Prevalence of Hyperkalemia among Hemodialysis Patients in Egypt

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?

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.

Prevalence and management of hyperkalemia in chronic kidney disease and heart failure patients in the Gulf Cooperation Council (GCC)

Hyperkalemia is a frequent complication in patients with chronic kidney disease (CKD) or heart failure (HF) and associated with neuromuscular manifestations, changes in the electrocardiogram, and increased risk of mortality. While data on the prevalence and management of hyperkalemia in the gulf region are scarce, risk factors such as preference for potassium-rich foods (e.g., dates and dried fruits/vegetables), periods of intense fasting (e.g., Ramadan), and diabetes (an ancestor of CKD and HF) are common. Therefore, a panel of nephrologists and cardiologists from countries of the Gulf Cooperation Council (GCC) convened to collate and review available data on the prevalence, regional drivers, and current practice in the management of hyperkalemia in the region. Eventually, this review provides consensus recommendations on a balanced utilization of dietary and pharmacological options including new potassium binders for achieving and sustainably maintaining desirable serum potassium levels in countries of the GCC region. Alignment with regional habits and practice was a key aspect to facilitate the uptake of the recommendations into physicians' practice and patients' lives.

Nutritional Assessment of Adult Patients Undergoing Maintenance Hemodialysis in the Gaza Strip

Malnutrition is a common condition in patients undergoing hemodialysis (HD), and it is associated with increased morbidity and mortality. The main objective of the study was to evaluate the nutritional status of patients on maintenance HD. After applying eligibility criteria, 141 HD patients attending major governmental dialysis centers were randomly recruited in this cross-sectional study and assessed for nutritional status using the Patient-Generated Subjective Global Assessment (PG-SGA) tool. The PG-SGA categorizes patients as well-nourished, moderately malnourished, and severely malnourished. Different anthropometric measurements, laboratory investigations, blood pressure measurements, and 24-h dietary recall were collected from each patient. According to PG- SGA results, 78% of patients were moderately malnourished and 22% of patients were severely malnourished. The mean body mass index was 27.8 kg/m2, and 5.7% of patients were underweight. There were significant differences in the mid-upper arm muscle circumference (P = 0.020) between the PG-SGA groups. The total energy and protein intake were significantly (P <0.001) less than the recommended dietary intake by 1268.9 kcal and 41.4 g, respectively. The albumin level in 37.6% of patients was less than the normal level, and the results indicated that there were significant differences in serum iron (P = 0.022) between the moderately and severely malnourished patients. The results of this study indicated that all HD patients were suffering from different degrees of malnutrition and, unfortunately, most of their energy and nutrient intake was far less than the requirements, which might be the reason why they face nutritional and health risks.

Can Novel Potassium Binders Liberate People with Chronic Kidney Disease from the Low-Potassium Diet? A Cautionary Tale

The advent of new potassium binders provides an important breakthrough in the chronic management of hyperkalemia for people with CKD. In addition to the direct benefits of managing hyperkalemia, many researchers and clinicians view these new medications as a possible means to safely transition patients away from the low-potassium diet to a more healthful eating pattern. In this review, we examine the mechanisms of potassium binders in the context of hyperkalemia risk related to dietary potassium intake in people with CKD. We note that whereas these medications target hyperkalemia caused by potassium bioaccumulation, the primary evidence for restricting dietary potassium is risk of postprandial hyperkalemia. The majority of ingested potassium is absorbed alongside endogenously secreted potassium in the small intestines, but the action of these novel medications is predominantly constrained to the large intestine. As a result and despite their effectiveness in lowering basal potassium levels, it remains unclear whether potassium binders would provide protection against hyperkalemia caused by excessive dietary potassium intake in people with CKD. Until this knowledge gap is bridged, clinicians should consider postprandial hyperkalemia risk when removing restrictions on dietary potassium intake in people with CKD on potassium binders.

A Comparison of Dietary Intake Between Individuals Undergoing Maintenance Hemodialysis in the United Kingdom and China

OBJECTIVE

Protein-energy wasting is highly prevalent in people with end-stage kidney disease receiving regular hemodialysis. Currently, it is unclear what the optimal nutritional recommendations are, which is further complicated by differences in dietary patterns between countries. The aim of the study was to understand and compare dietary intake between individuals receiving hemodialysis in Leicester, UK and Nantong, China.

METHODS

The study assessed 40 UK and 44 Chinese participants' dietary intake over a period of 14 days using 24-hour diet recall interviews. Nutritional blood parameters were obtained from medical records. Food consumed by participants in the UK and China was analyzed using the Nutritics and Nutrition calculator to quantify nutritional intake.

RESULTS

Energy and protein intake were comparable between UK and Chinese participants, but with both below the recommended daily intake. Potassium intake was higher in UK participants compared to Chinese participants (2,115 [888] versus 1,159 [861] mg/d; P < .001), as was calcium (618 [257] versus 360 [312] mg/d; P < .001) and phosphate intake (927 [485] versus 697 [434] mg/d; P = .007). Vitamin C intake was lower in UK participants compared to their Chinese counterparts (39 [51] versus 64 [42] mg/d; P = .024). Data are reported here as median (interquartile range).

CONCLUSION

Both UK and Chinese hemodialysis participants have insufficient protein and energy in their diet. New strategies are required to increase protein and energy intakes. All participants had inadequate daily intake of vitamins C and D; there may well be a role in the oral supplementation of these vitamins, and further studies are urgently needed.

Prevalence, recurrence and seasonal variation of hyperkalemia among patients on hemodialysis

PURPOSE

Observational studies have shown that among patients on hemodialysis, hyperkalemia is strongly associated with excess risk for cardiovascular-related hospitalizations and sudden cardiac death. However, the actual burden of hyperkalemia, the rates of its recurrence and seasonality in its variation still remain unclear.

METHODS

Between June 2020 and May 2021, 1786 mid-week pre-dialysis serum potassium (sK) measurements were retrospectively recorded from 149 patients receiving thrice-weekly hemodialysis in a single-center in Thessaloniki, Greece. The prevalence, recurrence and seasonal variation of hyperkalemia were assessed using three pre-specified sK thresholds (≥ 5.1, ≥ 5.5 and ≥ 6.0 mmol/L).

RESULTS

At baseline, 60.4%, 42.2% and 13.4% of patients had sK levels ≥ 5.1, ≥ 5.5 and ≥ 6.0 mmol/L, respectively. At any time-point during follow-up, 85.2%, 69.8% and 38.9% of patients experienced at least one hyperkalemic event ≥ 5.1, ≥ 5.5 and ≥ 6.0 mmol/L, respectively. Of the 104 patients experiencing an initial sK elevation ≥ 5.5 mmol/L, hyperkalemia at the same threshold reoccurred in 60.6% at month 1, in 47.1% at month 2 and in 46.1% at month 3 of follow-up. Seasonal variation was also observed, with the prevalence of hyperkalemia to be significantly higher in summer. Shorter delivered hemodialysis < 4 h/session (OR: 2.568; 95% CI 1.045-6.313) and the use of a high dialysate K concentration (OR: 14.646; 95% CI 2.727-78.647) were the 2 factors that were independently associated with hyperkalemia.

CONCLUSION

The present study shows that among hemodialysis patients, the rates of hyperkalemia prevalence and recurrence are very high, reflecting the large unmet need to identify more effective potassium-lowering therapeutic interventions in this high-risk population.

The effect of hyperkalemia and long inter-dialytic interval on morbidity and mortality in patients receiving hemodialysis: a systematic review

BACKGROUND

Patients with chronic kidney disease, especially those receiving hemodialysis (HD), are at risk of hyperkalemia (HK). This systematic review aimed to evaluate the prevalence of HK in patients with renal disease receiving HD and collate evidence on the effect of HK and differing HD patterns (i.e., long vs. short inter-dialytic intervals [LIDI and SIDI, respectively] in a thrice weekly schedule) on mortality.

METHODS

Comprehensive searches were conducted across six databases and selected conference proceedings by two independent reviewers up to September 2020. A hundred and two studies reporting frequency of HK, mortality, or cardiovascular (CV) outcomes in adult patients with acute, chronic or end-stage renal disease in receipt of HD were included. Narrative synthesis of results was undertaken with key findings presented in tables and figures.

RESULTS

Median prevalence of HK in patients with renal disease receiving HD was 21.6% and increased in patients receiving concomitant medications - mainly renin-angiotensin-aldosterone system inhibitors and potassium-sparing diuretics. Associations between elevated potassium levels and increased risk of both all-cause and CV mortality in the HD population were consistent across the included studies. In addition, there was a rise in all-cause and CV mortality on the day following LIDI compared with the day after the two SIDIs in patients on HD.

CONCLUSIONS

Evidence identified in this systematic review indicates a relationship between HK and LIDI with mortality in patients with renal disease receiving HD, emphasizing the need for effective monitoring and management to control potassium levels both in emergency and chronic HD settings.

Inpatient management and post-discharge outcomes of hyperkalemia

OBJECTIVES

Patients with hyperkalemia are commonly treated in the inpatient setting; however, real-world evidence is limited. The purpose of this study was to describe the inpatient management and post-discharge outcomes among patients with hyperkalemia.

METHODS

Electronic medical record data (2012-2018) were used to analyze US adult patients with an inpatient stay with hyperkalemia (≥1 potassium value >5.0mEq/L). Patient characteristics, treatments, and monitoring six months prior to and during the inpatient stay, and hyperkalemia recurrence and inpatient readmissions post-discharge were summarized and compared among patients with mild (>5.0-5.5mEq/L), moderate (>5.5-6.0), and severe (>6.0) hyperkalemia.

RESULTS

Of the 21,793 patients, 69.2% had mild, 19.0% had moderate, and 11.8% had severe hyperkalemia during inpatient care. The most common inpatient treatments were temporizing agents (mild: 28.9%; moderate: 46.0%; severe: 73.0%), diuretics (32.7%; 37.1%; 34.6%), and sodium-polystyrene sulfonate (11.7%; 27.8%; 45.3%). Almost no patients (0.1%) received a potassium binder at discharge. Most patients (86.8%) had their potassium levels return to ≤5.0mEq/L during the inpatient stay. Death during the inpatient stay occurred in 12.3% of mild, 15.5% of moderate, and 19.5% of severe hyperkalemic patients. Within 30 days of discharge, hyperkalemia recurred in 13.3%, 15.4%, and 18.4% of patients with mild, moderate, and severe hyperkalemia, respectively. Additionally, 19.7%, 21.5%, and 19.6% of patients were readmitted to inpatient care within 30 days post-discharge.

CONCLUSION

Among patients with hyperkalemia in the inpatient setting, treatment and normalization of serum potassium levels were common. However, death, readmission, and hyperkalemia recurrence were also fairly common across all cohorts. Future studies examining measures to reduce inpatient death, readmission, and hyperkalemia recurrence among patients with hyperkalemia in inpatient care are warranted.

A Mini Review of Plant-Based Diets in Hemodialysis

BACKGROUND

Plant-based diets are defined as an eating pattern focused on the consumption of unprocessed fruits, vegetables, nuts, whole grains, oils, and beans. They can include various forms of vegetarian, vegan, DASH, and Mediterranean diets. Plant-based diets have proven useful in the prevention and treatment of several lifestyle diseases like type 2 diabetes, hypertension, and obesity. Recently, a growing body of literature has emerged regarding plant-based diets for patients with kidney failure, including those on dialysis. Although evidence is still limited, preliminary findings are encouraging.

SUMMARY

This article reviews current literature on the use of plant-based diets in the treatment of patients on dialysis.

Does dietary potassium intake associate with hyperkalemia in patients with chronic kidney disease?

Background

Dietary potassium restriction is a strategy to control hyperkalemia in chronic kidney disease (CKD). However, hyperkalemia may result from a combination of clinical conditions. This study aimed to investigate whether dietary potassium or the intake of certain food groups associate with serum potassium in the face of other risk factors.

Methods

We performed a cross-sectional analysis including a nondialysis-dependent CKD (NDD-CKD) cohort and a hemodialysis (HD) cohort. Dietary potassium intake was assessed by 3-day food records. Underreporters with energy intake lower than resting energy expenditure were excluded. Hyperkalemia was defined as serum potassium &gt;5.0 mEq/L.

Results

The NDD-CKD cohort included 95 patients {median age 67 [interquartile range (IQR) 55–73] years, 32% with diabetes mellitus (DM), median estimated glomerular filtration rate 23 [IQR 18–29] mL/min/1.73 m2} and the HD cohort included 117 patients [median age 39 (IQR 18–67) years, 50% with DM]. In NDD-CKD, patients with hyperkalemia (36.8%) exhibited lower serum bicarbonate and a tendency for higher serum creatinine, a higher proportion of DM and the use of renin–angiotensin–aldosterone system blockers, but lower use of sodium bicarbonate supplements. No association was found between serum and dietary potassium (r = 0.01; P = 0.98) or selected food groups. Conditions associated with hyperkalemia in multivariable analysis were DM {odds ratio [OR] 3.55 [95% confidence interval (CI) 1.07–11.72]} and metabolic acidosis [OR 4.35 (95% CI 1.37–13.78)]. In HD, patients with hyperkalemia (50.5%) exhibited higher serum creatinine and blood urea nitrogen and lower malnutrition inflammation score and a tendency for higher dialysis vintage and body mass index. No association was found between serum and potassium intake (r = −0.06, P = 0.46) or food groups. DM [OR 4.22 (95% CI 1.31–13.6)] and serum creatinine [OR 1.50 (95% CI 1.24–1.81)] were predictors of hyperkalemia in multivariable analyses.

Conclusions

Dietary potassium was not associated with serum potassium or hyperkalemia in either NDD-CKD or HD patients. Before restricting dietary potassium, the patient’s intake of potassium should be carefully evaluated and other potential clinical factors related to serum potassium balance should be considered in the management of hyperkalemia in CKD.

Metabolic and volume status evaluation of hemodialysis patients with and without residual renal function in the long interdialytic interval

Introduction:

It is unclear whether residual renal function (RRF) in dialysis patients can attenuate the metabolic impact of the long 68-hour interdialytic interval, in which water, acid, and electrolyte accumulation occurs.

Objective:

to evaluate serum electrolyte levels, water balance, and acid-base status in dialytic patients with and without RRF over the long interdialytic interval (LII).

Methodology:

this was a single-center, cross-sectional, and analytical study that compared patients with and without RRF, defined by diuresis above 200 mL in 24 hours. Patients were weighed and serum samples were collected for biochemical and gasometric analysis at the beginning and at the end of the LII.

Results:

27 and 24 patients with and without RRF were evaluated, respectively. Patients without RRF had a higher increase in serum potassium during the LII (2.67 x 1.14 mEq/L, p < 0.001), reaching higher values at the end of the study (6.8 x 5.72 mEq/L, p < 0.001) and lower pH value at the beginning of the interval (7.40 x 7.43, p = 0.018). More patients with serum bicarbonate < 18 mEq/L (50 x 14.8%, p = 0.007) and mixed acid-base disorder (57.7 x 29.2%, p = 0.042), as well as greater interdialytic weight gain (14.67 x 8.87 mL/kg/h, p < 0.001) and lower natremia (137 x 139 mEq/L, p = 0.02) at the end of the interval. Calcemia and phosphatemia were not different between the groups.

Conclusion:

Patients with RRF had better control of serum potassium, sodium, acid-base status, and volemia throughout the LII.

Low dialysate potassium concentration: an overrated risk factor for cardiac arrhythmia?

Serum potassium concentrations rise with dietary potassium intake between dialysis sessions and are often at hyperkalemic levels by the next session. Conversely, potassium concentrations fall during each hemodialysis, and sometimes reach hypokalemic levels by the end. Low potassium dialysate, which rapidly decreases serum potassium and often brings it to hypokalemic levels, is almost universally considered a risk factor for life-threatening arrhythmias. While there is little doubt about the threat of lethal arrhythmias due to hyperkalemia, convincing evidence for the danger of low potassium dialysate and rapid or excess potassium removal has not been forthcoming. The original report of more frequent ventricular ectopy in early dialysis that was improved by reducing potassium removal has received very little confirmation from subsequent studies. Furthermore, the occurrence of ventricular ectopy during dialysis does not appear to predict mortality. Studies relating sudden deaths to low potassium dialysate are countered by studies with more thorough adjustment for markers of poor health. Dialysate potassium concentrations affect the excursions of serum potassium levels above or below the normal range, and have the potential to influence dialysis safety. Controlled studies of different dialysate potassium concentration and their effect on mortality and cardiac arrests have not been done. Until these results become available, I propose interim guidelines for the setting of dialysate potassium levels that may better balance risks and benefits.

Evaluation of potassium levels before hemodialysis access procedures

Few prospective studies have looked at the incidence of hyperkalemia in outpatient hemodialysis access procedures. Our study prospectively evaluated 167 procedures using a preadmit venous blood gas (VBG) and found that 14.3% had moderate or severe hyperkalemia. When the individual procedures were analyzed it was found that 38% of malfunctioning tunneled dialysis catheter (TDC) patients, 20% of new start TDC patients, 22% of thrombectomy patients, and only 5.8% of the angioplasty patients had moderate or severe hyperkalemia. We have changed our practice and now monitor the preprocedure potassium in all but the routine angioplasty patients and treat with the protocol described in the body of the article.

Yokukansan treatment of chronic renal failure patients receiving hemodialysis, with behavioral and psychological symptoms of dementia: an open-label study

OBJECTIVE

The efficacy and safety of yokukansan (YKS) for chronic renal failure (CRF) patients receiving hemodialysis with behavioral and psychological symptoms of dementia (BPSD) was evaluated.

METHODS

Twelve CRF patients receiving hemodialysis with BPSD were recruited and 7.5 g of YKS powder was added to ongoing therapy with antipsychotics. Neuropsychiatric Inventory (NPI) criteria and Barthel Index before and after 4-week YKS treatment were compared.

RESULTS

Analysis of the mean score for NPI revealed a significant improvement during the period of YKS administration (25.3 ± 17.6 versus 8.36 ± 4.46; p = 0.0069). The mean score for the Barthel Index showed no significant difference during the period of YKS administration. Mean level of serum potassium was still within the normal range. No subjects had severe adverse reactions necessitating discontinuation from the study.

CONCLUSION

Yokukansan significantly improved the symptoms of BPSD in CRF patients receiving hemodialysis without critical side effects.

Potassium balances in maintenance hemodialysis

Potassium is abundant in the ICF compartment in the body and its excretion primarily depends on renal (about 90%), and to a lesser extent (about 10%) on colonic excretion. Total body potassium approximated to 50mmol/kg body weight and 2% of total body potassium is in the ECF compartment and 98% of it in the intracellular compartment.Dyskalemia is a frequent electrolyte imbalance observed among the maintenance hemodialysis patients. In case of hyperkalemia, it is frequently "a silent and a potential life threatening electrolyte imbalance" among patients with ESRD under maintenance hemodialysis. The prevalence of hyperkalemia in maintenance HD patients was reported to be about 8.7-10%. Mortality related to the hyperkalemia has been shown to be about 3.1/1,000 patient-years and about 24% of patients with HD required emergency hemodialysis due to severe hyperkalemia. In contrast to the hyperkalemia, much less attention has been paid to the hypokalemia in hemodialysis patients because of the low prevalence under maintenance hemodialysis patients. Severe hypokalemia in the hemodialysis patients usually was resulted from low potassium intake (malnutrition), chronic diarrhea, mineralocorticoid use, and imprudent use of K-exchange resins. Recently, the numbers of the new patients with advanced chronic kidney disease undergoing maintenance hemodialysis are tremendously increasing worldwide. However, the life expectancy of these patients is still much lower than that of the general population. The causes of excess mortality in these patients seem to various, but dyskalemia is a common cause among the patients with ESRD undergoing hemodialysis.

Hyperkalemia of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in hemodialysis: a meta-analysis

The safety of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) used in hemodialysis (HD) patients was evaluated. Medline, Embase, the Cochrane Library, some databases of clinical trial registries, grey literatures, other reference lists of eligible articles and review articles for the randomized clinical trials (RCTs) on comparison of ACEIs/ARBs or placebo in HD patients were retrieved. RCTs reporting the risk of hyperkalemia by using ACEIs/ARBs in HD patients were selected. Eight articles met the eligibility criteria and were subjected to meta-analysis by using the Cochrane Collaboration's RevMan 4.2 software package. The results showed that there was no significant difference in hyperkalemia in HD patients between ACEIs or ARBs group and control group (ACEIs vs. control: RD=0.03, 95% CI=-0.13-0.18, Z=0.34, P=0.73; ARBs vs. control: RD=-0.02, 95% CI=-0.07-0.03, Z=0.75, P=0.45). However, there was no significant difference in the serum potassium between ACEIs or ARBs group and control group in HD patients (ACEIs vs. control: WMD=0.10, 95% CI=0.06-0.15, Z=4.64, P<0.00001; ARBs vs. control: WMD=-0.24, 95% CI=-0.37-0.11, Z=3.58, P=0.0003). The use of ACEIs or ARBs could not cause an increased risk of hyperkalemia in HD patients, however the serum potassium could be increased with use of ACEIs in HD patients. Therefore the serum potassium concentration should still be closely monitored when ACEIs are taken during the maintenance HD.