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Sun Z, Jiao J, Lu G, Liu R, Li Z, Sun Y, Chen Z. Overview of research progress on the association of dietary potassium intake with serum potassium and survival in hemodialysis patients, does dietary potassium restriction really benefit hemodialysis patients? Front Endocrinol (Lausanne) 2023; 14:1285929. [PMID: 38093955 PMCID: PMC10716210 DOI: 10.3389/fendo.2023.1285929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/13/2023] [Indexed: 12/18/2023] Open
Abstract
For the general population, increasing potassium intake can reduce the incidence of cardiovascular and cerebrovascular diseases. However, since hyperkalemia is a common and life-threatening complication in maintenance hemodialysis patients, which can increase the risk of malignant arrhythmia and sudden death, the current mainstream of management for hemodialysis patients is dietary potassium restriction in order to prevent hyperkalemia. Hemodialysis patients are usually advised to reduce dietary potassium intake and limit potassium-rich fruits and vegetables, but there is limited evidence to support this approach can reduce mortality and improve quality of life. There is still no consistent conclusion on the association between dietary potassium intake and serum potassium and survival in hemodialysis patients. According to the current small observational studies, there was little or even no association between dietary potassium intake and serum potassium in hemodialysis patients when assurance of adequate dialysis and specific dietary patterns (such as the plant-based diet mentioned in the article) are being followed, and excessive dietary potassium restriction may not benefit the survival of hemodialysis patients. Additionally, when assessing the effect of diet on serum potassium, researchers should not only focus on the potassium content of foods, but also consider the type of food and the content of other nutrients. However, more large-scale, multi-center clinical trials are required to provide high-quality evidence support. Besides, further research is also needed to determine the optimal daily potassium intake and beneficial dietary patterns for hemodialysis patients.
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Affiliation(s)
- Zuoya Sun
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Jian Jiao
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong First Medical University, Jinan, Shandong, China
| | - Gang Lu
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Ruihong Liu
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Zhuo Li
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yi Sun
- Department of Nephrology, Beijing Huairou Hospital of University of Chinese Academy of Sciences, Beijing, China
| | - Zhiyuan Chen
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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Davenport A. Why is Intradialytic Hypotension the Commonest Complication of Outpatient Dialysis Treatments? Kidney Int Rep 2023; 8:405-418. [PMID: 36938081 PMCID: PMC10014354 DOI: 10.1016/j.ekir.2022.10.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/30/2022] [Accepted: 10/31/2022] [Indexed: 11/11/2022] Open
Abstract
Intradialytic hypotension (IDH) is the most frequent complication of hemodialysis (HD) treatments with a frequency of 10% to 12% for patients with chronic kidney disease attending for outpatient treatments and is associated with both temporary ischemic stress to vital organs, including the heart and brain, and increased patient mortality. Although there have been many different definitions of IDH over the years, an absolute nadir systolic blood pressure (SBP) has the strongest association with patient outcomes. The unifying pathophysiology is one of reduced effective blood volume, resulting in lower plasma tonicity, and if this cannot be adequately compensated for by activation of neurohumeral systems, then arteriolar tone and blood pressure fall. The risk factors for developing IDH are numerous, ranging from patient-related factors, including age and comorbidity with reduced cardiac reserve, to patient compliance with dietary and lifestyle advice, to reactions with the extracorporeal circuit and medications, choice of dialysate composition and temperature, setting of postdialysis target weight, ultrafiltration rate, and profiling. Advances in dialysis machine technology by providing real time estimates of the effective circulating volume and adjusting dialysate composition to maintain vascular tonicity are being developed, but currently require more sophisticated biofeedback loops to be clinically effective in preventing IDH. While awaiting advances in artificial intelligence, the clinician continues to rely on patient education to limit interdialytic weight gains, frequent assessment of the postdialysis target weight, adjusting dialysate composition and temperature, introducing convective therapies to increase thermal losses, and altering dialysis session duration and frequency to reduce ultrafiltration rate requirements.
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Affiliation(s)
- Andrew Davenport
- Department of Renal Medicine, Royal Free Hospital, Faculty of Medical Sciences, University College London, London, UK
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3
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Genovesi S, Regolisti G, Burlacu A, Covic A, Combe C, Mitra S, Basile C. The conundrum of the complex relationship between acute kidney injury and cardiac arrhythmias. Nephrol Dial Transplant 2022; 38:1097-1112. [PMID: 35777072 DOI: 10.1093/ndt/gfac210] [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: 04/06/2022] [Indexed: 11/13/2022] Open
Abstract
Acute kidney injury (AKI) is defined by a rapid increase in serum creatinine levels, reduced urine output, or both. Death may occur in 16%-49% of patients admitted to an intensive care unit with severe AKI. Complex arrhythmias are a potentially serious complication in AKI patients with pre-existing or AKI-induced heart damage and myocardial dysfunction, fluid overload, and especially electrolyte and acid-base disorders representing the pathogenetic mechanisms of arrhythmogenesis. Cardiac arrhythmias, in turn, increase the risk of poor renal outcomes, including AKI. Arrhythmic risk in AKI patients receiving kidney replacement treatment may be reduced by modifying dialysis/replacement fluid composition. The most common arrhythmia observed in AKI patients is atrial fibrillation. Severe hyperkalemia, sometimes combined with hypocalcemia, causes severe bradyarrhythmias in this clinical setting. Although the likelihood of life-threatening ventricular arrhythmias is reportedly low, the combination of cardiac ischemia and specific electrolyte or acid-base abnormalities may increase this risk, particularly in AKI patients who require kidney replacement treatment. The purpose of this review is to summarize the available epidemiological, pathophysiological, and prognostic evidence aiming to clarify the complex relationships between AKI and cardiac arrhythmias.
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Affiliation(s)
- Simonetta Genovesi
- School of Medicine and Surgery, University of Milano - Bicocca, Nephrology Clinic, Monza, Italy.,Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Giuseppe Regolisti
- Clinica e Immunologia Medica -Azienda Ospedaliero-Universitaria e Università degli Studi di Parma, Parma, Italy
| | - Alexandru Burlacu
- Department of Interventional Cardiology - Cardiovascular Diseases Institute, and 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Adrian Covic
- Nephrology Clinic, Dialysis, and Renal Transplant Center - 'C.I. Parhon' University Hospital, and 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Christian Combe
- Service de Néphrologie Transplantation Dialyse Aphérèse, Centre Hospitalier Universitaire de Bordeaux, and Unité INSERM 1026, Université de Bordeaux, Bordeaux, France
| | - Sandip Mitra
- Department of Nephrology, Manchester Academy of Health Sciences Centre, Manchester University Hospitals Foundation Trust, Oxford Road, Manchester, UK
| | - Carlo Basile
- Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
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Chronic Hyperkaliemia in Chronic Kidney Disease: An Old Concern with New Answers. Int J Mol Sci 2022; 23:ijms23126378. [PMID: 35742822 PMCID: PMC9223624 DOI: 10.3390/ijms23126378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/05/2022] [Accepted: 06/06/2022] [Indexed: 12/04/2022] Open
Abstract
Increasing potassium intake ameliorates blood pressure (BP) and cardiovascular (CV) prognoses in the general population; therefore the World Health Organization recommends a high-potassium diet (90–120 mEq/day). Hyperkalaemia is a rare condition in healthy individuals due to the ability of the kidneys to effectively excrete dietary potassium load in urine, while an increase in serum K+ is prevalent in patients with chronic kidney disease (CKD). Hyperkalaemia prevalence increases in more advanced CKD stages, and is associated with a poor prognosis. This scenario generates controversy on the correct nutritional approach to hyperkalaemia in CKD patients, considering the unproven link between potassium intake and serum K+ levels. Another concern is that drug-induced hyperkalaemia leads to the down-titration or withdrawal of renin-angiotensin system inhibitors (RASI) and mineralocorticoids receptors antagonists (MRA) in patients with CKD, depriving these patients of central therapeutic interventions aimed at delaying CKD progression and decreasing CV mortality. The new K+-binder drugs (Patiromer and Sodium-Zirconium Cyclosilicate) have proven to be adequate and safe therapeutic options to control serum K+ in CKD patients, enabling RASI and MRA therapy, and possibly, a more liberal intake of fruit and vegetables.
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Uchida T, Ookawara S, Ito K, Okada H, Hayasaka H, Kofuji M, Kimura M, Ueda Y, Hasebe T, Momose N, Morishita Y. Lethal ventricular arrhythmia can be prevented by adjusting the dialysate potassium concentration and the use of anti-arrhythmic agents: a case report and literature review. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-022-00410-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hypokalemia is common in patients with malnutrition undergoing hemodialysis and is often involved in the development of lethal arrhythmia. Moreover, hemodialysis therapy decreases the serum potassium concentration due to potassium removal to the dialysate. However, it is difficult to adjust the dialysate potassium concentration owing to the use of the central dialysate delivery system in Japan. Here, we have presented a case undergoing hemodialysis with dialysate potassium concentration adjustment to prevent ventricular arrhythmia.
Case presentation
A 56-year-old man with Emery-Dreifuss muscular dystrophy and chronic heart failure was admitted to our hospital and needed subsequent hemodialysis therapy due to renal dysfunction. During hemodialysis, the cardiac resynchronization therapy defibrillator was activated to the treatment of his lethal ventricular arrhythmia. Decreases in serum potassium concentration after hemodialysis and changes in serum potassium concentration during HD were considered the causes of lethal ventricular arrythmia. Therefore, along with using anti-arrhythmic agents, the dialysate potassium concentration was increased from 2.0 to 3.5 mEq/L to minimize changes in the serum potassium concentration during hemodialysis. Post-dialysis hypokalemia disappeared and these changes during hemodialysis were minimized, and no lethal ventricular arrhythmia occurred thereafter.
Conclusions
In this case, we prevented lethal arrhythmia by maintaining the serum potassium concentration by increasing the dialysate potassium concentration, in addition to the use of anti-arrhythmic agents. In the acute phase of patients with frequent lethal arrhythmia undergoing hemodialysis, an increase in dialysate potassium concentration may be an effective method for preventing arrhythmogenic complications.
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Tsiagka D, Georgianos PI, Pikilidou MI, Vaios V, Roumeliotis S, Syrganis C, Mavromatidis K, Metallidis S, Liakopoulos V, Zebekakis PE. Prevalence, recurrence and seasonal variation of hyperkalemia among patients on hemodialysis. Int Urol Nephrol 2022; 54:2327-2334. [PMID: 35133576 DOI: 10.1007/s11255-022-03142-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 01/30/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE Observational studies have shown that among patients on hemodialysis, hyperkalemia is strongly associated with excess risk for cardiovascular-related hospitalizations and sudden cardiac death. However, the actual burden of hyperkalemia, the rates of its recurrence and seasonality in its variation still remain unclear. METHODS Between June 2020 and May 2021, 1786 mid-week pre-dialysis serum potassium (sK) measurements were retrospectively recorded from 149 patients receiving thrice-weekly hemodialysis in a single-center in Thessaloniki, Greece. The prevalence, recurrence and seasonal variation of hyperkalemia were assessed using three pre-specified sK thresholds (≥ 5.1, ≥ 5.5 and ≥ 6.0 mmol/L). RESULTS At baseline, 60.4%, 42.2% and 13.4% of patients had sK levels ≥ 5.1, ≥ 5.5 and ≥ 6.0 mmol/L, respectively. At any time-point during follow-up, 85.2%, 69.8% and 38.9% of patients experienced at least one hyperkalemic event ≥ 5.1, ≥ 5.5 and ≥ 6.0 mmol/L, respectively. Of the 104 patients experiencing an initial sK elevation ≥ 5.5 mmol/L, hyperkalemia at the same threshold reoccurred in 60.6% at month 1, in 47.1% at month 2 and in 46.1% at month 3 of follow-up. Seasonal variation was also observed, with the prevalence of hyperkalemia to be significantly higher in summer. Shorter delivered hemodialysis < 4 h/session (OR: 2.568; 95% CI 1.045-6.313) and the use of a high dialysate K concentration (OR: 14.646; 95% CI 2.727-78.647) were the 2 factors that were independently associated with hyperkalemia. CONCLUSION The present study shows that among hemodialysis patients, the rates of hyperkalemia prevalence and recurrence are very high, reflecting the large unmet need to identify more effective potassium-lowering therapeutic interventions in this high-risk population.
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Affiliation(s)
- Dimitra Tsiagka
- Section of Nephrology and Hypertension, 1St Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, St. Kyriakidi 1, 54636, Thessaloniki, Greece
| | - Panagiotis I Georgianos
- Section of Nephrology and Hypertension, 1St Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, St. Kyriakidi 1, 54636, Thessaloniki, Greece. .,Therapeutiki Dialysis Center, Thessaloniki, Greece.
| | - Maria I Pikilidou
- Section of Nephrology and Hypertension, 1St Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, St. Kyriakidi 1, 54636, Thessaloniki, Greece
| | - Vasilios Vaios
- Section of Nephrology and Hypertension, 1St Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, St. Kyriakidi 1, 54636, Thessaloniki, Greece
| | - Stefanos Roumeliotis
- Section of Nephrology and Hypertension, 1St Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, St. Kyriakidi 1, 54636, Thessaloniki, Greece
| | | | | | - Simeon Metallidis
- Section of Nephrology and Hypertension, 1St Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, St. Kyriakidi 1, 54636, Thessaloniki, Greece
| | - Vassilios Liakopoulos
- Section of Nephrology and Hypertension, 1St Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, St. Kyriakidi 1, 54636, Thessaloniki, Greece
| | - Pantelis E Zebekakis
- Section of Nephrology and Hypertension, 1St Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, St. Kyriakidi 1, 54636, Thessaloniki, Greece
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Pietribiasi M, Waniewski J, Załuska W, Wójcik-Załuska A, Leypoldt JK. Comparison of two single-solute models of potassium kinetics during hemodialysis. Biocybern Biomed Eng 2020. [DOI: 10.1016/j.bbe.2020.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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8
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Delanaye P, Krzesinski F, Dubois BE, Delcour A, Robinet S, Piette C, Krzesinski JM, Lancellotti P. A simple modification of dialysate potassium: its impact on plasma potassium concentrations and the electrocardiogram. Clin Kidney J 2019; 14:390-397. [PMID: 33564443 PMCID: PMC7857800 DOI: 10.1093/ckj/sfz157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/02/2019] [Indexed: 11/14/2022] Open
Abstract
Background Sudden death is frequent in haemodialysis (HD) patients. Both hyperkalaemia and change of plasma potassium (K) concentrations induced by HD could explain this. The impact of increasing dialysate K by 1 mEq/L on plasma K concentrations and electrocardiogram (ECG) results before and after HD sessions was studied. Methods Patients with pre-dialysis K >5.5 mEq/L were excluded. ECG and K measurements were obtained before and after the first session of the week for 2 weeks. Then, K in the dialysate was increased (from 1 or 3 to 2 or 4 mEq/L, respectively). Blood and ECG measurements were repeated after 2 weeks of this change. Results Twenty-seven prevalent HD patients were included. As expected, a significant decrease in K concentrations was observed after the dialysis session, but this decrease was significantly lower after the switch to an increased dialysate K. The pre-dialysis K concentrations were not different after changing, but post-dialysis K concentrations were higher after switching (P < 0.0001), with a lower incidence of post-dialysis hypokalaemia. Regarding ECG, before switching, the QT interval (QT) dispersion increased during the session, whereas no difference was observed after switching. One week after switching, post-dialysis QT dispersion [38 (34-42) ms] was lower than post-dialysis QT dispersion 2 weeks and 1 week before switching [42 (38-57) ms, P = 0.0004; and 40 (35-50) ms, P = 0.0002]. Conclusions A simple increase of 1 mEq/L of K in the dialysate is associated with a lower risk of hypokalaemia and a lower QT dispersion after the dialysis session. Further study is needed to determine if such a strategy is associated with a lower risk of sudden death.
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Affiliation(s)
- Pierre Delanaye
- Department of Nephrology, Dialysis, Transplantation, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium.,GIGA Cardiovascular Sciences, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - François Krzesinski
- Department of Cardiology, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Bernard E Dubois
- Department of Nephrology, Dialysis, Transplantation, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Alexandre Delcour
- Department of Cardiology, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Sébastien Robinet
- Department of Cardiology, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Caroline Piette
- Department of Cardiology, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Jean-Marie Krzesinski
- Department of Nephrology, Dialysis, Transplantation, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium.,GIGA Cardiovascular Sciences, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Patrizio Lancellotti
- GIGA Cardiovascular Sciences, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium.,Department of Cardiology, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
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9
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Sumida K, Kovesdy CP. Introduction to treatment considerations in conventional hemodialysis - What we know. Semin Dial 2018; 31:535-536. [PMID: 30394604 DOI: 10.1111/sdi.12747] [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]
Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee.,Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee
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