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Dewey H, Mahmood N, Abello SM, Sultana N, Jones J, Gluck JM, Budhathoki-Uprety J. Development of Optical Nanosensors for Detection of Potassium Ions and Assessment of Their Biocompatibility with Corneal Epithelial Cells. ACS OMEGA 2024; 9:27338-27348. [PMID: 38947780 PMCID: PMC11209934 DOI: 10.1021/acsomega.4c01867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/09/2024] [Accepted: 05/27/2024] [Indexed: 07/02/2024]
Abstract
Imbalance of potassium-ion levels in the body can lead to physiological dysfunctions, which can adversely impact cardiovascular, neurological, and ocular health. Thus, quantitative measurement of potassium ions in a biological system is crucial for personal health monitoring. Nanomaterials can be used to aid in disease diagnosis and monitoring therapies. Optical detection technologies along with molecular probes emitting within the near-infrared (NIR) spectral range are advantageous for biological measurements due to minimal interference from light scattering and autofluorescence within this spectral window. Herein, we report the development of NIR fluorescent nanosensors, which can quantitatively detect potassium ions under biologically relevant conditions. The optical nanosensors were developed by using photoluminescent single-walled carbon nanotubes (SWCNTs) encapsulated in polymers that contain potassium chelating moieties. The nanosensors, polystyrene sulfonate [PSS-SWCNTs, nanosensor 1 (NS1)] or polystyrene-co-polystyrene sulfonate [PS-co-PSS-SWCNTs, nanosensor 2 (NS2)], exhibited dose-dependent optical responses to potassium ion level. The nanosensors demonstrated their biocompatibility via the evaluation of cellular viability, proliferation assays, and expression of cytokeratin 12 in corneal epithelial cells (CEpiCs). Interestingly, the nanosensors' optical characteristics and their responses toward CEpiCs were influenced by encapsulating polymers. NS2 exhibited a 10 times higher fluorescence intensity along with a higher signal-to-noise ratio as compared to NS1. NS2 showed an optical response to potassium ion level in solution within 5 min of addition and a limit of detection of 0.39 mM. Thus, NS2 was used for detailed investigations including potassium ion level detection in serum. NS2 showed a consistent response to potassium ions at the lower millimolar range in serum. These results on optical sensing along with biocompatibility show a great potential for nanotube sensors in biomedical research.
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Affiliation(s)
| | | | - Sofia Mariapaz Abello
- Department of Textile Engineering,
Chemistry and Science, Wilson College of Textiles, North Carolina State University, Raleigh, North Carolina 27695, United States
| | - Nigar Sultana
- Department of Textile Engineering,
Chemistry and Science, Wilson College of Textiles, North Carolina State University, Raleigh, North Carolina 27695, United States
| | - Jaron Jones
- Department of Textile Engineering,
Chemistry and Science, Wilson College of Textiles, North Carolina State University, Raleigh, North Carolina 27695, United States
| | - Jessica M. Gluck
- Department of Textile Engineering,
Chemistry and Science, Wilson College of Textiles, North Carolina State University, Raleigh, North Carolina 27695, United States
| | - Januka Budhathoki-Uprety
- Department of Textile Engineering,
Chemistry and Science, Wilson College of Textiles, North Carolina State University, Raleigh, North Carolina 27695, United States
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2
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Hakimzadeh Z, Gilani A, Yousefichaijan P, Sarmadian R. Acute fatal ventricular arrhythmia induced by severe hyperkalemia in a toddler with decompensated methylmalonic acidemia. J Med Case Rep 2024; 18:73. [PMID: 38395924 PMCID: PMC10893669 DOI: 10.1186/s13256-024-04406-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 01/22/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Methylmalonic acidemia is a very rare genetic metabolic disease. Patients with isolated methylmalonic acidemia typically present with acute alterations of consciousness, failure to thrive, anorexia, vomiting, respiratory distress, and muscular hypotonia. Despite the evidence-based management, affected individuals experience significant morbidity and mortality. Hyperkalemia is one of the unusual complications of methylmalonic acidemia. CASE PRESENTATION In this paper, we describe a 4-year-old Persian boy with methylmalonic acidemia who developed life-threatening arrhythmia following severe hyperkalemia and metabolic acidosis. Emergent management of the condition was successfully carried out, and the rhythm changed to normal sinus rhythm by effectively reducing the serum potassium level. We discuss the possible etiology of this lethal condition and describe its management on the basis of the available evidence. CONCLUSION During metabolic decompensation in methylmalonic acidemia, frequent blood gas and electrolyte testing to prescribe and adjust therapy and annual echocardiogram and electrocardiogram screening are essential.
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Affiliation(s)
- Zahra Hakimzadeh
- Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Abolfazl Gilani
- Department of Pediatric Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Roham Sarmadian
- Infectious Disease Research Center, Arak University of Medical Sciences, Arak, Iran.
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3
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Mahfooz K, Sohail H, Gvajaia A, Arif U, Grewal D, Muppidi MR, Vohra V, Tarique A, Vasavada A. Rasburicase in treating tumor lysis syndrome: An umbrella review. CANCER PATHOGENESIS AND THERAPY 2023; 1:262-271. [PMID: 38327601 PMCID: PMC10846299 DOI: 10.1016/j.cpt.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/10/2023] [Accepted: 07/16/2023] [Indexed: 02/09/2024]
Abstract
Tumor lysis syndrome (TLS) remains a debilitating cause of hospitalization and death in patients with cancer and is a significant challenge for healthcare providers despite advancements in its management. This umbrella review analyzed the results of meta-analyses on the use of rasburicase in the treatment of patients with cancer. A literature search was performed of five databases (PubMed, Google Scholar, Cochrane Library, Scopus, Global Index Medicus, and ScienceDirect) for articles with full texts available online. A measurement tool to assess systematic reviews 2 (AMSTAR 2) was used to assess the quality of the included studies, and Review Manager software was used to conduct all statistical analyses. The systematic search identified eight relevant meta-analyses, with primary analyses including outcome data that analyzed mortality, renal failure, and comparisons with allopurinol. The pooled data showed that rasburicase effectively reduced TLS development and serum uric acid levels in children and adults with malignancies. Most outcomes did not differ significantly compared with those of allopurinol. Future trials should focus on the cost-effectiveness of rasburicase compared to that of allopurinol while including high-, intermediate-, and low-risk patients. Rasburicase is safe and effective for managing patients with TLS. However, recent large-scale meta-analyses have reported conflicting results. Most meta-analyses were graded as low to critically low as per AMSTAR 2. The analysis revealed that the benefit of rasburicase did not differ significantly from that of allopurinol, which has higher cost-effectiveness and fewer side effects.
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Affiliation(s)
- Kamran Mahfooz
- Department of Internal Medicine, Lincoln Medical Center, Community Hospital, New York, 10451, USA
| | - Haris Sohail
- Department of Internal Medicine, Lincoln Medical Center, Community Hospital, New York, 10451, USA
| | - Ani Gvajaia
- Department of Internal Medicine, Lincoln Medical Center, Community Hospital, New York, 10451, USA
| | - Uroosa Arif
- Department of Internal Medicine, Lincoln Medical Center, Community Hospital, New York, 10451, USA
| | - Daisy Grewal
- Department of Internal Medicine, St. Georges University, St. Georges, Grenada
| | - Monica Reddy Muppidi
- Department of Internal Medicine, Lincoln Medical Center, Community Hospital, New York, 10451, USA
| | - Vanya Vohra
- Department of Pediatrics, St Barnabas Hospital, Bronx, NY, 10457, USA
| | - Aamir Tarique
- Department of Medicine, ESIC Medical College, Faridabad, 121001, India
| | - Advait Vasavada
- Department of Medicine, MP Shah Medical College, Jamnagar, 361008, India
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4
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Long B, Liang SY, Gottlieb M. Crush injury and syndrome: A review for emergency clinicians. Am J Emerg Med 2023; 69:180-187. [PMID: 37163784 DOI: 10.1016/j.ajem.2023.04.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/17/2023] [Indexed: 05/12/2023] Open
Abstract
INTRODUCTION Primary disasters may result in mass casualty events with serious injuries, including crush injury and crush syndrome. OBJECTIVE This narrative review provides a focused overview of crush injury and crush syndrome for emergency clinicians. DISCUSSION Millions of people worldwide annually face natural or human-made disasters, which may lead to mass casualty events and severe medical issues including crush injury and syndrome. Crush injury is due to direct physical trauma and compression of the human body, most commonly involving the lower extremities. It may result in asphyxia, severe orthopedic injury, compartment syndrome, hypotension, and organ injury (including acute kidney injury). Crush syndrome is the systemic manifestation of severe, traumatic muscle injury. Emergency clinicians are at the forefront of the evaluation and treatment of these patients. Care at the incident scene is essential and focuses on treating life-threatening injuries, extrication, triage, fluid resuscitation, and transport. Care at the healthcare facility includes initial stabilization and trauma evaluation as well as treatment of any complication (e.g., compartment syndrome, hyperkalemia, rhabdomyolysis, acute kidney injury). CONCLUSIONS Crush injury and crush syndrome are common in natural and human-made disasters. Emergency clinicians must understand the pathophysiology, evaluation, and management of these conditions to optimize patient care.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA.
| | - Stephen Y Liang
- Divisions of Emergency Medicine and Infectious Diseases, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO 63110, USA.
| | - Michael Gottlieb
- Ultrasound Director, Assistant Professor, Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Ward T, Lewis RD, Brown T, Baxter G, de Arellano AR. A cost-effectiveness analysis of patiromer in the UK: evaluation of hyperkalaemia treatment and lifelong RAASi maintenance in chronic kidney disease patients with and without heart failure. BMC Nephrol 2023; 24:47. [PMID: 36890464 PMCID: PMC9995261 DOI: 10.1186/s12882-023-03088-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 02/15/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) patients with and without heart failure (HF) often present with hyperkalaemia (HK) leading to increased risk of hospitalisations, cardiovascular related events and cardiovascular-related mortality. Renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, the mainstay treatment in CKD management, provides significant cardiovascular and renal protection. Nevertheless, its use in the clinic is often suboptimal and treatment is frequently discontinued due to its association with HK. We evaluated the cost-effectiveness of patiromer, a treatment known to reduce potassium levels and increase cardiorenal protection in patients receiving RAASi, in the UK healthcare setting. METHODS A Markov cohort model was generated to assess the pharmacoeconomic impact of patiromer treatment in regulating HK in patients with advanced CKD with and without HF. The model was generated to predict the natural history of both CKD and HF and quantify the costs and clinical benefits associated with the use of patiromer for HK management from a healthcare payer's perspective in the UK. RESULTS Economic evaluation of patiromer use compared to standard of care (SoC) resulted in increased discounted life years (8.93 versus 8.67) and increased discounted quality-adjusted life years (QALYs) (6.36 versus 6.16). Furthermore, patiromer use resulted in incremental discounted cost of £2,973 per patient and an incremental cost-effectiveness ratio (ICER) of £14,816 per QALY gained. On average, patients remained on patiromer therapy for 7.7 months, and treatment associated with a decrease in overall clinical event incidence and delayed CKD progression. Compared to SoC, patiromer use resulted in 218 fewer HK events per 1,000 patients, when evaluating potassium levels at the 5.5-6 mmol/l; 165 fewer RAASi discontinuation episodes; and 64 fewer RAASi down-titration episodes. In the UK, patiromer treatment was predicted to have a 94.5% and 100% chance of cost-effectiveness at willingness-to-pay thresholds (WTP) of £20,000/QALY and £30,000/QALY, respectively. CONCLUSION This study highlights the value of both HK normalisation and RAASi maintenance in CKD patients with and without HF. Results support the guidelines which recommend HK treatment, e.g., patiromer, as a strategy to enable the continuation of RAASi therapy and improve clinical outcomes in CKD patients with and without HF.
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Affiliation(s)
- Thomas Ward
- Health Economics and Outcomes Research Ltd., Rhymney House Unit A Copse Walk Cardiff Gate Business Park, Cardiff, CF23 8RB, UK.,Health Economics Group, College of Medicine and Health, University of Exeter, Exeter, England
| | - Ruth D Lewis
- Health Economics and Outcomes Research Ltd., Rhymney House Unit A Copse Walk Cardiff Gate Business Park, Cardiff, CF23 8RB, UK
| | - Tray Brown
- Health Economics and Outcomes Research Ltd., Rhymney House Unit A Copse Walk Cardiff Gate Business Park, Cardiff, CF23 8RB, UK.
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Emektar E. Acute hyperkalemia in adults. Turk J Emerg Med 2023; 23:75-81. [PMID: 37169032 PMCID: PMC10166290 DOI: 10.4103/tjem.tjem_288_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 03/06/2023] Open
Abstract
Hyperkalemia is a common, life-threatening medical situation in chronic renal disease patients in the emergency department (ED). Since hyperkalemia does not present with any specific symptom, it is difficult to diagnose clinically. Hyperkalemia causes broad and dramatic medical presentations including cardiac arrhythmia and sudden death. Hyperkalemia is generally determined through serum measurement in the laboratory. Treatment includes precautions to stabilize cardiac membranes, shift potassium from the extracellular to the intracellular, and increase potassium excretion. The present article discusses the management of hyperkalemia in the ED in the light of current evidence.
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7
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Muacevic A, Adler JR. Resolution of Left Bundle Branch Block After Calcium Administration in the Prehospital Setting. Cureus 2022; 14:e32442. [PMID: 36644037 PMCID: PMC9833622 DOI: 10.7759/cureus.32442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2022] [Indexed: 12/14/2022] Open
Abstract
Hyperkalemia is a medical emergency with potentially severe consequences that can be avoided by early recognition and effective treatment. Electrocardiogram (ECG) changes can help elucidate hyperkalemia prior to obtaining lab results and assist in early decisions on treatment, especially in the prehospital setting. ECG changes commonly associated with hyperkalemia are peaked T-waves, PR prolongation, P-wave flattening, QRS widening, or a sine-wave pattern at severely elevated potassium levels. Bundle branch blocks (BBBs) are associated with hyperkalemia but are less common and less well known in this setting. We report a case of a prehospital ECG showing a left bundle branch block (LBBB) in a patient who had end-stage renal disease, and the prehospital treatment with calcium chloride lead to resolution of the LBBB. The patient was eventually found to have a serum potassium level of 6.1 mEq/L.
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8
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Treatment of Presumed Hyperkalemia in the Prehospital Setting. Prehosp Disaster Med 2022; 37:693-697. [PMID: 35924713 DOI: 10.1017/s1049023x22001091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Hyperkalemia (HK) is common and potentially a life-threatening condition. If untreated, HK can progress to ventricular arrhythmia and cardiac arrest. Early treatment reduces mortality in HK. This study evaluates a novel protocol for identification and empiric management of presumed HK in the prehospital setting. METHODS This was a retrospective, observational chart review of a single, large, suburban Emergency Medical Services (EMS) system. Patients treated for presumed HK, with both a clinical concern for HK and electrocardiogram (ECG) changes consistent with HK, from February 2018 through February 2021 were eligible for inclusion. Patients were excluded if found to be in cardiac arrest on EMS arrival. Empiric treatment of HK included administration of calcium, sodium bicarbonate, and albuterol. Post-treatment, patients were placed on cardiac monitoring and adverse events recorded enroute to receiving hospital. Protocol compliance was assessed by two independent reviewers. Serum potassium (K) level was obtained from hospital medical records. RESULTS A total of 582 patients were treated for HK, of which 533 patients were excluded due to cardiac arrest prior to EMS arrival. The remaining 48 patients included in the analysis had a mean age of 56 (SD = 20) years and were 60.4% (n = 29) male with 77.1% (n = 37) Caucasian, 10.4% (n = 5) African American, and 12.5% (n = 6) Hispanic. Initial blood draw at the receiving facilities showed K >5.0mEq/L in 22 (45.8%), K of 3.5-5.0mEq/L in 23 (47.9%), and K <3.5mEq/L in three patients (6.3%). Independent review of the EMS ECG found the presence of hyperkalemic-related change in 43 (89.6%) cases, and five (10.4%) patients did not meet criteria for treatment due to lack of either appropriate ECG findings or clinical suspicion. No episodes of unstable tachyarrhythmia or cardiac arrest occurred during EMS treatment or transport. CONCLUSION The study evaluated a novel protocol for detecting and managing HK in the prehospital setting. It is feasible for EMS crews to administer this protocol, although a larger study is needed to make the results generalizable.
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9
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Hyperkalemia as a limiting factor of neurohormonal blockade/modulation in everyday clinical practice. Rev Port Cardiol 2022; 41:521-527. [DOI: 10.1016/j.repc.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/16/2021] [Accepted: 04/07/2021] [Indexed: 11/15/2022] Open
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10
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Gonzalez Gomez A, Auckburally A, Bettschart‐Wolfensberger R. Unexpected hyperkalaemia in an anaesthetised calf undergoing umbilical fistula resection. VETERINARY RECORD CASE REPORTS 2022. [DOI: 10.1002/vrc2.351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Ana Gonzalez Gomez
- Department of Anaesthesia Southern Counties Veterinary Specialists, Hangersley Ringwood Hampshire UK
| | - Adam Auckburally
- Southern Counties Veterinary Specialists, Hangersley Ringwood Hampshire UK
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11
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Leli K, Warren G, Horras S, Bepko J, Longstreet N. Fluid, Electrolyte, and Acid–Base Disorders. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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12
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Scully TG, Wong GR, Teh AW, Lim HS. Severe hyperkalaemia in the setting of tumour lysis syndrome. BMJ Case Rep 2021; 14:e246184. [PMID: 34625445 PMCID: PMC8504348 DOI: 10.1136/bcr-2021-246184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Timothy G Scully
- Cardiology department, Austin Health, Heidelberg, Victoria, Australia
| | - Geoffrey R Wong
- Cardiology department, Austin Health, Heidelberg, Victoria, Australia
| | - Andrew W Teh
- Cardiology department, Austin Health, Heidelberg, Victoria, Australia
| | - Han S Lim
- Cardiology department, Austin Health, Heidelberg, Victoria, Australia
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13
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Rafique Z, Peacock F, Armstead T, Bischof JJ, Hudson J, Weir MR, Neuenschwander J. Hyperkalemia management in the emergency department: An expert panel consensus. J Am Coll Emerg Physicians Open 2021; 2:e12572. [PMID: 34632453 PMCID: PMC8485984 DOI: 10.1002/emp2.12572] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/18/2021] [Accepted: 09/16/2021] [Indexed: 01/11/2023] Open
Abstract
Hyperkalemia is a common electrolyte abnormality identified in the emergency department (ED) and potentially fatal. However, there is no consensus over the potassium threshold that warrants intervention or its treatment algorithm. Commonly used medications are at best temporizing measures, and the roles of binders are unclear in the emergent setting. As the prevalence of comorbid conditions altering potassium homeostasis rises, hyperkalemia becomes more common, and hence there is a need to standardize management. A panel was assembled to synthesize the available evidence and identify gaps in knowledge in hyperkalemia treatment in the ED. The panel was composed of 7 medical practitioners, including 5 physicians, a nurse, and a clinical pharmacist with collective expertise in the areas of emergency medicine, nephrology, and hospital medicine. This panel was sponsored by the American College of Emergency Physicians with a goal to create a consensus document for managing acute hyperkalemia. The panel evaluated the evidence on calcium for myocyte stabilization and potassium shifting and excretion. This article summarizes information on available therapies for hyperkalemia and proposes a hyperkalemia treatment algorithm for the ED practitioner based on the currently available literature and highlights diagnostic pitfalls and evidence gaps.
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Affiliation(s)
- Zubaid Rafique
- Baylor College of MedicineDepartment of Emergency MedicineBen Taub General HospitalHoustonTexasUSA
| | - Frank Peacock
- Baylor College of MedicineDepartment of Emergency MedicineBen Taub General HospitalHoustonTexasUSA
| | | | - Jason J. Bischof
- The Ohio State UniversityDepartment of Emergency MedicineColumbusOhioUSA
| | - Joanna Hudson
- The University of Tennessee Health Science CenterDepartments of Clinical Pharmacy and Translational Science & Medicine (Nephrology)MemphisTennesseeUSA
| | - Matthew R. Weir
- Division of NephrologyDepartment of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - James Neuenschwander
- The Ohio State UniversityDepartment of Emergency MedicineColumbusOhioUSA
- Genesis Healthcare SystemDepartment of Emergency MedicineZanesvilleOhioUSA
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Freeze TA, Skerry L, Kervin E, Nunn R, Woodland J, Hanson N, MacKinnon M. Treatment of Mild Hyperkalemia in Hospitalized Patients: An Unnecessary Practice? Can J Hosp Pharm 2021; 74:269-276. [PMID: 34248167 DOI: 10.4212/cjhp.v74i3.3154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Background Sodium polystyrene sulfonate (SPS) is one of the most commonly used treatments for mild hyperkalemia. Other treatments include insulin, sodium bicarbonate, and salbutamol, which may be given alone or in combination. The results of research examining treatment effectiveness for mild hyperkalemia (e.g., the ability of SPS to achieve normokalemia) thus far have been inconsistent. Given that the effectiveness of treatment for mild hyperkalemia is debatable, new research is needed. Objective To determine whether treatment of hospitalized patients with mild hyperkalemia (using SPS or another approach, relative to no treatment) was associated with achievement of normokalemia (serum potassium < 5.1 mmol/L). Methods For this retrospective, quasi-experimental study, hospitalized patients with index serum potassium level between 5.1 and 6.4 mmol/L were identified. Post-index serum potassium level within 24 hours was dichotomized (< 5.1 or ≥ 5.1 mmol/L). Pre-index serum creatinine and serum potassium levels were recorded as the average of the first 5 values immediately before the index potassium value. For each patient, treatment was categorized as no treatment, SPS treatment, or other treatment strategy. Results Among the 1944 patients included in the analysis, the average age was 66.8 (standard deviation 13.5) years; 605 (31.1%) of the patients were women and 1339 (68.9%) were men. Logistic regression results indicated that patients who were female and/or had higher pre-index serum potassium were less likely to return to normokalemia within 24 hours after the time of the index serum potassium value. Treatment category was not a statistically significant predictor of the achievement of normokalemia. Most patients with mild hyperkalemia (> 74.5% in each treatment category) achieved normokalemia, whether or not they received treatment. Conclusions The findings of this study suggest that although follow-up is required for mild hyperkalemia in hospitalized patients, active treatment may be unnecessary.
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Affiliation(s)
- Tracy A Freeze
- , PhD, is with Horizon Health Network, Saint John Regional Hospital, Saint John, New Brunswick
| | - Leanne Skerry
- , MA, is with Horizon Health Network, Saint John Regional Hospital, Saint John, New Brunswick
| | - Emily Kervin
- , MA, is with Horizon Health Network, Saint John Regional Hospital, Saint John, New Brunswick
| | - Rosemary Nunn
- , BN, RN, is with Saint John Regional Hospital, Saint John, New Brunswick
| | - Jennifer Woodland
- , PhD, is with Horizon Health Network, Saint John Regional Hospital, Saint John, New Brunswick
| | - Natasha Hanson
- , PhD, is with Horizon Health Network, Saint John Regional Hospital, Saint John, New Brunswick
| | - Martin MacKinnon
- , MD, FRCPC, is with the Department of Nephrology, Horizon Health Network, New Brunswick, and the Department of Medicine, Dalhousie University, Halifax, Nova Scotia
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15
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Moussavi K, Garcia J, Tellez-Corrales E, Fitter S. Reduced alternative insulin dosing in hyperkalemia: A meta-analysis of effects on hypoglycemia and potassium reduction. Pharmacotherapy 2021; 41:598-607. [PMID: 33993515 DOI: 10.1002/phar.2596] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/01/2021] [Accepted: 04/18/2021] [Indexed: 11/08/2022]
Abstract
STUDY OBJECTIVE Recent studies have identified that reduced alternative intravenous insulin doses, such as 5 units or 0.1 units/kg, may reduce the risk of hypoglycemia compared to standard doses of 10 units in patients treated for hyperkalemia. However, some studies suggest that these alternative doses may reduce the ability to lower serum potassium. This study was performed to determine the impact of alternative insulin dosing on hypoglycemia and potassium reduction in patients with hyperkalemia. DESIGN Meta-analysis. DATA SOURCE PubMed/MEDLINE, CENTRAL, Ovid, and ClinicalTrials.gov were searched from inception through November 2020. PATIENTS Patients treated with standard (10 units) or alternative (<10 units) insulin dosing strategies for hyperkalemia. Only studies that evaluated hypoglycemia (serum glucose <70 mg/dl), severe hypoglycemia (serum glucose <50 mg/dl), and potassium reduction post-treatment were included in the meta-analysis. All articles were assessed for bias using the Cochrane Risk of Bias Assessment Tool and Newcastle-Ottawa scales for randomized prospective trials and retrospective trials, respectively. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Ten retrospective cohort studies (n = 3437) were included and had low- or moderate-risk of bias. Alternative insulin dosing strategies included 5 units, 0.1 units/kg, and <10 units. Alternative dosing had lower pooled odds of hypoglycemia (odds ratio [OR] 0.55, 95% confidence interval [CI] 0.43-0.69, I2 = 8%) and severe hypoglycemia (OR 0.41, 95% CI 0.27-0.64, I2 = 0%). No difference in potassium reduction was detected (mean difference -0.02 mmol/L, 95% CI -0.11-0.07, I2 = 53%). CONCLUSIONS Alternative insulin dosing strategies for hyperkalemia management resulted in less hypoglycemia and severe hypoglycemia without compromising potassium reduction compared to standard dose. Prospective studies are needed to confirm these findings.
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Affiliation(s)
- Kayvan Moussavi
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, California, USA
| | - Joshua Garcia
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, California, USA
| | - Eglis Tellez-Corrales
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, California, USA
| | - Scott Fitter
- Emergency Medicine, Loma Linda University Medical Center, Loma Linda, California, USA.,Loma Linda University School of Pharmacy, Loma Linda, California, USA
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Campbell P, McKeveney P, Donegan K, Ataliotis C, Patton C, Mullan R. Practical guidance for the use of potassium binders in the management of hyperkalaemia in patients with heart failure and/or chronic kidney disease. Br J Hosp Med (Lond) 2021; 82:1-11. [PMID: 33914625 DOI: 10.12968/hmed.2021.0215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Given the critical physiological role of potassium, it is understandable that the development of severe hyperkalaemia requires effective management to reduce its effects, which include muscle weakness, paralysis and cardiac arrhythmias. Hyperkalaemia most often results from the failure of renal adaptation to potassium imbalance. Patients who are most susceptible to the development of hyperkalaemia include those with chronic kidney disease and those with heart failure. These patients are often treated with renin-angiotensin-aldosterone system (RAAS) inhibitors, such as angiotensin-converting enzyme inhibitors and angiotensin II-receptor blockers, but the development of hyperkalaemia can require down-titration or cessation of RAAS inhibitors. This presents a significant challenge to nephrologists, cardiologists and healthcare professionals treating these patients as this can prevent them from receiving maximum guideline-directed RAAS inhibitor therapy. Panellists in this roundtable discussion shared their clinical experiences of using potassium binders to manage hyperkalaemia in patients with chronic kidney disease and patients with heart failure (illustrated with case studies) in Northern Ireland and considered recommendations for the implementation and maintenance of chronic potassium-lowering treatment.
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Affiliation(s)
| | | | | | | | - Carol Patton
- Craigavon Hospital, Southern HSC Trust, Portadown, Craigavon
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Tamargo J, Caballero R, Delpón E. The pharmacotherapeutic management of hyperkalemia in patients with cardiovascular disease. Expert Opin Pharmacother 2021; 22:1319-1341. [PMID: 33620275 DOI: 10.1080/14656566.2021.1891223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Patients with cardiovascular diseases (CVD) are at increased risk of hyperkalemia, particularly when treated with renin-angiotensin-aldosterone inhibitors (RAASIs). Because the occurrence or fear of hyperkalemia, RAASIs are frequently down-titrated or discontinued in patients with CVD, with consequent worse outcomes than patients who remain on maximum doses.Areas covered: This article reviews potassium homeostasis, epidemiology, risk factors, and outcomes of hyperkalemia, and efficacy and safety of the drugs used for acute and chronic treatment of hyperkalemia. A literature search was carried out using the PubMed and guidelines for the management of hyperkalemia.Expert opinion: The emergency treatment of hyperkalemia is not supported by high-quality evidence and clinical trials did not report drug effects on clinical outcomes. Two potassium binders, patiromer and sodium zirconium cyclosilicate, represent a new approach in the treatment of chronic hyperkalemia as they may allow the titration and maintenance of guidelines-recommended doses of RAASIs in patients with CVD who otherwise would not tolerate them due to the risk of hyperkalemia.Further studies are needed to evaluate the safety and efficacy of drug therapy and support the development of guidelines for acute and chronic hyperkalemia.
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Affiliation(s)
- Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense, Instituto De Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ricardo Caballero
- Department of Pharmacology, School of Medicine, Universidad Complutense, Instituto De Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Eva Delpón
- Department of Pharmacology, School of Medicine, Universidad Complutense, Instituto De Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Kwon Y, Kim JH, Yoon J, Park J, Kang SS, Hwang SM. Effects of estimated glomerular filtration rate and diabetes mellitus on the effect of insulin for treating hyperkalemia during anesthesia. J Anesth 2021; 35:483-487. [PMID: 33861365 DOI: 10.1007/s00540-021-02933-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/04/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE We analyzed the effectiveness of insulin for treating hyperkalemia (≥ 5 mEq/L) during anesthesia and the effects of the estimated glomerular filtration rate (eGFR) and diabetes mellitus (DM) on the insulin treatment. METHODS Patients 18 years of age and older who received intravenous insulin lispro for hyperkalemia under general anesthesia between January 2010 and March 2020 were enrolled. We performed three propensity score matching analyses according to eGFR stages (eGFR ≥ 60 vs. 30 ≤ eGFR < 60 and eGFR ≥ 60 vs. eGFR < 30 mL/min/1.73 m2) and DM status. RESULTS The study included 475 patients. For patients with hyperkalemia during surgery, the odds ratios [ORs] of failure to decrease potassium (K+) after insulin treatment were higher in patients with eGFR < 30 mL/min/1.73 m2 (adjusted OR 3.24; 95% confidence interval 1.38-7.64; P = 0.007) than in patients with eGFR ≥ 60 mL/min/1.73 m2. There was no significant difference in the ORs of patients with 30 ≤ eGFR < 60 mL/min/1.73 m2 and DM. CONCLUSION The patients with a low eGFR had a higher incidence of K+ not decreasing after insulin treatment. Periodic assessment of K+ may be required during anesthesia.
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Affiliation(s)
- Youngsuk Kwon
- Department of Anesthesiology and Pain Medicine, Hallym University School of Medicine, Chuncheon Sacred Heart Hospital, 77 Sakju-ro, Chuncheon, 24253, South Korea
| | - Jong Ho Kim
- Department of Anesthesiology and Pain Medicine, Hallym University School of Medicine, Chuncheon Sacred Heart Hospital, 77 Sakju-ro, Chuncheon, 24253, South Korea
| | - Juhyun Yoon
- Department of Anesthesiology and Pain Medicine, Kangdong Sacred Heart Hospital, Seoul, South Korea
| | - Jaehyun Park
- Department of Anesthesiology and Pain Medicine, Kangdong Sacred Heart Hospital, Seoul, South Korea
| | - Sang Soo Kang
- Department of Anesthesiology and Pain Medicine, Kangdong Sacred Heart Hospital, Seoul, South Korea
| | - Sung Mi Hwang
- Department of Anesthesiology and Pain Medicine, Hallym University School of Medicine, Chuncheon Sacred Heart Hospital, 77 Sakju-ro, Chuncheon, 24253, South Korea.
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Abstract
OBJECTIVE Severe toxicity from ingestions of oral sustained-release potassium is rare. While acute hyperkalaemia requires urgent intervention given the risk of cardiac toxicity, there is a lack of clinical consensus on optimal management. The aim of this study was to characterise the clinical manifestations of acute potassium overdose and its management approach. METHODS This is a retrospective case series of patients presenting following oral potassium overdose of ≥6000mg between January 2009 and December 2020 in Queensland, Australia as recorded in the state's Poisons Information Centre database and a tertiary Clinical Toxicology Unit database. Patients were identified from prospective databases maintained by both units and data were extracted from these in addition to medical records. RESULTS Thirteen presentations in eleven patients occurred in the twelve-year period. The median age was 35 years (range 14-55 years). The median dose ingested was 6.4 mmol/kg (range 0.9-30.8 mmol/kg). Severe hyperkalaemia >7mmol/L occurred in five patients, four with ingestions ≥60,000mg. All patients with hyperkalaemia received multiple modes of intracellular potassium shifting therapy. Four patients had endoscopic removal of pharmacobezoars. One also underwent whole bowel irrigation. Three presentations were managed with haemodialysis. All patients were discharged home with a median length of stay of 20 h. CONCLUSION Aggressive medical therapy to shift potassium into cells appears to be the mainstay of treatment in patients with normal renal function. Early decontamination may limit peak potassium concentrations. It is unclear if haemodialysis provides significant additional benefit in patients with normal renal function.
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Affiliation(s)
- Arushi Madan
- Department of Clinical Pharmacology, Princess Alexandra Hospital, Brisbane, Australia.,Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Christopher Morris
- Department of Clinical Pharmacology, Princess Alexandra Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Anna Goggin
- Queensland Poisons Information Centre, Queensland Children's Hospital, South Brisbane, Australia
| | - Katherine Z Isoardi
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Queensland Poisons Information Centre, Queensland Children's Hospital, South Brisbane, Australia
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Lemoine L, Le Bastard Q, Batard E, Montassier E. An Evidence-Based Narrative Review of the Emergency Department Management of Acute Hyperkalemia. J Emerg Med 2021; 60:599-606. [PMID: 33423833 DOI: 10.1016/j.jemermed.2020.11.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/02/2020] [Accepted: 11/22/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The normal range for potassium is within narrow limits. Hyperkalemia is an electrolyte disorder that frequently affects patients in the emergency department (ED), and can result in significant morbidity and mortality if not identified and treated rapidly. OBJECTIVE This article provides an evidence-based narrative review of the management of hyperkalemia, with focused updates for the emergency clinician. METHODS We searched in MEDLINE, EMBASE, Web of Science, and Scopus databases for articles in English published in peer-reviewed journals and indexed up until May 2020. We used multiple search terms, including hyperkalemia, potassium, acute hyperkalemia, emergency department, dyskalemia, potassium disorders, kidney disease, epidemiology, electrolyte disturbance, severe hyperkalemia, and emergency management. DISCUSSION In the ED, interventions aimed to protect patients from the immediate dangers of elevated serum potassium are divided into the following: stabilizing cardiac membrane potentials, reducing serum potassium levels through shift from the extracellular fluid to intracellular fluid, and elimination of potassium through excretion via urinary or fecal excretion. Calcium is widely recommended to stabilize the myocardial cell membrane, but additional research is necessary to establish criteria for use, dosages, and preferred solutions. Redistribution of potassium ions from the bloodstream into the cells is based on intravenous insulin or nebulized β2-agonists. CONCLUSIONS Hyperkalemia is a frequent electrolyte disorder in the ED. Because of the risk of fatal dysrhythmia due to cardiac membrane instability, hyperkalemia is a medical emergency. There is a lack of scientific evidence on the optimal management of hyperkalemia and more research is needed to establish optimal strategies to manage acute hyperkalemia in the emergency department.
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Affiliation(s)
- Loic Lemoine
- Department of Emergency Medicine, Nantes University Hospital, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nantes, France
| | - Quentin Le Bastard
- Department of Emergency Medicine, Nantes University Hospital, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nantes, France; Microbiota, Hôtes, Antibiotiques et Résistances Laboratory, Université de Nantes, Nantes, France
| | - Eric Batard
- Department of Emergency Medicine, Nantes University Hospital, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nantes, France; Microbiota, Hôtes, Antibiotiques et Résistances Laboratory, Université de Nantes, Nantes, France
| | - Emmanuel Montassier
- Department of Emergency Medicine, Nantes University Hospital, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nantes, France; Microbiota, Hôtes, Antibiotiques et Résistances Laboratory, Université de Nantes, Nantes, France
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Rizk J, Quan D, Gabardi S, Rizk Y, Kalantar-Zadeh K. Novel approaches to management of hyperkalaemia in kidney transplantation. Curr Opin Nephrol Hypertens 2021; 30:27-37. [PMID: 33027094 DOI: 10.1097/mnh.0000000000000657] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Medications used frequently after kidney transplantation, including calcineurin inhibitors, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta blockers and antimicrobials, are considered the leading culprit for posttransplant hyperkalaemia in recipients with a well functioning allograft. Other risk factors include comorbidities such as diabetes, hypertension and heart failure; and consumption of a potassium-enriched diet. We review the mechanisms for hyperkalaemia following kidney transplantation that are addressed using nonpharmacological and pharmacological interventions. We also discuss emerging therapeutic approaches for the management of recurrent hyperkalaemia in solid organ transplantation, including newer potassium binding therapies. RECENT FINDINGS Patiromer and sodium zirconium cyclosilicate are emerging potassium binders approved for the treatment of hyperkalaemia. Patiromer is a polymer that exchanges potassium for calcium ions. In contrast, sodium zirconium cyclosilicate is a nonpolymer compound that exchanges potassium for sodium and hydrogen ions. Both agents are efficacious in the treatment of chronic or recurrent hyperkalaemia and may result in fewer gastrointestinal side effects than older potassium binders such as sodium polystyrene sulfonate and calcium polystyrene sulfonate. Large-scale clinical studies have not been performed in kidney transplant patients. Patiromer may increase serum concentrations of tacrolimus, but not cyclosporine. Sodium zirconium cyclosilicate does not appear to compromise tacrolimus pharmacokinetics, although it may have a higher sodium burden. SUMMARY Patiromer and sodium zirconium cyclosilicate may be well tolerated options to treat asymptomatic hyperkalaemia and have the potential to ease potassium dietary restrictions in kidney transplant patients by maintaining a plant-dominant, heart-healthy diet. Their efficacy, better tolerability and comparable cost with respect to previously available potassium binders make them an attractive therapeutic option in chronic hyperkalaemia following kidney transplantation.
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Affiliation(s)
- John Rizk
- Arizona State University, Edson College, Phoenix, Arizona
| | - David Quan
- UCSF Medical Center, University of California San Francisco, San Francisco, California
| | - Steven Gabardi
- Department of Transplant Surgery, Brigham and Women's Hospital
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Youssef Rizk
- Department of Family Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange
- Department of Epidemiology, University of California, Los Angeles, UCLA Fielding School of Public Health, Los Angeles, California, USA
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Crnobrnja L, Metlapalli M, Jiang C, Govinna M, Lim AKH. The Association of Insulin-dextrose Treatment with Hypoglycemia in Patients with Hyperkalemia. Sci Rep 2020; 10:22044. [PMID: 33328554 PMCID: PMC7745028 DOI: 10.1038/s41598-020-79180-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/04/2020] [Indexed: 12/16/2022] Open
Abstract
Treatment of hyperkalemia with intravenous insulin-dextrose is associated with a risk of hypoglycemia. We aimed to determine the factors associated with hypoglycemia (glucose < 3.9 mmol/L, or < 70 mg/dL) and the critical time window with the highest incidence. In a retrospective cohort study in a tertiary hospital network, we included 421 adult patients with a serum potassium ≥ 6.0 mmol/L who received insulin-dextrose treatment. The mean age was 70 years with 62% male predominance. The prevalence of diabetes was 60%, and 70% had chronic kidney disease (eGFR < 60 ml/min/1.73 m2). The incidence of hypoglycemia was 21%. In a multivariable logistic regression model, the factors independently associated with hypoglycemia were: body mass index (per 5 kg/m2, OR 0.85, 95% CI: 0.69–0.99, P = 0.04), eGFR < 60 mL/min/1.73 m2 (OR 2.47, 95% CI: 1.32–4.63, P = 0.005), diabetes (OR 0.57, 95% CI 0.33–0.98, P = 0.043), pre-treatment blood glucose (OR 0.84, 95% CI: 0.77–0.91, P < 0.001), and treatment in the emergency department compared to other locations (OR 2.53, 95% CI: 1.49–4.31, P = 0.001). Hypoglycemia occurred most frequently between 60 and 150 min, with a peak at 90 min. Understanding the factors associated with hypoglycemia and the critical window of risk is essential for the development of preventive strategies.
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Affiliation(s)
- Ljiljana Crnobrnja
- Department of General Medicine, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Manogna Metlapalli
- Department of General Medicine, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Cathy Jiang
- Department of General Medicine, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Mauli Govinna
- Department of General Medicine, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Andy K H Lim
- Department of General Medicine, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia. .,Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia.
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Salvadori FA, Moreira EM, Dias MB, Duarte-Neto AN, Paiva EFD. Cardiac Arrest Due to Hypocalcemia. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2020. [DOI: 10.36660/ijcs.20200034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Wong SWS, Zhang G, Norman P, Welihinda H, Wijeratne DT. Polysulfonate Resins in Hyperkalemia: A Systematic Review. Can J Kidney Health Dis 2020; 7:2054358120965838. [PMID: 33240515 PMCID: PMC7675864 DOI: 10.1177/2054358120965838] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/24/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Hyperkalemia is a potentially life-threatening electrolyte abnormality defined as a serum potassium above the lab reference range (usually >5.0-5.5 mEq/L). Polystyrene resins, including sodium polystyrene sulfonate (SPS) and calcium polystyrene sulfonate (CPS), have long been used to treat hyperkalemia. Sodium polystyrene sulfonate/calcium polystyrene sulfonate act by exchanging a cation for potassium within the intestinal lumen. While SPS and CPS have been available since the 1960s, there are rising concerns about the validity of the data supporting its use and about serious adverse gastrointestinal effects. OBJECTIVE The objective of this systematic review was to quantify the efficacy and safety of polystyrene sulfonate resins (SPS/CPS) in the treatment of adults with hyperkalemia. This review focuses on the randomized control trial (RCT), interventional non-RCT, and observational data available on SPS/CPS use. DESIGN Systematic review. SETTING Any country of origin. Both inpatient and outpatient settings. PATIENTS Adults with hyperkalemia treated with polystyrene sulfonate resins. MEASUREMENTS The primary outcome was change in serum potassium. The secondary outcomes included adverse effects of SPS/CPS and prevention of recurrent hyperkalemia. METHODS We conducted a systematic review using Cochrane Library, EMBASE (1947-2019), and Medline (1946-2019) databases. Literature reviews, systematic reviews, case studies, case series, and editorial pieces were excluded. Included studies were assessed for risk of bias. RESULTS Four RCTs, 21 observational studies, and 5 quasi-experimental trials were included. A total of 212 351 patients were included. Two thousand and fifty-eight patients were studied for the primary outcome and 210 293 patients were studied for the secondary outcomes. Study designs were heterogeneous and not amenable to meta-analysis. Most studies included nonhemodialysis outpatients older than 65 years. Of the included studies, 22/25 (88%) demonstrated a reduction of serum potassium >0.5 mEq/L over the study period. The magnitude of reduction in serum potassium of potassium resin compared with placebo or matched controls in the 3 low-risk studies identified was 0.14 to 1.04 mEq/L. However, each study used different dosing regimens. Ten of 22 studies reported the effects of polystyrene resins on serum potassium within 24 hours. A few high-quality observational studies suggest an increased risk of serious adverse gastrointestinal events with a relative risk of 2.10 and a hazard ratio of 1.25 to 1.94; however, the absolute risk remains low. The incidence of adverse gastrointestinal events is 16 to 23 events per 1000 person-years. LIMITATIONS We acknowledge several limitations in this study. Case studies and case series were excluded from the search results. Large case series may have been excluded despite having comparable sample sizes to studies included due to lack of a comparator and calculated estimates. Due to the heterogeneity of the studies, the data were unable to be meta-analyzed and as such the potassium-lowering effect of polystyrene sulfonate resins remains founded on small studies with potential confounders. CONCLUSIONS This systematic review demonstrates a continued lack of high-quality evidence for the use of SPS/CPS in hyperkalemia. Studies investigated highly variable timelines and the most robust evidence for SPS/CPS use is in chronic hyperkalemia. While the absence of high-quality evidence does not exclude the possibility of benefit, prescribers must understand that the use of SPS/CPS in acute hyperkalemia is not supported by high-quality evidence. TRIAL REGISTRATION The protocol for this systematic review was not registered.
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Affiliation(s)
| | - Grace Zhang
- Department of Internal Medicine, Queen’s University, Kingston, ON, Canada
| | | | - Hasitha Welihinda
- School of Medicine, Queen’s University, Kingston, ON, Canada
- Kingston Health Sciences Centre, ON, Canada
| | - Don Thiwanka Wijeratne
- School of Medicine, Queen’s University, Kingston, ON, Canada
- Kingston Health Sciences Centre, ON, Canada
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Schnaubelt S, Niederdoeckl J, Schoergenhofer C, Cacioppo F, Schuetz N, Spiel AO, Hecking M, Domanovits H. Hyperkalemia: A persisting risk. A case report and update on current management. Clin Case Rep 2020; 8:1748-1753. [PMID: 32983489 PMCID: PMC7495804 DOI: 10.1002/ccr3.2974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/03/2020] [Accepted: 05/07/2020] [Indexed: 12/28/2022] Open
Abstract
We report a case of hemodynamic instability due to bradycardia on the basis of severe hyperkalemia. Diabetic ketoacidosis and acute kidney injury together with polypharmacy triggered the acute onset. Potentially life-threatening hyperkalemia is often induced by drug interactions. ECG features may be crucial for diagnosis, and treatment depends on setting and resources.
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Affiliation(s)
| | - Jan Niederdoeckl
- Department of Emergency MedicineMedical University of ViennaViennaAustria
| | | | - Filippo Cacioppo
- Department of Emergency MedicineMedical University of ViennaViennaAustria
| | - Nikola Schuetz
- Department of Emergency MedicineMedical University of ViennaViennaAustria
| | - Alexander O. Spiel
- Department of Emergency MedicineMedical University of ViennaViennaAustria
- Department of Emergency MedicineWilheminenspital ViennaViennaAustria
| | - Manfred Hecking
- Division of Nephrology and DialysisDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Hans Domanovits
- Department of Emergency MedicineMedical University of ViennaViennaAustria
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Dewey J, Mastenbrook J, Bauler LD. Differentiating Pseudohyperkalemia From True Hyperkalemia in a Patient With Chronic Lymphocytic Leukemia and Diverticulitis. Cureus 2020; 12:e9800. [PMID: 32953312 PMCID: PMC7494421 DOI: 10.7759/cureus.9800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Haas JS, Krinke KS, Maas C, Hardt T, Barck I, Braun S. The burden of hyperkalemia in Germany - a real world evidence study assessing the treatment and costs of hyperkalemia. BMC Nephrol 2020; 21:332. [PMID: 32770956 PMCID: PMC7414716 DOI: 10.1186/s12882-020-01942-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/12/2020] [Indexed: 11/10/2022] Open
Abstract
Background Hyperkalemia (HK) can affect health outcomes and quality of life, as it is referred to as a potentially life-threatening condition caused by an increased serum potassium concentration in the blood. Patients suffering from heart failure or chronic kidney diseases are at a higher risk of HK, which can further be amplified by the treatment received. To date, data on HK prevalence is lacking for Germany and the aims of this study were to assess HK and compare health-relevant outcomes and healthcare costs between HK patients and non-HK patients. Methods The InGef research database containing healthcare claims of over 4 million individuals in Germany was utilized for this retrospective, matched cohort analysis. Patients with non-acute outpatient treated and a subgroup of patients with chronic HK, were identified in 2015 with an individual 1 year pre- and post-index period, taking the first observable HK diagnosis/treatment in 2015 into account as the index event. To identify non-acute outpatient treated HK patients, at least two ICD-10-GM diagnosis codes E87.5 “Hyperkalemia” and/or prescriptions of polystyrene sulfonate were required. Chronic HK patients had additional diagnoses and/or prescriptions in all quarters following the first observable HK diagnosis. Patients without HK were matched 1:1 to the respective HK cohorts. Results In the year 2015, 3333 patients with non-acute outpatient treated HK were identified of which 1693 were patients with chronic HK. After matching, 3191 and 1664 HK patients and controls were available for analysis. A significantly higher number of hospitalizations was observed for both HK cohorts in comparison to their matched controls. Dialysis initiation as well as the healthcare costs were higher for both HK cohorts when compared to their matched counterparts. Conclusions The disease burden was higher for patients with HK, based on a higher proportion of patients with dialysis initiation and higher healthcare costs.
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Affiliation(s)
| | | | | | - Thomas Hardt
- Vifor Pharma Gruppe, Pharma Deutschland GmbH, Baierbrunner Str. 29, 81379, Munich, Germany
| | - Isabella Barck
- Vifor Pharma Gruppe, Pharma Deutschland GmbH, Baierbrunner Str. 29, 81379, Munich, Germany
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Soliman R, Nofal H. The effect of perioperative magnesium sulfate on blood sugar in patients with diabetes mellitus undergoing cardiac surgery: A double-blinded randomized study. Ann Card Anaesth 2020; 22:151-157. [PMID: 30971596 PMCID: PMC6489401 DOI: 10.4103/aca.aca_32_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Objective The aim of the present study was to evaluate the perioperative effect of magnesium infusion on blood sugar level in patients with diabetes mellitus undergoing cardiac surgery. Design This was a double-blind randomized study. Setting The study was conducted at cardiac center. Patients The study included 122 adult patients. Intervention Group M - The patients received a continuous infusion of magnesium sulfate (without a loading dose) at 15 mg/kg/h. The infusion rate was started 20 min before induction maintained during surgery and the first postoperative 24 h. The medication was prepared by adding 5 g magnesium sulfate in 50 ml syringe. Group C - The patients received equal amount of normal saline. Measurements The monitors included heart rate, mean arterial blood pressure, central venous pressure, urine output, blood levels of magnesium, sugar, and potassium. Results The blood sugar level and the required insulin significantly decreased with Group M than Group C (P < 0.05). There were minimal changes in the potassium level in Group M, but potassium decreased in patients of Group C (P < 0.05). The amount of urine output was too much higher in Group M than Group C (P < 0.05). The pharmacological and mechanical support significantly decreased with Group M than Group C (P < 0.05). The hospital and Intensive Care Unit length of stay significantly decreased with Group M than Group C (P < 0.05). Conclusion The magnesium sulfate produced a better-controlled effect on the blood sugar level. It decreased the requirement of insulin infusion and minimized the changes in the blood level of potassium.
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Affiliation(s)
- Rabie Soliman
- Department of Anesthesia, Cairo University, Cairo, Egypt; Department of Cardiac Anesthesia, Cardiac Center, Aldar Hospital, Almadinah Almonwarah, Saudi Arabia
| | - Hussein Nofal
- Department of Cardiac Surgery, Cardiac Center, Aldar Hospital, Almadinah Almonwarah, Saudi Arabia; National Heart Institute, Giza, Egypt
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Sigurdsson TS, Þorvaldsson AP, Asgeirsdottir S, Sigvaldason K. Cardiac arrest in a COVID-19 patient after receiving succinylcholine for tracheal reintubation. Br J Anaesth 2020; 125:e255-e257. [PMID: 32423609 PMCID: PMC7252067 DOI: 10.1016/j.bja.2020.04.073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 04/24/2020] [Accepted: 04/25/2020] [Indexed: 01/08/2023] Open
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Moussavi K, Nguyen LT, Hua H, Fitter S. Comparison of IV Insulin Dosing Strategies for Hyperkalemia in the Emergency Department. Crit Care Explor 2020; 2:e0092. [PMID: 32426734 PMCID: PMC7188424 DOI: 10.1097/cce.0000000000000092] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The objectives of this study were to evaluate the safety and efficacy of insulin dosing of less than 10 units versus 10 units in patients receiving hyperkalemia treatment. DESIGN Retrospective single-center study. SETTING Emergency department at a large academic medical center in the United States. PATIENTS Seven hundred adults treated for hyperkalemia with IV regular insulin between April 1, 2013, and September 27, 2018. INTERVENTIONS Patients that received less than 10 units of insulin were compared to those that received 10 units of insulin. MEASUREMENTS AND MAIN RESULTS Patients treated with less than 10 units had significantly lower frequency of hypoglycemia (11.2% vs 17.6%; p = 0.008). Reduction in serum potassium was significantly more modest in size in patients treated with less than 10 units (mean reduction 0.94 ± 0.71 mMol/L) compared with patients treated with 10 units (mean reduction 1.11 ± 0.8 mMol/L; p = 0.008). There were no statistically significant differences between groups in time to hypoglycemia, nadir serum glucose, severe hypoglycemia (<40 mg/dL), dextrose requirements, use of concurrent agents for hyperkalemia, need for repeat insulin dosing, length of stay, or mortality. CONCLUSIONS Patients treated for hyperkalemia with insulin doses less than 10 units had reduced frequency of hypoglycemia; however, potassium reduction post treatment was more modest in these patients. These findings suggest providers choosing to administer 10 units IV insulin should ensure patients have adequate monitoring for hypoglycemia.
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Affiliation(s)
- Kayvan Moussavi
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, CA
| | - Lani T Nguyen
- Department of Pharmacy, Loma Linda University Medical Center, Loma Linda, CA
| | - Henry Hua
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, CA
| | - Scott Fitter
- Emergency Department, Department of Pharmacy, Loma Linda University Medical Center, Loma Linda, CA
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA
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Leli K, Warren G, Horras S, Bepko J, Longstreet N. Fluid, Electrolyte, and Acid–Base Disorders. Fam Med 2020. [DOI: 10.1007/978-1-4939-0779-3_103-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Beusekamp JC, Tromp J, Cleland JG, Givertz MM, Metra M, O’Connor CM, Teerlink JR, Ponikowski P, Ouwerkerk W, van Veldhuisen DJ, Voors AA, van der Meer P. Hyperkalemia and Treatment With RAAS Inhibitors During Acute Heart Failure Hospitalizations and Their Association With Mortality. JACC-HEART FAILURE 2019; 7:970-979. [DOI: 10.1016/j.jchf.2019.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/11/2019] [Accepted: 07/15/2019] [Indexed: 12/28/2022]
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Thomsen RW, Nicolaisen SK, Hasvold P, Sanchez RG, Pedersen L, Adelborg K, Egstrup K, Egfjord M, Sørensen HT. Elevated potassium levels in patients with chronic kidney disease: occurrence, risk factors and clinical outcomes-a Danish population-based cohort study. Nephrol Dial Transplant 2019; 33:1610-1620. [PMID: 29177463 DOI: 10.1093/ndt/gfx312] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 10/04/2017] [Indexed: 11/14/2022] Open
Abstract
Background Data on the true burden of hyperkalemia (HK) in patients with chronic kidney disease (CKD) in a real-world setting are scarce. Methods The incidence rate of HK [first blood test with an elevated blood potassium level level >5.0 mmol/L] in primary or hospital care was assessed in a population-based cohort of all newly diagnosed CKD patients [second estimated glomerular filtration rate (eGFR) measurement <60 mL/min/1.73 m2 or hospital diagnosis] in northern Denmark. Risk factors and clinical outcomes were compared for CKD patients with HK and matched CKD patients without HK. Results Of 157 766 patients with CKD, 28% experienced HK, for an overall HK incidence rate of 70/1000 person-years. Among patients with Stage 3A, 3B, 4 or 5 CKD, 9, 18, 31 and 42%, respectively, experienced HK within the first year. Important HK risk factors included diabetes {prevalence ratio [PR] 1.74 [95% confidence interval (CI) 1.69-1.79]}, heart failure [PR 2.31 (95% CI 2.23-2.40)] and use of angiotensin-converting enzyme inhibitors [PR 1.45 (95% CI 1.42-1.48)], potassium supplements [PR 1.59 (95% CI 1.55-1.62)] or spironolactone [PR 2.53 (95% CI 2.44-2.63)]. In CKD patients who developed HK, 34% had any acute hospitalization 6 months before the HK event, increasing to 57% 6 months after HK [before-after risk ratio 1.72 (95% CI 1.69-1.74)]. The 6-month mortality following HK was 26%, versus 6% in matched non-HK patients. Compared with non-HK patients, 6-month hazard ratios for any acute hospitalization in HK patients were 2.11-fold higher, including hazard ratios of 2.07 for cardiac diagnoses, 2.29 for ventricular arrhythmias, 3.26 for cardiac arrest, 4.77 for intensive care and 4.85 for death. Conclusions More than one in four CKD patients develops HK. Patients with severe CKD, diabetes, heart failure or use of spironolactone are at high risk. HK is associated with severe clinical outcomes.
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Affiliation(s)
- Reimar W Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Sia K Nicolaisen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Pål Hasvold
- AstraZeneca Nordic Medical Department, Etterstad, Oslo, Norway
| | | | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Kasper Adelborg
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Kenneth Egstrup
- Department of Cardiology, Svendborg Hospital, Svendborg, Denmark
| | - Martin Egfjord
- Department of Nephrology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Awlad Thani S, Al Farsi M, Al Omrani S. Life threatening hyperkalemia treated with prolonged continuous insulin infusion. Int J Pediatr Adolesc Med 2019; 6:118-120. [PMID: 31700971 PMCID: PMC6824155 DOI: 10.1016/j.ijpam.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 04/04/2019] [Accepted: 04/14/2019] [Indexed: 11/22/2022]
Abstract
Hyperkalemia is a life threatening electrolyte imbalance that may be fatal if not treated appropriately. There are multiple medications used to treat hyperkalemia to lower it to a safe level. We report a case of a 4-month old infant with Pseudohypoaldosteronism who had cardiac arrest secondary to severe hyperkalemia of 12.3mmol/l. It was refractory to anti hyperkalemic medications that necessitated the transfer of the patient to a tertiary hospital for dialysis. The potassium level has dropped gradually to a normal level with continuous insulin infusion and dextrose for almost 12 hours that waved the need of the dialysis. This case highlights the effectiveness of prolonged continuous insulin infusion in treating life-threatening hyperkalemia especially in hospitals where there are no dialysis services available or until the dialysis is initiated.
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Vanholder R, Van Biesen W, Nagler EV. Treating potassium disturbances: kill the killers but avoid overkill. Acta Clin Belg 2019; 74:215-228. [PMID: 30353786 DOI: 10.1080/17843286.2018.1531206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES In this publication, we review the definitions, symptoms, causes, differential diagnoses and therapies of hypokalemia and hyperkalemia. METHODS Comprehensive tables and diagnostic algorithms are provided when appropriate. RESULTS AND CONCLUSIONS Although both hypokalemia and hyperkalemia may be life-threatening, this is essentially the case with severe changes (serum potassium < 2.5 or > 6.5 mmol/L), the presence of symptoms or electrocardiographic deviations, the association with aggravating factors (e.g. digitalis intake) and/or rapid acute changes. Only these truly need an emergency therapeutic approach. In all other cases, a careful consideration of the causes and their correction should prevail over additional approaches to modify serum potassium concentration. Although most therapeutic approaches to both hypokalemia and hyperkalemia have been well established since many years, recently two new intestinal potassium binders have been introduced on the market. It remains to be elucidated whether these drugs truly have an additional role on top of the existing treatments.
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Affiliation(s)
- R. Vanholder
- Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Belgium
| | - W. Van Biesen
- Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Belgium
| | - E. V. Nagler
- Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Belgium
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Long B, Warix JR, Koyfman A. Hyperkalemia in the Emergency Department: Yes, a Need for Further Evidence, but Do Not Discount What We Have. J Emerg Med 2019; 57:103-105. [PMID: 31326003 DOI: 10.1016/j.jemermed.2019.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 03/16/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Justin R Warix
- Department of Emergency Medicine, Central Peninsula Hospital, Soldotna, Alaska
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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Moussavi K, Fitter S, Gabrielson SW, Koyfman A, Long B. Management of Hyperkalemia With Insulin and Glucose: Pearls for the Emergency Clinician. J Emerg Med 2019; 57:36-42. [DOI: 10.1016/j.jemermed.2019.03.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/16/2019] [Accepted: 03/31/2019] [Indexed: 12/13/2022]
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Athyros VG, Sachinidis AG, Zografou I, Simoulidou E, Piperidou A, Stavropoulos N, Karagiannis A. Boosting the Limited Use of Mineralocorticoid Receptor Antagonists Through New Agents for Hyperkalemia. Curr Pharm Des 2019; 24:5542-5547. [DOI: 10.2174/1381612825666190306162339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 02/26/2019] [Indexed: 11/22/2022]
Abstract
Background:
Hyperkalemia is an important clinical problem that is associated with significant lifethreatening
complications. Several conditions are associated with increased risk for hyperkalemia such as chronic
kidney disease, diabetes mellitus, heart failure, and the use of renin-angiotensin-aldosterone system (RAAS)
inhibitors.
Objective:
The purpose of this review is to present and critically discuss treatment options for the management of
hyperkalemia.
Method:
A comprehensive review of the literature was performed to identify studies assessing the drug-induced
management of hyperkalemia.
Results:
The management of chronic hyperkalemia seems to be challenging and includes a variety of traditional
interventions, such as restriction in the intake of the dietary potassium, loop diuretics or sodium polystyrene sulfonate.
In the last few years, several new agents have emerged as promising options to reduce potassium levels in
hyperkalemic patients. Patiromer and sodium zirconium cyclosilicate 9 (ZS-9) have been examined in hyperkalemic
patients and were found to be efficient and safe. Importantly, the efficacy of these novel drugs might allow
the continuation of the use of RAAS inhibitors, morbidity- and mortality-wise beneficial class of drugs in the
setting of chronic kidney disease and heart failure.
Conclusion:
Data support that the recently emerged patiromer and ZS-9 offer significant hyperkalemia-related
benefits. Larger trials are needed to unveil the impact of these drugs in other patients’ subpopulations, as well.
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Affiliation(s)
- Vasilios G. Athyros
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | | | - Ioanna Zografou
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - Elisavet Simoulidou
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - Alexia Piperidou
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - Nikiforos Stavropoulos
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - Asterios Karagiannis
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
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Wooten JM, Kupferman FE, Kupferman JC. A Brief Review of the Pharmacology of Hyperkalemia: Causes and Treatment. South Med J 2019; 112:228-233. [DOI: 10.14423/smj.0000000000000957] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Lemoine L, Legrand M, Potel G, Rossignol P, Montassier E. Prise en charge de l’hyperkaliémie aux urgences. ANNALES FRANCAISES DE MEDECINE D URGENCE 2019. [DOI: 10.3166/afmu-2018-0108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’hyperkaliémie est l’un des désordres hydroélectrolytiques les plus fréquemment rencontrés aux urgences. Les étiologies principales sont l’insuffisance rénale aiguë ou chronique, le diabète et l’insuffisance cardiaque. L’hyperkaliémie aiguë peut être une urgence vitale, car elle est potentiellement létale du fait du risque d’arythmie cardiaque. Sa prise en charge aux urgences manque actuellement de recommandations claires en ce qui concerne le seuil d’intervention et les thérapeutiques à utiliser. Les thérapeutiques couramment appliquées sont fondées sur un faible niveau de preuve, et leurs effets secondaires sont mal connus. Des études supplémentaires sont nécessaires pour évaluer l’utilisation de ces traitements et celle de nouveaux traitements potentiellement prometteurs. Nous faisons ici une mise au point sur les données connues en termes d’épidémiologie, de manifestations cliniques et électrocardiographiques, et des différentes thérapeutiques qui peuvent être proposées dans la prise en charge de l’hyperkaliémie aux urgences.
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Abstract
Hyperkalaemia causes significant burden, and even mild hyperkalaemia has been independently associated with increased morbidity and mortality. Patients with chronic disease states, such as heart failure, hypertension, chronic kidney disease and diabetes mellitus, are increasingly susceptible to the development of hyperkalaemia. Options for management of hyperkalaemia had mainly been limited to short-term, temporizing methods with focus on rapid achievement of normokalaemia. Until recently, there was a lack of safe, efficacious and well-tolerated therapies for long-term management. Two novel potassium binders, patiromer and sodium zirconium cyclosilicate, have recently been approved by the US Food and Drug Administration for the management of hyperkalaemia. This review discusses these potassium binders with focus largely on the clinical implications of these agents in patients with chronic cardiovascular conditions.
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Affiliation(s)
- Shilpa Vijayakumar
- Department of Medicine, Stony Brook University, 101 Nicolls Road, Stony Brook, NY, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi, 2500 North State Street, Jackson, MS, USA
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin-Brandenburg Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany; and.,Department of Cardiology, Universityätsmedizin Göttingen (UMG), Göttingen, Germany
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Tayari H, Cuypers C, Schäffler L, Proost K, Schauvliege S. Fatal cardiac arrest in a calf with uroperitoneum. VETERINARY RECORD CASE REPORTS 2019. [DOI: 10.1136/vetreccr-2018-000730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
| | - Charlotte Cuypers
- Department of Surgery and Anaesthesia of Domestic AnimalsUniversiteit Gent Faculteit DiergeneeskundeMerelbekeBelgium
| | - Lisa Schäffler
- Department of Large Animal Internal MedicineUniversiteit Gent Faculteit DiergeneeskundeMerelbekeBelgium
| | - Kirsten Proost
- Department of Surgery and AnaesthesiologyGhent UniversityMerelbekeBelgium
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Vijayakumar S, Butler J, Bakris GL. Barriers to guideline mandated renin-angiotensin inhibitor use: focus on hyperkalaemia. Eur Heart J Suppl 2019; 21:A20-A27. [PMID: 30837801 PMCID: PMC6392419 DOI: 10.1093/eurheartj/suy030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hyperkalaemia in patients with chronic disease states can be caused by both abnormalities of potassium homeostasis as well as extrinsic factors such as medication use and potassium intake. In patients with heart failure (HF), chronic kidney disease (CKD), diabetes mellitus (DM), and in those who use renin-angiotensin-aldosterone system inhibitors (RAASi), there is particularly increased risk of chronic or recurrent hyperkalaemia. Hyperkalaemia is often a reason for the suboptimal dosing or complete discontinuation of RAASi. This review presents current options for the management of hyperkalaemia in patients with chronic disease states. It also explores barriers to guideline-mediated RAASi prescribing patterns in these high-risk patients and highlights the unmet need for agents that adequately manage hyperkalaemia in patients with chronic diseases on concomitant RAASi therapy.
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Affiliation(s)
- Shilpa Vijayakumar
- Department of Medicine, Stony Brook University, 101 Nicolls Road, Stony Brook, NY, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi, 2500 North State Street, Jackson, MS, USA
| | - George L Bakris
- Department of Medicine, Comprehensive Hypertension Center, The University of Chicago Medicine, 5481 S. Maryland Avenue MC 1027, Chicago, IL, USA
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Rafique Z, Chouihed T, Mebazaa A, Frank Peacock W. Current treatment and unmet needs of hyperkalaemia in the emergency department. Eur Heart J Suppl 2019; 21:A12-A19. [PMID: 30837800 PMCID: PMC6392420 DOI: 10.1093/eurheartj/suy029] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hyperkalaemia is a common electrolyte abnormality and can cause life-threatening cardiac arrhythmia. Even though it is common in patients with diabetes, heart failure, and kidney disease, there is poor consensus over its definition and wide variability in its treatment. Medications used to treat hyperkalaemia in the emergent setting do not have robust efficacy and safety data to guide treatment leading to mismanagement due to poor choice of some agents or inappropriate dosing of others. Moreover, the medications used in the emergent setting are at best temporizing measures, with dialysis being the definitive treatment. New and old k binder therapies provide means to excrete potassium, but their roles are unclear in the emergent setting. Electrocardiograms are the corner stones of hyperkalaemia management; however, recent studies show that they might manifest abnormalities infrequently, even in severe hyperkalaemia, thus questioning their role. With an aging population and a rise in rates of heart and kidney failure, hyperkalaemia is on the rise, and there is a need, now more than ever, to understand the efficacy and safety of the current medications and to develop newer ones.
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Affiliation(s)
- Zubaid Rafique
- Baylor College of Medicine, Ben Taub General Hospital, Houston, TX, USA
| | - Tahar Chouihed
- Emergency Department, University Hospital of Nancy, France; Clinical Investigation Center-Unit 1433; INSERM U1116, University of Lorraine, Nancy, France
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care, APHP - Saint Louis Lariboisière University Hospitals, University Paris Diderot and INSERM UMR-S 942, Paris, France
| | - W Frank Peacock
- Baylor College of Medicine, Ben Taub General Hospital, Houston, TX, USA
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Association of Abnormal Serum Potassium Levels with Arrhythmias and Cardiovascular Mortality: a Systematic Review and Meta-Analysis of Observational Studies. Cardiovasc Drugs Ther 2019; 32:197-212. [PMID: 29679302 DOI: 10.1007/s10557-018-6783-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To provide the first systematic review and meta-analysis of observational studies on the association of abnormal serum potassium and cardiovascular outcomes. METHODS Medline and ISI Web of Knowledge were systematically searched from inception until November 24, 2017. Data synthesis of relevant studies was performed using random effects model meta-analyses. RESULTS Meta-analyses included 310,825 participants from 24 studies. In the older general population, low serum potassium was associated with a 1.6-fold increased risk of supraventricular arrhythmias (risk ratio [95% confidence interval] 1.62 [1.02-2.55]). Contrarily, high serum potassium was associated with increased cardiovascular mortality (CVM) (1.38 [1.14-1.66]). In patients with acute myocardial infarction, the risk of ventricular arrhythmias was increased for high serum potassium (2.33 [1.60-3.38]). A U-shaped association was observed with a composite cardiovascular outcome in hypertensive patients (2.6-fold increased risk with hypokalemia and 1.7-fold increased risk with hyperkalemia), with CVM in dialysis patients (1.1-fold increased risk with hypokalemia and 1.4-fold increased risk with hyperkalemia) and with CVM in heart failure patients (albeit not statistically significant). Further, only hyperkalemia was associated with an increased risk of a composite cardiovascular outcome in both dialysis (1.12 [1.03-1.23]) and chronic kidney disease (1.34 [1.06-1.71]) patients. CONCLUSIONS Controlled clinical trials are needed to determine which populations may profit from more frequent potassium-monitoring and subsequent interventions, e.g., change or withdrawal of potassium-influencing drugs, in order to restore normal values and prevent cardiovascular outcomes. REGISTRATION DETAILS Registration in PROSPERO (Centre for Reviews and Dissemination University of York, York, UK): CRD42016048897 ( https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=48897 ).
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Canlas JF, Ponmani C. Congenital adrenal hyperplasia with salt-wasting crisis and arrhythmia: a case study. BMJ Case Rep 2019; 12:12/1/e227565. [PMID: 30700462 PMCID: PMC6352754 DOI: 10.1136/bcr-2018-227565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We report a case of a 10-day-old male infant who presented to the emergency department with severe electrolyte imbalance and life-threatening arrhythmia. The parents reported a 3-day history of poor feeding and lethargy. On examination, he was bradycardic (heart rate of 65 beats/min) with signs of dehydration. His ECG showed broad complex bradycardia. Blood gas showed metabolic acidosis with hyponatraemia and hyperkalaemia. A probable diagnosis of congenital adrenal hyperplasia (CAH) with salt-wasting crisis was made and treatment was commenced. He was given saline bolus, nebulised salbutamol, calcium gluconate and hydrocortisone. Following the above interventions, his heart rate rose to 150 beats/min with a regular sinus rhythm within a period of 40 min. The diagnosis of CAH secondary to 21-hydroxylase deficiency with mutation in CYP21A2 was confirmed by genetic studies. He was discharged home with hydrocortisone, fludrocortisone and sodium chloride.
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Affiliation(s)
- Johnny Figueroa Canlas
- Department of Paediatrics, Barking Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - Caroline Ponmani
- Department of Paediatrics, Barking Havering and Redbridge University Hospitals NHS Trust, Romford, UK
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Evidence-based perioperative management of patients with high serum potassium level in resource-limited areas: A systematic review. INTERNATIONAL JOURNAL OF SURGERY OPEN 2019. [DOI: 10.1016/j.ijso.2019.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Thomsen RW, Nicolaisen SK, Adelborg K, Svensson E, Hasvold P, Palaka E, Pedersen L, Sørensen HT. Hyperkalaemia in people with diabetes: occurrence, risk factors and outcomes in a Danish population-based cohort study. Diabet Med 2018; 35:1051-1060. [PMID: 29790603 DOI: 10.1111/dme.13687] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2018] [Indexed: 01/28/2023]
Abstract
AIMS To examine the incidence, risk factors and clinical outcomes of hyperkalaemia in people with diabetes in a real-world setting. METHODS Using Danish health registries, we identified a population-based cohort of people with first-time drug-treated diabetes, in the period 2000-2012. First, the cumulative incidence of hyperkalaemia, defined as first blood test with potassium level >5.0 mmol/l after diabetes treatment initiation, was ascertained. Second, in a case-control analysis, risk factors were compared in people with vs without hyperkalaemia. Third, clinical outcomes were assessed among individuals with hyperkalaemia in a before-after analysis, and among people with and without hyperkalaemia in a matched cohort analysis. RESULTS Of 68 601 individuals with diabetes (median age 62 years, 47% women), 16% experienced hyperkalaemia (incidence rate 40 per 1000 person-years) during a mean follow-up of 4.1 years. People who developed hyperkalaemia had a higher prevalence of chronic kidney disease [prevalence ratio 1.74 (95% CI 1.68-1.81)], heart failure [prevalence ratio 2.35 (95% CI 2.18-2.54)], use of angiotensin-converting enzyme inhibitors [prevalence ratio 1.24 (95% CI 1.20-1.28)], use of spironolactone [prevalence ratio 2.68 (95% CI 2.48-2.88)] and potassium supplements [prevalence ratio 1.59 (95% CI 1.52-1.67)]. In people with diabetes who developed hyperkalaemia, 31% were acutely hospitalized within 6 months before hyperkalaemia, increasing to 50% 6 months after hyperkalaemia [before-after risk ratio 1.67 (95% CI 1.61-1.72)]. The 6-month mortality rate after hyperkalaemia was 20%. Compared with matched individuals without hyperkalaemia, the hazard ratio for death was 6.47 (95% CI 5.81-7.21). CONCLUSIONS One in six newly diagnosed people with diabetes experienced a hyperkalaemic event, which was associated with severe clinical outcomes and death.
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Affiliation(s)
- R W Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - S K Nicolaisen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - K Adelborg
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - E Svensson
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - P Hasvold
- AstraZeneca Nordic, Medical Department, Etterstad, Oslo, Norway
| | - E Palaka
- AstraZeneca, Global Payer Evidence, Cambridge, UK
| | - L Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - H T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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