Regulation of Potassium Homeostasis

Association between urinary potassium excretion and blood pressure: A systematic review and meta-analysis of observational studies

Background

The evidence base regarding the association between urinary potassium and blood pressure (BP), or risk of hypertension, is inconsistent. Therefore, we sought to conduct a qualitative and quantitative literature review on the association between potassium excretion and BP.

Materials and Methods

Medline, Scopus, Web of Science, Science Direct, and Google Scholar were searched up to June 2020. All observational studies that reported BP and measured potassium excretion in overnight or 24-h urine samples were included. Correlation coefficients, mean urinary potassium excretion, and odds ratio (ORs) of hypertension were extracted from the included studies. There were no language or publication date restrictions.

Results

Overall, twelve observational studies, including 16,174 subjects, were identified for inclusion in the present meta-analysis, and 21 effect sizes were extracted. Pooled mean potassium excretion was 3.46 mmol/24 h higher in normotensive individuals compared with hypertensive subjects (95% confidence interval [CI]: 0.61, 6.31). High urinary potassium excretion was not associated with the risk of hypertension (OR: 0.95; 95% CI: 0.79, 1.13). The pooled correlation coefficient between BP and urinary potassium was not significant (ES: 0.01; 95% CI: -0.03, 0.05). However, a subgroup analysis by age indicated a significant positive correlation between urinary potassium and systolic BP in children (ES: 0.12; 95% CI: 0.04, 0.19).

Conclusion

24 h urinary potassium excretion was not correlated to BP and risk of hypertension. In contrast, mean urinary potassium excretion was higher in normotensive individuals compared with hypertensive counterparts. Future studies should focus on the association between different sources of dietary potassium and BP.

Nutrient Effect on the Taste of Mineral Waters: Evidence from Europe

In this study, 15 selected bottled mineral waters from chosen European countries were tested for their mineral nutrient contents. In particular, six important nutrients (Ca2+, Mg2+, Na+, K+, HCO3-, Cl-) were measured using atomic absorption spectroscopy. The content of mineral nutrients in all sampled mineral waters were compared to their expected content based on the label. Consequently, their taste was evaluated by 60 trained panelists who participated in the sensory analysis. The results from both the atomic absorption spectroscopy and sensory analysis were analyzed using the regression framework. On the basis of the results from the regression analysis, we determined to what extent the individual mineral nutrients determined the taste of the mineral water. According to the regression results, four out of six analyzed nutrients had a measurable impact on taste. These findings can help producers to provide ideal, health-improving nutrients for mineral water buyers.

A dual-fluorophore sensor approach for ratiometric fluorescence imaging of potassium in living cells

Potassium is the most abundant intracellular metal in the body, playing vital roles in regulating intracellular fluid volume, nutrient transport, and cell-to-cell communication through nerve and muscle contraction. On the other hand, aberrant alterations in K+ homeostasis contribute to a diverse array of diseases spanning cardiovascular and neurological disorders to diabetes to kidney disease to cancer. There is an unmet need for studies of K+ physiology and pathology owing to the large differences in intracellular versus extracellular K+ concentrations ([K+]intra = 150 mM, [K+]extra = 3-5 mM). With a relative dearth of methods to reliably measure dynamic changes in intracellular K+ in biological specimens that meet the dual challenges of low affinity and high selectivity for K+, particularly over Na+, currently available fluorescent K+ sensors are largely optimized with high-affinity receptors that are more amenable for extracellular K+ detection. We report the design, synthesis, and biological evaluation of Ratiometric Potassium Sensor 1 (RPS-1), a dual-fluorophore sensor that enables ratiometric fluorescence imaging of intracellular potassium in living systems. RPS-1 links a potassium-responsive fluorescent sensor fragment (PS525) with a low-affinity, high-selectivity crown ether receptor for K+ to a potassium-insensitive reference fluorophore (Coumarin 343) as an internal calibration standard through ester bonds. Upon intracellular delivery, esterase-directed cleavage splits these two dyes into separate fragments to enable ratiometric detection of K+. RPS-1 responds to K+ in aqueous buffer with high selectivity over competing metal ions and is sensitive to potassium ions at steady-state intracellular levels and can respond to decreases or increases from that basal set point. Moreover, RPS-1 was applied for comparative screening of K+ pools across a panel of different cancer cell lines, revealing elevations in basal intracellular K+ in metastatic breast cancer cell lines vs. normal breast cells. This work provides a unique chemical tool for the study of intracellular potassium dynamics and a starting point for the design of other ratiometric fluorescent sensors based on two-fluorophore approaches that do not rely on FRET or related energy transfer designs.

Serum potassium in chronic kidney disease: prevalence, patient characteristics and clinical outcomes

BACKGROUND & AIMS

Abnormalities in serum potassium are a well-known complication of chronic kidney disease (CKD), but little is known about their impact on inpatient outcomes. To better understand the role of dyskalaemia in hospital in-patients, we assessed the epidemiology of potassium disorders among CKD patients, and the association between admission potassium and inpatient mortality or intensive care unit (ICU) requirement.

METHODS

This retrospective hospital-based cohort study (n = 11 156) included patients with eGFR<60 mL/min/1.73m² admitted to Austin Health between 2014 and 2018 and who had an admission potassium value. Dialysis patients or those with a renal transplant were excluded. Multivariate logistic analysis was conducted to identify factors associated with hyperkalaemia (≥5.5 mmol/L) and hypokalaemia (<3.5 mmol/L). Odds ratios for inpatient mortality and ICU admission between potassium categories were obtained by multivariate regression with adjustments for demographics, renal function and comorbidities.

RESULTS

Hyperkalaemia and hypokalaemia were present in 6.86% and 2.94% of hospital admissions, respectively. In multivariate regression male sex, lower eGFR, diabetes and cardiac failure were associated with higher odds of hyperkalaemia. Thiazide diuretics, loop diuretics, infectious disease and endocrine pathology were associated with higher odds of hypokalaemia. A U-shaped association was noted between potassium and inpatient mortality. Potassium <4.0 mmol/L and ≥ 5.0 mmol/L was associated with increased mortality. Only patients with potassium ≥5.5 mmol/L had increased ICU admission risk.

CONCLUSION

Derangements in potassium frequently occur in CKD inpatients and are independently associated with higher mortality and ICU requirement. Further studies are required to determine whether interventions to maintain normokalaemia improve outcomes in this population. This article is protected by copyright. All rights reserved.

Genetic renal disease classification by hormonal axes

The kidneys, which regulate many homeostatic pathways, are also a major endocrinological target organ. Many genetic renal diseases can be classified according to the affected protein along such endocrinological pathways. In this review, we examine the hypothesis that a more severe phenotype is expected as the affected protein is located more distally along such pathways. Thus, the location of a defect along its endocrinological pathway should be taken into consideration, in addition to the mutation type, when assessing genetic renal disease severity.

Does dietary potassium intake associate with hyperkalemia in patients with chronic kidney disease?

Background

Dietary potassium restriction is a strategy to control hyperkalemia in chronic kidney disease (CKD). However, hyperkalemia may result from a combination of clinical conditions. This study aimed to investigate whether dietary potassium or the intake of certain food groups associate with serum potassium in the face of other risk factors.

Methods

We performed a cross-sectional analysis including a nondialysis-dependent CKD (NDD-CKD) cohort and a hemodialysis (HD) cohort. Dietary potassium intake was assessed by 3-day food records. Underreporters with energy intake lower than resting energy expenditure were excluded. Hyperkalemia was defined as serum potassium &gt;5.0 mEq/L.

Results

The NDD-CKD cohort included 95 patients {median age 67 [interquartile range (IQR) 55–73] years, 32% with diabetes mellitus (DM), median estimated glomerular filtration rate 23 [IQR 18–29] mL/min/1.73 m2} and the HD cohort included 117 patients [median age 39 (IQR 18–67) years, 50% with DM]. In NDD-CKD, patients with hyperkalemia (36.8%) exhibited lower serum bicarbonate and a tendency for higher serum creatinine, a higher proportion of DM and the use of renin–angiotensin–aldosterone system blockers, but lower use of sodium bicarbonate supplements. No association was found between serum and dietary potassium (r = 0.01; P = 0.98) or selected food groups. Conditions associated with hyperkalemia in multivariable analysis were DM {odds ratio [OR] 3.55 [95% confidence interval (CI) 1.07–11.72]} and metabolic acidosis [OR 4.35 (95% CI 1.37–13.78)]. In HD, patients with hyperkalemia (50.5%) exhibited higher serum creatinine and blood urea nitrogen and lower malnutrition inflammation score and a tendency for higher dialysis vintage and body mass index. No association was found between serum and potassium intake (r = −0.06, P = 0.46) or food groups. DM [OR 4.22 (95% CI 1.31–13.6)] and serum creatinine [OR 1.50 (95% CI 1.24–1.81)] were predictors of hyperkalemia in multivariable analyses.

Conclusions

Dietary potassium was not associated with serum potassium or hyperkalemia in either NDD-CKD or HD patients. Before restricting dietary potassium, the patient’s intake of potassium should be carefully evaluated and other potential clinical factors related to serum potassium balance should be considered in the management of hyperkalemia in CKD.

Low Serum Potassium Levels and Clinical Outcomes in Peritoneal Dialysis-International Results from PDOPPS

Introduction

Hypokalemia, including normal range values <4 mEq/l, has been associated with increased peritonitis and mortality in patients with peritoneal dialysis. This study sought to describe international variation in hypokalemia, potential modifiable hypokalemia risk factors, and the covariate-adjusted relationship of hypokalemia with peritonitis and mortality.

Methods

Baseline serum potassium was determined in 7421 patients from 7 countries in the Peritoneal Dialysis Outcomes and Practice Patterns Study (2014-2017). Association of baseline patient and treatment factors with subsequent serum potassium <4 mEq/l was evaluated by logistic regression, whereas baseline serum potassium levels (4-month average and fraction of 4 months having hypokalemia) on clinical outcomes was assessed by Cox regression.

Results

Hypokalemia was more prevalent in Thailand and among black patients in the United States. Characteristics/treatments associated with potassium <4 mEq/l included protein-energy wasting indicators, lower urine volume, lower blood pressure, higher dialysis dose, greater diuretic use, and not being prescribed a renin-angiotensin system inhibitor. Persistent hypokalemia (all 4 months vs. 0 months over the 4-month exposure period) was associated with 80% higher subsequent peritonitis rates (at K <3.5 mEq/l) and 40% higher mortality (at K <4.0 mEq/l) after extensive case mix/potential confounding adjustments. Furthermore, adjusted peritonitis rates were higher if having mean serum K over 4 months <3.5 mEq/l versus 4.0-4.4 mEq/l (hazard ratio, 1.15 [95% confidence interval, 0.96-1.37]), largely because of Gram-positive/culture-negative infections.

Conclusions

Persistent hypokalemia is associated with higher mortality and peritonitis even after extensive adjustment for patient factors. Further studies are needed to elucidate mechanisms of these poorer outcomes and modifiable risk factors for persistent hypokalemia.

A G-quadruplex nanoswitch in the SGK1 promoter regulates isoform expression by K+/Na+ balance and resveratrol binding

BACKGROUND

High sodium intake can up-regulate the level of renal serum- and glucocorticoid-inducible kinase-1 (SGK1), which plays a pivotal role in controlling blood pressure via activation of the epithelial sodium channel (ENaC), which can lead to salt-sensitive hypertension. Increased potassium intake, or a vegetarian diet, counteracts salt-sensitive hypertension, but the underlying mechanisms are not fully understood.

METHODS

Bioinformatics and molecular modeling were used to identify G-quadruplex (G4) and their conformations in the SGK1 promoter. CD spectra and UV melting dynamics were measured to study the stability of G4 as influenced by potassium/sodium balance and resveratrol. RT-PCR and Western blot were employed to study the effects of potassium and resveratrol on the SGK1 isoform expression.

RESULTS

The SGK1 gene encodes a G4 structure in the proximal upstream of promoter-2; the G4 structure is stabilized by potassium or resveratrol, but destabilized by sodium. Super-physiological levels of sodium stimulate the transcription of all SGK1 isoforms, whereas resveratrol or potassium supplementation inhibits the transcription of iso-2 and iso-3, but not iso-1.

CONCLUSIONS

Stabilizing the G4 by potassium or resveratrol induces alternative promoter usage and/or pre-mRNA splicing in the transcription of SGK1.

GENERAL SIGNIFICANCE

Potassium/sodium ion balance or resveratrol binding can act to regulate G4 molecular switches for controlling SGK1 gene expression, thereby presenting a new avenue for drug development.

Hypokalemia associated with topical administration of dorzolamide 2% ophthalmic solution in cats

OBJECTIVE

To evaluate the effect of dorzolamide 2% ophthalmic solution on serum potassium and other hematologic parameters in cats.

MATERIALS AND METHODS

Part I: Medical records from a single institution were retrospectively reviewed. Inclusion criteria consisted of cats diagnosed with glaucoma for which appropriate clinicopathological data were available both prior to and after the initiation of therapy with dorzolamide 2% ophthalmic solution. Part II: Healthy adult cats were enrolled in a prospective double-masked, randomized, cross-over study. Either dorzolamide 2% ophthalmic solution or placebo was administered OU t.i.d. for 6 weeks. Serum potassium, sodium, chloride, glucose, ALP, and ALT levels were assessed every 2 weeks. After a 2-week washout period, each cat was given the opposite topical preparation, and the study process was repeated.

RESULTS

Part I: Of the twenty-seven eligible cases, hypokalemia developed in 29.6% (n = 8). While female spayed cats were significantly more likely to become hypokalemic, serum potassium was not significantly affected by age, weight, dosing frequency, or number of eyes treated. Part II: Ten cats participated in the study. Potassium values were significantly lower in cats receiving dorzolamide 2% ophthalmic solution compared to placebo at each time point throughout the 6-week study period. Additionally, chloride values were significantly greater in the treatment group at week two and four compared to the placebo group.

CONCLUSIONS

Administration of dorzolamide 2% ophthalmic solution has a measurable effect on serum potassium level in cats and may result in clinical hypokalemia. Therefore, routine electrolyte monitoring is advised for feline patients receiving this medication.

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

Rationale & Objective

Hyperkalemia is a common electrolyte abnormality of chronic kidney disease and heart failure associated with increased mortality and morbidity. We aimed to assess the long-term economic burden of hyperkalemia.

Design

Observational cohort study using a Japanese nationwide hospital claims database (April 1, 2008, to September 30, 2018).

Setting & Population

: Patients 18 years or older with at least 1 serum potassium value (N = 1,208,894).

Exposures

Hyperkalemia defined with the presence of at least 2 serum potassium values ≥ 5.1 mmol/L.

Outcome Measures

Direct health care costs and resource use in patients with hyperkalemia within and after 12 months from first hyperkalemia episodes.

Analytical Approach

Health care costs and resource use were compared with propensity score–matched or nonmatched normokalemic controls. Multivariable regression analysis was performed to examine factors associated with health care costs.

Results

27,534 patients with hyperkalemia and 233,098 normokalemic controls were studied. Mean ± SD age was 73±13 years in patients with hyperkalemia; among them, 59% and 35% had chronic kidney disease and heart failure, respectively. In the propensity score–matched cohort (n = 5,859 in each group), average numbers of hospitalizations per patient per year in patients with hyperkalemia within and after 12 months were 1.2 and 1.6 times higher, respectively, compared with those in patients with normokalemia. The total cost per patient in patients with hyperkalemia was higher than for controls, with mean differences of $8,611 (95% CI, $8,046-$9,175) within 12 months and $5,150 (95% CI, $4,733-$5,566) after 12 months. The number of repeat hyperkalemic episodes was the factor with the strongest association with long-term health care costs, whereas severity of hyperkalemia was not associated.

Limitations

This study used secondary data; therefore, residual confounders may not be fully excluded.

Conclusions

Hyperkalemia was associated with significant long-term economic burden with frequent hospitalizations due to recurrent episodes, indicating the importance of hyperkalemia treatment for the sake of reducing health economic burdens and clinical complications.

The struggle to equilibrate outer and inner milieus: Renal evolution revisited

The journey of life, from primordial protoplasm to a complex vertebrate form, is a tale of survival against incessant alterations in climate, surface topography, food chain, and chemistry of the external environment. Kidneys present with an ensemble embodiment of the adaptations devised by diverse life-forms to cope with such challenges and maintain a chemical equilibrium of water and solutes, both in and outside the body. This minireview revisits renal evolution utilizing the classic: From Fish to Philosopher; the story of our internal environment, by Prof. Homer W. Smith (1895-1962) as a template. Prof. Smith's views exemplified the invention of glomeruli, or its abolishment, as a mechanism to filter water. Moreover, with the need to preserve water, as in reptiles, the loop of Henle was introduced to concentrate urine. When compared to smaller mammals, the larger ones, albeit having loops of Henle of similar lengths, demonstrated a distinct packing of the nephrons in kidneys. Moreover, the renal portal system degenerated in mammals, while still present in other vertebrates. This account will present with a critique of the current concepts of renal evolution while examining how various other factors, including the ones that we know more about now, such as genetic factors, synchronize to achieve renal development. Finally, it will try to assess the validity of ideas laid by Prof. Smith with the knowledge that we possess now, and understand the complex architecture that evolution has imprinted on the kidneys during its struggle to survive over epochs.

Combined imaging of potassium and sodium in human skeletal muscle tissue at 7 T

PURPOSE

To validate the feasibility of quantitative combined potassium (³⁹ K) and sodium (²³ Na) MRI in human calf muscle tissue, as well as to evaluate the reproducibility of the apparent tissue potassium concentration (aTPC) and apparent tissue sodium concentration (aTSC) determination in healthy muscle tissue.

METHODS

Quantitative ²³ Na and ³⁹ K MRI acquisition protocols were implemented on a 7 T MR system. A double-resonant ²³ Na/³⁹ K birdcage RF coil was used. Measurements of human lower leg were performed in a total acquisition time of TA_Na = 10:54 min/TA_K = 8:06 min and using a nominal spatial resolution of 2.5 × 2.5 × 15 mm³ /7.5 × 7.5 × 30 mm³ for ²³ Na/³⁹ K MRI. Two aTSC and aTPC examinations in muscle tissue were performed during the same day on 10 healthy subjects.

RESULTS

The proposed acquisition and postprocessing workflow for ²³ Na and ³⁹ K MRI data sets provided reproducible aTSC and aTPC measurements. In human calf muscle tissue, the coefficient of variation between scan and re-scan was 5.7% for both aTSC and aTPC determination. Overall, mean values of aTSC = (17 ± 1) mM and aTPC = (85 ± 5) mM were measured. Moreover, for ³⁹ K in calf muscle tissue, T 2 ∗ components of T 2 f ∗ = (1.2 ± 0.2) ms and T 2 s ∗ = (7.9 ± 0.9) ms, as well as a residual quadrupolar interaction of ω q ¯ = (143 ± 17) Hz, were determined. The fraction of the fast component was f = (58 ± 4)%.

CONCLUSION

Using the presented measurement and postprocessing approach, a reproducible aTSC and aTPC determination using ²³ Na and ³⁹ K MRI at 7 T in human skeletal muscle tissue is feasible in clinically acceptable acquisition durations.

Role of potassium channels in female reproductive system

Potassium channels are widely expressed in most types of cells in living organisms and regulate the functions of a variety of organs, including kidneys, neurons, cardiovascular organs, and pancreas among others. However, the functional roles of potassium channels in the reproductive system is less understood. This mini-review provides information about the localization and functions of potassium channels in the female reproductive system. Five types of potassium channels, which include inward-rectifying (Kir), voltage-gated (Kv), calcium-activated (K_Ca), 2-pore domain (K_2P), and rapidly-gating sodium-activated (Slo) potassium channels are expressed in the hypothalamus, ovaries, and uterus. Their functions include the regulation of hormone release and feedback by Kir6.1 and Kir6.2, which are expressed in the luteal granulosa cells and gonadotropin-releasing hormone neurons respectively, and regulate the functioning of the hypothalamus–pituitary–ovarian axis and the production of progesterone. Both channels are regulated by subtypes of the sulfonylurea receptor (SUR), Kir6.1/SUR2B and Kir6.2/SUR1. K_v and Slo2.1 affect the transition from uterine quiescence in late pregnancy to the state of strong myometrial contractions in labor. Intermediate- and small-conductance K_Ca modulate the vasodilatation of the placental chorionic plate resistance arteries via the secretion of nitric oxide and endothelium-derived hyperpolarizing factors. Treatment with specific channel activators and inhibitors provides information relevant for clinical use that could help alter the functions of the female reproductive system.

Innovative prolonged-release oral alkalising formulation allowing sustained urine pH increase with twice daily administration: randomised trial in healthy adults

A multi-particulate fixed-dose combination product, consisting of a combination of two alkalising salts formulated as prolonged-release granules, ADV7103, was developed to obtain a sustained and prolonged alkalising effect. The specific release of both types of granules was shown in vitro through their dissolution profiles, which indicated that potassium citrate was released within the first 2-3 h and potassium bicarbonate up to 10-12 h after administration. The long-lasting coverage of ADV7103 was confirmed through a randomised, placebo-controlled, double-blind, two-period study, measuring its effect on urine pH in healthy adults (n = 16) at doses of alkalising agent ranging between 0.98 and 2.88 meq/kg/day. A significant increase of urine pH with a positive dose-response in healthy adult subjects was shown. Urine pH above 7 was maintained during 24 h with a dosing equivalent to 1.44 meq/kg twice a day, while urine pH was below 6 most of the time with placebo. The effect observed was non-saturating within the range of doses evaluated and the formulation presented a good safety profile. ADV7103 provided an effective prolonged release of alkalising salts to cover a 12-h effect with adequate tolerability and could afford a twice a day (morning and evening) dosing in patients requiring long-term treatment.

A method comparison study of a point-of-care blood gas analyser with a laboratory auto-analyser for the determination of potassium concentrations during hyperkalaemia in patients with kidney disease

Introduction

Hyperkalaemia is a common electrolyte disorder that may cause life-threatening cardiac arrythmias. We aimed to determine the agreement of potassium concentrations between GEM premier 3500 point-of-care blood gas analyser (POC-BGA) and Roche Cobas 6000 c501 auto-analyser in patients with hyperkalaemia.

Methods

A prospective, cross-sectional study of all consecutive adult patients referred to the Renal Unit with a serum potassium concentration ≥ 5.5 mmol/L was performed. A total of 59 paired venous blood samples were included in the final statistical analysis. Passing-Bablok regression and Bland Altman analysis were used to compare the two methods.

Results

The median laboratory auto-analyser potassium concentration was 6.1 (5.9-7.1) mmol/L as compared to the POC-BGA potassium concentration of 5.7 (5.5-6.8) mmol/L with a mean difference of - 0.43 mmol/L and 95% upper and lower limits of agreement of 0.35 mmol/L and - 1.21 mmol/L, respectively. Regression analysis revealed proportional systematic error. Test for linearity did not indicate significant deviation (P = 0.297).

Conclusion

Although regression analysis indicated proportional systematic error, on Bland Altman analysis, the mean difference appeared to remain relatively constant across the potassium range that was evaluated. Therefore, in patients presenting to the emergency department with a clinical suspicion of hyperkalaemia, POC-BGA potassium concentrations may be considered a surrogate for laboratory auto-analyser measurements once clinicians have been cautioned about this difference.

Aquaporin-2 and NKCC2 expression pattern in patients with hepatosplenic schistosomiasis

OBJECTIVE

Schistosoma mansoni infection is considered a public health problem. Glomerular involvement in schistosomiasis is a well-documented complication, especially in hepatosplenic schistosomiasis (HSS). However, renal tubular function is poorly understood. The aim of this study was to investigate, through urinary exosomes, tubular transporters functionally in HSS patients.

METHODS

Cross-sectional study of 20 HSS patients who had isolated exosomes from urine samples. Protease inhibitor was added in the urine samples who were immediately frozen at -80 °C for further exosomes isolation. After urine had thawed, urinary exosomes were obtained using extensive vortexing, centrifugation and ultracentrifugation steps of urine. Urinary transporters expression from exosomes was evaluated by western blot, including NHE3, AQP2 and NKCC2. Charge amounts for gel electrophoresis were adjusted by urinary creatinine concentration of each patient to avoid urinary concentration bias. All protein expression of HSS patients was relative to healthy controls.

RESULTS

The expression of aquaporin-2 (AQP2) was lower in HSS patients than in controls (46.8 ± 40.7 vs. 100 ± 70.2%, P = 0.03) and the expression of the NKCC2 co-transporter was higher (191.7 ± 248.6 vs. 100 ± 43.6%, P = 0.02).

CONCLUSIONS

The decrease of AQP2 and the increase of NKCC2 expression in HSS patients seem to be involved with the inability of urinary concentration in these patients. These data show renal tubular abnormalities in HSS patients without manifest clinical disease.

Vancomycin-induced hypokalemia: A proof-of-concept case report

BACKGROUND

Vancomycin is used on a large scale in medical practice, mostly for the treatment of serious gram-positive bacterial infection. Many adverse effects have been linked to vancomycin use with nephrotoxicity being one of its most prevalent side effects.

CASE REPORT

We present the case of an 81 years-old woman who had sustained vancomycin-induced hypokalemia while treating an infected surgical wound. She was under chronic use of losartan for high blood pressure but she was not diabetic. Potassium in serum reached critically low levels during the use of this antibiotic - despite intravenous reposition - and returned to normal right after the drug was stopped, in two different occasions. Elevated urinary potassium levels indicated renal potassium wasting, though serum creatinine levels remained within the normal range throughout hospitalization.

CONCLUSIONS

Vancomycin must be considered as a possible cause for hypokalemia of unknown etiology and physicians should be aware of this potential severe adverse effect.

Dietary Exposure of Heavy Metals, Minerals and Trace Elements through Cereals Commonly Consumed by Dhaka City Residents

Background:

Contamination of soil and agricultural products by heavy metals resulting from rapid industrial development has caused major concern. Dietary exposure to heavy metals has been associated with toxic and adverse health effects. The main threats to human health from heavy metals are associated with exposure to Pb, Cd and Hg. The aim of this study was to monitor the presence of heavy metals, minerals and trace elements in cereals consumed by Dhaka city residents.

Methods:

One hundred and sixty cereal samples were collected for eight (08) composited samples and analyzed for the determination of sixteen elements. Heavy metals were analyzed by Inductively Coupled Plasma Mass Spectrometry (ICP-MS), and other elements were determined by Atomic Absorption Spectrometry (AAS).

Results:

The average concentrations of elements in cereals fall within the safe limit except for Pb, Cr, Na and Mg, which exceeded the safe limits. The daily intake of Cd (23.0 μg), Hg (63.0 μg) and As (13.6 μg) through cereals was below the risk level except for Pb (634.0 μg) and Cr (263.1 μg). The dietary intake of Na (1860.0 mg), Mg (347.0 mg) and Mn (4600.0 μg) exceeded the toxic level while K (829 mg) was below the RDA.

Conclusion:

As the main meal of average Bangladeshi people is boiled rice served with some vegetables, our findings indicate that the residents of Dhaka city are at risk from Pb and Cr contamination and their dietary need for some important minerals and trace elements is not fulfilled by cereals.

Impact of Dietary Potassium Restrictions in CKD on Clinical Outcomes: Benefits of a Plant-Based Diet

In patients with advanced-stage chronic kidney disease (CKD), progressive kidney function decline leads to increased risk for hyperkalemia (serum potassium > 5.0 or >5.5 mEq/L). Medications such as renin-angiotensin-aldosterone system inhibitors pose an additional hyperkalemia risk, especially in patients with CKD. When hyperkalemia develops, clinicians often recommend a diet that is lower in potassium content. This review discusses the barriers to adherence to a low-potassium diet and the impact of dietary restrictions on adverse clinical outcomes. Accumulating evidence indicates that a diet that incorporates potassium-rich foods has multiple health benefits, which may also be attributable to the other vitamin, mineral, and fiber content of potassium-rich foods. These benefits include blood pressure reductions and reduced risks for cardiovascular disease and stroke. High-potassium foods may also prevent CKD progression and reduce mortality risk in patients with CKD. Adjunctive treatment with the newer potassium-binding agents, patiromer and sodium zirconium cyclosilicate, may allow for optimal renin-angiotensin-aldosterone system inhibitor therapy in patients with CKD and hyperkalemia, potentially making it possible for patients with CKD and hyperkalemia to liberalize their diet. This may allow them the health benefits of a high-potassium diet without the increased risk for hyperkalemia, although further studies are needed.

Plant-based diets to manage the risks and complications of chronic kidney disease

Traditional dietary recommendations for patients with chronic kidney disease (CKD) focus on the quantity of nutrients consumed. Without appropriate dietary counselling, these restrictions can result in a low intake of fruits and vegetables and a lack of diversity in the diet. Plant nutrients and plant-based diets could have beneficial effects in patients with CKD: increased fibre intake shifts the gut microbiota towards reduced production of uraemic toxins; plant fats, particularly olive oil, have anti-atherogenic effects; plant anions might mitigate metabolic acidosis and slow CKD progression; and as plant phosphorus has a lower bioavailability than animal phosphorus, plant-based diets might enable better control of hyperphosphataemia. Current evidence suggests that promoting the adoption of plant-based diets has few risks but potential benefits for the primary prevention of CKD, as well as for delaying progression in patients with CKD G3-5. These diets might also help to manage and prevent some of the symptoms and metabolic complications of CKD. We suggest that restriction of plant foods as a strategy to prevent hyperkalaemia or undernutrition should be individualized to avoid depriving patients with CKD of these potential beneficial effects of plant-based diets. However, research is needed to address knowledge gaps, particularly regarding the relevance and extent of diet-induced hyperkalaemia in patients undergoing dialysis.

Direct Visualization of Perm-Selective Ion Transportation

Perm-selective ion transportation in a nanoscale structure such as nanochannel, nanoporous membrane or nanojunction has been extensively studied with aids of nanofabrication technology for a decade. While theoretical and experimental advances pushed the phenomenon to seminal innovative applications, its basic observation has relied only on an indirect analysis such as current-voltage relation or fluorescent imaging adjacent to the nanostructures. Here we experimentally, for the first time, demonstrated a direct visualization of perm-selective ion transportation through the nanoscale space using an ionic plasma generation. A micro/nanofluidic device was employed for a micro bubble formation, plasma negation and penetration of the plasma along the nanojunction. The direct observation provided a keen evidence of perm-selectivity, i.e. allowing cationic species and rejecting anionic species. Furthermore, we can capture the plasma of lithium, which has lower mobility than sodium in aqueous state, passed the nanojunction faster than sodium due to the absence of hydrated shells around lithium. This simple, but essential visualization technique would be effective means not only for advancing the fundamental nanoscale electrokinetic study as well as interfacial ion transportation between liquid and plasma but also for providing the insight of new innovative engineering applications.

Hypokalemia and the Prevalence of Primary Aldosteronism

Hypokalemia is closely linked with the pathophysiology of primary aldosteronism (PA). Although hypokalemic PA is less common than the normokalemic course of the disease, hypokalemia is of particular importance for the manifestation and development of comorbidities. Specifically, a growing body of evidence demonstrates that hypokalemia in PA patients is associated with a more severe disease course regarding cardiovascular and metabolic morbidity and mortality. It is also well appreciated that low potassium levels per se can promote or exacerbate hypertension. The spectrum of hypokalemia-related symptoms ranges from asymptomatic courses to life-threatening conditions. Hypokalemia is found in 9-37% of all cases of PA with a predominance in patients with aldosterone producing adenoma. Conversely, hypokalemia resolves in almost 100% of cases after both, specific medical or surgical treatment of the disease. However, to date, high-level evidence about the prevalence of primary aldosteronism in a hypokalemic population is missing. Epidemiological data are expected from the recently launched IPAHK+study ("Incidence of Primary Aldosteronism in Patients with Hypokalemia").

Effects of dietary electrolyte balance and calcium supply on mineral and acid-base status of piglets fed a diversified diet

Dietary electrolyte balance (dEB) is known to affect acid-base status and mineral metabolism, but is rarely considered in diet formulation for pigs. Yet, the use of a wide variety of local feedstuffs in Europe contributes to lowering the dEB and increasing the fibre content. Hence, mineral requirements may be modified and skeletal health affected. Therefore, the effects of a lower dEB and a higher dietary Ca level on acid-base balance and mineral status were assessed in young pigs fed a diversified diet. A total of twenty-four weaned pigs were fed a control moderate-dEB diet (C) or a diversified moderate-dEB (D), low-dEB (D-A) or low-dEB supplemented with Ca (D-CA) diet. Growth performance, venous blood gas and chemistry, urine pH, mineral balance and femur characteristics were determined. With an equivalent dEB compared with the C diet, the D diet caused an acidification of the urine and increased the excretion of P as a result of a higher dietary content of S. Low-grade metabolic acidosis occurred in piglets fed the D-A diet with changes at systemic and urine levels. A higher excretion of ammonia and P in urine was observed and some bone characteristics tended to be negatively affected. Ca supplementation partially counteracted the effects of low-grade acidosis. Urine excretion of P and ammonia was alleviated and bone characteristics improved. In conclusion, a higher Ca supply must be considered in more diversified diets to counteract the risk of evolving towards low-grade metabolic acidosis which can negatively affect bone.

Evaluation of the biocompatibility of the GSH-coated Ag2S quantum dots in vitro: a perfect example for the non-toxic optical probes

Near-infrared quantum dots (NIR QDs) are promising candidate for the fluorescent probes due to their better penetration depth, long-lived luminescence with size-tunable photoluminescence wavelengths. Glutathione-coated silver sulfide quantum dots (GSH-Ag₂S QDs) were synthesized using AgNO₃ and Na₂S in the aqueous media and they can give reaction with glutathione reductase (GR) and glutathione-s transferase (GST) enzymes as acting substrate analogue in vitro. Investigation of the toxicity of the nanomaterials are necessary to use them in the medical field and biomedical applications. Thus, in this study we investigated biocompatibility of the GSH-Ag₂S QDs in vitro using 293 T and CFPAC-1 cell lines. Cell viability by MTT assay, light microscopy, fluorescence microscopy, oxidative stress enzyme activities and ICP-MS analysis were performed to evaluate the cytotoxicity and internalization of the GSH-Ag₂S QDs. GSH-Ag₂S QDs showed great biocompatibility with both cell lines and did not cause imbalance in the oxidative stress metabolism. The ultralow solubility product constant of Ag₂S QDs (K_sp = 6.3 × 10^-50) prevents release of Ag ions into the biological systems that is in agreement with data obtained by ICP-MS. In conclusion, this data prove potential of GSH-Ag₂S QDs as a biocompatible optical probe to be used for the detection and/or targeting of GSH impaired diseases including cancer.

The Na+-K+-ATPase is needed in glia of touch receptors for responses to touch in C. elegans

Four of the five types of mammalian mechanosensors are composed of nerve endings and accessory cells. In Caenorhabditis elegans we showed that glia support the function of nose touch neurons via the activity of glial Na+ and K+ channels. We show here that a third regulator of Na+ and K+, the Na+-K+-ATPase, is needed in glia of nose touch neurons for touch. Importantly, we show that two Na+-K+-ATPase genes are needed for the function rather than structural integrity and that their ion transport activity is crucial for touch. Finally, when glial Na+-K+-ATPase genes are knocked out, touch can be restored by activation of a third Na+-K+-ATPase. Taken together, these data show the requirement in glia of touch neurons of the function of the Na+-K+-ATPase. These data underscore the importance of the homeostasis of Na+ and K+, most likely in the space surrounding touch neurons, in touch sensation, a function that might be conserved across species.NEW & NOTEWORTHY Increasing evidence supports that accessory cells in mechanosensors regulate neuronal output; however, the glial molecular mechanisms that control this regulation are not fully understood. We show here in Caenorhabditis elegans that specific glial Na+-K+-ATPase genes are needed for nose touch-avoidance behavior. Our data support the requirement of these Na+-K+-ATPases for homeostasis of Na+ and K+ in nose touch receptors. Our data add to our understanding of glial regulation of mechanosensors.

Estimated population wide benefits and risks in China of lowering sodium through potassium enriched salt substitution: modelling study

OBJECTIVES

To estimate the effects of nationwide replacement of discretionary salt (used at table or during cooking) with potassium enriched salt substitute on morbidity and death from cardiovascular disease in China.

DESIGN

Modelling study.

SETTING

China.

POPULATION

Adult population in China, and specifically individuals with chronic kidney disease (about 17 million people).

INTERVENTIONS

Comparative risk assessment models were used to estimate the effects of a nationwide intervention to replace discretionary dietary salt with potassium enriched salt substitutes (20-30% potassium chloride). The models incorporated existing data and corresponding uncertainties from randomised trials, the China National Survey of Chronic Kidney Disease, the Global Burden of Disease Study, and the Chronic Kidney Disease Prognosis Consortium.

MAIN OUTCOME MEASURES

Averted deaths from cardiovascular disease, non-fatal events, and disability adjusted life years from a reduction in blood pressure were estimated after implementation of potassium enriched salt substitution. In individuals with chronic kidney disease, additional deaths from cardiovascular disease related to hyperkalaemia from increased intake of potassium were calculated. The net effects on deaths from cardiovascular disease were estimated as the difference and ratio of averted and additional deaths from cardiovascular disease.

RESULTS

Nationwide implementation of potassium enriched salt substitution could prevent about 461 000 (95% uncertainty interval 196 339 to 704 438) deaths annually from cardiovascular disease, corresponding to 11.0% (4.7% to 16.8%) of annual deaths from cardiovascular disease in China; 743 000 (305 803 to 1 273 098) non-fatal cardiovascular events annually; and 7.9 (3.3 to 12.9) million disability adjusted life years related to cardiovascular disease annually. The intervention could potentially produce an estimated 11 000 (6422 to 16 562) additional deaths related to hyperkalaemia in individuals with chronic kidney disease. The net effect would be about 450 000 (183 699 to 697 084) fewer deaths annually from cardiovascular disease in the overall population and 21 000 (1928 to 42 926) fewer deaths in individuals with chronic kidney disease. In deterministic sensitivity analyses, with changes to key model inputs and assumptions, net benefits were consistent in the total population and in individuals with chronic kidney disease, with averted deaths outweighing additional deaths.

CONCLUSIONS

Nationwide potassium enriched salt substitution in China was estimated to result in a substantial net benefit, preventing around one in nine deaths from cardiovascular disease overall. Taking account of the risks of hyperkalaemia, a substantial net benefit was also estimated for individuals with chronic kidney disease.

Effects of natural polyphenol-rich pomegranate juice supplementation on plasma ion and lipid profiles following resistance exercise: a placebo-controlled trial

Background

Pomegranate juice (POMj) contains abundant soluble polyphenolic antioxidant compounds and is recommended for its cardioprotective/atheroprotective properties. However, very few studies have investigated the efficacy of POMj supplementation to alter physiological responses during intensive physical exercise. This placebo-controlled study aimed to examine whether supplementation with natural polyphenol-rich-POMj could influence the ionic or lipid responses to an intensive resistance training session in elite athletes.

Methods

Nine elite weightlifters (21 ± 1 years) performed two Olympic-weightlifting sessions after ingesting placebo and POMj supplements. Venous blood samples were collected at rest and 3 min after each session for assessment of plasma sodium ([Na⁺]), potassium ([K⁺]), chloride ([Cl^-]), calcium ([Ca²⁺]), triglyceride ([TG]) and high-density lipoprotein ([HDL-C]), low-density lipoprotein ([HDL-C]) and total ([TC]) cholesterol concentrations.

Results

Plasma [K⁺] and [TG] were lowered post-exercise compared to resting values in the PLA condition (p = 0.03 for K⁺ and p = 0.02 for TG) with no pre-to-post exercise differences in the other plasma ion and lipid markers (p > 0.05). Compared to rest, plasma [Na⁺] and [Cl^-] were increased (p = 0.04, %change = 4.10% for Na⁺ and p = 0.02, %change = 4.44% for Cl^-), but there were no differences in the other plasma ion or lipid markers post-exercise after POMj supplementation (p > 0.05). Post-exercise plasma [Na⁺], [Cl^-], and [HDL-C] were greater following POMj supplementation compared to PLA (p = 0.01 for Cl- and HDL-C, p = 0.02 for Na+, and p = 0.04 for TC), with no between-supplement post-exercise differences in the other ion and lipid markers (p > 0.05).

Conclusion

In conclusion, supplementation with POMj has the potential to attenuate the acute imbalance of plasma [K⁺] and to improve blood lipid responses (i.e., HDL-C) following resistance exercises in elite weightlifters. However, further large research in both athletic and non-athletic populations is needed to corroborate these preliminary observations and to elucidate the potential underlying mechanisms and translational potential of our novel observations.

Trial registration

Name of the registry:ClinicalTrials.gov PRSThe registration number:NCT02697903.Date of Registry: 03/03/2016 'Retrospectively registered'.The registration title: Pomegranate Improve Biological Recovery Kinetics in Elite Weightlifter.

Graphical abstract

Differential role of planar cell polarity gene Vangl2 in embryonic and adult mammalian kidneys

Planar cell polarity (PCP) pathway is crucial for tissue morphogenesis. Mutations in PCP genes cause multi-organ anomalies including dysplastic kidneys. Defective PCP signaling was postulated to contribute to cystogenesis in polycystic kidney disease. This work was undertaken to elucidate the role of the key PCP gene, Vangl2, in embryonic and postnatal renal tubules and ascertain whether its loss contributes to cyst formation and defective tubular function in mature animals. We generated mice with ubiquitous and collecting duct-restricted excision of Vangl2. We analyzed renal tubules in mutant and control mice at embryonic day E17.5 and postnatal days P1, P7, P30, P90, 6- and 9-month old animals. The collecting duct functions were analyzed in young and adult mutant and control mice. Loss of Vangl2 leads to profound tubular dilatation and microcysts in embryonic kidneys. Mechanistically, these abnormalities are caused by defective convergent extension (larger tubular cross-sectional area) and apical constriction (cuboidal cell shape and a reduction of activated actomyosin at the luminal surface). However, the embryonic tubule defects were rapidly resolved by Vangl2-independent mechanisms after birth. Normal collecting duct architecture and functions were found in young and mature animals. During embryogenesis, Vangl2 controls tubular size via convergent extension and apical constriction. However, rapidly after birth, PCP-dependent control of tubular size is switched to a PCP-independent regulatory mechanism. We conclude that loss of the Vangl2 gene is dispensable for tubular elongation and maintenance postnatally. It does not lead to cyst formation and is unlikely to contribute to polycystic kidney disease.

Efficacy of Furosemide, Oral Sodium Chloride, and Fluid Restriction for Treatment of Syndrome of Inappropriate Antidiuresis (SIAD): An Open-label Randomized Controlled Study (The EFFUSE-FLUID Trial)

RATIONALE & OBJECTIVE

First-line therapy for syndrome of inappropriate antidiuresis (SIAD) is fluid restriction. Additional treatment for patients who do not respond to fluid restriction are water restriction with furosemide or water restriction with furosemide and salt supplementation. However, the efficacy of these treatments has never been tested in a randomized controlled study. The objective of this study was to investigate whether, combined with fluid restriction, furosemide with or without sodium chloride (NaCl) supplementation was more effective than fluid restriction alone in the treatment of hyponatremia in SIAD.

STUDY DESIGN

Open-label randomized controlled study.

SETTING & PARTICIPANTS

Patients with serum sodium concentrations ([Na⁺]) ≤ 130mmol/L due to SIAD.

INTERVENTION(S)

Random assignment to 1 of 3 groups: fluid restriction alone (FR), fluid restriction and furosemide (FR+FM), or fluid restriction, furosemide, and NaCl (FR+FM+NaCl). Strictness of fluid restriction (<1,000 or<500mL/d) was guided by the urine to serum electrolyte ratio. Furosemide dosage was 20 to 40mg/d. NaCl supplements were 3g/d. All treatments were continued for 28 days.

OUTCOMES

The primary outcome was change in [Na⁺] at days 4, 7, 14, and 28 after randomization.

RESULTS

92 patients were recruited (FR, n=31; FR+FM, n=30; FR+FM+NaCl, n=31). Baseline [Na⁺] was 125±4mmol/L, and there were no significant differences between groups. Mean [Na⁺] on day 4 in all treatment groups was significantly increased from baseline by 5mmol/L (P<0.001); however, the change in [Na⁺] was not significantly different across groups (P=0.7). There was no significant difference in percentage of patients or time to reach [Na⁺] ≥ 130 or≥135mmol/L across the 3 groups. Acute kidney injury and hypokalemia (potassium≤3.0mmol/L) were more common in patients receiving furosemide.

LIMITATIONS

Open-label treatment.

CONCLUSIONS

In patients with SIAD, furosemide with NaCl supplement in combination with fluid restriction did not show benefits in correction of [Na⁺] compared with treatment with fluid restriction alone. Incidences of acute kidney injury and hypokalemia were increased in patients receiving furosemide.

FUNDING

None.

TRIAL REGISTRATION

Registered at the Thai Clinical Trial Registry with study number TCTR20170629004.

Current Management of Hyperkalemia in Patients on Dialysis

Patients with end-stage renal disease (ESRD) on maintenance dialysis have a high risk of developing hyperkalemia, generally defined as serum potassium (K⁺) concentrations of >5.0 mmol/l, particularly those undergoing maintenance hemodialysis. Currently, the key approaches to the management of hyperkalemia in patients with ESRD are dialysis, dietary K⁺ restriction, and avoidance of medications that increase hyperkalemia risk. In this review, we highlight the issues and challenges associated with effective management of hyperkalemia in patients undergoing maintenance dialysis using an illustrative case presentation. In addition, we examine the potential nondialysis options for the management of these patients, including use of the newer K⁺ binder agents patiromer and sodium zirconium cyclosilicate, which may reduce the need for the highly restrictive dialysis diet, with its own implication on nutritional status in patients with ESRD, as well as reducing the risk of potentially life-threatening hyperkalemia.

Potassium Homeostasis, Chronic Kidney Disease, and the Plant-Enriched Diets

There are data demonstrating that ingestion of potassium-rich foods reduces the incidence of stroke, hypertension, nephrolithiasis, and osteoporosis. Dietary-consumption data indicate Westernized diets are high in processed foods, high in sodium content, and low in potassium. In fact, there are data suggesting individuals are not consuming enough potassium in their diet. Although consumption of diets high in plant proteins, fruits, and vegetables-which are excellent sources of potassium-is recognized as healthy and beneficial, individuals with decrements in their kidney function have been advised to avoid these foods. In reviewing the literature that provides the rationale for potassium restriction in patients with reductions in kidney function, it appears there is little direct evidence to support the levels of restriction which are now prescribed. Additionally, there are two new potassium-binding agents which are well tolerated and have been documented to be effective in controlling serum potassium. Therefore, with the new binding agents and the lack of empirical evidence supporting the stringent dietary potassium restrictions, the authors conclude by indicating the pressing need for further research focusing on dietary liberalization of potassium in patients with reductions in kidney function to enhance overall health and well being, to provide them cardiovascular benefits, and to reduce overall risk of mortality through the incorporation of potassium-enriched foods.

Hyperkalemia treatment modalities: A descriptive observational study focused on medication and healthcare resource utilization

Renin-angiotensin-aldosterone system inhibitor (RAASi) therapy has been shown to improve outcomes among patients with congestive heart failure, diabetes, or renal dysfunction. These patients are also at risk for the development of hyperkalemia (HK), often leading to down-titration and/or discontinuation of RAASi therapy. Patiromer is the first sodium-free, non-absorbed potassium (K⁺) binder approved for the treatment of hyperkalemia (HK) in over 50 years. We described the association between use of K⁺ binders (Patiromer and sodium polystyrene sulfonate [SPS]) and renin-angiotensin-aldosterone system inhibitor (RAASi), on healthcare resource utilization (HRU). The study population consisted of Medicare Advantage patients with HK (K⁺ ≥ 5.0 mmol/L) in Optum’s Clinformatics^® Data Mart between 1/1/2016–12/31/2017. Patiromer and (SPS) initiators, and HK patients not exposed to a K⁺ binder (NoKb) were included. The index date was the date of the first K⁺ binder dispensing or HK diagnosis. Outcomes assessed at 6 months post-index were: (1) K⁺ binder utilization, (2) RAASi continuation, and (3) HRU (pre- vs post-index). HRU change was analyzed using McNemar’s statistical test. Study cohorts included 610 (patiromer), 5556 (SPS), and 21,282 (NoKb) patients. Overall baseline patient characteristics were: mean age 75 years; female 49%, low-income subsidy 29%, chronic kidney disease 48% (63% for patiromer cohort), and congestive heart failure 29%. At 6 months post-index, 28% (patiromer) and 2% (SPS) remained continuously exposed to the index K⁺ binder. RAASi continued for 78% (patiromer), 57% (SPS), and 57% (NoKb). The difference (pre- vs post-index) in hospitalized patients was: –9.4% (patiromer; P<0.05), –7.2% (SPS), and +16.8% (NoKb; P<0.001). Disparate K⁺ binder utilization patterns were observed. The majority of patiromer patients continued RAASi therapy while the percentage of SPS patients that continued RAASi therapy was lower, overlapping CIs were observed. Following continuous patiromer exposure, statistically significant reductions in hospital admissions and emergency department visits were observed, continuous SPS exposure observed no statistically significant reductions in either hospitalizations or ED visits, while NoKb patients with continuous exposure had statistically significant increases in both. Further research, with a larger sample size using comparative analytic methods, is warranted.

Regulation of the Renal NaCl Cotransporter and Its Role in Potassium Homeostasis

Daily dietary potassium (K+) intake may be as large as the extracellular K+ pool. To avoid acute hyperkalemia, rapid removal of K+ from the extracellular space is essential. This is achieved by translocating K+ into cells and increasing urinary K+ excretion. Emerging data now indicate that the renal thiazide-sensitive NaCl cotransporter (NCC) is critically involved in this homeostatic kaliuretic response. This suggests that the early distal convoluted tubule (DCT) is a K+ sensor that can modify sodium (Na+) delivery to downstream segments to promote or limit K+ secretion. K+ sensing is mediated by the basolateral K+ channels Kir4.1/5.1, a capacity that the DCT likely shares with other nephron segments. Thus, next to K+-induced aldosterone secretion, K+ sensing by renal epithelial cells represents a second feedback mechanism to control K+ balance. NCC’s role in K+ homeostasis has both physiological and pathophysiological implications. During hypovolemia, NCC activation by the renin-angiotensin system stimulates Na+ reabsorption while preventing K+ secretion. Conversely, NCC inactivation by high dietary K+ intake maximizes kaliuresis and limits Na+ retention, despite high aldosterone levels. NCC activation by a low-K+ diet contributes to salt-sensitive hypertension. K+-induced natriuresis through NCC offers a novel explanation for the antihypertensive effects of a high-K+ diet. A possible role for K+ in chronic kidney disease is also emerging, as epidemiological data reveal associations between higher urinary K+ excretion and improved renal outcomes. This comprehensive review will embed these novel insights on NCC regulation into existing concepts of K+ homeostasis in health and disease.

Potassium-Enriched Salt Substitutes as a Means to Lower Blood Pressure: Benefits and Risks

Use of salt substitutes containing potassium chloride is a potential strategy to reduce sodium intake, increase potassium intake, and thereby lower blood pressure and prevent the adverse consequences of high blood pressure. In this review, we describe the rationale for using potassium-enriched salt substitutes, summarize current evidence on the benefits and risks of potassium-enriched salt substitutes and discuss the implications of using potassium-enriched salt substitutes as a strategy to lower blood pressure. A benefit of salt substitutes that contain potassium chloride is the expected reduction in dietary sodium intake at the population level because of reformulation of manufactured foods or replacement of sodium chloride added to food during home cooking or at the dining table. There is empirical evidence that replacement of sodium chloride with potassium-enriched salt substitutes lowers systolic and diastolic blood pressure (average net Δ [95% CI] in mm Hg: -5.58 [-7.08 to -4.09] and -2.88 [-3.93 to -1.83], respectively). The risks of potassium-enriched salt substitutes include a possible increased risk of hyperkalemia and its principal adverse consequences: arrhythmias and sudden cardiac death, especially in people with conditions that impair potassium excretion such as chronic kidney disease. There is insufficient evidence regarding the effects of potassium-enriched salt substitutes on the occurrence of hyperkalemia. There is a need for additional empirical research on the effect of increasing dietary potassium and potassium-enriched salt substitutes on serum potassium levels and the risk of hyperkalemia, as well as for robust estimation of the population-wide impact of replacing sodium chloride with potassium-enriched salt substitutes.

Fluctuations in plasma potassium in patients on dialysis

Plasma potassium concentration is maintained in a narrow range to avoid deleterious electrophysiologic consequences of both abnormally low and high levels. This is achieved by redundant physiologic mechanisms, with the kidneys playing a central role in maintaining both short-term plasma potassium stability and long-term total body potassium balance. In patients with end-stage renal disease, the lack of kidney function reduces the body’s ability to maintain normal physiologic potassium balance. Routine thrice-weekly dialysis therapy achieves long-term total body potassium mass balance, but the intermittent nature of dialytic therapy can result in wide fluctuations in plasma potassium concentration and consequently contribute to an increased risk of arrhythmogenicity. Various dialytic and nondialytic interventions can reduce the magnitude of these fluctuations, but the impact of such interventions on clinical outcomes remains unclear.

Hyperkalemia and blood pressure regulation

Hypertension is common in the general population. Management of hypertensive patients at risk of hyperkalemia is challenging due to potential life-threatening complications such as cardiac arrest. Chronic hyperkalemia is often associated with impaired renal ability to excrete excessive potassium ions (K+). This may refer to chronic kidney disease or certain pharmacological interventions, including broadly used renin-angiotensin-aldosterone system and calcineurin inhibitors. Understanding the intrinsic mechanisms permitting kidney adaptations to hyperkalemia is critical for choosing therapeutic strategies. Valuable insights were obtained from the analysis of familial hyperkalemic hypertension (FHHt) syndrome, which became a classic model for coincidence of high blood pressure and hyperkalemia. FHHt can be caused by mutations in several genes, all of them resulting in excessive activity of with-no-lysine kinases (WNKs) in the distal nephron of the kidney. WNKs have been increasingly recognized as key signalling enzymes in the regulation of renal sodium ions (Na+) and K+ handling, enabling adaptive responses to systemic shifts of potassium homoeostasis consequent to variations in dietary potassium intake or disease. The WNK signalling pathway recruits a complex protein network mediating catalytic and non-catalytic effects of distinct WNK isoforms on relevant Na+- or K+-transporting proteins. In this review article, we summarize recent progress in understanding WNK signalling. An update of available models for renal adaptation to hyperkalemic conditions is presented. Consequences for blood pressure regulation are discussed. Pharmacological targeting of WNKs or their substrates offers promising options to manage hypertension while preventing hyperkalemia.

The Economic Implications of Hyperkalemia in a Medicaid Managed Care Population

BACKGROUND

Hyperkalemia, defined as a serum potassium level >5 mEq/L that results from multiple mechanisms, is a serious medical condition that can lead to life-threatening arrhythmias and sudden cardiac death. The coexistence of cardiac and renal diseases (ie, cardiorenal syndrome) significantly increases the complexity of care, but its economic impact is not well-characterized in this understudied Medicaid managed care population with hyperkalemia.

OBJECTIVE

To calculate the economic impact of hyperkalemia on patients with cardiorenal syndrome in a Medicaid managed care population in the United States using real-world data.

METHODS

In this retrospective cohort study, we used a proprietary Medicaid managed care database from 1 southern state. The total study population included 3563 patients, including 973 patients with hyperkalemia and 2590 controls (without hyperkalemia), who were matched based on age, comorbidities, and Medicaid eligibility status and duration, during a 30-month period between 2013 and 2016. The inclusion criteria for the hyperkalemia cohort were age ≥18 years, Medicaid-only insurance status, coded cardiorenal diagnosis, and a claim for hyperkalemia during the study period. The cost was determined using paid claims data.

RESULTS

The mean healthcare costs (medical and pharmacy per member per year [PMPY] for patients with hyperkalemia was higher than that for the control cohort without hyperkalemia ($56,002 vs $23,653, respectively). These cost differences were driven by medical costs accrued in the hyperkalemia and in the control cohorts ($49,648 and $18,399 PMPY, respectively). Two of the largest drivers of the medical cost variance were inpatient costs ($33,116 vs $10,629 PMPY for the hyperkalemia and control cohorts, respectively) and dialysis costs ($2716 vs $810 PMPY, respectively). The medical loss ratios were 552% for the hyperkalemia cohort and 260% for the control cohort. Both cohorts had revenue deficits to the health plan, but the hyperkalemia cohort had double the medical loss ratio compared with the control cohort.

CONCLUSIONS

The findings from this Medicaid managed care population suggest that hyperkalemia increases healthcare utilization and costs, which were primarily driven by the costs associated with inpatient care and dialysis. Our findings demonstrate that the Medicaid beneficiaries who have cardiorenal comorbidities accrue high costs to the Medicaid health plan, and these costs are even higher if a hyperkalemia diagnosis is present. The very high medical loss ratio for the hyperkalemia cohort in our analysis indicates that enhanced monitoring and management of patients with hyperkalemia should be considered.

Identification and classification of epithelial cells in nephron segments by actin cytoskeleton patterns

The basic functional unit in a kidney is the nephron, which is a long and morphologically segmented tubule. The nephron begins with a cluster of capillaries called glomerulus through which the blood is filtered into the Bowman's space. The filtrate flows through the nephron segments. During this flow, electrolytes and solutes are reabsorbed by channels and transport systems into the capillaries wrapped around the nephron. Many questions related to renal function focus on identifying the sites of expression of these systems. In this study, we mapped whole kidney sections by confocal microscopic imaging of fluorescent phalloidin, which binds to actin filaments. In tile scans (composed of hundreds of images) of these sections, the cortex and the medullary regions (outer and inner stripes of the outer medulla, and inner medulla) could be easily identified by their cytoskeletal patterns. At a higher resolution, we identified distinct features of the actin cytoskeleton in the apical, basal, and lateral borders of the cells. These features could be used to identify segments of a nephron (the proximal tubule, thin and thick segments of Henle's loop, and distal tubule), the collecting duct system, the papillary ducts in the papilla, and the urothelium that covers the pelvis. To verify our findings, we used additional markers, including aquaporin isoforms, cytokeratin 8‐18, and WGA lectin. This study highlights the power of high‐resolution confocal microscopy for identifying specific cell types using the simple probe of F‐actin‐binding phalloidin.

6-Substituted amiloride derivatives as inhibitors of the urokinase-type plasminogen activator for use in metastatic disease

The oral K+-sparing diuretic amiloride shows anti-cancer side-activities in multiple rodent models. These effects appear to arise, at least in part, through moderate inhibition of the urokinase-type plasminogen activator (uPA, K_i = 2.4 µM), a pro-metastatic trypsin-like serine protease that is upregulated in many aggressive solid malignancies. In applying the selective optimization of side-activity (SOSA) approach, a focused library of twenty two 6-substituted amiloride derivatives were prepared, with multiple examples displaying uPA inhibitory potencies in the nM range. X-ray co-crystal structures revealed that the potency increases relative to amiloride arise from increased occupancy of uPA's S1β subsite by the appended 6-substituents. Leading compounds were shown to have high selectivity over related trypsin-like serine proteases and no diuretic or anti-kaliuretic effects in rats. Compound 15 showed anti-metastatic effects in a xenografted mouse model of late-stage lung metastasis.

Purification and Application of Genetically Encoded Potassium Ion Indicators for Quantification of Potassium Ion Concentrations within Biological Samples

Vital cells maintain a steep potassium ion (K+ ) gradient across the plasma membrane. Intracellular potassium ion concentrations ([K+ ]) and especially the [K+ ] within the extracellular matrix are strictly regulated, the latter within a narrow range of ∼3.5 to 5.0 mM. Alterations of the extracellular K+ homeostasis are associated with severe pathological alterations and systemic diseases including hypo- or hypertension, heart rate alterations, heart failure, neuronal damage or abnormal skeleton muscle function. In higher eukaryotic organisms, the maintenance of the extracellular [K+ ] is mainly achieved by the kidney, responsible for K+ excretion and reabsorption. Thus, renal dysfunctions are typically associated with alterations in serum- or plasma [K+ ]. Generally, [K+ ] quantifications within bodily fluids are performed using ion selective electrodes. However, tracking such alterations in experimental models such as mice features several difficulties, mainly due to the small blood volume of these animals, hampering the repetitive collection of sample volumes required for measurements using ion selective electrodes. We have recently developed highly sensitive, genetically encoded potassium ion indicators, the GEPIIs, applicable for in vitro determinations of [K+ ]. In addition to the determination of [K+ ] within bodily fluids, GEPIIs proved suitable for the real-time visualization of cell viability over time and the exact determination of the number of dead cells. © 2019 The Authors.

Dietary potassium and available phosphorous on broiler growth performance, carcass characteristics, and wooden breast

Broiler dietary potassium (K) and available phosphorous (AvP) have decreased in recent years but both ions are intimately involved in the elimination of hydrogen ions that are produced during rapid growth. It was hypothesized that the decrease of these dietary electrolytes was related to the development of myopathies, and thus increased dietary K and/or AvP would reduce the occurrence of breast myopathies. A total of 320 Ross male broiler chicks were placed into 16 pens and fed 2 diet series containing either decreasing AvP levels of 0.45, 0.40, and 0.35% in the starter, grower, and finisher diets, respectively (Decline), or a fixed AvP of 0.45% in all dietary phases (Fixed). To complete a 2 × 2 design either normal basal dietary K (K-) (0.86, 0.77, 0.68%) or added dietary K (K+) (1.01, 0.93, 0.88%) were also applied to starter, grower, and finisher diets, respectively. Blood physiology was measured at 29 and 42 d. Carcass data, wooden breast and white striping scores were measured at 35 and 43 d. The K+ diets improved feed conversion ratio at 35 d (1.52 vs 1.57 g: g), reduced body weight at 42 d (3524 vs 3584 g), reduced hemoglobin (6.83 vs 7.58 g/dL), and packed cell volume (20.1 vs 22.3%) at 29 d, reduced ionized blood calcium (1.42 vs 1.47 mmol/L) at 42 d, and reduced partial pressure of blood CO2 (49.1 vs 54.7 mm/Hg) at 42 d relative to broilers fed basal K- diets (P < 0.05). Fixed AvP diets improved feed conversion ratio at 28 and 42 d, increased percentage breast meat (28.85 vs 27.58%) and carcass water pickup (2.72 vs 1.42%) at 35 d, and reduced wooden breast (2.88 vs 3.69) at 43 d (P < 0.05).