Higher Incidence Of Hypokalemia Research Articles

Target organ damage in untreated hypertensive patients with primary aldosteronism.

An increased risk of target organ damage (TOD) has been reported in patients with primary aldosteronism (PA). However, there is relatively little related research on the correlation between the degree of TOD and those with and without PA in newly diagnosed hypertensive patients. The aim of this study was to assess the association between PA and TOD among patients with newly diagnosed hypertension. Newly diagnosed hypertensive patients were consecutively recruited from January 2015 to June 2020 at the University of Hong Kong-Shenzhen Hospital. Patients were stratified into those with and without PA. Data for left ventricular mass index (LVMI), carotid intima-media thickness (CIMT) and plaque, and microalbuminuria were systematically collected. A total of 1044 patients with newly diagnosed hypertension were recruited, 57 (5.5%) of whom were diagnosed with PA. Patients with PA had lower blood pressure, serum lipids, body mass index, and plasma renin activity and a higher incidence of hypokalemia than those without PA. In contrast, the prevalence of left ventricular hypertrophy, increased CIMT, and microalbuminuria was higher in patients with PA than in those without PA. Multivariable regression analysis demonstrated that PA was independently associated with increased LVMI, CIMT and microalbuminuria. Among patients with newly diagnosed hypertension, those with PA had more severe TOD, including a higher LVMI, CIMT and microalbuminuria, than those without PA. These findings emphasize the need for screening TOD in newly diagnosed hypertension due to underlying PA.

Abstract 13202: Efficacy and Safety of Combining a Thiazide Diuretic With a Loop Diuretic in Decompensated Heart Failure: A Systematic Review and Meta-Analysis

Background: Acute decompensated heart failure (ADHF) has several presentations, one of the most common being congestion which is treated by intravenous loop diuretics. However, prolonged use of this therapy may lead to resistance that can be overcome with a sequential nephron blockade by adding a thiazide diuretic. Less is known about the safety of that combination. Research question: Is the combination of a thiazide diuretic and a loop diuretic safe and effective? Goal: To perform a meta-analysis of the association between the combination of loop and thiazide diuretics, their efficacy, and potential adverse effects. Methods: We systematically searched PubMed, Embase, and Cochrane for randomized controlled trials that compared patients with ADHF using only a loop diuretic and patients using a thiazide adjuvant therapy, and reported the outcomes of (1) weight change; (2) hypokalemia (potassium ≤ 3.5 mmol/L or potassium ≤ 3.5 mEq/L); (3) 30-day rehospitalization; and (4) length of stay. Heterogeneity was examined with I2 statistics. A random-effects model was employed. Review manager 5.4 was used for statistical analyses. Results: In 4 studies, among 424 patients with ADHF, 212 (50%) were treated with a combination of loop and thiazide diuretics and 212 (50%) had a loop monotherapy treatment. Overall, individuals receiving the diuretic combination experienced greater weight loss (MD -0.73; 95% CI -1.23, -0.24; p=0.004; Fig. 1A), but had higher incidence of hypokalemia (RR 2.36; 95% CI 1.56, 3.58; p<0.0001; Fig. 1B) compared to those who were not receiving. There was no significant difference between both groups in all-cause 30-day rehospitalization (RR 1.26; 95% CI 0.81, 1.96; p=0.30; Fig. 1C) or length of hospital stay (MD 0.26; 95% CI -1.03, 1.54; p=0.70; Fig. 1D). Conclusions: These findings suggest that the combination of a loop and a thiazide diuretic may lower body weight in patients with ADHF. However, its role in improving clinical outcomes remains unclear.

Gastrointestinal Toxicity of High-Dose Melphalan in Autologous Stem-Cell Transplantation: Identification of Risk Factors and a Benchmark for Experimental Therapies

Gastrointestinal (GI) adverse effects are the dose limiting toxicity of high-dose melphalan (HDM), and despite prophylactic measures, continue to have a significant impact on morbidity, length of stay, and quality of life. There are limited contemporary data on gastrointestinal toxicity associated with HDM. Our objective was to characterize the GI toxicity of HDM and identify risk factors for severe toxicity in a cohort of patients.We conducted a retrospective study on 100 consecutive patients with multiple myeloma, amyloidosis, or lymphoma who underwent autologous stem-cell transplant at Columbia University Irving Medical Center using HDM, either alone or in combination with other chemotherapeutic agents. Gastrointestinal adverse events, use of rescue medications, infectious complications, and length of stay were collected from electronic medical records. CTCAE (Common Terminology for Adverse Events) grading for GI events was conducted daily. Risk factors for GI toxicity were identified using linear regression and then examined in a multivariable model.Patients (median age 56 years, range 20-73) had myeloma (42%), lymphoma (42%), or amyloidosis (16%). Melphalan dose was 200 (40%), 140 (59%), or 100 mg/m2 (1%). Ninety-seven percent of patients experienced diarrhea ranging 1 - 18 daily bowel movements (Figure 1) and lasting 0 - 17 days (median 7). Nausea and vomiting of any grade occurred in 88% and 61% of patients, respectively. Sixty-two percent developed grade≥2 diarrhea, and grade≥2 nausea and vomiting was observed in 35% and 7%, respectively. The mean total number of bowel movements during a 14-day period post-transplant was 39 (maximum 67). Rescue loperamide was given 10 doses on average overall (range 0-43). Eighteen percent experienced weight loss of more than 10% and 38% dropped albumin level by at least 1g/dL.Patients with grade≥2 diarrhea had a higher incidence of hypokalemia, hypoalbuminemia, required greater electrolyte repletions (Figure 2), utilized more rescue medications, and had prolonged diarrhea (average 8.7 v. 5 days, p<0.0001) compared to patients with grade 1 diarrhea. Patients with grade≥2 diarrhea were also more likely to stay in the hospital more than 23 days (p=0.07). Of the entire cohort, eleven percent had at least one episode of incontinence and 15% had an infection identified in stool studies. To rule out further complications, 31% of patients had CT scans of the abdomen and pelvis but only 8% showed evidence of colitis.Grade≥2 diarrhea was independently associated with age>50 years (p=0.04), creatinine clearance <60 ml/min (p=0.05), and female sex (p=0.04). Female sex was also associated with developing grade≥1 nausea (p=0.05) and vomiting (p=0.09). Melphalan dose, underlying disease, and HDM v. BEAM (BCNU, Etoposide, Ara-C, Melphalan) were not significantly associated with diarrhea severity, although numerically there were more patients with grade≥2 diarrhea in the HDM 200 mg/m2 compared to 140 mg/m2 (70% vs. 59%).Diarrhea remains a very common side effect of HDM with no improvement over historical rates and no known prophylactic measures. Female sex, a low creatinine clearance, and age over 50 years portend a higher risk for severe diarrhea, and female sex for nausea and vomiting. Novel therapies for chemotherapy-induced diarrhea are critically needed for patients undergoing stem-cell transplantation. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Electrolyte disorders are ERAS-associated in patients undergoing hepato-pancreato-biliary surgery.

Emerging evidences have raised concerns about electrolyte disorders caused by restrictive fluid management in the enhanced recovery after surgery (ERAS) protocol. This study aims to investigate the morbidity and treatment of electrolyte disorders associated with ERAS in patients undergoing hepato-pancreato-biliary (HPB) surgery. Clinical data from 157 patients under the ERAS program and 166 patients under the traditional (Non-ERAS) program after HPB surgery were retrospectively analyzed. Risk factors and predictive factors of postoperative electrolyte disorders were analyzed by logistic regression analysis and receiver operator characteristic (ROC) curve analysis, respectively. The average of intravenous fluid, sodium, chloride, and potassium supplementation after surgery were significantly lower in the ERAS group. Hypokalemia was the most common type of electrolyte disorders in the ERAS group, whose incidence was substantially increased compared to that in the Non-ERAS group [28.77% vs. 8.97%, p < 0.001, on postoperative (POD) 5]. Logistic regression analysis identified the ERAS program and age as independent risk factors of hypokalemia. ROC curve analysis identified serum potassium levels below 3.76mmol/L on POD 3 (area under curve 0.731, sensitivity 58.54%, specificity 82.69%) as a predictive factor for postoperative hypokalemia in ERAS patients. Oral supplementation at an average of 35.41mmol potassium per day was effective in restoring the ERAS-associated hypokalemia. ERAS procedures were particularly associated with a lower supplementation of potassium and a higher incidence of hypokalemia in patients after HPB surgery. Oral potassium supplementation could be an adopted ERAS program for the elderly undergoing HPB surgery.

The number of positive confirmatory tests is associated with the clinical presentation and incidence of cardiovascular and cerebrovascular events in primary aldosteronism.

Primary aldosteronism (PA) is a major cause of secondary hypertension and presents a higher risk for cardio-cerebrovascular (CCV) events compared with essential hypertension. To diagnose PA after a positive screening test, at least one of three available confirmatory tests [the saline infusion test (SIT), the captopril challenge test (CCT) or the furosemide upright test (FUT)] should be performed. The aim of our study was to investigate the relationship between the number of positive confirmatory tests using SIT and CCT and the clinical presentation and prevalence of CCV events in 398 PA patients. The number of PA patients doubled when PA diagnosis was defined by positive results on either the SIT or CCT confirmatory tests (single positive) compared to positive results on both the SIT and CCT confirmatory tests (double positive). We also found a more typical clinical presentation of PA, such as the use of more antihypertensive drugs to control blood pressure and a higher incidence of hypokalemia, in PA patients with double positive confirmatory tests than in those with a single positive confirmatory test. The incidence of CCV events in PA patients with double positive confirmatory tests was significantly higher than that in those with a single positive confirmatory test. Our results demonstrated that the number of PA patients was doubled by the use of PA diagnostic criteria using a single positive confirmatory test compared to the use of double positive confirmatory tests. PA patients with double positive confirmatory tests were associated with a more typical clinical presentation and a higher incidence of CCV events than those with a single positive confirmatory test.

154 - Gastrointestinal Toxicity of High-Dose Melphalan in Autologous Stem-Cell Transplantation: Identification of Risk Factors and a Benchmark for Experimental Therapies

Gastrointestinal (GI) adverse effects are the dose limiting toxicity of high-dose melphalan (HDM), and despite prophylactic measures, continue to have a significant impact on morbidity, length of stay, and quality of life. There are limited contemporary data on gastrointestinal toxicity associated with HDM. Our objective was to characterize GI toxicity of HDM and identify risk factors for severe toxicity in a cohort of patients. We conducted a retrospective study on 100 consecutive patients with multiple myeloma, amyloidosis, or lymphoma who underwent autologous stem-cell transplant at Columbia University Medical Center using HDM, either alone or in combination with other chemotherapeutic agents. Patients (median age 56 years, range 20-73) had myeloma (42%), lymphoma (42%), or amyloidosis (16%). Melphalan dose was 200 (40%), 140 (59%), or 100 mg/m2 (1%). Ninety-seven percent of patients experienced diarrhea ranging 1 – 18 daily bowel movements (Figure 1) and lasting 0 – 17 days (median 7). Nausea and vomiting of any grade occurred in 88% and 61% of patients, respectively. Sixty-two percent developed grade ≥ 2 diarrhea, and grade ≥ 2 nausea and vomiting was observed in 35% and 7%, respectively. The mean total number of bowel movements during a 14-day period post-transplant was 39 (maximum 67). Rescue loperamide was given 10 doses on average overall (range 0-43). Eighteen percent experienced weight loss of more than 10% and 38% dropped albumin level by at least 1g/dL. Patients with grade ≥ 2 diarrhea had a higher incidence of hypokalemia, hypoalbuminemia, required greater electrolyte repletions (Figure 2), utilized more rescue medications, and had prolonged diarrhea (average 8.7 v. 5 days, P < .0001). Patients with grade ≥ 2 diarrhea were also more likely to stay in the hospital more than 23 days (P = .07). Eleven percent had at least one episode of incontinence and 15% had an infection identified in stool studies. To rule out further complications, 31% of patients had CT scans of the abdomen and pelvis but only 8% showed evidence of colitis. Grade ≥ 2 diarrhea was independently associated with age > 50 years (P = .04), creatinine clearance <60 ml/min (P = .05), and female sex (P = .04). Female sex was also associated with developing grade ≥ 1 nausea (P = .05) and vomiting (P = .09). Melphalan dose, underlying disease, and HDM v. BEAM, were not significantly associated with diarrhea severity, although numerically there were more patients with grade ≥ 2 diarrhea in the HDM 200 mg/m2 compared to 140 mg/m2 (70% vs. 59%). Diarrhea remains a very common side effect of HDM. Female sex, a low creatinine clearance, and age over 50 years portend a higher risk for severe diarrhea, and female sex for nausea and vomiting. Novel therapies for chemotherapy-induced diarrhea are critically needed for patients undergoing stem-cell transplantation.

Potassium Supplementation Requirement Post Orthotopic Liver Transplantation in Children

Electrolyte disturbances, particularly hypokalemia, are a potentially underreported phenomenon among the over 500 pediatric orthotopic liver transplantations (OLTs) performed annually in the United States. Differing from the reported adult hyperkalemia during OLT, intraoperative hypokalemia has been documented in pediatric patients; however, biomedical literature reporting on the occurrence of postoperative potassium disturbances is lacking. The maintenance of potassium homeostasis is crucial to a patient’s cardiac, neuromuscular, and renal functions; alterations to potassium homeostasis may complicate their postoperative course. The goals of the study were to investigate and quantify the degree of potassium supplementation required in patients with postoperative hypokalemia and to determine whether pediatric post OLT patients possessed altered potassium needs. This retrospective study analyzed serum potassium concentrations and potassium supplementation within the pediatric OLT patients who had procedures performed between 1985-2011 at Mayo Clinic in Rochester, MN. Postoperative data from a sample size of 60 patients was examined by chart review and compared to the patient’s own baseline. Postoperative hypokalemia was noted in approximately 50% of patients within the first three postoperative days. Due to this hypokalemic state, patients required 0.5 m Eq/kg/day of potassium supplementation on average. The highest incidence of decreased serum potassium occurred within the first 72 hours post-transplantation. Age less than one year and use of diuretics were the identified variables associated with increased incidence of potassium supplementation. In conclusion, potassium supplementation is necessary in pediatric patients post OLT due to the high incidence of hypokalemia. Anticipatory and sufficient potassium supplementation in the initial postoperative period may be warranted, especially in infants. Further studies are needed to determine the etiology of this finding and its impact on morbidity and mortality in this patient population.

Are Chlorthalidone and Hydrochlorothiazide Equivalent Blood‐Pressure‐Lowering Medications?

Only one large out-come trial, the Multiple Risk Factor Intervention Trial (MRFIT), used both HCTZ and CTD, but no head-to-head comparisons were performed. In MRFIT, after about 5 years patients who received each diuretic as initial therapy were compared against the common “referred care” group. For patients who used CTD as initial therapy, there was a trend indicating lower mortality compared with those using HCTZ. Use of CTD declined after research studies using high doses suggested an increased risk of cardiovascular deaths and a high incidence of hypokalemia.

Encefalopatía, convulsiones e hipopotasemia en la intoxicación teofílínica: Análisis de un caso

A 73-year-old man was admitted to our hospital after convulsive seizures preceded by encephalopathy lasting one week. He had a history of long-standing chronic obstructive pulmonary disease and analysis showed hypokalemia, respiratory alkalosis and toxic levels of theophylline. We discuss the severity of the convulsions and arrhythmias, the high incidence of hypokalemia in theophylline poisoning, as well as the role of hypokalemia in the pathogenesis of the convulsions and the high level of mortality in this type of intoxication. Other possible mechanisms involved in theophylline encephalopathy are mentioned, along with the controversial use of theophylline for continuous treatment of chronic obstructive pulmonary disease.

Loop diuretic therapy in liver cirrhosis with ascites.

Medical treatment of ascites is aimed at reverting sodium retention, that is, at creating a negative sodium balance to relieve ascites. Bed rest and low-sodium diet induce the disappearance of ascites in about 10% of patients. Loop diuretics and aldosterone antagonists must be administered to the patients not responding to the previous regimen. Available evidence indicates that aldosterone antagonists are the first-choice drugs, as these substances are more effective than furosemide. Nevertheless, loop diuretics potentiate the effects of aldosterone antagonists. The reduced efficacy of furosemide in these patients, when compared with that of spironolactone, may be related to an impairment of both pharmacodynamics and pharmacokinetics. In fact, most sodium not reabsorbed in Henle's loop, due to the action of furosemide, is subsequently taken up in the distal nephron because of hyperaldosteronism. A further mechanism of resistance may be related to an impaired excretion of furosemide into the tubular lumen. The use of diuretics in the treatment of ascites is associated with several side effects, including prerenal azotemia, hepatic encephalopathy, and electrolyte and acid-base disorders. A stepped-care approach, together with careful monitoring of patients, is the best way to reduce the incidence of these complications. Ethacrynic acid has been shown to be highly effective in the treatment of ascites, even in patients refractory to other diuretics, but its use is associated with a high incidence of hypokalemia and hypochloremic alkalosis. Bumetanide and piretanide are comparable to furosemide, in terms of both efficacy and side effects.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of Mild Chronic Congestive Heart Failure with Ibopamine, Hydrochlorothiazide, Ibopamine plus Hydrochlorothiazide or Placebo

This multicentre, double-blind, double-dummy, randomised parallel group study in 247 patients with mild chronic congestive heart failure compared the efficacy and tolerability of ibopamine, hydrochlorothiazide (HCTZ), ibopamine plus HCTZ and placebo during an 8-week treatment period. The combination of ibopamine and HCTZ resulted in a significantly greater reduction in body weight (p less than 0.05) than HCTZ alone. Trends in favour of the combination as compared to ibopamine or HCTZ alone and in favour of ibopamine as compared to HCTZ were observed. All active treatments were superior to placebo. All active treatments were well tolerated. There was a trend towards a higher incidence of hypokalemia in patients treated with HCTZ, alone or in combination, compared to those receiving ibopamine alone or placebo.

Occurrence of hypokalemia in suspected acute myocardial infarction and its relation to clinical history and clinical course

In 1350 patients with suspected acute myocardial infarction, serum potassium levels during the first 3 days in hospital was correlated to clinical history and clinical course. A higher incidence of hypokalemia was observed in women, in patients with hypertension, and in those on chronic diuretic treatment. Patients with anterior infarction had a higher incidence of hypokalemia than those with inferior infarction, as did patients with large as compared with small infarcts. No clear difference was observed between patients whose infarction was confirmed and those in whom the diagnosis was not confirmed. Independent predictors for hypokalemia were treatment with diuretics before admission to hospital, infarct size, and female sex. Hypokalemia during the first 3 days of hospitalization was associated with the occurrence of severe ventricular arrhythmias during hospitalization, but not with survival during a 5-year follow-up.