapse
|
5
|
Kim T, Rhee CM, Streja E, Soohoo M, Obi Y, Chou JA, Tortorici AR, Ravel VA, Kovesdy CP, Kalantar-Zadeh K. Racial and Ethnic Differences in Mortality Associated with Serum Potassium in a Large Hemodialysis Cohort. Am J Nephrol 2017; 45:509-521. [PMID: 28528336 PMCID: PMC5546877 DOI: 10.1159/000475997] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 01/14/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hyperkalemia is observed in chronic kidney disease patients and may be a risk factor for life-threatening arrhythmias and death. Race/ethnicity may be important modifiers of the potassium-mortality relationship in maintenance hemodialysis (MHD) patients given that potassium intake and excretion vary among minorities. METHODS We examined racial/ethnic differences in baseline serum potassium levels and all-cause and cardiovascular mortality using Cox proportional hazard models and restricted cubic splines in a cohort of 102,241 incident MHD patients. Serum potassium was categorized into 6 groups: ≤3.6, >3.6 to ≤4.0, >4.0 to ≤4.5 (reference), >4.5 to ≤5.0, >5.0 to ≤5.5, and >5.5 mEq/L. Models were adjusted for case-mix and malnutrition-inflammation cachexia syndrome (MICS) covariates. RESULTS The cohort was composed of 50% whites, 34% African-Americans, and 16% Hispanics. Hispanics tended to have the highest baseline serum potassium levels (mean ± SD: 4.58 ± 0.55 mEq/L). Patients in our cohort were followed for a median of 1.3 years (interquartile range 0.6-2.5). In our cohort, associations between higher potassium (>5.5 mEq/L) and higher mortality risk were observed in African-American and whites, but not Hispanic patients in models adjusted for case-mix and MICS covariates. While in Hispanics only, lower serum potassium (<3.6 mEq/L) levels were associated with higher mortality risk. Similar trends were observed for cardiovascular mortality. CONCLUSIONS Higher potassium levels were associated with higher mortality risk in white and African-American MHD patients, whereas lower potassium levels were associated with higher death risk in Hispanics. Further studies are needed to determine the underlying mechanisms for the differential association between potassium and mortality across race/ethnicity.
Collapse
Affiliation(s)
- Taehee Kim
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Chen Y, Sang Y, Ballew SH, Tin A, Chang AR, Matsushita K, Coresh J, Kalantar-Zadeh K, Molnar MZ, Grams ME. Race, Serum Potassium, and Associations With ESRD and Mortality. Am J Kidney Dis 2017; 70:244-251. [PMID: 28363732 DOI: 10.1053/j.ajkd.2017.01.044] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/07/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Recent studies suggest that potassium levels may differ by race. The basis for these differences and whether associations between potassium levels and adverse outcomes differ by race are unknown. STUDY DESIGN Observational study. SETTING & PARTICIPANTS Associations between race and potassium level and the interaction of race and potassium level with outcomes were investigated in the Racial and Cardiovascular Risk Anomalies in Chronic Kidney Disease (RCAV) Study, a cohort of US veterans (N=2,662,462). Associations between African ancestry and potassium level were investigated in African Americans in the Atherosclerosis Risk in Communities (ARIC) Study (N=3,450). PREDICTORS Race (African American vs non-African American and percent African ancestry) for cross-sectional analysis; serum potassium level for longitudinal analysis. OUTCOMES Potassium level for cross-sectional analysis; mortality and end-stage renal disease for longitudinal analysis. RESULTS The RCAV cohort was 18% African American (N=470,985). Potassium levels on average were 0.162mmol/L lower in African Americans compared with non-African Americans, with differences persisting after adjustment for demographics, comorbid conditions, and potassium-altering medication use. In the ARIC Study, higher African ancestry was related to lower potassium levels (-0.027mmol/L per each 10% African ancestry). In both race groups, higher and lower potassium levels were associated with mortality. Compared to potassium level of 4.2mmol/L, mortality risk associated with lower potassium levels was lower in African Americans versus non-African Americans, whereas mortality risk associated with higher levels was slightly greater. Risk relationships between potassium and end-stage renal disease were weaker, with no difference by race. LIMITATIONS No data for potassium intake. CONCLUSIONS African Americans had slightly lower serum potassium levels than non-African Americans. Consistent associations between potassium levels and percent African ancestry may suggest a genetic component to these differences. Higher and lower serum potassium levels were associated with mortality in both racial groups.
Collapse
Affiliation(s)
- Yan Chen
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Adrienne Tin
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Alex R Chang
- Division of Nephrology, Geisinger Health System, Danville, PA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research & Epidemiology, University of California Irvine Medical Center, Irvine, CA; Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN; Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD.
| |
Collapse
|
7
|
Bankir L, Bouby N, Blondeau B, Crambert G. Glucagon actions on the kidney revisited: possible role in potassium homeostasis. Am J Physiol Renal Physiol 2016; 311:F469-86. [DOI: 10.1152/ajprenal.00560.2015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 03/31/2016] [Indexed: 12/25/2022] Open
Abstract
It is now recognized that the metabolic disorders observed in diabetes are not, or not only due to the lack of insulin or insulin resistance, but also to elevated glucagon secretion. Accordingly, selective glucagon receptor antagonists are now proposed as a novel strategy for the treatment of diabetes. However, besides its metabolic actions, glucagon also influences kidney function. The glucagon receptor is expressed in the thick ascending limb, distal tubule, and collecting duct, and glucagon regulates the transepithelial transport of several solutes in these nephron segments. Moreover, it also influences solute transport in the proximal tubule, possibly by an indirect mechanism. This review summarizes the knowledge accumulated over the last 30 years about the influence of glucagon on the renal handling of electrolytes and urea. It also describes a possible novel role of glucagon in the short-term regulation of potassium homeostasis. Several original findings suggest that pancreatic α-cells may express a “potassium sensor” sensitive to changes in plasma K concentration and could respond by adapting glucagon secretion that, in turn, would regulate urinary K excretion. By their combined actions, glucagon and insulin, working in a combinatory mode, could ensure an independent regulation of both plasma glucose and plasma K concentrations. The results and hypotheses reviewed here suggest that the use of glucagon receptor antagonists for the treatment of diabetes should take into account their potential consequences on electrolyte handling by the kidney.
Collapse
Affiliation(s)
- Lise Bankir
- INSERM UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
- Université Pierre et Marie Curie, Paris, France; and
| | - Nadine Bouby
- INSERM UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
- Université Pierre et Marie Curie, Paris, France; and
- Université Paris-Descartes, Paris, France
| | - Bertrand Blondeau
- INSERM UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
- Université Pierre et Marie Curie, Paris, France; and
| | - Gilles Crambert
- INSERM UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
- Université Pierre et Marie Curie, Paris, France; and
| |
Collapse
|
8
|
Rosa RM, De Jesus E, Sperling K, Suh A, Gmurczyk A, Myrie KA, Rosner K, Lerma E, Yu W, Breuer R, Young JB. Gastrointestinal and renal excretion of potassium in African-Americans and White Americans. J Hypertens 2013; 30:2373-7. [PMID: 23111624 DOI: 10.1097/hjh.0b013e32835a27b3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Several studies have confirmed the remarkable observation that cumulative urinary potassium (K(+)) excretion is less in African-Americans than White Americans even when identical amounts of potassium are provided in the diet. This study was designed to examine whether this decrease in urinary potassium could be compensatory to an increase in gastrointestinal excretion of potassium in African-Americans. METHODS Twenty-three young, healthy, normotensive participants of both sexes and races were placed on a fixed diet of 100 mEq per day of K(+) and 180 mEq per day of sodium (Na(+)) for 9 days. All urine and stool were collected daily and analyzed for electrolytes. Blood was obtained for determination of electrolytes, blood urea nitrogen (BUN), creatinine, glucose, insulin, renin, and aldosterone at the beginning and at the end of the study period. RESULTS Cumulative urinary excretion of K(+) was significantly less in African-Americans (609 ± 31 mEq) compared with White Americans (713 ± 22 mEq, P = 0.015). There was no significant racial difference, however, in the cumulative gastrointestinal excretion of K (105 ± 11 versus 95 ± 9 mEq, P = 0.28) in African-Americans versus White Americans, respectively. CONCLUSION The racial difference in urinary K(+) handling manifested by decreased excretion of K(+) in African-Americans cannot be attributed to an increase in net gastrointestinal excretion of this cation.
Collapse
Affiliation(s)
- Robert M Rosa
- Division of Nephrology/Hypertension, Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611-3008, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Turban S, Thompson CB, Parekh RS, Appel LJ. Effects of Sodium Intake and Diet on Racial Differences in Urinary Potassium Excretion: Results From the Dietary Approaches to Stop Hypertension (DASH)-Sodium Trial. Am J Kidney Dis 2013; 61:88-95. [DOI: 10.1053/j.ajkd.2012.08.036] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Accepted: 08/17/2012] [Indexed: 11/11/2022]
|
10
|
Hayes J, Kalantar-Zadeh K, Lu JL, Turban S, Anderson JE, Kovesdy CP. Association of hypo- and hyperkalemia with disease progression and mortality in males with chronic kidney disease: the role of race. NEPHRON. CLINICAL PRACTICE 2011; 120:c8-16. [PMID: 22156587 PMCID: PMC3267990 DOI: 10.1159/000329511] [Citation(s) in RCA: 111] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 05/11/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Abnormal serum potassium is associated with higher mortality in dialysis patients, but its impact on outcomes in predialysis chronic kidney disease (CKD) is less clear. Furthermore, blacks with normal kidney function have lower urinary potassium excretion, but it is unclear if such differences have a bearing on race-associated outcomes in CKD. METHODS We studied predialysis mortality and slopes of estimated glomerular filtration rate, eGFR) associated with serum potassium in 1,227 males with CKD. Mortality was examined in time-dependent Cox models, and slopes of eGFR in linear mixed effects models with adjustments for case mix and laboratory values. RESULTS Both hypo- and hyperkalemia were associated with mortality overall and in 933 white patients, but in 294 blacks hypokalemia was a stronger death predictor. Hypokalemia was associated with loss of kidney function independent of race: a 1 mEq/l lower potassium was associated with an adjusted difference in slopes of eGFR of -0.13 ml/min/1.73 m(2)/year (95% CI: -0.20 to -0.07), p < 0.001. CONCLUSION Hypo- and hyperkalemia are associated with higher mortality in CKD patients. Blacks appear to better tolerate higher potassium than whites. Hypokalemia is associated with faster CKD progression independent of race. Hyperkalemia management may warrant race-specific consideration, and hypokalemia correction may slow CKD progression.
Collapse
Affiliation(s)
- John Hayes
- Division of Nephrology, University of Virginia, Charlottesville, Va
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Torrance, Calif
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, Calif
| | | | - Sharon Turban
- Division of Nephrology, Johns Hopkins University, Baltimore, Md., USA
| | - John E. Anderson
- Division of Nephrology, Johns Hopkins University, Baltimore, Md., USA
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Virginia, Charlottesville, Va
- Division of Nephrology, Salem Veterans Affairs Medical Center, Salem, Va
| |
Collapse
|
11
|
Bielecka-Dabrowa A, Rysz J, Mikhailidis DP, Banach M. What is the risk of hyperkalaemia in heart failure? Expert Opin Pharmacother 2011; 12:2329-38. [PMID: 21770818 DOI: 10.1517/14656566.2011.601743] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Chronic heart failure (CHF) is the only major cardiovascular disease whose prevalence and incidence are thought to be increasing. Potassium balance may be lost both through the neurohormonal mechanisms involved in cardiovascular diseases and through the drugs used in their treatment. Avoiding both hypo- and hyperkalemia is difficult but beneficial in CHF. AREAS COVERED Aldosterone production is decreased in the elderly, diabetic patients, and those receiving drugs that block the production or action of renin and angiotensin II. As a result, these groups, as well as those with already impaired potassium excretion due to progressive age or disease-related decline in glomerular filtration rate, are particularly vulnerable to the development of hyperkalemia. EXPERT OPINION Evidence from several studies suggests that, in patients with CHF, serum potassium should be maintained between 4.0 and 5.5 mEq/L. To gain the maximum benefit from aldosterone antagonists it is necessary to individualize their use; it is also necessary to carefully monitor electrolytes.
Collapse
Affiliation(s)
- Agata Bielecka-Dabrowa
- Medical University of Lodz, WAM University Hospital in Lodz, Department of Hypertension, Zeromskiego 113, 90-549 Lodz, Poland
| | | | | | | |
Collapse
|
12
|
Izzo JL, Zion AS. Combined aliskiren-amlodipine treatment for hypertension in African Americans: clinical science and management issues. Ther Adv Cardiovasc Dis 2011; 5:169-78. [PMID: 21606125 DOI: 10.1177/1753944711409615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
While it may seem at first that antihypertensive drug combinations run counter to the desire to 'personalize' the management of hypertension, the best combinations have predictable efficacy in different individuals and subpopulations. Race is probably not a valid surrogate for clinically meaningful genetic variation or guide to therapy. Most guidelines suggest similar blood pressure goals for different races but drug treatment recommendations have diverged. In the United States, race is not considered to be a major factor in drug choice, but in England and other countries, initial therapy with renin-angiotensin system blocking drugs is not recommended in Blacks. In this review we: (1) examine new trends in race-based research; (2) emphasize the weaknesses of race-based treatment recommendations; and (3) explore the effects of a new combination, renin inhibition (aliskiren) and amlodipine, in African Americans.
Collapse
Affiliation(s)
- Joseph L Izzo
- Department of Medicine, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, 462 Grider Street, Buffalo, NY 14215, USA.
| | | |
Collapse
|
13
|
Ibrahim HN, Wang C, Ishani A, Collins AJ, Foley RN. Screening for chronic kidney disease complications in US adults: racial implications of a single GFR threshold. Clin J Am Soc Nephrol 2008; 3:1792-9. [PMID: 18784208 DOI: 10.2215/cjn.01890408] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES An ideal and effective screening tool should perform equally across ethnic groups. The objective of this study was to determine whether the widely advocated creatinine-based estimated GFR (eGFR) threshold of 60 ml/min per 1.73 m(2) identifies the typical metabolic abnormalities related to chronic kidney disease equally well in minority and nonminority adults. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This objective was addressed using data for 8918 minority and nonminority adult participants in the National Health and Nutrition Examination Survey 2003 through 2006, which used stratified, multistage, probability sampling methods to assemble a nationwide probability sample of the noninstitutionalized population of the United States. Metabolic abnormalities including BP, potassium, hemoglobin, bicarbonate, uric acid, calcium, phosphorus, and parathyroid hormone were defined by fifth or 95th percentile values. RESULTS Among participants with eGFR <60 ml/min per 1.73 m(2), black individuals were more likely than white individuals to have low hemoglobin (adjusted odds ratio [aOR] 3.76; 95% confidence interval [CI] 1.94 to 7.28), elevated uric acid (aOR 2.15; 95% CI 1.26 to 3.68), and elevated parathyroid hormone (aOR 3.93; 95% CI 2.33 to 6.66). CONCLUSIONS Metabolic consequences of reduced eGFR are more common in black individuals and seem to be present at levels well above 60 ml/min per 1.73 m(2); thus, black individuals should be screened for the metabolic complications of chronic kidney at higher GFR levels.
Collapse
|
14
|
Turban S, Miller ER, Ange B, Appel LJ. Racial differences in urinary potassium excretion. J Am Soc Nephrol 2008; 19:1396-402. [PMID: 18579642 DOI: 10.1681/asn.2007101142] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Racial differences in potassium (K) intake and urinary K excretion may contribute to the higher BP observed in black compared with white individuals. Although black individuals typically consume less dietary K than white individuals, the lower urinary K excretion observed in black individuals may reflect more than differences in intake. In this study, data from the Dietary Approaches to Stop Hypertension (DASH) trial (413 white and black participants) were used to evaluate urinary K excretion in black and white individuals with similar K intake. At screening, mean urinary K excretion was higher in white than black individuals (mean Delta = 645 mg/d for white minus black individuals, adjusted for age, gender, and weight; P < 0.001). After a 3-wk run-in period during which all participants received a low-K control diet, a significant racial difference remained (mean Delta = 201 mg/d, adjusted for age, gender, and caloric intake; P < 0.001). Participants were then randomly assigned to continue the control diet or switch to a high-K diet (either a high fruit/vegetable diet or the DASH diet) for 8 wk. At the end of intervention, the mean difference in urinary K in white compared with black individuals after adjustment for age, gender, and caloric intake was -6 mg/d (P = 0.95) in the control group, 163 mg/d in the fruits/vegetables group (P = 0.39), and 903 mg/d in the DASH group (P < 0.001). Racial differences in urinary K excretion seem to reflect more than intake differences; further studies are needed to understand their potential impact on clinical outcomes.
Collapse
Affiliation(s)
- Sharon Turban
- Division of Nephrology, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 416, Baltimore, MD 21205, USA.
| | | | | | | |
Collapse
|
15
|
Jones JM, Dowling TC, Park JJ, Phares DA, Park JY, Obisesan TO, Brown MD. Differential aerobic exercise-induced changes in plasma aldosterone between African Americans and Caucasians. Exp Physiol 2007; 92:871-9. [PMID: 17483200 PMCID: PMC2729146 DOI: 10.1113/expphysiol.2007.037408] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Aldosterone influences the kidney's regulation of blood pressure (BP), but aldosterone can contribute to the pathogenesis of hypertension. Blood pressure is reduced with aerobic exercise training (AEX), but the extent to which plasma aldosterone (PA) levels change is unclear. The purpose of this study was to determine whether 6 months of AEX changed PA levels, 24 h sodium (Na(+)) excretion and BP in prehypertensive and hypertensive subjects and whether these changes differed according to ethnicity. The study was performed in the Kinesiology Department at the University of Maryland, College Park, and 35 (22 Caucasian; 13 African American) sedentary prehypertensive and hypertensive subjects completed 6 months of AEX. Blood samples were collected under fasting and supine conditions, and PA was measured by radioimmunoassay. In total population aerobic exercise training increased maximal oxygen consumption (24 +/- 0.8 versus 28 +/- 1 ml kg(-1) min(-1), P < 0.001) and decreased PA levels (97 +/- 11 versus 72 +/- 6 pg ml(-1), P = 0.01), body mass index (28 +/- 0.5 versus 28 +/- 0.5 kg m(-2), P = 0.004) and weight (85 +/- 2 versus 83 +/- 2 kg, P = 0.003). Aerobic exercise training decreased PA levels (from 119 +/- 16 to 81 +/- 7 pg ml(-1), P = 0.02) in the Caucasians but there was no change in BP or Na(+) excretion. African American participants had no significant changes in PA levels, BP and Na(+) excretion. Plasma aldosterone levels were 47% lower at baseline (P = 0.01) and 30% lower after AEX (P = 0.04) in African American participants compared with Caucasians. Baseline (P = 0.08) and final PA levels (P = 0.17) did not differ between the two groups after accounting for baseline and final intra-abdominal fat, respectively. The reduction in PA levels with AEX appeared to be driven by the change in PA levels in Caucasian participants. Fat distribution contributed to the ethnic differences in PA levels.
Collapse
Affiliation(s)
- Jennifer M Jones
- Department of Kinesiology, University of Maryland, College Park, MD, USA.
| | | | | | | | | | | | | |
Collapse
|
16
|
Klevay LM, Bogden JD, Aladjem M, Sandstead HH, Kemp FW, Li W, Skurnick J, Aviv A. Renal and gastrointestinal potassium excretion in humans: new insight based on new data and review and analysis of published studies. J Am Coll Nutr 2007; 26:103-10. [PMID: 17536121 DOI: 10.1080/07315724.2007.10719591] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Little is known about the relationship between the renal and gastrointestinal excretion of potassium in humans. This information is important in light of strong associations of potassium intake with hypertension and occlusive stroke. METHODS We determined the relationship between fecal and urinary excretion of potassium under both fixed and variable potassium intakes using our unpublished archival data and published data of others. Twenty-five subjects were evaluated. RESULTS On a fixed, low oral potassium intake (61.2 +/- 4.7 mmol/day; mean +/- SD), there was an inverse relationship between fecal and urinary potassium excretion (r = -0.66, p = 0.040). In studies in which potassium intake varied between 61-135 mmol/day, fecal and urinary potassium excretions were positively correlated (r = 0.58, p = 0.024). Considerable within-and-between-subject variation was observed in the relationship between fecal and urinary potassium excretion. CONCLUSIONS Inter-individual variation in fecal potassium excretion may arise from both variation in dietary potassium intake and intrinsic individual differences in the renal versus gastrointestinal handling of potassium.
Collapse
Affiliation(s)
- Leslie M Klevay
- Department of Agricultrue, Agricultural Research Service, Human Nutrition Research Center, Grand Forks, North Dakota, USA
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Foley RN, Wang C, Ishani A, Collins AJ. NHANES III: influence of race on GFR thresholds and detection of metabolic abnormalities. J Am Soc Nephrol 2007; 18:2575-82. [PMID: 17656476 DOI: 10.1681/asn.2006121411] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Whether the creatinine-based glomerular filtration rate (GFR) thresholds used to define chronic kidney disease (CKD) identify metabolic abnormalities similarly in minority and nonminority populations is unknown. We addressed this question among adult participants in the Third National Health and Nutrition Examination Survey (NHANES III) (n = 15,837). GFR was estimated from serum creatinine values and metabolic abnormalities were defined by 5th or 95th percentile values. After adjustment for age, demographic characteristics, and GFR, black participants were significantly more likely than white participants to have abnormal levels of systolic and diastolic blood pressure, hemoglobin, phosphorus, and uric acid. Hispanic subjects were significantly more likely to have abnormal levels of systolic blood pressure, hemoglobin, bicarbonate, and phosphorus. Among participants with GFR < 60 mL/min per 1.73 m(2), black participants were significantly more likely to have abnormal levels of systolic and diastolic blood pressure, hemoglobin, and uric acid; Hispanic subjects were significantly more likely to have abnormal systolic blood pressure levels. Metabolic abnormalities were more common in minority populations, and low GFR appeared to have a multiplicative effect. Defining CKD using a single GFR threshold may be disadvantageous for minority populations because metabolic abnormalities are present at higher levels of GFR.
Collapse
Affiliation(s)
- Robert N Foley
- United States Renal Data System Coordinating Center, Minneapolis, MN 55404, USA.
| | | | | | | |
Collapse
|
18
|
Haddad N, Rajan J, Nagaraja HN, Agarwal AK, Hebert LA. Usual ACE Inhibitor Therapy in CKD Patients Is Associated with Lower Plasma Aldosterone Levels than Usual Angiotensin Receptor Blocker Therapy. Kidney Blood Press Res 2007; 30:299-305. [PMID: 17641546 DOI: 10.1159/000106021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2007] [Accepted: 06/11/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Attenuating aldosterone (ALDO) effects may be important in slowing kidney and cardiovascular disease progression. This study tested whether ACE inhibitor (I) therapy achieves lower plasma (p) ALDO levels than angiotensin receptor blocker (ARB) therapy when they are used under usual clinical conditions in chronic kidney disease (CKD) patients. METHODS Consecutive CKD patients (n = 123) were studied. They were clinically stable and receiving either ACEI (n = 77) or ARB (n = 46) (physician's choice) for > or = 3 months. RESULTS Mean pALDO in the ACEI cohort was 7.8 +/- 5.7 (SD) ng/dl compared to 12.3 +/- 9.8 ng/dl in the ARB cohort (p = 0.0018, normal ambulatory pALDO 9.4-33.8 ng/dl). The pALDO difference was not explained by differences in age, sex, race, body weight, diagnosis of diabetes; the use of beta-blockers, calcium channel blockers or diuretic; systolic or diastolic blood pressure; plasma renin, serum creatinine, sodium, potassium, or bicarbonate levels; 24-hour urine potassium, sodium, urea or protein excretion; or ACEI or ARB dose. CONCLUSIONS Mean pALDO is about 60% higher with ARB therapy than ACEI therapy when these drugs are customarily used in CKD patients. This difference could be clinically important with regard to kidney and cardiovascular protection.
Collapse
Affiliation(s)
- Nabil Haddad
- Department of Internal Medicine, The Ohio State University, Columbus, Ohio 43210, USA
| | | | | | | | | |
Collapse
|
19
|
Cavallari LH, Groo VL, Momary KM, Fontana D, Viana MA, Vaitkus P. Racial Differences in Potassium Response to Spironolactone in Heart Failure. ACTA ACUST UNITED AC 2007; 12:200-5. [PMID: 16894278 DOI: 10.1111/j.1527-5299.2006.05502.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Evidence of racial differences in aldosterone concentrations and K+ disposition suggests that response to aldosterone antagonism might vary by race. The authors sought to determine whether K+ response to spironolactone differs between African Americans and Caucasians with heart failure. Heart failure patients of African-American (n = 34) or Caucasian (n = 17) race were started on spironolactone 12.5 mg/d, with up-titration as tolerated. Laboratory values and drug therapy were similar between racial groups at baseline. Spironolactone was titrated to a median dose of 25 mg/d in both groups. Neither concomitant medications nor serum creatinine changed significantly in either group during spironolactone dose titration. Median serum K+ concentrations increased by 0.5 mEq/L (range, -0.7 to 1.6 mEq/L) in Caucasians, but only 0.1 mEq/L (range, -0.8 to 0.9 mEq/L) in African Americans; p < 0.01. These data suggest that African Americans with heart failure may be less responsive to the renal effects of spironolactone.
Collapse
Affiliation(s)
- Larisa H Cavallari
- Department of Pharmacy Practice, College of Pharmacy, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612-7230, USA.
| | | | | | | | | | | |
Collapse
|
20
|
Delgado-Almeida A. Reinterpreting Sodium-Potassium Data in Salt-Sensitivity Hypertension: A Prospective Debate. Hypertension 2005; 45:e4; author reply e4. [PMID: 15630043 DOI: 10.1161/01.hyp.0000154194.49725.b7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|