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Riccio E, D'Ercole A, Sannino A, Hamzeh S, De Marco O, Capuano I, Buonanno P, Rizzo M, Pisani A. Real-world management of chronic and postprandial hyperkalemia in CKD patients treated with patiromer: a single-center retrospective study. J Nephrol 2024; 37:1077-1084. [PMID: 38319545 DOI: 10.1007/s40620-024-01897-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/07/2024] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Hyperkalemia, one of the most important electrolyte abnormalities of chronic kidney disease (CKD), often limits the use of renin-angiotensin-aldosterone system inhibitors and can increase in the postprandial period. In this study we report a real-world experience with the new non-adsorbed potassium binder patiromer in stage 3b-4 CKD patients. Moreover, we performed a cross-sectional analysis to evaluate, for the first time, the efficacy of patiromer in the control of postprandial potassium concentrations. METHODS We retrospectively collected data of 40 patients at the time of patiromer initiation (T0), and after 2 (T2), 6 (T6) and 12 (T12) months of treatment. For cross sectional analysis, a blood sample was collected 2 h after the main meal for the evaluation of postprandial potassium concentrations. RESULTS Eighty-two point five percent of patients (33/40) reached normal potassium concentrations at T2. Serum potassium significantly decreased at T2 compared to T0 (5.13 ± 0.48 vs 5.77 ± 0.41 mmol/L, respectively; p < 0.001) and the reduction remained significant during the follow-up (5.06 ± 0.36 at T6 and 5.77 ± 0.41 at T12; p < 0.001 vs T0). Renin-angiotensin-aldosterone system inhibitors were continued by 93% of patients (27/29). Adverse events were reported in 27.5% of patients and were all mild-to-moderate. Postprandial potassium concentrations did not significantly change compared to fasting state potassium measured at T12 (4.53 ± 0.33 vs 5.06 ± 0.36 mmol/L; p = 0.15). CONCLUSIONS In a real-world setting of advanced CKD patients, patiromer is a useful treatment for hyperkalemia, since it significantly reduces serum potassium levels over the long term and is able to maintain potassium concentrations in the normal range even in the post-prandial period.
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Affiliation(s)
- Eleonora Riccio
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy.
| | - Anna D'Ercole
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Anna Sannino
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Sarah Hamzeh
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Oriana De Marco
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Ivana Capuano
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Pasquale Buonanno
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Manuela Rizzo
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Antonio Pisani
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
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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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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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