Reduced Serum Potassium Levels Research Articles

Use of Fludrocortisone for Hyperkalemia in Chronic Kidney Disease Not Yet on Dialysis.

Hyperkalemia is a frequent and potentially lethal complication of chronic kidney disease (CKD). We retrospectively examined the potassium-lowering effect of oral fludrocortisone and its adverse effects in hyperkalemic CKD patients not yet on dialysis. Thirty-three patients (23 men and 10 women, ages 69±14 years) were included. To control hyperkalemia at the outpatient clinic, twenty-one patients (Group 1) received fludrocortisone (0.05-0.1 mg/day) without changes in angiotensin II receptor blockers (ARBs) and calcium polystyrene sulfonate (CPS), while twelve patients (Group 2) were treated with fludrocortisone in addition to stopping ARBs and/or adding low-dose CPS. Fludrocortisone was administered for a median of 169 days (interquartile range, 47-445). At the first follow-up after fludrocortisone administration, serum potassium dropped from 6.14±0.32 mEq/L to 4.52±1.06 mEq/L (p<0.001) in Group 1 and from 6.37±0.35 mEq/L to 4.08±0.74 mEq/L (p<0.01) in Group 2. Ten patients in Group 1 and five patients in Group 2 measured serum potassium levels at four outpatient visits before and after fludrocortisone administration, respectively. The frequency of serum potassium ≥6.0 mEq/L decreased from 19/40 (48%) to 2/40 (5%) (p<0.001) in Group 1 and from 11/20 (55%) to 0/20 (0%) (p<0.001) in Group 2. Eleven patients experienced sodium retention-related problems after fludrocortisone administration: 7 with worsening leg edema, 2 with pleural effusions, and 2 with pulmonary edema. In pre-dialysis CKD patients, fludrocortisone at low doses effectively reduced serum potassium levels; however, sodium retention was a common adverse effect.

Mortality and hyperkalaemia-associated hospitalisation in patients with chronic kidney disease: comparison of sodium zirconium cyclosilicate and sodium/calcium polystyrene sulfonate.

Sodium zirconium cyclosilicate (SZC), a novel drug used for treating hyperkalaemia, is effective in reducing serum potassium levels. The effects of potassium adsorbents on the mortality and hyperkalaemia-associated hospitalisation rates remain unclear. We aimed to examine how mortality and hyperkalaemia-associated hospitalisation rates vary with usage of various potassium adsorbents. This retrospective study used patients' data between April 2008 and August 2021 obtained from a large-scale Japanese medical claims database. Consecutive patients with chronic kidney disease (CKD) prescribed potassium adsorbents were enrolled and divided into three groups according to the adsorbent type [SZC, calcium polystyrene sulfonate (CPS), and sodium polystyrene sulfonate (SPS)] and were observed for 1 year. The primary outcome was a composite of mortality and hyperkalaemia-associated hospitalisation. In total, 234, 54 183, and 18 692 patients were prescribed SZC, CPS, and SPS, respectively. The SZC group showed a higher event-free survival rate than the other two groups. The hazard ratio for the primary outcome in the CPS and SPS groups was similar in the analyses of the subgroups of patients who did not receive renal replacement therapy and those who received haemodialysis. The SZC group had a higher renin-angiotensin-aldosterone system inhibitors (RAASi) continuation rate compared to CPS and SPS groups, the difference being especially significant for SPS. This real-world study demonstrated the therapeutic effect of SZC in reducing mortality and hyperkalaemia-associated hospitalisations. The high RAASi continuation rate in the SZC group might be a contributing factor for improvement of the primary outcome.

Management of Hyperkalemia in Patients with Chronic Kidney Disease Using Renin Angiotensin Aldosterone System Inhibitors.

Use of renin-angiotensin-aldosterone system (RAAS) inhibiting medications is critical in the prevention of cardiovascular disease and kidney function decline in patients with chronic kidney disease (CKD); however, these agents can lead to hyperkalemia, an electrolyte disorder associated with risk of arrythmia, conduction disorders, and increased overall mortality. Discontinuation, or reduction of dose, of RAAS inhibitor therapy in hyperkalemic patients with CKD can lead to loss of kidney and cardiovascular protection afforded by these medications. Given the high prevalence of hyperkalemia among patients with CKD utilizing RAAS inhibitors, clear management principles are critical to minimize risk and maximize benefit when facing this clinical dilemma. Strategies to mitigate hyperkalemia that do not interfere with optimal RAAS inhibitor therapy should be prioritized when managing potassium elevation in patients with CKD. These strategies include discontinuing non-RAAS inhibitor medications known to cause hyperkalemia, correction of metabolic acidosis, and maximization of medication therapies that lower serum potassium, including diuretics and sodium-glucose cotransporter-2 (SGLT-2) inhibitors. Initiation of potassium exchange resins should also be considered to allow for sustained RAAS inhibitor utilization. An approach which employs multiple strategies concurrently is important to mitigate hyperkalemia and maintain long-term use of RAAS-inhibitors. Persistence of RAAS inhibitor use in patients with CKD is important to slow kidney function decline, delay onset of dialysis or the need for kidney transplant, and prevent adverse cardiovascular outcomes. When hyperkalemia develops among patients with CKD utilizing a RAAS inhibitor, a deliberate effort to reduce serum potassium levels using an approach that allows for continuation of maximally dosed RAAS inhibitor therapy is important. Patient education and engagement in the potassium management process is important for sustained success.

Single Dose of Sodium Zirconium Cyclosilicate Versus Sodium Polystyrene Sulfonate in Hospitalized Patients With Hyperkalemia.

Sodium zirconium cyclosilicate (SZC) is an inorganic zirconium silicate compound that selectively exchanges potassium for hydrogen and sodium. "Once" doses of SZC (with option to redose) in patients with hyperkalemia in hospitalized settings have not been evaluated. We hypothesized that a once dose of SZC would be non-inferior to sodium polystyrene sulfonate (SPS) in reducing serum potassium. The objective of our study is to evaluate the effect of a "once" dose of SZC when compared with SPS in reducing serum potassium levels. This was a retrospective analysis of patients who received either a "once" dose of SZC or single or repeated doses of SPS for hyperkalemia. The primary endpoint was mean absolute reduction in the first serum potassium value at least 4 hours after administration. The secondary efficacy endpoints were the rate of additional potassium-lowering therapies and the rate of normokalemia within 48 hours. Safety endpoints were the incidence of electrolyte abnormalities, hypoglycemia, hypertension, hypotension, and colonic necrosis. A total of 260 patients were included in the analysis. The mean initial serum potassium was similar between groups (5.6 ± 0.4). The absolute serum potassium reduction was -0.88 ± 0.64 mEq/L and -0.75 ± 0.65 mEq/L with SZC and SPS, respectively. The "once" regimen of SZC demonstrated non-inferiority compared with SPS (P < 0.0001). The proportion of patients achieving normokalemia within 48 hours and the proportion of patients receiving additional potassium-lowering therapies did not differ between groups. The "once" dose regimen (with redose option) of SZC was non-inferior to the "once" or repeated dosing regimen of SPS with regard to absolute potassium reduction. There were no significant differences in the rate of additional potassium-lowering therapies and the rate of normokalemia at 48 hours. The incidence of hypertension was less common among patients who received SZC.

Non-Selective PDE4 Inhibition Induces a Rapid and Transient Decrease of Serum Potassium in Mice.

The analysis of blood samples from mice treated with the PDE4 inhibitor Roflumilast revealed an unexpected reduction in serum potassium levels, while sodium and chloride levels were unaffected. Treatment with several structurally distinct PAN-PDE4 inhibitors, including Roflumilast, Rolipram, RS25344, and YM976 dose-dependently reduced serum potassium levels, indicating the effect is a class-characteristic property. PDE4 inhibition also induces hypothermia and hypokinesia in mice. However, while general anesthesia abrogates these effects of PDE4 inhibitors, potassium levels decrease to similar extents in both awake as well as in fully anesthetized mice. This suggests that the hypokalemic effects of PDE4 inhibitors occur independently of hypothermia and hypokinesia. PDE4 inhibition reduces serum potassium within 15 min of treatment, consistent with a rapid transcellular shift of potassium. Catecholamines promote the uptake of potassium into the cell via increased cAMP signaling. PDE4 appears to modulate these adrenoceptor-mediated effects, as PDE4 inhibition has no additional effects on serum potassium in the presence of saturating doses of the β-adrenoceptor agonist Isoprenaline or the α2-blocker Yohimbine, and is partially blocked by pre-treatment with the β-blocker Propranolol. Together, these data suggest that PDE4 inhibitors reduce serum potassium levels by modulating the adrenergic regulation of cellular potassium uptake.

Potassium Level Variation Following Packed Cell Transfusion in Critically Ill Adult Patients-How Alert Should We Be?

One of the most clinically important effects following the administration of packed cell transfusion (PCT) is hyperkalemia, which can cause severe life-threatening cardiac arrhythmias. This retrospective population-based cohort study included adults hospitalized between January 2007 and December 2019 in a general intensive care unit for 24 h or more, with normal levels of serum potassium on admission. We assessed changes in serum potassium levels after administration of one unit of packed cells and sought to identify clinical parameters that may affect these changes. We applied adjusted linear mixed models to assess changes in serum potassium. The mean increase in serum potassium was 0.09 mEq/L (C.U 0.04–0.14, p-value < 0.001) among the 366 patients who were treated with a single PCT compared to those not treated with PCT. Increased serum potassium levels were also found in patients who required mechanical ventilation, and to a lesser degree in those treated with vasopressors. Hypertension, the occurrence of a cerebrovascular accident, and increased creatinine levels were all associated with reduced serum potassium levels. Due to the small rise in serum potassium levels following PCT, we do not suggest any particular follow-up measures for critically ill patients who receive PCT.

Experience of using different dosages of the drug kalimate in order to correct hyperkalemia in chronic kidney disease

THE AIM: to evaluate the efficacy, safety, and tolerability of the preparation of calcium polystyrene sulfonate (Kalimate ® ), clinical observation was conducted in patients with chronic kidney disease who do not need dialysis, using different dosages of the drug with incomplete effectiveness of the hypokalemic diet as monotherapy for hyperkalemia. PATIENTS AND METHODS: the study included 70 patients suffering from chronic kidney disease who do not need renal replacement therapy, and with a plasma potassium level of 5.5 mmol/l or higher, after the use of hypokalemic diet therapy was ineffective. The patients were divided into 4 groups depending on the dose of calcium polystyrene sulfate. The 3 groups differed in the dose of the drug taken, the 4th group consisted of patients with reduced nutrition. Patients in all groups underwent control studies of serum potassium concentration before the start of the study, after 1 week, after 2 weeks, after 1 month, after 3, and after 6 months of treatment. RESULTS: The decrease in the level of potassium in the blood serum of group 1 patients for 6 months was 24.15 % (95 % CI 16.32-31.4 %), which in absolute value was 1.485± 0.513 mmol/l. Similar parameters for groups 2, 3 and 4 were, respectively: 22.59 % (95 %CI 15.57–31.12 %) and 1.38±0.487 mmol/L, 19.72 % (95 %CI 12.08–25.32 %) and 1.215±0.45 mmol/L, 25.24 % (95 % CI 17.86–30.24 %) and 1.58±0.502 mmol/l. CONCLUSION: the effectiveness of reducing serum potassium levels in patients with hyperkalemia on the background of chronic kidney disease who do not receive dialysis and follow only a hypokalemic diet, when using the drug polystyrene sulfate according to the instructions for 15-30 grams per day for at least 1 week with subsequent dose adjustment is an effective way of treating and correcting hyperkalemia.

Evaluation of Drug Combinations’ Effectiveness in Hyperkalemia Management of Chronic Kidney Disease Patients

Objective: This study aims to compare the effectiveness of hyperkalemia drug combinations in reducing potassium levels in chronic kidney disease (CKD) patients. Methods: This is an observational study on medical records of CKD patients with hyperkalemia at Dr. Saiful Anwar and Lavalette Hospitals, Malang, Indonesia. From 2017 to 2019, 78 hyperkalemia correction data were obtained from 47 patients’ medical records. The hypothesis test used in this study was the one-way ANOVA test. Results: Drug combinations of calcium gluconate, Actrapid® HM, and D40% (∆p = 0.62 mmol/L); calcium gluconate, Actrapid® HM, D40%, and Ventolin® Nebules (∆p = 0.72 mmol/L); and calcium gluconate, NovoRapid®, and D40%® (∆p = 1.03 mmol/L) were able to significantly reduce serum potassium levels (p &lt; 0.05). A drug combination of calcium gluconate, Humulin® R, and D40% (∆p = 0.84 mmol/L) was also able to reduce serum potassium levels but not statistically significant (p &gt; 0.05). The comparison test results of the four groups of drug combinations showed that no combination of drugs was superior to others in lowering potassium levels (p &gt; 0.05). Conclusions: The four groups of hyperkalemia drug combinations can reduce the patient’s serum potassium level and have the same effectiveness.

Relationship between long-term use of proton pump inhibitor (PPI) and hypomagnesemia in patients with gastroesophageal reflux disease.

Background:The aim of this study was to evaluate the relationship between the long-term use of PPI and hypomagnesemia in patients with gastroesophageal reflux disease.Methods:This case control study was conducted on GERD patients with long-term use of proton pump inhibitor and patients with no history of gastroesophageal reflux and proton pump inhibitor referring to gastrointestinal clinic in 2019. Then concentration of serum magnesium (Mg) and potassium (K) were measured using atomic absorption spectrophotometer according to protocol. Other data were extracted from medical records. Statistical tests such as t-test, chi-square test and ONE WAY ANOVA were used for analysis of data.Results:In the current study, 263 patients were classified into two groups (case: 132, control: 131). The mean level of potassium in case and control groups was 3.92±0.64 and 4.20±0.43, respectively (P=0.001). Moreover, the mean level of Mg in two groups was 2.03±0.36 and 2.09±0.52, respectively (P=0.24). In addition, significant difference was seen between serum level of K, regarding the type of proton pump inhibitor and duration of medication use (p<0.01). However, no significant difference was seen between serum levels of Mg, regarding the type of proton pump inhibitor such as omeprazole, pantoprazole and other drugs (p>0.05).Conclusion:Based on these results, long-term use of proton pump inhibitors is not associated with hypomagnesemia in GERD patients. However, long-term use of PPIs may reduce serum potassium levels in these patients. Therefore, periodic evaluation of serum Mg level in PPI-treated patients seems to be unnecessary.

English

BACKGROUND Organophosphorus (OP) pesticides are one of the most common cause of morbidity and mortality due to poisoning worldwide especially in agrarian countries like India. Hence it is prudent to undertake a detailed study of clinico-pathological evaluation of OP poisoning and assess the role of serum potassium as an alternative, easy and convenient prognostic indicator in estimating the severity of OP poisoning. This study was undertaken to assess serum potassium levels in patients of acute organophosphorus poisoning and determine association between serum potassium level and outcome in cases of acute organophosphorus poisoning. METHODS This was a prospective observational study conducted in Department of General Medicine, Silchar Medical College &amp; Hospital for one year from 1st June 2019 to 31st May 2020 with a sample size of 100 after satisfying the inclusion and exclusion criteria. Peradeniya organophosphorus poisoning (POP) scale was used for categorizing study population according to severity. RESULTS Among patients who were admitted with organophosphorus poisoning, 72 % of the patients discharged were having normal serum potassium levels on admission, whereas 22 % (n = 22) patients who died had hypokalaemia at the time of admission. The chi-square value for the association between serum potassium and outcome is statistically significant [P value is 0.001 (P &lt; 0.05)]. CONCLUSIONS The serum potassium level on the day of admission was significantly correlated with the severity of the acute organophosphate poisoning as determined by Peradeniya OP poisoning scale. The cases that had lower serum potassium levels on admission had poor outcome. Reduced serum potassium levels also had significant association with the need for ventilator support. Therefore, serum potassium can be used as a predictive marker of severity in organophosphorus poisoning. This can help in early triage of patients and will be helpful in reducing mortality and morbidity. KEYWORDS Organophosphorus Compound Poisoning, Serum Potassium, POP Scale

An Evidence-Based Narrative Review of the Emergency Department Management of Acute Hyperkalemia

The normal range for potassium is within narrow limits. Hyperkalemia is an electrolyte disorder that frequently affects patients in the emergency department (ED), and can result in significant morbidity and mortality if not identified and treated rapidly. This article provides an evidence-based narrative review of the management of hyperkalemia, with focused updates for the emergency clinician. We searched in MEDLINE, EMBASE, Web of Science, and Scopus databases for articles in English published in peer-reviewed journals and indexed up until May 2020. We used multiple search terms, including hyperkalemia, potassium, acute hyperkalemia, emergency department, dyskalemia, potassium disorders, kidney disease, epidemiology, electrolyte disturbance, severe hyperkalemia, and emergency management. In the ED, interventions aimed to protect patients from the immediate dangers of elevated serum potassium are divided into the following: stabilizing cardiac membrane potentials, reducing serum potassium levels through shift from the extracellular fluid to intracellular fluid, and elimination of potassium through excretion via urinary or fecal excretion. Calcium is widely recommended to stabilize the myocardial cell membrane, but additional research is necessary to establish criteria for use, dosages, and preferred solutions. Redistribution of potassium ions from the bloodstream into the cells is based on intravenous insulin or nebulized β2-agonists. Hyperkalemia is a frequent electrolyte disorder in the ED. Because of the risk of fatal dysrhythmia due to cardiac membrane instability, hyperkalemia is a medical emergency. There is a lack of scientific evidence on the optimal management of hyperkalemia and more research is needed to establish optimal strategies to manage acute hyperkalemia in the emergency department.

SO046REGULATION OF GUT MICROBIOTA AND HOST CO-METABOLISM BY POTASSIUM HOMEOSTASIS IN PATIENTS ON HEMODIALYSIS

Abstract Background and Aims Gut microbiota composition is dysregulated in hemodialysis patients. However, the impact of potassium homeostasis on the gut microbiota and their metabolites has not been studied. Patiromer is a potassium binding polymer that exchanges calcium for potassium in the gastrointestinal (GI) tract, thereby increasing fecal potassium excretion and reducing serum potassium levels. Method In this non-randomized, open label, 3-period crossover trial with repeated measures within each period, we investigated the effect of 12 weeks of treatment with patiromer on the microbiome profile and microbiota-related metabolites in 27 hemodialysis patients using multi-omics integration of data from shotgun metagenomic sequencing and untargeted and targeted metabolomic profiling. Data from hemodialysis patients at baseline was first compared with individuals without kidney disease (n=20). Results We found that 18 bacterial species and 49 plasma chemical clusters were significantly different between patients and controls. Serum potassium decreased significantly from baseline (5.62±0.65 mEq/L) with patiromer treatment (4.80±0.46 meq/L) and increased during the post-treatment phase (5.45 ± 0.67 meq/L), (p&amp;lt;0.001). Three bacterial species and one bacterial pathway were altered by patiromer. We identified 52 serum metabolites, which were significantly different in patients at baseline compared with controls, and were partially reversed with patiromer treatment. Specifically, the serum levels of polyphenols such as vanillic acid, gallic acid and benzoic acid, and other microbiota-related metabolites such as 2,6-diaminopimelic acid, 2-ketogluconic acid, indole-3-carboxaldehyde and 3-hydroxyphenylacetic acid were reduced by patiromer treatment. Conclusion Our study suggests that control of hyperkalemia by patiromer alters the gut microbial composition and host co-metabolism in hemodialysis patients.

P0187COMPARING OPAL-HK DATA TO REAL-WORLD DATA FROM THE UNITED KINGDOM: HOW EFFECTIVE IS PATIROMER AT ACHIEVING NORMOKALAEMIA?

Abstract Background and Aims The first phase of the published OPAL-HK study showed that Patiromer, an oral potassium binder, was effective at reducing serum potassium levels in patients with chronic kidney disease (CKD) stages 3 to 4. This phase was a 4-week, single-group treatment phase. Given the lack of a control arm, the aim of our study was to use real-world data from a large CKD cohort to provide a control comparison to evaluate the efficacy of Patiromer in normalising serum potassium. Method The initial phase of OPAL-HK comprised 243 patients with CKD G3-4 with a baseline serum potassium of 5.1 to &amp;lt;6.5mmol/L. To acquire a comparative matched cohort, patients were selected from the Salford Kidney Study (SKS), a prospective observational cohort study in the United Kingdom that has been recruiting patients aged ≥18 years old with CKD G3-5 since 2002. A 3-step process was applied to generate a propensity matched cohort. First, patients were chosen if they had an outpatient potassium level at any point after recruitment into SKS between 5.1mmol/L to &amp;lt;6.5mmol/L and whose next outpatient potassium level was checked 24 to 42 days (3.5 to 6 weeks) later (n=755). Second, all key OPAL-HK inclusion and exclusion criteria were applied. This left 162 patients who were then accurately matched in a 1:1 fashion to the 243 OPAL-HK patients using propensity score matching based on 6 baseline variables: age, gender, eGFR, diabetes mellitus, heart failure and potassium level. This produced a cohort of 87 SKS patients matched to their 87 OPAL-HK partner patients. We compared the two patient groups for the following OPAL-HK study endpoints: the mean change in serum potassium from baseline to follow-up at week 4, and the proportion of patients with a serum potassium of 3.8 to &amp;lt;5.1mmol/L at week 4. Results The groups were extremely well matched: between SKS vs. OPAL-HK, the mean (±SD) age was 63.9±13.3 vs. 63.7±9.5years (p=0.93); mean eGFR was 30.9±11.6 vs. 31.2±11.7ml/min/1.73m2 (p=0.85); 45 vs. 46 patients were diabetics (p=0.88); 29 vs. 24 had heart failure (p=0.41) and the mean potassium was 5.5±0.3mmol/L in both groups (p=0.68). The follow-up in the SKS cohort was 31±5 days. At the end of follow-up, the mean potassium level remained 5.5±0.3mmol/L in SKS patients but had reduced to 4.5±0.5mmol/L in the OPAL-HK group (p&amp;lt;0.001), a mean (±SE) change of -1.00±0.06mmol/L. For the secondary endpoint, 74% of patients in OPAL-HK reached the target potassium range of 3.8 to &amp;lt;5.1mmol/L at week 4 compared with 0% from the comparator SKS cohort (see Figure). Conclusion Using real-world data as a tightly-matched control arm for the first phase of the OPAL-HK study, Patiromer is shown to be effective at reducing potassium levels in patients with CKD G3-4.

Perspiration interventions for conservative management of kidney disease and uremia.

There has been an increasing interest in developing novel technologies to treat patients with chronic kidney disease as evidenced by KidneyX, the public-private partnership between government and industry. Perhaps a simple technology for treating kidney failure would be to utilize perspiration. It is a physiological process, and when used properly it might not be an unpleasant experience. This review will explore the current state of knowledge regarding perspiration therapy in the setting of far advanced kidney failure. A literature review using the PubMed database was conducted between 1 April 2019 and 3 September 2019. Search terms are shown in Table 1. Major themes of the results include diaphoresis therapy for patients with chronic kidney disease, excessive perspiration causing kidney disease, analysis of sweat to diagnose cystic fibrosis, and analysis of sweat to replenish lost electrolytes. This review will focus on intentional perspiration for the treatment of patients with end-stage renal disease (ESRD). Studies have shown that perspiration, or sweat-based therapies, can provide some of the most important currently recognized therapeutic goals in treating ESRD. These goals include decreased interdialytic weight gain, reduced serum potassium levels, and benefits to cardiovascular status. Research has shed light on some of the mechanisms, both molecular and clinical, that may be involved in induced perspiration therapy in ESRD. There is a long history of humans using perspiration for both recreation and therapy. Perspiration therapy for ESRD experienced a surge in the United States in the 1960s but does not have much modern momentum. With the continued growth of the ESRD population worldwide this could be considered an appropriate time to conduct more research into this promising therapy.

Antimicrobial Agents-induced Hypokalemia: A Possible Causality Association.

ABSTRACTBackgroundDrugs including some of the antimicrobial agents (AMAs) can cause mild to severe intensity of hypokalemia, which leads to cardiac, muscular, renal, gastrointestinal, and metabolic manifestations.ObjectiveTo explore the possible association of AMAs use and the development of hypokalemia as an adverse drug reaction (ADR).MethodologyRetrospective analysis of spontaneously individual case safety reports (ICSRs) received during January 2015 to September 2017 for any reduction in serum potassium levels following the use of AMAs. Such ICSRs were further analyzed for age, gender, seriousness and severity of hypokalemia, outcome, concomitant drugs, management of hypokalemia, and causality assessment using WHO-UMC causality assessment scale.ResultOut of total 2,880 spontaneous ICSR, 53 had report title of hypokalemia. In almost half of these (27) ICSRs, AMAs were suspected to induced hypokalemia. Ceftriaxone (24.5%) and azithromycin (10.5%) were most suspected AMAs. Females (74.19%) aged between 21 years and 40 years experienced more AMA induced hypokalemia. The mild, moderate, and severe hypokalemia was present in 53.8%, 40.7%, and 7.4% of ICSRs, respectively. Drug–drug interaction of AMA with either furosemide, hydrocortisone and/or deriphyllin was present in six ICSRs. Causal association of all the ICSRs with AMA induced hypokalemia was possible.ConclusionAntimicrobial agents (especially ceftriaxone and azithromycin)-induced hypokalemia alert needs to be investigated. Further, healthcare professionals are advocated to take caution by monitoring serum potassium levels routinely for such patients.How to cite this articleRehan HS, Hotha P, Antimicrobial Agentsinduced Hypokalemia: A Possible Causality Association. Indian J Crit Care Med 2019;23(4):175-177.

Pharmacologic Treatment of Chronic Hyperkalemia in Patients with Chronic Kidney Disease.

Hyperkalemia is frequently complicated in patients with advanced chronic kidney disease (CKD) because kidney is the major route of potassium excretion. Urinary potassium excretion is reduced according to the decline in glomerular filtration rate, and the risk of hyperkalemia is increased in patients with high potassium intake, advanced age, diabetes mellitus, congestive heart failure, and medications such as renin-angiotensin-aldosterone system(RAAS) blockades. On the other hand, the benefits of RAAS blockades and a high-potassium diet should be considered in CKD patients. To overcome these contradictory treatment strategies, potassium binders have emerged as new options to enhance fecal potassium excretion. In different regions of the world, four types of potassium binders are preferentially used. Whereas sodium polystyrene sulfonate (SPS) exchanges sodium for potassium, calcium polystyrene sulfonate (CPS) has the advantage of avoiding hypervolemia because it exchanges calcium for potassium. SPS was first introduced in the 1950s and used for a long time in western countries, and CPS is currently prescribed in Asia including South Korea. In contrast with the paucity of clinical studies using SPS or CPS, the recent randomized, controlled trials reported that two newer potassium binders, patiromer and sodium zirconium cyclosilicate (ZS-9), effectively and safely reduce serum potassium levels in CKD patients taking RAAS blockades. Our experiences showed that the long-term administration of a small dose of CPS was also effective and safe in treatment of chronic hyperkalemia. Further comparative trials among patiromer, ZS-9, and CPS are required to provide guides to cost-effective management of hyperkalemia in CKD patients.

Calcium-Polystyrene Sulfonate Decreases Inter-Dialytic Hyperkalemia in Patients Undergoing Maintenance Hemodialysis: A Prospective, Randomized, Crossover Study.

Hyperkalemia is a life-threatening emergency in maintenance hemodialysis (MHD) patients. This clinical trial investigated the efficacy and safety of calcium-polystyrene sulfonate (Ca-PS) in MHD patients with interdialytic hyperkalemia. A total of 58 hemodialysis patients with hyperkalemia (≥5.5 mol/L) were selected and administered either a 3-week Ca-PS (3 × 5 g/day) or a blank control following the model of a prospective, randomized, crossover clinical trial with a 1-week washout period. All patients were followed up for another 3 weeks for safety evaluations. The primary outcome was the magnitude of the change in serum potassium levels. The secondary outcomes were electrocardiography (ECG) changes and treatment safety (volume overload, electrolyte imbalance). Compared with the control group, Ca-PS treatment significantly reduced serum potassium levels (P <0.01). More patients in the Ca-PS group had lower serum potassium levels than the safety level of <5.5 mmol/L (32% for control vs. 61% for Ca-PS, P <0.01). Peaked T-wave occurred less frequently in patients in the Ca-PS group (13.8% for Ca-PS vs. 31.03% for control, P <0.01). In addition, Ca-PS reduced serum phosphorus levels with no effects on serum levels of calcium and sodium, fluid volume, blood pressure, or interdialytic weight gain. Ca-PS treatment decreases serum levels of potassium and phosphorus in MHD patients with interdialytic hyperkalemia. Ca-PS does not induce volume overload or disrupt electrolyte balance.

Patiromer: A Review in Hyperkalaemia.

Patiromer (Veltassa®) for oral suspension is a non-absorbed, sodium-free potassium binding polymer that exchanges calcium for potassium in the gastrointestinal (GI) tract, thereby increasing faecal potassium excretion and reducing serum potassium levels. Patiromer was approved in the USA in 2015 and is now approved in several other countries, including those of the EU, for the treatment of hyperkalaemia in adults. In clinical trials, patiromer reduced serum potassium levels and the risk of recurrent hyperkalaemia in patients with chronic kidney disease (CKD) and/or diabetic nephropathy with or without heart failure (HF), allowing the majority of patients to continue receiving renin-angiotensin-aldosterone system (RAAS) inhibitors (drugs that inhibit the renal excretion of potassium) for up to 52weeks. Patiromer also maintained normokalaemia in patients with HF and a propensity for hyperkalaemia, enabling concomitant administration and up-titration of spironolactone. Patiromer was generally well tolerated, with a low risk of hypokalaemia. GI disorders and hypomagnesaemia were the most common adverse events; these were generally of mild or moderate severity. Therefore, oral patiromer is a valuable treatment option for the long-term management of hyperkalaemia.

Revisiting RAAS blockade in CKD with newer potassium-binding drugs

Among patients with proteinuric chronic kidney disease (CKD), current guideline recommendations mandate the use of agents blocking the renin angiotensin aldosterone system (RAAS) as first-line antihypertensive therapy based on randomized trials demonstrating that RAAS inhibitors are superior to other antihypertensive drug classes in slowing nephropathy progression to end-stage renal disease. However, the opportunities for adequate RAAS blockade in CKD are often limited, and an important impediment is the risk of hyperkalemia, especially when RAAS inhibitors are used in maximal doses or are combined. Accordingly, a large proportion of patients with proteinuric CKD may not have the anticipated renoprotective benefits since RAAS blockers are often discontinued due to incident hyperkalemia or are administered at suboptimal doses for fear of the development of hyperkalemia. Two newer potassium binders, patiromer and sodium zirconium cyclosilicate (ZS-9), have been shown to effectively and safely reduce serum potassium levels and maintain long-term normokalemia in CKD patients receiving background therapy with RAAS inhibitors. Whether these novel potassium-lowering therapies can overcome the barrier of hyperkalemia and enhance the tolerability of RAAS inhibitor use in proteinuric CKD awaits randomized trials.

Hypoglycemia following intravenous insulin plus glucose for hyperkalemia in patients with impaired renal function.

BackgroundHypoglycemia is a serious complication following the administration of insulin for hyperkalemia. We determined the incidence of hypoglycemia and severe hypoglycemia (blood glucose <70 or ≤40 mg/dl, respectively) in a cohort of AKI and non-dialysis dependent CKD patients who received an intravenous infusion of insulin plus glucose to treat hyperkalemia.MethodsWe retrospectively reviewed charts of all AKI and non-dialysis dependent CKD patients who received 10 U of insulin plus 50 g glucose to treat hyperkalemia from December 1, 2013 to May 31, 2015 at our Department.ResultsOne hundred sixty four episodes of hyperkalemia were treated with insulin plus glucose and were eligible for analysis. Serum potassium levels dropped by 1.18 ± 1.01 mmol/l. Eleven treatments (6.1%) resulted in hypoglycemia and two (1.2%) in severe hypoglycemia. A lower pretreatment blood glucose tended to associate with a higher subsequent risk of hypoglycemia. Age, sex, renal function, an established diagnosis of diabetes or previous treatment were not associated with the development of this complication. We did not register any significant adverse events.ConclusionOur intravenous regimen combining an infusion of insulin plus glucose effectively reduced serum potassium levels compared to previous studies and associated a low risk of symptomatic hypoglycemia and other complications.