Management Of Hyperkalemia In Patients Research Articles

Detecting Potassium Rebound in a Prevalent Hemodialysis Population

Abstract Background One of the fundamental goals of hemo dialysis (HD) prescription is to maintain serum potassium (K) levels within a narrow normal range during both the intradialytic and interdialytic intervals. Considering the extraordinarily high rate of cardiovascular mortality in HD population, clinicians are obligated to explore whether factors related to dialytic K removal can be modified to improve clinical outcomes. Aim of the Work The aim of the study was to detect potassium rebound after HD sessions in patients on maintenance HD Patients and Methods This was a prospective cohort study that was held in Hemodialysis units in Nephrology department - Ain Shams University Hospital and Sheikh Zayed Specialized Hospital for 3 months. The study included 60 male and female ESRD patients on maintenance HD, in which prevalent HD patients on maintenance HD 3 times/week. Results We found that that there were significant positive correlations between K levels before the sessions, immediately after the sessions and after 6 hours of the sessions. While there was significant negative correlations between K levels immediately after HD sessions and Hb levels and urea levels. There was also a highly significant negative correlation between K levels before the sessions and time of session (in hours). While there were highly significant negative correlations between K levels immediately after the sessions, after 6 hours of sessions and time of session (in hours). There was non-significant negative correlations between all K levels (before HD sessions, immediately after the sessions and 6 hours after the sessions) and frequency of sessions (per week), with p value 0.388, 0.299 and 0.086 respectively. Also, it showed non-significant negative correlations between all K levels (before HD sessions, immediately after the sessions and 6 hours after the sessions) and frequency of sessions (per month), with p value 0.086, 0.089 and 0.083 respectively. Our results showed a significant positive relation between the number of K raising antihypertensive drugs used by the patients and K levels before HD sessions. Conclusion Patients with end-stage renal disease (ESRD) on maintenance dialysis have a high risk of developing hyperkalemia, generally defined as serum potassium (K+) concentrations of > 5.0 mmol/l, particularly those undergoing maintenance hemodialysis. Currently, the key approaches to the management of hyperkalemia in patients with ESRD are dialysis, dietary K+ restriction, and avoidance of medications that increase hyperkalemia risk. Management of these modifiable factors plays a crucial role in preventing hyperkalemia in patients undergoing dialysis. The availability of new oral K+-binders may potentially reduce the need for a highly restricted diet in patients with ESRD, and reduce the risk of potentially life-threatening hyperkalemia and the cardiovascular complications associated with rapid shifts in serum K+ concentrations that can occur with HD.

A cost-effectiveness analysis of patiromer for the treatment of hyperkalemia in chronic kidney disease patients with and without heart failure in Spain

Aims Renin-angiotensin-aldosterone system inhibitors (RAASi) therapy is commonly used to reduce the risk of death and to slow down disease progression in patients with chronic kidney disease (CKD), heart failure (HF) and hypertension. However, the cardio-renal benefits of RAASi therapy are also associated with an increased risk of hyperkalemia (HK), which may lead to dose reduction or discontinuation of therapy. Patiromer has demonstrated to reduce the risk of HK, which enables to maintain optimal doses of RAASi therapy. This study aimed to assess the cost-effectiveness of patiromer for the management of HK in CKD patients with and without HF in Spain. Methods A Markov model was developed to evaluate the costs and benefits of patiromer for the management of HK in patients with CKD stages 3–4 with and without HF treated with RAASi over a lifetime horizon. The main outcomes included total direct costs (€2021), quality-adjusted life-years (QALYs), life-years gained (LYG) and incremental cost-effectiveness ratio (ICER). Deterministic one-way and probabilistic sensitivity analyses were performed to assess the robustness of the results. Results Patiromer was more effective compared to no patiromer (5.76 vs 5.57 QALYs; 7.73 vs 7.50 LYG), and resulted in an incremental cost of €3,574, yielding an ICER of €19,092/QALY gained and of €15,236/LYG. Sensitivity analyses suggested that the results were robust to changes in most input parameters. Conclusions Patiromer is a cost-effective intervention in maintaining normokalemia and enabling optimal RAASi therapy in patients with CKD stages 3–4 with and without HF in Spain.

Prevention and management of hyperkalemia in patients treated with renin-angiotensin-aldosterone system inhibitors.

KEY POINTS Hyperkalemia, defined as a serum potassium level of 5.0 mmol/L or greater, can lead to severe electrophysiological disturbances, including cardiac arrythmias, that increase morbidity and risk of death.[1][1] It is common in patients with conditions that impair potassium excretion by the

Abstract 8895: Design of Phase IV, Double-Blind, Placebo-Controlled, Randomized-Withdrawal Trial Evaluating Sodium Zirconium Cyclosilicate for the Management of Hyperkalemia in Patients With Symptomatic Heart Failure With Reduced Ejection Fraction (REALIZE-K Trial)

Introduction: International guideline-recommended therapies for heart failure (HF) with reduced ejection fraction (HFrEF), including mineralocorticoid receptor antagonists (MRA), are underutilized, in part due to concerns of hyperkalemia (HK) especially among those at high risk. The REALIZE-K trial aims to evaluate the efficacy and safety of sodium zirconium cyclosilicate (SZC), a selective potassium (K + ) binder, to enable MRA use in patients with HFrEF at high risk for HK. Methods: REALIZE-K is a prospective, double-blind, placebo (PBO)-controlled randomized withdrawal trial enrolling symptomatic HFrEF (NYHA class II-IV and LVEF ≤40%) patients on guideline-directed medical therapy (but not full-dose MRA) with either HK (serum K + 5.1-5.9 mmol/L) or high risk for HK during MRA titration. All eligible patients enter a 1-month open-label run-in phase, during which patients with hyperkalemia receive SZC to correct HK; all patients undergo protocol-mandated titration of spironolactone (SPL) as tolerated to a target of 50 mg QD with supplemental SZC to maintain normokalemia (serum K + 3.5-5.0 mmol/L; Figure ). All patients tolerating ≥25 mg QD of SPL will be randomly assigned to continued SPL+SZC or SPL+PBO during an 8-month double-blind withdrawal phase. Serial K + monitoring will guide protocol-directed dosing of SZC/PBO and SPL during the randomized period. The primary study endpoint is the occurrence at 8 months of normokalemia on SPL ≥25 mg QD without the need for rescue therapy for severe HK in the SZC vs PBO group. Secondary endpoints include individual components of the primary endpoint and health status assessed by Kansas City Cardiomyopathy Questionnaire Total Symptom Score. Exploratory endpoints include time to first occurrence of the composite of CV death or worsening HF, and change in mean urine albumin-creatinine ratio. Conclusions: REALIZE-K will evaluate the efficacy and safety of SZC, enabling MRA therapy for HFrEF patients at high risk for HK.

Consensus on the management of hyperkalemia in patients with heart failure: Recommendations from the SEC-SEMI

Use of renin-angiotensin-aldosterone system inhibitors (RAASi) in patients with heart failure (HF) and reduced ejection fraction is associated with functional improvement, an increase in perceived quality of life, a reduction in the probability of cardiovascular death, and a decrease in the number of hospitalizations. Some of these drugs are also efficacious in patients with chronic kidney disease and albuminuria as well as in patients with resistant hypertension. Despite their numerous benefits, RAASi are associated with an increase in incidence of hyperkalemia, especially in patients with concomitant chronic kidney disease. Hyperkalemia is a common electrolyte disorder that is defined as an elevation in plasma concentrations of potassium above 5 mEq/L. It has been related to rehospitalizations, malignant arrhythmias, and an increase in mortality. On the other hand, optimized treatment with RAASi requires progressive dose increases which can in turn entail a greater probability of hyperkalemia. For all of these reasons, it is necessary to establish management and treatment guidelines for these patients. This consensus document arises from this objective. Its recommendations have been developed by a group of ten experts and reviewed by a panel of another ten specialists in the treatment of patients with HF (ten cardiologists and ten internists in total). This document has been endorsed by the Spanish Society of Cardiology (SEC, for its initials in Spanish) and the Spanish Society of Internal Medicine (SEMI, for its initials in Spanish).

Management of hyperkalemia in patients with kidney disease: a position paper endorsed by the Italian Society of Nephrology

Hyperkalemia (HK) is the most common electrolyte disturbance observed in patients with kidney disease, particularly in those in whom diabetes and heart failure are present or are on treatment with renin–angiotensin–aldosterone system inhibitors (RAASIs). HK is recognised as a major risk of potentially life threatening cardiac arrhythmic complications. When an acute reduction of renal function manifests, both in patients with chronic kidney disease (CKD) and in those with previously normal renal function, HK is the main indication for the execution of urgent medical treatment and the recourse to extracorporeal replacement therapies. In patients with end-stage renal disease, the presence of HK not responsive to medical therapy is an indication at the beginning of chronic renal replacement therapy. HK can also be associated indirectly with the progression of CKD, because the finding of high potassium values leads to withdrawal of treatment with RAASIs, which constitute the first choice nephro-protective treatment. It is therefore essential to identify patients at risk of developing HK, and to implement therapeutic interventions aimed at preventing and treating this dangerous complication of kidney disease. Current strategies aimed at the prevention and treatment of HK are still unsatisfactory, as evidenced by the relatively high prevalence of HK also in patients under stable nephrology care, and even in the ideal setting of randomized clinical trials where optimal treatment and monitoring are mandatory. This position paper will review the main therapeutic interventions to be implemented for the prevention, detection and treatment of HK in patients with CKD on conservative care, in those on dialysis, in patients in whom renal disease is associated with diabetes, heart failure, resistant hypertension and who are on treatment with RAASIs, and finally in those presenting with severe acute HK.

Evaluation of the tolerability and efficacy of sodium polystyrene sulfonate for long-term management of hyperkalemia in patients with chronic kidney disease

Sodium polystyrene sulfonate (SPS) is a cation-exchanging resin that has been widely used for several decades as first-line therapy of mild chronic hyperkalemia in patients with chronic kidney disease (CKD). However, evidence to prove the long-term tolerability and efficacy of SPS for the treatment of this condition is still missing. In this retrospective, observational study, we enrolled 26 outpatients with stages 3-4 CKD who received oral therapy with low-dose SPS for mild chronic hyperkalemia in the Outpatient Nephrology clinic of our Department during 2010-2016. We obtained medical records on side effects potentially attributable to SPS use, and we analyzed the changes in serum electrolytes before and after the initiation of SPS therapy. Serum potassium levels fell from 5.9±0.4 to 4.8±0.5mmol/l (P<0.001) over a median follow-up of 15.4months (range 3-27months). SPS use was associated with a slight, but significant elevation in serum sodium levels (139.5±2.9 vs 141.2±2.4, P=0.006), whereas serum calcium and phosphate remained unchanged before and after the initiation of SPS. We recorded ten episodes of recurrent serum potassium elevation ≥5.5mmol/l, none of which required hospitalization or acute dialysis. No episode of colonic necrosis or any other serious drug-related adverse event was observed. SPS therapy was well-tolerated, since only 1 out of 26 patients discontinued SPS at 3months due to gastrointestinal intolerance. This study suggests that low-dose SPS is well-tolerated and can effectively normalize elevated serum potassium over several weeks in CKD outpatients with mild chronic hyperkalemia.

Treatment of Hyperkalemia in Heart Failure.

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. 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.

Long‐Term Enteral Nutrition: Flexible Management of Hyperkalemia

Management of hyperkalemia in patients receiving enteral tube feeding is often challenging, particularly in the presence of chronic organ dysfunction. We present a case report describing successful reduction of serum potassium concentration with a tube feeding regimen involving nocturnal infusion of a mixture of Deliver 2.0 (Mead Johnson Nutritionals, Evansville, IN) and sodium polystyrene sulfonate (SPS) powder. The patient described in this report has maintained acceptable serum potassium concentrations without significant alteration of other serum electrolyte parameters. Subsequent in vitro evaluation of Nutren 1.0/SPS (Clintec Nutrition Co, Deerfield, IL) and Deliver 2.0/SPS admixtures revealed that SPS in a concentration of 15 g/L produces a nearly 50% reduction in the potassium content of these enteral feeding formulations. A 30‐g/L SPS concentration reduces potassium content by almost two thirds. This decrease in potassium content is accompanied by a reduction in magnesium content and an increase in sodium content.