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Zhang H, Liu J, Liu X, Guo W, Huang H, Liu W, Diao Z. Pre- to post-dialysis potassium gradient and mortality in patients on hemodialysis: A propensity-matched analysis. Ther Apher Dial 2024. [PMID: 39342973 DOI: 10.1111/1744-9987.14213] [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: 07/17/2024] [Revised: 09/07/2024] [Accepted: 09/16/2024] [Indexed: 10/01/2024]
Abstract
INTRODUCTION Pre- to post-dialysis potassium gradient (ΔK) has arrhythmogenic effects; however, its effect on mortality remains unclear. The relationship between ΔK and mortality was assessed. METHODS All patients undergoing hemodialysis in Beijing in 2014 were eligible for inclusion. The low (≤1.2 mmol/L), median (1.2-1.8 mmol/L), and high (>1.8 mmol/L) ΔK groups were matched by sex, age, diabetes, and dialysis time for enrollmen. The primary and secondary outcomes were all-cause and cardiovascular death within the follow-up. Cox regression analysis was performed to evaluate the effect of ΔK on mortality. We also analyzed the associations of combinations of ΔK and pre-dialysis potassium with mortality. RESULTS We enrolled 2181 patients in three matched groups (n = 727 per group). The median follow-up was 72.0 (interquartile range, 53.7-72.0) months. All-cause mortality occurred in 215/727 (29.6%), 95/727 (13.1%), and 198/727 (27.2%) patients in the low-, median-, and high-ΔK groups, respectively. After adjusting for multiple factors, the median ΔK group had better survival than the low- (hazard ratio (HR), 1.91; 95% confidence interval [95% CI], 1.45-2.52; p < 0.001) and high-ΔK groups (HR, 2.17; 95% CI, 1.57-2.99; p < 0.001). Further analysis based on pre-dialysis potassium revealed that when maintaining a level of 4.5-5.5 mmol/L and ΔK of 1.2-1.8 mmol/L, patients had the lowest risk of mortality, whereas the highest risk was observed when pre-dialysis potassium was >5.5 mmol/L and ΔK was >1.8 mmol/L. CONCLUSION Maintaining serum potassium within a appropriate range and reducing potassium fluctuations during dialysis may help to reduce the mortality risk of maintenance hemodialysis patients. These findings provide important data support for the quality control of hemodialysis.
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Affiliation(s)
- Huixian Zhang
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jing Liu
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xu Liu
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wang Guo
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hongdong Huang
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wenhu Liu
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zongli Diao
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Guo L, Ji Y, Sun T, Liu Y, Jiang C, Wang G, Xing H, Yang B, Xu A, Xian X, Yang H. Management of Chronic Heart Failure in Dialysis Patients: A Challenging but Rewarding Path. Rev Cardiovasc Med 2024; 25:232. [PMID: 39076321 PMCID: PMC11270084 DOI: 10.31083/j.rcm2506232] [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: 08/20/2023] [Revised: 01/15/2024] [Accepted: 03/04/2024] [Indexed: 07/31/2024] Open
Abstract
Chronic heart failure (CHF) is a common complication and cause of death in dialysis patients. Although several clinical guidelines and expert consensus on heart failure (HF) in the general population have been issued in China and abroad, due to abnormal renal function or even no residual renal function (RRF) in dialysis patients, the high number of chronic complications, as well as the specificity, variability, and limitations of hemodialysis (HD) and peritoneal dialysis (PD) treatments, there are significant differences between dialysis patients and the general population in terms of the treatment and management of HF. The current studies are not relevant to all dialysis-combined HF populations, and there is an urgent need for high-quality studies on managing HF in dialysis patients to guide and standardize treatment. After reviewing the existing guidelines and literature, we focused on the staging and diagnosis of HF, management of risk factors, pharmacotherapy, and dialysis treatment in patients on dialysis. Based on evidence-based medicine and clinical trial data, this report reflects new perspectives and future trends in the diagnosis and treatment of HF in dialysis patients, which will further enhance the clinicians' understanding of HF in dialysis patients.
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Affiliation(s)
- Luxuan Guo
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, 300193 Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, 300193 Tianjin, China
- Tianjin University of Traditional Chinese Medicine, 301617 Tianjin, China
| | - Yue Ji
- Dongzhimen Hospital, Beijing University of Traditional Chinese Medicine, Institute of Nephrology & Beijing Key Laboratory, 100700 Beijing, China
| | - Tianhao Sun
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, 300193 Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, 300193 Tianjin, China
- Tianjin University of Traditional Chinese Medicine, 301617 Tianjin, China
| | - Yang Liu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, 300193 Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, 300193 Tianjin, China
- Tianjin University of Traditional Chinese Medicine, 301617 Tianjin, China
| | - Chen Jiang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, 300193 Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, 300193 Tianjin, China
- Tianjin University of Traditional Chinese Medicine, 301617 Tianjin, China
| | - Guanran Wang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, 300193 Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, 300193 Tianjin, China
- Tianjin University of Traditional Chinese Medicine, 301617 Tianjin, China
| | - Haitao Xing
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, 300193 Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, 300193 Tianjin, China
- Tianjin University of Traditional Chinese Medicine, 301617 Tianjin, China
| | - Bo Yang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, 300193 Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, 300193 Tianjin, China
- Tianjin University of Traditional Chinese Medicine, 301617 Tianjin, China
| | - Ao Xu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, 300193 Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, 300193 Tianjin, China
- Tianjin University of Traditional Chinese Medicine, 301617 Tianjin, China
| | - Xian Xian
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, 300193 Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, 300193 Tianjin, China
- Tianjin University of Traditional Chinese Medicine, 301617 Tianjin, China
| | - Hongtao Yang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, 300193 Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, 300193 Tianjin, China
- Tianjin University of Traditional Chinese Medicine, 301617 Tianjin, China
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Quan Z, Li C, Zhao L, Cui D, Liu S, Yin Y, Tang Q, Zeng D, Song L, Fu X. Effect of banana intake on serum potassium level in patients undergoing maintenance hemodialysis: A randomized controlled trial. Int J Nurs Sci 2024; 11:197-204. [PMID: 38707694 PMCID: PMC11064587 DOI: 10.1016/j.ijnss.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 02/05/2024] [Accepted: 03/12/2024] [Indexed: 05/07/2024] Open
Abstract
Objective This study aimed to assess the effect of banana intake during hemodialysis on serum potassium levels in maintenance hemodialysis (MHD) patients. Methods This study was a single-center, randomized controlled clinical trial conducted from September 15 to December 15, 2021, at a tertiary hospital in southern China. A total of 126 MHD patients were randomly assigned to either the intervention group (n = 64) or the control group (n = 62). Patients in the intervention group consumed approximately 250 g of bananas during hemodialysis, while those in the control group did not consume any food during hemodialysis. Demographic information and hemodialysis-related parameters were collected through case information collection before hemodialysis. Laboratory indicators (such as complete blood count, biochemical indicators, inflammation markers, liver function, kidney function, etc.) were evaluated by collecting pre-hemodialysis blood samples from patients. Serum potassium and blood glucose levels were measured at 2 h and 4 h of hemodialysis, as well as before the next hemodialysis session, and hemodialysis-related complications were recorded. The blood potassium and blood glucose indicators during hemodialysis were compared using repeated measures analysis. Results A total of 122 MHD patients completed the study (61 in each group). The results showed that there was no significant interaction between group and time on serum potassium levels. However, serum potassium levels in the intervention group were higher than those in the control group at 2 h (3.9 ± 0.5 mmol/L vs. 3.6 ± 0.3 mmol/L, P < 0.01) and 4 h (3.5 ± 0.4 mmol/L vs. 3.3 ± 0.3 mmol/L, P < 0.01) of hemodialysis. There was no interaction between group and time on blood glucose levels. The incidence of arrhythmias (8.2% vs. 29.5%, P = 0.003) and hypokalemia (52.5% vs. 80.3%, P = 0.002) during hemodialysis was significantly lower in the intervention group compared to the control group. Conclusion Consuming approximately 250 g of bananas at the start of hemodialysis does not lead to hyperkalemia. It can effectively reduce the incidence of hypokalemia and arrhythmias, and prevent a rapid decline in serum potassium levels during hemodialysis.
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Affiliation(s)
- Zilin Quan
- The Department of Nephrology, The Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Caixia Li
- The Department of Nursing, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Liyan Zhao
- The Department of Nephrology, The Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Dongmei Cui
- The Department of Nephrology, The Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Shuangxin Liu
- The Department of Nephrology, The Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Yan Yin
- The Department of Nephrology, The Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Qi Tang
- The Department of Nephrology, The Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Dehan Zeng
- The Department of Nephrology, The Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Li Song
- The Department of Nephrology, The Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Xia Fu
- The Department of Nursing, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
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Zhang Z, Wang Y. Management of Cardiovascular Diseases in Chronic Hemodialysis Patients. Rev Cardiovasc Med 2023; 24:185. [PMID: 39077004 PMCID: PMC11266462 DOI: 10.31083/j.rcm2407185] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 02/01/2023] [Accepted: 02/23/2023] [Indexed: 07/31/2024] Open
Abstract
Hemodialysis (HD) is the main treatment modality for patients with end-stage kidney disease. Cardiovascular diseases (CVD) are highly prevalent in HD patients and are the leading cause of death in this population, with the mortality from CVD approximately 20 times higher than that of the general population. Traditional and non-traditional cardiovascular risk factors accelerate progression of CVD and exacerbate the prognosis in HD patients. This review provides a brief overview of the characteristics of CVD in HD patients, and a description of advances in its management.
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Affiliation(s)
- Zhen Zhang
- Department of Nephrology, Zhongshan Hospital, Fudan University, 200032 Shanghai, China
- Shanghai Medical Center for Kidney Disease, Shanghai Municipal Health Commission, 200032 Shanghai, China
- Shanghai Institute of Kidney and Dialysis, 200032 Shanghai, China
- Hemodialysis Quality Control Center of Shanghai, Shanghai Medical Quality Control Management Center, 200032 Shanghai, China
| | - Yaqiong Wang
- Department of Nephrology, Zhongshan Hospital, Fudan University, 200032 Shanghai, China
- Shanghai Medical Center for Kidney Disease, Shanghai Municipal Health Commission, 200032 Shanghai, China
- Shanghai Institute of Kidney and Dialysis, 200032 Shanghai, China
- Hemodialysis Quality Control Center of Shanghai, Shanghai Medical Quality Control Management Center, 200032 Shanghai, China
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Miller F, Murray J, Budhota A, Harake T, Steig A, Whittaker D, Gupta S, Sivaprakasam R, Kuraguntla D. Evaluation of a wearable biosensor to monitor potassium imbalance in patients receiving hemodialysis. SENSING AND BIO-SENSING RESEARCH 2023. [DOI: 10.1016/j.sbsr.2023.100561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
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Iwagami M, Kanemura Y, Morita N, Yajima T, Fukagawa M, Kobayashi S. Association of Hyperkalemia and Hypokalemia with Patient Characteristics and Clinical Outcomes in Japanese Hemodialysis (HD) Patients. J Clin Med 2023; 12:jcm12062115. [PMID: 36983118 PMCID: PMC10058536 DOI: 10.3390/jcm12062115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 03/11/2023] Open
Abstract
This study aimed to examine the characteristics and clinical outcomes of Japanese hemodialysis patients with dyskalemia. A retrospective study was conducted using a large Japanese hospital group database. Outpatients undergoing thrice-a-week maintenance hemodialysis were stratified into hyperkalemia, hypokalemia, and normokalemia groups based on their pre-dialysis serum potassium (sK) levels during the three-month baseline period. Baseline characteristics of the three groups were described and compared for the following outcomes during follow-up: all-cause mortality, all-cause hospitalization, major adverse cardiovascular events (MACE), cardiac arrest, fatal arrythmia, and death related to arrhythmia. The study included 2846 eligible patients, of which 67% were men with a mean age of 65.65 (SD: 12.63) years. When compared with the normokalemia group (n = 1624, 57.06%), patients in the hypokalemia group (n = 313, 11.00%) were older and suffered from malnutrition, whereas patients in the hyperkalemia group (n = 909, 31.94%) had longer dialysis vintage. The hazard ratios for all-cause mortality and MACE in the hypokalemia group were 1.47 (95% confidence interval [CI], 1.13–1.92) and 1.48 (95% CI, 1.17–1.86), respectively, whereas that of death related to arrhythmia in the hyperkalemia group was 3.11 (95% CI, 1.03–9.33). Thus, dyskalemia in maintenance hemodialysis patients was associated with adverse outcomes, suggesting the importance of optimized sK levels.
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Affiliation(s)
- Masao Iwagami
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba 305-8575, Japan
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Yuka Kanemura
- Cardiovascular, Renal, and Metabolism, Medical Affairs, AstraZeneca K.K., Osaka 530-0011, Japan
| | - Naru Morita
- Cardiovascular, Renal, and Metabolism, Medical Affairs, AstraZeneca K.K., Osaka 530-0011, Japan
| | - Toshitaka Yajima
- Cardiovascular, Renal, and Metabolism, Medical Affairs, AstraZeneca K.K., Osaka 530-0011, Japan
- Correspondence: ; Tel.: +81-6-4802-3600; Fax: +81-3-3457-9301
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology, and Metabolism, Tokai University School of Medicine, Isehara 259-1193, Japan
| | - Shuzo Kobayashi
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, Kamakura 247-8533, Japan
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QT-Prolonging Antibiotics, Serum-to-Dialysate Potassium Gradient, and Risk of Sudden Cardiac Death Among Patients Receiving Maintenance Hemodialysis. Kidney Med 2023; 5:100618. [PMID: 37113163 PMCID: PMC10127135 DOI: 10.1016/j.xkme.2023.100618] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
Rationale & Objective Treatment with certain QT interval-prolonging antibiotics is associated with a higher risk of sudden cardiac death among individuals with hemodialysis-dependent kidney failure. Concurrent exposure to large serum-to-dialysate potassium gradients, which promote large potassium shifts, may augment the proarrhythmic effects of these medications. The primary objective of this study was to examine whether the serum-to-dialysate gradient modifies the cardiac safety of azithromycin, and separately, levofloxacin/moxifloxacin. Study Design Retrospective observational cohort study using a new-user study design. Setting & Population Adult in-center hemodialysis patients with Medicare coverage in the US Renal Data System (2007-2017). Exposure Initiation of azithromycin (or levofloxacin/moxifloxacin) as compared to amoxicillin-based antibiotics (exposure). Serum-to-dialysate potassium gradient (effect modifier). Individual patients could contribute multiple study antibiotic treatment episodes to the analyses. Outcomes Sudden cardiac death (14 days). Analytical Approach Inverse probability of treatment-weighted survival models to estimate HRs and robust 95% CIs. Results The azithromycin versus amoxicillin-based antibiotic cohort included 89,379 unique patients with 113,516 azithromycin and 103,493 amoxicillin-based treatment episodes. Azithromycin versus amoxicillin-based antibiotic treatment was associated with a higher risk of sudden cardiac death overall, HR, 1.68; 95% CI, 1.31-2.16. The risk was numerically higher when the baseline serum-to-dialysate potassium gradient was ≥3 mEq/L compared with <3 mEq/L (HR, 2.22; 95% CI, 1.46-3.40 vs HR, 1.43; 95% CI. 1.04-1.96, P interaction = 0.07). Analogous analyses in a respiratory fluoroquinolone (levofloxacin/moxifloxacin) versus amoxicillin-based antibiotic cohort with 79,449 unique patients and 65,959 respiratory fluoroquinolone and 103,776 amoxicillin-based treatment episodes yielded similar results. Limitations Residual confounding. Conclusions Although treatment with azithromycin and, separately, respiratory fluoroquinolones were each associated with a heightened risk of sudden cardiac death, this risk was augmented in the setting of larger serum-to-dialysate potassium gradients. Minimizing the potassium gradient may be an approach to reduce the cardiac risk of these antibiotics.
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Assimon MM, Pun PH, Wang L, Al-Khatib SM, Brookhart MA, Weber DJ, Winkelmayer WC, Flythe JE. Azithromycin use increases the risk of sudden cardiac death in patients with hemodialysis-dependent kidney failure. Kidney Int 2022; 102:894-903. [PMID: 35752324 PMCID: PMC9509424 DOI: 10.1016/j.kint.2022.05.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/15/2022] [Accepted: 05/13/2022] [Indexed: 12/14/2022]
Abstract
Azithromycin is an antibiotic with QT-prolonging potential commonly prescribed to individuals receiving hemodialysis. Hemodialysis patients have a high prevalence of clinical conditions, such as structural heart disease, that can enhance the pro-arrhythmic effects azithromycin, but were excluded from prior investigations evaluating the cardiac safety of azithromycin. Using data from the United States Renal Data System (2007-2017), we conducted two cohort studies to examine the cardiac safety of azithromycin relative to amoxicillin-based antibiotics (amoxicillin, amoxicillin/clavulanic acid) and levofloxacin (a fluoroquinolone antibiotic known to prolong the QT-interval) in the hemodialysis population. The primary outcome was five-day sudden cardiac death. Using inverse probability of treatment weighted survival models, we estimated hazard ratios, risk differences, and 95% confidence intervals. The azithromycin vs. amoxicillin-based antibiotic cohort included 282,899 patients and 725,431 treatment episodes (381,306 azithromycin and 344,125 amoxicillin-based episodes). Azithromycin vs. amoxicillin-based antibiotic treatment was associated with higher relative and absolute risks of sudden cardiac death, weighted hazard ratio of 1.70 (95% Confidence Interval, 1.36 to 2.11) and weighted risk difference per 100,000 treatment episodes of 25.0 (15.5 to 36.5). The azithromycin vs. levofloxacin cohort included 245,143 patients and 554,557 treatment episodes (387,382 azithromycin and 167,175 levofloxacin episodes). Azithromycin vs. levofloxacin treatment was associated with lower relative and absolute risks of sudden cardiac death, weighted hazard ratio of 0.79 (0.64 to 0.96) and weighted risk difference per 100,000 treatment episodes of -18.9 (-35.5 to -3.8). Thus, when selecting among azithromycin, levofloxacin, and amoxicillin-based antibiotics, clinicians should weigh the relative antimicrobial benefits of these drugs against their potential cardiac risks.
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Affiliation(s)
- Magdalene M Assimon
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Patrick H Pun
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Lily Wang
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - M Alan Brookhart
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - David J Weber
- Division of Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Jennifer E Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA.
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Association of Serum Potassium Levels with Mortality and Cardiovascular Events: Findings from the Chinese Multi-provincial Cohort Study. J Gen Intern Med 2022; 37:2446-2453. [PMID: 34505984 PMCID: PMC9360291 DOI: 10.1007/s11606-021-07111-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Dyskalemia involves critical electrolyte abnormalities and increases mortality risk in patients with acute clinical conditions. However, the association between dyskalemia and adverse outcomes in the general population is less well established. OBJECTIVE To investigate the association of serum potassium levels with mortality and cardiovascular events in the general population and to explore the characteristics of individuals at high risk. DESIGN A prospective cohort study. PARTICIPANTS A total of 5220 participants aged 50-79 years in the Chinese Multi-provincial Cohort Study. MAIN MEASURES Serum potassium levels were measured by the ion-selective electrode method. The outcomes were incident cardiovascular disease (CVD), CVD death, non-CVD death, and total death. KEY RESULTS Of the 5220 participants, 48.2% were men, and the mean age was 62.3 (SD 7.6) years. Hyperkalemia was found in 8.7% of the participants and was significantly associated with total death (hazard ratio [HR], 1.62; 95% confidence interval [CI], 1.18-2.23) and CVD death (HR, 2.12; 95% CI, 1.25-3.61) after adjustment. Furthermore, the HRs (95% CIs) of hyperkalemia combined with 2 and ≥ 3 risk factors were 2.37 (1.50-3.74) and 4.06 (2.37-6.95) for total death and 3.26 (1.56-6.80) and 8.42 (4.06-17.50) for CVD death, respectively. The 10-year cumulative incidence of total death was 17.4% for participants with 2 or more risk factors. CONCLUSION Hyperkalemia is associated with an increased risk of all-cause and CVD death, and this risk is more pronounced in patients with multiple risk factors. Our findings suggest that early identification and management of hyperkalemia in the general population are warranted.
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Assimon MM, Pun PH, Al-Khatib SM, Brookhart MA, Gaynes BN, Winkelmayer WC, Flythe JE. The modifying effect of the serum-to-dialysate potassium gradient on the cardiovascular safety of SSRIs in the hemodialysis population: a pharmacoepidemiologic study. Nephrol Dial Transplant 2022; 37:2241-2252. [PMID: 35793567 DOI: 10.1093/ndt/gfac214] [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: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hypokalemia is a risk factor for drug-induced QT-prolongation. Larger serum-to-dialysate potassium gradients during hemodialysis may augment the proarrhythmic risks of selective serotonin reuptake inhibitors (SSRIs). METHODS We conducted a cohort study using 2007-2017 data from the United States Renal Data System and a large dialysis provider to examine if the serum-to-dialysate potassium gradient modifies SSRI cardiac safety. Using a new-user design, we compared 1-year sudden cardiac death (SCD) risk among hemodialysis patients newly treated with higher (citalopram, escitalopram) vs. lower (fluoxetine, fluvoxamine, paroxetine, sertraline) QT-prolonging potential SSRIs, overall and stratified by baseline potassium gradient (≥4 vs. <4 mEq/L). We used inverse probability of treatment weighted survival models to estimate weighted hazard ratios (HRs) and 95% confidence intervals (CIs), and conducted a confirmatory nested case-control study. RESULTS The study included 25,099 patients: 11,107 (44.3%) higher QT-prolonging potential SSRI new-users and 13,992 (55.7%) lower QT-prolonging potential SSRI new-users. Overall, higher vs. lower QT-prolonging potential SSRI use was not associated with SCD, weighted HR of 1.03 (95% CI, 0.86-1.24). However, a greater risk of SCD was associated with higher vs. lower QT-prolonging potential SSRI use among patients with baseline potassium gradients ≥4 mEq/L, but not among those with gradients <4 mEq/L, weighted HR of 2.17 (95% CI, 1.16-4.03) vs. 0.95 (0.78-1.16). Nested case-control analyses yielded analogous results. CONCLUSIONS The serum-to-dialysate potassium gradient may modify the association between higher vs. lower QT-prolonging SSRI use and SCD among people receiving hemodialysis. Minimizing the potassium gradient in the setting of QT-prolonging medication use may be warranted.
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Affiliation(s)
- Magdalene M Assimon
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC, USA
| | - Patrick H Pun
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute, Durham NC, USA
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Durham NC, USA.,Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - M Alan Brookhart
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Bradley N Gaynes
- Department of Psychiatry, UNC School of Medicine, Chapel Hill, NC, USA.,Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Jennifer E Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC, USA.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
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Cojocaru C, Pupăză A, Iorgulescu C, Onciul S, Câlmâc L, Vătăşescu R. Case Report: Pulmonary Vein Isolation as a Tailored Treatment for Recurrent Ventricular Tachycardia During Hemodialysis in a Patient With Right Coronary Artery Chronic Total Occlusion. Front Cardiovasc Med 2022; 9:871386. [PMID: 35707126 PMCID: PMC9189425 DOI: 10.3389/fcvm.2022.871386] [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: 02/08/2022] [Accepted: 04/27/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundCatheter ablation of the ventricular substrate can reduce ventricular tachycardia (VT) recurrence and mortality in an electrical storm (ES). However, identification and specific treatment of plausible triggers is mandatory and may lead to the resolution of ES.ObjectiveThis case presentation seeks to exemplify how pulmonary vein isolation (PVI) may represent a tailored treatment of ES in cases of ventricular substrate, which only becomes arrhythmogenic during high-rate episodes of paroxysmal atrial fibrillation (PAF).ResultsA 54-year-old male with a history of inferior myocardial infarction (MI) and long-term hemodialysis was referred for repetitive implantable cardioverter-defibrillator (ICD) shocks for apparently scar-related monomorphic VT episodes preceded by PAF initiation strictly during hemodialysis. He had recently undergone ICD implantation for similar episodes of ES preceded by the rapid-ventricular response (RVR) PAF during hemodialysis. The patient had no other history of VTs. Electrocardiogram (EKG) changes occurred exclusively during PAF and suggested functional myocardial ischemia. Coronary angiography demonstrated isolated right coronary artery (RCA) chronic total occlusion (CTO). Cardiac magnetic resonance demonstrated RCA-territory residual myocardial viability and mild LV systolic dysfunction. Surgical revascularization was not feasible due to a history of bilateral above-the-knee post-traumatic amputation and severe calcification of internal mammary (IMA) and radial arteries. Subsequent CTO-percutaneous coronary intervention attempt was unsuccessful. The difficulty of assessing LV-substrate ablation end-points due to the “functional” character of the substrate, which only became arrhythmogenic during hemodialysis-related PAF, was considered. Consequently, PVI was performed rather than VT/VF substrate ablation. Twelve months after PVI, the patient remains free of PAF and VT/VF despite chronic hemodialysis sessions.ConclusionThe ES episodes can be triggered by situational factors, such as RVR-PAF and functional ischemia, during hemodialysis in patients with CTO with otherwise no episodes of VT. Tailored treatment of such factors may lead to long-term VT freedom.
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Affiliation(s)
- Cosmin Cojocaru
- Department of Cardiothoracic Pathology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Emergency Clinic Hospital of Bucharest, Bucharest, Romania
| | - Adelina Pupăză
- Emergency Clinic Hospital of Bucharest, Bucharest, Romania
| | | | - Sebastian Onciul
- Department of Cardiothoracic Pathology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Emergency Clinic Hospital of Bucharest, Bucharest, Romania
| | - Lucian Câlmâc
- Emergency Clinic Hospital of Bucharest, Bucharest, Romania
| | - Radu Vătăşescu
- Department of Cardiothoracic Pathology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Emergency Clinic Hospital of Bucharest, Bucharest, Romania
- *Correspondence: Radu Vătăşescu
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Uchida T, Ookawara S, Ito K, Okada H, Hayasaka H, Kofuji M, Kimura M, Ueda Y, Hasebe T, Momose N, Morishita Y. Lethal ventricular arrhythmia can be prevented by adjusting the dialysate potassium concentration and the use of anti-arrhythmic agents: a case report and literature review. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-022-00410-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hypokalemia is common in patients with malnutrition undergoing hemodialysis and is often involved in the development of lethal arrhythmia. Moreover, hemodialysis therapy decreases the serum potassium concentration due to potassium removal to the dialysate. However, it is difficult to adjust the dialysate potassium concentration owing to the use of the central dialysate delivery system in Japan. Here, we have presented a case undergoing hemodialysis with dialysate potassium concentration adjustment to prevent ventricular arrhythmia.
Case presentation
A 56-year-old man with Emery-Dreifuss muscular dystrophy and chronic heart failure was admitted to our hospital and needed subsequent hemodialysis therapy due to renal dysfunction. During hemodialysis, the cardiac resynchronization therapy defibrillator was activated to the treatment of his lethal ventricular arrhythmia. Decreases in serum potassium concentration after hemodialysis and changes in serum potassium concentration during HD were considered the causes of lethal ventricular arrythmia. Therefore, along with using anti-arrhythmic agents, the dialysate potassium concentration was increased from 2.0 to 3.5 mEq/L to minimize changes in the serum potassium concentration during hemodialysis. Post-dialysis hypokalemia disappeared and these changes during hemodialysis were minimized, and no lethal ventricular arrhythmia occurred thereafter.
Conclusions
In this case, we prevented lethal arrhythmia by maintaining the serum potassium concentration by increasing the dialysate potassium concentration, in addition to the use of anti-arrhythmic agents. In the acute phase of patients with frequent lethal arrhythmia undergoing hemodialysis, an increase in dialysate potassium concentration may be an effective method for preventing arrhythmogenic complications.
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13
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Fishbane S, Ford M, Fukagawa M, McCafferty K, Rastogi A, Spinowitz B, Staroselskiy K, Vishnevskiy K, Lisovskaja V, Al-Shurbaji A, Guzman N, Bhandari S. Hypokalemia Events with Sodium Zirconium Cyclosilicate and Placebo in Hemodialysis Patients. Kidney Int Rep 2022; 7:908-912. [PMID: 35497779 PMCID: PMC9039482 DOI: 10.1016/j.ekir.2022.01.1058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 11/19/2021] [Accepted: 01/21/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Steven Fishbane
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | - Martin Ford
- Department of Renal Medicine, King's College Hospital NHS Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | | | - Anjay Rastogi
- UCLA CORE Kidney Program, University of California, Los Angeles, Los Angeles, California, USA
| | - Bruce Spinowitz
- Department of Medicine, New York-Presbyterian Queens, Queens, New York, USA
| | | | - Konstantin Vishnevskiy
- Department of Internal Medicine, Clinical Pharmacology and Nephrology, North-Western State Medical University named after I.I. Mechnikov, St. Petersburg, Russia
| | - Vera Lisovskaja
- Biometrics and Information, AstraZeneca BioPharmaceuticals Research and Development Gothenburg, Mölndal, Sweden
| | - Ayman Al-Shurbaji
- Global Medicines Development, AstraZeneca BioPharmaceuticals Research and Development Gothenburg, Mölndal, Sweden
| | - Nicolas Guzman
- Global Medicines Development, AstraZeneca BioPharmaceuticals Research and Development, Gaithersburg, Maryland, USA
| | - Sunil Bhandari
- Department of Renal and Transplant Medicine, Hull University Teaching Hospitals NHS Trust, Hull, UK
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14
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de Rooij EN, Dekker FW, Le Cessie S, Hoorn EJ, de Fijter JW, Hoogeveen EK, Bijlsma J, Boekhout M, Boer W, van der Boog P, Büller H, van Buren M, Charro FD, Doorenbos C, van den Dorpel M, van Es A, Fagel W, Feith G, de Fijter C, Frenken L, Grave W, van Geelen J, Gerlag P, Gorgels J, Huisman R, Jager K, Jie K, Koning-Mulder W, Koolen M, Hovinga TK, Lavrijssen A, Luik A, van der Meulen J, Parlevliet K, Raasveld M, van der Sande F, Schonck M, Schuurmans M, Siegert C, Stegeman C, Stevens P, Thijssen J, Valentijn R, Vastenburg G, Verburgh C, Vincent H, Vos P. Serum Potassium and Mortality Risk in Hemodialysis Patients: A Cohort Study. Kidney Med 2022; 4:100379. [PMID: 35072043 PMCID: PMC8767120 DOI: 10.1016/j.xkme.2021.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Rationale & Objective Both hypo- and hyperkalemia can cause fatal cardiac arrhythmias. Although predialysis serum potassium level is a known modifiable risk factor for death in patients receiving hemodialysis, especially for hypokalemia, this risk may be underestimated. Therefore, we investigated the relationship between predialysis serum potassium level and death in incident hemodialysis patients and whether there is an optimum level. Study Design Prospective multicenter cohort study. Setting & Participants 1,117 incident hemodialysis patients (aged >18 years) from the Netherlands Cooperative Study on the Adequacy of Dialysis-2 study were included and followed from their first hemodialysis treatment until death, transplantation, switch to peritoneal dialysis, or a maximum of 10 years. Exposure Predialysis serum potassium levels were obtained every 6 months and divided into 6 categories: ≤4.0 mmol/L, >4.0 mmol/L to ≤4.5 mmol/L, >4.5 mmol/L to ≤5.0 mmol/L, >5.0 mmol/L to ≤5.5 mmol/L (reference), >5.5 mmol/L to ≤6.0 mmol/L, and >6.0 mmol/L. Outcomes 6-month all-cause mortality. Analytical Approach Cox proportional hazards and restricted cubic spline analyses with time-dependent predialysis serum potassium levels were used to calculate the adjusted HRs for death. Results At baseline, the mean age of the patients was 63 years (standard deviation, 14 years), 58% were men, 26% smoked, 24% had diabetes, 32% had cardiovascular disease, the mean serum potassium level was 5.0 mmol/L (standard deviation, 0.8 mmol/L), 7% had a low subjective global assessment score, and the median residual kidney function was 3.5 mL/min/1.73 m2 (IQR, 1.4-4.8 mL/min/1.73 m2). During the 10-year follow-up, 555 (50%) deaths were observed. Multivariable adjusted HRs for death according to the 6 potassium categories were as follows: 1.42 (95% CI, 1.01-1.99), 1.09 (95% CI, 0.82-1.45), 1.21 (95% CI, 0.94-1.56), 1 (reference), 0.95 (95% CI, 0.71-1.28), and 1.32 (95% CI, 0.97-1.81). Limitations Shorter intervals between potassium measurements would have allowed for more precise mortality risk estimations. Conclusions We found a U-shaped relationship between serum potassium level and death in incident hemodialysis patients. A low predialysis serum potassium level was associated with a 1.4-fold stronger risk of death than the optimal level of approximately 5.1 mmol/L. These results may imply the cautious use of potassium-lowering therapy and a potassium-restricted diet in patients receiving hemodialysis.
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Ni Z, Jin H, Lu R, Zuo L, Yu W, Ren Y, Yang Q, Xiao J, Zhang Q, Zhang L, Zhang X, Chen Q, Chen C, Shao G, Luo Q, Yao L, Qin S, Peng H, Zhao Q. Hyperkalaemia prevalence, recurrence and treatment in patients on haemodialysis in China: protocol for a prospective multicentre cohort study (PRECEDE-K). BMJ Open 2021; 11:e055770. [PMID: 34937724 PMCID: PMC8705221 DOI: 10.1136/bmjopen-2021-055770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Hyperkalaemia (HK) is a potentially life-threatening electrolyte imbalance associated with several adverse clinical outcomes and is common in patients with kidney failure. However, there is no evidence on the occurrence, recurrence and treatment of HK in patients on haemodialysis (HD) in China. METHODS AND ANALYSIS The HK Prevalence, Recurrence, and Treatment in Haemodialysis Study is a prospective, multicentre, observational, cohort study being conducted across 15-18 sites in China. Approximately 600 patients with end-stage kidney disease on HD are anticipated to be enrolled and will be followed up for 24 weeks. Patients will be in the long interdialytic interval (LIDI) at enrolment and will receive follow-up care every 4 weeks in LIDI for pre-dialysis and post-dialysis (at enrolment only) serum potassium measurements. To obtain pre-dialysis serum potassium levels in the short interdialytic interval (SIDI), a follow-up visit will be performed in the SIDI during the first week. Information on concomitant medications, blood gas analysis and biochemistry measurements will be obtained at enrolment and at each follow-up visit. The primary endpoint will be the proportion of patients experiencing HK (defined as serum potassium level >5.0 mmol/L) at the study enrolment or during the 24-week follow-up. The key secondary endpoint will be the proportion of patients experiencing HK recurrence (defined as any HK event after the first HK event) within 1-6 months (if applicable) during the 24-week follow-up, including enrolment assessment. ETHICS AND DISSEMINATION This study has been approved by Shanghai Jiaotong University School of Medicine, Renji Hospital Ethics Committee (2020-040). Other participating subcentres must also obtain ethics committee approval prior to the start of the study. The Good Clinical Practice regulations shall be strictly followed during the test implementation. Amendments to the protocol will be reviewed by the ethics committees. Written informed consent will be obtained from all participants before collection of any patient data and patient information. The findings of this study will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT04799067).
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Affiliation(s)
- Zhaohui Ni
- Department of Nephrology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haijiao Jin
- Department of Nephrology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Renhua Lu
- Department of Nephrology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Weimin Yu
- Department of Nephrology, Shanxi Bethune Hospital, Taiyuan, China
| | - Yuqing Ren
- Department of Nephrology, Yangquan Coal Industry (Group) General Hospital, Yangquan, China
| | - Qiongqiong Yang
- Department of Nephrology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jie Xiao
- Department of Nephrology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Qinghong Zhang
- Department of Nephrology, Taihe Hospital, Shiyan, Hubei, China
| | - Lihong Zhang
- Department of Nephrology, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xinzhou Zhang
- Department of Nephrology, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Qinkai Chen
- Department of Nephrology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Chaosheng Chen
- Department of Nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Guojian Shao
- Department of Nephrology, Wenzhou Central Hospital, Wenzhou, Zhejiang, China
| | - Qun Luo
- Department of Nephrology, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China
| | - Li Yao
- Department of Nephrology, The first hospital of China Medical University, Shenyang, China
| | - Shuguang Qin
- Department of Nephrology, Guangzhou First People's Hospital, Guangzhou, Guangdong, China
| | - Hui Peng
- Department of Nephrology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Qing Zhao
- Medical Affaires, AstraZeneca Investment China Co, Shanghai, China
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16
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Shibata S, Uchida S. Hyperkalemia in patients undergoing hemodialysis: its pathophysiology and management. Ther Apher Dial 2021; 26:3-14. [PMID: 34378859 PMCID: PMC9291487 DOI: 10.1111/1744-9987.13721] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/01/2021] [Accepted: 08/09/2021] [Indexed: 11/28/2022]
Abstract
Potassium is a major intracellular cation in the body, regulating membrane potential of excitable cells, such as cardiomyocytes and skeletal muscle cells. Because the kidney plays a critical role in controlling potassium balance, the elevation in serum potassium levels is one of the most common complications in patients with maintenance hemodialysis (MHD). In addition to reduced renal potassium excretion, the alteration in body potassium distribution owing to comorbid conditions may also contribute to dyskalemia. Besides potassium elimination through hemodialysis in MHD patients, accumulating data indicate the potential importance of extra‐renal elimination involving the gastrointestinal system, which can be affected by the inhibitors of the renin‐angiotensin‐aldosterone system. In this article, the literature on potassium physiology in MHD patients is reviewed with an emphasis on the changes from individuals with normal kidney function. This article also summarizes the findings of recent studies on dietary control, dialysate prescription, and pharmacological therapy.
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Affiliation(s)
- Shigeru Shibata
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Shunya Uchida
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan.,Department of Health Care, Teikyo Heisei University, Tokyo, Japan
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17
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Liu D, Lin Y, Gong N, Xiao Z, Zhang F, Zhong X, Yi Z, Yang C, Zhang G, Ai J. Degree and duration of hypokalemia associated with peritonitis in patients undergoing peritoneal dialysis. Int J Clin Pract 2021; 75:e14188. [PMID: 33783932 DOI: 10.1111/ijcp.14188] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 03/25/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Hypokalemia (LK) was associated with peritonitis in peritoneal dialysis (PD) patients, while the role of its degree and duration have not been fully established. Here, we conducted a retrospective cohort study to identify the relationships of LK degree and duration with peritonitis in PD patients. METHODS A total of 602 PD patients in our department from Jan 1st, 2009 to Dec 31st, 2019 entered the last analysis. Data were collected from their medical records. Serum potassium (SK) levels, degree of hypokalemia, and duration of hypokalemia were analysed with peritonitis. The time association of hypokalemia and peritonitis was also analysed. RESULTS There were totally 320 (53.7%) and 123 (20.7%) patients who had ever suffered from LK and serious hypokalemia (SLK) in the cohort. Only 6.82% and 0.5% of patients had LK and SLK at baseline, while the incidence increased and kept in 25%-32% and 5.5%-8.2% after PD. Both LK (HR 1.437, 95% CI 1.014-2.038, P = .042) and SLK (HR 2.021, 95% CI 1.429-2.857, P < .001) did correlate to peritonitis after adjusted analyses, while only SLK remained the significance at each follow-up point. The LK/SLK durations were 6 (3-12) and 6 (3-6) months, and only longer SLK duration correlated with peritonitis after adjusted analyses. After categorised, those LK durations more than 6 months and SLK durations more than 3 months presented a significant association with peritonitis. Of the patients who suffered from both hypokalemia and peritonitis, 70.4% patients' LK times were earlier than peritonitis time, while most SLK times (62.7%) were later. SLK also correlated with combined endpoint. CONCLUSIONS Hypokalemia degree and duration were tightly associated with peritonitis. Hypokalemia might be a causal factor of peritonitis, while peritonitis might also aggravate hypokalemia. We should manage SK as much as possible and avoid hypokalemia, especially serious hypokalemia in clinic practice.
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Affiliation(s)
- Danyang Liu
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
- School of Nursing, Southern Medical University, Guangzhou, P.R. China
| | - Yanhong Lin
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Nirong Gong
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Zhiwen Xiao
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Fen Zhang
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Xiaohong Zhong
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Zhixiu Yi
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Cong Yang
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Guangqing Zhang
- Administrative Office, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Jun Ai
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
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Correa S, Scovner KM, Tumlin JA, Roy-Chaudhury P, Koplan BA, Costea AI, Kher V, Williamson D, Pokhariyal S, McClure CK, Mc Causland FR, Charytan DM. Electrolyte Changes in Contemporary Hemodialysis: A Secondary Analysis of the Monitoring in Dialysis (MiD) Study. KIDNEY360 2021; 2:695-707. [PMID: 34676372 PMCID: PMC8528069 DOI: 10.34067/kid.0007452020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is a paucity of contemporary data examining electrolyte changes during and immediately after hemodialysis (HD), and their relationship with dialysate prescriptions. The present study examines these relationships. METHODS We analyzed patient- (n=66) and HD session-level pre- and post-dialysis laboratory data (n=1,713) over a six-month period from the Monitoring in Dialysis Study. We fit mixed effects regression models to analyze electrolyte, blood urea nitrogen, creatinine, and albumin levels immediately post-HD, accounting for pre-HD and dialysate prescriptions. In a subset of US patients (n=40), 15-minute post-HD and 30-minute post-HD values were available at one session. Predictive models were fit to estimate electrolyte levels immediately post-HD, accounting for pre-HD concentrations and dialysate prescriptions. RESULTS Serum bicarbonate, calcium, and albumin increased (mean increase 4.9±0.3 mEq/L, 0.7±0.1 mEq/L, and 0.4±0.03 g/dL, respectively), whereas potassium, magnesium, and phosphorus decreased immediately post-HD (mean -1.2±0.1 mEq/L, -0.3±0.03 mEq/L, and -3.0±0.2 mg/dL, respectively). Hypokalemia and hypophosphatemia were present in 40% of and 67% of immediate post-HD samples, respectively. Dynamic changes were observed in electrolyte concentrations at 15- and 30-minutes post-HD, compared to immediately post-HD. CONCLUSION We describe the magnitude of post-dialytic changes in serum electrolytes with contemporary HD, reporting a high incidence of electrolyte abnormalities post-HD, and present predictive nomograms relating electrolyte changes immediately post-HD to dialysate prescriptions. Our results may be useful for clinical care and provide insights for future research on dialysate prescriptions.
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Affiliation(s)
- Simon Correa
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Katherine Mikovna Scovner
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | | | - Prabir Roy-Chaudhury
- University of North Carolina Kidney Center, Chapel Hill, North Carolina,W. G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, North Carolina
| | - Bruce A. Koplan
- Cardiology Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Vijay Kher
- Medanta Kidney & Urology Institute, Medanta The Medicity, Haryana, India
| | - Don Williamson
- Southeastern Clinical Research Institute, Augusta, Georgia
| | | | | | - Finnian R. Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - David M. Charytan
- New York University School of Medicine and New York University Langone Medical Center, New York, New York
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Kacharam S, Lynch MR, Shemin D, Abuelo JG. Should serum potassium levels be routinely checked after the last dialysis of the week and before the first dialysis of the week? Hemodial Int 2020; 25:142-144. [PMID: 33094526 DOI: 10.1111/hdi.12897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/06/2020] [Accepted: 10/08/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Sumanth Kacharam
- Division of Hypertension and Kidney Diseases, Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Matthew R Lynch
- Division of Hypertension and Kidney Diseases, Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Douglas Shemin
- Division of Hypertension and Kidney Diseases, Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Julian Gary Abuelo
- Division of Hypertension and Kidney Diseases, Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Potassium homeostasis and management of dyskalemia in kidney diseases: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2020; 97:42-61. [DOI: 10.1016/j.kint.2019.09.018] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/13/2019] [Accepted: 09/30/2019] [Indexed: 12/19/2022]
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21
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Delanaye P, Krzesinski F, Dubois BE, Delcour A, Robinet S, Piette C, Krzesinski JM, Lancellotti P. A simple modification of dialysate potassium: its impact on plasma potassium concentrations and the electrocardiogram. Clin Kidney J 2019; 14:390-397. [PMID: 33564443 PMCID: PMC7857800 DOI: 10.1093/ckj/sfz157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/02/2019] [Indexed: 11/14/2022] Open
Abstract
Background Sudden death is frequent in haemodialysis (HD) patients. Both hyperkalaemia and change of plasma potassium (K) concentrations induced by HD could explain this. The impact of increasing dialysate K by 1 mEq/L on plasma K concentrations and electrocardiogram (ECG) results before and after HD sessions was studied. Methods Patients with pre-dialysis K >5.5 mEq/L were excluded. ECG and K measurements were obtained before and after the first session of the week for 2 weeks. Then, K in the dialysate was increased (from 1 or 3 to 2 or 4 mEq/L, respectively). Blood and ECG measurements were repeated after 2 weeks of this change. Results Twenty-seven prevalent HD patients were included. As expected, a significant decrease in K concentrations was observed after the dialysis session, but this decrease was significantly lower after the switch to an increased dialysate K. The pre-dialysis K concentrations were not different after changing, but post-dialysis K concentrations were higher after switching (P < 0.0001), with a lower incidence of post-dialysis hypokalaemia. Regarding ECG, before switching, the QT interval (QT) dispersion increased during the session, whereas no difference was observed after switching. One week after switching, post-dialysis QT dispersion [38 (34-42) ms] was lower than post-dialysis QT dispersion 2 weeks and 1 week before switching [42 (38-57) ms, P = 0.0004; and 40 (35-50) ms, P = 0.0002]. Conclusions A simple increase of 1 mEq/L of K in the dialysate is associated with a lower risk of hypokalaemia and a lower QT dispersion after the dialysis session. Further study is needed to determine if such a strategy is associated with a lower risk of sudden death.
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Affiliation(s)
- Pierre Delanaye
- Department of Nephrology, Dialysis, Transplantation, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium.,GIGA Cardiovascular Sciences, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - François Krzesinski
- Department of Cardiology, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Bernard E Dubois
- Department of Nephrology, Dialysis, Transplantation, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Alexandre Delcour
- Department of Cardiology, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Sébastien Robinet
- Department of Cardiology, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Caroline Piette
- Department of Cardiology, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Jean-Marie Krzesinski
- Department of Nephrology, Dialysis, Transplantation, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium.,GIGA Cardiovascular Sciences, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Patrizio Lancellotti
- GIGA Cardiovascular Sciences, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium.,Department of Cardiology, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
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Leypoldt JK, Kraus MA, Jaber BL, Weinhandl ED, Collins AJ. Effect of dialysate potassium and lactate on serum potassium and bicarbonate concentrations during daily hemodialysis at low dialysate flow rates. BMC Nephrol 2019; 20:252. [PMID: 31288787 PMCID: PMC6617706 DOI: 10.1186/s12882-019-1450-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 07/01/2019] [Indexed: 12/29/2022] Open
Abstract
Background Observational studies of hemodialysis patients treated thrice weekly have shown that serum and dialysate potassium and bicarbonate concentrations are associated with patient outcomes. The effect of more frequent hemodialysis on serum potassium and bicarbonate concentrations has rarely been studied, especially for treatments at low dialysate flow rate. Methods These post-hoc analyses evaluated data from patients who transferred from in-center hemodialysis (HD) to daily HD at low dialysate flow rates during the FREEDOM Study. The primary outcomes were the change in predialysis serum potassium and bicarbonate concentrations after transfer from in-center HD (mean during the last 3 months) to daily HD (mean during the first 3 months). Results After transfer from in-center HD to daily HD (data from 345 patients, 51 ± 15 years of age, mean ± standard deviation), predialysis serum potassium decreased (P < 0.001) by approximately 0.4 mEq/L when dialysate potassium concentration during daily HD was 1 mEq/L; no change occurred when dialysate potassium concentration during daily HD was 2 mEq/L. After transfer from in-center HD to daily HD (data from 284 patients, 51 ± 15 years of age), predialysis serum bicarbonate concentration decreased (P = 0.0022) by 1.0 ± 3.3 mEq/L when dialysate lactate concentration was 40 mEq/L but increased (P < 0.001) by 2.5 ± 3.5 mEq/L when dialysate lactate concentration was 45 mEq/L. These relationships were dependent on serum potassium and bicarbonate concentrations during in-center HD. Conclusions Control of serum potassium and bicarbonate concentrations during daily HD at low dialysate flow rates is readily achievable; the choice of dialysate potassium and lactate concentration can be informed when transfer is from in-center HD to daily HD. Electronic supplementary material The online version of this article (10.1186/s12882-019-1450-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | - Eric D Weinhandl
- NxStage Medical, Lawrence, MA, USA.,Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN, USA
| | - Allan J Collins
- NxStage Medical, Lawrence, MA, USA.,Medical School, University of Minnesota, Minneapolis, MN, USA
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