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Lefevre F, Mousseaux C, Bobot M. [What's new in hyperkalemia management?]. Rev Med Interne 2024; 45:350-353. [PMID: 38220492 DOI: 10.1016/j.revmed.2024.01.004] [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: 11/12/2023] [Revised: 12/19/2023] [Accepted: 01/01/2024] [Indexed: 01/16/2024]
Abstract
Hyperkalemia is common in everyday clinical practice, and is a major risk factor for mortality. It mainly affects patients with chronic renal failure (CKD), diabetes or receiving treatment with inhibitors of the renin-angiotensin-aldosterone system (iRAAS). Therapeutic management aims not only to avoid the complications of hyperkalemia, but also to avoid discontinuation of cardio- and nephroprotective treatments such as iRAAS. The use of polystyrene sulfonate, widely prescribed, is often limited by patient acceptability. Recent data have cast doubt on its safety, particularly in terms of digestive tolerance. Two new potassium exchange molecules have appeared on the market: patiromer and zirconium sulfonate. Their value in clinical practice, and their acceptability in the event of prolonged prescription, remain to be demonstrated. The combination of a thiazide diuretic or an inhibitor of the sodium-glucose cotransporter type 2 (iSGLT2) with iRAAS therapy in CKD, may also improve control of kalemia. At present, there are no recommendations for the positioning of the various hypokalemic treatments. The choice of these treatments must be adapted to the patient's pathologies and consider the other expected effects of these molecules.
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Affiliation(s)
- F Lefevre
- Centre de néphrologie et transplantation rénale, hôpital de la Conception, AP-HM, 147, boulevard Baille, 13005 Marseille, France
| | - C Mousseaux
- Sorbonne université, CORAKID, Inserm UMR_S1155, hôpital Tenon, Paris, France; Soins intensifs néphrologiques-Rein Aigu, hôpital Tenon, AP-HP, Paris, France
| | - M Bobot
- Centre de néphrologie et transplantation rénale, hôpital de la Conception, AP-HM, 147, boulevard Baille, 13005 Marseille, France; Aix-Marseille université, C2VN, Inserm 1263, INRAE 1260, CERIMED, Marseille, France.
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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.
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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.
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Khandelwal P, Shah S, McAlister L, Cleghorn S, King L, Shroff R. Safety and efficacy of sodium zirconium cyclosilicate for the management of acute and chronic hyperkalemia in children with chronic kidney disease 4-5 and on dialysis. Pediatr Nephrol 2024; 39:1213-1219. [PMID: 37857905 DOI: 10.1007/s00467-023-06176-6] [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: 07/18/2023] [Revised: 09/15/2023] [Accepted: 09/15/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Sodium zirconium cyclosilicate (SZC), an ion-exchange resin, is effective in the control of hyperkalemia in adults with chronic kidney disease (CKD); reports of use in children are limited. Prolonged therapy with SZC to relax dietary potassium restriction in CKD has not been examined. METHODS We conducted a retrospective chart review of patients 6 months to 18 years of age with CKD stage 4-5 or on dialysis (5D) administered SZC for sustained hyperkalemia (potassium ≥ 5.5 mEq/L, three consecutive values). Patients received SZC (0.5-10 g per dose; age-based) either short-term (< 30 days) or long-term (> 30 days). RESULTS Twenty patients with median age 10.8 (inter-quartile range 3.9, 13.4) years were treated with SZC. Short-term SZC, for 5 (3, 19) days, was associated with safe management of dialysis catheter insertions (n = 5) and access dysfunction (n = 4), and was useful during palliative care (n = 1). Serum potassium levels decreased from 6.7 (6.1, 6.9) to 4.4 (3.7, 5.2) mEq/L (P < 0.001). Long-term SZC for 5.3 (4.2, 10.1) months achieved decline in serum potassium from 6.1 (5.8, 6.4) to 4.8 (4.2, 5.4) mEq/L (P < 0.001). SZC use was associated with liberalization of diet (n = 6) and was useful in patients with poor adherence to dietary restriction (n = 3). Adverse events or edema were not observed; serum sodium and blood pressure remained stable. CONCLUSIONS SZC was safe and effective for the management of acute and chronic hyperkalemia in children with CKD4-5/5D. Its use was associated with relaxation of dietary potassium restriction. Studies to examine its routine use to improve diet and nutritional status in children with CKD are required.
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Affiliation(s)
- Priyanka Khandelwal
- Renal Unit, UCL Great Ormond Street Hospital and Institute of Child Health, London, WC1N 3JH, UK
| | - Sarit Shah
- Pharmacy Department, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Louise McAlister
- Dietetic Department, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Shelley Cleghorn
- Dietetic Department, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Lillian King
- Dietetic Department, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital and Institute of Child Health, London, WC1N 3JH, UK.
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Sembajwe FL, Namaganda A, Nfambi J, Muwonge H, Katamba G, Nakato R, Nabachenje P, Kawala Kagoya E, Namubamba A, Kiggundu D, Bitek B, Kalyesubula R, Iputo J. Dietary intake, body composition and micronutrient profile of patients on maintenance hemodialysis attending Kiruddu National Referral Hospital, Uganda: A cross sectional study. PLoS One 2023; 18:e0291813. [PMID: 37856499 PMCID: PMC10586598 DOI: 10.1371/journal.pone.0291813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 09/05/2023] [Indexed: 10/21/2023] Open
Abstract
Patients on maintenance hemodialysis are at a great risk for altered nutritional status, characterized by protein energy wasting and micronutrient deficiency due to medication interactions and dietary restrictions. This study determined the dietary intake, micronutrient profile and body composition of patients on maintenance hemodialysis at Kiruddu National referral hospital (KNRH), Uganda. A cross sectional study was done among adult CKD patients on maintenance hemodialysis therapy at KNRH. Data concerning patients' demographics, clinical history and dietary intake was obtained using interactive and quantitative food frequency questionnaires. Body composition was obtained using the TANITA BC-351, Japan weighing Bathroom scale and anthropometric measurements using standard methods and procedures. Serum micronutrient profile assessment was done using the COBAS Auto analyzer. Data analysis was done using the SPSS software version 20. T-test was used to make comparisons and logistic regression analysis was done to check for any correlations. A P-value of < 0.05 was considered statistically significant. Among the 63 hemodialysis patients, 38% were female, with a median duration of hemodialysis of 12 months and the overall age range of patients was 31-40 years. Majority (92.1%) of the patients had hypertension. Carbohydrates like maize flour were highly consumed, in addition to eggs among the proteins on the daily basis. Fruits and vegetables were not highly consumed. Regarding body composition; 75% of the study participants had normal Body mass Index (BMI), the mean muscle mass was 51.94±8.68, body fat was 15.25±7.35, bone mass was 2.77±0.46 and body water was 62.04±9.06. Patients had deranged micronutrient levels especially for Vitamin D, Potassium and phosphorus. In conclusion, hemodialysis patients at KNRH, have altered nutritional status as evidenced by altered body weight for some patients and deranged micronutrient levels. We recommend that hemodialysis patients should be regularly assessed for nutritional status, appropriately treated and educated about their nutritional status.
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Affiliation(s)
- Fred Lawrence Sembajwe
- Department of Medical Physiology, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Agnes Namaganda
- Department of Medical Physiology, Faculty of Health Sciences, Busitema University, Mbale, Uganda
- Department of Medical Physiology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joshua Nfambi
- Department of Medical Physiology, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Haruna Muwonge
- Department of Medical Physiology, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Godfrey Katamba
- Department of Physiology, College of Health, Medicine and Life Sciences, King Ceasor University, Kampala, Uganda
| | - Ritah Nakato
- Department of Pharmacology, College of Medicine, Lira University, Lira, Uganda
| | - Prossy Nabachenje
- Department of Pediatrics, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Enid Kawala Kagoya
- Department of Community Health and Behavioural Sciences, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Annet Namubamba
- Department of Public Health, School of public Health Kololo Annex, Makerere University, Kampala, Uganda
| | - Daniel Kiggundu
- Department of Medicine, Dialysis Unit, Kiruddu National Referral Hospital, Kampala, Uganda
| | - Brian Bitek
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Robert Kalyesubula
- Department of Medical Physiology, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Jehu Iputo
- Department of Medical Physiology, College of Health Sciences, Makerere University, Kampala, Uganda
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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.
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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
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