Severe Hyperkalemia Research Articles

Clinical and Economic Burden of Hyperkalemia: A Nationwide Hospital-Based Cohort Study in Japan

Rationale & ObjectiveHyperkalemia is a common electrolyte abnormality of chronic kidney disease and heart failure associated with increased mortality and morbidity. We aimed to assess the long-term economic burden of hyperkalemia.DesignObservational cohort study using a Japanese nationwide hospital claims database (April 1, 2008, to September 30, 2018).Setting & Population: Patients 18 years or older with at least 1 serum potassium value (N = 1,208,894).ExposuresHyperkalemia defined with the presence of at least 2 serum potassium values ≥ 5.1 mmol/L.Outcome MeasuresDirect health care costs and resource use in patients with hyperkalemia within and after 12 months from first hyperkalemia episodes.Analytical ApproachHealth care costs and resource use were compared with propensity score–matched or nonmatched normokalemic controls. Multivariable regression analysis was performed to examine factors associated with health care costs.Results27,534 patients with hyperkalemia and 233,098 normokalemic controls were studied. Mean ± SD age was 73±13 years in patients with hyperkalemia; among them, 59% and 35% had chronic kidney disease and heart failure, respectively. In the propensity score–matched cohort (n = 5,859 in each group), average numbers of hospitalizations per patient per year in patients with hyperkalemia within and after 12 months were 1.2 and 1.6 times higher, respectively, compared with those in patients with normokalemia. The total cost per patient in patients with hyperkalemia was higher than for controls, with mean differences of $8,611 (95% CI, $8,046-$9,175) within 12 months and $5,150 (95% CI, $4,733-$5,566) after 12 months. The number of repeat hyperkalemic episodes was the factor with the strongest association with long-term health care costs, whereas severity of hyperkalemia was not associated.LimitationsThis study used secondary data; therefore, residual confounders may not be fully excluded.ConclusionsHyperkalemia was associated with significant long-term economic burden with frequent hospitalizations due to recurrent episodes, indicating the importance of hyperkalemia treatment for the sake of reducing health economic burdens and clinical complications.

Prevalence and Severity of Hyperkalemia in Patients Referred to Nephrology Consultation: Epidemiologic Data from 1106 Mexican Patients at a National Reference Hospital

Prevalence and Severity of Hyperkalemia in Patients Referred to Nephrology Consultation: Epidemiologic Data from 1106 Mexican Patients at a National Reference Hospital

Severe Hyperkalemia in a 4-Month-Old Female due to Cullin-3 Mutation

Severe Hyperkalemia in a 4-Month-Old Female due to Cullin-3 Mutation

A CASE OF THYROTOXIC PERIODIC PARALYSIS IN AN AFRICAN AMERICAN MALE REQUIRING MECHANICAL VENTILATION AND HEMODIALYSIS

SESSION TITLE: Medical Student/Resident Critical Care SESSION TYPE: Med Student/Res Case Report PRESENTED ON: October 18-21, 2020 INTRODUCTION: Thyrotoxic periodic paralysis (TPP) represents a rare, acquired form of hypokalemic periodic paralysis characterized by acute onset muscle weakness and hypokalemia. We report a severe presentation requiring mechanical ventilation and hemodialysis (HD). CASE PRESENTATION: A 25 year old African American male presented with bilateral lower extremity weakness and hypokalemia at 1.6 mmol/L with characteristic hypokalemic ECG changes. After receiving 40 mEq IV potassium chloride, his hypokalemia worsened to 1.1. Given acute progression of ascending paralysis to complete paraplegia, 3/5 strength in upper extremities and concern for impending diaphragmatic weakness, he was intubated. Despite an additional 170 mEq of potassium, his repeat K+ was 1.5 with progressive EKG changes. He also had a metabolic acidosis with pH of 7.208 and a lactic acid of 8.7. Given refractory hypokalemia and concern that bicarbonate therapy for acidosis would worsen the hypokalemia, the patient was initiated on HD with a high potassium bath. The team confirmed suspicion of TPP upon return of TSH level <0.015 mU/L and administered 3 doses of 1 mg IV Propranolol during which he exhibited spontaneous extremity movements. Serial labs then revealed a rebound hyperkalemia up to 7.4 mmol/L with characteristic hyperkalemic ECG changes. He received usual stabilizing treatments and a second session of emergent HD to correct the up trending hyperkalemia. Diagnosis and recovery was confirmed after stable potassium levels, resolved acidosis, complete recovery of his neurological exam and notably elevated T4 and T3 levels. He was extubated without complication and discharged home on Propylthiouracil with instructions to follow-up with endocrinology for further evaluation of his hyperthyroidism. DISCUSSION: As compared to prior published cases of TPP most often amongst Asian males, management of this African American patient differed with the use of mechanical ventilation for airway protection due to rapidly progressive ascending paralysis and down trending negative inspiratory forces and vital capacities. It also necessitated the use of hemodialysis to correct both the refractory hypokalemia and concomitant acidosis. It is believed that a thyrotoxic-mediated beta-adrenergic response drives potassium into cells hyperpolarizing muscle fibers, causes an extracellular shift of hydrogen and increases conversion of pyruvate to lactate resulting in acidosis. The concern with addressing this with a bicarbonate drip was that a secondary alkalosis would further intracellularly shift potassium. Fortunately, already having a HD catheter in place allowed for more rapid treatment of the severe rebound hyperkalemia. CONCLUSIONS: Initial suspicion of TPP on the differential for ascending paralysis and earlier use of IV propranolol can prevent progression of paralysis, rebound hyperkalemia, lactic acidosis and life-threatening cardiac arrhythmias. Reference #1: Younis AA. Thyrotoxic Periodic Paralysis as a Presentation of Thyrotoxicosis: A Case Report and review of the literature. Mediterr J Rheumatol. 2018;29(1):46–48. Reference #2: Wong P. Hypokalemic thyrotoxic periodic paralysis: a case series. CJEM. 2003;5(5):353–355. Reference #3: Tassone H, Moulin A, Henderson SO. The pitfalls of potassium replacement in thyrotoxic periodic paralysis: a case report and review of the literature. J Emerg Med. 2004;26(2):157–161. DISCLOSURES: No relevant relationships by Firth Bowden, source=Web Response No relevant relationships by Uday Gulati, source=Web Response No relevant relationships by Asma Qayyum, source=Web Response No relevant relationships by samson zarbiv, source=Admin input

Hyperkalemic Cardiac Arrest in a Patient with Diabetic Ketoacidosis.

AimTo highlight the occurrence of cardiac arrest due to hyperkalemia in diabetic ketoacidosis (DKA).BackgroundDiabetic ketoacidosis is a commonly encountered condition. These patients can have normal or mildly elevated levels of potassium. Our patient had severe hyperkalemia due to DKA resulting in cardiac arrest. Her high potassium diet and use of angiotensin receptor blocker along with acute kidney injury (AKI) would have also contributed to hyperkalemia.Case descriptionA 58-year-old female, known case of diabetes mellitus on insulin therapy and hypertension on telmisartan, presented with nausea, vomiting, and abdominal pain. She was diagnosed to have DKA with AKI precipitated by missed insulin and urinary tract infection. She was also on high potassium diet. Her electrocardiogram showed sinus bradycardia with prolonged QRS interval. Her potassium levels were elevated. She soon went into asystole and cardiac arrest and was resuscitated. Diabetic ketoacidosis protocols were followed along with antibiotics, and the patient improved.ConclusionSevere hyperkalemia in DKA is uncommon, and this hyperkalemia resulting in cardiac arrest is an unreported scenario. Potassium correction along with DKA management protocol forms the mainstay of treatment.Clinical significanceMild to moderate elevation in serum potassium occurs frequently in DKA. However, severe hyperkalemia is uncommon and is likely to be the result of insulin deficiency, acidosis, hyperosmolality, severe dehydration, and renal potassium retention. Such elevated level of potassium requires urgent correction in order to prevent cardiac arrest.How to cite this articleManappallil RG, Nambiar J. Hyperkalemic Cardiac Arrest in a Patient with Diabetic Ketoacidosis. Indian J Crit Care Med 2020;24(8):737–738.

Effect of high-dose mineralocorticoid receptor antagonist eplerenone on urinary albumin excretion in patients with type 2 diabetes and high cardiovascular risk: Data from the MIRAD trial

AimAs mineralocorticoid receptor antagonists (MRAs) may possess renoprotective effects in type 2 diabetes (T2D), it was decided to investigate the impact of high-dose MRA on prespecified secondary endpoints—namely, change in urinary albumin–creatinine ratio (UACR) and 24-h ambulatory blood pressure—in the MIRAD trial. MethodsThis was a double-blind clinical trial in which T2D patients at high risk of or with established cardiovascular disease (CVD) were randomized to either high-dose (100–200 mg) eplerenone or a dose-matched placebo as an add-on to background antihypertensive treatment for 26 weeks. Safety was evaluated by the incidence of hyperkalaemia and kidney-related adverse events. ResultsA total of 140 patients were enrolled (70 in each group). Baseline UACR was 17 mg/g (geometric mean; 95% CI: 13–22); this decreased by 34% in the eplerenone group compared with the placebo group at week 26 (95% CI: −51% to −12%; P = 0.005). There was no significant decrease in 24-h systolic blood pressure (SBP) due to treatment (−3 mmHg; 95% CI: −6 to 1; P = 0.150). However, the observed change in 24-h SBP correlated with the relative change in UACR in the eplerenone group (r = 0.568, P < 0.001). Mean baseline (± SD) estimated glomerular filtration rate (eGFR) was 85 (± 18.6) mL/min/1.73 m2, and 12 (± 9%) had an eGFR of 41–59 mL/min/1.73 m2. No significant differences in the incidence of mild hyperkalaemia (≥ 5.5 mmol/L; eplerenone vs placebo: 6 vs 2, respectively; P = 0.276) and no severe hyperkalaemia (≥ 6.0 mmol/L) were observed. ConclusionThe addition of high-dose eplerenone to T2D patients at high risk of CVD can markedly reduce UACR with an acceptable safety profile.

Severe hypokalemia and rebound hyperkalemia during barbiturate coma in patients with severe traumatic brain injury

ObjectivesTo evaluate the incidence of severe potassium disturbances during barbiturate coma therapy in patients with severe traumatic brain injury (TBI), and the characteristics of these patients. MethodsThe study comprised 37 patients with severe TBI who were treated for barbiturate coma between 2015 and 2017 in level 3 intensive care units of two hospitals. ResultsNo potassium disturbance occurred in 14 patients. Seventeen patients developed mild-moderate hypokalemia (2.6–3.5mEq/L), and 6 patients developed severe hypokalemia (<2.5mEq/L) following the induction of barbiturate therapy. The incidence of mild-to-severe barbiturate-induced hypokalemia was 62.2% and the rate of severe hypokalemia was 16.2%. The mean potassium supply per day during thiopentone therapy was statistically significantly different between patients with mild-to-moderate hypokalemic and those with severe hypokalemic (p<0.001). Four of 6 patients with severe hypokalemia developed rebound hyperkalemia exceeding 6mEq/L following the cessation of barbiturate infusion. The nadir potassium concentration was 1.5mEq/L and the highest value was 6.8mEq/L. The mean time to reach nadir potassium concentrations was 2.8 days. The mortality rate of the 6 patients was 66.7%. Of the 2 survivors of severe hypokalemia, the Glasgow Outcome Scale (GOS) on discharge and the extended GOS one year after the trauma were 5 and 8 respectively. ConclusionsSevere hypokalemia refractory to medical treatment and rebound hyperkalemia is a serious adverse effect of thiopentone coma therapy in patients with severe TBI. Excessive and aggressive potassium replacement during the barbiturate-induced hypokalemia period must be avoided. Weaning barbiturate treatment over time may be advantageous in the management of severe serum potassium disturbances.

Cystatin C and Sarcopenia Predict Acute on Chronic Liver Failure Development and Mortality in Patients on the Liver Transplant Waiting List.

Cystatin C (CysC) is an early biomarker of renal dysfunction scarcely studied in patients awaiting liver transplantation (LT). Sarcopenia is frequent in cirrhosis and impacts prognosis. We aimed to assess the capability of these factors to predict survival and acute-on-chronic liver failure (ACLF) in patients awaiting LT, as well as early post-LT outcomes. Single-center study that included all cirrhotic patients listed for LT between 2014 and 2017. Competing risk regression analysis was used to evaluate the capability of liver-, kidney-, and global status-related variables at waitlist (WL) inclusion to predict WL mortality and ACLF. Variables associated with post-LT outcomes were evaluated with logistic regression analysis. One-hundred-and-eighty patients were included. Fifty-six (31%) patients developed ACLF, 54 (30%) underwent LT and 35 (19%) died. In the adjusted competing risk regression analysis, CysC ≥ 1.5 mg/L, sarcopenia and MELD-Na were independent predictors of ACLF in the WL, while CysC ≥ 1.5 mg/L, sarcopenia and albumin were independent predictors of mortality. The cumulative incidence of ACLF and mortality at 12 months were 50% and 34% in patients with sarcopenia and CysC ≥1.5 mg/L. An estimated glomerular filtration rate by chronic kidney disease (CKD)-EPI-CysC-creatinine <60 mL/min/1.73 m at WL inclusion was an independent predictor of the need for renal replacement therapy (RRT) in the first month post-LT. Higher levels of CysC and sarcopenia are strongly associated with the ACLF and mortality in WL. The assessment of both risk factors may improve the prognostic evaluation and allow identifying a group of patients with a very high risk of poor outcomes while awaiting LT.

A case of severe pseudohyperkalaemia due to muscle contraction

IntroductionSevere hyperkalaemia is a serious medical condition requiring immediate medical attention. Before medical treatment is started, pseudohyperkalaemia has to be ruled out.Case descriptionA 10-month old infant presented to the emergency department with fever and coughing since 1 week. Routine venous blood testing revealed a severe hyperkalaemia of 6.9 mmol/L without any indication of haemolysis. Reanalysis of the plasma sample confirmed the hyperkalaemia (7.1 mmol/L). Based on these results, the clinical pathologist suggested to perform a venous blood gas analysis and electrocardiogram (ECG) which revealed a normal potassium of 3.7 mmol/L and normal ECG, ruling out a potentially life-treating hyperkalaemia. The child was diagnosed with pneumonia. The paediatrician had difficulty to perform the first venous blood collection due to excessive movement of the infant during venipuncture. The muscle contractions of the child in combination with venous stasis most probably led to a local increase of potassium in the sampled limbs. The second sample collected under optimal preanalytical circumstances had a normal potassium. Since muscle contraction typically does not cause severe hyperkalaemia, other causes of pseudohyperkalaemia were excluded. K3-EDTA contamination and familial hyperkalaemia were ruled out and the patient did not have extreme leucocytosis or thrombocytosis. By exclusion a diagnosis of pseudohyperkalaemia due to intense muscle movement and venous stasis was made.ConclusionThis case suggests that intense muscle contraction and venous stasis can cause severe pseudohyperkalemia without hemolysis. Once true hyperkalemia has been ruled out, a laboratory work-up can help identify the cause of pseudohyperkalaemia.

P0220EFFECTIVENESS OF SODIUM ZIRCONIUM CYCLOSILICATE (SZC) IN HAEMODIALYSIS PATIENTS WITH SEVERE HYPERKALAEMIA IN THE DIALIZE STUDY

Abstract Background and Aims Patients with severe hyperkalaemia require urgent intervention to avoid serious adverse outcomes and mortality. The phase 3b DIALIZE study (NCT03303521) showed that sodium zirconium cyclosilicate (SZC) reduces predialysis serum potassium (sK+) after the long interdialytic interval and is well tolerated in haemodialysis patients with hyperkalaemia. This post-hoc analysis of the DIALIZE data assessed the efficacy of SZC in patients with severe hyperkalaemia (defined as sK+ ≥6.0 mmol/L) at baseline. Method The DIALIZE study randomised 196 patients 1:1 to placebo (n=99) or SZC (n=97). The study consisted of an 8-week treatment period, comprising a 4-week SZC dose titration phase followed by a 4-week evaluation phase. The starting dose of SZC was 5 g orally once daily on non-dialysis days (4 days/week) for the 4-week dose titration phase (titrated in 5 g increments to a maximum of 15 g on non-dialysis days) to achieve predialysis sK+ 4.0–5.0 mmol/L. Patients maintained a stable dose of SZC for the 4-week evaluation phase (SZC 5, 10 or 15 g). Here, treatment response was defined as achievement of predialysis sK+ of 4.0–5.5 mmol/L during ≥3 of 4 haemodialysis treatments after the long interdialytic interval during the 4-week evaluation phase and not requiring potassium-lowering rescue therapy. Rates of response were compared between those patients with and without baseline severe hyperkalaemia (sK+ ≥6 mmol/L and &amp;lt;6 mmol/L, respectively). The sK+ measurement on Visit 1 (Day –7) was used as the baseline value. Results At baseline, 88 patients had sK+ ≥6 mmol/L (SZC n=46, placebo n=42) and 106 patients had sK+ &amp;lt;6 mmol/L (SZC n=49, placebo n=57); data were missing for two SZC patients. The overall proportion of treatment responders (irrespective of treatment and dose) in patients with baseline sK+ ≥6 mmol/L and &amp;lt;6 mmol/L was 44.3% and 43.4%, respectively. The proportion of treatment responders was greater with SZC compared with placebo in patients with baseline sK+ ≥6 mmol/L and sK+ &amp;lt;6 mmol/L (Figure). For patients receiving SZC, the proportion of treatment responders was consistent in those with baseline sK+ ≥6 mmol/L (67.4%) compared with those with baseline sK+ &amp;lt;6 mmol/L (71.4%; Figure). Conclusion Our results suggest that SZC is effective in haemodialysis patients with severe hyperkalaemia.

P1852REGISTRATION WITH PATIENT-FACING ONLINE HEALTH RECORDS IN CHRONIC KIDNEY DISEASE IS ASSOCIATED WITH A LOWER INCIDENCE OF HYPERKALAEMIA

Abstract Background and Aims PatientView (https://patientview.org) is a web-based health record available throughout the United Kingdom which allows patients to review blood results and clinical communication from renal services. PatientView registration may differ across demographic groups and may be associated with improved clinical end points. We investigated the demographic factors associated with PatientView registration, and the association with incidence of severe hyperkalaemia. Method A retrospective analysis was performed of a prospectively-acquired database of adults with chronic kidney disease (CKD) stages 3 – 5 in a single Scottish health board attending 2006–2017. Individual start date was point of first clinic attendance; end date was date of death, commencement of renal replacement therapy or point of data extraction. Covariates included age, sex, biochemistry, socioeconomic status and co-morbidity. The Scottish Index of Multiple Deprivation (SIMD) was used as a measure of socioeconomic status, where quintile 1 is most deprived. A survival analysis of time to severe hyperkalaemia (&amp;gt;6.5mmol/L) was performed with PatientView registration as a time dependent covariate. Results Of 9935 patients, 967 (9.7%) were registered users of PatientView. The PatientView group had lower age in years (54.7 [42.7-65.6] vs 71.5 [62.1-78.4], p&amp;lt;0.001), estimated glomerular filtration rate (eGFR) (27.1 [18.6-38.8] vs 38.5 [28.3-51.8] ml/min/1.73m2, p&amp;lt;0.001), and higher SIMD (indicating lower levels of deprivation) (23 vs 13% in least deprived quintile, 25 vs 37% in most deprived quintile, p&amp;lt;0.001); fewer patients were female in the PatientView group (46 vs 51%, p&amp;lt;0.001). PatientView users had lower body mass index (29.1±7.6 vs 29.8±7.3 kg/m2, p&amp;lt;0.001), and lower prevalence of diabetes (28 vs 33%, p&amp;lt;0.001), heart failure (5 vs 7%, p&amp;lt;0.001), myocardial infarction (13 vs 22%, p&amp;lt;0.001) and stroke (3 vs 6%, p&amp;lt;0.001). On Cox regression, PatientView was associated with reduced risk of hyperkalaemia (HR 0.43, 95% CI 0.32,0.58) after adjustment for baseline eGFR, baseline serum potassium, SIMD, sex, diabetes and heart failure. Conclusion PatientView use is more prevalent amongst male, middle-aged patients with higher socioeconomic status. Registration with PatientView is associated with reduced likelihood of adverse clinical events including hyperkalaemia. Limitations include lack of ethnicity data, retrospective design and drug therapy. PatientView usage may associate with concordance to a low potassium diet, reflecting general health literacy. However, it is plausible that a causal relationship exists between Patientview usage and hyperkalaemia, by facilitating feedback on, and engagement with, lifestyle changes encouraged by healthcare providers. Whilst there remains a lack of PatientView registration in certain demographic groups, these should be targeted via quality improvement initiatives to enhance renal outcomes in underserved groups.

P0837HYPERKALEMIA IN RENAL PATIENTS, THE GREAT FORGOT?

Abstract Background and Aims Hyperkalemia constitutes an electrolyte imbalance that frequently appears in patients with Chronic Renal Disease (CKD) and is related to an increase in morbidity and mortality. Today, computerization of laboratory systems allows us to have access to these data to analyze the real prevalence of hyperkalemia in these patients, which we currently do not know. Our purpose is to analyze the frequency and characteristics of nephrologic patients with hyperkalemia and identify the most prevalent areas. Method Using a coding established by the laboratory, we have selected all patients with potassium greater than 5.5 mEq / l in analytics requested by any nephrologist of our hospital during the months of January to March 2019. It was established as mild hyperkalemia values up to 5.5mEq / l, and up to 6.5 mEq / l, severe hyperkalemia. We retrospectively analyzed the characteristics of these patients and the prevalence according to etiology and units within our service, relating potassium levels to the prescription of hyperkalemiant or related drugs. Results After analyzing the data, using as a reference the total number of patients seen in each area, we obtain an estimated total prevalence of 3.5% (86/2480). We found a distribution by sex with a predominance of men (56%), with a mean age of 62 years. The highest prevalence is obtained in the Hemodialysis unit (39.8%), followed by Peritoneal Dialysis (11%), Transplantation (5%), Hospitalization (4.3%), Interconsultations (3.8%), ERCA (2.7%) and External Consultations (0.6%). 65% had moderate hyperkalemia (defined as potassium levels of 5.5-6.5 mEq / l). Regarding the etiology of CKD, the most prevalent were: Vascular (29.2%), Diabetic (20.7%), Glomerular (19.5%) and Interstitial (14.6%). These etiologies also coincide with higher mean potassium levels, although without significant differences. There is also an increase in potassium levels the lower the glomerular filtration rate. However, when performing linear regression analysis we found no significant differences. Analyzing the drugs, it should be noted that the patients with the highest potassium levels were those taking anticoagulants, anticalcineurinics or resins (mean 6.17 mEq / l), finding significant differences only with the resins. In addition, most did not take ACE inhibitors, ARA-II or Beta blockers. Conclusion The prevalence of hyperkalemia in our population represents 3.5%. Being in most cases mild-moderate. The prevalence of hyperkalemia is higher in protein and kidney nephropathies and vascular nephropathies, probably associated with increased use of antiproteinuric drugs with hyperkalemic effect. Hyperkalemia is more prevalent in patients in patients undergoing renal replacement therapy reaching 40% in hemodialysis. The prevalence in CKD has been lower than expected, possibly in relation to greater patient awareness and adherence to the indications. Despite not finding a significant relationship, (due to the size of the sample) there is a relationship with the prescription of hyperkalemiant drugs. Resin prescription does not correct hyperkalemia

P0189SODIUM ZIRCONIUM CYCLOSILICATE CORRECTS HYPERKALAEMIA WITHIN 72 HOURS AMONG OUTPATIENTS WITH SEVERE HYPERKALAEMIA (BASELINE SERUM POTASSIUM ≥6 MMOL/L) REGARDLESS OF RENAL FUNCTION LEVEL OR RAASI USE: POST HOC SUBGROUP ANALYSIS OF A PHASE 3 TRIAL

Abstract Background and Aims Most patients with severe hyperkalaemia are treated in hospital settings and are often receiving renin–angiotensin–aldosterone system inhibitors (RAASi) and/or have chronic kidney disease. Sodium zirconium cyclosilicate (SZC; formerly ZS-9) is an orally-administered, non-absorbable, inorganic, selective potassium (K+) binder for the treatment of adults with hyperkalaemia. SZC entraps K+ throughout the gastrointestinal tract in exchange for hydrogen and sodium ions and significantly reduces serum K+ within one hour of administration. We report time to achievement of normokalaemia by baseline RAASi use and estimated glomerular filtration (eGFR) level from a 12-month Phase 3 sub-study among outpatients with baseline serum K+ ≥6 mmol/L undergoing acute treatment up to 72 hours. Method This international, multicentre, open-label, single-arm trial among adults with point-of-care (i-STAT) K+ ≥5.1 mmol/L included prespecified efficacy analyses by baseline serum K+ ≥6 mmol/L. During the acute phase (AP), patients received SZC 10 g three times a day from 24 up to 72 hours until normokalaemia (i-STAT K+ 3.5–5 mmol/L) was achieved, whereupon they entered maintenance treatment. In this analysis of the AP only, we report time to achievement of normokalemia (serum K+ 3.5–5 mmol/L) using the Kaplan-Meier (KM) method, mean change in serum K+ from baseline at 24 hours and distribution of change during the entire AP, and adverse events (AEs) by baseline RAASi use and eGFR level (&amp;lt;30 vs ≥30 mL/min/1.73m2). Results Of 749 patients in the intention-to-treat AP population of the main study, 126 (16.8%) had baseline serum K+ ≥6 mmol/L, and the vast majority of these patients had achieved normokalaemia by 72 hours (KM estimated proportions 98.6% and 96.1% in the serum K+ &amp;lt;6 and ≥6 mmol/L groups, respectively). Among patients with baseline serum K+ ≥6 mmol/L not on RAASi with an eGFR ≥30 mL/min/173m2 (no RAASi/eGFR ≥30), KM estimated median time to normokalemia was fastest, 22.5 hours (95% Confidence Interval [CI]: 22.0, 68.3), followed by patients on RAASi with an eGFR ≥30 mL/min/173m2 (RAASi/eGFR ≥30), 23.5 hours (95% CI: 22.6, 46.1), followed by patients not on RAASi with an eGFR &amp;lt;30 mL/min/173m2 (no RAASi/eGFR &amp;lt;30), 45.2 hours (95% CI: 22.6, 46.6), and slowest among patients on RAASi with an eGFR &amp;lt;30 mL/min/173m2 (RAASi/eGFR &amp;lt;30), 46.6 hours (95% CI: 45.7, 47.4). KM estimated proportions achieving normokalaemia at 24, 48 and 72 hours, respectively, were 57.1%, 69.4%, and 89.8% with no RAASi/eGFR ≥30; 54.9%, 73.0%, and 86.5% with RAASi/eGFR ≥30; 41.3%, 80.4%, and 100% with no RAASi/eGFR &amp;lt;30; and 25.4%, 75.8% and 100% with RAASi/eGFR &amp;lt;30. Median/range/mean change serum K+ values at 24 hours were 4.9/4.3-6/−1.22, 5.1/3.8-6.2/−1.26, 5.3/4.7-6/−1.02, and 5.3/4-6.6/−1.00 mmol/L in the no RAASi/eGFR ≥30, RAASi/eGFR ≥30, no RAASi/eGFR &amp;lt;30, and RAASi/eGFR &amp;lt;30 groups, respectively. No patients with baseline serum K+ ≥6 mmol/L experienced an increase in serum K+ or hypokalaemia. No AEs occurred in the no RAASi/eGFR ≥30 group. AEs occurred in 10.3% of patients in the RAASi/eGFR ≥30 group (n=1 each of myopia, nausea, urinary incontinence, and hypertension), 23.1% of patients in the no RAASi/eGFR &amp;lt;30 group (n=1 each of diarrhoea, urinary tract infection, and muscle spasms), and 8.7% of patients in the RAASi/eGFR &amp;lt;30 group (n=1 each of constipation, peripheral oedema, sinusitis, urinary tract infection, back pain, and skin ulcer). No AEs were serious or led to discontinuation. Conclusion Outpatient treatment with SZC rapidly normalized serum K+ among patients with baseline serum K+ ≥6 mmol/L with few adverse events. Although patients on RAASis and with an eGFR &amp;lt;30 mL/min/1.73m2 normalized at a slower rate, these patients nevertheless achieved normokalaemia by 72 hours. Neither concomitant RAASi therapy nor eGFR level appear to limit achievement of normokalemia with SZC among this population of outpatients with high baseline serum K+ ≥6 mmol/L.

P0771STOPPING MINERALOCORTICOID RECEPTOR ANTAGONISTS AFTER HYPERKALEMIA AND RISK OF ADVERSE OUTCOMES IN PATIENTS WITH HEART FAILURE

Abstract Background and Aims Stopping mineralocorticoid receptor antagonists (MRAs) after an episode of hyperkalemia is common, particularly among patients with chronic kidney disease (CKD). This may involve therapeutic compromises, in that the cessation of MRAs deprives patients of their beneficial cardiovascular effects. The aim of this study is to determine the risks of adverse health outcomes in heart failure patients after an episode of hyperkalemia, comparing users of MRA who stop treatment to those who continue the drugs. Method Observational study from the Stockholm Creatinine Measurements (SCREAM) project. We identified patients with heart failure patients initiating MRAs and surviving a first-detected episode of hyperkalemia (plasma potassium &amp;gt;5.0 mmol/L). We used Cox regression, adjusting for multiple confounders, to estimate hazard ratios (HR) for adverse events following hyperkalemia. The primary outcome was the composite of hospital admission with heart failure, stroke, myocardial infarction or death. The secondary outcome was a new hyperkalemia event. We compared risks between people who stopped MRA treatment and those who continued MRA within 4 months from the hyperkalemia event (landmark analysis at month 4 after event). Results We identified 1,330 patients with heart failure that developed hyperkalemia after initiating MRA therapy. Their median age was 80 years, 46% were women and their median eGFR was 43 ml/min/1.73m2. Of those, 595 (45%) had discontinued MRA by 4 months after hyperkalemia. Patients who stopped MRA were more likely to have eGFR &amp;lt;60 ml/min/1.73m2 (81% vs 71%), had a more severe index hyperkalemia (potassium&amp;gt;5.5 mmol/L, 35% vs 21%), and had hyperkalemia occur earlier in the course of MRA therapy (within 3 months from MRA initiation, 66% vs 51%). During median 1.5 years of follow-up, a total of 846 patients (64%) experienced the primary composite outcome. Compared to patients who discontinued MRA, those who continued had a similar risk of the primary composite outcome (HR 0.95, 95% CI 0.82-1.10). A total of 569 patients (43%) developed a subsequent hyperkalemia event. Compared to patients who discontinued MRA, those who continued with the therapy were at higher risk of another hyperkalemia (HR 1.46, 95% CI 1.21-1.75). Results were consistent across age strata, sex and presence of CKD. Conclusion Continuing treatment with MRA after an episode of hyperkalemia was not associated with different medium-term cardiovascular risk compared to those who stopped the drugs.

P1299SODIUM ZIRCONIUM CYCLOSILICATE FOR THE TREATMENT OF PERSISTENT HYPERKALAEMIA IN PREVALENT HAEMODIALYSIS PATIENTS: EXPERIENCE FROM CLINICAL PRACTICE

Abstract Background and Aims Sodium zirconium cyclosilicate (SZC) (Lokelma®) is a new oral potassium binder. In September 2019 the UK National Institute for Health and Care Excellence (NICE) did not recommend SZC for dialysis patients due to a lack of evidence. The recent DIALIZE phase 3b randomised controlled trial concluded that SZC is an effective and well-tolerated treatment for hyperkalemia in haemodialysis (HD) patients. We offer an insight into SZC treatment in HD patients with persistent hyperkalaemia in clinical practice. Method Adult prevalent HD patients prescribed SZC for persistent hyperkalaemia were included for analysis. The highest pre-dialysis serum potassium (sK+) values were recorded each month before (M-6 to M-1) and after (M1 to M5) SZC initiation. The primary efficacy measure was a reduction in sK+ with SZC treatment. Results Sixteen patients (mean age 53.5 years, 56.3% male) were included for analysis. 43.8% (n=7) were diabetic. At the time of SZC initiation 43.8% (n=7) received HD via arteriovenous fistula, 12.4% (n=2) via arteriovenous graft and 43.8% (n=7) via tunnelled central venous catheter. The mean Urea Reduction Ratio [SD] was 68.5% [10.8] and the mean [SD] pre-HD bicarbonate was 22.8mmol/L [2.7]. The dialysate potassium prescription was 2mmol/L for 93.8% of patients (n=15) and 1mmol/L for 6.2% of patients (n=1). The mean [SD] achievement of prescribed dialysis hours over the previous 4 weeks was 93.5% [12.2]. 68.8% (n=11) had previous treatment with calcium polystyrene sulfonate and 12.5% (n=2) with patiromer. 18.8% (n=3) were currently prescribed a renin-angiotensin-aldosterone system inhibitor. 93.8% (n=15) had received dietetic advice. SZC starting doses ranged from 5g four times a week on non-dialysis days to 10g three times a day. Mean [SD] sK+ at month-1 (M-1) (immediate pre-treatment period) was 7.38mmol/L [0.31]. Mean [SD] sK+ at month 1 (M1) was 6.37mmol/L [1.21]. The statistical difference between these groups was p=0.0023 (paired two-tailed T-test). Figure 1 includes mean maximum monthly pre-dialysis sK+ from M-6 to M5. SZC was stopped in two patients (after M1 with sK+ 5.0mmol/L and after M4 with sK+ 4.3mmol/L) as it was no longer clinically indicated. Two patients became non-compliant (clinician-suspected or confirmed by patient) with SZC after M2 (sK+ 6.7mmol/L and sK+ 6.4mmol/L). Subsequent sK+ values would not reflect treatment with SZC in these patients. Figure 2 includes mean maximum monthly sK+ for the 12 patients on SZC from M-3 to M5. ANOVA and post-hoc Dunnett’s tests were undertaken to compare SZC treatment months (M1, 2, 3, 4 and 5) to the immediate pre-treatment period (M-1). ANOVA was close to significance (p=0.058), with post-hoc corrected for multiple comparisons finding the data to be significant for M1 vs. M-1 (p=0.045) and M5 vs. M-1 (p=0.018). The same tests across M1 through M5 revealed no significant difference (p=0.968 ANOVA and p=0.555 Dunnett’s), demonstrating that continued treatment with SZC to M5 did not result in a further decline in sK+. Conclusion Sodium zirconium cyclosilicate is effective in reducing pre-dialysis sK+ in patients with moderate and severe hyperkalaemia undergoing haemodialysis in clinical practice.

Hemodialysis treatment in patients with severe electrolyte disorders: Management of hyperkalemia and hyponatremia.

Significant deviations of serum potassium and sodium levels are frequently observed in hospitalized patients and are both associated with increased all‐cause and cardiovascular mortality. The presence of acute or chronic renal failure facilitates the pathogenesis and complicates the clinical management. In the absence of reliable outcome data in the context of dialysis prescription, requirement of renal replacement therapy in patients with severe electrolyte disturbances constitutes a therapeutic challenge. Recommendations for intradialytic management are based on pathophysiologic reasoning and clinical observations only, and as such, heterogeneous and limited to expert opinion level. This article reviews current strategies for the management of severe hyperkalemia and hyponatremia in hemodialysis patients.

Potassium levels after liver reperfusion in adult patients undergoing cadaveric liver transplantation: A retrospective cohort study

BackgroundHyperkalemia is a common cause of arrhythmias in patients undergoing liver transplantation. We examined the pattern of change of potassium levels during and immediately after reperfusion of the donor liver. Materials and methodsPotassium levels of 30 consecutive adult patients undergoing cadaveric liver transplantation were assessed before and after liver reperfusion. Changes in potassium levels over 13 predefined timepoints were analyzed. Primary aim: to describe the pattern of change of potassium levels during the reperfusion period. Correlation between changes in potassium levels during reperfusion and a-priori variables were investigated. ResultsBaseline median (IQR) potassium levels were 4.1 (3.8:4.5) mmol/L. Thirteen patients (43%) developed hyperkalemia, 10 (33%) of whom developed severe hyperkalemia. Potassium levels peaked at 80 s post reperfusion, plateaued until 2 min, before returning toward baseline values at 5 min. There was a strong association between pre-reperfusion/baseline potassium levels and peak potassium values during reperfusion (95%CI: 0.26 to 0.77, p < 0.001). A baseline potassium level of 4.45 mmol/L was a good predictor of reperfusion hyperkalemia with a sensitivity of 69.2% and specificity of 94.1% (AUC = 0.894, 95%CI: 0.779 to 1.000, p < 0.001). ConclusionHyperkalemia during cadaveric liver transplantation is common affecting almost 1 in 2 patients during reperfusion. During reperfusion potassium levels peaked within 2 min and over a third of patients developed severe hyperkalemia. Higher peak potassium levels correlated strongly with higher pre-reperfusion potassium values. These findings guide clinicians with timing of sampling of blood to check for hyperkalemia and identify modifiable factors associated with the development of hyperkalemia.

SUN-203 Hyponatremia and Hyperkalemia in a Child with Chylothorax: Is This Adrenal Insufficiency?

Hyponatremia and Hyperkalemia in a child with chylothorax: Is this adrenal insufficiency? Context: Chylothoraces are relatively rare within the pediatric population. Drainage of a chylothorax can lead to potentially serious complications including electrolyte imbalances and protein loss. The literature on hyponatremia and hyperkalemia developing after a chylothorax drainage is sparse. We report a case of electrolyte derangements after a chylothorax drainage in a pediatric patient. Repeated drainage of a large-volume chylothorax without adequate fluid replacement may lead to electrolyte imbalances that in our case mimicked adrenal insufficiency. Early identification and correct fluid replacement can avoid unnecessary complications of a chylothorax. Case Description: A 2-year-old female with history of congenital left pulmonary lymphangectasia and subsequent pleural effusion was admitted to a pediatric hospital for persistent tachycardia after an outpatient elective chest MRI. A chest tube was placed to drain the effusion with large volume output was noted over the first day (1200 cc/24 hours). Further chemical analysis determined the effusion to be consistent with a chylothorax. Blood work done after chest tube placement demonstrated severe hyponatremia and hyperkalemia. Additionally, the patient was noted to be irritable. Both lab and clinical findings raised concern for possible underlying adrenal insufficiency, and further work-up (i.e. cortisol level, ACTH level) was sent. The patient was started on stress-dose steroids. ACTH and cortisol levels resulted normal. Steroids were subsequently discontinued. The patient’s chest tube output was slowly replaced with normal saline with noted improvement in both lab and clinical findings. Conclusion: Although not well documented in pediatric literature, hyponatremia and hyperkalemia are complications of large-volume drainage of chylothoraces without proper fluid replacement. The subsequent lab findings could be consistent with adrenal insufficiency, however a full clinical picture along with a cortisol and an ACTH level can help differentiate etiologies.

Prevalence and correlates of hyperkalemia in a renal nutrition clinic

Hyperkalemia (HK) is a frequent complication of chronic kidney disease (CKD). Vegetable-based renal diets are considered at risk due to the high potassium (K) content. The aim of this study was to describe the prevalence and correlates of chronic hyperkalemia (HK) in CKD patients on nutritional care, and in particular, the risk of HK in patients on plant-based versus animal-based low-protein diets. We recruited adult patients affected by CKD not on dialysis, afferent to our renal nutrition clinic from November 2014 to May 2019. We evaluated a total of 870 accesses in 219 patients (172m, 47 f, age 67 ± 13years). HK was defined as mild when K serum level was 5.1-5.9mEq/l, moderate when K serum level was 6.0-6.9mEq/l, and severe HK when K serum level was ≥ 7mEq/l. Biochemical, anthropometric data and medications were recorded. The prevalence of HK in all the renal nutrition visits was 26.1%; all but six cases were mild HK, whereas no severe HK was observed. The prevalence of HK was associated with decreased eGFR, up to 36.5% for eGFR < 20ml/min. Medications were similar in hyperkalemic and normokalemic patients, RAASi being present in up to 85% of patients. In a follow-up of 40 ± 14months, no association was found between HK and mortality, whereas HK, at the start of follow-up, showed a trend to increased ESRD risk. Serum potassium levels and prevalence of HK were not different between patients on animal-based low-protein diet and plant-based low-protein diet. In conclusion, chronic HK is quite prevalent in a renal nutrition clinic, especially when eGFR falls down below 60ml/min, thereby reaching the highest prevalence in CKD stage 4. Hyperkalemia is mostly mild, being moderate to severe HK quite infrequent. Hyperkalemia was not associated with higher risk of mortality, whereas a trend, although not statistically significant, was observed for lower ESRD-free survival. Plant-based low-protein diet is not associated with significant higher prevalence of HK with respect to animal-based LPD at the same residual kidney function.

P140: Variability in practice patterns in the emergency department treatment of hyperkalemia

Introduction: Hyperkalemia is a common electrolyte disturbance associated with morbidity and mortality. Commonly used therapies for hyperkalemia include IV calcium, sodium bicarbonate, insulin, beta-adrenergic agents, ion-exchange resins, diuretics and hemodialysis. This study aims to evaluate which treatments are more commonly used to treat hyperkalemia and to examine factors which influence those clinical decisions. Methods: This is a retrospective chart review of all cases of hyperkalemia encountered in 2017 at a Canadian adult ED. Potassium values were classified as mild (5.5 - 6.5 mEq/L), moderate (&gt;6.5 - 7.5 mEq/L) and severe (&gt;7.5 mEq/L). Treatment choices were then recorded and matched to hemodynamic stability, degree of hyperkalemia and ECG findings. More statistical methods to test correlation between treatment and specific variables will be performed over the next 2 months, including logistic regression to highlight potential determinants of treatment and Chi-square tests to verify randomness and to construct 95% confidence intervals. Results: 1867 ED visits were identified, of which 479 met the inclusion criteria. 89.1% of hyperkalemia cases were mild, 8.2% were moderate, and 2.7% were severe. IV insulin was used in 22.1% of cases, followed by Kayexalate in 20.5%, sodium bicarbonate in 12.3%, IV calcium in 9.4%, frusemide in 7.3%, salbutamol in 2.7%, and dialysis in 1.9%. Moderate and severe hyperkalemia were associated with higher use of insulin (79.5% and 64.3% respectively), IV calcium (41% and 64.3% respectively), sodium bicarbonate (56.4% and 85.7% respectively). Bradycardia was associated with higher insulin and IV calcium use (46.7% and 33.3% respectively). Hypotension was associated with a similar increase in use of insulin and IV calcium (34.2% and 23.7% respectively). There were only 15 cases of cardiac arrest in which sodium bicarbonate and IV calcium were more frequently used (80% and 60% respectively). Conclusion: This study demonstrates variability in the ED management of hyperkalemia. We found that Insulin and Kayexalate were the 2 most common interventions, with degree of hyperkalemia, bradycardia and hypotension influencing rates of treatment. Overuse of kayexalate for emergent treatment of hyperkalemia is evident despite weak supporting evidence. Paradoxically, beta adrenergic agents were underutilized despite their rapid effect and safer profile. The development of a widely accepted guideline may help narrow the differences in practice and potentially improve outcomes.