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Hussain J, Imsirovic H, Canney M, Clark EG, Elliott MJ, Ravani P, Tanuseputro P, Akbari A, Hundemer GL, Ramsay T, Tangri N, Knoll GA, Sood MM. Impaired Renal Function and Major Cardiovascular Events in Young Adults. J Am Coll Cardiol 2023; 82:1316-1327. [PMID: 37730288 DOI: 10.1016/j.jacc.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Cardiovascular (CV) disease in young adults (aged 18-39 years) is on the rise. Whether subclinical reductions in kidney function (ie, estimated glomerular filtration rate [eGFR] above the current threshold for chronic kidney disease but below age-expected values) are associated with elevated CV risk is unknown. OBJECTIVES The goal of this study was to examine age-specific associations of subclinical eGFR reductions in young adults with major adverse cardiovascular events (MACEs) and MACE plus heart failure (MACE+). METHODS A retrospective cohort study of 8.7 million individuals (3.6 million aged 18-39 years) was constructed using linked provincial health care data sets from Ontario, Canada (January 2008-March 2021). Cox models were used to examine the association of categorized eGFR (50-120 mL/min/1.73 m2) with MACE (first of CV mortality, acute coronary syndrome, and ischemic stroke) and MACE+, stratified according to age (18-39, 40-49, and 50-65 years). RESULTS In the study cohort (mean age 41.3 years; mean eGFR 104.2 mL/min/1.73 m2; median follow-up 9.2 years), a stepwise increase in the relative risk of MACE and MACE+ was observed as early as eGFR <80 mL/min/1.73 m2 in young adults (eg, for MACE, at eGFR 70-79 mL/min/1.73 m2, ages 18-30 years: 2.37 events per 1,000 person years [HR: 1.31; 95% CI: 1.27-1.40]; ages 40-49 years: 6.26 events per 1,000 person years [HR: 1.09; 95% CI: 1.06-1.12]; ages 50-65 years: 14.9 events per 1,000 person years [HR: 1.07; 95% CI: 1.05-1.08]). Results persisted for each MACE component and in additional analyses (stratifying according to past CV disease, accounting for albuminuria at index, and using repeated eGFR measures). CONCLUSIONS In young adults, eGFR below age-expected values were associated with an elevated risk for MACE and MACE+, warranting age-appropriate risk stratification, proactive monitoring, and timely intervention.
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Affiliation(s)
- Junayd Hussain
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; ICES, Ottawa, Ontario, Canada
| | | | - Mark Canney
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Meghan J Elliott
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Division of Nephrology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Pietro Ravani
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Division of Nephrology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Peter Tanuseputro
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; ICES, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Ayub Akbari
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Gregory L Hundemer
- ICES, Ottawa, Ontario, Canada; Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Tim Ramsay
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Navdeep Tangri
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Greg A Knoll
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Manish M Sood
- ICES, Ottawa, Ontario, Canada; Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada.
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Hussain J, Grubic N, Akbari A, Canney M, Elliott MJ, Ravani P, Tanuseputro P, Clark EG, Hundemer GL, Ramsay T, Tangri N, Knoll GA, Sood MM. Associations between modest reductions in kidney function and adverse outcomes in young adults: retrospective, population based cohort study. BMJ 2023; 381:e075062. [PMID: 37353230 PMCID: PMC10286512 DOI: 10.1136/bmj-2023-075062] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE To study age specific associations of modest reductions in estimated glomerular filtration rate (eGFR) with adverse outcomes. DESIGN Retrospective, population based cohort study. SETTING Linked healthcare administrative datasets in Ontario, Canada. PARTICIPANTS Adult residents (18-65 years) with at least one outpatient eGFR value (categorized in 10 unit increments from 50 mL/min/1.73m2 to >120 mL/min/1.73m2), with no history of kidney disease. MAIN OUTCOME MEASURES eGFRs and hazard ratios of composite adverse outcome (all cause mortality, any cardiovascular event, and kidney failure) stratified by age (18-39 years, 40-49 years, and 50-65 years), and relative to age specific eGFR referents (100-110 mL/min/1.73m2) for ages 18-39 years, 90-100 for 40-49 years, 80-90 for 50-65 years). RESULTS From 1 January 2008 to 31 March 2021, among 8 703 871 adults (mean age 41.3 (standard deviation 13.6) years; mean index eGFR 104.2 mL/min/1.73m2 (standard deviation 16.1); median follow-up 9.2 years (interquartile range 5.7-11.4)), modestly reduced eGFR measurements specific to age were recorded in 18.0% of those aged 18-39, 18.8% in those aged 40-49, and 17.0% in those aged 50-65. In comparison with age specific referents, adverse outcomes were consistently higher by hazard ratio and incidence for ages 18-39 compared with older groups across all eGFR categories. For modest reductions (eGFR 70-80 mL/min/1.73m2), the hazard ratio for ages 18-39 years was 1.42 (95% confidence interval 1.35 to 1.49), 4.39 per 1000 person years; for ages 40-49 years was 1.13 (1.10 to 1.16), 9.61 per 1000 person years; and for ages 50-65 years was 1.08 (1.07 to 1.09), 23.4 per 1000 person years. Results persisted for each individual outcome and in many sensitivity analyses. CONCLUSIONS Modest eGFR reductions were consistently associated with higher rates of adverse outcomes. Higher relative hazards were most prominent and occurred as early as eGFR <80 mL/min/1.73m2 in younger adults, compared with older groups. These findings suggest a role for more frequent monitoring of kidney function in younger adults to identify individuals at risk to prevent chronic kidney disease and its complications.
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Affiliation(s)
- Junayd Hussain
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Institute of Clinical Evaluative Sciences, Ottawa, ON, Canada
| | - Nicholas Grubic
- Institute of Clinical Evaluative Sciences, Ottawa, ON, Canada
| | - Ayub Akbari
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Mark Canney
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, K1Y 4E9, Canada
| | - Meghan J Elliott
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Pietro Ravani
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Peter Tanuseputro
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Institute of Clinical Evaluative Sciences, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, K1Y 4E9, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, K1Y 4E9, Canada
| | - Gregory L Hundemer
- Institute of Clinical Evaluative Sciences, Ottawa, ON, Canada
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, K1Y 4E9, Canada
| | - Tim Ramsay
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, K1Y 4E9, Canada
| | - Navdeep Tangri
- Division of Nephrology, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Greg A Knoll
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, K1Y 4E9, Canada
| | - Manish M Sood
- Institute of Clinical Evaluative Sciences, Ottawa, ON, Canada
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, K1Y 4E9, Canada
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Farfan Ruiz AC, Malick R, Rhodes E, Clark E, Hundemer G, Karaboyas A, Robinson B, Pecoits R, Sood MM. Adverse Gastrointestinal Events With Sodium Polystyrene Sulfonate Use in Patients on Maintenance Hemodialysis: An International Cohort Study. Can J Kidney Health Dis 2023; 10:20543581231172405. [PMID: 37359984 PMCID: PMC10288443 DOI: 10.1177/20543581231172405] [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] [Received: 11/29/2022] [Accepted: 03/19/2023] [Indexed: 06/28/2023] Open
Abstract
Background There are concerns regarding the gastrointestinal (GI) safety of sodium polystyrene sulfonate (SPS), a medication commonly used in the management of hyperkalemia. Objective To compare the risk of GI adverse events among users versus non-users of SPS in patients on maintenance hemodialysis. Design International prospective cohort study. Setting Seventeen countries (Dialysis Outcomes and Practice Patterns Study [DOPPS] phase 2-6 from 2002 to 2018). Patients 50 147 adults on maintenance hemodialysis. Measurements An adverse GI event defined by a GI hospitalization or GI fatality with SPS prescription compared with no SPS prescription. Methods Overlap propensity score-weighted Cox models. Results Sodium polystyrene sulfonate prescription was present in 13.4% of patients and ranged from 0.42% (Turkey) to 20.6% (Sweden) with 12.5% use in Canada. A total of 935 (1.9%) adverse GI events (140 [2.1%] with SPS, 795 [1.9%] with no SPS; absolute risk difference 0.2%) occurred. The weighted hazard ratio (HR) of a GI event was not elevated with SPS use compared with non-use (HR = 0.93, 95% confidence interval = 0.83-1.6). The results were consistent when examining fatal GI events and/or GI hospitalization separately. Limitations Sodium polystyrene sulfonate dose and duration were unknown. Conclusions Sodium polystyrene sulfonate use in patients on hemodialysis was not associated with a higher risk of an adverse GI event. Our findings suggest that SPS use is safe in an international cohort of maintenance hemodialysis patients.
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Affiliation(s)
- Ana Cecilia Farfan Ruiz
- Division of Nephrology, Department of Medicine, Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, ON, Canada
| | - Ranjeeta Malick
- Division of Nephrology, Department of Medicine, Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, ON, Canada
| | - Emily Rhodes
- Division of Nephrology, Department of Medicine, Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, ON, Canada
- Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada
| | - Edward Clark
- Division of Nephrology, Department of Medicine, Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, ON, Canada
| | - Greg Hundemer
- Division of Nephrology, Department of Medicine, Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, ON, Canada
| | | | | | | | - Manish M. Sood
- Division of Nephrology, Department of Medicine, Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, ON, Canada
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Larivée NL, Michaud JB, More KM, Wilson JA, Tennankore KK. Hyperkalemia: Prevalence, Predictors and Emerging Treatments. Cardiol Ther 2023; 12:35-63. [PMID: 36503972 PMCID: PMC9742042 DOI: 10.1007/s40119-022-00289-z] [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: 09/12/2022] [Accepted: 11/02/2022] [Indexed: 12/14/2022] Open
Abstract
It is well established that an elevated potassium level (hyperkalemia) is associated with a risk of adverse events including morbidity, mortality and healthcare system cost. Hyperkalemia is commonly encountered in many chronic conditions including kidney disease, diabetes and heart failure. Furthermore, hyperkalemia may result from the use of renin-angiotensin-aldosterone system inhibitors (RAASi), which are disease-modifying treatments for these conditions. Therefore, balancing the benefits of optimizing treatment with RAASi while mitigating hyperkalemia is crucial to ensure patients are optimally treated. In this review, we will briefly discuss the definition, causes, epidemiology and consequences of hyperkalemia. The majority of the review will be focused on management of hyperkalemia in the acute and chronic setting, emphasizing contemporary approaches and evolving data on the relevance of dietary restriction and the use of novel potassium binders.
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Affiliation(s)
- Natasha L Larivée
- Dalhousie University and Nova Scotia Health, 5820 University Avenue, Halifax, NS, B3H 1V8, Canada
- Dalhousie University and Horizon Health Network, Saint John, NB, Canada
| | - Jacob B Michaud
- Dalhousie University and Nova Scotia Health, 5820 University Avenue, Halifax, NS, B3H 1V8, Canada
- Dalhousie University and Horizon Health Network, Saint John, NB, Canada
| | - Keigan M More
- Dalhousie University and Nova Scotia Health, 5820 University Avenue, Halifax, NS, B3H 1V8, Canada
| | - Jo-Anne Wilson
- Dalhousie University and Nova Scotia Health, 5820 University Avenue, Halifax, NS, B3H 1V8, Canada
| | - Karthik K Tennankore
- Dalhousie University and Nova Scotia Health, 5820 University Avenue, Halifax, NS, B3H 1V8, Canada.
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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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Hundemer GL, Sood MM, Ramsay T, Akbari A. Urinary Potassium Excretion and Progression From Advanced CKD to Kidney Failure. Can J Kidney Health Dis 2022; 9:20543581221084501. [PMID: 35321236 PMCID: PMC8935582 DOI: 10.1177/20543581221084501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/23/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Increased dietary potassium intake has well-proven beneficial effects on cardiovascular health and mortality. However, the association between dietary potassium intake and chronic kidney disease (CKD) progression remains unclear with prior studies reporting conflicting results. Objective: To study the association between 24-hour urinary potassium excretion (a surrogate for dietary potassium intake) and progression to kidney failure. Design: Retrospective cohort study. Setting: Ottawa, Canada Patients: Patients with advanced CKD referred to the Ottawa Hospital Multi-Care Kidney Clinic from 2010 to 2020. Measurements: Twenty-four-hour urinary potassium excretion measured upon referral to the Ottawa Hospital Multi-Care Kidney Clinic as part of routine clinic protocol. Methods: Multivariable Cox and Fine and Gray models provided hazard ratios (HRs) and 95% confidence intervals (CIs) to estimate the association between quartiles of 24-hour urinary potassium excretion and progression to kidney failure. A restricted cubic spline analysis examined the possible nonlinear relationship between 24-hour urinary potassium excretion (as a continuous variable) and progression to kidney failure. Results: Overall, 432/695 (62%) patients progressed to kidney failure. Across all models, there was no significant difference in kidney failure risk by quartile of 24-hour urinary potassium excretion (all P values for trend ≥.05). Hazard ratios (95% CIs) from the multivariable-adjusted Cox model were as follows: quartile 1, referent; quartile 2, 0.95 (0.71-1.27); quartile 3, 1.00 (0.76-1.33); and quartile 4 0.85 (0.63-1.14); P value for trend = .36. Restricted cubic spline analysis showed an overall linear and nonsignificant relationship between 24-hour urinary potassium excretion as a continuous variable and progression to kidney failure. Limitations: Observational design, single center. Conclusions: We found no association between 24-hour urinary potassium excretion and progression to kidney failure in patients with advanced CKD. Therefore, we identified no clear evidence that increasing or decreasing dietary potassium intake significantly associates with CKD progression in this population. Trial Registration: Not registered.
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Affiliation(s)
- Gregory L. Hundemer
- Division of Nephrology, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Manish M. Sood
- Division of Nephrology, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Tim Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Ayub Akbari
- Division of Nephrology, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
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Janse RJ, Fu EL, Clase CM, Tomlinson L, Lindholm B, van Diepen M, Dekker FW, Carrero JJ. Stopping Versus Continuing Renin-Angiotensin System Inhibitors After Acute Kidney Injury and Adverse Clinical Outcomes; An Observational Study From Routine Care Data. Clin Kidney J 2022; 15:1109-1119. [PMID: 35664269 PMCID: PMC9155253 DOI: 10.1093/ckj/sfac003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Indexed: 11/18/2022] Open
Abstract
Background The risk–benefit ratio of continuing with renin–angiotensin system inhibitors (RASi)
after an episode of acute kidney injury (AKI) is unclear. While stopping RASi may
prevent recurrent AKI or hyperkalaemia, it may deprive patients of the cardiovascular
benefits of using RASi. Methods We analysed outcomes of long-term RASi users experiencing AKI (stage 2 or 3, or
clinically coded) during hospitalization in Stockholm and Sweden during 2007–18. We
compared stopping RASi within 3 months after discharge with continuing RASi. The primary
study outcome was the composite of all-cause mortality, myocardial infarction (MI) and
stroke. Recurrent AKI was our secondary outcome and we considered hyperkalaemia as a
positive control outcome. Propensity score overlap weighted Cox models were used to
estimate hazard ratios (HRs), balancing 75 confounders. Weighted absolute risk
differences (ARDs) were also determined. Results We included 10 165 individuals, of whom 4429 stopped and 5736 continued RASi, with a
median follow-up of 2.3 years. The median age was 78 years; 45% were women and median
kidney function before the index episode of AKI was 55 mL/min/1.73 m2. After
weighting, those who stopped had an increased risk [HR, 95% confidence interval (CI)] of
the composite of death, MI and stroke [1.13, 1.07–1.19; ARD 3.7, 95% CI 2.6–4.8]
compared with those who continued, a similar risk of recurrent AKI (0.94, 0.84–1.05) and
a decreased risk of hyperkalaemia (0.79, 0.71–0.88). Discussion Stopping RASi use among survivors of moderate-to-severe AKI was associated with a
similar risk of recurrent AKI, but higher risk of the composite of death, MI and
stroke.
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Affiliation(s)
- Roemer J Janse
- Department of Clinical Epidemiology, Leiden University Medical Center, The Netherlands
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden
| | - Edouard L Fu
- Department of Clinical Epidemiology, Leiden University Medical Center, The Netherlands
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Ontario, Canada
| | - Laurie Tomlinson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Bengt Lindholm
- Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, The Netherlands
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden
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Hundemer GL, Sood MM. Hyperkalemia with RAAS inhibition: Mechanism, clinical significance, and management. Pharmacol Res 2021; 172:105835. [PMID: 34438065 DOI: 10.1016/j.phrs.2021.105835] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/09/2021] [Accepted: 08/16/2021] [Indexed: 12/30/2022]
Abstract
Renin-angiotensin-aldosterone system (RAAS) inhibitors are evidence-based treatments for a number of conditions including hypertension, diabetes mellitus, chronic kidney disease, and congestive heart failure. Among the most common adverse effects of RAAS inhibitors is hyperkalemia which results from either reduced secretion of aldosterone or increased resistance to aldosterone. Many of the conditions for which RAAS inhibitors are recommended further amplify the risk for hyperkalemia in and of themselves. RAAS inhibitor-related hyperkalemia is associated with an increased risk for cardiovascular events, hospitalizations, and death. Yet discontinuation of RAAS inhibitors for patients with chronic kidney disease and congestive heart failure is also associated with an increased risk for cardiovascular events, hospitalizations, and death. Therefore, clinicians are often left to struggle with the dilemma of the best management approach to RAAS inhibitor-related hyperkalemia. The ideal solution involves pharmacotherapies that are safe and effective in mitigating hyperkalemia and allow patients to continue to receive the beneficial effects from RAAS inhibitors. In this regard, modern pharmacologic agents such as patiromer and zirconium cyclosilicate are providing a mechanism whereby physicians are better equipped to maintain their patients on RAAS inhibitors.
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Affiliation(s)
- Gregory L Hundemer
- Department of Medicine (Division of Nephrology) and The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
| | - Manish M Sood
- Department of Medicine (Division of Nephrology) and The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Institute for Clinical Evaluative Sciences, Ottawa, Canada
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Trevisan M, Fu EL, Xu Y, Savarese G, Dekker FW, Lund LH, Clase CM, Sjölander A, Carrero JJ. Stopping mineralocorticoid receptor antagonists after hyperkalaemia: trial emulation in data from routine care. Eur J Heart Fail 2021; 23:1698-1707. [PMID: 34196082 DOI: 10.1002/ejhf.2287] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/16/2021] [Accepted: 06/28/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS Whether to continue or stop mineralocorticoid receptor antagonists (MRA) after an episode of hyperkalaemia is a challenge in clinical practice. While stopping MRA may prevent recurrent hyperkalaemias, it deprives patients of their cardioprotection. We here assessed the association between stopping vs. continuing MRA therapy after hyperkalaemia and the subsequent risks of adverse health events. METHODS AND RESULTS Observational study from the Stockholm CREAtinine Measurements (SCREAM) project 2006-2018. We identified patients initiating MRA and surviving a first-detected episode of hyperkalaemia (plasma potassium >5.0 mmol/L). Using target trial emulation methods, we assessed the association between stopping vs. continuing MRA within 6 months after hyperkalaemia and subsequent outcomes. The primary outcome was the composite of hospital admission with heart failure, stroke, myocardial infarction, or death. The secondary outcome was occurrence of another hyperkalaemia event. Among 39 518 patients initiating MRA, we identified 7366 who developed hyperkalaemia. Median age was 76 years, 45% were women and 69% had a history of heart failure. Following hyperkalaemia, 2222 (30%) discontinued treatment. Compared with continuing MRA, stopping therapy was associated with a lower 2-year risk of recurrent hyperkalaemia [hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.72-0.79], but a higher risk of the primary outcome (HR 1.10, 95% CI 1.06-1.14). Similar results were observed in patients with heart failure, after censoring when treatment decision was changed, and across pre-specified subgroups. CONCLUSIONS Stopping MRA after an episode of hyperkalaemia was associated with reduced risk for recurrent hyperkalaemia, but higher risk of death or cardiovascular events. Recurrent hyperkalaemia was common in either strategy.
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Affiliation(s)
- Marco Trevisan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Edouard L Fu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Yang Xu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Catherine M Clase
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Department of Medicine, St Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Arvid Sjölander
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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