Abstract
Background:The risk of hyperkalemia is elevated in chronic kidney disease (CKD); however, the initial and recurrent risk among older individuals is less clear.Objectives:We set out to examine the initial and 1-year recurrent risk of hyperkalemia by level of kidney function (estimated glomerular filtration rate, eGFR) in older adults (≥66 years old).Design:Population-based, retrospective cohort studySettings:Ontario, CanadaParticipants:905 167 individuals (≥66 years old) from 2008 to 2015.Measurements:Serum potassium valuesMethods:Individuals were stratified by eGFR (≥90, 60-89, 30-59, 15-29 mL/min/1.73 m2) and examined for the risk of incident hyperkalemia (K ≥ 5.5 mEq/L) using adjusted Cox proportional hazards models. The 1-year risk of recurrent hyperkalemia was examined using multivariable Andersen-Gill models.Results:Among a population of 905 167 individuals (15% eGFR ≥ 90, 58% eGFR 60-89, 25% eGFR 30-59, 3% eGFR 15-29) with a potassium measurement, there were a total of 18 979 (2.1%) individuals with hyperkalemia identified. The event rate (per 1000 person-years) and adjusted hazard ratio (HR) of hyperkalemia was inversely associated with eGFR (mL/min; eGFR >90 mL/min: 8.8, referent, 60-89 mL/min: 11.8 HR 1.41; eGFR 30-59: 39.8, HR 4.37; eGFR 15-29: 133.6, 13.65) and with an increasing urine albumin-to-creatinine ratio (ACR, mg/mmol; ACR< 3: 14, referent, ACR 3-30: 35.1, HR 1.98; ACR >30: 93.7, 4.71). The 1-year event rate and adjusted risk of recurrent hyperkalemia was similarly inversely associated with eGFR (eGFR ≥ 90: 10.1, referent, eGFR 60-89: 14.4, HR 1.47; eGFR 30-59: 54.8, HR 4.90; eGFR 15-29: 208.0, HR 12.98). Among individuals with a baseline eGFR of 30 to 59 and 15 to 29, 0.9 and 3.8% had greater than 2 hyperkalemia events. The relative risk of initial and recurrent hyperkalemia was marginally higher with RAAS blockade. Roughly 1 in 4 individuals with hyperkalemia required hospitalization the day of or within 30 days after their hyperkalemia event.Limitations:Limited to individuals aged 66 years and above.Conclusions:Patients with low eGFR are at a high risk of initial and recurrent hyperkalemia.Trial registration: N/A
Highlights
The risk of hyperkalemia is elevated in chronic kidney disease (CKD); the initial and recurrent risk among older individuals is less clear
63% of the subjects were on an angiotensin converting enzyme (ACE)/angiotensinogen receptor blockers (ARB), 3% were on potassium sparing diuretic, and 11% were prescribed NSAIDs
Low eGFR was associated with increased albuminuria with a prevalence of 26% in subjects with eGFR 15 to 29 mL/ min/1.73m2 compared to 2% in subjects with eGFR ≥ 90 mL/min/1.73 m2
Summary
The risk of hyperkalemia is elevated in chronic kidney disease (CKD); the initial and recurrent risk among older individuals is less clear. Chronic kidney disease, defined by a reduction in eGFR for greater than 90 days or persistent albuminuria, is a wellidentified risk factor for hyperkalemia.[1,2,3,4,5,6,7,8,9,10] As many of the risk factors for hyperkalemia are irreversible, there is a persistent risk of recurrence.[11,12,13] This is of particular concern among older adults, in whom the prevalence of both CKD and risk factors for hyperkalemia is highest,[14,15] Older adults appear to have a confluence of hyperkalemia risk factors (heart failure, diabetes, medications) and physiologic processes associated with aging such as reduced renal potassium handling with reduced renal mass, impaired potassium secretion from the distal nephron, and a higher prevalence of hyporeninemic hypoaldosteronism that increase their susceptibility.[16,17,18] The burden of hyperkalemia and its risk of recurrence is less well characterized at the population level.
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