Drug-induced hyperkalemia

Anaphylaxis induced bradycardia, renal failure, AV-nodal blockade, shock, and hyperkalemia: A-BRASH in the emergency department

The emergency department (ED) is responsible for managing a variety of acute illnesses including undifferentiated shock. A newer less recognized syndrome termed BRASH - bradycardia, renal failure, AV-node blockers, shock and hyperkalemia - is a cycle of synergy between hyperkalemia and AV-blockade that can result in shock. This entity is more common amongst the elderly, considering polypharmacy and co-morbid diseases. Some cases have an inciting trigger of hypovolemia. Anaphylaxis is a potentially lethal form of shock that most emergency physicians (EP) treat in the ED. The two entities have never occurred simultaneously. Herein, we report a case of anaphylaxis induced BRASH syndrome occurring in an elderly diabetic man. The EP should be aware of this unique presentation of BRASH. It was concluded that the patient's anaphylaxis, caused hypovolemia, coupled with polypharmacy, and physiological stress, precipitated this severe form of shock and multi-organ system failure.

Barriers to guideline mandated renin-angiotensin inhibitor use: focus on hyperkalaemia

Hyperkalaemia in patients with chronic disease states can be caused by both abnormalities of potassium homeostasis as well as extrinsic factors such as medication use and potassium intake. In patients with heart failure (HF), chronic kidney disease (CKD), diabetes mellitus (DM), and in those who use renin-angiotensin-aldosterone system inhibitors (RAASi), there is particularly increased risk of chronic or recurrent hyperkalaemia. Hyperkalaemia is often a reason for the suboptimal dosing or complete discontinuation of RAASi. This review presents current options for the management of hyperkalaemia in patients with chronic disease states. It also explores barriers to guideline-mediated RAASi prescribing patterns in these high-risk patients and highlights the unmet need for agents that adequately manage hyperkalaemia in patients with chronic diseases on concomitant RAASi therapy.

Treatment of Hyperkalemia in Heart Failure

PURPOSE OF REVIEW

The aim of this paper is to discuss strategies for prevention and management of hyperkalemia in patients with heart failure, including the role of novel therapies.

RECENT FINDINGS

Renin-angiotensin-aldosterone system (RAAS) antagonists, including angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and mineralocorticoid receptor antagonists (MRA) decrease mortality and morbidity in heart failure but increase the risk of hyperkalemia, especially when used in combination. Prevention of hyperkalemia and its associated complications requires careful patient selection, counseling regarding dietary potassium intake, awareness of drug interactions, and regular laboratory surveillance. Recent data suggests that the risk of hyperkalemia may be further moderated through the use of combined angiotensin-neprilysin inhibitors, novel MRAs, and novel potassium binding agents. Clinicians should be mindful of the risk of hyperkalemia when prescribing RAAS inhibitors to patients with heart failure. In patients at highest risk, such as those with diabetes, the elderly, and advanced chronic kidney disease, more intensive laboratory surveillance of potassium and creatinine may be required. Novel therapies hold promise for reducing the risk of hyperkalemia and enhancing the tolerability of RAAS antagonists.

Hyperkalemia among hospitalized patients and association between duration of hyperkalemia and outcomes

INTRODUCTION

The aim of the study was to investigate predictors of mortality in patients hospitalized with hyperkalemia.

MATERIAL AND METHODS

Data among hospitalized patients with hyperkalemia (serum potassium ≥ 5.1 mEq/l) were collected. Patients with end-stage renal disease on dialysis were excluded.

RESULTS

Of 15,608 hospitalizations, 451 (2.9%) episodes of hyperkalemia occurred in 408 patients. In patients with hyperkalemia, chronic kidney disease, hypertension, diabetes, coronary artery disease and heart failure were common comorbidities. Acute kidney injury (AKI) and metabolic acidosis were common metabolic abnormalities, and 359 patients (88%) were on at least one drug associated with hyperkalemia. Mean duration to resolution of hyperkalemia was 12 ±9.9 h. Nonsteroidal anti-inflammatory drugs (HR = 1.59), highest potassium level (HR = 0.61), tissue necrosis (HR = 0.61), metabolic acidosis (HR = 0.77), and AKI (HR = 0.77) were significant independent determinants of duration prior to hyperkalemia resolution. Tissue necrosis (OR = 4.55), potassium supplementation (OR = 5.46), metabolic acidosis (OR = 4.84), use of calcium gluconate for treatment of hyperkalemia (OR = 4.62), AKI (OR = 3.89), and prolonged duration of hyperkalemia (OR = 1.06) were significant independent predictors of in-hospital mortality.

CONCLUSIONS

Tissue necrosis, potassium supplementation, metabolic acidosis, calcium gluconate for treatment of hyperkalemia, AKI and prolonged duration of hyperkalemia are independent predictors of in-hospital mortality.