Potassium Lowering Research Articles

Evaluation of Monotherapy Sodium Zirconium Cyclosilicate Versus Sodium Polystyrene Sulfonate for Acute Hyperkalemia: A Cohort Study

Comparison of monotherapy sodium zirconium cyclosilicate (SZC) versus sodium polystyrene sulfonate (SPS) is lacking. We aimed to evaluate the effectiveness of SZC versus SPS for acute potassium lowering. This retrospective cohort study included hospitalized adult patients with acute hyperkalemia treated with SZC or SPS monotherapy. The primary outcome was time to normalization of serum potassium. Secondary outcomes included necessity of additional treatment, achievement of normokalemia at 1, 2, 4, 8, and 24 hours, and change in serum potassium from baseline to 1, 2, 4, 8, and 24 hours. Fifty-one patients received SZC and 50 received SPS. Mean baseline potassium was 5.4 mmol/L for both groups. Median time to normokalemia was 14 (IQR 8-20) hours in the SZC group versus 17 (IQR 10-21) hours in the SPS group ( P = .26). Normokalemia was achieved at 24 hours in 80% versus 77% in each group, respectively ( P = .56). Six patients per group required additional treatment ( P = .97). Mean serum potassium at all time points was numerically lower with SZC, but statistical significance was only observed at hour 8 (4.6 vs 5.0 mmol/L, P = .005), which was associated with a −0.77 versus −0.51 mmol/L decrease in serum potassium from baseline in each group, respectively ( P = .026). SZC monotherapy is at least as effective as SPS in treating mild hyperkalemia and may reduce serum potassium more quickly and to a greater degree than SPS. Future research in more severe hyperkalemia and with monitoring of potassium at regular intervals is needed to better understand the role and potential advantages of SZC over SPS.

Machine learning models for early prediction of potassium lowering effectiveness and adverse events in patients with hyperkalemia

The aim of this study was to develop a model for early prediction of adverse events and treatment effectiveness in patients with hyperkalemia. We collected clinical data from patients with hyperkalemia in the First Hospital of Zhejiang University School of Medicine between 2015 and 2021. The least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression were used to analyze the predictors on the full dataset. We randomly divided the data into a training group and a validation group, and used LASSO to filter variables in the training set. Six machine learning methods were used to develop the models. The best model was selected based on the area under the curve (AUC). Shapley additive exPlanations (SHAP) values were used to explain the best model. A total of 1074 patients with hyperkalemia were finally enrolled. Diastolic blood pressure (DBP), breathing, oxygen saturation (SPO2), Glasgow coma score (GCS), liver disease, oliguria, blood sodium, international standardized ratio (ISR), and initial blood potassium were the predictors of the occurrence of adverse events; peripheral edema, estimated glomerular filtration rate (eGFR), blood sodium, actual base residual, and initial blood potassium were the predictors of therapeutic effect. Extreme gradient boosting (XGBoost) model achieved the best performance (adverse events: AUC = 0.87; therapeutic effect: AUC = 0.75). A model based on clinical characteristics was developed and validated with good performance.

Evaluating Risk Factors for Developing Hypoglycemia During Treatment of Hyperkalemia With Intravenous Regular Insulin

Background: The conventional dose of 10 units of intravenous (IV) regular insulin to treat hyperkalemia has been associated with hypoglycemia. There have been retrospective studies evaluating weight-based dose vs conventional dose of IV regular insulin but the comparative efficacy and safety is not well established. Objective: Evaluate the difference in weight-based dosing of IV regular insulin between patients who experienced hypoglycemia vs. patients who did not experience hypoglycemia after the administration of IV regular insulin. Methods: This was a retrospective, electronic chart review at a single academic medical center which included patients ≥18 years of age with an emergency department or inpatient encounter who were administered IV regular insulin within 6 hours of a pre-treatment potassium of ≥5 mmol/L. Results: There was no significant difference in the weight-based insulin dose between patients who experienced a hypoglycemic event and patients who did not experience a hypoglycemic event (.14 vs .22 units/kg; P = .44). The potassium-lowering effect was similar between the two groups (1.02 vs .96 mmol/L; P = .56). A regression analysis revealed that female sex, low baseline blood glucose (glucose <140 mg/dL), and those who received a repeat dose of IV regular insulin were independent risk factors for development of hypoglycemia. Conclusion: This study found no difference in hypoglycemic events and potassium lowering based on IV weight-based regular insulin dosing, however other risk factors may predict hypoglycemia.

Comparison of Sodium Zirconium Cyclosilicate to Sodium Polystyrene Sulfonate in the Inpatient Management of Acute Hyperkalemia

Background: Oral potassium binders have a role in the management of acute hyperkalemia among hospitalized patients. However, with therapeutic additions to this class, there is insufficient evidence between potassium binders to support a standard of care recommendation for use in this acute setting. Objective: The purpose of this study was to compare the acute potassium lowering effects of sodium zirconium cyclosilicate (SZC) and sodium polystyrene sulfonate (SPS). Methods: A retrospective review of admitted patients who received SZC or SPS was conducted after exemption from the Institutional Review Board. Patients with baseline potassium values less than 5.1 mmol/L or factors contributing to potentially false report of serum potassium were excluded. The primary outcome was the average change in potassium from baseline to 24 hours following potassium binder administration. Secondary outcomes compared changes to potassium from baseline to various time periods after administration, presence of electrolyte changes, and documentation of serious adverse events. Results: A total of 246 patients were included, with 128 receiving SZC and 118 receiving SPS. Mean change in serum potassium (mmol/L) at 24 hours was not significant between binders (−.78 vs −.91; P = .22). Secondary efficacy and safety outcomes were also similar between groups. A total of 5 serious adverse events were reported, occurring only in the SPS group. Conclusion: SZC and SPS have comparable effects in acute potassium reduction, with serious gastrointestinal adverse events documented only in SPS patients. Health systems may consider this data in determining medication formularies or during order set development.

Treatment and factors associated with prognosis of hyperkalemia in the emergency department

To survey treatment and prognosis of hyperkalemia patients in the emergency department and to analyze factors associated with all-cause in-hospital mortality. We implemented electronic hospital information system, extracted demographic characteristics, underlying diseases, laboratory findings, potassium lowering therapy and prognosis of hyperkalemia patients [age ≥ 18 years, serum potassium (K+) concentration ≥ 5.5 mmol/L] in the emergency department of Peking Union hospital in Beijing between June 1st 2019 to May 31st 2020. The enrolled subjects were divided into the non-survival group and the survival group according to their prognosis. Univariate analysis and Cox regression model were adopted to analyze factors affecting all-cause in-hospital mortality of hyperkalemia patients. A total of 579 patients [median age 64 (22) years; 310 men (53.5%) and 269 women (46.5%)] with hyperkalemia were enrolled, among which, 317 (54.7%), 143 (24.7%) and 119 (20.6%) were mild, moderate, and severe hyperkalemia, respectively. 499 (86.20%) patients received potassium-lowering therapy, forty-four treatment regimens were administered. Insulin and glucose (I+G, 61.3%), diuretics (Diu, 57.2%), sodium bicarbonate (SB, 41.9%) and calcium gluconate/chloride (CA, 44.4%) were commonly used for the treatment of hyperkalemiain the emergency department. The combination of insulin and glucose, calcium gluconate/chloride, diuretics and sodium bicarbonate (I+G+CA+Diu+SB) was the most favored combined treatment regimen of hyperkalemia in the emergency department. The higher serum potassium concentration, the higher proportion of administrating combined treatment regimen and/or hemodialysis (HD) (the proportion of administrating combined treatment regimen in mild, moderate, and severe hyperkalemia patients were 58.4%, 82.5% and 94.8%; the proportion of administrating HD in mild, moderate, and severe hyperkalemia patients were 9.7%, 13.3% and 16.0%, respectively). The proportion of achievement of normokalaemia elevated as the kinds of potassium lowering treatment included in the combined treatment regimen increased. The proportion of achievement of normokalaemia was 100% in the combined treatment regimen including 6 kinds of potassium lowering therapy. Among various potassium lowering treatments, HD contributed to the highest rate of achievement of normokalaemia (93.8%). 111 of 579 (19.20%) hyperkalemia patients died in hospital. Cox regression model revealed that complicated with cardiac dysfunction predicted higher mortality [hazard ratio (HR) = 1.757, 95% confidence interval (95%CI) was 1.155-2.672, P = 0.009]. Achievement of normokalaemia and administration of diuretics attributed to lower mortality (HR = 0.248, 95%CI was 0.155-0.398, P = 0.000; HR = 0.335, 95%CI was 0.211-0.531, P = 0.000, respectively). Treatment of hyperkalemia in the emergency department were various. Complicated with cardiac dysfunction were associated with higher mortality. Achieving normokalaemia was associated with decreased mortality.

743: EVALUATION OF REGULAR INSULIN 10 UNITS VERSUS 5 UNITS FOR THE TREATMENT OF HYPERKALEMIA

Introduction: Hyperkalemia is a common problem faced in the intensive care unit (ICU) and emergency department. Traditionally, regular insulin 10 units IV has been used in combination with dextrose to shift potassium intracellularly to prevent cardiac abnormalities. Available literature supports the use of different insulin regimens based on a patient’s weight, renal function, and diabetes status. Currently, our institution has a hyperkalemia order set that includes varying regular insulin doses, dextrose, and scheduled lab draws for potassium and glucose. The purpose of this study was to compare the efficacy and safety of regular insulin 5 units and 10 units for the treatment of hyperkalemia. Methods: This was a single-center, retrospective, cohort study of ICU and emergency department patients who received regular insulin 10 units or 5 units IV push for hyperkalemia treatment. The primary outcome was the decrease in potassium in mmol/L after insulin administration. Secondary outcomes included the incidence of hypoglycemia, rate of order set utilization, and incidence of inappropriate omission of dextrose. Results: Forty-three patients were included in the study, with 21 receiving 10 units and 22 receiving 5 units. Patients who received 5 units of insulin had worse renal function (serum creatinine 5.6 mg/dL vs 3.5 mg/dL) and lower glucose values prior to insulin (glucose 133.7 mg/dL vs 184.8 mg/dL) compared to those who received 10 units. Both groups had similar potassium levels upon presentation, 6.19 mmol/L in insulin 5 unit group compared to 6.20 mmol/L in the 10 unit group. Average decrease in potassium levels was 1.1 mmol/L with 5 units and 1.0 mmol/L with 10 units. Two patients in each group experienced hypoglycemia after insulin administration. Both groups had similar rates of dextrose orders omitted and need for additional units of insulin within 24 hours. Conclusions: The potassium lowering effects were not different between groups based on the units of insulin received. Regular insulin 10 units did not result in a higher incidence of hypoglycemia or a need for less additional insulin orders. This study demonstrated that the use of regular insulin 5 units had similar outcomes compared to the use of 10 units for the treatment of hyperkalemia.

Sodium bicarbonate administration and subsequent potassium concentration in hyperkalemia treatment.

Hyperkalemia is an electrolyte disorder commonly encountered in the emergency department that can result in significant morbidity and mortality. While sodium bicarbonate is often used for acute lowering of serum potassium, its efficacy is not well established. The purpose of this study was to evaluate and quantify the amount of potassium reduction in emergency department patients who received intravenous sodium bicarbonate as part of treatment for hyperkalemia compared with those who did not. A retrospective electronic chart review was conducted on adult patients who presented to the emergency department with initial potassium concentration greater than or equal to 5.4 mMol/L and received intravenous insulin as part of hyperkalemia treatment. Patients who received intravenous sodium bicarbonate in addition to intravenous insulin were included in the sodium bicarbonate group. The control group included patients who did not receive intravenous sodium bicarbonate. The primary objective of this study was to compare the absolute reduction in serum potassium between initial and second concentrations in patients from the sodium bicarbonate group and those in the control group. A total of 106 patients were included in this study with 38 patients in the sodium bicarbonate group and 68 patients in the control group. Median initial potassium concentration was 6.6 mMol/L in the sodium bicarbonate group and 6.1 mMol/L in the control group (P = 0.009). Absolute reduction of potassium at first repeat was 1 and 0.9 mMol/L in sodium bicarbonate group and control group respectively (P = 0.976). The addition of sodium bicarbonate therapy to intravenous insulin in the treatment of hyperkalemia did not offer statistically significant added efficacy in potassium lowering. Larger studies are needed to further validate the result findings.

Observational study of the relative efficacy of insulin-glucose treatment for hyperkalaemia in patients with liver cirrhosis

ObjectivesTo determine if liver cirrhosis is associated with reduced efficacy of insulin-glucose treatment in moderate to severe hyperkalaemia.DesignRetrospective, cohort study.SettingTwo secondary and one tertiary care hospital at a large metropolitan...

Comparing the effect of insulin infusion alone and in combination of insulin infusion with salbutamol nebulization in treatment of hyperkalemia in diabetic and non-diabetic patients

Objective: To evaluate the clinical efficacy and comparison of potassium lowering effect of insulin infusion alone and insulin infusion with salbutamol nebulization. Methods: This interventional study was conducted in a tertiary care hospital, for a period of one year. A total of 190 patients with hyperkalemia were divided into two groups. Group-A (diabetic [D] and non-diabetic [ND] patients) received salbutamol 20 mg three times daily (TDS) (nebulizer 5mg/2.5mL) administered over a period of 15 minutes with 10 units of regular insulin (diluted with 25% dextrose in non-diabetic only) over 30 minute TDS via infusion. Group-B (diabetic and non-diabetic patients) received 10 units of regular insulin (diluted with 25% dextrose in non-diabetic patients only) administered over 30 minute TDS via infusion. Potassium and glucose level was measured in patient blood sample after 0, 6, 12 and 24 hrs of treatment. Results: The potassium level was decreased by 30.09% (D) and 31.98% (ND) in Group-A, whereas by 31.98% (D) and 20.49% (ND) in Group-B, after 24 hrs. Whereas blood glucose level in diabetic patients of Group-A and Group-B was found to decrease up to 28.85 % and 40.78 % respectively after 6 hours. Both the treatments were found to be effective without any complication i.e. hypoglycaemia and hypokalaemia. Moreover, renal, liver, cardiac and respiratory function test also did not show significant changes after treatments when recorded bihourly Conclusion: From the results, salbutamol nebulizer with insulin is more effective in the treatment of hyperkalemia in diabetic and non-diabetic patients.

Saved by Insulin! Continuous Intravenous Insulin Infusion as an Adjunctive Treatment for Refractory Hyperkalaemia

Intravenous insulin infusion which is used in treatment of hyperglycaemic emergencies can cause hypokalemia. We report a case of how this disadvantage was utilised to save a patient with life threatening hyperkalaemia. A 46-year-old lady with diabetes mellitus and chronic kidney disease (CKD) presented with breathlessness for 3 days. She had been taking excessive durian for 5 days before admission. Her medications included atenolol. On examination, she was severely bradycardic with pulse rate of 35 beats per minute. She had clinical features of fluid overload. Her renal profile showed elevated urea (17.5 mmol/l) potassium (7.8 mmol/l) and creatinine (322 umol/l). Electrocardiograph (ECG) showed junctional bradycardia. Despite counselling, she declined renal replacement therapy. Various potassium lowering therapies were given including regular nebulised salbutamol, calcium polystyrene sulfonate, intravenous furosemide, and regular insulin chase. After 5 rounds of insulin chases, potassium level remained markedly elevated at 8.2 mmol/l. When she finally consented, haemodialysis was performed. 9 hours post haemodialysis, potassium level was 7.6 mmol/l. While waiting for a next session of haemodialysis, fixed rate intravenous insulin infusion (0.1 unit/kg/hour) was given with concurrent dextrose fluids. Blood glucose was monitored hourly. 15 hours later potassium dropped to 5 mmol/l. ECG changes resolved with resolution of hyperkalemia. She did not require further haemodialysis. Patients with CKD should be cautious with durian intake as it is rich in potassium and may lead to severe hyperkalemia. This case highlights a novel use of continuous fixed-rate insulin infusion for treatment of refractory hyperkalemia when all else fails.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S8

Effectiveness of Sodium Zirconium Cyclosilicate in Hemodialysis Patients With Severe Hyperkalemia

Effectiveness of Sodium Zirconium Cyclosilicate in Hemodialysis Patients With Severe Hyperkalemia

The Effect of Patient Factors and Cotreatments on the Magnitude of Potassium Lowering with Insulin-Glucose Treatment in Patients with Hyperkalemia.

The management of hyperkalemia with insulin-glucose/dextrose treatment (IDT) may be influenced by patient factors and cotreatments. We aimed to determine the magnitude of potassium lowering by IDT while considering patient factors and cotreatments. We observed the change in serum potassium in 410 patients with a mean serum potassium of 6.6 mmol/L (SD, 0.6 mmol/L) treated with IDT at three major metropolitan hospitals. Mean potassium lowering was 1.4 mmol/L (SD, 0.8 mmol/L) and 53% achieved normokalemia. Cotreatment with sodium polystyrene sulfonate, salbutamol, or sodium bicarbonate occurred in 64%, 12%, and 10% of patients, respectively. In multiple linear regression analysis, cotreatment with sodium polystyrene sulfonate or sodium bicarbonate was not associated with any significant reduction in serum potassium beyond that achieved by IDT, within the initial 6 h of treatment. We observed an additional lowering of serum potassium with salbutamol of 0.3 mmol/L (95% CI: 0.1 to 0.6 mmol/L; p = 0.009) but the clinical significance was unclear as the proportion of patients achieving normokalemia was not affected by cotreatment within the initial 6 h after IDT. We also found evidence that the potassium-lowering effect of IDT was dependent on the pre-treatment serum potassium. For every 1 mmol/L increase in pre-treatment serum potassium over 6.0 mmol/L, there was an associated 0.7 mmol/L increase in the potassium-lowering effect of IDT, on average, which was independent of any cotreatment. There was no significant impact of acute kidney injury or chronic kidney disease status on the efficacy of IDT.

Short-term effect of sodium zirconium cyclosilicate on potassium lowering in chronic kidney disease patients with hyperkalemia

Objective: To investigate the efficacy of sodium zirconium cyclosilicate on emergency correction of hyperkalemia in chronic kidney disease patients. Methods: Patients with chronic kidney disease who were admitted to the Department of Nephrology of the First Affiliated Hospital of Zhengzhou University from May to June 2020 were selected. Those who had hyperkalemia and took sodium zirconium cyclosilicate powder were finally included. The patient's clinical data and laboratory results were collected. Results: A total of 24 results were included from 21 patients. The age of patients was (48.9±13.5) years old. Fourteen patients were male, and 7 patients were female. After 2 hours of administration, the venous potassium level decreased from (5.85±0.52) mmol/L to (5.15±0.43) mmol/L (P<0.001, n=21), with an average decline of (0.71±0.43) mmol/L. Meanwhile, the arterial potassium level decreased from (5.50±0.40) mmol/L to (4.88±0.33) mmol/L (P<0.001, n=10), with an average decline of (0.62±0.29) mmol/L. Based on the initial venous potassium level, the patients were further divided into three groups. The average potassium decrease in<5.5 mmol/L group (4 patients), 5.5-<6.0 mmol/L group (11 patients) and ≥6.0 mmol/L group (6 patients) was (0.46±0.26) mmol/L, (0.62±0.38) mmol/L and (1.04±0.45) mmol/L, respectively. There was statistically significant difference of potassium reduction among the three groups (P=0.045). Moreover, the extent of potassium reduction was positively correlated with baseline venous potassium level (r=0.603, P=0.004, n=21). The study did not reveal any treatment-related adverse event. Conclusion: Sodium zirconium cyclosilicate powder can rapidly and effectively reduce the serum potassium level in chronic kidney disease patients with hyperkalemia.

P1445ESPECIALLY HYPOKALEMIA IS A RISK FACTOR FOR ALL-CAUSE MORTALITY IN INCIDENT HEMODIALYSIS PATIENTS

Abstract Background and Aims Both hypo- and hyperkalemia can potentially induce fatal cardiac arrhythmias in the general population. However, little is known about the effect of potassium as a modifiable risk factor in hemodialysis (HD) patients. Therefore, we investigated the relation between serum potassium level and all-cause mortality in incident HD patients and whether there is an optimum serum potassium level to pursue. Method All incident HD patients (&amp;gt;18 y) from the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD), a prospective multi-center cohort study, were included. These patients were followed from the start of their first dialysis treatment until death, transplantation or a maximum of 2 years. Serum potassium levels were obtained at fixed 6-month time intervals and divided into six categories: ≤ 4.0, &amp;gt; 4.0 - ≤ 4.5, &amp;gt; 4.5 - ≤ 5.0, &amp;gt; 5.0 - ≤ 5.5 (reference), &amp;gt; 5.5 - ≤ 6.0 and &amp;gt; 6.0 mmol/L. Using a Cox proportional-hazards model with serum potassium category as a time-dependent variable, hazard ratios (HR) for all-cause mortality were calculated, adjusted for baseline age, sex, current smoking, diabetes and residual kidney function. Results In total, 1278 HD patients were included. At baseline, mean (±SD) age was 64 (±14) years, 60% were men, 23% were current smokers, 21% had diabetes and the median (interquartile range) residual kidney function was 3.0 (1.5-4.8) ml/min/1.73m2. Mean (±SD) serum potassium level was 4.8 (±0.8) mmol/L. The prevalence of the six potassium categories was: 10%, 19%, 26%, 22%, 15% and 8%, respectively. A total of 298 (23%) deaths was observed during 2 years of follow-up. After multivariable adjustment the HR (95% CI) for any death according to the six potassium categories were: 2.5 (1.5-4.3), 1.9 (1.2-3.0), 1.6 (1.0-2.5), 1 (reference), 1.3 (0.8-2.2) and 1.7 (1.0-3.0). Conclusion We found a U-shaped relation between serum potassium and all-cause mortality in incident hemodialysis patients. Especially, low serum potassium was a 2.5-fold stronger risk factor for all-cause mortality compared to normal serum potassium. Our results indicate an optimum serum potassium level between 5.0 - 5.5 mmol/L, emphasizing that potassium lowering therapy should be used with caution in hemodialysis patients.

Noninvasive Monitoring of Potassium Fluctuations During the Long Interdialytic Interval

Hemodialysis patients are susceptible to life-threatening arrhythmias whose incidence is markedly higher during the long interdialytic interval due to electrolyte fluctuations. Noninvasive monitoring of electrolyte fluctuations, particularly those of potassium, would enable restoring electrolyte balance before the onset of arrhythmias. This study investigates the feasibility of continuous long-term monitoring of potassium fluctuations using a single-lead electrocardiogram. We evaluate patient-specific T-wave morphology changes in the electrocardiogram using two descriptors: 1) a model-based descriptor, θ <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">8</sub> , developed to account for overall morphology changes, and 2) the currently available descriptor, T <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">SA</sub> , sensitive to potassium levels in single-lead electrocardiograms. Electrocardiograms of 15 hemodialysis patients with pre-existent cardiac diseases were acquired continuously over the long interdialytic interval along with blood samples at predetermined time instants. Results reveal that θ <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">8</sub> and T <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">SA</sub> respond concordantly with potassium levels, and reacts to potassium lowering medication. The overlapping index of the daily distributions of θ <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">8</sub> and T <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">SA</sub> are moderately correlated with changes in potassium levels (r = -0.56 and r = -0.57, respectively). θ <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">8</sub> exhibits circadian variation, peaking amidst morning and decreasing until evening. θ <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">8</sub> appears to be less affected by motion-induced noise, which is preferable for ambulatory monitoring. Although long-term monitoring of potassium fluctuations is feasible even in complicated hemodialysis patients, the presence of concomitant electrolyte (calcium and bicarbonate) imbalances should be accounted for since it can hamper a reliable estimation. Considering that intradialytic T-wave morphologies may differ from the ones manifested between hemodialysis sessions, future studies should also strive to collect blood samples outside of hemodialysis to improve electrolyte estimation methods.

Sodium Zirconium Cyclosilicate: A Review in Hyperkalaemia.

Sodium zirconium cyclosilicate (Lokelma™) [hereafter referred to as SZC] is a non-absorbed, non-polymer zirconium silicate compound that preferentially exchanges hydrogen and sodium for potassium and ammonium ions in the gastrointestinal tract (GIT), thereby increasing faecal potassium excretion and lowering serum potassium levels. It is available as a powder for oral suspension (in water) and is approved in the EU and the USA for the treatment of hyperkalaemia in adults. In two multinational, phase III studies in adults with hyperkalaemia, SZC 10 g three times daily lowered serum potassium levels to within the normal range (3.5–5.0 mmol/L) during the first 48 h of treatment, and SZC 5 and 10 g once daily maintained normokalaemia over ≤ 28 days’ therapy. These beneficial effects were consistent across all patient subgroups (e.g. chronic kidney disease, diabetes, heart failure, concomitant use of RAAS inhibitor therapy), and appeared to be maintained over the longer term (≤ 12 months). SZC was generally well tolerated in adults with hyperkalaemia. Its tolerability profile was generally similar to that seen with placebo over ≤ 28 day, and its safety profile appeared to remain consistent over the longer term (≤ 12 months). Moreover, the incidence of hypokalemia was low. Current evidence indicates that SZC is a promising therapy for the management of hyperkalaemia in adults.

Nephro protection property of double blockade versus single blocked of RAAS in delaying the progression of CKD

Background: Dual renin angiotensin aldosterone system blockade using angiotensin receptor blockers in combination with angiotensin converting enzyme inhibitors is reported to improve proteinuria in non-diabetic patients.Methods: A prospective observational study was done on 810 non-diabetic chronic kidney disease patients during July 2012 to August 2014 to compare the nephro protection property of double blockade and single blocked of renin angiotensin aldosterone system in delaying the progression of chronic kidney disease.Results: At the end of 24 months urinary protein excretion rate of group I and group III were compared by using student t-test and p value (0.0001) was found significant. Similarly, on comparing group II and group III, p value (0.003) was again significant. Mean arterial blood pressure of group I and group III were statistically significant (&lt;0.0496) while comparing group II and group III, p value (0.0419) was again significant.Conclusions: The study concludes that the use of double renin angiotensin aldosterone system blockade therapy is more effective than monotherapy at reducing albuminuria and proteinuiria, and in decreasing blood pressure at the same time not causing significant deterioration in glomerular filtration rate. Newer potassium lowering therapies can effectively and safely correct hyperkalemia and maintain normokalemia in patients receiving background treatment with renin angiotensin aldosterone system blockade. However, the use of new potassium binders for cardiovascular and renal risk reduction with combined renin angiotensin aldosterone system blockade therapy will require phase III trials.

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.

Sodium zirconium cyclosilicate

Sodium zirconium cyclosilicate

Advances in the management of hyperkalemia in chronic kidney disease.

Patients with chronic kidney disease (CKD) have an increased risk of hyperkalemia that increases both short-term and long-term mortality. Historically, managing hyperkalemia has relied upon dietary modifications, augmentation of urinary potassium excretion and enhanced enteral potassium elimination. This review discusses current treatments and their limitations and summarizes the evidence supporting novel agents for potassium lowering in patients with CKD. The introduction of two novel ion exchange resins represents the first new pharmacologic therapies for hyperkalemia in the last 50 years. Patiromer, which was recently approved for use in the United States, has been shown to be well tolerated and effective for decreasing serum potassium in patients with CKD when taken for up to a year. Sodium zirconium cyclosilicate for which approval is pending has also shown promise in treating both acute and chronic hyperkalemia in patients with CKD. Both medications have been well tolerated with minimal adverse events in relatively short-term follow-up. Novel ion exchange resins have the potential to provide new strategies for safely and effectively managing hyperkalemia in the CKD population. This may decrease morbidity and mortality associated with hyperkalemia and allow more broad use of medications whose use is otherwise limited by hyperkalemia.