1
|
Hu JR, Schwann AN, Tan JW, Nuqali A, Riello RJ, Beasley MH. Sequencing Quadruple Therapy for Heart Failure with Reduced Ejection Fraction: Does It Really Matter? Heart Fail Clin 2024; 20:373-386. [PMID: 39216923 DOI: 10.1016/j.hfc.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
The conventional sequence of guideline-directed medical therapy (GDMT) initiation in heart failure with reduced ejection fraction (HFrEF) assumes that the effectiveness and tolerability of GDMT agents mirror their order of discovery, which is not true. In this review, the authors discuss flexible GDMT sequencing that should be permitted in special populations, such as patients with bradycardia, chronic kidney disease, or atrial fibrillation. Moreover, the initiation of certain GDMT medications may enable tolerance of other GDMT medications. Most importantly, the achievement of partial doses of all four pillars of GDMT is better than achievement of target dosing of only a couple.
Collapse
Affiliation(s)
- Jiun-Ruey Hu
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA. https://twitter.com/ruey_hu
| | - Alexandra N Schwann
- Department of Internal Medicine, Yale New Haven Hospital, P.O. Box 208030, New Haven, CT, 06520-8030, USA. https://twitter.com/aschwann212
| | - Jia Wei Tan
- Division of Nephrology, Stanford University School of Medicine, 780 Welch Road, Palo Alto, CA 94304, USA. https://twitter.com/jiiiiawei
| | - Abdulelah Nuqali
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA. https://twitter.com/AbdulelahNuqali
| | - Ralph J Riello
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA. https://twitter.com/ralphadelta
| | - Michael H Beasley
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA.
| |
Collapse
|
2
|
Coats AJS, Anker SD, Lund LH, Filippatos G, Rossignol P, Pitt B, Weir MR, Kosiborod MN, Metra M, Böhm M, Ezekowitz JA, Bayes-Genis A, Mentz RJ, Ponikowski P, Senni M, Cleland JGF, Goudev A, Khintibidze I, Lindenfeld J, Merkely B, Waechter S, Budden J, Perrin A, Butler J. Patiromer for Heart Failure Medication Optimization in Patients With Current or Past Hyperkalemia: DIAMOND Subanalysis. JACC. HEART FAILURE 2024:S2213-1779(24)00602-4. [PMID: 39340493 DOI: 10.1016/j.jchf.2024.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 08/05/2024] [Accepted: 08/06/2024] [Indexed: 09/30/2024]
Abstract
BACKGROUND For heart failure with reduced ejection fraction (HFrEF), suboptimal use of renin-angiotensin-aldosterone system inhibitors (RAASis), including mineralocorticoid receptor antagonists (MRAs), due to hyperkalemia, may be improved by potassium binders. OBJECTIVES This prespecified analysis of the phase 3 DIAMOND (Patiromer for the Management of Hyperkalemia in Subjects Receiving RAASi Medications for the Treatment of Heart Failure) trial assessed the effect of patiromer in patients with HFrEF and either current or past hyperkalemia. METHODS Patients with HFrEF and current or past (within 1 year before enrollment) hyperkalemia (serum potassium [sK+] >5.0 mmol/L) entered a single-blind, run-in phase to optimize RAASis while receiving patiromer. They were subsequently randomized, double-blind, to continue patiromer or change to placebo. RESULTS Of the 1,038 patients who completed run-in, 354 (83.9%) of 422 with current hyperkalemia and 524 (85.1%) of 616 with past hyperkalemia achieved RAASi optimization and were randomized to treatment. During the double-blind phase, patiromer lowered sK+ levels compared with placebo in both the current and past hyperkalemia subgroups: difference in adjusted mean change from baseline: -0.12 (95% CI: -0.17 to -0.07) and -0.08 (95% CI: -0.12 to -0.05), respectively; Pinteraction = 0.166. Patiromer was more effective than placebo in maintaining MRA at target dose in patients with current vs past hyperkalemia (HR: 0.45 [95% CI: 0.26-0.76] vs HR: 0.85 [95% CI: 0.54-1.32]; Pinteraction = 0.031). Adverse events were similar between subgroups. CONCLUSIONS The use of patiromer facilitates achieving target doses of RAASis in patients with HFrEF with either current or past hyperkalemia. For those with current hyperkalemia before RAASi optimization, use of patiromer may be more beneficial in helping to maintain sK+ control and achieve MRA target dose. (Patiromer for the Management of Hyperkalemia in Subjects Receiving RAASi Medications for the Treatment of Heart Failure [DIAMOND]; NCT03888066).
Collapse
Affiliation(s)
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité, Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Lars H Lund
- Department of Medicine, Unit of Cardiology, Karolinska Institutet, Solna, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Patrick Rossignol
- Université de Lorraine, Centre d'Investigations Cliniques-Plurithématique 14-33, Inserm U1116, CHRU Nancy, and F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France; Medical Specialties and Nephrology Departments, Princess Grace Hospital, and Monaco Private Hemodialysis Centre, Monaco, Monaco
| | - Bertram Pitt
- Division of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mikhail N Kosiborod
- Department of Cardiovascular Disease, Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Marco Metra
- Cardiology, ASST Spedali Civili and University, Brescia, Italy
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Justin A Ezekowitz
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Antoni Bayes-Genis
- Cardiology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, CIBERCV, Spain
| | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Michele Senni
- University of Milano-Bicocca, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - John G F Cleland
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Assen Goudev
- Department of Emergency Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Irakli Khintibidze
- Alexandre Aladashvili Clinic, Tbilisi State Medical University, Tbilisi, Georgia
| | - Joann Lindenfeld
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Bela Merkely
- Semmelweis University Heart and Vascular Center, Budapest, Hungary
| | | | | | | | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| |
Collapse
|
3
|
Weir MR, Rossignol P, Pitt B, Lund LH, Coats AJS, Filippatos G, Perrin A, Waechter S, Budden J, Kosiborod M, Metra M, Boehm M, Ezekowitz JA, Bayes-Genis A, Mentz RJ, Ponikowski P, Senni M, Castro-Montes E, Nicolau JC, Parkhomenko A, Seferovic P, Cohen-Solal A, Anker SD, Butler J. Patiromer-Facilitated Renin-Angiotensin-Aldosterone System Inhibitor Utilization in Patients with Heart Failure with or without Comorbid Chronic Kidney Disease: Subgroup Analysis of DIAMOND Randomized Trial. Am J Nephrol 2024:1-18. [PMID: 39159624 DOI: 10.1159/000540453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 07/03/2024] [Indexed: 08/21/2024]
Abstract
INTRODUCTION Renin-angiotensin-aldosterone system inhibitor (RAASi; including mineralocorticoid receptor antagonists [MRAs]) benefits are greatest in patients with heart failure with reduced ejection fraction (HFrEF) and chronic kidney disease (CKD); however, the risk of hyperkalemia (HK) is high. METHODS The DIAMOND trial (NCT03888066) assessed the ability of patiromer to control serum potassium (sK+) in patients with HFrEF with/without CKD. Prior to randomization (double-blind withdrawal, 1:1), patients on patiromer had to achieve ≥50% recommended doses of RAASi and 50 mg/day of MRA with normokalemia during a run-in period. The present analysis assessed the effect of baseline estimated glomerular filtration rate (eGFR) in subgroups of ≥/<60, ≥/<45 (prespecified), and ≥/<30 mL/min/1.73 m2 (added post hoc). RESULTS In total, 81.3, 78.9, and 81.1% of patients with eGFR <60, <45, and <30 mL/min/1.73 m2 at screening achieved RAASi/MRA targets. A greater efficacy of patiromer versus placebo to control sK+ in patients with more advanced CKD was reported (p-interaction ≤ 0.027 for all eGFR subgroups). Greater effects on secondary endpoints were observed with patiromer versus placebo in patients with eGFR <60 and <45 mL/min/1.73 m2. Adverse effects were similar between patiromer and placebo across subgroups. CONCLUSION Patiromer enabled use of RAASi, controlled sK+, and minimized HK risk in patients with HFrEF, with greater effect sizes for most endpoints noted in patient subgroups with lower eGFR. Patiromer was well tolerated by patients in all eGFR subgroups.
Collapse
Affiliation(s)
- Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Patrick Rossignol
- INSERM CIC-P 1433, CHRU de Nancy, INSERM U1116, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
- Department of Medical Specialties and Nephrology-Hemodialysis, Princess Grace Hospital, Centre d'Hémodialyse Privé de Monaco, Monaco, Monaco
| | - Bertram Pitt
- Division of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lars H Lund
- Department of Medicine, Unit of Cardiology, Karolinska Institutet, Solna, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Gerasimos Filippatos
- School of Medicine, Athens University Hospital Attikon, National and Kapodistrian University of Athens, Haidari, Greece
| | | | | | | | - Mikhail Kosiborod
- Department of Cardiovascular Disease, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Marco Metra
- Cardiology, ASST Spedali Civili and University, Brescia, Italy
| | - Michael Boehm
- Klinik für Innere Medizin III, Saarland University, Homburg, Germany
| | - Justin A Ezekowitz
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Antoni Bayes-Genis
- Cardiology Department, Hospital Universitari Germans Trias i Pujol, CIBERCV, Barcelona, Spain
| | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Michele Senni
- Cardiovascular Department, ASST Papa Giovanni XXIII Hospital, University of Milano - Bicocca, Bergamo, Italy
| | - Eliodoro Castro-Montes
- Instituto de Corazon de Queretaro (ICQ), Faculty of Medicine Universidad Autonoma de Queretaro, Santiago de Queretaro, Mexico
| | - Jose Carlos Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Petar Seferovic
- University of Belgrade - Faculty of Medicine, Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Alain Cohen-Solal
- Université de Paris, INSERM U942, APHP, Hospital Lariboisiere, Paris, France
| | - Stefan D Anker
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardiology (CVK), German Heart Center Charité, Institute of Health Center for Regenerative Therapies (BCRT), German Center for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Javed Butler
- Division of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
4
|
Zheng Z, Su Y, Schmidt-Rohr K. Vinyl and methyl-ester groups in the insoluble polymer drug patiromer identified and quantified by solid-state NMR. J Pharm Biomed Anal 2024; 246:116228. [PMID: 38781726 DOI: 10.1016/j.jpba.2024.116228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 05/12/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024]
Abstract
Patiromer (Veltassa®) is a crosslinked, insoluble co-polymer drug used as a nonabsorbent potassium binder, approved for treatment of hyperkalemia. Quantitative solid-state 13C nuclear magnetic resonance (NMR) analysis with comprehensive peak assignment, component quantification, and calculation of mole and weight fractions of monomer units was performed on three doses of patiromer. The workflow is documented in detail. Spectrally edited solid-state 13C NMR spectra of patiromer show =CHn peaks of matching intensity at 116 and 141 ppm, characteristic of -CH=CH2 vinyl groups. Similar spectral features can be observed in earlier studies but were previously ignored. In this study, the vinyl signals are well-resolved in a 2-s direct polarization (DP) spectrum without and with dipolar dephasing, which confirms that these sp2-hybridized carbons are bonded to hydrogen and partially mobile, consistent with vinyl side groups from incompletely reacted divinyl crosslinkers. The vinyl groups account for 1.6% of all carbon, 3% of the monomer units, and nearly 1/3 of the crosslinkers. Furthermore, an unexpected OCH3 moiety accounting for ∼1.2% of all carbons was identified by spectral editing; its chemical shift of 54 ppm is more consistent with a methyl ester than with a methyl ether. It can originate from incomplete hydrolysis of ∼6% of methyl-2-fluoroacrylate, the main monomer of patiromer. Characteristic cross peaks in two-dimensional 1H-13C heteronuclear correlation NMR confirm the presence of the vinyl and OCH3 groups. Trace amounts of xanthan gum are also detected. The quantitative 13C NMR spectrum of patiromer has been matched in a simulation using a model with five monomer units.
Collapse
Affiliation(s)
- Zhaoxi Zheng
- Department of Chemistry, Brandeis University, Waltham, MA 02453, USA
| | - Yongchao Su
- Analytical Research and Development, Merck & Co. Inc., Rahway, NJ 07065, USA; Pharmaceutical Sciences and Clinical Supply, Merck & Co. Inc., Rahway, NJ 07065, USA
| | | |
Collapse
|
5
|
Logan Ellis H, Al-Agil M, Kelly PA, Teo J, Sharpe C, Whyte MB. The burden of hyperkalaemia on hospital healthcare resources. Clin Exp Med 2024; 24:190. [PMID: 39136879 PMCID: PMC11322248 DOI: 10.1007/s10238-024-01452-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 07/26/2024] [Indexed: 08/16/2024]
Abstract
Hyperkalaemia is associated with prolonged hospital admission and worse mortality. Hyperkalaemia may also necessitate clinical consults, therapies for hyperkalaemia and high-dependency bed utilisation. We evaluated the 'hidden' human and organisational resource utilisation for hyperkalaemia in hospitalised patients. This was a single-centre, observational cohort study (Jan 2017-Dec 2020) at a tertiary-care hospital. The CogStack system (data processing and analytics platform) was used to search unstructured and structured data from individual patient records. Association between potassium and death was modelled using cubic spline regression, adjusted for age, sex, and comorbidities. Cox proportional hazards estimated the hazard of death compared with normokalaemia (3.5-5.0 mmol/l). 129,172 patients had potassium measurements in the emergency department. Incidence of hyperkalaemia was 85.7 per 1000. There were 49,011 emergency admissions. Potassium > 6.5 mmol/L had 3.9-fold worse in-hospital mortality than normokalaemia. Chronic kidney disease was present in 21% with potassium 5-5.5 mmol/L and 54% with potassium > 6.5 mmol/L. For diabetes, it was 20% and 32%, respectively. Of those with potassium > 6.5 mmol/L, 29% had nephrology review, and 13% critical care review; in this group 22% transferred to renal wards and 8% to the critical care unit. Dialysis was used in 39% of those with peak potassium > 6.5 mmol/L. Admission hyperkalaemia and hypokalaemia were independently associated with reduced likelihood of hospital discharge. Hyperkalaemia is associated with greater in-hospital mortality and reduced likelihood of hospital discharge. It necessitated significant utilisation of nephrology and critical care consultations and greater likelihood of patient transfer to renal and critical care.
Collapse
Affiliation(s)
- Hugh Logan Ellis
- Department of Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Mohammad Al-Agil
- Department of Basic and Clinical Neuroscience, School of Neuroscience, King's College London, London, UK
| | - Philip A Kelly
- Department of Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - James Teo
- Department of Basic and Clinical Neuroscience, School of Neuroscience, King's College London, London, UK
| | - Claire Sharpe
- Renal Sciences, Department of Inflammation Biology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Martin B Whyte
- Department of Medicine, King's College Hospital NHS Foundation Trust, London, UK.
- Department of Medicine, King's College Hospital NHS Foundation Trust, London, UK.
| |
Collapse
|
6
|
Holleck JL, Han L, Skanderson M, Bastian LA, Gunderson CG, Brandt CA, Perkal M, Chang JJ, Akgün KM. Risk of Serious Adverse Gastrointestinal Events with Potassium Binders in Hospitalized Patients: A National Study. J Gen Intern Med 2024:10.1007/s11606-024-08979-1. [PMID: 39103605 DOI: 10.1007/s11606-024-08979-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 07/26/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Concerns about serious adverse gastrointestinal (GI) events with sodium polystyrene sulfonate (SPS) led to development of two new potassium binders, patiromer and sodium zirconium cyclosilicate (SZC), for treatment of hyperkalemia. OBJECTIVE To compare risk of intestinal ischemia/thrombosis or other serious GI events associated with SPS, patiromer, or SZC in hospitalized patients. DESIGN Retrospective cohort study. PARTICIPANTS National sample of 3,144,960 veterans hospitalized 2016-2022 in the U.S. Department of Veterans Affairs Healthcare System. MAIN MEASURES Demographics, comorbidities, medications and outcomes were ascertained from the VA Corporate Data Warehouse. Exposures were SPS, patiromer, SZC. Outcomes were 30-day intestinal ischemia/thrombosis, and a composite of intestinal ischemia/thrombosis, peptic ulcer/perforation or bowel resection/ostomy. KEY RESULTS Potassium binders were used during 39,270 (1.3%) hospitalizations: SPS = 30,040 (1.0%), patiromer = 3,750 (0.1%), and SZC = 5,520 (0.2%). Intestinal ischemia/thrombosis occurred with 106/30,040 (0.4%) SPS, 12/3750 (0.3%) patiromer and 24/5520 (0.4%) SZC, vs. 6998/3,105,650 (0.2%) without potassium binder. Adjusted odds ratios (aOR) were 1.40 [95% CI, 1.16 to 1.69] with SPS, 1.36 [CI, 0.79 to 2.36] with patiromer, and 1.78 [CI, 1.21 to 2.63] with SZC exposures. Composite GI adverse events occurred with 754/30,040 (2.5%) SPS, 96/3750 (2.6%) patiromer, 2.6% SZC, vs. 144/5520 (2.4%) without binder; aOR were 1.00 [CI, 0.94 to 1.08] with SPS, 1.08 [CI, 0.89 to 1.32] with patiromer, and 1.08 [CI, 0.93 to 1.27] with SZC exposures. No statistical difference in intestinal ischemia/thrombosis between each new agent and SPS was seen (p = 0.274 for SPS vs. SZC; p = 0.916 for SPS vs. patiromer). CONCLUSION Risk of intestinal ischemia/thrombosis or other serious adverse GI events was low and did not differ across three potassium-binding drugs.
Collapse
Affiliation(s)
- Jürgen L Holleck
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.
| | - Ling Han
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Melissa Skanderson
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Lori A Bastian
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Craig G Gunderson
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Cynthia A Brandt
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Biomedical Informatics & Data Science, Yale School of Medicine, New Haven, CT, USA
| | - Melissa Perkal
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
- Department of Surgery, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - John J Chang
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Kathleen M Akgün
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| |
Collapse
|
7
|
Rydell A, Thackrey C, Molki M, Mullins BP. Effectiveness of Patiromer Versus Sodium Zirconium Cyclosilicate for the Management of Acute Hyperkalemia. Ann Pharmacother 2024; 58:790-795. [PMID: 37953506 DOI: 10.1177/10600280231209968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Patiromer and sodium zirconium cyclosilicate (SZC) are 2 oral potassium binders approved for chronic hyperkalemia. It is unknown if one is more effective at reducing serum potassium than the other in acute hyperkalemia. OBJECTIVE The objective of this study was to determine if there was a difference between patiromer and SZC in the reduction of serum potassium in patients with acute hyperkalemia. METHODS This was a single-center, retrospective, observational study. Patients with a nonhemolyzed serum potassium level of 5.5 mEq/L or greater and received at least one dose of patiromer or SZC were included. The primary outcome was to determine the difference in effectiveness between patiromer and SZC in lowering of serum potassium 6 to 24 hours after administration. Secondary outcomes included description of total dosage received in 24 hours and incidence of electrolyte changes. RESULTS A total of 200 patients were included in this study, with 100 patients in each group. Serum potassium was significantly reduced by both patiromer (-1.2 mEq/L, 95% confidence interval [CI]: -2.3 to -0.2) and SZC (-0.8 mEq/L, 95% CI: -1.0 to -0.7), but there was no difference between the 2 medications in the amount of potassium reduction (P = 0.464). No clinically significant differences in electrolyte changes were seen. CONCLUSIONS AND RELEVANCE This study represents the first head-to-head comparison of patiromer and SZC in the setting of acute hyperkalemia. No difference in effectiveness between patiromer and SZC in reducing serum potassium was seen. Both agents can be considered in acute hyperkalemia management.
Collapse
Affiliation(s)
- Alison Rydell
- Pharmacy Department, Carle Foundation Hospital, Urbana, IL, USA
| | | | - Maryam Molki
- Pharmacy Department, St. Luke's Hospital, Chesterfield, MO, USA
| | | |
Collapse
|
8
|
Mårup FH, Peters CD, Nielsen SF, Nygaard L, Madsen B, Mose FH, Birn H. Patiromer to Reduce Albuminuria Through Increased Renin Angiotensin Aldosterone System Inhibition in Patients With CKD-A Feasibility Trial. Kidney Int Rep 2024; 9:2399-2409. [PMID: 39156169 PMCID: PMC11328543 DOI: 10.1016/j.ekir.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 04/11/2024] [Accepted: 05/06/2024] [Indexed: 08/20/2024] Open
Abstract
Introduction We tested the feasibility of adding a potassium binder to enable increased renin angiotensin aldosterone system inhibition (RAASi) and reduce albuminuria in patients with chronic kidney disease (CKD). In a controlled trial design, a potassium binder was introduced exclusively in patients developing hyperkalemia after intensified RAASi, thereby mirroring clinical decision-making. Methods We planned to include 140 patients aged 18 to 80 years with estimated glomerular filtration rate (eGFR) 25 to 60 ml/min per 1.73 m2, albuminuria, and a history of hyperkalemia to an open-label, randomized trial comparing treatment with or without patiromer alongside maximally tolerated RAASi. Patients were randomized only if developing a documented P-potassium >5.5 mmol/l during run-in with intensified RAASi (losartan/spironolactone). The primary end point was change in urine albumin-creatinine ratio (UACR). Results Screening among 800,000 individuals with available laboratory results yielded just 317 candidates meeting major selection criteria during 18⅔ months, with 75 ultimately included. Among them, only 23 developed P-potassium >5.5 mmol/l, qualifying for randomization. Consequently, only 20 participants completed the study, falling short of the planned 98, precluding a significant effect on the primary outcome. Inclusion and randomization challenges stemmed from a limited pool of eligible patients for intensified RAASi at risk of hyperkalemia, along with a lower than expected incidence of hyperkalemia during run-in. Conclusion Despite extensive screening efforts, few eligible patients were identified, and fewer developed hyperkalemia during run-in. Hence, a trial design limited to CKD patients at high hyperkalemia risk and including a run-in phase appears unlikely to provide evidence for a potential renal benefit from additional use of potassium binders.
Collapse
Affiliation(s)
- Frederik H. Mårup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Christian D. Peters
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Steffen F. Nielsen
- University Clinic in Nephrology and Hypertension, Gødstrup Hospital, Herning, Denmark
| | - Louis Nygaard
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Bo Madsen
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Frank H. Mose
- University Clinic in Nephrology and Hypertension, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Henrik Birn
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
9
|
Li H, Gu X, Qiu L, Wang X, Li Y. The Effect of Dietary Fiber on Hyperkalemia in Maintenance Hemodialysis Patients: A Cross-Sectional Study. J Ren Nutr 2024:S1051-2276(24)00168-7. [PMID: 39074597 DOI: 10.1053/j.jrn.2024.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 05/30/2024] [Accepted: 07/21/2024] [Indexed: 07/31/2024] Open
Abstract
OBJECTIVE To explore the relationship between dietary fiber (DF) intake and hyperkalemia in maintenance hemodialysis (MHD) patients. METHODS A total of 110 MHD patients were included, including 67 males and 43 females. Patients were divided into normal serum potassium group (N) and a hyperkalemia group (H) according to the serum potassium level before dialysis. The daily diet was recorded by the 3-day dietary recording method. The daily dietary nutrient intake of patients was analyzed. Logistic regression was used to analyze the relationship between hyperkalemia and DF intake. A receiver operating characteristic curve was used to analyze the cutoff value of DF intake to prevent hyperkalemia. RESULTS Of the 110 patients, 38 had hyperkalemia (serum potassium >5.5 mmol/L) before dialysis. There was no difference in sex, residual kidney function, body mass index, energy intake, fat intake, protein intake, calcium intake, sodium intake, phosphorus intake or the administration history of potassium-lowering drugs between the 2 groups (P > .05). Compared with the H group, patients in the N group had higher carbohydrate intake (315 ± 76 g/d vs. 279 ± 66 g/d, P = .016), dietary fiber intake (19 ± 5 g/d vs. 12 ± 8 g/d, P < .0001), and potassium intake (1,698 ± 392 mg/d vs. 1,533 ± 413 mg/d, P = .041), and more patients in group N used renin-angiotensin-aldosterone system inhibitors (52.78% vs. 23.68%, P = .003). However, the number of patients with constipation in group N was less than that in group H (20.83% vs. 42.11%, P = .018). Logistic regression analysis showed that DF intake was an independent protective factor for hyperkalemia [P < .0001, odds ratio = 0.766 (95% confidence intervals: 0.675-0.870)]. Receiver operating characteristic analysis showed that daily intake of DF greater than 15.33 g may be helpful to prevent hyperkalemia. CONCLUSION Insufficient dietary nutrient intake is prevalent in MHD patients, especially DF intake, which may be associated with hyperkalemia. Clinically, attention should be given to the dietary balance of MHD patients, especially DF intake.
Collapse
Affiliation(s)
- Hui Li
- Department of Nephrology, Lingcheng District People's Hospital, Dezhou, Shandong, China
| | - Xin Gu
- Department of Emergency, Lingcheng District People's Hospital, Dezhou, Shandong, China
| | - Likui Qiu
- Department of Orthopaedics, Lingcheng District People's Hospital, Dezhou, Shandong, China
| | - Xianghua Wang
- Department of Orthopaedics, Lingcheng District People's Hospital, Dezhou, Shandong, China
| | - Yang Li
- Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Nephrology, Jinan, Shandong, China.
| |
Collapse
|
10
|
Tungsanga S, Bello AK. Prevention of Chronic Kidney Disease and Its Complications in Older Adults. Drugs Aging 2024; 41:565-576. [PMID: 38926293 DOI: 10.1007/s40266-024-01128-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2024] [Indexed: 06/28/2024]
Abstract
In an era marked by a global demographic shift towards an aging society, there is a heightened prevalence of chronic kidney disease (CKD) among older adults. The burden of CKD spans from kidney-related complications to impacting psychological well-being, giving rise to depressive symptoms and caregiver burnout. This article delves into CKD prevention strategies within the context of aging, contributing to the discourse by exploring its multifaceted aspects. The prevention of CKD in the older adults necessitates a comprehensive approach. Primary prevention is centered on the modification of risk factors, acknowledging the intricate interplay of various comorbidities. Secondary prevention focuses on early CKD identification. Tertiary prevention aims to address factors contributing to CKD progression and complications, emphasizing the importance of timely interventions. This comprehensive strategy aims to enhance the quality of life for individuals affected by CKD, decelerating the deterioration of functional status. By addressing CKD at multiple levels, this approach seeks to effectively and compassionately care for the aging population.
Collapse
Affiliation(s)
- Somkanya Tungsanga
- Division of Nephrology and Immunology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Division of General Internal Medicine-Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Aminu K Bello
- Division of Nephrology and Immunology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
| |
Collapse
|
11
|
Li X, Ma F, Wang Y, Zhao H, Gao J. Incidence of hyperkalemia in anuric hemodialysis patients treated with sacubitril/valsartan. Hemodial Int 2024; 28:336-342. [PMID: 38558252 DOI: 10.1111/hdi.13150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/26/2024] [Accepted: 03/14/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Sacubitril/valsartan is increasingly used in hemodialysis patients due to its cardioprotective benefits. However, its impact on serum potassium levels in anuric patients undergoing hemodialysis remains controversial. METHODS We conducted a retrospective data from patients undergoing hemodialysis at two dialysis centers. A total of 71 out of 332 patients receiving hemodialysis treatment were enrolled. Mean serum potassium (mean value of 6-8 determinations), peak serum potassium (maximum K value observed during follow-up observations), and other biochemical parameters were recorded at baseline and during the follow-up period. FINDINGS After 6 months of follow-up, mean serum potassium increased from 4.84 ± 0.45 mmol/L at baseline to 5.07 ± 0.46 mmol/L at 3 months and 5.04 ± 0.46 mmol/L at 6 months (p < 0.001). Notably, no significant group differences were found in peak serum potassium concentrations between baseline and 6 months after sacubitril/valsartan therapy (5.69 ± 0.56 vs. 5.75 ± 0.41, p = 0.419). Prior to starting sacubitril/valsartan treatment, none of the patients had severe hyperkalemia; however, after 3 and 6 months of sacubitril/valsartan therapy, two (2.80%) and three (4.20%) patients experienced severe hyperkalemia, respectively; however, this difference was not statistically significant. Additionally, there was a significant reduction in blood pressure; however, serum sodium, bicarbonate, and Kt/V values did not change significantly during either period. DISCUSSION Sacubitril/valsartan therapy is associated with an increase in serum potassium levels in anuric hemodialysis patients. Nevertheless, the proportion of patients with severe hyperkalemia did not increase significantly. This suggests that the use of sacubitril/valsartan in anuric patients on hemodialysis is relatively safe.
Collapse
Affiliation(s)
- Xiaofan Li
- Department of Nephrology, Peking University Shougang Hospital, Beijing, China
| | - Fei Ma
- Blood Purification Center, Chifeng Municipal Hospital, Chifeng, China
| | - Yan Wang
- Department of Internal Medicine, Beijing, China
| | - Haidan Zhao
- Department of Nephrology, Peking University Shougang Hospital, Beijing, China
| | - Jianjun Gao
- Department of Nephrology, The Chinese PLA Strategic Support Force Characteristic Medical Center, Beijing, China
| |
Collapse
|
12
|
Murea M, Raimann JG, Divers J, Maute H, Kovach C, Abdel-Rahman EM, Awad AS, Flythe JE, Gautam SC, Niyyar VD, Roberts GV, Jefferson NM, Shahidul I, Nwaozuru U, Foley KL, Trembath EJ, Rosales ML, Fletcher AJ, Hiba SI, Huml A, Knicely DH, Hasan I, Makadia B, Gaurav R, Lea J, Conway PT, Daugirdas JT, Kotanko P. Comparative effectiveness of an individualized model of hemodialysis vs conventional hemodialysis: a study protocol for a multicenter randomized controlled trial (the TwoPlus trial). Trials 2024; 25:424. [PMID: 38943204 PMCID: PMC11212207 DOI: 10.1186/s13063-024-08281-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/20/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Most patients starting chronic in-center hemodialysis (HD) receive conventional hemodialysis (CHD) with three sessions per week targeting specific biochemical clearance. Observational studies suggest that patients with residual kidney function can safely be treated with incremental prescriptions of HD, starting with less frequent sessions and later adjusting to thrice-weekly HD. This trial aims to show objectively that clinically matched incremental HD (CMIHD) is non-inferior to CHD in eligible patients. METHODS An unblinded, parallel-group, randomized controlled trial will be conducted across diverse healthcare systems and dialysis organizations in the USA. Adult patients initiating chronic hemodialysis (HD) at participating centers will be screened. Eligibility criteria include receipt of fewer than 18 treatments of HD and residual kidney function defined as kidney urea clearance ≥3.5 mL/min/1.73 m2 and urine output ≥500 mL/24 h. The 1:1 randomization, stratified by site and dialysis vascular access type, assigns patients to either CMIHD (intervention group) or CHD (control group). The CMIHD group will be treated with twice-weekly HD and adjuvant pharmacologic therapy (i.e., oral loop diuretics, sodium bicarbonate, and potassium binders). The CHD group will receive thrice-weekly HD according to usual care. Throughout the study, patients undergo timed urine collection and fill out questionnaires. CMIHD will progress to thrice-weekly HD based on clinical manifestations or changes in residual kidney function. Caregivers of enrolled patients are invited to complete semi-annual questionnaires. The primary outcome is a composite of patients' all-cause death, hospitalizations, or emergency department visits at 2 years. Secondary outcomes include patient- and caregiver-reported outcomes. We aim to enroll 350 patients, which provides ≥85% power to detect an incidence rate ratio (IRR) of 0.9 between CMIHD and CHD with an IRR non-inferiority of 1.20 (α = 0.025, one-tailed test, 20% dropout rate, average of 2.06 years of HD per patient participant), and 150 caregiver participants (of enrolled patients). DISCUSSION Our proposal challenges the status quo of HD care delivery. Our overarching hypothesis posits that CMIHD is non-inferior to CHD. If successful, the results will positively impact one of the highest-burdened patient populations and their caregivers. TRIAL REGISTRATION Clinicaltrials.gov NCT05828823. Registered on 25 April 2023.
Collapse
Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA.
| | | | - Jasmin Divers
- Department of Foundations of Medicine, Center for Population and Health Services Research, NYU Grossman Long Island School of Medicine, New York, NY, USA
| | - Harvey Maute
- Department of Foundations of Medicine, Center for Population and Health Services Research, NYU Grossman Long Island School of Medicine, New York, NY, USA
| | - Cassandra Kovach
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Emaad M Abdel-Rahman
- Division of Nephrology, University of Virginia Health System, Charlottesville, VA, USA
| | - Alaa S Awad
- Division of Nephrology, University of Florida, Jacksonville, FL, USA
| | - Jennifer E Flythe
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC, USA
| | - Samir C Gautam
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Vandana D Niyyar
- Division of Nephrology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Glenda V Roberts
- External Relations and Patient Engagement, Division of Nephrology, Department of Medicine, Kidney Research Institute and Center for Dialysis Innovation, University of Washington, Seattle, WA, USA
| | | | - Islam Shahidul
- Department of Foundations of Medicine, Center for Population and Health Services Research, NYU Grossman Long Island School of Medicine, New York, NY, USA
| | - Ucheoma Nwaozuru
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Kristie L Foley
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | | | - Alison J Fletcher
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Sheikh I Hiba
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Anne Huml
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Daphne H Knicely
- Division of Nephrology, University of Virginia Health System, Charlottesville, VA, USA
| | - Irtiza Hasan
- Division of Nephrology, University of Florida, Jacksonville, FL, USA
| | | | - Raman Gaurav
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Janice Lea
- Division of Nephrology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Paul T Conway
- American Association of Kidney Patients, Tampa, FL, USA
| | - John T Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois College of Medicine, Chicago, IL, USA
| | - Peter Kotanko
- Department of Internal Medicine, Section on Nephrology, LLC Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| |
Collapse
|
13
|
Arici M, Altun B, Araz M, Atmaca A, Demir T, Ecder T, Guz G, Gogas Yavuz D, Yildiz A, Yilmaz T. The significance of finerenone as a novel therapeutic option in diabetic kidney disease: a scoping review with emphasis on cardiorenal outcomes of the finerenone phase 3 trials. Front Med (Lausanne) 2024; 11:1384454. [PMID: 38947237 PMCID: PMC11214281 DOI: 10.3389/fmed.2024.1384454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/22/2024] [Indexed: 07/02/2024] Open
Abstract
This scoping review prepared by endocrinology and nephrology experts aimed to address the significance of finerenone, as a novel therapeutic option, in diabetic kidney disease (DKD), based on the biological prospect of cardiorenal benefit due to non-steroidal mineralocorticoid receptor antagonist (MRA) properties, and the recent evidence from the finerenone phase 3 program clinical trials. The importance of finerenone in slowing DKD progression was critically reviewed in relation to the role of MR overactivation in the pathogenesis of cardiorenal disease and unmet needs in the current practice patterns. The efficacy and safety outcomes of finerenone phase III study program including FIDELIO-DKD, FIGARO-DKD and FIDELITY were presented. Specifically, perspectives on inclusion of patients with preserved estimated glomerular filtration rate (eGFR) or high albuminuria, concomitant use of sodium-glucose co-transporter-2 inhibitor (SGLT2i) or glucagon-like peptide 1 receptor agonist (GLP-1 RA), baseline glycated hemoglobin (HbA1c) level and insulin treatment, clinically meaningful heart failure outcomes and treatment-induced hyperkalemia were addressed. Finerenone has emerged as a new therapeutic agent that slows DKD progression, reduces albuminuria and risk of cardiovascular complications, regardless of the baseline HbA1c levels and concomitant treatments (SGLT2i, GLP-1 RA, or insulin) and with a favorable benefit-risk profile. The evolving data on the benefit of SGLT2is and non-steroidal MRAs in slowing or reducing cardiorenal risk seem to provide the opportunity to use these pillars of therapy in the management of DKD, after a long-period of treatment scarcity in this field. Along with recognition of the albuminuria as a powerful marker to detect those patients at high risk of cardiorenal disease, these important developments would likely to impact standard-of-care options in the setting of DKD.
Collapse
Affiliation(s)
- Mustafa Arici
- Department of Nephrology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| | - Bulent Altun
- Department of Nephrology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| | - Mustafa Araz
- Department of Endocrinology and Metabolic Diseases, Gaziantep University Faculty of Medicine, Gaziantep, Türkiye
| | - Aysegul Atmaca
- Department of Endocrinology and Metabolic Diseases, Ondokuz Mayis University Faculty of Medicine, Samsun, Türkiye
| | - Tevfik Demir
- Department of Endocrinology and Metabolic Diseases, Dokuz Eylul University Faculty of Medicine, Izmir, Türkiye
| | - Tevfik Ecder
- Department of Nephrology, Istinye University Faculty of Medicine, Istanbul, Türkiye
| | - Galip Guz
- Department of Nephrology, Gazi University Faculty of Medicine, Ankara, Türkiye
| | - Dilek Gogas Yavuz
- Section of Endocrinology and Metabolism, Marmara University School of Medicine, Istanbul, Türkiye
| | - Alaattin Yildiz
- Department of Nephrology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - Temel Yilmaz
- Clinics of Endocrinology and Metabolic Diseases, Florence Nightingale Hospital, Istanbul, Türkiye
| |
Collapse
|
14
|
Yap DYH, Ma RCW, Wong ECK, Tsui MSH, Yu EYT, Yu V, Szeto CC, Pang WF, Tse HF, Siu DCW, Tan KCB, Chen WWC, Li CL, Chen W, Chan TM. Consensus statement on the management of hyperkalaemia-An Asia-Pacific perspective. Nephrology (Carlton) 2024; 29:311-324. [PMID: 38403867 DOI: 10.1111/nep.14281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/17/2024] [Accepted: 02/07/2024] [Indexed: 02/27/2024]
Abstract
Hyperkalaemia is an electrolyte imbalance that impairs muscle function and myocardial excitability, and can potentially lead to fatal arrhythmias and sudden cardiac death. The prevalence of hyperkalaemia is estimated to be 6%-7% worldwide and 7%-10% in Asia. Hyperkalaemia frequently affects patients with chronic kidney disease, heart failure, and diabetes mellitus, particularly those receiving treatment with renin-angiotensin-aldosterone system (RAAS) inhibitors. Both hyperkalaemia and interruption of RAAS inhibitor therapy are associated with increased risks for cardiovascular events, hospitalisations, and death, highlighting a clinical dilemma in high-risk patients. Conventional potassium-binding resins are widely used for the treatment of hyperkalaemia; however, caveats such as the unpalatable taste and the risk of gastrointestinal side effects limit their chronic use. Recent evidence suggests that, with a rapid onset of action and improved gastrointestinal tolerability, novel oral potassium binders (e.g., patiromer and sodium zirconium cyclosilicate) are alternative treatment options for both acute and chronic hyperkalaemia. To optimise the care for patients with hyperkalaemia in the Asia-Pacific region, a multidisciplinary expert panel was convened to review published literature, share clinical experiences, and ultimately formulate 25 consensus statements, covering three clinical areas: (i) risk factors of hyperkalaemia and risk stratification in susceptible patients; (ii) prevention of hyperkalaemia for at-risk individuals; and (iii) correction of hyperkalaemia for at-risk individuals with cardiorenal disease. These statements were expected to serve as useful guidance in the management of hyperkalaemia for health care providers in the region.
Collapse
Affiliation(s)
- Desmond Y H Yap
- Division of Nephrology, Department of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Ronald C W Ma
- Division of Endocrinology and Diabetes, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Emmanuel C K Wong
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Matthew S H Tsui
- Department of Accident and Emergency, Queen Mary Hospital, Hong Kong SAR, China
| | - Esther Y T Yu
- Department of Family Medicine and Primary Care, University of Hong Kong, Hong Kong SAR, China
| | - Vivien Yu
- Department of Dietetics, Queen Mary Hospital, Hong Kong SAR, China
| | - Cheuk Chun Szeto
- Division of Nephrology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Wing Fai Pang
- Division of Nephrology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - David C W Siu
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Kathryn C B Tan
- Endocrinology and Metabolism Division, Department of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Walter W C Chen
- Division of Cardiology, Virtus Medical Group, Hong Kong SAR, China
| | - Chiu Leong Li
- Division of Nephrology, Centro Hospitalar Conde de São Januário, Macau SAR, China
| | - Wei Chen
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Tak Mao Chan
- Division of Nephrology, Department of Medicine, University of Hong Kong, Hong Kong SAR, China
| |
Collapse
|
15
|
Savarese G, Lindberg F, Christodorescu RM, Ferrini M, Kumler T, Toutoutzas K, Dattilo G, Bayes-Genis A, Moura B, Amir O, Petrie MC, Seferovic P, Chioncel O, Metra M, Coats AJS, Rosano GMC. Physician perceptions, attitudes, and strategies towards implementing guideline-directed medical therapy in heart failure with reduced ejection fraction. A survey of the Heart Failure Association of the ESC and the ESC Council for Cardiology Practice. Eur J Heart Fail 2024; 26:1408-1418. [PMID: 38515385 DOI: 10.1002/ejhf.3214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/14/2024] [Accepted: 03/13/2024] [Indexed: 03/23/2024] Open
Abstract
AIMS Recent guidelines recommend four core drug classes (renin-angiotensin system inhibitor/angiotensin receptor-neprilysin inhibitor [RASi/ARNi], beta-blocker, mineralocorticoid receptor antagonist [MRA], and sodium-glucose cotransporter 2 inhibitor [SGLT2i]) for the pharmacological management of heart failure (HF) with reduced ejection fraction (HFrEF). We assessed physicians' perceived (i) comfort with implementing the recent HFrEF guideline recommendations; (ii) status of guideline-directed medical therapy (GDMT) implementation; (iii) use of different GDMT sequencing strategies; and (iv) barriers and strategies for achieving implementation. METHODS AND RESULTS A 26-question survey was disseminated via bulletin, e-mail and social channels directed to physicians with an interest in HF. Of 432 respondents representing 91 countries, 36% were female, 52% were aged <50 years, and 90% mainly practiced in cardiology (30% HF). Overall comfort with implementing quadruple therapy was high (87%). Only 12% estimated that >90% of patients with HFrEF without contraindications received quadruple therapy. The time required to initiate quadruple therapy was estimated at 1-2 weeks by 34% of respondents, 1 month by 36%, 3 months by 24%, and ≥6 months by 6%. The average respondent favoured traditional drug sequencing strategies (RASi/ARNi with/followed by beta-blocker, and then MRA with/followed by SGLT2i) over simultaneous initiation or SGLT2i-first sequences. The most frequently perceived clinical barriers to implementation were hypotension (70%), creatinine increase (47%), hyperkalaemia (45%) and patient adherence (42%). CONCLUSIONS Although comfort with implementing all four core drug classes in patients with HFrEF was high among physicians, a majority estimated implementation of GDMT in HFrEF to be low. We identified several important perceived clinical and non-clinical barriers that can be targeted to improve implementation.
Collapse
Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ruxandra M Christodorescu
- Department V Internal Medicine, University of Medicine and Pharmacy V. Babes Timisoara, Institute of Cardiology Research Center, Timișoara, Romania
| | - Marc Ferrini
- Department of Cardiology and Vascular Pathology, CH Saint Joseph and Saint Luc, Lyon, France
| | - Thomas Kumler
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Denmark
| | - Konstantinos Toutoutzas
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, 'Hippokration' General Hospital of Athens, Athens, Greece
| | - Giuseppe Dattilo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Antoni Bayes-Genis
- Institut del Cor, Hospital Universitari Germans Trias I Pujol, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV; Departamento de Medicina, Universitat Autònoma de Barcelona), Barcelona, Spain
| | - Brenda Moura
- Armed Forces Hospital, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Offer Amir
- Heart Institute, Hadassah Medical Center & Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, The University Court of the University of Glasgow, Glasgow, UK
| | - Petar Seferovic
- University Medical Center, Medical Faculty University of Belgrade, Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Giuseppe M C Rosano
- Cardiovascular Clinical Academic Group, St George's University Hospital, London, UK
- Cardiology, IRCCS San Raffaele, Rome, Italy
| |
Collapse
|
16
|
Stawowczyk E, Ward T, Paoletti E, Senni M, de Arellano AR. Hyperkalemia in chronic kidney disease patients with and without heart failure: an Italian economic modelling study. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2024; 22:42. [PMID: 38769560 PMCID: PMC11106859 DOI: 10.1186/s12962-024-00547-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 04/18/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Hyperkalemia (HK) is frequently present in chronic kidney disease (CKD). Risk factors for HK among CKD patients include comorbidities and renin-angiotensin-aldosterone system inhibitor (RAASi) treatment. Current standard of care (SoC) often necessitates RAASi down-titration or discontinuation, resulting in poorer cardiorenal outcomes, hospitalization and mortality. This study evaluates the cost-effectiveness of patiromer for HK in CKD patients with and without heart failure (HF) in an Italian setting. METHODS A lifetime Markov cohort model was developed based on OPAL-HK to assess the health economic impact of patiromer therapy in comparison to SoC after accounting for the effects of HK and RAASi use on clinical events. Outcomes included accumulated clinical events, number needed to treat (NNT) and the incremental cost-effectiveness ratio (ICER). Subgroup analysis was conducted in CKD patients with and without HF. RESULTS Patiromer was associated with an incremental discounted cost of €4,660 and 0.194 quality adjusted life years (QALYs), yielding an ICER of €24,004. Per 1000 patients, patiromer treatment prevented 275 moderate/severe HK events, 54 major adverse cardiovascular event, 246 RAASi discontinuation and 213 RAASi up-titration/restart. Subgroup analysis showed patiromer was more effective in preventing clinical events in CKD patients with HF compared to those without; QALY gains were greater in CKD patients without HF versus those with HF (0.267 versus 0.092, respectively). Scenario analysis and sensitivity analysis results support base-case conclusions. CONCLUSION Patiromer is associated with QALY gains in CKD patients with and without HF compared to SoC in Italy. Patiromer prevented HK events, enabled RAASi therapy maintenance and reduced cardiovascular event risk.
Collapse
Affiliation(s)
- Ewa Stawowczyk
- Health Economics and Outcomes Research Ltd, Cardiff, UK.
| | - Thomas Ward
- Health Economics and Outcomes Research Ltd, Cardiff, UK
- Health Economics Group, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Ernesto Paoletti
- Nephrology, Dialysis and Transplantation, University of Genoa and Policlinico, San Martino Genoa, Italy
| | - Michele Senni
- Cardiovascular Department and Cardiology Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | |
Collapse
|
17
|
Cheema HA, Shafiee A, Teymouri Athar MM, Rafiei MA, Shahid A, Awan RU, Khan Minhas AM, Ahmad M, Nashwan AJ, Fudim M. Efficacy and Safety of Patiromer for Chronic Hyperkalemia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Am J Ther 2024; 31:e307-e311. [PMID: 37335598 DOI: 10.1097/mjt.0000000000001623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Affiliation(s)
| | - Arman Shafiee
- Clinical Research Development Unit, Alborz University of Medical Sciences, Karaj, Iran
- Student Research Committee, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | | | - Mohammad Ali Rafiei
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abia Shahid
- Department of Cardiology, King Edward Medical University, Lahore, Pakistan
| | | | | | - Mohsin Ahmad
- Department of Internal Medicine, Merit Health Wesley, Hattiesburg, MS
| | | | - Marat Fudim
- Department of Medicine, Duke University Medical Center, Durham, NC; and
- Department of Cardiology, Duke Clinical Research Institute, Durham, NC
| |
Collapse
|
18
|
Riccio E, D'Ercole A, Sannino A, Hamzeh S, De Marco O, Capuano I, Buonanno P, Rizzo M, Pisani A. Real-world management of chronic and postprandial hyperkalemia in CKD patients treated with patiromer: a single-center retrospective study. J Nephrol 2024; 37:1077-1084. [PMID: 38319545 DOI: 10.1007/s40620-024-01897-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/07/2024] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Hyperkalemia, one of the most important electrolyte abnormalities of chronic kidney disease (CKD), often limits the use of renin-angiotensin-aldosterone system inhibitors and can increase in the postprandial period. In this study we report a real-world experience with the new non-adsorbed potassium binder patiromer in stage 3b-4 CKD patients. Moreover, we performed a cross-sectional analysis to evaluate, for the first time, the efficacy of patiromer in the control of postprandial potassium concentrations. METHODS We retrospectively collected data of 40 patients at the time of patiromer initiation (T0), and after 2 (T2), 6 (T6) and 12 (T12) months of treatment. For cross sectional analysis, a blood sample was collected 2 h after the main meal for the evaluation of postprandial potassium concentrations. RESULTS Eighty-two point five percent of patients (33/40) reached normal potassium concentrations at T2. Serum potassium significantly decreased at T2 compared to T0 (5.13 ± 0.48 vs 5.77 ± 0.41 mmol/L, respectively; p < 0.001) and the reduction remained significant during the follow-up (5.06 ± 0.36 at T6 and 5.77 ± 0.41 at T12; p < 0.001 vs T0). Renin-angiotensin-aldosterone system inhibitors were continued by 93% of patients (27/29). Adverse events were reported in 27.5% of patients and were all mild-to-moderate. Postprandial potassium concentrations did not significantly change compared to fasting state potassium measured at T12 (4.53 ± 0.33 vs 5.06 ± 0.36 mmol/L; p = 0.15). CONCLUSIONS In a real-world setting of advanced CKD patients, patiromer is a useful treatment for hyperkalemia, since it significantly reduces serum potassium levels over the long term and is able to maintain potassium concentrations in the normal range even in the post-prandial period.
Collapse
Affiliation(s)
- Eleonora Riccio
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy.
| | - Anna D'Ercole
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Anna Sannino
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Sarah Hamzeh
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Oriana De Marco
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Ivana Capuano
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Pasquale Buonanno
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Manuela Rizzo
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Antonio Pisani
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| |
Collapse
|
19
|
Gonzalez-Ortiz A, Clase CM, Bosi A, Fu EL, Pérez-Guillé BE, Faucon AL, Evans M, Zoccali C, Carrero JJ. Evaluation of the introduction of novel potassium binders in routine care; the Stockholm CREAtinine measurements (SCREAM) project. J Nephrol 2024; 37:961-972. [PMID: 38236474 PMCID: PMC11239771 DOI: 10.1007/s40620-023-01860-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/29/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND The pharmacological management of hyperkalemia traditionally considered calcium or sodium polystyrene sulfonate and, since recently, the novel binders patiromer and sodium zirconium cyclosilicate. We evaluated their patterns of use, duration of treatment and relative effectiveness/safety in Swedish routine care. METHODS Observational study of adults initiating therapy with sodium polystyrene sulfonate or a novel binder (sodium zirconium cyclosilicate or patiromer) in Stockholm 2019-2021. We quantified treatment duration by repeated dispensations, compared mean achieved potassium concentration within 60 days, and potential adverse events between treatments. RESULTS A total of 1879 adults started treatment with sodium polystyrene sulfonate, and 147 with novel binders (n = 41 patiromer and n = 106 sodium zirconium cyclosilicate). Potassium at baseline for all treatments was 5.7 mmol/L. Sodium polystyrene sulfonate patients stayed on treatment a mean of 61 days (14% filled ≥3 consecutive prescriptions) compared to 109 days on treatment (49% filled ≥3 prescriptions) for novel binders. After 15 days of treatment, potassium similarly decreased to 4.6 (SD 0.6) and 4.8 (SD 0.6) mmol/L in the sodium polystyrene sulfonate and novel binder groups, respectively, and was maintained over the 60 days post-treatment. In multivariable regression, the odds ratio for novel binders (vs sodium polystyrene sulfonate) in reaching potassium ≤ 5.0 mmol/L after 15 days was 0.65 (95% CI 0.38-1.10) and after 60 days 0.89 (95% CI 0.45-1.76). Hypocalcemia, hypokalemia, and initiation of anti-diarrheal/constipation medications were the most-commonly detected adverse events. In multivariable analyses, the OR for these events did not differ between groups. CONCLUSION We observed similar short-term effectiveness and safety for all potassium binders. However, treatment duration was longer for novel binders than for sodium polystyrene sulfonate.
Collapse
Affiliation(s)
- Ailema Gonzalez-Ortiz
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels Väg 12A, Box 281, 171 77, Stockholm, Solna, Sweden
- Translational Research Center, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - Catherine M Clase
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research and Methodology, McMaster University, Hamilton, ON, Canada
| | - Alessandro Bosi
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels Väg 12A, Box 281, 171 77, Stockholm, Solna, Sweden
| | - Edouard L Fu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels Väg 12A, Box 281, 171 77, Stockholm, Solna, Sweden
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Anne-Laure Faucon
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels Väg 12A, Box 281, 171 77, Stockholm, Solna, Sweden
- INSERM U1018, Department of Clinical Epidemiology, Centre for Epidemiology and Population Health, Paris-Saclay University, Gif-sur-Yvette, France
| | - Marie Evans
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Carmine Zoccali
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Juan-Jesús Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels Väg 12A, Box 281, 171 77, Stockholm, Solna, Sweden.
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.
| |
Collapse
|
20
|
Adenwalla SF, Hull KL, Graham-Brown MP. What to do with foundation therapies for heart failure for patients with end-stage kidney disease on haemodialysis. Br J Hosp Med (Lond) 2024; 85:1-10. [PMID: 38708982 DOI: 10.12968/hmed.2023.0452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
There is a significant burden of cardiovascular disease morbidity and mortality in the end-stage kidney disease population, driven by traditional and non-traditional risk factors. Despite its prevalence, heart failure is difficult to diagnose in the dialysis population due to overlapping clinical presentations, limitations of investigations, and the impact on the cardiorenal axis. 'Foundation therapies' are the key medications which improve patient outcomes in heart failure with reduced ejection fraction and include beta-blockers, renin-angiotensin-aldosterone system inhibitors and sodium-glucose cotransporter-2 inhibitors. They are underutilised in the dialysis population due to the exclusion of chronic kidney disease patients from major trials and legitimate clinical concerns e.g. hyperkalaemia, intradialytic hypotension and residual kidney function preservation. A coordinated cardiorenal multidisciplinary approach can guide appropriate diagnostic considerations (biomarkers interpretation, imaging, addressing unique complications of kidney disease), optimise dialysis management (prescription length, frequency and ultrafiltration targets) and when at euvolaemia facilitate the stepwise introduction of appropriate foundation therapies.
Collapse
Affiliation(s)
- Sherna F Adenwalla
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Department of Renal Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Katherine L Hull
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Department of Renal Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Matthew Pm Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Department of Renal Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| |
Collapse
|
21
|
De Nicola L, Ferraro PM, Montagnani A, Pontremoli R, Dentali F, Sesti G. Recommendations for the management of hyperkalemia in patients receiving renin-angiotensin-aldosterone system inhibitors. Intern Emerg Med 2024; 19:295-306. [PMID: 37775712 PMCID: PMC10954964 DOI: 10.1007/s11739-023-03427-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/04/2023] [Indexed: 10/01/2023]
Abstract
Hyperkalemia is common in clinical practice and can be caused by medications used to treat cardiovascular diseases, particularly renin-angiotensin-aldosterone system inhibitors (RAASis). This narrative review discusses the epidemiology, etiology, and consequences of hyperkalemia, and recommends strategies for the prevention and management of hyperkalemia, mainly focusing on guideline recommendations, while recognizing the gaps or differences between the guidelines. Available evidence emphasizes the importance of healthcare professionals (HCPs) taking a proactive approach to hyperkalemia management by prioritizing patient identification and acknowledging that hyperkalemia is often a long-term condition requiring ongoing treatment. Given the risk of hyperkalemia during RAASi treatment, it is advisable to monitor serum potassium levels prior to initiating these treatments, and then regularly throughout treatment. If RAASi therapy is indicated in patients with cardiorenal disease, HCPs should first treat chronic hyperkalemia before reducing the dose or discontinuing RAASis, as reduction or interruption of RAASi treatment can increase the risk of adverse cardiovascular and renal outcomes or death. Moreover, management of hyperkalemia should involve the use of newer potassium binders, such as sodium zirconium cyclosilicate or patiromer, as these agents can effectively enable optimal RAASi treatment. Finally, patients should receive education regarding hyperkalemia, the risks of discontinuing their current treatments, and need to avoid excessive dietary potassium intake.
Collapse
Affiliation(s)
- Luca De Nicola
- Nephrology Unit, Advanced Medical and Surgical Sciences Department, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Pietro Manuel Ferraro
- U.O.S. Terapia Conservativa della Malattia Renale Cronica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy.
- Section of Nephrology, Department of Medicine, Università degli Studi di Verona, Verona, Italy.
| | - Andrea Montagnani
- Department of Internal Medicine, Hospital Misericordia, Grosseto, Italy
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, University of Rome-Sapienza, Rome, Italy
| |
Collapse
|
22
|
Wheeler DC, Søndergaard H, Gwynn C, Hedman K, Hedberg J, Allum A, Chung HL, Någård M, Stjernlöf G, Wittbrodt E, Kim J, Morris J. Randomised, blinded, cross-over evaluation of the palatability of and preference for different potassium binders in participants with chronic hyperkalaemia in the USA, Canada and Europe: the APPETIZE study. BMJ Open 2024; 14:e074954. [PMID: 38387989 PMCID: PMC10882352 DOI: 10.1136/bmjopen-2023-074954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 01/09/2024] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVES Traditional potassium (K+) binders for treating hyperkalaemia are unpalatable and poorly tolerated. Newer K+ binders are reportedly better tolerated; however, no published data describe their palatability, a determinant of long-term adherence. This study evaluated the palatability of and preference for three K+ binders: sodium and calcium polystyrene sulfonate (S/CPS), sodium zirconium cyclosilicate (SZC) and calcium patiromer sorbitex (patiromer). DESIGN Phase 4, randomised, participant-blinded, cross-over study. Participants were randomised to one of six taste sequences and, using a 'sip and spit' approach, tasted each K+ binder before completing a survey. SETTING 17 centres across the USA, Canada and European Union. PARTICIPANTS 144 participants with chronic kidney disease, hyperkalaemia and no recent use of K+ binders. MAIN OUTCOME MEASURES For the primary (USA) and key secondary (Canada and European Union) endpoints, participants rated palatability attributes (taste, texture, smell and mouthfeel) and willingness to take each K+ binder on a scale of 0-10 (rational evaluation). Feelings about each attribute, and the idea of taking the product once daily, were evaluated using a non-verbal, visual measure of emotional response. Finally, participants ranked the K+ binders according to palatability. RESULTS In each region, SZC and patiromer outperformed S/CPS on overall palatability (a composite of taste, texture, smell and mouthfeel), based on rational evaluation and emotional response. Taking the product once daily was more appealing for SZC and patiromer, creating greater receptivity than the idea of taking S/CPS. The emotional response to mouthfeel had the strongest influence on feelings about taking each product. In each region, a numerically greater proportion of participants ranked SZC as the most preferred K+ binder versus patiromer or S/CPS. CONCLUSIONS Preference for more palatable K+ binders such as SZC and patiromer may provide an opportunity to improve adherence to long-term treatment of hyperkalaemia. TRIAL REGISTRATION NUMBER NCT04566653.
Collapse
Affiliation(s)
- David C Wheeler
- Department of Renal Medicine, Centre for Nephrology, University College London, London, UK
| | | | | | | | - Jonatan Hedberg
- BioPharmaceuticals Medical Evidence and Observational Research, AstraZeneca, Gothenburg, Sweden
| | - Alaster Allum
- UK Global Medical Affairs, AstraZeneca, Cambridge, UK
| | - Hui-Lan Chung
- BioPharmaceuticals Medical Evidence, AstraZeneca, Taipei, Taiwan
| | - Mats Någård
- Clinical Pharmacology and Safety Sciences, AstraZeneca, Gaithersburg, Maryland, USA
| | | | - Eric Wittbrodt
- Global Medical Affairs, BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Maryland, USA
| | - Jennifer Kim
- Global Pricing and Market Access, AstraZeneca, Gaithersburg, Maryland, USA
| | - Jon Morris
- AdSAM, Gainesville, Florida, USA
- College of Journalism and Communications, University of Florida, Gainesville, Florida, USA
| |
Collapse
|
23
|
Chen X, Li X, Zhang K, Lian K, Zhang W, Song Y, Kan C, Zhang J, Han F, Sun X, Guo Z. The role of a novel mineralocorticoid receptor antagonist, finerenone, in chronic kidney disease: mechanisms and clinical advances. Clin Exp Nephrol 2024; 28:125-135. [PMID: 37847437 DOI: 10.1007/s10157-023-02413-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/20/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) poses a significant health risk in contemporary society. Current CKD treatments primarily involve renin-angiotensin-aldosterone system inhibitors and mineralocorticoid receptor antagonists, albeit associated with hyperkalemia risks. A novel selective mineralocorticoid receptor antagonist, finerenone, offers a promising, safer alternative for CKD therapy. This review comprehensively assesses the role and efficacy of finerenone in CKD treatment by analyzing clinical and animal studies. Emerging evidence consistently supports finerenone's ability to effectively slow the progression of CKD. By targeting the mineralocorticoid receptor, finerenone not only mitigates renal damage but also exhibits a favorable safety profile, minimizing hyperkalemia concerns. CONCLUSION Finerenone emerges as a valuable addition to CKD therapy, demonstrating potential benefits in delaying CKD progression while minimizing side effects. Nevertheless, further clinical trials are necessary to provide a comprehensive understanding of its safety and efficacy.
Collapse
Affiliation(s)
- Xinping Chen
- Department of Nephrology, Affiliated Hospital of Weifang Medical University, Weifang, 261031, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, 261031, China
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, 2428 Yuhe Road, Weifang, 261031, China
| | - Xuan Li
- Department of Nephrology, Affiliated Hospital of Weifang Medical University, Weifang, 261031, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, 261031, China
| | - Kexin Zhang
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, 2428 Yuhe Road, Weifang, 261031, China
| | - Kexin Lian
- Department of Nephrology, Affiliated Hospital of Weifang Medical University, Weifang, 261031, China
| | - Wenqiang Zhang
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, 2428 Yuhe Road, Weifang, 261031, China
- Department of Pathology, Affiliated Hospital of Weifang Medical University, Weifang, 261031, China
| | - Yixin Song
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, 2428 Yuhe Road, Weifang, 261031, China
| | - Chengxia Kan
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, 261031, China
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, 2428 Yuhe Road, Weifang, 261031, China
| | - Jingwen Zhang
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, 261031, China
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, 2428 Yuhe Road, Weifang, 261031, China
| | - Fang Han
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, 2428 Yuhe Road, Weifang, 261031, China
- Department of Pathology, Affiliated Hospital of Weifang Medical University, Weifang, 261031, China
| | - Xiaodong Sun
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, 261031, China.
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, 2428 Yuhe Road, Weifang, 261031, China.
| | - Zhentao Guo
- Department of Nephrology, Affiliated Hospital of Weifang Medical University, Weifang, 261031, China.
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, 261031, China.
| |
Collapse
|
24
|
Palomo-Piñón S, Enciso-Muñoz JM, Meaney E, Díaz-Domínguez E, Cardona-Muller D, Pérez FP, Cantoral-Farfán E, Anda-Garay JC, Mijangos-Chavez J, Antonio-Villa NE. Strategies to prevent, diagnose and treat kidney disease related to systemic arterial hypertension: a narrative review from the Mexican Group of Experts on Arterial Hypertension. BMC Nephrol 2024; 25:24. [PMID: 38238661 PMCID: PMC10797813 DOI: 10.1186/s12882-023-03450-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 12/27/2023] [Indexed: 01/22/2024] Open
Abstract
This narrative review highlights strategies proposed by the Mexican Group of Experts on Arterial Hypertension endorsed to prevent, diagnose, and treat chronic kidney disease (CKD) related to systemic arterial hypertension (SAH). Given the growing prevalence of CKD in Mexico and Latin America caused by SAH, there is a need for context-specific approaches to address the effects of SAH, given the diverse population and unique challenges faced by the region. This narrative review provides clinical strategies for healthcare providers on preventing, diagnosing, and treating kidney disease related to SAH, focusing on primary prevention, early detection, evidence-based diagnostic approaches, and selecting pharmacological treatments. Key-strategies are focused on six fundamental areas: 1) Strategies to mitigate kidney disease in SAH, 2) early detection of CKD in SAH, 3) diagnosis and monitoring of SAH, 4) blood pressure targets in patients living with CKD, 5) hypertensive treatment in patients with CKD and 6) diuretics and Non-Steroidal Mineralocorticoid Receptor Inhibitors in Patients with CKD. This review aims to provide relevant strategies for the Mexican and Latin American clinical context, highlight the importance of a multidisciplinary approach to managing SAH, and the role of community-based programs in improving the quality of life for affected individuals. This position paper seeks to contribute to reducing the burden of SAH-related CKD and its complications in Mexico and Latin America.
Collapse
Affiliation(s)
- Silvia Palomo-Piñón
- Grupo de Expertos en Hipertensión Arterial México (GREHTA), Ciudad de México, México.
- Colaborador Externo, Unidad de Investigación Médica en Enfermedades Nefrológicas Siglo XXI (UIMENSXII), UMAE Hospital de Especialidades "Dr. Bernardo Sepúlveda G" Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México.
- Grupo Colaborativo en Hipertensión Arterial (GCHTA), Ciudad de México, México.
- Grupo de Expertos en Hipertensión Arterial México (GREHTA), Calle Retorno del Escorial #13, Col. El Dorado, Tlanepantla de Baz, Estado de México, 54020, México.
| | - José Manuel Enciso-Muñoz
- Grupo de Expertos en Hipertensión Arterial México (GREHTA), Ciudad de México, México
- Asociación Mexicana para la Prevención de la Aterosclerosis y sus Complicaciones A.C, Ciudad de México, México
| | - Eduardo Meaney
- Grupo de Expertos en Hipertensión Arterial México (GREHTA), Ciudad de México, México
- Escuela Superior de Medicina, Instituto Politecnico Nacional, Ciudad de México, México
| | - Ernesto Díaz-Domínguez
- Grupo de Expertos en Hipertensión Arterial México (GREHTA), Ciudad de México, México
- UMAE Hospital de Cardiología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - David Cardona-Muller
- Grupo de Expertos en Hipertensión Arterial México (GREHTA), Ciudad de México, México
- Universidad de Guadalajara, Guadalajara, Jalisco, México
| | - Fabiola Pazos Pérez
- Grupo de Expertos en Hipertensión Arterial México (GREHTA), Ciudad de México, México
- UMAE Hospital de Especialidades "Dr. Bernardo Sepúlveda G" Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Emilia Cantoral-Farfán
- Grupo de Expertos en Hipertensión Arterial México (GREHTA), Ciudad de México, México
- Jefatura de Nefrología, Hospital General De Zona Médico Familiar No. 8 Gilberto Flores Izquierdo, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Juan Carlos Anda-Garay
- Grupo de Expertos en Hipertensión Arterial México (GREHTA), Ciudad de México, México
- UMAE Hospital de Especialidades "Dr. Bernardo Sepúlveda G" Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Janet Mijangos-Chavez
- Grupo de Expertos en Hipertensión Arterial México (GREHTA), Ciudad de México, México
- Jefatura de Cardiología, UMAE Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Neftali Eduardo Antonio-Villa
- Grupo de Expertos en Hipertensión Arterial México (GREHTA), Ciudad de México, México
- Departamento de Endocrinologia, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| |
Collapse
|
25
|
Obi Y, Thomas F, Dashputre AA, Goedecke P, Kovesdy CP. Long-term Patiromer Use and Outcomes Among US Veterans With Hyperkalemia and CKD: A Propensity-Matched Cohort Study. Kidney Med 2024; 6:100757. [PMID: 38192434 PMCID: PMC10772292 DOI: 10.1016/j.xkme.2023.100757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024] Open
Abstract
Rationale & Objective Patiromer is a potassium binder approved for the long-term management of hyperkalemia. Although patiromer use among patients with advanced chronic kidney disease (CKD) has been shown to reduce the discontinuation of renin-angiotensin-aldosterone system inhibition therapy, it remains unclear whether patiromer can improve clinical outcomes. The aim of this study was to examine the association of long-term patiromer use with clinical outcomes among hyperkalemic patients with CKD. Study Design This was a longitudinal observational study. Setting & Participants We evaluated a national cohort of 854,217 US Veterans who had at least 1 serum potassium measurement of ≥5.1 mEq/L and were treated at US Department of Veterans Affairs health care facilities between January 2016 and September 2019. Exposure The exposure was long-term patiromer use. Outcomes The outcomes were as follows: (1) composite endpoint of kidney failure with replacement therapy (KFRT) or all-cause death and (2) all-cause death including the post-KFRT period. Analytical Approach Cox proportional Fine-Gray subdistribution hazard models were used in a propensity-matched cohort. Results Among 2,004 patients who ever used patiromer during the study period (0.2% of the cohort), 666 met the criteria for long-term patiromer use. We matched 308 long-term patiromer users to 308 nonusers based on propensity scores. The median estimated glomerular filtration rate was 23.5 mL/min/1.73m2, and the median potassium level was 5.2 mEq/L. Approximately 45% were on renin-angiotensin system inhibitor(s) at baseline. During follow-up, 93 patients developed KFRT, and 134 patients died. Long-term patiromer users, when compared to nonusers, experienced a 26% lower risk of the composite outcome (HR, 0.74; 95% CI, 0.53-1.01; P = 0.06) and a 41% lower risk of all-cause mortality (HR, 0.59; 95% CI, 0.41-0.84; P = 0.003). Limitations The study cohort included mostly male veterans with relatively short follow-up periods. Conclusions Long-term patiromer use was associated with a lower risk of all-cause mortality among patients with CKD and hyperkalemia. Long-term potassium binder use for hyperkalemia may improve clinical outcomes in CKD. Plain-Language Summary Hyperkalemia is a common complication of chronic kidney disease (CKD) and can result in the discontinuation of renin-angiotensin-aldosterone system inhibition therapy, a cornerstone of CKD management. Patiromer is a new potassium binder approved for the long-term management of hyperkalemia, but it remains unclear whether patiromer can improve clinical outcomes. We examined a cohort of US Veterans with hyperkalemia between January 2016 and September 2019 and found that patiromer use was uncommon for treating hyperkalemia during this study period. We then matched 308 long-term patiromer users and 308 nonusers based on propensity scores. Long-term patiromer users, when compared to nonusers, experienced a 26% lower risk of the composite outcome and a 41% lower risk of all-cause mortality. These findings indicate that long-term potassium binder use for hyperkalemia may improve clinical outcomes in CKD.
Collapse
Affiliation(s)
- Yoshitsugu Obi
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Fridtjof Thomas
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Ankur A. Dashputre
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
- Health Economics & Outcomes Research, Bausch Health US LLC, Bridgewater, NJ
| | - Patricia Goedecke
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
- Nephrology Section, Veterans Memphis Affairs Medical Center, Memphis, TN
| |
Collapse
|
26
|
Elsisi GH, Mahmoud MMI, Al-Humood K, Al-Yousef A. Cost-effectiveness analysis of sodium zirconium cyclosilicate for hyperkalemia among patients with chronic kidney disease or heart failure in Kuwait. J Med Econ 2024; 27:253-265. [PMID: 38318718 DOI: 10.1080/13696998.2024.2314930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/02/2024] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Our model was conducted from Kuwaiti payer's perspective to provide evidence on the cost-effectiveness of Sodium zirconium cyclosilicate (SZC) versus patiromer to correct and maintain serum potassium (K+) in combination with renin-angiotensin-aldosterone system inhibitors (RAASis) with different dose titration in patients with chronic kidney disease/heart failure (CKD/HF) with/without renal replacement therapy (RRT). METHODOLOGY The model was developed as a patient-level, fixed-time increment stochastic simulation to simulate the complexity of disease, including multiple coexisting and competing conditional risks. This model was established to compare SZC versus patiromer as a treatment for hyperkalemia (HK) among adult populations with underlying conditions of advanced CKD stages 3a-5 or HF to correct and maintain serum K + over a lifetime horizon. The clinical outcomes of SZC and patiromer were demonstrated through arm-specific K + trajectories extracted from the HARMONIZE trial and OPAL-HK trial, respectively. The utility data was captured from different studies. Direct medical cost was captured from local data from Kuwaiti hospitals. Sensitivity analyses were conducted to assess the uncertainty in the model. RESULTS Within different scenarios of CKD/HF, SZC was a cost-saving option, with/without RRT, whether one-off administration or repeated administration, except for one-off treatment administration among the HF cohort, which generated an incremental cost effectiveness ratio of KWD 331/quality adjusted life year (QALY). The incremental QALY of SZC ranged from 0.007 to 0.202. In addition, the savings observed with SZC fall within a range of KWD -60 to KWD -1,235 at serum K+ ≥ 5.1 mmol/L. CONCLUSION The evidence generated by our model recommends the inclusion of SZC as a treatment option to correct HK and maintain normal serum K + level for CKD/HF patients within the Kuwaiti healthcare system. The costs saved from reducing frequent HK episodes, RAASis discontinuation/down titration, major cardiovascular events, and hospitalization offset the drug acquisition cost of SZC.
Collapse
Affiliation(s)
- Gihan Hamdy Elsisi
- HTA Office, LLC, Cairo, Egypt
- Health Economics, American University in Cairo, Cairo, Egypt
| | | | | | - Anas Al-Yousef
- Head of Cardiology Department, Adan Hospital - MOH, Kuwait
| |
Collapse
|
27
|
Shockey W, Wiegel JJ, Parajuli S, Garg N, Swanson KJ, Mandelbrot DA. Potassium-lowering effects of sodium zirconium cyclosilicate in the early post-transplant period. Clin Transplant 2024; 38:e15156. [PMID: 37812572 DOI: 10.1111/ctr.15156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/08/2023] [Accepted: 09/24/2023] [Indexed: 10/11/2023]
Abstract
PROBLEM Hyperkalemia is a serious condition among intra-abdominal transplant recipients, and the safety and efficacy of sodium zirconium cyclosilicate (SZC) for its management during the early post-transplant period are not well-established. METHODS Adults who received at least one 10-g dose of SZC within 14 days after an intra-abdominal transplant between January 2020 and July 2022 were included in our study. The primary outcome was the change in potassium (K+) levels following the first SZC dose. Other analyses explored adjunctive potassium-lowering therapies, potential gastrointestinal complications, and patient subgroups based on therapy and transplant type. RESULTS Among the recipients (n = 46), 11 were kidney recipients, 26 were liver recipients, seven were simultaneous liver/kidney recipients, and two were simultaneous pancreas/kidney recipients. The mean time to first dose post-transplant was 7.6 (±4) days, and the mean change in serum K+ after the initial SZC dose was -.27 mEq (p = .001). No gastrointestinal complications were observed following the SZC dose. The mean increase in serum bicarbonate was .58 mEq (p = .41) following the first dose of SZC. Four kidney recipients required dialysis following the SZC dose. CONCLUSION This study represents the largest investigation on the use of SZC in transplant recipients. A single 10-g dose of SZC reduced serum K+ levels in all subgroups, while the use of adjunctive K+-lowering therapies did not provide additional reduction beyond the effects of SZC. Importantly, no gastrointestinal complications were observed. These findings suggest that SZC may be a safe and promising therapeutic option for hyperkalemia management following solid organ transplantation.
Collapse
Affiliation(s)
- William Shockey
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Joshua J Wiegel
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Sandesh Parajuli
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Neetika Garg
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kurtis J Swanson
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Didier A Mandelbrot
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| |
Collapse
|
28
|
Sinnathamby ES, Banh KT, Barham WT, Hernandez TD, De Witt AJ, Wenger DM, Klapper VG, McGregor D, Paladini A, Ahmadzadeh S, Shekoohi S, Kaye AD, Varrassi G. Hyperkalemia: Pharmacotherapies and Clinical Considerations. Cureus 2024; 16:e52994. [PMID: 38406030 PMCID: PMC10894645 DOI: 10.7759/cureus.52994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/26/2024] [Indexed: 02/27/2024] Open
Abstract
Hyperkalemia has been defined as a condition where a serum potassium level is >5.5 mmol/l. It is associated with fatal dysrhythmias and muscular dysfunction. Certain medical conditions, such as chronic kidney disease (CKD), diabetes mellitus, and others, can lead to hyperkalemia. Many of the signs of hyperkalemia are nonspecific. A history and physical examination can be beneficial in the diagnosis of the condition. In this regard, certain characteristic electrocardiogram findings are associated with hyperkalemia along with laboratory potassium levels. In acute and potentially lethal conditions, hyperkalemia treatments include glucose and insulin, bicarbonate, calcium gluconate, beta-2 agonists, hyperventilation, and dialysis. There are several drugs, both old and new, that can additionally aid in the reduction of serum potassium levels. The present investigation evaluated some of these different drugs, including sodium polystyrene sulfonate (SPS), sodium zirconium cyclosilicate (SZC), and patiromer. These drugs each have increased selectivity for potassium and work primarily in the gastrointestinal (GI) tract. Each of these medications has unique benefits and contraindications. Clinicians must be aware of these medications when managing patients with hyperkalemia.
Collapse
Affiliation(s)
- Evan S Sinnathamby
- Medicine, Louisiana State University Health Sciences Center, New Orleans, USA
| | - Kelly T Banh
- Medicine, Louisiana State University Health Sciences Center, New Orleans, USA
| | - William T Barham
- Medicine, Louisiana State University Health Sciences Center, New Orleans, USA
| | - Tyler D Hernandez
- Medicine, Louisiana State University Health Sciences Center, New Orleans, USA
| | - Audrey J De Witt
- Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Danielle M Wenger
- Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, USA
| | - Vincent G Klapper
- Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - David McGregor
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Antonella Paladini
- Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, ITA
| | - Shahab Ahmadzadeh
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Sahar Shekoohi
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | | |
Collapse
|
29
|
Gupta A, Kammerer J, Shaik I, Mukherjee KG, Oliveira J, Thakar C. Evaluation of longer- vs short-term use of patiromer on health care resource utilization in the patiromer longer-term use evaluation (VALUE) study. J Manag Care Spec Pharm 2024; 30:52-60. [PMID: 37966126 PMCID: PMC10775774 DOI: 10.18553/jmcp.2023.23100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
BACKGROUND Studies suggest that continuous long-term use of patiromer by patients with hyperkalemia is associated with less health care resource utilization compared with not using potassium binders. OBJECTIVE To retrospectively evaluate health care resource utilization and costs with longer-term adherent vs short-term use of patiromer. METHODS Time-restricted extracts from Optum's de-identified Clinformatics® Data Mart Database (CDM; January 2016-May 2019) and Symphony Health (SHA; January 2016-September 2018) deidentified databases were analyzed. Both include participants enrolled in commercial and privatized public insurance programs (SHA includes some government programs). Both integrate health care claims data from medical and pharmacy claims. Patients aged 18 years or older with hyperkalemia and an index patiromer prescription were selected. Patiromer use was identified as short-term (<2 months) and any fill quantity or adherent longer-term with claims for at least 2 consecutive months and fill quantities of at least 80% of the total days. Groups were matched on multiple categorical covariates to control for demographic variables, baseline characteristics, and markers of disease severity. Random sampling without replacement was performed 50 times to identify 50 sets of patients matched from the short-term cohort to the longer-term cohort. Health care costs/charges and encounters were compared for a 6-month post-index period using t-tests. RESULTS Of the CDM patients, 1,267 (40.2%) vs 1,887 (59.8%) and of the SHA patients, 2,234 (35.1%) vs 4,132 (64.9%) experienced longer-term vs short-term patiromer use, respectively. Patient sampling selected 242 and 485 patient-matched pairs from CDM and SHA databases, respectively. At 6 months post-index in longer-term vs short-term patiromer groups (P < 0.0001 for all differences shown), respective mean medical and prescription costs/charges were $42,000 vs $54,311 (-$12,311) and $6,816 vs $4,786 (+$2,030), respectively, for CDM patients and $75,147 vs $84,414 (-$9,267) and $4,689 vs $3,736 (+$953) for SHA patients. In the CDM database, medical costs were lower for longer-term vs short-term cohorts for end-stage renal disease services charges ($10,342 vs $14,976 [-$4,634]), inpatient charges ($15,789 vs $21,473 [-$5,684]), and office visit charges ($10,152 vs $13,152 [-$3,000]). Patient out-of-pocket costs ($658 vs $420 [+$238]) and total prescription charges ($6,158 vs $4,366 [+$1,792]) were higher for the longer-term cohort of CDM patients, with similar findings in the SHA dataset. CONCLUSIONS Adherent, longer-term use of patiromer is associated with significantly lower medical costs offsetting higher prescription costs, driven by the largest changes in inpatient and clinic services at CDM and SHA, respectively. This illustrates an economic value of longer-term adherence to patiromer.
Collapse
|
30
|
Rastogi A, Collins A, Kelepouris E, Kotzker W, Middleton JP, Rajpal M, Roy-Chaudhury P, Chertow GM. Practical Considerations and Implementation of Sodium-Glucose Co-Transporter-2 Inhibitors in Chronic Kidney Disease: Who, When, and How? A Position Statement by Nephrologists. J Prim Care Community Health 2024; 15:21501319241259905. [PMID: 39143759 PMCID: PMC11327967 DOI: 10.1177/21501319241259905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 08/16/2024] Open
Abstract
INTRODUCTION There remains an unmet need to reduce kidney and cardiovascular risk in patients with chronic kidney disease (CKD). This report is therefore intended to provide real-world clinical guidance to primary care providers on sodium-glucose co-transporter-2 (SGLT2) inhibitor use in patients with CKD, focusing on practical considerations. Initially developed as glucose-lowering drugs, SGLT2 inhibitors preserve kidney function and reduce risks of cardiovascular events and mortality. Clinical benefits of SGLT2 inhibitors in CKD have been demonstrated in multiple clinical trials, yet utilization in practice remains relatively low, likely due to the complexity of labeled indications (past and present) and misconceptions about SGLT2 inhibitors as a class. METHODS A panel of 8 US-based nephrologists convened in August 2022 to develop consensus guidance for the primary care community surrounding risk assessment as well as initiation and implementation of SGLT2 inhibitors in patients with CKD. Here, we provide an adapted version of the Kidney Disease: Improving Global Outcomes (KDIGO) heatmap and a treatment-decision algorithm. CONCLUSIONS We advocate SGLT2 inhibitors as co-first-line therapy with renin-angiotensin-aldosterone system (RAAS) inhibitors, where RAAS inhibitor dose titration need not be completed before initiation of an SGLT2 inhibitor. In fact, SGLT2 inhibitor therapy may facilitate up-titration or maintenance of optimal RAAS inhibitor dosing. We describe potential strategies to aid implementation of an SGLT2 inhibitor in clinical practice, including improving education and awareness among care providers and patients and dispelling misconceptions about the safety of SGLT2 inhibitors. In summary, we support the use of SGLT2 inhibitors with RAAS inhibitors as co-first-line therapy in most patients with CKD.
Collapse
Affiliation(s)
| | - Ashté Collins
- George Washington University School of Medicine, Washington, DC, USA
| | | | | | | | | | - Prabir Roy-Chaudhury
- University of North Carolina Kidney Center, Chapel Hill, NC, USA and the WG (Bill) Hefner Salisbury VA Medical Center, Salisbury, NC, USA
| | | |
Collapse
|
31
|
Gruver J, Al-Makki A, Shepler B. Therapeutic update on oral potassium exchange resin use in chronic kidney disease patients: a systematic review of randomized controlled clinical trials. JOURNAL OF PHARMACY & PHARMACEUTICAL SCIENCES : A PUBLICATION OF THE CANADIAN SOCIETY FOR PHARMACEUTICAL SCIENCES, SOCIETE CANADIENNE DES SCIENCES PHARMACEUTIQUES 2023; 26:11892. [PMID: 38173862 PMCID: PMC10761527 DOI: 10.3389/jpps.2023.11892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/08/2023] [Indexed: 01/05/2024]
Abstract
Hyperkalemia is a common electrolyte disorder in patients with chronic kidney disease (CKD) that increases in prevalence with the decline of glomerular fltration rate (GFR). Another risk of hyperkalemia is the use of renin-angiotensin-aldosterone system inhibitors (RAASi) and/or mineralocorticoid receptor antagonists (MRAs) in managing CKD and proteinuria. The treatment of chronic hyperkalemia is challenging especially for outpatients. Treatment options for hyperkalemia include the potassium exchange resins of which two new potassium binders, Patiromer Sorbitex Calcium, and Sodium Zirconium Cyclosilicate (SZC) have demonstrated their clinical efficacy in reducing serum potassium with a positive safety profile. The old potassium exchange resin sodium polystyrene sulfonate (Kayexalate™) has some negative side effects including colonic necrosis, hypomagnesemia, and hypernatremia. In this review and literature search, we compare the available oral potassium exchange resins, highlight their advantages and disadvantages and comment on efficacy and safety parameters specifically in CKD patients.
Collapse
Affiliation(s)
- Jaclyn Gruver
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN, United States
| | - Akram Al-Makki
- Nephrology Clinic, Indiana University Health Arnett, West Lafayette, IN, United States
| | - Brian Shepler
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN, United States
| |
Collapse
|
32
|
Sun Z, Jiao J, Lu G, Liu R, Li Z, Sun Y, Chen Z. Overview of research progress on the association of dietary potassium intake with serum potassium and survival in hemodialysis patients, does dietary potassium restriction really benefit hemodialysis patients? Front Endocrinol (Lausanne) 2023; 14:1285929. [PMID: 38093955 PMCID: PMC10716210 DOI: 10.3389/fendo.2023.1285929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/13/2023] [Indexed: 12/18/2023] Open
Abstract
For the general population, increasing potassium intake can reduce the incidence of cardiovascular and cerebrovascular diseases. However, since hyperkalemia is a common and life-threatening complication in maintenance hemodialysis patients, which can increase the risk of malignant arrhythmia and sudden death, the current mainstream of management for hemodialysis patients is dietary potassium restriction in order to prevent hyperkalemia. Hemodialysis patients are usually advised to reduce dietary potassium intake and limit potassium-rich fruits and vegetables, but there is limited evidence to support this approach can reduce mortality and improve quality of life. There is still no consistent conclusion on the association between dietary potassium intake and serum potassium and survival in hemodialysis patients. According to the current small observational studies, there was little or even no association between dietary potassium intake and serum potassium in hemodialysis patients when assurance of adequate dialysis and specific dietary patterns (such as the plant-based diet mentioned in the article) are being followed, and excessive dietary potassium restriction may not benefit the survival of hemodialysis patients. Additionally, when assessing the effect of diet on serum potassium, researchers should not only focus on the potassium content of foods, but also consider the type of food and the content of other nutrients. However, more large-scale, multi-center clinical trials are required to provide high-quality evidence support. Besides, further research is also needed to determine the optimal daily potassium intake and beneficial dietary patterns for hemodialysis patients.
Collapse
Affiliation(s)
- Zuoya Sun
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Jian Jiao
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong First Medical University, Jinan, Shandong, China
| | - Gang Lu
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Ruihong Liu
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Zhuo Li
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yi Sun
- Department of Nephrology, Beijing Huairou Hospital of University of Chinese Academy of Sciences, Beijing, China
| | - Zhiyuan Chen
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| |
Collapse
|
33
|
Lorente A. Consensus document on the management of hyperkalaemia. Response. Nefrologia 2023; 43:795-796. [PMID: 38218664 DOI: 10.1016/j.nefroe.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 09/26/2023] [Indexed: 01/15/2024] Open
|
34
|
Senni M, Sciatti E, Bussalino E, D'Elia E, Ravera M, Paoletti E. Practical patient care appraisals with use of new potassium binders in heart failure and chronic kidney diseases. J Cardiovasc Med (Hagerstown) 2023; 24:781-789. [PMID: 37695628 DOI: 10.2459/jcm.0000000000001555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Hyperkalaemia is a life-threatening condition leading to significant morbidity and mortality. It is common in heart failure and in chronic kidney disease (CKD) patients due to the diseases themselves, which often coexist, the high co-presence of diabetes, the fluctuations in renal function, and the use of some drugs [i.e. renin-angiotensin-aldosterone system (RAAS) inhibitors]. Hyperkalaemia limits their administration or uptitration, thus impacting on mortality. New K + binders, namely patiromer and sodium zirconium cyclosilicate (ZS-9), are an intriguing option to manage hyperkalaemia in heart failure and/or CKD patients, both to reduce its fatal effects and to let clinicians uptitrate RAAS inhibition. Even if their real impact on strong outcomes is still to be determined, we hereby provide a practical approach to favour their use in routine clinical practice in order to gain the correct confidence and provide an additive tool to heart failure and CKD patients' wellbeing. New trials are welcome to fill the gap in knowledge.
Collapse
Affiliation(s)
- Michele Senni
- Unità di Cardiologia, Dipartimento Cardiovascolare, ASST Papa Giovanni XXIII, Bergamo
- Università Milano-Bicocca, Milan
| | - Edoardo Sciatti
- Unità di Cardiologia, Dipartimento Cardiovascolare, ASST Papa Giovanni XXIII, Bergamo
| | - Elisabetta Bussalino
- Clinica Nefrologica, Dialisi e Trapianto, Policlinico San Martino, Genova, Italy
| | - Emilia D'Elia
- Unità di Cardiologia, Dipartimento Cardiovascolare, ASST Papa Giovanni XXIII, Bergamo
| | - Maura Ravera
- Clinica Nefrologica, Dialisi e Trapianto, Policlinico San Martino, Genova, Italy
| | - Ernesto Paoletti
- Clinica Nefrologica, Dialisi e Trapianto, Policlinico San Martino, Genova, Italy
| |
Collapse
|
35
|
Kalantar-Zadeh K, Forfang D, Bakris G, Martin KJ, Moe SM, Sprague SM. Managing Phosphate Burden in Patients Receiving Dialysis: Beyond Phosphate Binders and Diet. KIDNEY360 2023; 4:1650-1656. [PMID: 37870525 PMCID: PMC10695651 DOI: 10.34067/kid.0000000000000262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/07/2023] [Indexed: 10/24/2023]
Abstract
Most patients receiving dialysis rely on dietary restriction and phosphate binders to minimize the risk of hyperphosphatemia, which is associated with increased mortality. However, dietary restriction is difficult because of hidden phosphate additives in processed foods and medications. Restriction of dietary phosphate sources such as protein may increase the risk of malnutrition. Phosphate binders, the only pharmacologic option for phosphate management since aluminum salts were introduced several decades ago, are often insufficient for binding the 1400-2500 mg of phosphate potentially consumed daily. Over the last decade, serum phosphate levels in the United States have risen, and >69% of patients receiving dialysis exhibited a most recent phosphate level >4.5 mg/dl (above the normal range), indicating an urgent need for new, more effective therapies to manage phosphate burden. Novel, nonbinder therapies such as transcellular and paracellular phosphate absorption inhibitors may be used for phosphate management, and future studies should examine whether they allow fewer dietary restrictions for patients receiving dialysis, potentially improving patient quality of life and nutritional status. It is imperative that we collaborate to move beyond the restrictive approaches available today and provide patients and clinicians with an array of strategies so that they may choose the most appropriate patient-centered therapy.
Collapse
Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Irvine, California
| | - Derek Forfang
- The Co-Chair of the National Forum of ESRD Network's Kidney Patient Advisory Council (KPAC), Henrico, Virginia
- National Kidney Foundation, Public Policy Committee, New York, New York
| | - George Bakris
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Kevin J. Martin
- Department of Internal Medicine, Division of Nephrology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Sharon M. Moe
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana
| | - Stuart M. Sprague
- Division of Nephrology and Hypertension, NorthShore University Health System-University of Chicago Pritzker School of Medicine, Evanston, Illinois
| |
Collapse
|
36
|
de Sequera P, Bover R, Ivanova-Markova Y, Ivanova A, González-Domínguez A, Valls M, Campos V. Economic impact of the use of patiromer in chronic kidney disease or heart failure for the treatment of chronic hyperkalemia in Spain. Nefrologia 2023; 43:721-730. [PMID: 38228463 DOI: 10.1016/j.nefroe.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 08/25/2022] [Indexed: 01/18/2024] Open
Abstract
INTRODUCTION Chronic hyperkalemia has negative consequences in the medium and long term, and determines the suspension of nephro and cardioprotective drugs, such as renin-angiotensin-aldosterone system inhibitors (RAASi). There is an alternative to the suspension or dose reduction of these treatments: the administration of potassium chelators. The aim of this study is to estimate the economic impact of the use of patiromer in patients with chronic kidney disease (CKD) or heart failure (HF) and hyperkalemia in Spain. MATERIALS AND METHOD The annual economic impact of the use of patiromer has been estimated from the perspective of the Spanish society. Two scenarios were compared: patients with CKD or HF and hyperkalemia treated with and without patiromer. The costs have been updated to 2020 euros, using the Health Consumer Price Index. Direct healthcare costs related to the use of resources (treatment with RAASi, CKD progression, cardiovascular events and hospitalization due to hyperkalemia), direct non-healthcare costs (informal care: costs derived from time dedicated by patient's relatives), the indirect costs (productivity loss), as well as an intangible cost (due to premature mortality) were considered. A deterministic sensitivity analysis was performed to validate the robustness of the study results. RESULTS The mean annual cost per patient in the scenario without patiromer is €9,834.09 and €10,739.37 in CKD and HF, respectively. The use of patiromer would lead to cost savings of over 30% in both diseases. The greatest savings in CKD come from the delay in the progression of CKD. While in the case of HF, 80.1% of these savings come from premature mortality reduction. The sensitivity analyses carried out show the robustness of the results, obtaining savings in all cases. CONCLUSIONS The incorporation of patiromer allows better control of hyperkalemia and, as a consequence, maintain treatment with RAASi in patients with CKD or HF. This would generate a 32% of annual savings in Spain (€3,127 in CKD; €3,466 in HF). The results support the positive contribution of patiromer to health cost in patients with only CKD or in patients with only HF.
Collapse
Affiliation(s)
- Patricia de Sequera
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Ramón Bover
- Servicio de Cardiología, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | | | | | | | | | | |
Collapse
|
37
|
Hu JR, Schwann AN, Tan JW, Nuqali A, Riello RJ, Beasley MH. Sequencing Quadruple Therapy for Heart Failure with Reduced Ejection Fraction: Does It Really Matter? Cardiol Clin 2023; 41:511-524. [PMID: 37743074 DOI: 10.1016/j.ccl.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
The conventional sequence of guideline-directed medical therapy (GDMT) initiation in heart failure with reduced ejection fraction (HFrEF) assumes that the effectiveness and tolerability of GDMT agents mirror their order of discovery, which is not true. In this review, the authors discuss flexible GDMT sequencing that should be permitted in special populations, such as patients with bradycardia, chronic kidney disease, or atrial fibrillation. Moreover, the initiation of certain GDMT medications may enable tolerance of other GDMT medications. Most importantly, the achievement of partial doses of all four pillars of GDMT is better than achievement of target dosing of only a couple.
Collapse
Affiliation(s)
- Jiun-Ruey Hu
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA. https://twitter.com/ruey_hu
| | - Alexandra N Schwann
- Department of Internal Medicine, Yale New Haven Hospital, P.O. Box 208030, New Haven, CT, 06520-8030, USA. https://twitter.com/aschwann212
| | - Jia Wei Tan
- Division of Nephrology, Stanford University School of Medicine, 780 Welch Road, Palo Alto, CA 94304, USA. https://twitter.com/jiiiiawei
| | - Abdulelah Nuqali
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA. https://twitter.com/AbdulelahNuqali
| | - Ralph J Riello
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA. https://twitter.com/ralphadelta
| | - Michael H Beasley
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA.
| |
Collapse
|
38
|
Ortiz A, Galán CDA, Carlos Fernández-García J, Cerezo JG, Ochoa RI, Núñez J, Gutiérrez FP, Navarro-González JF. Consensus document on the management of hyperkalemia. Nefrologia 2023; 43:765-782. [PMID: 38169239 DOI: 10.1016/j.nefroe.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/08/2023] [Indexed: 01/05/2024] Open
Abstract
Hyperkalaemia is a common electrolyte imbalance with potentially serious short-, medium- and long-term consequences on morbidity and mortality rates and the use of national health service resources. The fact that different medical specialities can manage hyperkalaemia makes it important to have a unified approach, and the recent availability of new specific drug treatments means that the approach needs to be updated. This consensus document from the scientific societies most directly involved in the management of hyperkalaemia (Sociedad Española de Cardiología [Spanish Society of Cardiology], Sociedad Española de Endocrinología y Nutrición [Spanish Society of Endocrinology and Nutrition], Sociedad Española de Medicina Interna [Spanish Society of Internal Medicine], Sociedad Española de Medicina de Urgencias y Emergencias [Spanish Society of Accident and Emergency Medicine] and Sociedad Española de Nefrología [Spanish Society of Nephrology]) first of all reviews basic aspects of potassium balance and blood potassium. Then it goes on to focus on the concept, epidemiology, pathophysiology and diagnostic and therapeutic approaches to hyperkalaemia. The available evidence and the main published studies have been reviewed with the aim of providing a useful tool in the multidisciplinary approach to patients with hyperkalaemia.
Collapse
Affiliation(s)
| | | | | | | | - Rosa Ibán Ochoa
- Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), Spain
| | - Julio Núñez
- Sociedad Española de Cardiología (SEC), Spain
| | | | | |
Collapse
|
39
|
Fravel MA, Meaney CJ, Noureddine L. Management of Hyperkalemia in Patients with Chronic Kidney Disease Using Renin Angiotensin Aldosterone System Inhibitors. Curr Hypertens Rep 2023; 25:395-404. [PMID: 37747576 DOI: 10.1007/s11906-023-01265-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 09/26/2023]
Abstract
PURPOSE OF REVIEW 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. RECENT FINDINGS 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.
Collapse
Affiliation(s)
- Michelle A Fravel
- University of Iowa College of Pharmacy, 167 CPB, 180 S. Grand Ave, Iowa City, IA, 52242, USA.
| | | | - Lama Noureddine
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| |
Collapse
|
40
|
Colbert GB, Elrggal ME, Gaddy A, Madariaga HM, Lerma EV. Management of Hypertension in Diabetic Kidney Disease. J Clin Med 2023; 12:6868. [PMID: 37959333 PMCID: PMC10648605 DOI: 10.3390/jcm12216868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/24/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
Hypertension is a critical component of cardiovascular disease progression in patients with chronic kidney disease, and specifically diabetic kidney disease (DKD). Causation versus correlation remains up for debate, but what has been confirmed is the delay of DKD progression when hypertension is controlled or moved to guideline drive ranges. Many medications have been studied and used in real world experience for best outcomes, and we discuss below the proven winners thus far making up the renin angiotensin aldosterone system. As well, we discuss guideline changing medications including sodium-glucose cotransporter 2 inhibitors and newer generation mineralocorticoid receptor antagonists. With the growing prevalence of diabetes and DKD in the population, newer agents are emerging in multiple drug class and will be highlighted below. Clinicians continue to search for the optimal care plans for this challenging patient population.
Collapse
Affiliation(s)
- Gates B. Colbert
- Division of Nephrology, Texas A&M University College of Medicine at Dallas, Dallas, TX 75246, USA
| | | | - Anna Gaddy
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | | | - Edgar V. Lerma
- Section of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA;
| |
Collapse
|
41
|
Martínez-Hernández SL, Muñoz-Ortega MH, Ávila-Blanco ME, Medina-Pizaño MY, Ventura-Juárez J. Novel Approaches in Chronic Renal Failure without Renal Replacement Therapy: A Review. Biomedicines 2023; 11:2828. [PMID: 37893201 PMCID: PMC10604533 DOI: 10.3390/biomedicines11102828] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/28/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Chronic kidney disease (CKD) is characterized by renal parenchymal damage leading to a reduction in the glomerular filtration rate. The inflammatory response plays a pivotal role in the tissue damage contributing to renal failure. Current therapeutic options encompass dietary control, mineral salt regulation, and management of blood pressure, blood glucose, and fatty acid levels. However, they do not effectively halt the progression of renal damage. This review critically examines novel therapeutic avenues aimed at ameliorating inflammation, mitigating extracellular matrix accumulation, and fostering renal tissue regeneration in the context of CKD. Understanding the mechanisms sustaining a proinflammatory and profibrotic state may offer the potential for targeted pharmacological interventions. This, in turn, could pave the way for combination therapies capable of reversing renal damage in CKD. The non-replacement phase of CKD currently faces a dearth of efficacious therapeutic options. Future directions encompass exploring vaptans as diuretics to inhibit water absorption, investigating antifibrotic agents, antioxidants, and exploring regenerative treatment modalities, such as stem cell therapy and novel probiotics. Moreover, this review identifies pharmaceutical agents capable of mitigating renal parenchymal damage attributed to CKD, targeting molecular-level signaling pathways (TGF-β, Smad, and Nrf2) that predominate in the inflammatory processes of renal fibrogenic cells.
Collapse
Affiliation(s)
- Sandra Luz Martínez-Hernández
- Departamento de Microbiología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes 20100, Ags, Mexico
| | - Martín Humberto Muñoz-Ortega
- Departamento de Química, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes 20100, Ags, Mexico
| | - Manuel Enrique Ávila-Blanco
- Departamento de Morfología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes 20100, Ags, Mexico
| | - Mariana Yazmin Medina-Pizaño
- Departamento de Morfología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes 20100, Ags, Mexico
| | - Javier Ventura-Juárez
- Departamento de Morfología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes 20100, Ags, Mexico
| |
Collapse
|
42
|
Palmer BF, Clegg DJ. Pathophysiology and clinical management of hyperkalemia in chronic kidney disease. Minerva Med 2023; 114:719-735. [PMID: 36912858 DOI: 10.23736/s0026-4806.23.08465-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Adaptive increases in kidney and gastrointestinal excretion of K+ help to prevent hyperkalemia in patients with chronic kidney disease (CKD) as long as the glomerular filtration rate (GFR) remains >15-20 mL/min. K+ balance is maintained by increased secretion per functioning nephron, which is mediated by elevated plasma K+ concentration, aldosterone, increased flow rate, and enhanced Na+-K+-ATPase activity. Fecal losses of potassium also increase in CKD. These mechanisms are effective in preventing hyperkalemia if urine output is in excess of 600 mL/day and the GFR exceeds 15 mL/min. Development of hyperkalemia with only mild to moderate reductions in GFR should prompt a search for intrinsic disease of the collecting duct, disturbances in mineralocorticoid activity, and/or decreased delivery of sodium to the distal nephron. The initial approach to treatment is to review the patient's medication profile and whenever possible discontinue drugs that impair kidney K+ excretion. Patients should be educated on sources of K+ in the diet and should be strongly encouraged to avoid the use of K+ containing salt substitutes as well as herbal remedies since herbs may be a hidden source of dietary K+. Effective diuretic therapy and correction of metabolic acidosis are effective strategies to minimize the potential for hyperkalemia. Discontinuation or use of submaximal doses of renin-angiotensin blockers should be discouraged given the cardiovascular protective effect these drugs provide. Potassium binding drugs can be useful to enable use of these drugs and potentially allow liberalization of the diet in CKD patients.
Collapse
Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA -
| | - Deborah J Clegg
- Department of Internal Medicine, Texas Tech Health Sciences Center, El Paso, TX, USA
| |
Collapse
|
43
|
Chinnadurai R, Rengarajan S, Budden JJ, Quinn CM, Kalra PA. Maintaining Renin-Angiotensin-Aldosterone System Inhibitor Treatment with Patiromer in Hyperkalaemic Chronic Kidney Disease Patients: Comparison of a Propensity-Matched Real-World Population with AMETHYST-DN. Am J Nephrol 2023; 54:408-415. [PMID: 37725919 DOI: 10.1159/000533753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/18/2023] [Indexed: 09/21/2023]
Abstract
INTRODUCTION Guideline-directed renin-angiotensin-aldosterone system inhibitor (RAASi) therapy is rarely achieved in clinical settings, often due to hyperkalaemia. We assessed the potassium binder, patiromer, on continuation of RAASi therapy in hyperkalaemic patients with chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM) in the AMETHYST-DN trial, propensity score-matched to a real-world cohort not receiving patiromer (Salford Kidney Study). METHODS The phase 2, open-label AMETHYST-DN trial (NCT01371747) randomized 304 adults with CKD on RAASi, T2DM, hyperkalaemia (serum potassium [sK+] >5.0 mEq/L), and hypertension to receive patiromer, 8.4-33.6 g/day for 12 months. Patients underwent propensity score matching for systolic blood pressure (BP), heart failure status, and estimated glomerular filtration rate (eGFR), with 321 patients with CKD, T2DM, hyperkalaemia, and on RAASi from a prospective CKD cohort (Salford Kidney Study). Changes in RAASi utilization, sK+, BP, proteinuria, and eGFR during 12-month follow-up were assessed by Mann-Whitney U or χ2 tests. RESULTS Matching produced 135:135 patients with no significant differences in age, sex, systolic BP, sK+, eGFR, or heart failure status, although differences in diastolic BP remained (p < 0.001). After 12 months, 100% of AMETHYST-DN patients receiving patiromer remained on RAASi therapy, whereas 38.5% of the Salford Kidney Cohort discontinued RAASi (p < 0.001); hyperkalaemia contributed in 16% of patients (42% of RAASi discontinuations). Significantly greater reductions in sK+ and BP, but not proteinuria or eGFR, were observed in AMETHYST-DN, compared with Salford Kidney Study patients (p < 0.05). CONCLUSIONS These results demonstrate the benefit of patiromer for sK+ management to enable RAASi use while revealing beneficial effects on BP.
Collapse
Affiliation(s)
- Rajkumar Chinnadurai
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Sharmilee Rengarajan
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | | | | | - Philip A Kalra
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| |
Collapse
|
44
|
Sampani E, Theodorakopoulou M, Iatridi F, Sarafidis P. Hyperkalemia in chronic kidney disease: a focus on potassium lowering pharmacotherapy. Expert Opin Pharmacother 2023; 24:1775-1789. [PMID: 37545002 DOI: 10.1080/14656566.2023.2245756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/01/2023] [Accepted: 08/04/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Hyperkalemia is one of the most common electrolyte disorders in chronic kidney disease (CKD) and is associated with serious adverse outcomes. Hyperkalemia risk is even greater when CKD patients also have additional predisposing conditions such as diabetes or heart failure. Renin-angiotensin-aldosterone-system blockers are first-line treatments for cardio- and nephroprotection, but their use is often limited due to K+ elevation, resulting in high rates of discontinuation. AREAS COVERED This article provides an overview of factors interfering with K+ homeostasis and discusses recent data on newer therapeutic agents used for the treatment of hyperkalemia. A detailed literature search was performed in two major databases (PubMed/MEDLINE and Scopus) up to April 2023. EXPERT OPINION Major clinical trials have tested new and promising kidney protective therapies such as sodium/glucose-cotransporter-2 inhibitors and mineralocorticoid-receptor-antagonists, with promising results. Until recently, the only treatment option for hyperkalemia was the cation-exchanging resin sodium-polystyrene-sulfonate. However, despite its common use, the efficacy and safety data of this drug in the long-term management of hyperkalemia are scarce. During the last decade, two novel orally administered K+-exchanging compounds (patiromer and sodium-zirconium-cyclosilicate) have been approved for the treatment of adults with hyperkalemia, as they both effectively reduce elevated serum K+ and maintain chronically K+ balance within the normal range with an excellent tolerability and no serious adverse events.
Collapse
Affiliation(s)
- Erasmia Sampani
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Marieta Theodorakopoulou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Fotini Iatridi
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
45
|
Kettritz R, Loffing J. Potassium homeostasis - Physiology and pharmacology in a clinical context. Pharmacol Ther 2023; 249:108489. [PMID: 37454737 DOI: 10.1016/j.pharmthera.2023.108489] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
Membrane voltage controls the function of excitable cells and is mainly a consequence of the ratio between the extra- and intracellular potassium concentration. Potassium homeostasis is safeguarded by balancing the extra-/intracellular distribution and systemic elimination of potassium to the dietary potassium intake. These processes adjust the plasma potassium concentration between 3.5 and 4.5 mmol/L. Several genetic and acquired diseases but also pharmacological interventions cause dyskalemias that are associated with increased morbidity and mortality. The thresholds at which serum K+ not only associates but also causes increased mortality are hotly debated. We discuss physiologic, pathophysiologic, and pharmacologic aspects of potassium regulation and provide informative case vignettes. Our aim is to help clinicians, epidemiologists, and pharmacologists to understand the complexity of the potassium homeostasis in health and disease and to initiate appropriate treatment strategies in dyskalemic patients.
Collapse
Affiliation(s)
- Ralph Kettritz
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité Universitätsmedizin Berlin, Germany.
| | | |
Collapse
|
46
|
Rossignol P, Pitt B. Sodium polystyrene is unsafe and should not be prescribed for the treatment of hyperkalaemia: primum non nocere! Clin Kidney J 2023; 16:1221-1225. [PMID: 37529653 PMCID: PMC10387396 DOI: 10.1093/ckj/sfad090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Indexed: 08/03/2023] Open
Abstract
'Old-generation' potassium (K) binders [i.e. sodium (SPS) and calcium polystyrene sulfonate] are widely used, but with substantial heterogeneity across countries to treat hyperkalaemia (HK). However, there are no randomized data to support their chronic use to manage HK, nor have they been shown to have a renin-angiotensin-aldosterone system inhibitor (RAASi)-enabling effect. These compounds have poor tolerability and an unpredictable onset of action and magnitude of K lowering. Furthermore, SPS may induce fluid overload, owing to the fact that it exchanges K for sodium. Its use has also been associated with colonic necrosis, as emphasized by a black box warning from the US Food and Drug Administration. In contrast, two new K binders, patiromer and sodium zirconium cyclosilicate, have been shown to be safe and well tolerated for chronic management of HK, thereby enabling RAASi optimization, as acknowledged by the latest international cardiorenal guidelines. In view of the lack of reliable evidence regarding the efficacy and safety of the old-generation K binders compared with the placebo-controlled randomized and real-word evidence demonstrating the safety, efficacy and RAASi-enabling effect of the new K binders, clinicians should now use these new K binders to treat HK (primum non nocere!).
Collapse
Affiliation(s)
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| |
Collapse
|
47
|
Carrero JJ, Sood MM, Gonzalez-Ortiz A, Clase CM. Pharmacological strategies to manage hyperkalaemia: out with the old, in with the new? Not so fast…. Clin Kidney J 2023; 16:1213-1220. [PMID: 37529644 PMCID: PMC10387386 DOI: 10.1093/ckj/sfad089] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Indexed: 08/03/2023] Open
Abstract
Since the 1950s, sodium polystyrene sulphonate (SPS) has been the dominant cation exchange agent prescribed for hyperkalaemia. Clinicians have had plenty of time to learn of SPS's advantages and limitations. The demands of drug regulatory agencies regarding the incorporation of medications into the market were not so stringent then as they are today, and the efficacy and safety of SPS have been questioned. In recent years, two novel cation exchangers, patiromer and sodium zirconium cyclosilicate, have received (or are in the process of receiving) regulatory approval in multiple jurisdictions globally, after scrutiny of carefully conducted trials regarding their short-term and mid-term efficacy. In this debate, we defend the view that all three agents are likely to have similar efficacy. Harms are much better understood for SPS than for newer agents, but currently there are no data to suggest that novel agents are safer than SPS. Drug choices need to consider costs, access and numbers-needed-to-treat to prevent clinically important events; for potassium exchangers, we need trials directly examining clinically important events.
Collapse
Affiliation(s)
| | - Manish M Sood
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ailema Gonzalez-Ortiz
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Translational Research Center, Instituto Nacional de Pediatria, Mexico City, Mexico
| | - Catherine M Clase
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methodology, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
48
|
Costa D, Patella G, Provenzano M, Ielapi N, Faga T, Zicarelli M, Arturi F, Coppolino G, Bolignano D, De Sarro G, Bracale UM, De Nicola L, Chiodini P, Serra R, Andreucci M. Hyperkalemia in CKD: an overview of available therapeutic strategies. Front Med (Lausanne) 2023; 10:1178140. [PMID: 37583425 PMCID: PMC10424443 DOI: 10.3389/fmed.2023.1178140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/10/2023] [Indexed: 08/17/2023] Open
Abstract
Hyperkalemia (HK) is a life-threatening condition that often occurs in patients with chronic kidney disease (CKD). High serum potassium (sKsK) is responsible for a higher risk of end-stage renal disease, arrhythmias and mortality. This risk increases in patients that discontinue cardio-nephroprotective renin-angiotensin-aldosterone system inhibitor (RAASi) therapy after developing HK. Hence, the management of HK deserves the attention of the clinician in order to optimize the therapeutic strategies of chronic treatment of HK in the CKD patient. The adoption in clinical practice of the new hypokalaemic agents patiromer and sodium zirconium cyclosilicate (SZC) for the prevention and chronic treatment of HK could allow patients, suffering from heart failure and chronic renal failure, to continue to benefit from RAASi therapy. We have updated a narrative review of the clear variables, correct definition, epidemiology, pathogenesis, etiology and classifications for HK among non-dialysis CKD (ND CKD) patients. Furthermore, by describing the prognostic impact on mortality and on the progression of renal damage, we want to outline the strategies currently available for the control of potassium (K+) plasma levels.
Collapse
Affiliation(s)
- Davide Costa
- Department of Law, Economics and Sociology, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Gemma Patella
- Renal Unit, Department of Health Sciences, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Michele Provenzano
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Nicola Ielapi
- Department of Public Health and Infectious Disease, Sapienza University of Rome, Rome, Italy
| | - Teresa Faga
- Renal Unit, Department of Health Sciences, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Mariateresa Zicarelli
- Renal Unit, Department of Health Sciences, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Franco Arturi
- Unit of Internal Medicine, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Giuseppe Coppolino
- Renal Unit, Department of Health Sciences, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Davide Bolignano
- Renal Unit, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | | | | | - Luca De Nicola
- Renal Unit, University of Campania “LuigiVanvitelli”, Naples, Italy
| | - Paolo Chiodini
- Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Raffaele Serra
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Michele Andreucci
- Renal Unit, Department of Health Sciences, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| |
Collapse
|
49
|
Bushinsky DA, Budden JJ, Kalra PA, Yuan J, Quinn CM, Epstein M. Patiromer Treatment in Patients With CKD, Hyperkalemia, and Hyperphosphatemia: A Post Hoc Analysis of 3 Clinical Trials. Am J Kidney Dis 2023; 82:97-104. [PMID: 36965827 DOI: 10.1053/j.ajkd.2023.01.444] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 01/12/2023] [Indexed: 03/27/2023]
Abstract
RATIONALE & OBJECTIVE Patients with chronic kidney disease (CKD), hyperkalemia (serum potassium [sK+]>5.0 mEq/L), and hyperphosphatemia experience poor clinical outcomes. Patiromer, a potassium binder that uses calcium as the exchange ion, may also reduce serum phosphorus (sP). We characterized the effect of patiromer on sP in patients with CKD, hyperkalemia, and hyperphosphatemia. STUDY DESIGN A post hoc pooled analysis of individual-level data from the AMETHYST-DN, OPAL-HK, and TOURMALINE trials of patiromer. SETTING & PARTICIPANTS Patients with CKD and hyperkalemia. EXPOSURE Patients treated with patiromer (8.4-33.6 g/day). OUTCOME Mean changes from baseline in sP, sK+, serum calcium (sCa2+), and serum magnesium (sMg2+) after 2 and 4 weeks of treatment. ANALYTICAL APPROACH Descriptive statistics to summarize pooled data on the study outcomes from the 3 studies. RESULTS We included 578 patients in the analysis. Of these participants, 86 patients (14.9%) had baseline hyperphosphatemia of whom 75.6% (65 of 86) had CKD stage 4/5 and 31.1% (153 of 492) with sP≤4.5mg/dL had CKD stage 4/5. Among the patients with elevated sP and sK+at baseline, the mean±SD reduction in sP and sK+after 4 weeks of patiromer treatment was-0.62±1.09mg/dL and-0.71± 0.51 mEq/L, respectively. Additionally, the mean±SD reduction in sMg2+in these patients was -0.25±0.23mg/dL while sCa2+remained unchanged. Both sMg2+and sCa2+remained within the normal range. Patiromer was generally well tolerated, and no serious adverse events were considered related to patiromer. LIMITATIONS These were post hoc analyses, no placebo comparison was performed due to the design of the original studies, and the follow-up period was limited to 4 weeks. CONCLUSIONS Reductions in sP and sK+to the normal range were observed after 2 weeks of patiromer treatment, and the reduction was sustained during 4 weeks of treatment among patients with non-dialysis-dependent CKD, hyperkalemia, and hyperphosphatemia. Future controlled trials are needed to establish if patiromer is useful to reduce both sK+and sP in hyperkalemic patients with CKD and hyperphosphatemia.
Collapse
Affiliation(s)
- David A Bushinsky
- University of Rochester School of Medicine and Dentistry, Rochester, New York.
| | | | - Philip A Kalra
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | | | | | | |
Collapse
|
50
|
Massicotte-Azarniouch D, Canney M, Sood MM, Hundemer GL. Managing Hyperkalemia in the Modern Era: A Case-Based Approach. Kidney Int Rep 2023; 8:1290-1300. [PMID: 37441466 PMCID: PMC10334407 DOI: 10.1016/j.ekir.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 04/15/2023] [Accepted: 04/17/2023] [Indexed: 07/15/2023] Open
Abstract
The last decade has seen tremendous advances in the prevention and treatment of recurrent hyperkalemia. In this narrative review, we aim to highlight contemporary data on key areas in the epidemiology and management of hyperkalemia. Focusing on drug-induced hyperkalemia (the implications of renin-angiotensin-aldosterone system inhibitors [RAASi] discontinuation and the role of mineralocorticoid receptor antagonists), newer concurrent therapies that modify potassium handling (sodium-glucose transporter 2 inhibitors [SGLT2i]), the introduction of new treatment agents (oral potassium binding agents), and the controversial role of dietary potassium restriction, we apply recent research findings and review the evidence in a case-based format.
Collapse
Affiliation(s)
- David Massicotte-Azarniouch
- Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mark Canney
- Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Manish M. Sood
- Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Gregory L. Hundemer
- Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|