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Bai Z, Lu G, Yang H, Zhang D, Zhang Y, Sun Z. Seasonal variation of serum potassium in hemodialysis patients: myth or reality? A narrative review of literature. Ren Fail 2024; 46:2359640. [PMID: 38832483 DOI: 10.1080/0886022x.2024.2359640] [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: 12/04/2023] [Accepted: 05/20/2024] [Indexed: 06/05/2024] Open
Abstract
Research has shown that patients undergoing hemodialysis experience seasonal variations in their serum potassium levels. There was inconsistent seasonal fluctuation in serum potassium levels among the hemodialysis population across different locations. In the form of narrative review for the first time, the article discusses the seasonal changes of serum potassium in this population and its potential reasons, this article demonstrates that it is primarily attributable to seasonal dietary potassium intake. However, existing studies have not quantified seasonal dietary potassium intake, so the results are still speculative. Furthermore, future research ought to further expound upon the clinical implications of seasonal variations in serum potassium levels among dialysis patients, as well as other influencing mechanisms such as the pathophysiological causes of these seasonal changes, particularly those pertaining to dietary, geographical, and regional factors. These findings contribute to a more thorough interpretation of laboratory results in hemodialysis patients and provide important guidance for their individualized dietary management.
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Affiliation(s)
- Zhe Bai
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, PR China
| | - Gang Lu
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, PR China
| | - Hengchao Yang
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, PR China
| | - Dahao Zhang
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, PR China
| | - Yuanyuan Zhang
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, PR China
| | - Zuoya Sun
- Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, PR China
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2
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Sun J, Liu Q, Seery S, Sun L, Yuan Y, Wang W, Wang Y, Cui Z, Wang Y, Wang Y, Zhu J, Zhang M, Lai Y, Jin K. The impact of hyperkalemia on ICU admission and mortality: a retrospective study of Chinese emergency department data. BMC Emerg Med 2024; 24:95. [PMID: 38824546 PMCID: PMC11144311 DOI: 10.1186/s12873-024-01011-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/22/2024] [Indexed: 06/03/2024] Open
Abstract
OBJECTIVE This study assesses the influence of hyperkalemia on both disease severity and the risk of mortality among patients admitted to the emergency room. METHODS This retrospective observational study utilized data from the Chinese Emergency Triage Assessment and Treatment database (CETAT, version 2.0), which was designed to evaluate and optimize management strategies for emergency room (ER) patients. Patients were systematically categorized based on serum potassium levels. Relationships between serum potassium levels, risk of mortality, and the severity of illness were then analyzed using multifactorial logistic regression and through Receiver Operating Characteristic (ROC) analysis. The effectiveness of various treatments at lowering potassium levels was also investigated. RESULTS 12,799 emergency patients were enrolled, of whom 20.1% (n = 2,577) were hypokalemic and 2.98% (n = 381) were hyperkalemic. Among hyperkalemic patients, the leading reasons for visiting the ER were altered consciousness 23.88% (n = 91), cardiovascular symptoms 22.31% (n = 85), and gastrointestinal symptoms 20.47% (n = 78). Comparative analysis with patients exhibiting normal potassium levels revealed hyperkalemia as an independent factor associated with mortality in the ER. Mortality risk appears to positively correlate with increasing potassium levels, reaching peaks when blood potassium levels ranged between 6.5 and 7.0. Hyperkalemia emerged as a strong predictor of death in the ER, with an Area Under the Curve (AUC) of 0.89. The most frequently prescribed treatment for hyperkalemia patients was diuretics (57.32%, n = 188), followed by intravenous sodium bicarbonate (50.91%, n = 167), IV calcium (37.2%, n = 122), insulin combined with high glucose (27.74%, n = 91), and Continuous Renal Replacement Therapy (CRRT) for 19.82% (n = 65). Among these, CRRT appeared to be the most efficacious at reducing potassium levels. Diuretics appeared relatively ineffective, while high-glucose insulin, sodium bicarbonate, and calcium preparations having no significant effect on the rate of potassium decline. CONCLUSION Hyperkalemia is common in emergency situations, especially among patients with altered consciousness. There is a strong positive correlation between the severity of hyperkalemia and mortality risk. CRRT appears to be the most effective potassium reducting strategy, while the use of diuretics should be approached with caution.
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Affiliation(s)
- Jian Sun
- Department of Emergency Medicine, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, 230001, China
| | - Qingyuan Liu
- School of Mathematics and Physics, Anhui Jianzhu University, Hefei, Anhui, 230009, China
| | - Samuel Seery
- School of Mathematical Sciences, University of Science and Technology of China, 96 Jinzhai Road, Hefei, Anhui, 230026, China
- Faculty of Health and Medicine, Division of Health Research, Lancaster University, Lancaster, LA1 4YW, UK
| | - Lu Sun
- Department of Emergency Medicine, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, 230001, China
| | - Yuan Yuan
- Department of Emergency Medicine, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, 230001, China
| | - Wenwen Wang
- Department of Emergency Medicine, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, 230001, China
| | - Yan Wang
- Department of Emergency Medicine, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, 230001, China
| | - Ziwei Cui
- Department of Emergency Medicine, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, 230001, China
| | - Yueguo Wang
- Department of Emergency Medicine, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, 230001, China
| | - Yulan Wang
- Department of Emergency Medicine, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, 230001, China
| | - Jiashan Zhu
- Department of Emergency Medicine, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, 230001, China
| | - Mengping Zhang
- School of Mathematical Sciences, University of Science and Technology of China, 96 Jinzhai Road, Hefei, Anhui, 230026, China.
| | - Yinglei Lai
- School of Mathematical Sciences, University of Science and Technology of China, 96 Jinzhai Road, Hefei, Anhui, 230026, China.
| | - Kui Jin
- Department of Emergency Medicine, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, 230001, China.
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Dobson R. Semaglutide and Patients Receiving Hemodialysis: Case Reports of Unexpected Benefits for Hyperphosphatemia and Hyperkalemia. Can J Hosp Pharm 2024; 77:e3534. [PMID: 38720915 PMCID: PMC11060791 DOI: 10.4212/cjhp.3534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 01/16/2024] [Indexed: 05/12/2024]
Affiliation(s)
- Raea Dobson
- , BSc, BScPharm, ACPR, PharmD, is with Sunnybrook Health Sciences Centre, Toronto, Ontario
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Yan T, Ma Y, Wang Z, Lyu J, Wu S, Zhang C, Wei W, Zeng J, Ma Z, Xu K. Calcium administration appears not to benefit acute pancreatitis patients with hypocalcemia. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2024; 31:273-283. [PMID: 38058277 DOI: 10.1002/jhbp.1397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 10/07/2023] [Accepted: 10/27/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVE Hypocalcemia occurs commonly among patients with acute pancreatitis (AP) in the intensive care unit (ICU). Calcium therapy could be used to correct hypocalcemia and maintain calcium levels, but its impact on the prognosis has not been demonstrated. Our study aimed to determine whether calcium therapy could benefit the multiple outcomes of AP patients with hypocalcemia. METHODS We extracted 807 AP patients with hypocalcemia from the Beth Israel Deaconess Medical Center (MIMIC-IV) database and performed retrospective analyses. The outcomes were in-hospital, 28 days, ICU mortality, and the length of stay (LOS) in the hospital and ICU. We performed propensity matching (PSM) and inverse probability weighting (IPTW) to balance the baseline differences and conducted multivariate regression to investigate the impact of calcium therapy. RESULTS A total of 620 patients (76.8%) received calcium treatment (calcium group) during hospitalization, while 187 patients (non-calcium group) did not. Patients in the calcium group did not present significant survival differences between groups before and after matching. After including covariates, calcium administration had no association with patients' in-hospital (HR: 1.03, 95% Cl: 0.47-2.27, p = .942), 28 days and ICU mortality and was significantly associated with prolonged length of stay in the hospital (effect estimate: 6.18, 95% Cl: 3.27-9.09, p < .001) and ICU (effect estimate: 1.72, 95% Cl: 0.24-3.20, p < .001). Calcium therapy could not benefit patients in subgroups with exclusive parenteral infusion, early calcium therapy (<48 h), or various degrees of hypocalcemia. CONCLUSION AP patients with hypocalcemia could not benefit from calcium administration, which has no association with multiple mortality and is significantly associated with prolonged LOS in the hospital and ICU.
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Affiliation(s)
- Tianao Yan
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Pancreatic Disease Center of Xi'an Jiaotong University, Xi'an, China
| | - Yifei Ma
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Pancreatic Disease Center of Xi'an Jiaotong University, Xi'an, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Pancreatic Disease Center of Xi'an Jiaotong University, Xi'an, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shuai Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Pancreatic Disease Center of Xi'an Jiaotong University, Xi'an, China
| | - Chun Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Pancreatic Disease Center of Xi'an Jiaotong University, Xi'an, China
| | - Wanzhen Wei
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Pancreatic Disease Center of Xi'an Jiaotong University, Xi'an, China
| | - Jiahui Zeng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Pancreatic Disease Center of Xi'an Jiaotong University, Xi'an, China
| | - Zhenhua Ma
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Pancreatic Disease Center of Xi'an Jiaotong University, Xi'an, China
| | - Kedong Xu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Pancreatic Disease Center of Xi'an Jiaotong University, Xi'an, China
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Gebara S, Adans-Dester G, Bairy L. Severe Hyperkalemia During a Robot-Assisted Total Radical Prostatectomy in a Patient with Stage 3a Chronic Kidney Disease: A Case Report. A A Pract 2024; 18:e01760. [PMID: 38411589 DOI: 10.1213/xaa.0000000000001760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
A 63-year-old man with stage 3a chronic kidney disease (CKD) and mild hyperkalemia was scheduled for a robot-assisted prostatectomy. He was being treated with lisinopril. Owing to mild hyperkalemia (6.2 mmol/L), lisinopril was discontinued, and sodium polystyrene sulfonate was administered on the day before surgery. Three hours after incision, electrocardiographic signs of hyperkalemia manifested with the serum potassium concentration rising to 8 mmol/L. Although hyperkalemia is a common and well-documented side effect of angiotensin-converting enzyme inhibitors in patients with CKD, we report an extreme increase in potassium within a very short time period despite prior drug discontinuation.
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Affiliation(s)
- Sebastien Gebara
- From the Department of Anesthesiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | | - Laurent Bairy
- Department of Anesthesiology, CHU UCL Namur, Yvoir, Belgium
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Hunt AE, Crawford A, Newman G, Area SA. Hyperkalemic Periodic Paralysis Secondary to End-Stage Renal Disease and Excess Potato Consumption. Cureus 2024; 16:e57321. [PMID: 38690463 PMCID: PMC11060113 DOI: 10.7759/cureus.57321] [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: 03/25/2024] [Indexed: 05/02/2024] Open
Abstract
Hyperkalemic periodic paralysis is a rare medical condition characterized by periods of extreme muscle weakness or paralysis. While most cases of hyperkalemic periodic paralysis are associated with a genetic channelopathy, cases of secondary hyperkalemic periodic paralysis can pose a challenge for medical personnel in terms of timely recognition. Identification of this medical emergency early in its course is essential to preventing cardiac and neurological sequelae. We report a case of a 58-year-old female who presented with stroke-like symptoms and was found to have secondary hyperkalemic periodic paralysis attributed to the excess consumption of potatoes, a potassium-rich food. This case highlights the importance of considering hyperkalemic periodic paralysis early in the differentiation of patients with end-stage renal disease (ESRD) who present with muscle weakness and stroke-like symptoms.
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Affiliation(s)
- Amy E Hunt
- Emergency Medicine, Charleston Area Medical Center, Charleston, USA
| | - Adam Crawford
- Emergency Medicine, Charleston Area Medical Center, Charleston, USA
| | - Gretchen Newman
- Emergency Medicine, Charleston Area Medical Center, Charleston, USA
| | - Scott A Area
- Emergency Medicine, Charleston Area Medical Center, Charleston, USA
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7
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Hedlund Møller S, Haagensen Kofod D, Schou M, Torp-Pedersen C, Gislason G, Carlson N, Lindhardt M. Mineralocorticoid receptor antagonist treatment in patients with renal insufficiency and the associated risk of hyperkalemia and death. J Hypertens 2024; 42:564-571. [PMID: 38108246 PMCID: PMC10842657 DOI: 10.1097/hjh.0000000000003639] [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: 05/31/2023] [Revised: 11/26/2023] [Accepted: 11/26/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVES Mineralocorticoid receptor antagonist (MRA) treatment is kidney protective but not recommended to patients with advanced renal failure due to the risk of hyperkalemia and death. This study aimed to examine the impact of MRA treatment in patients with chronic kidney disease on risk of hyperkalemia and subsequent mortality. METHODS Rates of hyperkalemia were compared across strata of estimated glomerular filtration rate (eGFR) and MRA treatment based on cox regression using a nested case-control framework with 1 : 4 matching of patients with hyperkalemia (K + ≥6.0 mmol/l) with controls from the Danish general population on age, sex, diabetes, and hypertension. Risk of subsequent 30-day mortality was assessed in a cohort study with comparisons across strata of eGFR and MRA treatment based on multiple Cox regression. RESULTS Thirty-two thousand four hundred twenty-six cases with hyperkalemia were matched with 127 038 controls. MRA treatment was associated with an increased rate of hyperkalemia with hazard ratios [95% confidence interval (95% CI)] of 8.28 (7.78-8.81), 5.12 (4.67-5.62), 3.58 (3.23-3.97), and 1.89 (1.60-2.23) in patients with eGFR at least 60, 45-59, 30-44, and less than 30 ml/min/1.73 m 2 , respectively (Reference: No MRA).However, MRA-exposed patients had a lower 30-day mortality risk following hyperkalemia with absolute risks (95% CI) of 29.3% (27.8-31.1), 20.3% (18.7-22.4), 19.5% (17.9-21.7), and 19.7% (17.4-22.5) compared to 39.8% (38.8-40.8), 32.0% (30.7-33.1), 28.8% (27.5-31.2), and 22.5% (21.4-23.4) in patients without MRA exposure in patients with GFR at least 60, 45-59, 30-44, and less than 30 ml/min/1.7 3m 2 , respectively. CONCLUSION MRA treatment was associated with an increased rate of hyperkalemia but decreased risk of subsequent 30-day mortality across all stages of renal impairment.
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Affiliation(s)
- Sara Hedlund Møller
- Department of internal medicine, Copenhagen University Hospital Holbaek, Holbaek
| | | | - Morten Schou
- Department of cardiology, Herlev Hospital, University Copenhagen
- Department of cardiology, Copenhagen University Hospital Gentofte
| | | | - Gunnar Gislason
- Department of cardiology, Copenhagen University Hospital Gentofte
- Department of Research, The Danish Heart Foundation, Copenhagen, Denmark
| | - Nicholas Carlson
- Department of Nephrology, Copenhagen University Hospital Rigshospitalet
| | - Morten Lindhardt
- Department of internal medicine, Copenhagen University Hospital Holbaek, Holbaek
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Hirve AA, Repp AB, Burgess LAK. Things We Do for No Reason™: Obtaining an electrocardiogram for managing mild hyperkalemia in hospitalized adults. J Hosp Med 2024. [PMID: 38268413 DOI: 10.1002/jhm.13288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/30/2023] [Accepted: 01/09/2024] [Indexed: 01/26/2024]
Affiliation(s)
- Anirudh A Hirve
- The Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Allen B Repp
- Department of Medicine, Division of Hospital Medicine, The University of Vermont Medical Center, The Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Lee-Anna K Burgess
- Department of Medicine, Division of Hospital Medicine, The University of Vermont Medical Center, The Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, Vermont, USA
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Huang W, Zhu JY, Song CY, Lu YQ. Machine learning models for early prediction of potassium lowering effectiveness and adverse events in patients with hyperkalemia. Sci Rep 2024; 14:737. [PMID: 38184719 PMCID: PMC10771443 DOI: 10.1038/s41598-024-51468-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/05/2024] [Indexed: 01/08/2024] Open
Abstract
The aim of this study was to develop a model for early prediction of adverse events and treatment effectiveness in patients with hyperkalemia. We collected clinical data from patients with hyperkalemia in the First Hospital of Zhejiang University School of Medicine between 2015 and 2021. The least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression were used to analyze the predictors on the full dataset. We randomly divided the data into a training group and a validation group, and used LASSO to filter variables in the training set. Six machine learning methods were used to develop the models. The best model was selected based on the area under the curve (AUC). Shapley additive exPlanations (SHAP) values were used to explain the best model. A total of 1074 patients with hyperkalemia were finally enrolled. Diastolic blood pressure (DBP), breathing, oxygen saturation (SPO2), Glasgow coma score (GCS), liver disease, oliguria, blood sodium, international standardized ratio (ISR), and initial blood potassium were the predictors of the occurrence of adverse events; peripheral edema, estimated glomerular filtration rate (eGFR), blood sodium, actual base residual, and initial blood potassium were the predictors of therapeutic effect. Extreme gradient boosting (XGBoost) model achieved the best performance (adverse events: AUC = 0.87; therapeutic effect: AUC = 0.75). A model based on clinical characteristics was developed and validated with good performance.
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Affiliation(s)
- Wei Huang
- Department of Emergency Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China
- Key Laboratory for Diagnosis and Treatment of Aging and Physic-Chemical Injury Diseases of Zhejiang Province, Hangzhou, 310003, Zhejiang, People's Republic of China
| | - Jian-Yong Zhu
- Department of Emergency Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China
- Key Laboratory for Diagnosis and Treatment of Aging and Physic-Chemical Injury Diseases of Zhejiang Province, Hangzhou, 310003, Zhejiang, People's Republic of China
| | - Cong-Ying Song
- Department of Emergency Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China
- Key Laboratory for Diagnosis and Treatment of Aging and Physic-Chemical Injury Diseases of Zhejiang Province, Hangzhou, 310003, Zhejiang, People's Republic of China
| | - Yuan-Qiang Lu
- Department of Emergency Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China.
- Key Laboratory for Diagnosis and Treatment of Aging and Physic-Chemical Injury Diseases of Zhejiang Province, Hangzhou, 310003, Zhejiang, People's Republic of China.
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Obi Y, Thomas F, Dashputre AA, Goedecke P, Kovesdy CP. Long-term Patiromer Use and Outcomes Among US Veterans With Hyperkalemia and CKD: A Propensity-Matched Cohort Study. Kidney Med 2024; 6:100757. [PMID: 38192434 PMCID: PMC10772292 DOI: 10.1016/j.xkme.2023.100757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024] Open
Abstract
Rationale & Objective Patiromer is a potassium binder approved for the long-term management of hyperkalemia. Although patiromer use among patients with advanced chronic kidney disease (CKD) has been shown to reduce the discontinuation of renin-angiotensin-aldosterone system inhibition therapy, it remains unclear whether patiromer can improve clinical outcomes. The aim of this study was to examine the association of long-term patiromer use with clinical outcomes among hyperkalemic patients with CKD. Study Design This was a longitudinal observational study. Setting & Participants We evaluated a national cohort of 854,217 US Veterans who had at least 1 serum potassium measurement of ≥5.1 mEq/L and were treated at US Department of Veterans Affairs health care facilities between January 2016 and September 2019. Exposure The exposure was long-term patiromer use. Outcomes The outcomes were as follows: (1) composite endpoint of kidney failure with replacement therapy (KFRT) or all-cause death and (2) all-cause death including the post-KFRT period. Analytical Approach Cox proportional Fine-Gray subdistribution hazard models were used in a propensity-matched cohort. Results Among 2,004 patients who ever used patiromer during the study period (0.2% of the cohort), 666 met the criteria for long-term patiromer use. We matched 308 long-term patiromer users to 308 nonusers based on propensity scores. The median estimated glomerular filtration rate was 23.5 mL/min/1.73m2, and the median potassium level was 5.2 mEq/L. Approximately 45% were on renin-angiotensin system inhibitor(s) at baseline. During follow-up, 93 patients developed KFRT, and 134 patients died. Long-term patiromer users, when compared to nonusers, experienced a 26% lower risk of the composite outcome (HR, 0.74; 95% CI, 0.53-1.01; P = 0.06) and a 41% lower risk of all-cause mortality (HR, 0.59; 95% CI, 0.41-0.84; P = 0.003). Limitations The study cohort included mostly male veterans with relatively short follow-up periods. Conclusions Long-term patiromer use was associated with a lower risk of all-cause mortality among patients with CKD and hyperkalemia. Long-term potassium binder use for hyperkalemia may improve clinical outcomes in CKD. Plain-Language Summary Hyperkalemia is a common complication of chronic kidney disease (CKD) and can result in the discontinuation of renin-angiotensin-aldosterone system inhibition therapy, a cornerstone of CKD management. Patiromer is a new potassium binder approved for the long-term management of hyperkalemia, but it remains unclear whether patiromer can improve clinical outcomes. We examined a cohort of US Veterans with hyperkalemia between January 2016 and September 2019 and found that patiromer use was uncommon for treating hyperkalemia during this study period. We then matched 308 long-term patiromer users and 308 nonusers based on propensity scores. Long-term patiromer users, when compared to nonusers, experienced a 26% lower risk of the composite outcome and a 41% lower risk of all-cause mortality. These findings indicate that long-term potassium binder use for hyperkalemia may improve clinical outcomes in CKD.
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Affiliation(s)
- Yoshitsugu Obi
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Fridtjof Thomas
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Ankur A. Dashputre
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
- Health Economics & Outcomes Research, Bausch Health US LLC, Bridgewater, NJ
| | - Patricia Goedecke
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
- Nephrology Section, Veterans Memphis Affairs Medical Center, Memphis, TN
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Aver GP, Ribeiro GF, Ballotin VR, Santos FSD, Bigarella LG, Riva F, Brambilla E, Soldera J. Comprehensive analysis of sodium polystyrene sulfonate-induced colitis: A systematic review. World J Meta-Anal 2023; 11:351-367. [DOI: 10.13105/wjma.v11.i7.351] [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: 09/08/2023] [Revised: 10/04/2023] [Accepted: 10/23/2023] [Indexed: 12/14/2023] Open
Abstract
BACKGROUND Sodium polystyrene sulfonate (SPS) is commonly prescribed for the management of hyperkalemia, a critical electrolyte imbalance contributing to over 800000 annual visits to emergency departments.
AIM To conduct a systematic review of documented cases of SPS-induced colitis and assess its associated prognosis.
METHODS Following the PRISMA-P guidelines, our study employed Medical Subject Headings and Health Sciences Descriptors, skillfully combined using Boolean operators, to conduct comprehensive searches across various electronic databases, including Scopus, Web of Science, MEDLINE (PubMed), BIREME (Biblioteca Regional de Medicina), LILACS (Latin American and Caribbean Health Sciences Literature), SciELO (Scientific Electronic Library Online), Embase, and Opengray.eu. Language criteria were confined to English, Spanish, and Portuguese, with no limitations on the publication date. Additionally, we manually scrutinized the reference lists of retrieved studies. To present our findings, we utilized simple descriptive analysis.
RESULTS Our search strategy yielded a total of 442 references. After rigorous evaluation, we included 51 references, encompassing 59 documented cases of colitis. Predominant clinical presentations included abdominal pain, observed in 35 (60.3%) cases, and bloating, reported in 18 (31%) cases. The most frequently affected sites of inflammation were the cecum, rectum, and small intestine, accounting for 31%, 25.8%, and 22.4% of cases, respectively. Colonoscopy findings were described in 28 (48.2%) cases, and 29 (50%) of patients required surgical intervention. Among the subset of patients for whom outcome data was available, 39 (67.2%) experienced favorable outcomes, while 12 (20.6%) unfortunately succumbed to the condition. The mean time required for resolution was 36.7 d, with a range spanning from 1 to 120 d.
CONCLUSION SPS demonstrates the capacity to effectively lower serum potassium levels within 24 h. However, this benefit is not without the risk of bowel injury. Our study highlights the absence of high-quality data pertaining to the incidence of adverse events associated with SPS usage, making it challenging to determine whether the potential risks outweigh the benefits. However, a significant mortality rate related to SPS-induced colitis was noted. Future investigations should prioritize randomized controlled trials with a sufficiently large patient cohort to ascertain the true utility and safety profile of this medication.
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Affiliation(s)
- Gabriel Peixoto Aver
- School of Medicine, Universidade de Caxias do Sul, Caxias do Sul 95070-560, Brazil
| | | | | | | | | | - Floriano Riva
- Department of Pathology, CPM Laboratório de Patologia, Caxias do Sul 95084-900, RS, Brazil
| | - Eduardo Brambilla
- Clinical Gastroenterology, Universidade de Caxias do Sul, Caxias do Sul 95070-560, RS, Brazil
| | - Jonathan Soldera
- Acute Medicine and Gastroenterology, University of South Wales, Cardiff CF37 1DL, United Kingdom
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Al-Beltagi M, Saeed NK, Bediwy AS, Elbeltagi R, Hasan S, Hamza MB. Renal calcification in children with renal tubular acidosis: What a paediatrician should know. World J Clin Pediatr 2023; 12:295-309. [PMID: 38178934 PMCID: PMC10762599 DOI: 10.5409/wjcp.v12.i5.295] [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: 07/29/2023] [Revised: 09/15/2023] [Accepted: 10/16/2023] [Indexed: 12/08/2023] Open
Abstract
Renal tubular acidosis (RTA) can lead to renal calcification in children, which can cause various complications and impair renal function. This review provides pediatricians with a comprehensive understanding of the relationship between RTA and renal calcification, highlighting essential aspects for clinical management. The article analyzed relevant studies to explore the prevalence, risk factors, underlying mechanisms, and clinical implications of renal calcification in children with RTA. Results show that distal RTA (type 1) is particularly associated with nephrocalcinosis, which presents a higher risk of renal calcification. However, there are limitations to the existing literature, including a small number of studies, heterogeneity in methodologies, and potential publication bias. Longitudinal data and control groups are also lacking, which limits our understanding of long-term outcomes and optimal management strategies for children with RTA and renal calcification. Pediatricians play a crucial role in the early diagnosis and management of RTA to mitigate the risk of renal calcification and associated complications. In addition, alkaline therapy remains a cornerstone in the treatment of RTA, aimed at correcting the acid-base imbalance and reducing the formation of kidney stones. Therefore, early diagnosis and appropriate therapeutic interventions are paramount in preventing and managing renal calcification to preserve renal function and improve long-term outcomes for affected children. Further research with larger sample sizes and rigorous methodologies is needed to optimize the clinical approach to renal calcification in the context of RTA in the pediatric population.
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Affiliation(s)
- Mohammed Al-Beltagi
- Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta 31511, Alghrabia, Egypt
- Department of Pediatrics, University Medical Center, King Abdulla Medical City, Dr. Sulaiman Al Habib Medical Group, Manama, Bahrain, Manama 26671, Manama, Bahrain
| | - Nermin Kamal Saeed
- Medical Microbiology Section, Department of Pathology, Salmaniya Medical Complex, Ministry of Health, Kingdom of Bahrain, Manama 12, Manama, Bahrain
- Medical Microbiology Section, Department of Pathology, Irish Royal College of Surgeon, Bahrain, Busaiteen 15503, Muharraq, Bahrain
| | - Adel Salah Bediwy
- Department of Pulmonology, Faculty of Medicine, Tanta University, Tanta 31527, Alghrabia, Egypt
- Department of Chest Disease, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Dr. Sulaiman Al Habib Medical Group, Manama, Manama 26671, Manama, Bahrain
| | - Reem Elbeltagi
- Department of Medicine, The Royal College of Surgeons in Ireland - Bahrain, Busiateen 15503, Muharraq, Bahrain
| | - Samir Hasan
- Department of Pediatrics, Faculty of Medicine, Tanta University Hospital, Tanta 31511, Algharbia, Egypt
| | - Mohamed Basiony Hamza
- Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta 31511, Algharbia, Egypt
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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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Fravel MA, Meaney CJ, Noureddine L. Management of Hyperkalemia in Patients with Chronic Kidney Disease Using Renin Angiotensin Aldosterone System Inhibitors. Curr Hypertens Rep 2023; 25:395-404. [PMID: 37747576 DOI: 10.1007/s11906-023-01265-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 09/26/2023]
Abstract
PURPOSE OF REVIEW Use of renin-angiotensin-aldosterone system (RAAS) inhibiting medications is critical in the prevention of cardiovascular disease and kidney function decline in patients with chronic kidney disease (CKD); however, these agents can lead to hyperkalemia, an electrolyte disorder associated with risk of arrythmia, conduction disorders, and increased overall mortality. Discontinuation, or reduction of dose, of RAAS inhibitor therapy in hyperkalemic patients with CKD can lead to loss of kidney and cardiovascular protection afforded by these medications. Given the high prevalence of hyperkalemia among patients with CKD utilizing RAAS inhibitors, clear management principles are critical to minimize risk and maximize benefit when facing this clinical dilemma. RECENT FINDINGS Strategies to mitigate hyperkalemia that do not interfere with optimal RAAS inhibitor therapy should be prioritized when managing potassium elevation in patients with CKD. These strategies include discontinuing non-RAAS inhibitor medications known to cause hyperkalemia, correction of metabolic acidosis, and maximization of medication therapies that lower serum potassium, including diuretics and sodium-glucose cotransporter-2 (SGLT-2) inhibitors. Initiation of potassium exchange resins should also be considered to allow for sustained RAAS inhibitor utilization. An approach which employs multiple strategies concurrently is important to mitigate hyperkalemia and maintain long-term use of RAAS-inhibitors. Persistence of RAAS inhibitor use in patients with CKD is important to slow kidney function decline, delay onset of dialysis or the need for kidney transplant, and prevent adverse cardiovascular outcomes. When hyperkalemia develops among patients with CKD utilizing a RAAS inhibitor, a deliberate effort to reduce serum potassium levels using an approach that allows for continuation of maximally dosed RAAS inhibitor therapy is important. Patient education and engagement in the potassium management process is important for sustained success.
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Affiliation(s)
- Michelle A Fravel
- University of Iowa College of Pharmacy, 167 CPB, 180 S. Grand Ave, Iowa City, IA, 52242, USA.
| | | | - Lama Noureddine
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
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Dwyer JP, Agiro A, Desai P, Oluwatosin Y. Impact of Sodium Zirconium Cyclosilicate Plus Renin-Angiotensin-Aldosterone System Inhibitor Therapy on Short-Term Medical Costs in Hyperkalemia: OPTIMIZE II Real-World Study. Adv Ther 2023; 40:4777-4791. [PMID: 37606716 PMCID: PMC10567937 DOI: 10.1007/s12325-023-02631-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/28/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Patients receiving cardiorenal-protective renin-angiotensin-aldosterone system inhibitors (RAASis) are at increased risk of developing hyperkalemia, which is associated with increased medical costs. The aim of this study was to evaluate the impact of adding sodium zirconium cyclosilicate (SZC) therapy on 3-month medical costs in patients who experienced hyperkalemia while receiving RAASi therapy. METHODS The retrospective OPTIMIZE II study used medical and pharmacy claims data from IQVIA PharMetrics® Plus. Patients aged ≥ 18 years who received SZC (≥ 60 day supply over 3 months' follow-up) and continued RAASi between July 2019 and December 2021 (Continue RAASi + SZC cohort) were 1:1 exact and propensity score matched with patients who discontinued RAASi after hyperkalemia diagnosis and did not receive SZC (Discontinue RAASi + no SZC cohort). The primary outcome was hyperkalemia-related medical costs to payers over 3 months; all-cause medical and pharmacy costs were also analyzed. RESULTS In the Continue RAASi + SZC (n = 467) versus Discontinue RAASi + no SZC (n = 467) cohort, there were significant reductions in mean per-patient hyperkalemia-related medical costs (reduction of $2216.07; p = 0.01) and all-cause medical costs (reduction of $6102.43; p < 0.001); mean hyperkalemia-related inpatient medical costs and all-cause inpatient and emergency department medical costs were significantly reduced. The reduction in all-cause medical cost in the Continue RAASi + SZC cohort offset an increase in the mean per-patient all-cause pharmacy cost (increase of $3117.71; p < 0.001). CONCLUSION RAASi therapy has well-established cardiorenal benefits. In OPTIMIZE II, management of RAASi-induced hyperkalemia with SZC was associated with lower hyperkalemia-related and all-cause medical costs than RAASi discontinuation without SZC, demonstrating medical cost savings with maintaining RAASi therapy with SZC.
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Affiliation(s)
- Jamie P Dwyer
- Department of Internal Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Abiy Agiro
- US Evidence, US Medical Affairs, AstraZeneca, 1800 Concord Pike, Wilmington, DE, 19850, USA.
| | - Pooja Desai
- US Renal, US Medical Affairs, AstraZeneca, Wilmington, DE, USA
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Morel J, McNeilly O, Grundy S, Brown T, Gunawan C, Amal R, Scott JA. Nanoscale Titanium Surface Engineering via Low-Temperature Hydrothermal Etching for Enhanced Antimicrobial Properties. ACS APPLIED MATERIALS & INTERFACES 2023; 15:46247-46260. [PMID: 37738302 DOI: 10.1021/acsami.3c09525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
Bioinspired nanotopography artificially fabricated on titanium surfaces offers a solution for the rising issue of postoperative infections within orthopedics. On a small scale, hydrothermal etching has proven to deliver an effective antimicrobial nanospike surface. However, translation to an industrial setting is limited by the elevated synthesis temperature (150 °C) and associated equipment requirements. Here, for the first time, we fabricate surface nanostructures using comparatively milder synthesis temperatures (75 °C), which deliver physicochemical properties and antimicrobial capability comparable to the high-temperature surface. Using a KOH etchant, the simultaneous formation of titania and titanate crystals at both temperatures produces a one-dimensional nanostructure array. Analysis indicated that the formation mechanism comprises dissolution and reprecipitation processes, identifying the deposited titanates as hydrated layered tetra-titanates (K2Ti4O9·nH2O). A proposed nanospike formation mechanism was confirmed through the identification of a core and outer shell for individual nanostructures, primarily comprised of titanates and titania, respectively. Etching conditions dictated crystalline formation, favoring a thicker titanate core for nanorods under higher synthesis temperatures and etchant concentrations. A bactericidal investigation showed the efficacy against Gram-negative bacteria for a representative low-temperature nanosurface (34.4 ± 14.4%) was comparable to the higher temperature nanosurface (34.0 ± 17.0%), illustrating the potential of low-temperature hydrothermal synthesis. Our results provide valuable insight into the applicability of low-temperature etching protocols that are more favorable in large-scale manufacturing settings.
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Affiliation(s)
- James Morel
- School of Chemical Engineering, University of New South Wales, Kensington, NSW 2052, Australia
| | - Oliver McNeilly
- Australian Institute for Microbiology and Infection, University of Technology Sydney, Broadway, NSW 2007, Australia
| | - Sarah Grundy
- School of Chemical Engineering, University of New South Wales, Kensington, NSW 2052, Australia
| | - Toby Brown
- Corin Australia, Pymble, NSW 2073, Australia
| | - Cindy Gunawan
- Australian Institute for Microbiology and Infection, University of Technology Sydney, Broadway, NSW 2007, Australia
| | - Rose Amal
- School of Chemical Engineering, University of New South Wales, Kensington, NSW 2052, Australia
| | - Jason A Scott
- School of Chemical Engineering, University of New South Wales, Kensington, NSW 2052, Australia
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Yamaguchi K, Kitamura M, Otsuka E, Notomi S, Funakoshi S, Mukae H, Nishino T. Association between annual variability of potassium levels and prognosis in patients undergoing hemodialysis. Clin Exp Nephrol 2023; 27:873-881. [PMID: 37318722 DOI: 10.1007/s10157-023-02368-4] [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: 03/31/2023] [Accepted: 06/05/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Hyperkalemia and hypokalemia are associated with mortality in patients undergoing hemodialysis. However, there are few reports on the association between potassium level fluctuations and mortality. We retrospectively investigated the association between serum potassium level variability and mortality in patients undergoing hemodialysis. METHODS This study was conducted at a single center. Variability in serum potassium levels was evaluated using the standard deviation of potassium level from July 2011 to June 2012, and its association with prognosis was examined by following up the patients for 5 years. Serum potassium variability was assessed as the coefficient of variation, and the statistical analysis was performed after log transformation. RESULTS Among 302 patients (mean age 64.9 ± 13.3; 57.9% male; and median dialysis vintage 70.5 months [interquartile range, IQR 34-138.3]), 135 died during the observation period (median observation period 5.0 years [2.3-5.0]). Although the mean potassium level was not associated with prognosis, serum potassium level variability was associated with prognosis, even after adjustments for confounding factors such as age and dialysis time (hazard ratio: 6.93, 95% confidence interval [Cl] 1.98-25.00, p = 0.001). After the adjustments, the coefficient of variation of potassium level in the highest tertile (T3) showed a higher relative risk for prognosis than that in T1 (relative risk: 1.98, 95% CI 1.19-3.29, p = 0.01). CONCLUSIONS Variability in serum potassium levels was associated with mortality in patients undergoing hemodialysis. Careful monitoring of potassium levels and their fluctuations is necessary for this patient population.
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Affiliation(s)
- Kosei Yamaguchi
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Nagasaki Renal Center, Nagasaki, Japan
| | - Mineaki Kitamura
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
- Nagasaki Renal Center, Nagasaki, Japan.
| | | | | | | | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomoya Nishino
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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18
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Agiro A, Dwyer JP, Oluwatosin Y, Desai P. Medical Costs in Patients with Hyperkalemia on Long-Term Sodium Zirconium Cyclosilicate Therapy: The RECOGNIZE II Study. CLINICOECONOMICS AND OUTCOMES RESEARCH 2023; 15:691-702. [PMID: 37753303 PMCID: PMC10519215 DOI: 10.2147/ceor.s420217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 09/11/2023] [Indexed: 09/28/2023] Open
Abstract
Purpose Hyperkalemia, defined as abnormally high serum potassium levels of ≥5.1 mmol/L, is associated with increased medical costs. This real-world study evaluated the impact of long-term sodium zirconium cyclosilicate (SZC) therapy on medical costs in patients with hyperkalemia. Patients and Methods This retrospective, comparative study used claims data from IQVIA PharMetrics® Plus. Patients aged ≥18 years with hyperkalemia who had outpatient SZC fills (>3-month supply over 6 months) between July 2019 and December 2021 and continuous insurance coverage 6 months before and 6 months after the first SZC fill were included. These patients (SZC cohort) were 1:1 exact- and propensity score-matched on baseline variables with patients with hyperkalemia who did not receive SZC (non-SZC cohort). The primary endpoint was hyperkalemia-related medical costs to payers over 6 months. Results Each cohort included 661 matched patients. Mean per-patient hyperkalemia-related medical costs were reduced by 49.5% ($3728.47) for the SZC versus non-SZC cohort ($3798.04 vs $7526.51; P<0.001), whereas mean all-cause medical costs were reduced by 21.0% ($5492.20; $20,722.23 vs $26,214.43; P<0.01). A 39.8% ($3621.03) increase in all-cause pharmacy costs ($12,727.20 vs $9106.17; P<0.01) was offset by the medical cost savings. Conclusion This study demonstrated that long-term (>3 months) outpatient treatment with SZC was associated with medical cost savings compared with no SZC therapy.
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Affiliation(s)
- Abiy Agiro
- US Evidence, US Medical Affairs, AstraZeneca, Wilmington, DE, USA
| | - Jamie P Dwyer
- Department of Internal Medicine, University of Utah Health, Salt Lake City, UT, USA
| | | | - Pooja Desai
- US Renal, US Medical Affairs, AstraZeneca, Wilmington, DE, USA
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Bnaya A, Ganzel C, Shavit L. Pseudohyperkalemia in chronic lymphocytic leukemia: Prevalence, impact, and management challenges. Am J Med Sci 2023; 366:167-175. [PMID: 37285937 DOI: 10.1016/j.amjms.2023.04.031] [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: 06/28/2022] [Revised: 01/14/2023] [Accepted: 04/17/2023] [Indexed: 06/09/2023]
Abstract
The term pseudohyperkalemia refers to a false elevation in serum potassium levels due to potassium release from cells in vitro. Falsely elevated potassium levels have been reported in patients with thrombocytosis, leukocytosis, and hematologic malignancies. This phenomenon has been particularly described in chronic lymphocytic leukemia (CLL). Leukocyte fragility, extremely high leukocyte counts, mechanical stress, higher cell membrane permeability related to an interaction with lithium heparin in plasma blood samples, and metabolite depletion due to a high leukocyte burden have been reported to contribute to pseudohyperkalemia in CLL. The prevalence of pseudohyperkalemia is up to 40%, particularly in the presence of a high leukocyte count (>50 × 109/L). The diagnosis of pseudohyperkalemia is often overlooked, which may result in unnecessary and potentially harmful treatment. The use of whole blood testing and point-of-care blood gas analysis, along with thorough clinical evaluation, may help differentiate between true and pseudohyperkalemic episodes.
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Affiliation(s)
- Alon Bnaya
- Institute of Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Hadassah-Hebrew University Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Chezi Ganzel
- Institute of Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Linda Shavit
- Institute of Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Hadassah-Hebrew University Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Zardoost P, Khan Z, Kim R, Scott K, Wehrum HL. Stress-Dose Steroids: A Potential Therapeutic Option for Refractory Hyperkalemia. Cureus 2023; 15:e44770. [PMID: 37809248 PMCID: PMC10557372 DOI: 10.7759/cureus.44770] [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: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
Hyperkalemia refractory to standard temporization measures can be life-threatening, and urgent hemodialysis is often utilized as a final resort. Our patient presented with hyperkalemia that was multifactorial in etiology, with acute kidney injury complicated by adrenal insufficiency. Her hyperkalemia was refractory to temporization and excretion agents, and hemodialysis was being considered. Given a recent infection, surgery, and borderline hypotension with low adrenocorticotropic hormone, there was a concern for adrenal insufficiency. However, a full investigation for secondary adrenal insufficiency via magnetic resonance imaging could not be conducted as the patient suffered from claustrophobia. Continued concern for adrenal insufficiency prompted the initiation of intravenous hydrocortisone, and the patient's hyperkalemia resolved within 24 hours. While suspected adrenal insufficiency is already a basis for stress-dose steroids in the setting of pathologies such as severe sepsis, clinicians should have a low threshold for considering refractory hyperkalemia alone as an indication for stress-dose steroids. When dialysis is being considered as an option, this treatment modality should be given even more consideration. Adopting this practice may not only lead to improved mortality from hyperkalemia but also lead to fewer patients being exposed to the risks of dialysis.
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Affiliation(s)
- Pooya Zardoost
- Internal Medicine, OhioHealth Doctors Hospital, Columbus, USA
| | - Zeryab Khan
- Graduate Medical Education, OhioHealth Doctors Hospital, Columbus, USA
| | - Rachel Kim
- Graduate Medical Education, OhioHealth Doctors Hospital, Columbus, USA
| | - Kelsey Scott
- Graduate Medical Education, OhioHealth Doctors Hospital, Columbus, USA
| | - Henry L Wehrum
- Graduate Medical Education, OhioHealth Doctors Hospital, Columbus, USA
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Costa D, Patella G, Provenzano M, Ielapi N, Faga T, Zicarelli M, Arturi F, Coppolino G, Bolignano D, De Sarro G, Bracale UM, De Nicola L, Chiodini P, Serra R, Andreucci M. Hyperkalemia in CKD: an overview of available therapeutic strategies. Front Med (Lausanne) 2023; 10:1178140. [PMID: 37583425 PMCID: PMC10424443 DOI: 10.3389/fmed.2023.1178140] [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: 03/02/2023] [Accepted: 07/10/2023] [Indexed: 08/17/2023] Open
Abstract
Hyperkalemia (HK) is a life-threatening condition that often occurs in patients with chronic kidney disease (CKD). High serum potassium (sKsK) is responsible for a higher risk of end-stage renal disease, arrhythmias and mortality. This risk increases in patients that discontinue cardio-nephroprotective renin-angiotensin-aldosterone system inhibitor (RAASi) therapy after developing HK. Hence, the management of HK deserves the attention of the clinician in order to optimize the therapeutic strategies of chronic treatment of HK in the CKD patient. The adoption in clinical practice of the new hypokalaemic agents patiromer and sodium zirconium cyclosilicate (SZC) for the prevention and chronic treatment of HK could allow patients, suffering from heart failure and chronic renal failure, to continue to benefit from RAASi therapy. We have updated a narrative review of the clear variables, correct definition, epidemiology, pathogenesis, etiology and classifications for HK among non-dialysis CKD (ND CKD) patients. Furthermore, by describing the prognostic impact on mortality and on the progression of renal damage, we want to outline the strategies currently available for the control of potassium (K+) plasma levels.
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Affiliation(s)
- Davide Costa
- Department of Law, Economics and Sociology, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Gemma Patella
- Renal Unit, Department of Health Sciences, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Michele Provenzano
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Nicola Ielapi
- Department of Public Health and Infectious Disease, Sapienza University of Rome, Rome, Italy
| | - Teresa Faga
- Renal Unit, Department of Health Sciences, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Mariateresa Zicarelli
- Renal Unit, Department of Health Sciences, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Franco Arturi
- Unit of Internal Medicine, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Giuseppe Coppolino
- Renal Unit, Department of Health Sciences, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Davide Bolignano
- Renal Unit, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | | | | | - Luca De Nicola
- Renal Unit, University of Campania “LuigiVanvitelli”, Naples, Italy
| | - Paolo Chiodini
- Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Raffaele Serra
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Michele Andreucci
- Renal Unit, Department of Health Sciences, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
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Chang HH, Chiang JH, Tsai CC, Chiu PF. Predicting hyperkalemia in patients with advanced chronic kidney disease using the XGBoost model. BMC Nephrol 2023; 24:169. [PMID: 37308844 DOI: 10.1186/s12882-023-03227-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/01/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Hyperkalemia is a common complication of chronic kidney disease (CKD). Hyperkalemia is associated with mortality, CKD progression, hospitalization, and high healthcare costs in patients with CKD. We developed a machine learning model to predict hyperkalemia in patients with advanced CKD at an outpatient clinic. METHODS This retrospective study included 1,965 advanced CKD patients between January 1, 2010, and December 31, 2020 in Taiwan. We randomly divided all patients into the training (75%) and testing (25%) datasets. The primary outcome was to predict hyperkalemia (K+ > 5.5 mEq/L) in the next clinic vist. Two nephrologists were enrolled in a human-machine competition. The area under the receiver operating characteristic curves (AUCs), sensitivity, specificity, and accuracy were used to evaluate the performance of XGBoost and conventional logistic regression models with that of these physicians. RESULTS In a human-machine competition of hyperkalemia prediction, the AUC, PPV, and accuracy of the XGBoost model were 0.867 (95% confidence interval: 0.840-0.894), 0.700, and 0.933, which was significantly better than that of our clinicians. There were four variables that were chosen as high-ranking variables in XGBoost and logistic regression models, including hemoglobin, the serum potassium level in the previous visit, angiotensin receptor blocker use, and calcium polystyrene sulfonate use. CONCLUSIONS The XGBoost model provided better predictive performance for hyperkalemia than physicians at the outpatient clinic.
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Affiliation(s)
- Hsin-Hsiung Chang
- Division of Nephrology, Department of Internal Medicine, Antai Medical Care Corporation Antai Tian-Sheng Memorial Hospital, Pingtung County, Taiwan
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Jung-Hsien Chiang
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan, Taiwan.
| | - Chun-Chieh Tsai
- Division of Nephrology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Ping-Fang Chiu
- Division of Nephrology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan.
- Department of Post Baccalaureate, College of Medicine, National Chung Hsing University, Taichung, Taiwan.
- Department of Hospitality Management, MingDao University, Changhua, Taiwan.
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23
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Fu B, Xu X, Zhang X, Cheng S, El-Seedi HR, Du M. Identification and characterisation of taste-enhancing peptides from oysters (Crassostrea gigas) via the Maillard reaction. Food Chem 2023; 424:136412. [PMID: 37267650 DOI: 10.1016/j.foodchem.2023.136412] [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: 11/20/2022] [Revised: 05/12/2023] [Accepted: 05/16/2023] [Indexed: 06/04/2023]
Abstract
Oysters, which are flavourful edible marine products, have been utilised to produce Maillard reaction products (MRPs), which contribute to saltiness enhancement. Here, the molecular weight distribution, free amino acids, and taste characteristics of MRPs were analysed, while ultraviolet light was used to observe the Maillard reaction. Both thermal degradation and cross-linking reactions occur during the Maillard reaction. When the Maillard reaction time was 90 min, the saltiness, umami, and richness of the MRPs peaked, however bitterness reached its lowest value. Moreover, at an MRP concentration of 1.5 mg/mL, salts were reduced by 35.71% in a 3 mg/mL sodium chloride solution without reducing saltiness, based on sensory evaluation. Glycation sites of the MRPs, which are crucial for saltiness enhancement and derived from a variety of protein sources, were determined using nano-HPLC-MS/MS analysis. Our study establishes the foundation for preparing salt-enhancing peptides, accelerating the popularisation of oyster-derived flavouring agents.
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Affiliation(s)
- Baifeng Fu
- School of Food Science and Technology, Dalian Polytechnic University, No. 1st Qinggongyuan, Ganjingzi, Dalian, Liaoning 116034, China; Collaborative Innovation Center of Seafood Deep Processing, Dalian Polytechnic University, No. 1st Qinggongyuan, Ganjingzi, Dalian, Liaoning 116034, China
| | - Xianbing Xu
- School of Food Science and Technology, Dalian Polytechnic University, No. 1st Qinggongyuan, Ganjingzi, Dalian, Liaoning 116034, China; Collaborative Innovation Center of Seafood Deep Processing, Dalian Polytechnic University, No. 1st Qinggongyuan, Ganjingzi, Dalian, Liaoning 116034, China; National Engineering Research Center of Seafood, Dalian Polytechnic University, No. 1st Qinggongyuan, Ganjingzi, Dalian, Liaoning 116034, China
| | - Xin Zhang
- School of Food Science and Technology, Dalian Polytechnic University, No. 1st Qinggongyuan, Ganjingzi, Dalian, Liaoning 116034, China; Collaborative Innovation Center of Seafood Deep Processing, Dalian Polytechnic University, No. 1st Qinggongyuan, Ganjingzi, Dalian, Liaoning 116034, China
| | - Shuzhen Cheng
- School of Food Science and Technology, Dalian Polytechnic University, No. 1st Qinggongyuan, Ganjingzi, Dalian, Liaoning 116034, China; Collaborative Innovation Center of Seafood Deep Processing, Dalian Polytechnic University, No. 1st Qinggongyuan, Ganjingzi, Dalian, Liaoning 116034, China; National Engineering Research Center of Seafood, Dalian Polytechnic University, No. 1st Qinggongyuan, Ganjingzi, Dalian, Liaoning 116034, China
| | - Hesham R El-Seedi
- Pharmacognosy Group, Department of Pharmaceutical Biosciences, Uppsala University, BMC, P.O. Box 591, SE 751 24 Uppsala, Sweden; International Research Center for Food Nutrition and Safety, Jiangsu University, Zhenjiang 212013, China
| | - Ming Du
- School of Food Science and Technology, Dalian Polytechnic University, No. 1st Qinggongyuan, Ganjingzi, Dalian, Liaoning 116034, China; Collaborative Innovation Center of Seafood Deep Processing, Dalian Polytechnic University, No. 1st Qinggongyuan, Ganjingzi, Dalian, Liaoning 116034, China; National Engineering Research Center of Seafood, Dalian Polytechnic University, No. 1st Qinggongyuan, Ganjingzi, Dalian, Liaoning 116034, China.
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24
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Mattaliano G, Heberlein M, Cruz Benedetti I. Unanticipated hyperkalaemia and associated perioperative complications in three captive grey wolves (
Canis lupus
) undergoing general anaesthesia. VETERINARY RECORD CASE REPORTS 2023. [DOI: 10.1002/vrc2.597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Affiliation(s)
- Giorgio Mattaliano
- Department for Companion Animals and Horses Anaesthesiology and Perioperative Intensive‐Care Medicine, Vetmeduni Vienna Vienna Austria
| | | | - Inga‐Catalina Cruz Benedetti
- Department of Clinical Sciences, Faculty of Veterinary Medicine Université de Montréal Saint‐Hyacinthe Quebec Canada
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25
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Johnson M, Morrison FJ, McMahon G, Su M, Turchin A. Outcomes in patients with cardiometabolic disease who develop hyperkalemia while treated with a renin-angiotensin-aldosterone system inhibitor. Am Heart J 2023; 258:49-59. [PMID: 36642227 DOI: 10.1016/j.ahj.2023.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 01/06/2023] [Accepted: 01/07/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Many patients with indications for renin-angiotensin-aldosterone system inhibitor (RAASi) therapy are not receiving these medications. Concern about hyperkalemia is thought to contribute to this lack of evidence-based therapy. METHODS A retrospective cohort study included adult patients in primary care practices affiliated with an integrated health care delivery system treated with RAASi between 2000 and 2019 for any of the following indications: (a) coronary artery disease (CAD); (b) heart failure (HF) with a left ventricle ejection fraction ≤ 40%; (c) diabetes mellitus (DM) with proteinuria; or (d) chronic kidney disease (CKD) with proteinuria. Relationship between hyperkalemia (K > 5.0 mEg/L) over the first 12 months of follow-up and a composite end point of cardiovascular events, renal dysfunction, and all-cause mortality was evaluated. RESULTS Among 82,732 study patients, 7,727 (9.34%) developed hyperkalemia. Patients with hyperkalemia were older (69.0 vs 64.6) and more likely to have CAD (57.8 vs 53.7%), CKD (57.3 vs 51.1%), HF (19.3 vs 9.7%), and DM (45.3 vs 33.3%) (P < .001 for all). Five-year cumulative risk of the primary outcome was higher in patients who did (63.9%; 95% CI: 62.8%-65.1%) versus did not (37.2%; 95% CI: 36.8%-37.6%) develop hyperkalemia. Five-year cumulative risk of ED visit or hospitalization for hyperkalemia was 15.6% (14.7%-16.6%) for patients with versus 2.7% (95% CI: 2.6-2.9) for patients without hyperkalemia, rising to 25.9% (95% CI: 22.4-29.9) for patients with severe (K > 6.0 mEq/dL) hyperkalemia. Patients who experienced hyperkalemia were more likely (34.4%) than patients who did not (29.2%) to deintensify RAASi therapy (P < .001). Five-year cumulative risk of the primary outcome was higher in patients who lowered RAASi dose (50.4%; 95% CI: 48.5%-52.4%) or stopped RAASi therapy completely (49.3%; 95% CI: 48.5%-50.1%), compared to patients who continued RAASi therapy (36.1%; 95% CI: 25.7-36.5). Similar findings were observed in multivariable analyses and for individual components of the primary outcome. CONCLUSIONS Hyperkalemia is a common complication of RAASi therapy and is associated with an increased risk of multiple adverse outcomes. Patients who have their RAASi medications deintensified after a hyperkalemic event have higher incidence of cardiovascular events, renal dysfunction and death.
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Affiliation(s)
- Matthew Johnson
- Division of Endocrinology, Brigham and Women's Hospital, Boston, MA; Columbia University College of Physicians and Surgeons, New York, NY
| | | | - Gearoid McMahon
- Division of Endocrinology, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Maxwell Su
- Harvard School of Public Health, Boston, MA; Phase V, Wellesley Hills, MA
| | - Alexander Turchin
- Division of Endocrinology, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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26
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Milne A, Radhakrishnan A. Biochemical disturbance in damage control resuscitation: mechanisms, management and prognostic utility. Curr Opin Anaesthesiol 2023; 36:176-182. [PMID: 36728975 DOI: 10.1097/aco.0000000000001226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW With advances in resuscitative techniques, trauma patients are surviving increasingly severe injuries and physiological insult. Timely recognition of futility remains important in terms of patient dignity and resource preservation yet is increasingly challenging in the face of these advances. The understanding of biochemical derangement from pathophysiological processes of trauma and iatrogenic effects of resuscitation has expanded recently. RECENT FINDINGS Acidosis and hypocalcaemia have been recognized as important contributors to mortality among trauma patients. Although less well recognized and studied, critical injury and high blood product volume resuscitation render patients vulnerable to life-threatening hyperkalaemia. The methods of correcting disruptions to acid-base and electrolyte homeostasis during damage control resuscitation have changed little recently and often rely on evidence from undifferentiated populations. Biochemical disturbances have value as ancillary predictors of futility in trauma resuscitation. SUMMARY These findings will contribute to a greater understanding among anaesthesiologists of the causative mechanisms and effects of biochemical derangement after severe injury and aid them in the delivery of well tolerated and effective damage control resuscitation. Gaps in the evidence base are highlighted to encourage future work.
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Affiliation(s)
- Andrew Milne
- Trauma Anaesthesia Group, Barts Health NHS Trust, Royal London Hospital, London, UK
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27
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Mateus C, Luís P, Birne R. An Unusual Intestinal Finding in a Patient with ESKD and Abdominal Pain. KIDNEY360 2023; 4:425-426. [PMID: 36996305 PMCID: PMC10103329 DOI: 10.34067/kid.0000000000000070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 08/12/2022] [Indexed: 04/01/2023]
Affiliation(s)
- Catarina Mateus
- Centro Hospitalar Lisboa Ocidental, Nephrology, Lisbon, Portugal
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28
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Neuenschwander JF, Silverstein AR, Teigland CL, Kumar S, Zeng EY, Agiro AT, Pottorf WJ, Peacock WF. The Increased Clinical and Economic Burden of Hyperkalemia in Medicare Patients Admitted to Long-Term Care Settings. Adv Ther 2023; 40:1204-1223. [PMID: 36652174 PMCID: PMC9988794 DOI: 10.1007/s12325-022-02420-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/22/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Older patients are at increased risk for hyperkalemia (HK). This study describes the prevalence, recurrence, and clinical and economic burden of HK in Medicare patients admitted to a long-term care (LTC) setting. METHODS Retrospective cohort study using 100% Medicare Fee-for-Service (FFS) claims identified patients aged ≥ 65 years with index admission between 2017 and 2019 to a LTC setting (skilled nursing, home health, inpatient rehabilitation, or long-term acute care). Beneficiaries were required to have 12 months continuous medical and pharmacy coverage prior to index LTC admission and ≥ 30 days after LTC discharge (follow-up). Patient characteristics, healthcare resource utilization, and costs were assessed. HK was defined as ICD-10 diagnosis code E87.5 in any claim position or Medicare Part D fill for oral potassium binder. RESULTS Of 4,562,231 patients with a LTC stay, the prevalence of HK was 14.7% over the full study period (pre-index, index stay, and follow-up). Excluding those with HK only during the follow-up period resulted in 4,081,103 patients. Of these, 290,567 (7.1%) had HK and 3,790,536 (92.9%) did not have HK during or within 14 days prior to index LTC stay. The HK recurrence rate during index stay and follow-up was 48.3%. Unmatched HK versus non-HK patients were more often male (43.0% vs. 35.4%), Black (13.5% vs. 8.0%), dual eligible for Medicaid (34.2% vs. 25.0%), with higher mean Charlson Comorbidity Index scores (6.2 vs. 3.9) (all p < 0.0001). After propensity matching, HK patients were 2.2 times more likely to be hospitalized, with higher mortality (30.8% vs. 21.5%) and higher total healthcare costs during both index stay (US$26,520 vs. $18,021; p < 0.0011) and follow-up ($57,948 vs. $41,744 (p < 0.0011) versus matched non-HK patients. CONCLUSION Prevalence and recurrence of HK was high among LTC patients, and HK was associated with significantly greater clinical and economic burden during and post-LTC.
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Affiliation(s)
| | | | | | | | - Edric Y Zeng
- Avalere Health, 1201 New York Ave NW, Washington, DC, 20005, USA
| | - Abiy T Agiro
- AstraZeneca, 1800 Concord Pike, Wilmington, DE, 19803, USA
| | | | - W Frank Peacock
- Henry J.N. Taub Department of Emergency Medicine, Ben Taub Hospital, 1504 Taub Loop, Houston, TX, 77030, USA
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29
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Wang GHM, Morris EJ, Smith SM, Hallas J, Vouri SM. Continued potassium supplementation use following loop diuretic discontinuation in older adults: An evaluation of a prescribing cascade relic. J Am Geriatr Soc 2023; 71:505-515. [PMID: 36289555 PMCID: PMC9957829 DOI: 10.1111/jgs.18103] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/06/2022] [Accepted: 10/02/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The use of a new medication (e.g., potassium supplementation) for managing a drug-induced adverse event (e.g., loop diuretic-induced hypokalemia) constitutes a prescribing cascade. However, loop diuretics are often stopped while potassium may be unnecessarily continued (i.e., relic). We aimed to quantify the occurrence of relics using older adults previously experiencing a loop diuretic-potassium prescribing cascade as an example. METHODS We conducted a prescription sequence symmetry analysis using the population-based Medicare Fee-For-Service data (2011-2018) and partitioned the 150 days following potassium initiation by day to assess the daily treatment scenarios (i.e., loop diuretics alone, potassium alone, combination of loop diuretics and potassium, or neither). We calculated the proportion of patients developing the relic, proportion of person-days under potassium alone, the daily probability of the relic, and the proportion of patients filling potassium after loop diuretic discontinuation. We also identified the risk factors of the relic. RESULTS We identified 284,369 loop diuretic initiators who were 8 times more likely to receive potassium supplementation simultaneously or after (i.e., the prescribing cascade), rather than before, loop diuretic initiation (aSR 8.0, 95% CI 7.9-8.2). Among the 66,451 loop diuretic initiators who subsequently (≤30 days) initiated potassium, 20,445 (30.8%) patients remained on potassium after loop diuretic discontinuation, and 9365 (14.1%) patients subsequently filled another potassium supplementation. Following loop diuretic initiation, 4.0% of person-days were for potassium alone, and daily probability of the relic was the highest after day 90 of loop diuretic initiation (5.6%). Older age, female sex, higher diuretic daily dose, and greater baseline comorbidities were risk factors for the relic, while patients having the same prescriber or pharmacy involved in the use of both medications were less likely to experience the relic. CONCLUSIONS Our findings suggest the need for clinicians to be aware of the potential of relic to avoid unnecessary drug use.
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Affiliation(s)
- Grace Hsin-Min Wang
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States
| | - Earl J. Morris
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States
| | - Steven M. Smith
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, United States
| | - Jesper Hallas
- Department of Pharmacology, Odense University Hospital, Odense, Denmark
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Scott M. Vouri
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, United States
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30
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Pollack CV, Agiro A, Mu F, Cook EE, Lemus Wirtz E, Young JA, Betts KA, Brahmbhatt YG. Impact on hospitalizations of long-term versus short-term therapy with sodium zirconium cyclosilicate during routine outpatient care of patients with hyperkalemia: the recognize I study. Expert Rev Pharmacoecon Outcomes Res 2023; 23:241-250. [PMID: 36576213 DOI: 10.1080/14737167.2023.2161514] [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] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hyperkalemia is associated with increased healthcare resource utilization (HRU). This study evaluated the impact of sodium zirconium cyclosilicate (SZC) use on HRU in outpatients with hyperkalemia. RESEARCH DESIGN AND METHODS A retrospective noncomparative study using claims data from the HealthVerity warehouse, which included outpatients in the United States who initiated SZC between January and December 2019 (index date) with ≥6 months' continuous coverage before (baseline) and after (follow-up) the index date (total coverage of 12 months). The study aimed to describe HRU with long-term and short-term SZC (defined as >90 and ≤90 days' supply, respectively, during 180 days' follow-up) and identify characteristics associated with long-term versus short-term therapy. RESULTS Of 1153 patients, 748 (64.9%) received short-term and 405 (35.1%) received long-term therapy. During follow-up, lower proportions of patients on long-term versus short-term therapy had hyperkalemia-related hospitalizations (10.1% vs 15.1%; P < 0.05) and all-cause hospitalizations (22.5% vs 29.3%; P < 0.05). Hyperkalemia-related and all-cause hospitalization proportions were 33.0% and 23.3% lower, respectively. Predictors of long-term therapy included stage 3 chronic kidney disease. CONCLUSIONS Approximately one-third of patients with hyperkalemia received long-term SZC therapy. Hyperkalemia-related and all-cause hospitalization proportions were lower with long-term therapy, although further confirmatory studies are needed.
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Affiliation(s)
- Charles V Pollack
- Emergency Medicine, University of Mississippi, Jackson, Mississippi, United States
| | - Abiy Agiro
- US Medical Affairs, AstraZeneca, Wilmington, Delaware, United States
| | - Fan Mu
- Health Economics and Outcomes Research, Analysis Group, Boston, Massachusetts
| | - Erin E Cook
- Health Economics and Outcomes Research, Analysis Group, Boston, Massachusetts
| | - Esteban Lemus Wirtz
- Health Economics and Outcomes Research, Analysis Group, Boston, Massachusetts
| | - Joshua A Young
- Health Economics and Outcomes Research, Analysis Group, Boston, Massachusetts
| | - Keith A Betts
- Health Economics and Outcomes Research, Analysis Group, Boston, Massachusetts
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31
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Kanda E, Morita N, Yajima T. Impact of chronic potassium binder treatment on the clinical outcomes in patients with hyperkalemia: Results of a nationwide hospital-based cohort study. Front Physiol 2023; 14:1156289. [PMID: 37123269 PMCID: PMC10130648 DOI: 10.3389/fphys.2023.1156289] [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: 02/01/2023] [Accepted: 03/29/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction: Hyperkalemia (HK) is a common disorder in patients with heart failure or chronic kidney disease, and potassium binders (PBs) are recommended to control serum potassium (S-K) levels. Although HK is often a chronic condition, short-term and intermittent PBs treatment has been largely applied to control S-K levels, and little is known about the impact of long-term and chronic PBs treatment on clinical outcomes. Method: This retrospective cohort study was conducted using a Japanese claims database (April 2008-September 2018). HK was defined as at least two S-K ≥5.1 mmol/L within a 12-month(M) interval. The index date was defined as the initial PB prescription date, and the S-K values were examined at 3M, 6M, and 12M after the index. The medication possession ratio (MPR) was used to evaluate the length of the prescribed period of PB, as prescription refill was not allowed in Japan. Clinical outcomes were analyzed by comparing MPR <80% to MPR ≥80% using Cox proportional hazards regression. Results: We found 4,321 patients with HK and were on initial PB treatments, and 993 and 3,328 patients were categorized in the MPR <80% and MPR ≥80% groups, respectively. The mean prescription days ±SD in the MPR <80% and MPR ≥80% groups were 114.7 ± 9.1 and 1151.2 ± 22.5, respectively. S-K value with adjustment by covariates in MPR <80% and MPR ≥80% groups were 5.62 (95% CI: 5.57-5.68) and 5.72 (95% CI: 5.68-5.76) at index followed by 4.65 (95% CI: 4.58-4.71) and 4.57 (95% CI: 4.51-4.62) at 3M, respectively. The hazard ratios of incidence rates in hospitalization was 1.41 (p < 0.001), introduction of renal replacement therapy was 1.25 (p < 0.003), recurrent HK was 1.67 (p < 0.001), and decreased eGFR was 1.41 (p < 0.001), respectively. Conclusion: These results indicate a higher risk of adverse outcomes when PBs were not prescribed chronically, whereas S-K levels were similarly controlled. Chronic control with continued PBs rather than temporary treatment may be associated with the reduction of adverse clinical outcomes in patients with HK.
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Affiliation(s)
- Eiichiro Kanda
- Medical Science, Kawasaki Medical School, Okayama, Japan
| | - Naru Morita
- Cardiovascular, Renal, and Metabolism, Medical Affairs, Osaka, Japan
| | - Toshitaka Yajima
- Cardiovascular, Renal, and Metabolism, Medical Affairs, Osaka, Japan
- *Correspondence: Toshitaka Yajima,
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32
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Imamura T, Fujioka H, Narang N, Kinugawa K. Impact of Sodium Zirconium Cyclosilicate Therapy on Nutrition Status in Patients with Hyperkalemia. J Clin Med 2022; 12:jcm12010083. [PMID: 36614883 PMCID: PMC9821758 DOI: 10.3390/jcm12010083] [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: 11/21/2022] [Revised: 12/07/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Restriction of oral potassium intake is a necessary dietary intervention for managing chronic hyperkalemia. These dietary changes may have negative impacts on nutrition status, particularly in geriatric cohorts with multiple comorbidities. Sodium zirconium cyclosilicate (SZC) is a newly introduced potassium binder intended for patients with hyperkalemia. We aimed to investigate whether the improvements in hyperkalemia with SZC therapy and the liberation of potassium intake restriction may improve nutrition status in a primarily geriatric patient cohort with chronic hyperkalemia. Methods: Patients who were maintained on SZC therapy for at least 3 months were retrospectively studied. Following the initiation of SZC and improvement in hyperkalemia, instructions on the restriction of potassium intake were loosened according to the institutional protocol. The change in nutrition status during the 3 month therapeutic period using SZC was investigated by referencing the prognostic nutritional index score (PNI), geriatric nutritional risk index score (GNRI), and controlling nutritional status (CONUT) scores. Results: A total of 24 patients (median age 78 years, 58% men, median estimated glomerular filtration rate 29.8 mL/min//1.73 m2) were included. Serum potassium level decreased significantly from 5.4 (5.1, 5.9) to 4.4 (4.2, 4.9) mEq/L without any drug-related adverse events, including hypokalemia. Nutrition-related scores, including the PNI score, the GNRI score, and the CONUT score, improved significantly following 3 months of SZC therapy (p < 0.05 for all). Psoas muscle volume and average days for one movement also improved significantly during the therapeutic period (p < 0.05 for both). Conclusions: Mid-term SZC therapy and liberation of potassium intake restriction might improve nutrition status in geriatric patients with chronic hyperkalemia.
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Affiliation(s)
- Teruhiko Imamura
- Second Department of Medicine, University of Toyama, Toyama 930-0194, Japan
- Correspondence: ; Tel.: +81-76-434-2281; Fax: +81-76-434-5026
| | - Hayato Fujioka
- Second Department of Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Nikhil Narang
- Advocate Christ Medical Center, Oak Lawn, IL 60453, USA
| | - Koichiro Kinugawa
- Second Department of Medicine, University of Toyama, Toyama 930-0194, Japan
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Stanski NL, Gist KM, Pickett K, Brinton JT, Sadlowski J, Wong HR, Mourani P, Soranno DE, Kendrick J, Stenson EK. Electrolyte derangements in critically ill children receiving balanced versus unbalanced crystalloid fluid resuscitation. BMC Nephrol 2022; 23:388. [PMID: 36474179 PMCID: PMC9727874 DOI: 10.1186/s12882-022-03009-w] [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: 08/02/2022] [Accepted: 11/15/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Adult studies have demonstrated potential harm from resuscitation with 0.9% sodium chloride (0.9%NaCl), resulting in increased utilization of balanced crystalloids like lactated ringers (LR). The sodium and potassium content of LR has resulted in theoretical safety concerns, although limited data exists in pediatrics. We hypothesized that use of LR for resuscitation would not be associated with increased electrolyte derangements compared to 0.9%NaCl. METHODS A prospective, observational cohort study of critically ill children who received ≥ 20 ml/kg of fluid resuscitation and were admitted to two pediatric intensive care units from November 2017 to February 2020. Fluid groups included patients who received > 75% of fluids from 0.9%NaCl, > 75% of fluids from LR, and a mixed group. The primary outcome was incidence of electrolyte derangements (sodium, chloride, potassium) and acidosis. RESULTS Among 559 patients, 297 (53%) received predominantly 0.9%NaCl, 74 (13%) received predominantly LR, and 188 (34%) received a mixture. Extreme hyperkalemia (potassium ≥ 6 mmol/L) was more common in 0.9%NaCl group (5.8%) compared to LR group (0%), p 0.05. Extreme acidosis (pH > 7.1) was more common in 0.9%NaCl group (11%) compared to LR group (1.6%), p 0.016. CONCLUSIONS LR is associated with fewer electrolyte derangements compared to 0.9%NaCl. Prospective interventional trials are needed to validate these findings.
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Affiliation(s)
- Natalja L. Stanski
- grid.239573.90000 0000 9025 8099Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Katja M. Gist
- grid.24827.3b0000 0001 2179 9593Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH USA ,grid.239573.90000 0000 9025 8099Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Kaci Pickett
- grid.430503.10000 0001 0703 675XDepartment of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO USA ,grid.430503.10000 0001 0703 675XDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA
| | - John T. Brinton
- grid.430503.10000 0001 0703 675XDepartment of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO USA ,grid.430503.10000 0001 0703 675XDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA
| | - Jennifer Sadlowski
- grid.413957.d0000 0001 0690 7621Research Informatics, Children’s Hospital Colorado, Aurora, CO USA
| | - Hector R. Wong
- grid.239573.90000 0000 9025 8099Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Peter Mourani
- grid.241054.60000 0004 4687 1637Department of Pediatrics, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR USA ,grid.239305.e0000 0001 2157 2081Division of Critical Care Medicine, Arkansas Children’s Hospital, Little Rock, AR USA
| | - Danielle E. Soranno
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA ,grid.430503.10000 0001 0703 675XSection of Nephrology, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO USA ,grid.430503.10000 0001 0703 675XDivision of Renal Disease and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Jessica Kendrick
- grid.430503.10000 0001 0703 675XDivision of Renal Disease and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Erin K. Stenson
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA ,grid.430503.10000 0001 0703 675XSection of Critical Care, University of Colorado School of Medicine and Children’s Hospital Colorado, 13121 E 17th Avenue, MS8414, Aurora, CO 80045 USA
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Huda AB, Langford C, Lake J, Langford N. Hyperkalaemia and potassium binders: Retrospective observational analysis looking at the efficacy and cost effectiveness of calcium polystyrene sulfonate and sodium zirconium cyclosilicate. J Clin Pharm Ther 2022; 47:2170-2175. [PMID: 36114759 DOI: 10.1111/jcpt.13766] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/05/2022] [Accepted: 08/10/2022] [Indexed: 12/24/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Hyperkalaemia is a common medical emergency in patients admitted to hospital. There is a limited evidence base supporting some of the commonly applied treatment strategies. Although, NICE has recommended the use of sodium zirconium cyclosilicate (SZC) (TA599) and patiromer (TA623) in both acute and chronic hyperkalaemia, there is a limited evidence base for their use in acute hyperkalaemia in the hospital setting, particularly when compared to the present standard of care calcium polystyrene sulfonate (CPS). METHODS A retrospective review of the electronic patient record system across our hospital over a 6-month period identified 138 patients who received either SZC (65 patients) or CPS (73 patients) to manage hyperkalaemia, investigating their efficacy and cost effectiveness. Results were analysed using simple descriptive statistics. Based on the results a naïve cost comparison between the two drugs was made. RESULTS AND DISCUSSION CPS and SZC both effectively reduced plasm potassium concentrations in patients with hyperkalaemia (6.07 and 6.03 mmol/L respectively) by 1.17 mmol/L and 1.24 mmol/L taking a similar amount of time to work (2.97 days vs. 3 days). The principle causes of hyperkalaemia identified were acute kidney injury, medication, and chronic kidney disease. Cost comparison analysis which took into account raw product price and time needed to dispense medications revealed that CPS has slightly better cost effectiveness compared to SZC albeit at a cost of increased staff input. WHAT IS NEW AND CONCLUSION Both CPS and SZC were equally effective at lowering acutely raised potassium concentrations. The cost difference between the two products appears to be small. Claims regarding the benefits of newer agents over older established medications need to be properly explored in randomized trials rather than being based on small scale non-comparative studies.
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Affiliation(s)
- Abdullah Bin Huda
- Department of Acute Internal Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - James Lake
- Department of Acute Internal Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Nigel Langford
- Department of Acute Internal Medicine, University Hospitals of Leicester, Leicester, UK.,Honorary Senior Lecturer, University of Leicester, Leicester, UK
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Yao L, Xing X, Li Y, Zhang F, Li P, Liang X, Wang P. Effects of different potassium-lowering regimens on acute hyperkalemia in hemodialysis patients: a real-world, retrospective study. J Transl Med 2022; 20:333. [PMID: 35879718 PMCID: PMC9310460 DOI: 10.1186/s12967-022-03530-4] [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: 04/20/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Hyperkalemia is a common and potentially life-threatening electrolyte disorder in maintenance hemodialysis (MHD) patients. This study aimed to evaluate the efficacy and safety of potassium-lowering regimens during treatment of acute hyperkalemia in MHD patients. Methods This retrospective real-world study (RWS) was conducted among 139 MHD patients. They were given different potassium-lowering regimens, viz. the insulin and glucose (IG) intravenous administration group (IG, 46 patients), the sodium polystyrene sulfonate group (SPS, 33 patients), the sodium zirconium cyclosilicate group (SZC, 38 patients), the IG + SZC group (22 patients). The primary efficacy end point was the rate of serum potassium decline at 2 h. The rates of adverse events were also compared. Results At 2 h, the mean ± SE change of serum potassium level was − 0.71 ± 0.32 mmol per liter (mmol/L) in IG group, − 0.43 ± 0.38 mmol/L in SPS group, − 0.64 ± 0.36 mmol/L in SZC group, − 1.43 ± 0.38 mmol/L in IG + SZC group (P < 0.01). The serum potassium level in IG + SZC group decreased more than that in the other three groups (P < 0.01), while the serum potassium level in SPS group decreased less than that in the other three groups (P < 0.05). There was no significant difference on the decrease of the serum potassium level between IG group and the SZC group (P = 0.374). The IG group and the IG + SZC group had higher rates of symptomatic hypoglycemia. The SPS group had significant decreases of serum calcium and serum magnesium after treatment. Conclusions Among MHD patients with acute hyperkalemia, SZC had similar potassium-lowering efficacy with IG intravenous administration at 2 h and superior on convenience and side-effects. Supplementary Information The online version contains supplementary material available at 10.1186/s12967-022-03530-4.
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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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Kijprasert W, Tarudeeyathaworn N, Loketkrawee C, Pimpaporn T, Pattarasettaseranee P, Tangsuwanaruk T. Predicting hypoglycemia after treatment of hyperkalemia with insulin and glucose (Glu-K60 score). BMC Emerg Med 2022; 22:179. [DOI: 10.1186/s12873-022-00748-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Hyperkalemia can lead to fatal cardiac arrhythmias. Ten units of intravenous (IV) regular insulin with 25 g of glucose is the mainstay for treating hyperkalemia. However, the most important complication of this treatment is hypoglycemia. We aimed to develop a scoring model to predict hypoglycemia after the treatment of hyperkalemia.
Methods
A retrospective study was conducted at a university-based hospital between January 2013 and June 2021. We included the hyperkalemic patients (> 5.3 mmol/L) who were ≥ 18 years old and treated with 10 units of IV regular insulin with 25 g of glucose. Incomplete data on posttreatment blood glucose, pregnancy, and diabetes mellitus were excluded. Endpoint was posttreatment hypoglycemia (≤ 70 mg/dL or ≤ 3.9 mmol/L). Multivariable logistic regression was used to establish a full model and a subsequently reduced model using the backward elimination method. We demonstrated the model performance using the area under the receiver operating characteristic curve (AuROC), calibration plot, and Hosmer–Lemeshow goodness-of-fit test. Internal validation was done with a bootstrap sampling procedure with 1000 replicates. Model optimism was estimated.
Results
Three hundred and eighty-five patients were included, with 97 posttreatment hypoglycemia (25.2%). The predictive model comprised the following three criteria: age > 60 years old, pretreatment blood glucose ≤ 100 mg/dL (≤ 5.6 mmol/L), and pretreatment potassium > 6 mmol/L. The AuROC of this model was 0.671 (95% confidence interval [CI] 0.608 to 0.735). The calibration plot demonstrated consistency with the original data. Hosmer–Lemeshow goodness-of-fit test showed no evidence of lack-of-fit (p 0.792); therefore, the model was also fit to the original data. Internal validation via bootstrap sampling showed a consistent AuROC of 0.670 (95% CI 0.660 to 0.670) with minimal model optimism. A high risk for posttreatment hypoglycemia was indicated if the patient met at least one of those criteria. Sensitivity and specificity were 95.9% and 14.9%, respectively.
Conclusion
High risk was indicated when at least one of the criteria was met: age > 60 years old, pretreatment blood glucose ≤ 100 mg/dL (≤ 5.6 mmol/L), and pretreatment potassium > 6 mmol/L. Blood glucose levels should frequently check in the high-risk group.
Trial registration
TCTR20210225002 (www.thaiclinicaltrials.org).
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Dialysis as a Novel Adjuvant Treatment for Malignant Cancers. Cancers (Basel) 2022; 14:cancers14205054. [PMID: 36291840 PMCID: PMC9600214 DOI: 10.3390/cancers14205054] [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: 09/09/2022] [Revised: 10/05/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary There is a clear need for new cancer therapies as many cancers have a very short long-term survival rate. For most advanced cancers, therapy resistance limits the benefit of any single-agent chemotherapy, radiotherapy, or immunotherapy. Cancer cells show a greater dependence on glucose and glutamine as fuel than healthy cells do. In this article, we propose using 4- to 8-h dialysis treatments to change the blood composition, i.e., lowering glucose and glutamine levels, and elevating ketone levels—thereby disrupting major metabolic pathways important for cancer cell survival. The dialysis’ impact on cancer cells include not only metabolic effects, but also redox balance, immunological, and epigenetic effects. These pleiotropic effects could potentially enhance the effectiveness of traditional cancer treatments, such as radiotherapies, chemotherapies, and immunotherapies—resulting in improved outcomes and longer survival rates for cancer patients. Abstract Cancer metabolism is characterized by an increased utilization of fermentable fuels, such as glucose and glutamine, which support cancer cell survival by increasing resistance to both oxidative stress and the inherent immune system in humans. Dialysis has the power to shift the patient from a state dependent on glucose and glutamine to a ketogenic condition (KC) combined with low glutamine levels—thereby forcing ATP production through the Krebs cycle. By the force of dialysis, the cancer cells will be deprived of their preferred fermentable fuels, disrupting major metabolic pathways important for the ability of the cancer cells to survive. Dialysis has the potential to reduce glucose levels below physiological levels, concurrently increase blood ketone body levels and reduce glutamine levels, which may further reinforce the impact of the KC. Importantly, ketones also induce epigenetic changes imposed by histone deacetylates (HDAC) activity (Class I and Class IIa) known to play an important role in cancer metabolism. Thus, dialysis could be an impactful and safe adjuvant treatment, sensitizing cancer cells to traditional cancer treatments (TCTs), potentially making these significantly more efficient.
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Rajasekaran A, Bade N, Cutter GR, Rizk DV, Zarjou A. Lactated Ringer's solution and risk of hyperkalemia in patients with reduced kidney function. Am J Med Sci 2022; 364:433-443. [PMID: 35490704 PMCID: PMC10020946 DOI: 10.1016/j.amjms.2022.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 01/10/2022] [Accepted: 04/22/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Emerging evidence supports the superiority of balanced crystalloids such as Lactated Ringer's (LR) compared to normal saline but concerns for the development of hyperkalemia have limited its use. Although LR inherently contains potassium, there exists a paucity of evidence to suggest that LR could potentiate hyperkalemia. To address this, we evaluated the effect of LR on serum potassium in patients with reduced kidney function who are at risk of developing hyperkalemia. METHODS We conducted a single-center, retrospective cohort-based observational clinical study that included 293 clinical encounters who were hospitalized with an estimated glomerular filtration rate (eGFR) of < 30 ml/min/1.73m2, at the time of hospital admission. Subjects must have received a minimum of 500 ml of LR continuously during the admission. Only those with a minimum of one lab report within 24 hours prior to-, and post-LR administration that reported serum measurements of potassium, glucose, and bicarbonate levels were included. Other potential risk factors for developing hyperkalemia including medication, tube feeds, potassium supplements, and red blood cell transfusion during or within 24 hours after LR administration were recorded. RESULTS Serum potassium prior to LR use was highly correlated and predictive of the serum potassium after LR use [P < 0.0001; Odds Ratio 6.77 (3.73 - 12.28)]. Sixteen encounters (5%) developed de-novo hyperkalemia following LR use. No significant positive correlation between the amount of LR administered and the development of hyperkalemia was found. CONCLUSIONS LR use was not independently associated with the development of hyperkalemia in patients with reduced kidney function.
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Affiliation(s)
- Arun Rajasekaran
- Division of Nephrology, Department of Medicine, University of Alabama, Birmingham, AL, USA.
| | - Naveen Bade
- Division of Nephrology, Department of Medicine, University of Alabama, Birmingham, AL, USA.
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama, Birmingham, AL, USA.
| | - Dana V Rizk
- Division of Nephrology, Department of Medicine, University of Alabama, Birmingham, AL, USA.
| | - Abolfazl Zarjou
- Division of Nephrology, Department of Medicine, University of Alabama, Birmingham, AL, USA.
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Dong L, Xu W, Deng Y, Tan J, Qin W. Efficacy and safety of potassium binders in the treatment of patients with chronic kidney disease and hyperkalemia. Eur J Pharmacol 2022; 931:175174. [PMID: 35964658 DOI: 10.1016/j.ejphar.2022.175174] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/15/2022] [Accepted: 07/21/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Gastrointestinal cation exchangers that can bind potassium in the gut, including sodium polystyrene sulfonate (SPS), calcium polystyrene sulfonate (CPS), patiromer and sodium zirconium cyclosilicate (SZC), are emerging medications for the treatment of hyperkalemia with chronic kidney disease (CKD). However, which might be the best alternative for patients with chronic kidney disease and hyperkalemia remains disputed. METHODS We performed this systematic review and network meta-analysis with the Bayesian approach to conduct direct and indirect comparisons among potassium binders regarding their efficacy and safety. The surface under the cumulative ranking curve analysis (SUCRA) was used to calculate the best intervention for each outcome. RESULTS All four potassium binders had a promising effect regarding potassium reduction. SPS had favorable efficacy and safety for short-term use (MD: -0.94; 95% CIs: -1.4 to -0.48; SUCRA = 94.69%), but long-term treatment required strict dose control and assessment of gastrointestinal conditions. CPS had a positive effect on reducing potassium, and could especially maintain the serum potassium concentration in patients receiving renin-angiotensin-aldosterone system inhibitors (RAASi). Patiromer might reduce all-cause mortality in CKD patients with hyperkalemia and have a positive effect on potassium-lowering, though it had significant gastrointestinal adverse effects. SZC had a potassium-lowering effect in both the short-term and long-term, and can be a promising long-term treatment for the hyperkalemia in CKD patients, especially in combination with RAASi. CONCLUSION These four potassium binders had their own advantages and disadvantages, and the medication should be selected according to the clinical situation of the patient.
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Affiliation(s)
- Lingqiu Dong
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Weidong Xu
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Yi Deng
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Jiaxing Tan
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Wei Qin
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Janak E, Kramer H. Calamari, Hyperkalemia, and Renin-Angiotensin System Blockade. Clin J Am Soc Nephrol 2022; 17:1116-1118. [PMID: 35896278 PMCID: PMC9435975 DOI: 10.2215/cjn.07280622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Emily Janak
- Department of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Holly Kramer
- Department of Medicine, Loyola University Chicago, Maywood, Illinois,Division of Nephrology and Hypertension, Loyola University Chicago, Maywood, Illinois,Department of Public Health Sciences, Loyola University Chicago, Maywood, Illinois
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Thongprayoon C, Kattah AG, Mao MA, Keddis MT, Pattharanitima P, Vallabhajosyula S, Nissaisorakarn V, Erickson SB, Dillon JJ, Garovic VD, Cheungpasitporn W. Distinct phenotypes of hospitalized patients with hyperkalemia by machine learning consensus clustering and associated mortality risks. QJM 2022; 115:442-449. [PMID: 34270780 DOI: 10.1093/qjmed/hcab194] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/03/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hospitalized patients with hyperkalemia are heterogeneous, and cluster approaches may identify specific homogenous groups. This study aimed to cluster patients with hyperkalemia on admission using unsupervised machine learning (ML) consensus clustering approach, and to compare characteristics and outcomes among these distinct clusters. METHODS Consensus cluster analysis was performed in 5133 hospitalized adult patients with admission hyperkalemia, based on available clinical and laboratory data. The standardized mean difference was used to identify each cluster's key clinical features. The association of hyperkalemia clusters with hospital and 1-year mortality was assessed using logistic and Cox proportional hazard regression. RESULTS Three distinct clusters of hyperkalemia patients were identified using consensus cluster analysis: 1661 (32%) in cluster 1, 2455 (48%) in cluster 2 and 1017 (20%) in cluster 3. Cluster 1 was mainly characterized by older age, higher serum chloride and acute kidney injury (AKI), but lower estimated glomerular filtration rate (eGFR), serum bicarbonate and hemoglobin. Cluster 2 was mainly characterized by higher eGFR, serum bicarbonate and hemoglobin, but lower comorbidity burden, serum potassium and AKI. Cluster 3 was mainly characterized by higher comorbidity burden, particularly diabetes and end-stage kidney disease, AKI, serum potassium, anion gap, but lower eGFR, serum sodium, chloride and bicarbonate. Hospital and 1-year mortality risk was significantly different among the three identified clusters, with highest mortality in cluster 3, followed by cluster 1 and then cluster 2. CONCLUSION In a heterogeneous cohort of hyperkalemia patients, three distinct clusters were identified using unsupervised ML. These three clusters had different clinical characteristics and outcomes.
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Affiliation(s)
- C Thongprayoon
- From the Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - A G Kattah
- From the Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - M A Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - M T Keddis
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - P Pattharanitima
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, 10120, Thailand
| | - S Vallabhajosyula
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - V Nissaisorakarn
- Department of Internal Medicine, MetroWest Medical Center, Framingham, MA 01702, USA
| | - S B Erickson
- From the Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - J J Dillon
- From the Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - V D Garovic
- From the Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - W Cheungpasitporn
- From the Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Prognostic Factors in Patients with Sudden Cardiac Arrest and Acute Myocardial Infarction Undergoing Percutaneous Interventions with the LUCAS-2 System for Mechanical Cardiopulmonary Resuscitation. J Clin Med 2022; 11:jcm11133872. [PMID: 35807156 PMCID: PMC9267592 DOI: 10.3390/jcm11133872] [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: 05/27/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 02/01/2023] Open
Abstract
Sudden cardiac arrest (SCA) is one of the most perilous complications of acute myocardial infarction (AMI). For years, the return of spontaneous circulation (ROSC) has had to be achieved before the patient could be treated at the catheterization laboratory, as simultaneous manual chest compression and angiography were mutually exclusive. Mechanical chest compression devices enabled simultaneous resuscitation and invasive percutaneous procedures. The aim was to characterize the poorer responders that would allow one to predict the positive outcome of such a treatment. We retrospectively analyzed the medical charts of 94 patients with SCA due to AMI, who underwent mechanical cardiopulmonary resuscitation during angiography. In total, 48 patients, 8 (17%) of which survived the event, were included in the final analysis, which revealed that 83% of the survivors had mild to moderate hyperkalemia (potassium 5.0−6.0 mmol/L), in comparison to 15% of non-survivors (p = 0.002). In the age- and sex-adjusted model, patients with serum potassium > 5.0 mmol/L had 4.61-times higher odds of survival until discharge from the hospital (95% CI: 1.41−15.05, p = 0.01). Using the highest Youden index, we identified the potassium concentration of 5.1 mmol/L to be the optimal cut-off value for prediction of survival until hospital discharge (83.3% sensitivity and 87.9% specificity). The practical implications of these findings are that patients with potassium levels between 5.0 and 6.0 mmol/L may actually benefit most from percutaneous coronary interventions with ongoing mechanical chest compressions and that they do not need immediate correction for this electrolyte abnormality.
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Chenevert L, Truong J. What is causing this dialysis patient's intermittent weakness? JAAPA 2022; 35:63-65. [PMID: 35762960 DOI: 10.1097/01.jaa.0000832620.82159.4a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Laura Chenevert
- At New York-Presbyterian/Columbia University Irving Medical Center in New York City, Laura Chenevert practices in emergency medicine and Jimmy Truong is an assistant professor of emergency medicine. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Yıldırım R, Günsoy E, Eray O. Short-Term Prognosis of Patients with Hyperpotassemia in the Emergency Department. EURASIAN JOURNAL OF EMERGENCY MEDICINE 2022. [DOI: 10.4274/eajem.galenos.2021.60243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Yanagihara C, Kumagi T, Tasaka T, Watanabe Y, Kono T, Ohshima K, Ogimoto A. Potentially Life-threatening Arrhythmia Triggered by an Excessive Consumption of Dried Sweet Potato "Hoshi-Imo". Intern Med 2022; 61:1721-1725. [PMID: 34744114 PMCID: PMC9259324 DOI: 10.2169/internalmedicine.8479-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We herein report two cases of potentially life-threatening arrhythmia due to hyperkalemia triggered by the excessive consumption of "Hoshi-Imo" (dried sweet potato). Both patients with chronic renal disease on renin-angiotensin-aldosterone system inhibitors presented at the emergency room with non-specific symptoms. Electrocardiograms revealed potentially life-threatening arrhythmia due to hyperkalemia in both cases: sinus arrest with a ventricular escape rhythm, tall and peaked T waves; and a widened QRS complex in a nearly sine-wave configuration without discernible P wave. Both patients fully recovered after intensive care for hyperkalemia. Physicians should recognize the excessive consumption of "Hoshi-Imo" may lead to the development of life-threatening arrhythmia, especially in patients with risk factors for hyperkalemia.
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Affiliation(s)
- Chiaki Yanagihara
- Postgraduate Medical Education Center, Ehime University Hospital, Japan
- Postgraduate Medical Education Center, Uwajima Municipal Hospital, Japan
| | - Teru Kumagi
- Postgraduate Medical Education Center, Ehime University Hospital, Japan
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Raffee LA, Alawneh KZ, Ababneh MJ, Hijazi HH, Al Abdi RM, Aboozour MM, Alghzawi FA, Al-Mistarehi AH. Clinical and electrocardiogram presentations of patients with high serum potassium concentrations within emergency settings: a prospective study. Int J Emerg Med 2022; 15:23. [PMID: 35619089 PMCID: PMC9137132 DOI: 10.1186/s12245-022-00422-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Elevated potassium level is a common and reversible peri-arrest condition. Diagnosis and management of hyperkalemia in a short time is critical, where electrocardiogram (ECG) alterations might be helpful. We aimed to investigate the role of clinical features and ECGs in early diagnosing and treating hyperkalemia. METHODS Prospectively, adult patients who presented to the emergency department (ED) from July 2019 to March 2020 with hyperkalemia (serum potassium ≥5.5mmol/L) were included. History was obtained, and laboratory investigations and ECGs were performed at the presentation and before initiating hyperkalemia therapy. Hyperkalemia severity was divided into mild (5.5-5.9mmol/L), moderate (6.0-6.4mmol/L), and severe (≥6.5mmol/L). A cardiologist and emergency physician blinded to laboratory values, study design, and patients' diagnoses interpreted ECGs and presenting symptoms independently to predict hyperkalemia. RESULTS Sixty-seven hyperkalemic patients with a mean (±SD) serum potassium level of 6.5±0.7mmol/L were included in this study. The mean age was 63.9±15.1, and 58.2% were females. Hyperkalemia was mild in 10.4%, moderate in 40.3%, and severe in 49.3%. Almost two thirds of patients (71.6%) had hypertension, 67.2% diabetes, and 64.2% chronic kidney disease. About one-quarter of patients (22.4%) were asymptomatic, while fatigue (46.3%), dyspnea (28.4%), and nausea/vomiting (20.9%) were the most common presenting symptoms. Normal ECGs were observed in 25.4% of patients, while alterations in 74.6%. Atrial fibrillation (13.4%), peaked T wave (11.9%), widened QRS (11.9%), prolonged PR interval (10.5%), and flattening P wave (10.5%) were the most common. Peaked T wave was significantly more common in severe hyperkalemia (87.5%) than in mild and moderate hyperkalemia (12.5%, 0.0%, respectively) (p=0.041). The physicians' sensitivities for predicting hyperkalemia were 35.8% and 28.4%, improved to 51.5% and 42.4%, respectively, when limiting the analyses to severe hyperkalemia. The mean (±SD) time to initial hyperkalemia treatment was 63.8±31.5 min. Potassium levels were positively correlated with PR interval (r=0.283, p=0.038), QRS duration (r=0.361, p=0.003), peaked T wave (r=0.242, p=0.041), and serum levels of creatinine (r=0.347, p=0.004), BUN (r=0.312, p=0.008), and CK (r=0.373, p=0.039). CONCLUSIONS The physicians' abilities to predict hyperkalemia based on ECG and symptoms were poor. ECG could not be solely relied on, and serum potassium tests should be conducted for accurate diagnosis.
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Affiliation(s)
- Liqaa A Raffee
- Department of Accident and Emergency Medicine, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 630001, Irbid, 22110, Jordan.
| | - Khaled Z Alawneh
- Department of Diagnostic Radiology and Nuclear Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Muhannad J Ababneh
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Heba H Hijazi
- Chair of Department of Health Services Administration, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates.,Department of Health Management and Policy, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Rabah M Al Abdi
- Department of Biomedical Engineering, Faculty of Engineering, Jordan University of Science and Technology, Irbid, Jordan
| | - Mahmoud M Aboozour
- Department of Accident and Emergency Medicine, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 630001, Irbid, 22110, Jordan
| | - Fadi A Alghzawi
- Department of Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 630001, Irbid, 22110, Jordan
| | - Abdel-Hameed Al-Mistarehi
- Department of Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 630001, Irbid, 22110, Jordan.
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Plebani M. Competent Well-Trained Phlebotomists. Am J Clin Pathol 2022; 157:640-641. [PMID: 34932100 DOI: 10.1093/ajcp/aqab193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mario Plebani
- Department of Medicine-DIMED, University of Padova, and Department of Integrated Diagnostics, University-Hospital of Padova, Padova, Italy
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Lucas F, Mata DA, Greenblatt MB, Means J, Jarolim P. A Potassium-Based Quality-of-Service Metric Reduces Phlebotomy Errors, Resulting in Improved Patient Safety and Decreased Cost. Am J Clin Pathol 2022; 157:789-798. [PMID: 34932068 DOI: 10.1093/ajcp/aqab194] [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: 09/02/2021] [Accepted: 12/08/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Poor phlebotomy technique can introduce pseudohyperkalemia without hemolysis, requiring additional workup and placing a significant burden on patients, clinical teams, and laboratories. Such preanalytical biases can be detected through systematic evaluation of potassium concentrations on a per-phlebotomist basis. We report our long-term experience with a potassium-based quality-of-service phlebotomy metric and its effects on resource utilization. METHODS Potassium monitoring and retraining of 26 full-time phlebotomists were piloted as a quality-of-service intervention. Changes in potassium concentrations and impact on resource utilization were assessed. An algorithm for data monitoring and phlebotomist feedback was developed, followed by institution-wide implementation. RESULTS Systematic intervention and retraining normalized K+ concentrations and lowered the percentage of venipunctures with K+ above 5.2 mmol/L, leading to a marked increase in phlebotomist compliance. This change resulted in resources savings of 13% to 100% for individual phlebotomists, reducing the total extra laboratory time required for repeat phlebotomies to determine hyperkalemia, mostly in the high-volume phlebotomist group. CONCLUSIONS A quality-of-service algorithm that involved monitoring potassium concentrations on a per-phlebotomist basis with feedback and retraining contributed to a concrete, data-based quality improvement plan. The institution-wide implementation of this metric allowed for significant cost savings and a reduction in critical value alerts, directly affecting the quality of patient care.
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Affiliation(s)
- Fabienne Lucas
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Matthew B Greenblatt
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
- Research Division, Hospital for Special Surgery, New York, NY, USA
| | - Janet Means
- Dana Farber Cancer Institute, Boston, MA, USA
| | - Petr Jarolim
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Dana Farber Cancer Institute, Boston, MA, USA
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50
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Vinson AJ, Zanjir W, Nallbani M, Goldstein J, Swain J, Clark DA, More KM, Manderville JR, Fok PT, Wiemer H, Tennankore KK. Predictors of Hyperkalemia among Patients on Maintenance Hemodialysis Transported to the Emergency Department by Ambulance. KIDNEY360 2022; 3:615-626. [PMID: 35721611 PMCID: PMC9136889 DOI: 10.34067/kid.0008132021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/01/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Hyperkalemia is common among patients on maintenance hemodialysis (HD) and is associated with mortality. We hypothesized that clinical characteristics available at time of paramedic assessment before emergency department (ED) ambulance transport (ambulance-ED) would associate with severe hyperkalemia (K≥6 mmol/L). Rapid identification of patients who are at risk for hyperkalemia and thereby hyperkalemia-associated complications may allow paramedics to intervene in a timely fashion, including directing emergency transport to dialysis-capable facilities. METHODS Patients on maintenance HD from a single paramedic provider region, who had at least one ambulance-ED and subsequent ED potassium from 2014 to 2018, were examined using multivariable logistic regression to create risk prediction models inclusive of prehospital vital signs, days from last dialysis, and the presence of prehospital electrocardiogram (ECG) features of hyperkalemia. We used bootstrapping with replacement to validate each model internally, and performance was assessed by discrimination and calibration. RESULTS Among 704 ambulance-ED visits, severe hyperkalemia occurred in 75 (11%); 26 patients with ED hyperkalemia did not have a prehospital ECG. Younger age at transport, longer HD vintage, more days from last hemodialysis session (OR=49.84; 95% CI, 7.72 to 321.77 for ≥3 days versus HD the same day [before] ED transport), and prehospital ECG changes (OR=6.64; 95% CI, 2.31 to 19.12) were independently associated with severe ED hyperkalemia. A model incorporating these factors had good discrimination (c-statistic 0.82; 95% CI, 0.76 to 0.89) and, using a cutoff of 25% probability, correctly classified patients 89% of the time. CONCLUSIONS Characteristics available at the time of ambulance-ED were associated with severe ED hyperkalemia. An awareness of these associations may allow health care providers to define novel care pathways to ensure timely diagnosis and management of hyperkalemia.
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Affiliation(s)
- Amanda J Vinson
- Nova Scotia Health, Halifax, Canada
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| | | | | | - Judah Goldstein
- Emergency Health Services, Dartmouth, Canada
- Department of Emergency Medicine, Dalhousie University, Halifax, Canada
| | - Janel Swain
- Emergency Health Services, Dartmouth, Canada
- Department of Emergency Medicine, Dalhousie University, Halifax, Canada
| | - David A Clark
- Nova Scotia Health, Halifax, Canada
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Keigan M More
- Nova Scotia Health, Halifax, Canada
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| | | | - Patrick T Fok
- Department of Emergency Medicine, Dalhousie University, Halifax, Canada
| | - Hana Wiemer
- Department of Emergency Medicine, Dalhousie University, Halifax, Canada
| | - Karthik K Tennankore
- Nova Scotia Health, Halifax, Canada
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
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