Risk factors associated with a high velocity of the development of hyperkalaemia in hospitalised patients

Hyperkalemia Among Hospitalized Patients and Association Between Duration of Hyperkalemia and Outcomes

Background Hyperkalemia is a serious life-threatening condition that leads to significant morbidity and mortality. Objectives The aim of this study is to investigate the association between the duration and outcomes in patients hospitalized with hyperkalemia, as well as associated risk factors and drug-induced hyperkalemia. Methods A three-year retrospective chart review study was conducted at a tertiary hospital at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between January 2016 and April 2019. We included all hospitalized adults and patients with hyperkalemia. Pediatric patients and dialysis patients with end-stage renal failure were excluded. Results Out of a total of 300 hospitalized patients who were screened for hyperkalemia, only 142 patients were included. The majority of cases were males (56.3%), whereas 43.7% were females. Most patients were above 55 years old. Regarding comorbidities in patients with hyperkalemia, most of them suffered from high blood pressure or diabetes. The mean serum potassium value was 5.7 ± 0.51 mEq. The most frequent medications used in the study population were azole antifungal medication followed by nonsteroidal anti-inflammatory drugs, beta-blockers, and angiotensin-converting enzyme inhibitors. Around 54 patients were not treated with medication and were monitored for spontaneous correction of hyperkalemia. Insulin was the most used medication for the treatment of hyperkalemia. The mean duration for the resolution of hyperkalemia was 12 ±9.4 hours. Out of 142 patients, only 10 (7%) patients died with hyperkalemia. Conclusions Hospitalized patients are at risk of hyperkalemia. In our study, we found that patients who had hyperkalemia were significantly likely to have acute kidney injury or cardiovascular diseases, and azole antifungals and beta-blockers were the most commonly used medications.

Prevalence of Medication-Dietary Supplement Combined Use and Associated Factors

Introduction: The use of medication has increased in recent years in the US while the use of dietary supplements has remained stable but high. Interactions between these two kinds of products may have important consequences, especially in the case of widely used medications such as antihypertensives and antibiotics. The aim of this paper is to estimate the prevalence of potentially serious drug–dietary supplement interactions among tetracyclines, thiazides, and angiotensin II receptor blocker users by means of the NHANES 2013–2014 dataset. Methods: Data from 2013–2014 NHANES were obtained. Potential interactions analysed were tetracyclines with calcium, magnesium, and zinc, thiazides with vitamin D, and angiotensin II receptors blockers with potassium. Prevalence was calculated for each potential interaction. Logistic regression was used to assess associated factors. Results: 864 prescriptions issued to 820 patients were analysed. Overall prevalence of potential interaction was 49%. Older age and higher educational level were strongly associated with being at risk of a potential interaction. Factors such as age, race, civil status, citizenship, country of birth, BMI, and physical activity did not show notable associations. Conclusions: Healthcare professionals should be aware of other medical products when they prescribe or dispense a medication or a dietary supplement, especially to the older population and people with a higher educational level.

Mechanism of Action and Pharmacology of Patiromer, a Nonabsorbed Cross-Linked Polymer That Lowers Serum Potassium Concentration in Patients With Hyperkalemia

Hyperkalemia is a potentially life-threatening condition, and patients who have chronic kidney disease, who are diabetic, or who are taking renin-angiotensin-aldosterone system inhibitors are at increased risk. Therapeutic options for hyperkalemia tend to have limited effectiveness and can be associated with serious side effects. Colonic potassium secretion can increase to compensate when urinary potassium excretion decreases in patients with renal impairment, but this adaptation is insufficient and hyperkalemia still results. Patiromer is a novel, spherical, nonabsorbed polymer designed to bind and remove potassium, primarily in the colon, thereby decreasing serum potassium in patients with hyperkalemia. Patiromer has been found to decrease serum potassium in patients with hyperkalemia having chronic kidney disease who were on renin-angiotensin-aldosterone system inhibitors. Results of nonclinical studies and an early phase clinical study are reported here. Two studies with radiolabeled drug, one in rats and the other in dogs, confirmed that patiromer was not absorbed into the systemic circulation. Results of an in vitro study showed that patiromer was able to bind 8.5 to 8.8 mEq of potassium per gram of polymer at a pH similar to that found in the colon and had a much higher potassium-binding capacity compared with other resins, including polystyrene sulfonate. In a study in hyperkalemic rats, a decrease in serum potassium was observed via an increase in fecal potassium excretion. In a clinical study in healthy adult volunteers, a significant increase in fecal potassium excretion and a significant decrease in urinary potassium excretion were observed. Overall, patiromer is a high-capacity potassium binder, and the chemical and physical characteristics of patiromer may lead to good clinical efficacy, tolerability, and patient acceptance.

Multicentre randomized controlled trial of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker withdrawal in advanced renal disease: the STOP-ACEi trial

BACKGROUND

Blood pressure (BP) control and reduction of urinary protein excretion using agents that block the renin-angiotensin aldosterone system are the mainstay of therapy for chronic kidney disease (CKD). Research has confirmed the benefits in mild CKD, but data on angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) use in advanced CKD are lacking. In the STOP-ACEi trial, we aim to confirm preliminary findings which suggest that withdrawal of ACEi/ARB treatment can stabilize or even improve renal function in patients with advanced progressive CKD.

METHODS

The STOP-ACEi trial (trial registration: current controlled trials, ISRCTN62869767) is an investigator-led multicentre open-label, randomized controlled clinical trial of 410 participants with advanced (Stage 4 or 5) progressive CKD receiving ACEi, ARBs or both. Patients will be randomized in a 1:1 ratio to either discontinue ACEi, ARB or combination of both (experimental arm) or continue ACEi, ARB or combination of both (control arm). Patients will be followed up at 3 monthly intervals for 3 years. The primary outcome measure is eGFR at 3 years. Secondary outcome measures include the number of renal events, participant quality of life and physical functioning, hospitalization rates, BP and laboratory measures, including serum cystatin-C. Safety will be assessed to ensure that withdrawal of these treatments does not cause excess harm or increase mortality or cardiovascular events such as heart failure, myocardial infarction or stroke.

RESULTS

The rationale and trial design are presented here. The results of this trial will show whether discontinuation of ACEi/ARBs can improve or stabilize renal function in patients with advanced progressive CKD. It will show whether this simple intervention can improve laboratory and clinical outcomes, including progression to end-stage renal disease, without causing an increase in cardiovascular events.

Hyperkalemia among hospitalized patients and association between duration of hyperkalemia and outcomes

INTRODUCTION

The aim of the study was to investigate predictors of mortality in patients hospitalized with hyperkalemia.

MATERIAL AND METHODS

Data among hospitalized patients with hyperkalemia (serum potassium ≥ 5.1 mEq/l) were collected. Patients with end-stage renal disease on dialysis were excluded.

RESULTS

Of 15,608 hospitalizations, 451 (2.9%) episodes of hyperkalemia occurred in 408 patients. In patients with hyperkalemia, chronic kidney disease, hypertension, diabetes, coronary artery disease and heart failure were common comorbidities. Acute kidney injury (AKI) and metabolic acidosis were common metabolic abnormalities, and 359 patients (88%) were on at least one drug associated with hyperkalemia. Mean duration to resolution of hyperkalemia was 12 ±9.9 h. Nonsteroidal anti-inflammatory drugs (HR = 1.59), highest potassium level (HR = 0.61), tissue necrosis (HR = 0.61), metabolic acidosis (HR = 0.77), and AKI (HR = 0.77) were significant independent determinants of duration prior to hyperkalemia resolution. Tissue necrosis (OR = 4.55), potassium supplementation (OR = 5.46), metabolic acidosis (OR = 4.84), use of calcium gluconate for treatment of hyperkalemia (OR = 4.62), AKI (OR = 3.89), and prolonged duration of hyperkalemia (OR = 1.06) were significant independent predictors of in-hospital mortality.

CONCLUSIONS

Tissue necrosis, potassium supplementation, metabolic acidosis, calcium gluconate for treatment of hyperkalemia, AKI and prolonged duration of hyperkalemia are independent predictors of in-hospital mortality.

Patient- and physician-related risk factors for hyperkalaemia in potassium-increasing drug-drug interactions

PURPOSE

Hyperkalaemia due to potassium-increasing drug-drug interactions (DDIs) is a clinically important adverse drug event. The purpose of this study was to identify patient- and physician-related risk factors for the development of hyperkalaemia.

METHODS

The risk for adult patients hospitalised in the University Hospital Zurich between 1 December 2009 and 31 December 2011 of developing hyperkalaemia was correlated with patient characteristics, number, type and duration of potassium-increasing DDIs and frequency of serum potassium monitoring.

RESULTS

The 76,467 patients included in this study were prescribed 8,413 potentially severe potassium-increasing DDIs. Patient-related characteristics associated with the development of hyperkalaemia were pulmonary allograft [relative risk (RR) 5.1; p < 0.0001), impaired renal function (RR 2.7; p < 0.0001), diabetes mellitus (RR 1.6; p = 0.002) and female gender (RR 1.5; p = 0.007). Risk factors associated with medication were number of concurrently administered potassium-increasing drugs (RR 3.3 per additional drug; p < 0.0001) and longer duration of the DDI (RR 4.9 for duration ≥6 days; p < 0.0001). Physician-related factors associated with the development of hyperkalaemia were undetermined or elevated serum potassium level before treatment initiation (RR 2.2; p < 0.001) and infrequent monitoring of serum potassium during a DDI (interval >48 h: RR 1.6; p < 0.01).

CONCLUSION

Strategies for reducing the risk of hyperkalaemia during potassium-increasing DDIs should consider both patient- and physician-related risk factors.

Potential drug-drug interactions in prescriptions to patients over 45 years of age in primary care, southern Brazil

BACKGROUND

Few cross-sectional studies involving adults and elderly patients with major DDIs have been conducted in the primary care setting. The study aimed to investigate the prevalence of potential drug-drug interactions (DDIs) in patients treated in primary care.

METHODOLOGY/PRINCIPAL FINDINGS

A cross-sectional study involving patients aged 45 years or older was conducted at 25 Basic Health Units in the city of Maringá (southern Brazil) from May to December 2010. The data were collected from prescriptions at the pharmacy of the health unit at the time of the delivery of medication to the patient. After delivery, the researcher checked the electronic medical records of the patient. A total of 827 patients were investigated (mean age: 64.1; mean number of medications: 4.4). DDIs were identified in the Micromedex® database. The prevalence of potential DDIs and major DDIs was 63.0% and 12.1%, respectively. In both the univariate and multivariate analyses, the number of drugs prescribed was significantly associated with potential DDIs, with an increasing risk from three to five drugs (OR = 4.74; 95% CI: 2.90-7.73) to six or more drugs (OR = 23.03; 95% CI: 10.42-50.91). Forty drugs accounted for 122 pairs of major DDIs, the most frequent of which involved simvastatin (23.8%), captopril/enalapril (16.4%) and fluoxetine (16.4%).

CONCLUSIONS/SIGNIFICANCE

This is the first large-scale study on primary care carried out in Latin America. Based on the findings, the estimated prevalence of potential DDIs was high, whereas clinically significant DDIs occurred in a smaller proportion. Exposing patients to a greater number of prescription drugs, especially three or more, proved to be a significant predictor of DDIs. Prescribers should be more aware of potential DDIs. Future studies should assess potential DDIs in primary care over a longer period of time.

[When the resting membrane potential becomes restless. Acute hyperkalemia in the perioperative phase]

Acute hyperkalemia is a life-threatening event and often occurs abruptly and without warning in the perioperative field. Risk factors are found on multiple levels as they can derive from a patients pre-existing condition or result from the surgical intervention or management of anesthesia. The therapy of hyperkalemia depends on the dimensions of electrolyte disturbance and a distinction can be made between therapeutic measures with a rapid and those with a long-term effect.

Effect of heparin and low-molecular weight heparin on serum potassium and sodium levels

Introduction:

To study the effects of heparin and low-molecular weight heparin (LMWH) on potassium and sodium levels in patients with cardiovascular diseases (CVDs) and stroke.

Materials and Methods:

Sixty patients were recruited with 30 patients each receiving heparin and enoxaparin. Patients with CVD and stroke receiving heparin and LMWH were compared for their demographic profile and laboratory data, and this was analyzed by descriptive statistics. Risk factors associated with the development of hyperkalemia were analyzed using multiple logistic regression model.

Results:

There was an increase in potassium levels and decrease in sodium levels compared with baseline in both the groups. The difference between the groups with respect to sodium and potassium levels was not statistically significant. On analysis, the risk factors for development of hyperkalemia were baseline potassium levels, serum creatinine, and creatinine clearance. The change in sodium and potassium levels on the fifth day of therapy was increased with LMWH compared with heparin, although not statistically significant.

Conclusions:

The clinician should anticipate hyperkalemia especially in patients with renal impairment receiving these drugs.

Prevalence of potential drug interactions in patients in an intensive care unit of a university hospital in Brazil

OBJECTIVES

To investigate the prevalence of potential drug interactions at the intensive care unit of a university hospital in Brazil and to analyze their clinical significance.

METHODS

This cross-sectional retrospective study included 299 patients who had been hospitalized in the intensive care unit of the hospital. The drugs administered during the first 24 hours of hospitalization, in the 50th length-ofstay percentile and at the time of discharge were analyzed to identify potential drug-drug and drug-enteral nutrition interactions using DRUG-REAXH software. The drugs were classified according to the anatomical therapeutic chemical classification.

RESULTS

The median number of medications per patient was smaller at the time of discharge than in the 50th length-of-stay percentile and in the first 24 hours of hospitalization. There was a 70% prevalence of potential drug interactions at the intensive care unit at the studied time points of hospitalization. Most of the drug interactions were either severe or moderate, and the scientific evidence for the interactions was, in general, either good or excellent. Pharmacodynamic interactions presented a subtle predominance in relation to pharmacokinetic interactions. The occurrence of potential drug interactions was associated with the number of medications administered and the length of stay. Medications that induced cytochrome P450, drugs that prolong the QT interval and cardiovascular drugs were pharmacotherapy factors associated with potential drug interactions.

CONCLUSION

The study showed that potential drug interactions were prevalent in the intensive care unit due to the complexity of the pharmacotherapies administered. The interactions were associated with the number of drugs, the length of stay and the characteristics of the administered medications.

Hyperpotassemia and bradycardia in a bedridden elderly woman with selective hypoaldosteronism associated with low renin activity

A bedridden 85-year-old woman had hyperpotassemia (7.7 mEq/L) and bradycardia (30/min). Endocrinologic findings revealed a decrease in the renin-aldosterone system and normal adrenoglucocorticoid function. The results were consistent with the abnormalities seen in selective hypoaldosteronism with low renin activity. In addition, 9 of 11 patients, selected randomly from 72 bedridden elderly patients with normal serum sodium and potassium levels in our hospital, had diminished plasma renin activity (PRA) and plasma aldosterone concentration (PAC). The present patient was prescribed nonsteroidal anti-inflammatory drug (NSAID). NSAID reduces renal potassium excretion through the inhibition of renal prostaglandin synthesis. Therefore, the use of NSAID in bedridden elderly patients might intensify the underlying asymptomatic hypoaldosteronism and cause life-threatening hyperpotassemia.