Low Serum Potassium Research Articles

Knockout of Kcnj16 (Kir5.1) in Dahl Salt‐Sensitive Rats Produces Seizure Phenotype

Kir5.1 is a member of an inwardly rectifying potassium (Kir) channel family notably present in the kidney and brain. We previously established that a knockout rat model of Kcnj16 (gene encoding Kir5.1) on a Dahl salt‐sensitive background (SSKcnj16−/−) exhibits a severe cardiovascular phenotype (Palygin et al., JCI Insight, 2017). Mutations in ion channel genes can alter neuronal excitability and mutations in Kir genes have been linked to seizure disorders in humans. Since Kir5.1 is known to be expressed in the brain and may contribute to neuronal membrane potential and spatial potassium buffering, we hypothesized that in addition to cardiovascular and renal dysfunction, neurological phenotypes, including seizures, would be prevalent in the SSKcnj16−/−rats. We found that SSKcnj16−/− rats (but not control SS rats) experience tonic‐clonic seizures when exposed to a 10 kHz tone (86 dB for 2 min), whereas other frequencies (0.1 or 1 kHz) did not elicit seizures. When exposed to the seizure‐inducing acoustic stimulus once/day for 10 days, we noted that SSKcnj16−/− rats experienced a seizure in response to 92% of stimuli. SSKcnj16−/− rats also showed spontaneous mortality within hours after a stimulus with a survival rate of 67% (N=21) for the duration of the 10 day protocol. Control rats (N=10) had no incidence of seizure or death during the 10 days of acoustic stimulation. We found no difference among male and female SSKcnj16−/− rats, where both sexes had a similar audiogenic seizure response and reduced survival. Behavioral tests including a modified Irwin screen and open field test revealed that before and after seizure stimulation SSKcnj16−/− rats tended to have altered activity levels, gait, piloerection, and respiration rates. Analysis of blood electrolytes revealed critically low serum potassium levels in SSKcnj16−/− compared to SS controls, a difference that appeared to be exacerbated by repeated seizures. We hypothesize that seizures may be intensifying potassium imbalance and disrupting the homeostasis that is particularly essential for excitable cells such as neurons. We conclude that knockout of Kir5.1 leads to distinct neurological phenotypes including a seizure disorder and subsequent spontaneous death, which may have relevance to channelopathies associated with seizure disorders in humans.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Assessing the Impact of an Order Panel Utilizing Weight-Based Insulin and Standardized Monitoring of Blood Glucose for Patients With Hyperkalemia

Intravenous insulin with glucose is used in urgent treatment for hyperkalemia but has a significant risk of hypoglycemia. The authors developed an order panel within the electronic health record system that utilizes weight-based insulin dosing and standardized blood glucose monitoring to reduce hypoglycemia. As initial evaluation of this protocol, the authors retrospectively compared potassium and blood glucose lowering in patients treated with the weight-based (0.1 units/kg) insulin order panel (n = 195) with those given insulin based on provider judgment (n = 69). Serum potassium lowering did not differ between groups and there was no relationship between dose of insulin and amount of potassium lowering. There was a difference in hypoglycemia rates between groups ( P = .049), with fewer severe hypoglycemic events in the panel (2.56%) than in the non-panel group (10.14%). These data suggest weight-based insulin dosing is equally effective for lowering serum potassium and may lower risk of severe hypoglycemia.

Analysis of the genes involved in Mendelian forms of low-renin hypertension in Chinese early-onset hypertensive patients

The study aimed to analyze genes involved in Mendelian forms of low-renin hypertension in Chinese early-onset hypertensive patients. A panel of nine genes, namely SCNN1B, SCNN1G, WNK1, WNK4, KLHL3, CUL3, nuclear receptor subfamily 3, group C (NR3C)1, NR3C2, and HSD11B2 were screened by targeted resequencing in 260 Chinese early-onset hypertensive patients. Additionally, exon 13 of both SCNN1B and SCNN1G was sequenced in an independent cohort of 506 Chinese early-onset hypertensive patients. About 81 nonrare and 41 rare variants were, respectively, detected in 221 (85.0%) and 39 (15.0%) patients from the cohort of 260. Of the total 766 patients, those with rare variants in exon 13 of either SCNN1B or SCNN1G had a significantly earlier onset of hypertension (24.7 ± 7.5 vs. 29.0 ± 7.7 years, P = 0.015) and lower serum potassium (3.57 ± 0.59 vs. 3.96 ± 0.41 mmol/l, P = 0.007) than those without rare variants. However, other identified rare variants had no effects on clinical expression. Seven patients (0.91%) were diagnosed with Liddle's syndrome, and the Liddle's syndrome prevalence was 1.72% among the 407 patients with hypertension diagnosed before the age of 30. Genetic screening of the probands' relatives identified 10 additional Liddle's syndrome patients. Treatment of Liddle's syndrome patients with amiloride resulted in normalization of both blood pressure and serum potassium. Liddle's syndrome appears to be the most common low-renin Mendelian hypertension in young Chinese hypertensive patients. Sequencing exon 13 of both SCNN1B and SCNN1G is highly advisable in patients with early-onset and low-renin hypertension.

Screening of genetic mutations in a Chinese pedigree affected with hypokalemic periodic paralysis

OBJECTIVE To screen for mutations in a Chinese pedigree affected with hypokalemic periodic paralysis. METHODS The proband and nine family members were enrolled for the analysis of CACNA1S and SCN4A gene mutations. Genomic DNA was extracted from peripheral blood samples. The coding regions of the two genes were amplified with PCR and subjected to Sanger sequencing. Potential impact of suspected mutations was predicted with Bioinformatics software. The mutations were also verified among 100 healthy controls. RESULTS The proband and 5 family members (including 5 males and 1 female) had presented with episodes of flaccid paralysis accompanied by low serum potassium. Genetic testing has identified a c.664C>T (p.Arg222Trp) mutation in the proband, which has been reported previously. The same mutation was identified in other 5 affected members from the family. No mutation of the CACNA1S gene was detected. CONCLUSION The c.664C>T mutation of the SCN4A gene probably underlies the hypokalemic periodic paralysis in this family. All patients from the family have shown a complete penetrance of the disease.

Aldosterone induces left ventricular subclinical systolic dysfunction: a strain imaging study.

Primary aldosteronism is associated with a higher incidence of left ventricular (LV) hypertrophy and diastolic dysfunction than essential hypertension. However, systolic function via endocardial measurements is similar between patients with primary aldosteronism and essential hypertension. Speckle-tracking echocardiography is a sensitive tool which can detect subclinical impairments in systolic function. The aim of this study was to investigate aldosterone-induced subclinical impairments in systolic function. We prospectively enrolled patients with primary aldosteronism and essential hypertension and analyzed their clinical data, biochemical data, and echocardiographic parameters, including myocardial strain [global longitudinal strain (GLS)]. Thirty-six patients with primary aldosteronism and 31 patients with essential hypertension were enrolled for analysis. The patients with primary aldosteronism had significantly lower serum potassium levels, lower plasma renin activity, higher aldosterone-to-renin ratio (ARR), and higher 24-h urinary aldosterone levels than patients with essential hypertension. With regards to echocardiographic parameters, the patients with primary aldosteronism had a thicker ventricular wall and higher LV mass index than those with essential hypertension. Most importantly, we found significant degradation of GLS in the patients with primary aldosteronism compared with those with essential hypertension (-17.84 ± 2.36 vs. -20.13 ± 2.32, P < 0.001). In correlation analysis, GLS was significantly correlated with serum potassium level, LV mass index, log-transformed plasma renin activity, log-transformed ARR, and log-transformed 24-h urinary aldosterone levels (all P < 0.05). Multivariate linear regression analysis further identified log-transformed ARR (β = 0.771, 95% confidence interval: 0.011-1.530, P = 0.047), and log-transformed 24-h urinary aldosterone level (β = 1.765, 95% confidence interval: 0.01-3.529, P = 0.050) as independent factors correlated with GLS. Patients with primary aldosteronism have a lower magnitude of GLS than patients with essential hypertension, suggesting that aldosterone induces a subclinical decline in LV systolic function.

Screening for Primary Aldosteronism in Resistant Hypertension

Background: Resistant hypertension is associated with higher rates of cardiovascular disease, kidney disease, and death than essential hypertension. Although clinical practice guidelines recommend screening for primary aldosteronism among persons with resistant hypertension, rates of screening are unknown. Methods: We performed a cohort study in an academic health system using an electronic health registry to identify persons with resistant hypertension. We identified 145,670 persons with hypertension and excluded persons with congestive heart failure or advanced chronic kidney disease. We identified persons with resistant hypertension by conventional definitions. We determined screening rates for primary aldosteronism and demographic and clinical characteristics associated with screening. Findings: Among 5641 persons with resistant hypertension, 111 (2·0%) were screened for primary aldosteronism. Screened persons were younger (56·2 /- 13·0 years vs. 65·6 /- 11·6 years; p<·0001), and had higher diastolic blood pressure (81·9 /- 14·2 mmHg vs. 74·7 /- 13·6 mmHg; p<·0001), lower serum potassium concentrations (3·9 /- 0·6 mmol/L vs. 4·1 /- 0·5 mmol/L; p=0·01), and lower rates of diagnosed coronary artery disease (14·0% vs. 7·2%; p=0·04) than unscreened persons. Screened persons had significantly higher rates of prescription for calcium channel blockers, mixed alpha/beta adrenergic receptor antagonists, loop diuretics, sympatholytics, and vasodilators and lower rates of prescription of thiazide and thiazide-type diuretics (p=0·049). The prescription of mineralocorticoid receptor antagonists or other potassium sparing diuretics was not significantly different between groups (p=0·33). Interpretation: Patients with resistant hypertension are infrequently screened for primary aldosteronism. Efforts to highlight guideline-recommended screening and/or targeted therapy are warranted. Funding: Department of Medicine, Stanford University School of Medicine; National Institutes of Health. Conflict of Interests: The authors have no conflicts of interest to disclose. Ethical Approval Statement: The Institutional Review Board at Stanford University approved the study protocol, including a waiver of informed consent for this study.

Factors associated with non-response to lactulose therapy in cirrhotic patients with minimal hepatic encephalopathy

Background and objectives: Minimal hepatic encephalopathy (MHE) impairs health related quality of life and predicts overt hepatic encephalopathy (HE) in cirrhotic patients. Lactulose is effective in the treatment of MHE. But the response to lactulose treatment depends on several factors. This study was aimed to find out the contributing factors to non-response to lactulose therapy.Materials and methods: The study was carried out at the BIRDEM general hospital from September, 2013 to March, 2015. Sixty patients were enrolled to assess the response of lactulose therapy in cirrhotic patients with MHE. MHE was diagnosed based on abnormal psychometric tests namely, number connection test (NCT), digit symbol test (DST) and high serum ammonia level. A daily dose of 30-60 ml of lactulose was given to all patients for one month. The response to treatment with regard to MHE was determined after one month using defined criteria. The response was graded as responder and non-responder.Results: The mean age of the study population was 57.0±10.3 years. Out of 60 cases, 46 (77%) were male and 39 (65%) had diabetes. Out of 60 enrolled MHE cases, 16 (27%) had Child-Turcotte-Pugh-A (CTP-A) score and 44 (73%) belonged to CTP-B &amp; C category. Out of 60 MHE cases, 23 (38.3%) showed improvement in their MHE status based on normalization of psychometric tests and reduction of serum ammonia level to ≤32 μmol/L. Age, gender and diabetes were not associated with the response to lactulose therapy. Low baseline arterial pressure was significantly (p=0.003) associated with non-response to lactulose treatment. The mean baseline ammonia level was higher significantly among the nonresponders compared to the responders (83.6±21.4 μmol/L vs 58.8±19.8 μmol/L, p&lt;0.001). Compared to responders, low serum sodium and potassium and raised serum bilirubin levels of non-responders at baseline were found significantly (p&lt;0.05) associated with non-response to one month of lactulose treatment. Initial hemoglobulin, peripheral leucocyte and platelet counts did not have any effect on the response to lactulose treatment in MHE cases.Conclusions: The status of MHE in patients with cirrhosis improved by one-month treatment with lactulose. Baseline low arterial pressure, hyperammonemia, hypokalemia and hyponatremia were major contributors to non-response to lactulose therapy. The findings of the study would be useful in treating patients of cirrhosis with MHE.IMC J Med Sci 2018; 12(1): 15-21

Is it time to rethink about protocols for managing intraoperative serum potassium and blood glucose levels during off-pump coronary artery bypass surgery?

Background A low perioperative serum potassium level ( 200 mg/dl) during cardiac surgery is a preventable cause of high morbidity and mortality. In this study, we measured the changes in intraoperative levels of serum potassium and blood glucose in adult patients undergoing elective off-pump coronary artery bypass (OPCAB) surgery, while administering insulin intraoperatively as per the present guidelines. Patients and methods Thirty-six adults, aged 18–65 years, undergoing elective OPCAB surgery were enrolled in this study. Arterial blood gas analysis was performed at predetermined intraoperative time points to measure serum potassium and blood glucose levels as primary variables. Base excess, pH, and HCO3− were recorded as secondary variables. Insulin infusion was started according to the sliding scale, whenever blood glucose was more than 180 mg/dl. Intravenous potassium was supplemented, when serum potassium was less than 4 mEq/l. Quantitative variables were compared with baseline using paired t test and repeated measure analysis of variance was used for comparison across follow up. Results Potassium chloride had to be continuously administered intravenous to maintain serum potassium levels more than 4 mEq/l throughout OPCAB surgery. There was a highly significant (P Conclusion Patients are prone to hypokalemia and hyperglycemia during OPCAB surgery, despite following the current guidelines. More studies are needed to formulate a better insulin infusion protocol for maintaining normoglycemia and guidelines need to be formulated for continuous intraoperative potassium infusion during OPCAB surgery.

Complete Hypokalemic Quadriparesis as a First Presentation of Sjögren Syndrome.

Rationale:We hope to increase awareness that hypokalemic paralysis may be the first presentation of Sjögren syndrome, for which potassium-sparing diuretics can be an effective adjunct to potassium replenishment.Presenting concerns:A 73-year-old female presented to a peripheral hospital with quadriparesis and a critically low serum potassium of 1.6 mmol/L with U waves on the electrocardiogram (ECG). The initial arterial blood gas showed a pH of 7.19, bicarbonate of 13 mEq/L, and a CO2 of 35 mm Hg. Over the next 6 days, she was administered a total of 450 mEq of potassium supplements. Despite this, her potassium never increased above 2.9 mmol/L and was thus transferred to the University Hospital for further management. On arrival, her vital signs were within normal limits. Her only other symptoms were fatigue and ocular dryness. Physical exam showed slightly weakened quadriceps muscles bilaterally, graded 4/5. Examination was otherwise unremarkable. Admission investigations included a potassium of 2.8 mmol/L, chloride 118 mmol/L, sodium 136 mmol/L, and eGFR 48 mL/min/1.73 m2. Renin aldosterone ratio was normal.Diagnoses:Distal renal tubular acidosis (RTA) was diagnosed based on a normal anion gap metabolic acidosis, positive urine anion gap, and elevated urine potassium to creatinine ratio. Investigation of underlying causes revealed a positive Antinuclear antibody (ANA), elevated rheumatoid factor, and high anti-Ro/SSA titre which directed us toward a unifying diagnosis of Sjögren syndrome. A renal biopsy was undertaken as an outpatient and demonstrated severe interstitial nephritis with acute and chronic components, parenchymal scarring, atrophy, and small vessel arteriosclerosis.Interventions:In the acute setting, the patient was treated with bicarbonate and amiloride in addition to potassium supplementation.Outcomes:The patient’s hypokalemic paralysis and metabolic acidosis were corrected.Lessons Learned:Severe hypokalemic paralysis in distal RTA associated with Sjögren syndrome can be successfully treated with amiloride in addition to potassium supplementation. We also review the literature on the aberrancies seen in H+ATPase, Band 3, Pendrin, and carbonic anhydrase that may underlie the pathogenesis of distal RTA in Sjögren syndrome.

Clinical and diagnostic features of Bartter and Gitelman syndromes.

ABSTRACTBackgroundBartter and Gitelman syndromes are autosomal recessive disorders of renal tubular salt handling. Due to their rarity, limited long-term data are available to inform prognosis and management.MethodsLong-term longitudinal data were analysed for 45 children with pathogenic variants in SLC12A1 (n = 8), KCNJ1 (n = 8), CLCNKB (n = 17), BSND (n = 2) and SLC12A3 (n = 10) seen at a single centre between 1984 and 2014. Median follow-up was 8.9 [interquartile range (IQR) 0.7–18.1] years.ResultsPolyhydramnios and prematurity were seen in children with SLC12A1 and KCNJ1 mutations. Patients with CLCNKB mutations had the lowest serum potassium and serum magnesium and the highest serum bicarbonate levels. Fractional excretion of chloride was >0.5% in all patients prior to supplementation. Nephrocalcinosis at presentation was present in the majority of patients with SLC12A1 and KCNJ1 mutations, while it was only present in one patient with CLCNKB and not in SLC12A3 or BSND mutations. Growth was impaired, but within the normal range (median height standard deviation score −1.2 at the last follow-up). Impaired estimated glomerular filtration rate (eGFR <90 mL/min/1.73 m2) at the last follow-up was seen predominantly with SLC12A1 [71 mL/min/1.73 m2 (IQR 46–74)] and KCNJ1 [62 mL/min/1.73 m2 (IQR 48–72)] mutations. Pathological albuminuria was detected in 31/45 children.ConclusionsPatients with Bartter and Gitelman syndromes had a satisfactory prognosis during childhood. However, decreased eGFR and pathologic proteinuria was evident in a large number of these patients, highlighting the need to monitor glomerular as well as tubular function. Electrolyte abnormalities were most severe in CLCNKB mutations both at presentation and during follow-up. Fractional excretion of chloride prior to supplementation is a useful screening investigation in children with hypokalaemic alkalosis to establish renal salt wasting.

Scorpion envenoming in Morona Santiago, Amazonian Ecuador: Molecular phylogenetics confirms involvement of the Tityus obscurus group

Scorpion envenoming by species in the genus Tityus is hereby reported from rural locations in the Amazonian province of Morona Santiago, southeastern Ecuador. Twenty envenoming cases (18 patients under 15 years of age) including one death (a 4-year-old male) were recorded at the Macas General Hospital, Morona Santiago, between January 2015 and December 2016 from the counties of Taisha (n=17), Huamboyo (n=1), Palora (n=1), and Logroño (n=1). An additional fatality from 2014 (a 3-year-old female from Nayantza, Taisha county) is also reported. Leukocytosis and low serum potassium levels were detected in most patients. We observed a significant negative correlation between leukocytosis and hypokalemia. Scorpions involved in three accidents from Macuma, Taisha County, were identified as genetically related to Tityus obscurus from the Brazilian Amazonian region based on comparison of mitochondrial DNA sequences encoding cytochrome oxidase subunit I. These cases, along with previously reported envenoming from northern Manabí, reinforce the notion that scorpionism is a health hazard for children in Ecuador and emphasizes the need to supply effective antivenoms against local species, which are not currently available. The genetic affinity of the Ecuadorian specimens with T. obscurus may underlay toxinological, clinical, and venom antigenic relationships among Amazonian scorpions that deserves further exploration for designing therapeutic strategies to treat scorpionism in the region.

Potassium measurements and risk of type 2 diabetes: a dose-response meta-analysis of prospective cohort studies.

ObjectiveTo clarify the relationship between serum, dietary, and urinary potassium and the risk of type 2 diabetes mellitus (T2DM).Materials and MethodsWe searched PubMed and EMBASE through January 6, 2017 for studies reporting risk estimates on the association of potassium measurements and the risk of T2DM. The summary risk estimates were obtained through a random-effects model. Dose-response analysis was conducted.ResultsEight studies involving 5,053 cases and 119,993 individuals were included. A trend toward significance was found in the highest versus lowest meta-analysis on serum potassium and T2DM risk (RR = 0.79; 95% CI 0.60–1.04); moreover, the RR per 1 mmol/L increase in serum potassium was 0.83 (95% CI 0.73–0.95). A non-significant association of dietary potassium and T2DM risk was detected (RR for the highest versus lowest category: 0.93; 95% CI 0.81–1.06; RR for every 1000mg increase per day: 1.00, 95% CI 0.96–1.05). A similar non-significant association was found for urinary potassium and T2DM risk (RR for the highest versus lowest category: 0.83; 95% CI 0.39–1.75; RR per 10 mmol increase: 1.00; 95% CI 0.95–1.05). Evidence of a linear association between serum, dietary, and urinary potassium and the risk of T2DM was found (all Pnon-linearity > 0.05).ConclusionsLow serum potassium increases the risk of T2DM in a linear dose-response manner; nevertheless, neither dietary potassium nor urinary potassium shows any association with the risk of T2DM. However, these findings should be interpreted with caution due to limited studies.

The Spectrum of Subclinical Primary Aldosteronism and Incident Hypertension: A Cohort Study.

Primary aldosteronism is recognized as a severe form of renin-independent aldosteronism that results in excessive mineralocorticoid receptor (MR) activation. To investigate whether a spectrum of subclinical renin-independent aldosteronism that increases risk for hypertension exists among normotensive persons. Cohort study. National community-based study. 850 untreated normotensive participants in MESA (Multi-Ethnic Study of Atherosclerosis) with measurements of serum aldosterone and plasma renin activity (PRA). Longitudinal analyses investigated whether aldosterone concentrations, in the context of physiologic PRA phenotypes (suppressed, ≤0.50 µg/L per hour; indeterminate, 0.51 to 0.99 µg/L per hour; unsuppressed, ≥1.0 µg/L per hour), were associated with incident hypertension (defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or initiation of antihypertensive medications). Cross-sectional analyses investigated associations between aldosterone and MR activity, assessed via serum potassium and urinary fractional excretion of potassium. A suppressed renin phenotype was associated with a higher rate of incident hypertension than other PRA phenotypes (incidence rates per 1000 person-years of follow-up: suppressed renin phenotype, 85.4 events [95% CI, 73.4 to 99.3 events]; indeterminate renin phenotype, 53.3 events [CI, 42.8 to 66.4 events]; unsuppressed renin phenotype, 54.5 events [CI, 41.8 to 71.0 events]). With renin suppression, higher aldosterone concentrations were independently associated with an increased risk for incident hypertension, whereas no association between aldosterone and hypertension was seen when renin was not suppressed. Higher aldosterone concentrations were associated with lower serum potassium and higher urinary excretion of potassium, but only when renin was suppressed. Sodium and potassium were measured several years before renin and aldosterone. Suppression of renin and higher aldosterone concentrations in the context of this renin suppression are associated with an increased risk for hypertension and possibly also with increased MR activity. These findings suggest a clinically relevant spectrum of subclinical primary aldosteronism (renin-independent aldosteronism) in normotension. National Institutes of Health.

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Electrolytes imbalance caused by amikacin in patients receiving multi drug resistance- tuberculosis treatment at Hazara region Kpk, Pakistan.

Multi drug resistance-tuberculosis (MDR-TB) is considered amongst one of the fatal medical and public health issue. Greater frequency of adverse reactions has been observed using 2nd line antituberculosis drugs, which rises the rate of morbidity. Hypokalemia and hyponatremia are common in patients receiving MDR-TB treatment. This study was aimed to assess the effect of amikacin as multidrug resistance tuberculosis treatment on serum sodium and potassium level. A total 179 subjects (82 males and 97 females) were screened within the period of one year for their serum electrolyte levels before and during the treatment. Their body weight and sociodemographic characteristics were also taken into considerations. Data were expressed in the form of mean ± standard error using One-way analysis of variance (ANOVA), followed by Dunnett's test. All the statistical analyses were performed using GraphPad Prism v. 6. The results showed that amikacin caused a significant (p< 0.05) hypokalemia when used in combination with other drugs having no known effect on serum potassium level which proved to be the side effect of amikacin. The average serum potassium level in both intensive and continuation phase was significantly lower (p< 0.05) than the baseline (3.73 mmol/L), however, in the continuation phase the potassium level (3.58 mmol/L) was slightly higher than that of intensive phase (3.54 mmol/L). The average serum sodium level in both phases; intensive and continuation, remained in steady state (137.25 mmol/L and 137.87 mmol/L respectively) throughout the study period as compared to the base line (135.5 mmol/L). The amikacin drug lowered serum potassium level but had no effect on sodium level. It is concluded that the serum electrolytes should be monitored during the course of treatment and corrected accordingly.

Abstract P439: Fibromuscular Dysplasia Of The Iliac And Renal Arteries: A Rare Case Report And Literature Review

Background: Iliac arterial fibromuscular dysplasia (FMD) is an orphan type of FMD, a non-atherosclerotic non-inflammatory arteriopathy predominantly among women aging from 20 to 60. The demographic, clinical features and therapeutic algorithm of iliac arterial FMD have not been precisely described. Patient Concerns: A 31-year-old Chinese male was referred for 3-month-ago onset hypertension, low serum potassium, and small-sized right kidney with normal renal artery under ultrasound examination. Spirolactone was poorly effective in this patient. Diagnosis: Contrast-enhanced computed tomographic angiography (CTA) and three-dimensional reconstruction of the whole aorta discovered an aneurysm from right common iliac artery (CIA) to the internal iliac artery, consistent with left CIA dissection and a remarkable right renal artery aneurysm before a stenosis, which was then confirmed through digital subtraction angiography. Intervention: Percutaneous transluminal angioplasty (PTA) of right renal artery was operated and a stent was deployed in left CIA. Outcome: This patient was normotensive, asymptomatic and free from recurrence without any antihypertensive agents at an 8-month follow-up. Conclusions: A total of 111 iliac arterial FMD cases (female, 84.7%; median age, 52±12.8 years) have been reported. Asymptomatic condition (49.5%) and claudication (40.5%) consist the majority of clinical presentations. Bruit (64.9%) and pulse deficits (39.4%) are the most popular signs. External iliac artery involved is approximate threefold of common and internal iliac arteries, usually accompanied with renal artery (71.2%, presenting hypertension) or carotid artery involvement (50.5%). A system screening among iliac or renal arterial FMD patients is therefore suggested with CTA from neck to pelvis and MRA in head. Dissection accounts for 15.3% cases, usually presenting ischemia symptoms with an inclination to young males. Conservative medication is efficient among 61.3% patients and PTA was operated in 15 patients with satisfactory outcomes in 86.7%. Stenting is an optimal recommendation of iliac artery FMD with progressive dissection. PTA is the first choice of short-duration renovascular hypertension due to FMD especially in young patient.

In-Hospital Mortality in Hospitalized Patients with Congestive Heart Failure in Relation to Serum Potassium Levels in the US: National Inpatient Sample Analysis

Introduction: Alteration in serum potassium levels has been found to affect the mortality risk among patients with congestive heart failure (CHF). Methods: We utilized the National Inpatient Sample database. We selected patients (≥18 years and non-pregnant) admitted with CHF in US hospitals from 2009 to 2011. We substituted code for CHF (428) based on International Classification of disease-9 (ICD-9) with Clinical Classification Software-Diagnoses of 108. We added ICD-9 codes 404.03, 404.11, 404.13, 404.91, 404.93 and 402.11 to include all etiologies of heart failure. The ICD-9 codes for hypokalemia is 276.8 and hyperkalemia is 267.7. STATA version 13.0 (College Station, TX) was used for analysis. Multivariate analysis of mortality among CHF patients was done while controlling for age, sex, race, smoking, obesity, dyslipidemia, diabetes, hypertension and Charlson comorbidity index. Results: Our total study population was based on 2,660,609 discharge records. Hypokalemia was found to be associated with increased mortality risk (OR: 2.025) and hyperkalemia was associated with decreased mortality risk (OR: 0.935) in comparison to normokalemia (Table 1). Similar association was seen with etiologies (Acute coronary syndrome, Ischemic heart disease, valvular heart disease, hypertensive heart disease, cardiomyopathy, atrial fibrillation) and subtypes (systolic, diastolic and combined) of CHF with serum potassium levels (Table 2, Table 3). Discussion: Our study is the first to establish relationship of risk of mortality between subcategories of serum potassium levels with different etiologies and subtypes of CHF. Thus, regardless of the etiology or subtype of heart failure, hypokalemia increases mortality and hyperkalemia is associated with mortality benefit. Hypokalemia results from increased activation of Renin Angiotensin Aldosterone System. Low serum potassium increases the transmembrane resting potential of myocardial cells resulting in hyperpolarization and increased excitability. This increases risk of cardiac arrhythmias. Ventricular arrhythmias are the most common cause of death in these patients. Thus, normokalemia and hyperkalemia in patients admitted with CHF has a beneficial effect. This can be achieved by use of potassium supplements, ACE inhibitors and K-sparing diuretics. Whether correction of hypokalemia during hospital stay is beneficial or not is a matter of further studies.Table 1Multivariate analysis with logistic regression of mortality among CHF patients with hyperkalemia and hypokalemia with reference to normokalemia. (Controlled for age, sex, race, smoking, obesity, dyslipidemia, diabetes, hypertension, Charlson comorbidity index)Table 2Classification of mortality in relation to serum potassium levels in CHF and its subcategories. (CHF: congestive heart failure, SHF: systolic heart failure, DHF: diastolic heart failure, SDHF: systolic and diastolic heart failure)Table 2Classification of mortality in relation to serum potassium levels in CHF and its subcategories. (CHF: congestive heart failure, SHF: systolic heart failure, DHF: diastolic heart failure, SDHF: systolic and diastolic heart failure)Table 3Multivariate analysis with logistic regression of mortality among different etiologies of heart failure with hyperkalemia and hypokalemia with reference to normokalemia. (ACS: acute coronary syndrome, IHD: Ischemic heart disease, VHD: valvular heart disease, HHD: hypertensive heart disease, CM: cardiomyopathy, AF: atrial fibrillation)Table 3Multivariate analysis with logistic regression of mortality among different etiologies of heart failure with hyperkalemia and hypokalemia with reference to normokalemia. (ACS: acute coronary syndrome, IHD: Ischemic heart disease, VHD: valvular heart disease, HHD: hypertensive heart disease, CM: cardiomyopathy, AF: atrial fibrillation)

Intra-dialytic hypertension is associated with high mortality in hemodialysis patients.

BackgroundIntra-dialytic hypertension (IDH) is emerging as an important issue in hemodialysis patients. Its risk factors and clinical outcomes are unclear.MethodsA total of 73 prevalent hemodialysis patients were enrolled. They included 14 (19.2%) patients with baseline IDH and 59 patients without IDH. Their clinical parameters, laboratory parameters, and mortality were investigated over 78 months.ResultsThe risks factor of IDH included low serum potassium levels, low ultrafiltration, and low arm muscle area. Lower median survival was evident in the IDH group compared to the non-IDH group, but was not significantly different. After adjusting for relevant confounders for age, the IDH group displayed 2.846 times higher mortality rate than the non-IDH Group (adjusted hazard ratio: 2.846; 95% confidence interval: 1.081–7.490; P = 0.034).ConclusionIDH is associated with high mortality in hemodialysis patients. Clinicians should be aware of the risk factors. Future research studies are needed to explore the mechanisms involved in the association between IDH and mortality.

Voriconazole-induced QT prolongation among hemato-oncologic patients: clinical characteristics and risk factors.

The purpose of this study is to determine the rate of QTcP and associated risk factors in patients treated with voriconazole. We conducted a retrospective chart review of all patients treated with voriconazole in a large tertiary center between 2009 and 2015, using paired comparison of QTc intervals on and off voriconazole treatment, adjusted for comorbidities, electrolyte abnormalities, and concurrent medications. Fifty-four patients were included, of whom 53 were diagnosed with oncologic/hemato-oncologic disease. Mean QTc during voriconazole therapy (448.0±52.9msec) was significantly longer compared to QTc off voriconazole (421.8±42.2msec; p=0.002). QTcP ≥30msec and ≥60msec was demonstrated in 43% (23 patients) and 28% (15 patients), respectively. Multivariate analysis showed that QTcP was significantly associated with baseline QTc≥450msec (upper QTc quartile) (p<0.01) and low serum potassium levels (p<0.01). Contrarily, no significant association was found between mean voriconazole daily and cumulative dose and QTcP. Our findings indicate that hemato-oncologic patients treated with voriconazole are at increased risk for QTcP, especially in the presence of baseline QTc≥450msec and low serum potassium levels.

A Comparison between Intermittent Peritoneal Dialysis and Automatic Peritoneal Dialysis on Urgent Peritoneal Dialysis

Background: Urgent-start dialysis is a major problem for incident dialysis population. Urgent start on hemodialysis is associated with an increased risk of infectious or mechanical complications, and its mortality is equal to or higher than that of urgent start on peritoneal dialysis (PD). However, compared to patients starting PD in a planned setting, those on urgent-started PD have an increased risk of mechanical complications and lower technique survival. Methods: In this study, 101 adult incident dialysis patients (≥18 years old) who underwent Tenckhoff catheter implantation were enrolled. All of the patients were grouped according to the urgent PD mode: the intermittent PD (IPD) or automatic PD (APD) group, and patients were followed for 1 year. The paired or independent t test was used to analyze the change of laboratory variables. Pearson chi-square test was applied to compare the short outcome between the 2 groups. Results: When PD was treated for 7 days and 1 month, the APD group has the lower serum potassium and phosphorus levels than the IPD group. The incidence of catheter dysfunction was significantly lower in the APD group. The morbidity of infection associated with PD in the first year was lower in the APD group despite no significant difference existing. The technique survival and patient survival rate have no evident difference between the 2 groups. Conclusion: Compared to IPD, urgent start on APD could reduce the risk of mechanical complication, which could be considered a gentle, safe, and feasible alternative to urgent start on IPD.