1
|
Huang W, Zhu JY, Song CY, Lu YQ. Machine learning models for early prediction of potassium lowering effectiveness and adverse events in patients with hyperkalemia. Sci Rep 2024; 14:737. [PMID: 38184719 PMCID: PMC10771443 DOI: 10.1038/s41598-024-51468-y] [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: 08/09/2023] [Accepted: 01/05/2024] [Indexed: 01/08/2024] Open
Abstract
The aim of this study was to develop a model for early prediction of adverse events and treatment effectiveness in patients with hyperkalemia. We collected clinical data from patients with hyperkalemia in the First Hospital of Zhejiang University School of Medicine between 2015 and 2021. The least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression were used to analyze the predictors on the full dataset. We randomly divided the data into a training group and a validation group, and used LASSO to filter variables in the training set. Six machine learning methods were used to develop the models. The best model was selected based on the area under the curve (AUC). Shapley additive exPlanations (SHAP) values were used to explain the best model. A total of 1074 patients with hyperkalemia were finally enrolled. Diastolic blood pressure (DBP), breathing, oxygen saturation (SPO2), Glasgow coma score (GCS), liver disease, oliguria, blood sodium, international standardized ratio (ISR), and initial blood potassium were the predictors of the occurrence of adverse events; peripheral edema, estimated glomerular filtration rate (eGFR), blood sodium, actual base residual, and initial blood potassium were the predictors of therapeutic effect. Extreme gradient boosting (XGBoost) model achieved the best performance (adverse events: AUC = 0.87; therapeutic effect: AUC = 0.75). A model based on clinical characteristics was developed and validated with good performance.
Collapse
Affiliation(s)
- Wei Huang
- Department of Emergency Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China
- Key Laboratory for Diagnosis and Treatment of Aging and Physic-Chemical Injury Diseases of Zhejiang Province, Hangzhou, 310003, Zhejiang, People's Republic of China
| | - Jian-Yong Zhu
- Department of Emergency Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China
- Key Laboratory for Diagnosis and Treatment of Aging and Physic-Chemical Injury Diseases of Zhejiang Province, Hangzhou, 310003, Zhejiang, People's Republic of China
| | - Cong-Ying Song
- Department of Emergency Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China
- Key Laboratory for Diagnosis and Treatment of Aging and Physic-Chemical Injury Diseases of Zhejiang Province, Hangzhou, 310003, Zhejiang, People's Republic of China
| | - Yuan-Qiang Lu
- Department of Emergency Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China.
- Key Laboratory for Diagnosis and Treatment of Aging and Physic-Chemical Injury Diseases of Zhejiang Province, Hangzhou, 310003, Zhejiang, People's Republic of China.
| |
Collapse
|
2
|
Israni R, Betts KA, Mu F, Davis J, Wang J, Anzalone D, Uwaifo GI, Szerlip H, Fonseca V, Wu E. Determinants of Hyperkalemia Progression Among Patients with Mild Hyperkalemia. Adv Ther 2021; 38:5596-5608. [PMID: 34622391 PMCID: PMC8520872 DOI: 10.1007/s12325-021-01925-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/14/2021] [Indexed: 11/28/2022]
Abstract
Introduction The progression of mild hyperkalemia and the predictors of progression have not been well characterized. In this study we aimed to characterize the progression of hyperkalemia and identify the risk factors for hyperkalemia progression. Methods Adults with mild hyperkalemia (at least one serum potassium measure > 5.0 and ≤ 5.5 mEq/L) were identified using electronic medical records from the Research Action for Health Network (2012–2018). Progression to moderate-to-severe and progression to severe hyperkalemia were defined as the first occurrences of a serum potassium measure > 5.5 and > 6.0 mEq/L, respectively. Kaplan–Meier analyses were conducted to estimate progression rates for all patients and by pre-specified patient subgroups. Hazard ratios (HR) of moderate-to-severe and severe hyperkalemia progression were estimated using Cox models. Results Of 35,369 patients with mild hyperkalemia, 16.9% and 8.7% progressed to moderate-to-severe and severe hyperkalemia, respectively. Rates of hyperkalemia progression elevated with the severity of chronic kidney disease (CKD). The highest progression rates were seen in patients with CKD stage 5 (stage 5 vs. no CKD: moderate-to-severe, 50.2% vs. 12.0%; severe, 31.3% vs. 3.9%; p < 0.001). Higher progression rates were also observed in patients with heart failure, hypertension, and type II diabetes compared with patients without those conditions (all p < 0.001). The most prominent risk factors were CKD stage 5 (HR of progression to moderate-to-severe hyperkalemia, 3.32 [95% CI 3.03–3.64]; severe, 4.08 [3.55–4.69]), CKD stage 4 (2.19 [1.97–2.43], 2.28 [1.92–2.71]), CKD stage 3 (1.57 [1.46–1.68], 1.65 [1.46–1.87]), type I diabetes (1.37 [1.18–1.61], 1.54 [1.23–1.93]), and serum potassium (1.12 [1.10–1.15], 1.13 [1.10–1.17] per 0.1 mEq/L increase) (all p values < 0.05). Conclusion Hyperkalemia progression rates increased significantly with CKD stage and were also higher among patients with higher baseline potassium level, heart failure, hypertension, and diabetes. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01925-1.
Collapse
Affiliation(s)
| | - Keith A Betts
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA, 02199, USA
| | - Fan Mu
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA, 02199, USA.
| | | | - Jessie Wang
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA, 02199, USA
| | | | | | | | - Vivian Fonseca
- Tulane University Health Sciences Center, New Orleans, LA, USA
| | - Eric Wu
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA, 02199, USA
| |
Collapse
|
3
|
Bianchi S, Regolisti G. Pivotal clinical trials, meta-analyses and current guidelines in the treatment of hyperkalemia. Nephrol Dial Transplant 2019; 34:iii51-iii61. [DOI: 10.1093/ndt/gfz213] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Indexed: 01/14/2023] Open
Abstract
Abstract
Hyperkalemia (HK) is the most common electrolyte disturbance observed in patients with advanced stages of chronic kidney disease (CKD), is a potentially life-threatening clinical condition due to an increased risk of fatal arrhythmias, and strongly impacts the quality of life and prognosis of CKD patients. Moreover, while renin–angiotensin–aldosterone system inhibitors (RAASIs) represent the most cardio-nephro-protective drugs used in clinical practice, the treatment with these drugs per se increases serum potassium (sK) values, particularly when heart failure and diabetes mellitus coexist. In fact, the onset or recurrence of HK is frequently associated with not starting, down-titrating or withdrawing RAASIs, and is an indication to begin renal replacement treatment in end-stage renal disease. Current strategies aimed at preventing and treating chronic HK are still unsatisfactory, as evidenced by the relatively high prevalence of HK also in patients under stable nephrology care, and even in the ideal setting of randomized clinical trials. Indeed, dietary potassium restriction, the use of sodium bicarbonate or diuretics, the withdrawal or down-titration of RAASIs, or the administration of old potassium binders, namely sodium polystyrene sulphonate and calcium polystyrene sulphonate, have limited efficacy and are poorly tolerated; therefore, these strategies are not suitable for long-term control of sK. As such, there is an important unmet need for novel therapeutic options for the chronic management of patients at risk for HK. The development of new potassium binders may change the treatment landscape in the near future. This review summarizes the current evidence on the treatment of chronic HK in cardio-renal patients.
Collapse
Affiliation(s)
- Stefano Bianchi
- Nephrology and Dialysis Unit, Department of Internal Medicine, ASL Toscana Nordovest, Regione Toscana, Livorno, Italy
| | - Giuseppe Regolisti
- Unit of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
- Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| |
Collapse
|
4
|
Bianchi S, Aucella F, De Nicola L, Genovesi S, Paoletti E, Regolisti G. Management of hyperkalemia in patients with kidney disease: a position paper endorsed by the Italian Society of Nephrology. J Nephrol 2019; 32:499-516. [PMID: 31119681 PMCID: PMC6588653 DOI: 10.1007/s40620-019-00617-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 05/05/2019] [Indexed: 12/11/2022]
Abstract
Hyperkalemia (HK) is the most common electrolyte disturbance observed in patients with kidney disease, particularly in those in whom diabetes and heart failure are present or are on treatment with renin-angiotensin-aldosterone system inhibitors (RAASIs). HK is recognised as a major risk of potentially life threatening cardiac arrhythmic complications. When an acute reduction of renal function manifests, both in patients with chronic kidney disease (CKD) and in those with previously normal renal function, HK is the main indication for the execution of urgent medical treatment and the recourse to extracorporeal replacement therapies. In patients with end-stage renal disease, the presence of HK not responsive to medical therapy is an indication at the beginning of chronic renal replacement therapy. HK can also be associated indirectly with the progression of CKD, because the finding of high potassium values leads to withdrawal of treatment with RAASIs, which constitute the first choice nephro-protective treatment. It is therefore essential to identify patients at risk of developing HK, and to implement therapeutic interventions aimed at preventing and treating this dangerous complication of kidney disease. Current strategies aimed at the prevention and treatment of HK are still unsatisfactory, as evidenced by the relatively high prevalence of HK also in patients under stable nephrology care, and even in the ideal setting of randomized clinical trials where optimal treatment and monitoring are mandatory. This position paper will review the main therapeutic interventions to be implemented for the prevention, detection and treatment of HK in patients with CKD on conservative care, in those on dialysis, in patients in whom renal disease is associated with diabetes, heart failure, resistant hypertension and who are on treatment with RAASIs, and finally in those presenting with severe acute HK.
Collapse
Affiliation(s)
- Stefano Bianchi
- Nephrology and Dialysis Unit, Department of Internal Medicine, Azienda ASL Toscana Nord Ovest, Livorno, Italy
| | - Filippo Aucella
- Nephrology and Dialysis Unit, IRCCS “Casa Sollievo della Sofferenza” Scientific Institute for Research and Health Care, San Giovanni Rotondo, Italy
| | - Luca De Nicola
- Division of Nephrology, University of Campania, Naples, Italy
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milano - Bicocca San Gerardo Hospital, Nephrology Unit, Monza, Italy
| | - Ernesto Paoletti
- Nephrology, Dialysis and Transplantation, University of Genoa and Policlinico, San Martino Genoa, Italy
| | - Giuseppe Regolisti
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| |
Collapse
|
5
|
Fiel DC, Santos I, Santos JE, Vicente R, Ribeiro S, Silva A, Malvar B, Pires C. Cecum perforation associated with a calcium polystyrene sulfonate bezoar - a rare entity. ACTA ACUST UNITED AC 2018; 41:440-444. [PMID: 30534857 PMCID: PMC6788843 DOI: 10.1590/2175-8239-jbn-2018-0158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 09/23/2018] [Indexed: 11/22/2022]
Abstract
Hyperkalemia is one of the most common electrolyte disorders, responsible for a
high number of adverse outcomes, including life-threatening arrhythmias.
Potassium binders are largely prescribed drugs used for hyperkalemia treatment
but unfortunately, there are many adverse events associated with its use, mostly
gastrointestinal. Identification of patients at highest risk for the serious
complications associated with the current potassium binders, such as colon
necrosis and perforation, could prevent fatal outcomes. The authors present a
case of a 56-year-old man with secondary diabetes and chronic renal disease that
was treated for hyperkalemia with Calcium Polystyrene Sulfonate (CPS). He later
presented with acute abdomen due to cecum perforation and underwent ileocecal
resection but ultimately died from septic shock a week later. During surgery, a
solid white mass was isolated in the lumen of the colon. The mass was identified
as a CPS bezoar, a rare drug-mass formed in the gastrointestinal tract that
contributed to the perforation. A previous history of partial gastrectomy and
vagothomy was identified as a probable risk factor for the CPS bezoar
development. Hopefully, the two new potassium binders patiromer and (ZS-9)
Sodium Zirconium Cyclosilicate will help treat such high-risk patients, in the
near future.
Collapse
Affiliation(s)
- David Carvalho Fiel
- Hospital do Espírito Santo de Évora, Largo Senhor da Pobreza, Évora, Portugal
| | - Iolanda Santos
- Hospital do Espírito Santo de Évora, Largo Senhor da Pobreza, Évora, Portugal
| | | | - Rita Vicente
- Hospital do Espírito Santo de Évora, Largo Senhor da Pobreza, Évora, Portugal
| | - Susana Ribeiro
- Hospital do Espírito Santo de Évora, Largo Senhor da Pobreza, Évora, Portugal
| | - Artur Silva
- Hospital do Espírito Santo de Évora, Largo Senhor da Pobreza, Évora, Portugal
| | - Beatriz Malvar
- Hospital do Espírito Santo de Évora, Largo Senhor da Pobreza, Évora, Portugal
| | - Carlos Pires
- Hospital do Espírito Santo de Évora, Largo Senhor da Pobreza, Évora, Portugal
| |
Collapse
|
6
|
Epstein M, Lifschitz MD. The Unappreciated Role of Extrarenal and Gut Sensors in Modulating Renal Potassium Handling: Implications for Diagnosis of Dyskalemias and Interpreting Clinical Trials. Kidney Int Rep 2016; 1:43-56. [PMID: 29142913 PMCID: PMC5678840 DOI: 10.1016/j.ekir.2016.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/11/2016] [Indexed: 12/11/2022] Open
Abstract
In addition to the classic and well-established "feedback control" of potassium balance, increasing investigative attention has focused on a novel and not widely recognized complementary regulatory paradigm for maintaining potassium homeostasis-the "feed-forward control" of potassium balance. This regulatory mechanism, initially defined in rumen, has recently been validated in normal human subjects. Studies are being conducted to determine the location for this putative potassium sensor and to evaluate potential signals, which might increase renal potassium excretion. Awareness of this more updated integrative control mechanism for potassium homeostasis is ever more relevant today, when the medical community is increasingly focused on the challenges of managing the hyperkalemia provoked by renin-angiotensin-aldosterone system inhibitors (RAASis). Recent studies have demonstrated a wide gap between RAASi prescribing guidelines and real-world experience and have highlighted that this gap is thought to be attributable in great part to hyperkalemia. Consequently we require a greater knowledge of the complexities of the regulatory mechanisms subserving potassium homeostasis. Sodium polystyrene sulfonate has long been the mainstay for treating hyperkalemia, but its administration is fraught with challenges related to patient discomfort and colonic necrosis. The current and imminent availability of newer potassium binders with better tolerability and more predictive dose-response potassium removal should enhance the management of hyperkalemia. Consequently it is essential to better understand the intricacies of mammalian colonic K+ handling. We discuss colonic transport of K+ and review evidence for potassium (BK) channels being responsible for increased stool K+ in patients with diseases such as ulcerative colitis.
Collapse
Affiliation(s)
- Murray Epstein
- Division of Nephrology and Hypertension, University of Miami, Miller School of Medicine, South Florida Veterans Affairs Foundation for Research and Education (SFVAFRE), Miami, Florida, USA
| | - Meyer D. Lifschitz
- Adult Nephrology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| |
Collapse
|
7
|
Epstein M, Lifschitz MD. Potassium homeostasis and dyskalemias: the respective roles of renal, extrarenal, and gut sensors in potassium handling. Kidney Int Suppl (2011) 2016; 6:7-15. [PMID: 30675414 PMCID: PMC6340905 DOI: 10.1016/j.kisu.2016.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 01/08/2016] [Accepted: 01/08/2016] [Indexed: 12/11/2022] Open
Abstract
Integrated mechanisms controlling the maintenance of potassium homeostasis are well established and are defined by the classic "feedback control" of potassium balance. Recently, increasing investigative attention has focused on novel physiological paradigms that increase the complexity and precision of homeostasis. This review briefly considers the classic and well-established feedback control of potassium and then considers subsequent investigations that inform on an intriguing and not widely recognized complementary paradigm: the "feed-forward control of potassium balance." Feed-forward control refers to a pathway in a homeostatic system that responds to a signal in the environment in a predetermined manner, without responding to how the system subsequently reacts (i.e., without responding to feedback). Studies in several animal species, and recently in humans, have confirmed the presence of a feed-forward control mechanism that is capable of mediating potassium excretion independent of changes in serum potassium concentration and aldosterone. Knowledge imparted by this update of potassium homeostasis hopefully will facilitate the clinical management of hyperkalemia in patients with chronic and recurrent hyperkalemia. Awareness of this updated integrative control mechanism for potassium homeostasis is more relevant today when the medical community is increasingly focused on leveraging and expanding established renin-angiotensin-aldosterone system inhibitor treatment regimens and on successfully coping with the challenges of managing hyperkalemia provoked by renin-angiotensin-aldosterone system inhibitors. These new insights are relevant to the future design of clinical trials delineating renal potassium handling.
Collapse
Affiliation(s)
- Murray Epstein
- Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Meyer D. Lifschitz
- Adult Nephrology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| |
Collapse
|
8
|
Hyperkalemia constitutes a constraint for implementing renin-angiotensin-aldosterone inhibition: the widening gap between mandated treatment guidelines and the real-world clinical arena. Kidney Int Suppl (2011) 2016; 6:20-28. [PMID: 30675416 DOI: 10.1016/j.kisu.2016.01.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 01/13/2016] [Accepted: 01/13/2016] [Indexed: 12/11/2022] Open
Abstract
Recent studies have reported a large gap between the forceful and assertive recommendations in the guidelines and real-world practice in the use of renin-angiotensin-aldosterone inhibitors (RAASi) therapies. A comprehensive, retrospective analysis of a large database of electronic medical records (>7 million patients) was undertaken to evaluate 3 pivotal concerns: (i) whether RAASi are being prescribed according to treatment guidelines, (ii) what happens to RAASi prescriptions after hyperkalemia events, and (iii) what the clinical outcomes are in patients whose RAASi are discontinued or who are prescribed at doses lower than the guidelines recommend. The results indicate that a substantial gap exists between guideline recommendations and real-world prescribing patterns for RAASi. Among patients with cardiorenal comorbidities for which RAASi are recommended by the guidelines, more than one-half were prescribed lower-than-recommended doses, and approximately 14% to 16% discontinued RAASi therapy. RAASi prescribing patterns may be altered by the development of hyperkalemia. Moderate-to-severe hyperkalemia events were followed by down-titration or discontinuation of RAASi therapy in nearly one-half of all patients on maximal dose and by discontinuation in nearly one-third of patients on submaximal dose. This analysis highlights the challenge behind RAASi prescribing decisions, balancing the risk of provoking hyperkalemia with the benefits to reducing cardiorenal morbidity and mortality. Patients who are known to derive the greatest benefit from these drugs (chronic kidney disease patients with concomitant diabetes mellitus or heart failure) are the same patients who are at highest risk of developing hyperkalemia. These observations constitute a "call to action" to develop newer treatment modalities to lower serum potassium and to achieve and sustain normokalemia long-term.
Collapse
|