Consensus on the management of hyperkalemia in patients with heart failure: Recommendations from the SEC-SEMI

Risk and predictors of severe hyperkalemia after total parathyroidectomy without auto-transplantation in patients with secondary hyperparathyroidism

Objective

To identify the risk factors of postoperative severe hyperkalemia after total parathyroidectomy (TPTX) without auto-transplantation in patients with secondary hyperparathyroidism (SHPT).

Methods

Data on 406 consecutive patients who underwent TPTX without auto-transplantation for secondary hyperparathyroidism at the General Hospital of Northern Theater Command between January 2013 and January 2023, were prospectively collected. Then, patients were divided into the training set (n=203) and the validation set (n=203) in a ratio of 1:1 by timeline. The patients were divided into severe hyperkalemia group and non-hyperkalemia group according to the postoperative serum kalium level >6.0 mmol/L with ECG changes or serum kalium level ≥6.5 mmol/L. Univariate and multivariate logistic regression analyses were used to evaluate the possible risk factors associated with postoperative severe hyperkalemia after TPTX. The predictive performance was evaluated with receiver operating characteristic (ROC) curves with the areas under the ROC curve (AUC) and calibration curve. Decision curve and clinical impact curve analyses were used to validate the clinical application of the value.

Results

The incidence of postoperative severe hyperkalemia was 15.5% in all patients, 17.2% and 13.8% in the training and validation cohorts, respectively. The risk factors associated with postoperative severe hyperkalemia was higher preoperative kalium level. The optimal cut-off value for preoperative serum kalium level was 5.0mmol/L according to the ROC curve. The area under the curve (AUC) achieved good concordance indexes of 0.845 (95%CI, 0.776-0.914) in the training cohort. The sensitivities were 0.829 (95%CI: 0.663-0.934) and 0.857 (95%CI: 0.673-0.960) in the training and validation cohorts, respectively. The specificities were 0.798 (95%CI: 0.729-0.856) and 0.720 (95%CI:0.647-0.785) in the training and validation cohorts, respectively. Calibration curve exhibited a good consistency between actual observations and predicted severe hyperkalemia in the training and validation cohorts.

Conclusions

Our study found that the preoperative kalium levels is only a risk factor for postoperative severe hyperkalemia in patients undergoing TPTX for secondary hyperparathyroidism. The threshold for preoperative serum kalium levels is 5.0mmol/L that can serve as a useful indicator for identifying patients with severe hyperkalemia after surgery. These results provide valuable suggestion for clinical practice.

Consensus statement on the management of hyperkalaemia-An Asia-Pacific perspective

Hyperkalaemia is an electrolyte imbalance that impairs muscle function and myocardial excitability, and can potentially lead to fatal arrhythmias and sudden cardiac death. The prevalence of hyperkalaemia is estimated to be 6%-7% worldwide and 7%-10% in Asia. Hyperkalaemia frequently affects patients with chronic kidney disease, heart failure, and diabetes mellitus, particularly those receiving treatment with renin-angiotensin-aldosterone system (RAAS) inhibitors. Both hyperkalaemia and interruption of RAAS inhibitor therapy are associated with increased risks for cardiovascular events, hospitalisations, and death, highlighting a clinical dilemma in high-risk patients. Conventional potassium-binding resins are widely used for the treatment of hyperkalaemia; however, caveats such as the unpalatable taste and the risk of gastrointestinal side effects limit their chronic use. Recent evidence suggests that, with a rapid onset of action and improved gastrointestinal tolerability, novel oral potassium binders (e.g., patiromer and sodium zirconium cyclosilicate) are alternative treatment options for both acute and chronic hyperkalaemia. To optimise the care for patients with hyperkalaemia in the Asia-Pacific region, a multidisciplinary expert panel was convened to review published literature, share clinical experiences, and ultimately formulate 25 consensus statements, covering three clinical areas: (i) risk factors of hyperkalaemia and risk stratification in susceptible patients; (ii) prevention of hyperkalaemia for at-risk individuals; and (iii) correction of hyperkalaemia for at-risk individuals with cardiorenal disease. These statements were expected to serve as useful guidance in the management of hyperkalaemia for health care providers in the region.

Experience with the potassium binder patiromer in hyperkalaemia management in heart failure patients in real life

AIMS

Hyperkalaemia (HK) is common in heart failure (HF) patients, related to renal dysfunction and medical treatment. It limits medical therapy optimization, which impacts prognosis. New potassium (K) binders help control HK, allowing better medical management of HF.

METHODS AND RESULTS

A retrospective multicentre register included all outpatients with HF and HK (K ≥ 5.1 mEq/L) treated with patiromer according to current recommendations. We evaluated analytic and clinical parameters before starting the treatment and at 7, 30 and 90 days, as well as adverse events related to patiromer and treatment optimization. We included 74 patients (71.6% male) with a mean age of 70.8 years (SD 9.2). Sixty-seven patients (90.5%) presented HK in the previous year. Forty patients (54.1%) underwent down-titration of a renin-angiotensin-aldosterone inhibitor (RAASi) or a mineralocorticoid receptor antagonist (MRA), and 27 (36.5%) stopped any of them due to HK. Initial K was 5.5 mEq/L (SD 0.6), with a significantly reduction at 7 days (4.9 mEq/L (SD 0.8); P < 0.001), maintained at 90 days (4.9 mEq/L (SD 0.8); P < 0.001). There were no other electrolyte disturbances, with a slight improvement in renal function [glomerular filtration rate 39.6 mL/min (SD 20.4) to 42.7 mL/min (SD 23.2); P = 0.005]. Adverse events were reported in 33.9% of patients, the most common being hypomagnesaemia (16.3%), gastrointestinal disturbances (14.9%) and HK (2.8%). Withdrawal of patiromer was uncommon (12.2%) due to gastrointestinal disturbances in 66.7% of cases. Nine patients (12.2%) started on a RAASi, and 15 patients (20.3%) on an MRA during the follow-up. Forty-five patients (60.8%) increased the dose of RAASi or MRA, increasing to target doses in 5.4 and 10.8% of patients, respectively. At 90 days, NTproBNP values were reduced from 2509.5 pg/mL [IQR 1311-4,249] to 1396.0 pg/mL [IQR 804-4263]; P = 0.003, but the reduction was only observed in those who optimized HF medical treatment [NTproBNP from 1950.5 pg/mL (IQR 1208-3403) to 1349.0 pg/mL (IQR 804-2609); P < 0.01]. NYHA functional class only improved in 7.5% of patients, corresponding with those who optimized HF medical treatment. Compared with the previous 3 months before patiromer treatment, the rate of hospitalization was reduced from 28.4 to 10.9% (P < 0.01), and the emergency room visits from 18.9 to 5.4% (P < 0.01).

CONCLUSIONS

In a real-life cohort of patients with HF, patiromer reduced and maintained K levels during 3 months of follow-up. The most common adverse events were hypomagnesaemia and gastrointestinal disturbances. Patiromer helps optimize medical treatment, increasing the percentage of patients treated with RAASi and MRA at target doses. At the end of follow-up, natriuretic peptides values and hospital visits were reduced, suggesting the benefit of optimizing HF medical treatment.