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Alzahrani MA, AlAbdan NA, Alahmari ZS, Alshehri NM, Alotaibi LH, Almohammed OA. Hyperkalemia Management with Intravenous Insulin in Patients with Reduced Kidney Function. J Clin Med 2024; 13:5103. [PMID: 39274318 PMCID: PMC11396335 DOI: 10.3390/jcm13175103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Revised: 08/23/2024] [Accepted: 08/26/2024] [Indexed: 09/16/2024] Open
Abstract
Background: Insufficient kidney function increases the risk of hyperkalemia and hypoglycemia, particularly in hemodialysis-dependent patients. Hypoglycemia is a common complication of insulin-based hyperkalemia treatment. This study aims to evaluate the efficacy and safety of hyperkalemia treatment in hemodialysis-dependent and -non-dependent patients and identify risk factors associated with hypoglycemia. Methods: A retrospective observational cohort study was conducted to assess the efficacy and safety of hyperkalemia treatment including patients with reduced kidney function and hyperkalemia treated with intravenous insulin. The decline rate of potassium and glucose levels were compared between hemodialysis-dependent and non-dependent patients. In addition, univariate and multivariable logistic regression analyses were performed to identify risk factors associated with hypoglycemia. Results: A total of 172 patients with hyperkalemia and reduced kidney function were included. The steepest reduction of serum potassium levels happened within the first 6 h after insulin administration, at 1.1 and 0.9 mmol/L for hemodialysis-dependent and non-dependent patients, respectively. The incidence of hypoglycemia was 18%, and no significant difference was found between cohorts. Hemodialysis-dependent patients were more likely to be readmitted within one month with hyperkalemia, while all-cause ICU admission was more likely for non-dependent patients. Older patients, and those who had heart failure or received a second dose of insulin to treat hyperkalemia, were more likely to experience hypoglycemia. Conclusions: Monitoring blood glucose levels following insulin administration is essential given the complexity of patients' factors associated with hypoglycemia resulting from hyperkalemia treatment in patients with insufficient kidney function.
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Affiliation(s)
- Maram A Alzahrani
- Pharmaceutical Care Department, King Faisal Specialist Hospital and Research Centre, Riyadh 12713, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City-Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh 11481, Saudi Arabia
| | - Numan A AlAbdan
- Pharmaceutical Care Department, King Abdulaziz Medical City-Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh 11481, Saudi Arabia
| | - Zainab S Alahmari
- Pharmaceutical Care Department, King Abdulaziz Medical City-Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh 11481, Saudi Arabia
| | - Nouf M Alshehri
- Pharmaceutical Care Department, King Abdulaziz Medical City-Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh 11481, Saudi Arabia
| | - Lama H Alotaibi
- Pharmaceutical Care Department, King Abdulaziz Medical City-Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh 11481, Saudi Arabia
| | - Omar A Almohammed
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
- Pharmacoeconomics Research Unit, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
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Abou Sherif S, Katsaiti I, Jebb H, Banh S, Bedi R, Levy J, Thomas D, Ashby D, Corbett R. Reducing the harm associated in treating hyperkalaemia with insulin and dextrose. Clin Med (Lond) 2024; 24:100222. [PMID: 38871123 PMCID: PMC11268096 DOI: 10.1016/j.clinme.2024.100222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
Inpatient treatment of hyperkalaemia with insulin and dextrose can be complicated by iatrogenic hypoglycaemia. We sought to assess the incidence of hypoglycaemia in hospitalised patients with renal disease and assess the impact of the introduction of a local guideline incorporating the use of sodium zirconium cyclosilicate (SZC) for patients with moderate hyperkalaemia. After establishing a significant burden of hypoglycaemia in the initial observation period, a requirement for hourly capillary blood glucose monitoring (for up to 6 h) following the administration of insulin for hyperkalaemia was incorporated into the guidelines. The two-fold introduction of SZC alongside changes in patient care after the administration of insulin/dextrose resulted in more appropriate use of insulin/dextrose, as well as a significant (73%) reduction in the iatrogenic burden of hypoglycaemia (P = 0.04).
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Affiliation(s)
- Sara Abou Sherif
- Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Chelsea and Westminster Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom.
| | - Irene Katsaiti
- Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Hannah Jebb
- Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Serena Banh
- Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Rachna Bedi
- Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Jeremy Levy
- Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - David Thomas
- Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge, United Kingdom
| | - Damien Ashby
- Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Richard Corbett
- Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
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Dybdahl D, Roberson T, Rasor E, Kline L, Pershing M. Impact of a Hyperkalemia Protocol Tailored to Glucose Concentration and Renal Function on Insulin-Induced Hypoglycemia in Patients with Low Pretreatment Glucose. J Emerg Med 2024; 66:e421-e431. [PMID: 38462394 DOI: 10.1016/j.jemermed.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 12/01/2023] [Accepted: 12/08/2023] [Indexed: 03/12/2024]
Abstract
BACKGROUND Hyperkalemia is a common electrolyte abnormality that requires urgent treatment. Insulin is an effective treatment for hyperkalemia, but risk factors for developing insulin-induced hypoglycemia exist (e.g., low pretreatment glucose or renal impairment). OBJECTIVE This study evaluated the impact of a hyperkalemia protocol tailored to glucose concentration and renal function on insulin-induced hypoglycemia. METHODS This was a retrospective cohort study of emergency department patients with glucose ≤ 100 mg/dL treated with insulin for hyperkalemia. The primary outcome was incidence of hypoglycemia in patients treated prior to (July 1, 2018-June 30, 2019) vs. after (January 1, 2020-December 31, 2020) the protocol update, which individualized insulin and dextrose doses by glucose concentration and renal function. Secondary outcomes included change in potassium and protocol safety. We assessed factors associated with hypoglycemia using multiple logistic regression. RESULTS We included 202 total patients (preimplementation: 114, postimplementation: 88). Initial insulin dose was lower in the postimplementation group (p < 0.001). We found a nonsignificant reduction in hypoglycemia in the postimplementation group (42.1% vs. 30.7%, p = 0.10). Degree of potassium reduction was similar in patients who received insulin 5 units vs. 10 units (p = 0.72). Higher pretreatment glucose (log odds ratio [OR] -0.05, 95% confidence interval [CI] -0.08 to -0.02) and additional insulin administration (log OR -1.55, 95% CI -3.01 to -0.25) were associated with reduced risk of developing hypoglycemia. CONCLUSION A hyperkalemia protocol update was not associated with a significant reduction in hypoglycemia, and the incidence of hypoglycemia remained higher than anticipated. Future studies attempting to optimize treatment in this high-risk population are warranted.
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Affiliation(s)
- Daniel Dybdahl
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, Ohio
| | - Taylor Roberson
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, Ohio
| | - Emily Rasor
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, Ohio
| | - Laura Kline
- Department of Pharmacy, OhioHealth Riverside Methodist Hospital, Columbus, Ohio
| | - Michelle Pershing
- Department of Research, OhioHealth Research Institute, Columbus, Ohio
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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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McCulloch MI, Adabayeri VM, Goka S, Khumalo TS, Lala N, Leahy S, Ngubane-Mwandla N, Nourse PJ, Nyann BI, Petersen KL, Levy CS. Perspectives: Neonatal acute kidney injury (AKI) in low and middle income countries (LMIC). Front Pediatr 2022; 10:870497. [PMID: 36120656 PMCID: PMC9471194 DOI: 10.3389/fped.2022.870497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 07/13/2022] [Indexed: 11/22/2022] Open
Abstract
Neonatal AKI (NAKI) remains a challenge in low- and middle-income countries (LMICs). In this perspective, we address issues of diagnosis and risk factors particular to less well-resourced regions. The conservative management pre-kidney replacement therapy (pre-KRT) is prioritized and challenges of KRT are described with improvised dialysis techniques also included. Special emphasis is placed on ethical and palliation principles.
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Affiliation(s)
- Mignon I McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | | | - Selasie Goka
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Tholang S Khumalo
- Nelson Mandela Children's Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Nilesh Lala
- Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Shannon Leahy
- Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Peter J Nourse
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Beatrice I Nyann
- Department of Paediatrics, University of Ghana Medical Centre, Accra, Ghana
| | - Karen L Petersen
- Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Cecil S Levy
- Nelson Mandela Children's Hospital, University of the Witwatersrand, Johannesburg, South Africa
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