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Simeri A, Pezzi G, Arena R, Papalia G, Szili-Torok T, Greco R, Veltri P, Greco G, Pezzi V, Provenzano M, Zaza G. Artificial intelligence in chronic kidney diseases: methodology and potential applications. Int Urol Nephrol 2024:10.1007/s11255-024-04165-8. [PMID: 39052168 DOI: 10.1007/s11255-024-04165-8] [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: 07/06/2024] [Accepted: 07/17/2024] [Indexed: 07/27/2024]
Abstract
Chronic kidney disease (CKD) represents a significant global health challenge, characterized by kidney damage and decreased function. Its prevalence has steadily increased, necessitating a comprehensive understanding of its epidemiology, risk factors, and management strategies. While traditional prognostic markers such as estimated glomerular filtration rate (eGFR) and albuminuria provide valuable insights, they may not fully capture the complexity of CKD progression and associated cardiovascular (CV) risks.This paper reviews the current state of renal and CV risk prediction in CKD, highlighting the limitations of traditional models and the potential for integrating artificial intelligence (AI) techniques. AI, particularly machine learning (ML) and deep learning (DL), offers a promising avenue for enhancing risk prediction by analyzing vast and diverse patient data, including genetic markers, biomarkers, and imaging. By identifying intricate patterns and relationships within datasets, AI algorithms can generate more comprehensive risk profiles, enabling personalized and nuanced risk assessments.Despite its potential, the integration of AI into clinical practice faces challenges such as the opacity of some algorithms and concerns regarding data quality, privacy, and bias. Efforts towards explainable AI (XAI) and rigorous data governance are essential to ensure transparency, interpretability, and trustworthiness in AI-driven predictions.
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Affiliation(s)
- Andrea Simeri
- Department of Mathematics and Computer Science, University of Calabria, 87036, Rende, CS, Italy
| | - Giuseppe Pezzi
- Department of Medical and Surgical Sciences, University of Catanzaro, 88100, Catanzaro, Italy
| | - Roberta Arena
- Nephrology, Dialysis and Renal Transplant Unit, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende - Hospital 'SS. Annunziata', Cosenza, Italy
| | - Giuliana Papalia
- Nephrology, Dialysis and Renal Transplant Unit, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende - Hospital 'SS. Annunziata', Cosenza, Italy
| | - Tamas Szili-Torok
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Rosita Greco
- Nephrology, Dialysis and Renal Transplant Unit, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende - Hospital 'SS. Annunziata', Cosenza, Italy
| | - Pierangelo Veltri
- Department of Computer Science, Modeling, Electronics and Systems Engineering, University of Calabria, 87036, Rende, CS, Italy
| | - Gianluigi Greco
- Department of Mathematics and Computer Science, University of Calabria, 87036, Rende, CS, Italy
| | - Vincenzo Pezzi
- Nephrology, Dialysis and Renal Transplant Unit, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende - Hospital 'SS. Annunziata', Cosenza, Italy
| | - Michele Provenzano
- Nephrology, Dialysis and Renal Transplant Unit, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende - Hospital 'SS. Annunziata', Cosenza, Italy.
| | - Gianluigi Zaza
- Nephrology, Dialysis and Renal Transplant Unit, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende - Hospital 'SS. Annunziata', Cosenza, Italy
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Senni M, Sciatti E, Bussalino E, D'Elia E, Ravera M, Paoletti E. Practical patient care appraisals with use of new potassium binders in heart failure and chronic kidney diseases. J Cardiovasc Med (Hagerstown) 2023; 24:781-789. [PMID: 37695628 DOI: 10.2459/jcm.0000000000001555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Hyperkalaemia is a life-threatening condition leading to significant morbidity and mortality. It is common in heart failure and in chronic kidney disease (CKD) patients due to the diseases themselves, which often coexist, the high co-presence of diabetes, the fluctuations in renal function, and the use of some drugs [i.e. renin-angiotensin-aldosterone system (RAAS) inhibitors]. Hyperkalaemia limits their administration or uptitration, thus impacting on mortality. New K + binders, namely patiromer and sodium zirconium cyclosilicate (ZS-9), are an intriguing option to manage hyperkalaemia in heart failure and/or CKD patients, both to reduce its fatal effects and to let clinicians uptitrate RAAS inhibition. Even if their real impact on strong outcomes is still to be determined, we hereby provide a practical approach to favour their use in routine clinical practice in order to gain the correct confidence and provide an additive tool to heart failure and CKD patients' wellbeing. New trials are welcome to fill the gap in knowledge.
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Affiliation(s)
- Michele Senni
- Unità di Cardiologia, Dipartimento Cardiovascolare, ASST Papa Giovanni XXIII, Bergamo
- Università Milano-Bicocca, Milan
| | - Edoardo Sciatti
- Unità di Cardiologia, Dipartimento Cardiovascolare, ASST Papa Giovanni XXIII, Bergamo
| | - Elisabetta Bussalino
- Clinica Nefrologica, Dialisi e Trapianto, Policlinico San Martino, Genova, Italy
| | - Emilia D'Elia
- Unità di Cardiologia, Dipartimento Cardiovascolare, ASST Papa Giovanni XXIII, Bergamo
| | - Maura Ravera
- Clinica Nefrologica, Dialisi e Trapianto, Policlinico San Martino, Genova, Italy
| | - Ernesto Paoletti
- Clinica Nefrologica, Dialisi e Trapianto, Policlinico San Martino, Genova, Italy
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Costa D, Patella G, Provenzano M, Ielapi N, Faga T, Zicarelli M, Arturi F, Coppolino G, Bolignano D, De Sarro G, Bracale UM, De Nicola L, Chiodini P, Serra R, Andreucci M. Hyperkalemia in CKD: an overview of available therapeutic strategies. Front Med (Lausanne) 2023; 10:1178140. [PMID: 37583425 PMCID: PMC10424443 DOI: 10.3389/fmed.2023.1178140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/10/2023] [Indexed: 08/17/2023] Open
Abstract
Hyperkalemia (HK) is a life-threatening condition that often occurs in patients with chronic kidney disease (CKD). High serum potassium (sKsK) is responsible for a higher risk of end-stage renal disease, arrhythmias and mortality. This risk increases in patients that discontinue cardio-nephroprotective renin-angiotensin-aldosterone system inhibitor (RAASi) therapy after developing HK. Hence, the management of HK deserves the attention of the clinician in order to optimize the therapeutic strategies of chronic treatment of HK in the CKD patient. The adoption in clinical practice of the new hypokalaemic agents patiromer and sodium zirconium cyclosilicate (SZC) for the prevention and chronic treatment of HK could allow patients, suffering from heart failure and chronic renal failure, to continue to benefit from RAASi therapy. We have updated a narrative review of the clear variables, correct definition, epidemiology, pathogenesis, etiology and classifications for HK among non-dialysis CKD (ND CKD) patients. Furthermore, by describing the prognostic impact on mortality and on the progression of renal damage, we want to outline the strategies currently available for the control of potassium (K+) plasma levels.
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Affiliation(s)
- Davide Costa
- Department of Law, Economics and Sociology, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Gemma Patella
- Renal Unit, Department of Health Sciences, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Michele Provenzano
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Nicola Ielapi
- Department of Public Health and Infectious Disease, Sapienza University of Rome, Rome, Italy
| | - Teresa Faga
- Renal Unit, Department of Health Sciences, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Mariateresa Zicarelli
- Renal Unit, Department of Health Sciences, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Franco Arturi
- Unit of Internal Medicine, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Giuseppe Coppolino
- Renal Unit, Department of Health Sciences, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Davide Bolignano
- Renal Unit, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | | | | | - Luca De Nicola
- Renal Unit, University of Campania “LuigiVanvitelli”, Naples, Italy
| | - Paolo Chiodini
- Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Raffaele Serra
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Michele Andreucci
- Renal Unit, Department of Health Sciences, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
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Toto F, Salvioni E, Magrì D, Sciomer S, Piepoli M, Badagliacca R, Galotta A, Baracchini N, Paolillo S, Corrà U, Raimondo R, Lagioia R, Filardi PP, Iorio A, Senni M, Correale M, Cicoira M, Perna E, Metra M, Guazzi M, Limongelli G, Sinagra G, Parati G, Cattadori G, Bandera F, Bussotti M, Mapelli M, Cipriani M, Bonomi A, Cunha G, Re F, Vignati C, Garascia A, Lombardi C, Scardovi AB, Passantino A, Emdin M, Passino C, Santolamazza C, Girola D, Zaffalon D, Vizza D, De Martino F, Agostoni P. Does moderate hyperkalemia influence survival in HF? Insights from the MECKI score data base. Int J Cardiol 2023; 371:273-277. [PMID: 36115445 DOI: 10.1016/j.ijcard.2022.09.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The prognostic role of moderate hyperkalemia in reduced ejection fraction (HFrEF) patients is still controversial. Despite this, it affects the use of renin-angiotensin-aldosterone system inhibitors (RAASi) with therapy down-titration or discontinuation. OBJECTIVES Aim of the study was to assess the prognostic impact of moderate hyperkalemia in chronic HFrEF optimally treated patients. METHODS AND RESULTS We retrospectively analyzed MECKI (Metabolic Exercise test data combined with Cardiac and Kidney Indexes) database, with median follow-up of 4.2 [IQR 1.9-7.5] years. Data on K+ levels were available in 7087 cases. Patients with K+ plasma level ≥ 5.6 mEq/L and < 4 mEq/L were excluded. Remaining patients were categorized into normal >4 and < 5 mEq/L (n = 4826, 68%) and moderately high ≥5.0 and ≤ 5.5 mEq/L (n = 496, 7%) K+. Then patients were matched by propensity score in 484 couplets of patients. MECKI score value was 7% [IQR 3.1-14.1%] and 7.3% [IQR 3.4-15%] (p = 0.678) in patients with normal and moderately high K+ values while cardiovascular mortality events at two years follow-up were 41 (4.2%) and 33 (3.4%) (p = 0.333) in each group respectively. CONCLUSIONS Moderate hyperkalemia does not influence patients' outcome in a large cohort of ambulatory HFrEF patients.
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Affiliation(s)
- Federica Toto
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, Rome, Italy
| | | | - Damiano Magrì
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant'Andrea, "Sapienza" Università degli Studi di Roma, Roma, Italy
| | - Susanna Sciomer
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, "Sapienza", Rome University, Rome, Italy
| | | | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, Rome, Italy
| | | | - Nikita Baracchini
- Cardiovascular Department, "Azienda Sanitaria Universitaria Giuliano-Isontina", Trieste, Italy
| | | | - Ugo Corrà
- Cardiology Department, Istituti Clinici Scientifici Maugeri, IRCCS, Veruno Institute, Veruno, Italy
| | - Rosa Raimondo
- Divisione di Cardiologia Riabilitativa, Istituti Clinici Scientifici Maugeri, Tradate, Italy
| | - Rocco Lagioia
- UOC Cardiologia di Riabilitativa, Mater Dei Hospital, Bari, Italy
| | - Pasquale Perrone Filardi
- Department of Advanced Biomedical Sciences, Federico II University of Naples and Mediterranea CardioCentro, Naples, Italy
| | - Annamaria Iorio
- Department of Cardiology, Heart Failure and Heart Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Michele Senni
- Department of Cardiology, Heart Failure and Heart Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | | | | | - Enrico Perna
- Dipartimento Cardiologico "A. De Gasperis", Ospedale Cà Granda- A.O. Niguarda, Milano, Italy
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialities, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Guazzi
- Ospedale San Paolo, Università degli studi di Milano, Italy
| | - Giuseppe Limongelli
- Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Napoli
| | - Gianfranco Sinagra
- Cardiovascular Department, "Azienda Sanitaria Universitaria Giuliano-Isontina", Trieste, Italy
| | - Gianfranco Parati
- Istituto Auxologico Italiano, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Gaia Cattadori
- Unità Operativa Cardiologia Riabilitativa, IRCCS Multimedica, Milano, Italy
| | - Francesco Bandera
- Department of Biomedical Sciences for Health, University of Milano, Milan, Italy; Cardiology University Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Maurizio Bussotti
- Cardiac Rehabilitation Unit, Istituti Clinici Scientifici Maugeri, Scientific Institute of Milan, Milan, Italy
| | - Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of clinical sciences and community health, Cardiovascular section, University of Milan, Milan, Italy
| | - Manlio Cipriani
- ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Alice Bonomi
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Gonçalo Cunha
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Cardiology department, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Federica Re
- Cardiology Division, Cardiac Arrhythmia Center and Cardiomyopathies Unit, San Camillo-Forlanini Hospital, Roma, Italy
| | | | - Andrea Garascia
- Dipartimento Cardiologico "A. De Gasperis", Ospedale Cà Granda- A.O. Niguarda, Milano, Italy
| | - Carlo Lombardi
- Cardiology, Department of Medical and Surgical Specialities, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Andrea Passantino
- Division of Cardiology, Istituti Clinici Scientifici Maugeri, Institute of Bari, Bari, Italy
| | - Michele Emdin
- Institute of Life Science, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Gabriele Monasterio, CNR-Regione Toscana, Pisa, Italy
| | - Claudio Passino
- Institute of Life Science, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Caterina Santolamazza
- Dipartimento Cardiologico "A. De Gasperis", Ospedale Cà Granda- A.O. Niguarda, Milano, Italy
| | - Davide Girola
- Clinica Hildebrand Centro di riabilitazione Brissago, Switzerland
| | - Denise Zaffalon
- Cardiovascular Department, "Azienda Sanitaria Universitaria Giuliano-Isontina", Trieste, Italy
| | - Dario Vizza
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, Rome, Italy
| | | | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of clinical sciences and community health, Cardiovascular section, University of Milan, Milan, Italy,.
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O'Hara DV, Yi TW, Lee VW, Jardine M, Dawson J. Digital health technologies to support medication adherence in chronic kidney disease. Nephrology (Carlton) 2022; 27:917-924. [PMID: 36176176 PMCID: PMC9828762 DOI: 10.1111/nep.14113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/24/2022] [Accepted: 09/17/2022] [Indexed: 01/12/2023]
Abstract
Non-adherence to medications is a critical challenge in the management of people with chronic kidney disease (CKD). This review explores the complexities of adherence in this population, the unique barriers and enablers of good adherence behaviours, and the role of emerging digital health technologies in bridging the gap between evidence-based treatment plans and the real-world standard of care. We present the current evidence supporting the use of digital health interventions among CKD populations, identifying the key research questions that remain unanswered, and providing practical strategies for clinicians to support medication adherence in a digital age.
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Affiliation(s)
- Daniel V. O'Hara
- NHMRC Clinical Trials CentreThe University of SydneySydneyNew South WalesAustralia,Department of Renal MedicineRoyal North Shore HospitalSydneyNew South WalesAustralia
| | - Tae Won Yi
- NHMRC Clinical Trials CentreThe University of SydneySydneyNew South WalesAustralia,The George Institute for Global HealthUniversity of New South WalesSydneyNew South WalesAustralia,Department of Medicine, Clinician Investigator ProgramUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Vincent W. Lee
- Department of Renal MedicineWestmead HospitalSydneyNew South WalesAustralia,Westmead Applied Research Centre, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Meg Jardine
- NHMRC Clinical Trials CentreThe University of SydneySydneyNew South WalesAustralia,Department of Renal MedicineConcord Repatriation General HospitalSydneyNew South WalesAustralia
| | - Jessica Dawson
- NHMRC Clinical Trials CentreThe University of SydneySydneyNew South WalesAustralia,Department of Nutrition and DieteticsSt George HospitalSydneyNew South WalesAustralia
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6
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Sarnowski A, Gama RM, Dawson A, Mason H, Banerjee D. Hyperkalemia in Chronic Kidney Disease: Links, Risks and Management. Int J Nephrol Renovasc Dis 2022; 15:215-228. [PMID: 35942480 PMCID: PMC9356601 DOI: 10.2147/ijnrd.s326464] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/22/2022] [Indexed: 12/21/2022] Open
Abstract
Hyperkalemia is a common clinical problem with potentially fatal consequences. The prevalence of hyperkalemia is increasing, partially due to wide-scale utilization of prognostically beneficial medications that inhibit the renin-angiotensin-aldosterone-system (RAASi). Chronic kidney disease (CKD) is one of the multitude of risk factors for and associations with hyperkalemia. Reductions in urinary potassium excretion that occur in CKD can lead to an inability to maintain potassium homeostasis. In CKD patients, there are a variety of strategies to tackle acute and chronic hyperkalemia, including protecting myocardium from arrhythmias, shifting potassium into cells, increasing potassium excretion from the body, addressing dietary intake and treating associated conditions, which may exacerbate problems such as metabolic acidosis. The evidence base is variable but has recently been supplemented with the discovery of novel oral potassium binders, which have shown promise and efficacy in studies. Their use is likely to become widespread and offers another tool to the clinician treating hyperkalemia. Our review article provides an overview of hyperkalemia in CKD patients, including an exploration of relevant guidelines and nuances around management.
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Affiliation(s)
- Alexander Sarnowski
- Department of Renal Medicine and Transplantation, St George’s NHS University Hospitals NHS Foundation Trust, London, UK
| | - Rouvick M Gama
- Department of Renal Medicine and Transplantation, St George’s NHS University Hospitals NHS Foundation Trust, London, UK
| | - Alec Dawson
- Department of Renal Medicine and Transplantation, St George’s NHS University Hospitals NHS Foundation Trust, London, UK
| | - Hannah Mason
- Department of Renal Medicine and Transplantation, St George’s NHS University Hospitals NHS Foundation Trust, London, UK
| | - Debasish Banerjee
- Department of Renal Medicine and Transplantation, St George’s NHS University Hospitals NHS Foundation Trust, London, UK
- Correspondence: Debasish Banerjee, Department of Renal Medicine and Transplantation, St George’s NHS University Hospitals NHS Foundation Trust, Blackshaw Road, SW170QT, London, United Kingdom, Tel +44 2087151673, Email
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7
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Murphy D, Banerjee D. Hyperkalaemia in Heart Failure: Consequences for Outcome and Sequencing of Therapy. Curr Heart Fail Rep 2022; 19:191-199. [PMID: 35704263 PMCID: PMC9329160 DOI: 10.1007/s11897-022-00552-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 11/19/2022]
Abstract
Purpose of Review
Heart failure (HF), in conjunction with common comorbidities such as chronic kidney disease and diabetes and medical therapies such as RAASi, predisposes to hyperkalaemia which may lead to hospitalisation and death. This paper aims to review the most current evidence surrounding the risks and management of hyperkalaemia in HF, with particular focus on recent research into RAASi including novel selective mineralocorticoid receptor blockers and novel potassium binders. Recent Findings The most recent evidence shows that even moderate hyperkalaemia may predispose to adverse outcomes such as hospitalisation and death. Furthermore, it may prevent patients from receiving optimal medical therapy for HF by reducing prescription of RAASi therapy. Novel potassium binders such as sodium zirconium cyclosilicate (SZC) and patiromer present potential options to reduce and prevent hyperkalaemia as well as maintain optimal RAASi dosing in HF. Summary Management of hyperkalaemia in HF has advanced in recent years. New therapies such as SZC and patiromer are contributing to the management of acute hyperkalaemia and also access to life-saving RAASi therapies by tackling and preventing hyperkalaemia in the community.
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Affiliation(s)
- Daniel Murphy
- Institute of Medical and Biomedical Education, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.,Renal and Transplantation Department, St George's, University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Debasish Banerjee
- Institute of Medical and Biomedical Education, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK. .,Renal and Transplantation Department, St George's, University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.
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8
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Chronic Hyperkaliemia in Chronic Kidney Disease: An Old Concern with New Answers. Int J Mol Sci 2022; 23:ijms23126378. [PMID: 35742822 PMCID: PMC9223624 DOI: 10.3390/ijms23126378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/05/2022] [Accepted: 06/06/2022] [Indexed: 12/04/2022] Open
Abstract
Increasing potassium intake ameliorates blood pressure (BP) and cardiovascular (CV) prognoses in the general population; therefore the World Health Organization recommends a high-potassium diet (90–120 mEq/day). Hyperkalaemia is a rare condition in healthy individuals due to the ability of the kidneys to effectively excrete dietary potassium load in urine, while an increase in serum K+ is prevalent in patients with chronic kidney disease (CKD). Hyperkalaemia prevalence increases in more advanced CKD stages, and is associated with a poor prognosis. This scenario generates controversy on the correct nutritional approach to hyperkalaemia in CKD patients, considering the unproven link between potassium intake and serum K+ levels. Another concern is that drug-induced hyperkalaemia leads to the down-titration or withdrawal of renin-angiotensin system inhibitors (RASI) and mineralocorticoids receptors antagonists (MRA) in patients with CKD, depriving these patients of central therapeutic interventions aimed at delaying CKD progression and decreasing CV mortality. The new K+-binder drugs (Patiromer and Sodium-Zirconium Cyclosilicate) have proven to be adequate and safe therapeutic options to control serum K+ in CKD patients, enabling RASI and MRA therapy, and possibly, a more liberal intake of fruit and vegetables.
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9
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Provenzano M, Garofalo C, Gorriz JL, Andreucci M. Editorial: Management of Patients With Non-dialysis Dependent Chronic Kidney Disease (ND-CKD). Front Med (Lausanne) 2022; 8:827245. [PMID: 35186981 PMCID: PMC8850404 DOI: 10.3389/fmed.2021.827245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michele Provenzano
- Renal Unit, Department of Health Sciences, Magna Graecia University, Catanzaro, Italy
| | - Carlo Garofalo
- Department of Advanced Medical and Surgical Sciences, University of Campania "L.Vanvitelli", Naples, Italy
| | - Jose Luis Gorriz
- Department of Nephrology, Hospital Clínico Universitario, Health Research Institute of Valencia (INCLIVA), University of Valencia, Valencia, Spain
| | - Michele Andreucci
- Renal Unit, Department of Health Sciences, Magna Graecia University, Catanzaro, Italy
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10
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OMICS in Chronic Kidney Disease: Focus on Prognosis and Prediction. Int J Mol Sci 2021; 23:ijms23010336. [PMID: 35008760 PMCID: PMC8745343 DOI: 10.3390/ijms23010336] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/26/2021] [Accepted: 12/27/2021] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD) patients are characterized by a high residual risk for cardiovascular (CV) events and CKD progression. This has prompted the implementation of new prognostic and predictive biomarkers with the aim of mitigating this risk. The ‘omics’ techniques, namely genomics, proteomics, metabolomics, and transcriptomics, are excellent candidates to provide a better understanding of pathophysiologic mechanisms of disease in CKD, to improve risk stratification of patients with respect to future cardiovascular events, and to identify CKD patients who are likely to respond to a treatment. Following such a strategy, a reliable risk of future events for a particular patient may be calculated and consequently the patient would also benefit from the best available treatment based on their risk profile. Moreover, a further step forward can be represented by the aggregation of multiple omics information by combining different techniques and/or different biological samples. This has already been shown to yield additional information by revealing with more accuracy the exact individual pathway of disease.
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11
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Panuccio V, Leonardis D, Tripepi R, Versace MC, Torino C, Tripepi G, D'Arrigo G, Mallamaci F, Zoccali C. Epidemiology of hyperkalemia in CKD patients under nephrological care: a longitudinal study. Intern Emerg Med 2021; 16:1803-1811. [PMID: 33575905 DOI: 10.1007/s11739-021-02653-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 01/22/2021] [Indexed: 12/17/2022]
Abstract
Hyperkalemia is a potential life-threatening condition among chronic kidney disease (CKD) patients. Available estimates of the burden of this alteration in CKD are mainly derived from large administrative databases. Since K measurements in patients in these databases are often dictated by clinical reasons, longitudinal studies including pre-planned measurements of potassium independently of clinical complication/symptoms may produce more reliable estimates of the frequency and the risk factors underlying hyperkalemia in CKD patients. We estimated the prevalence and the incidence of hyperkalemia in a longitudinal study in 752 stages 2-5 CKD patients lasting 3 years and including up to seven pre-planned assessment of key biochemical measurements including K. At baseline, 203 out of 752 patients (27%) had serum K > 5.0 mM/L and 33% had acidosis (HCO3 ≤ 22 mmol/L). Among those without hyperkalemia at baseline (n = 549), 284 patients developed this alteration across the 3-year follow-up. The point prevalence of hyperkalemia rose from 27% (baseline) to 30% (last visit) (P = 0.001). In a multivariate model, hyperkalemia at baseline [odds ratio (OR):7.29, 95% CI 5.65-9.41, P < 0.001], venous bicarbonate levels [OR (1 mmol/l): 0.92, 0.89-0.96, P < 0.001], eGFR [OR (1 ml/min/1.73m2): 0.98, 0.97-0.99, P < 0.001], use of ACE inhibitors (OR: 1.68, 1.28-2.19, P < 0.001) and angiotensin II antagonists (OR: 1.30, 1.01-1.68, P = 0.045) were related to hyperkalemia over time. Of note, venous bicarbonate levels emerged as an independent risk factor of hyperkalemia over time also in a separate analysis of patients with and without hyperkalemia at baseline. In a cohort of CKD patients including pre-planned measurements of K, 27% of patients had hyperkalemia. Metabolic acidosis and the use of drugs interfering with renin-angiotensin system were the strongest modifiable risk factors for this potentially life-threatening alteration in CKD in longitudinal analyses in the whole study cohort and in patients developing de novo hyperkalemia over time.
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Affiliation(s)
- Vincenzo Panuccio
- Nephrology, Dialysis and Transplantation Unit, Grande Ospedale Metropolitano BMM di Reggio Calabria, Reggio Calabria, Italy
| | - Daniela Leonardis
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-IFC of Reggio Calabria, Reggio Calabria, Italy
| | - Rocco Tripepi
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-IFC of Reggio Calabria, Reggio Calabria, Italy
| | - Maria Carmela Versace
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-IFC of Reggio Calabria, Reggio Calabria, Italy
| | - Claudia Torino
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-IFC of Reggio Calabria, Reggio Calabria, Italy
| | - Giovanni Tripepi
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-IFC of Reggio Calabria, Reggio Calabria, Italy
| | - Graziella D'Arrigo
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-IFC of Reggio Calabria, Reggio Calabria, Italy
| | - Francesca Mallamaci
- Nephrology, Dialysis and Transplantation Unit, Grande Ospedale Metropolitano BMM di Reggio Calabria, Reggio Calabria, Italy
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-IFC of Reggio Calabria, Reggio Calabria, Italy
| | - Carmine Zoccali
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-IFC of Reggio Calabria, Reggio Calabria, Italy.
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12
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Trevisan M, Clase CM, Evans M, Popov T, Ludvigsson JF, Sjölander A, Carrero JJ. Patterns of chronic and transient hyperkalaemia and clinically important outcomes in patients with chronic kidney disease. Clin Kidney J 2021; 15:153-161. [PMID: 35035946 PMCID: PMC8757415 DOI: 10.1093/ckj/sfab159] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Indexed: 12/27/2022] Open
Abstract
Background Whether hyperkalaemia in CKD is chronic or transient, and whether this has different outcome implications, is not known. Methods This was an observational study of adults with CKD G3–5 from Stockholm, Sweden 2006–11. We examined individual trajectories of potassium from all measurements obtained through routine outpatient care. For each month of follow-up, we created a rolling assessment of the proportion of time in which potassium was abnormal during the previous 12 months. We defined patterns of hyperkalaemia as transient (≤50% of time during the previous year with potassium >5.0 mmol/L) and chronic (>50% of time with potassium >5.0 mmol/L), and examined whether previous hyperkalaemia pattern offers additional predictive value beyond that provided by the most recent (current) potassium value. Results We included 36 511 participants (56% women) with CKD G3–5 and median estimated glomerular filtration rate 46 mL/min/1.73 m2. Transient and chronic hyperkalaemia, respectively, were observed in 15% and 4% of patients with CKD G3a, and in 50% and 17% of patients with CKD G5. In fully adjusted models, transient (hazard ratio 1.36, 95% confidence interval 1.29–1.46) or chronic (1.16, 1.04–1.32) hyperkalaemia patterns, but not current hyperkalaemia, were associated with major adverse cardiovascular events (MACE), compared with normokalaemia. Transient hyperkalaemia (1.43, 1.35–1.52) and current potassium values, but not chronic hyperkalaemia, were associated with the risk of death. Conclusions Between 4% and 17% of patients with CKD G3–5 develop chronic hyperkalaemia. In general, hyperkalaemia predicted MACE and death; however, the lack of effect of current potassium on MACE when adjusted for the previous pattern, and the stronger effects on death than on MACE, lead us to question whether hyperkalaemia is causal in these relationships.
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Affiliation(s)
- Marco Trevisan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, ON, Hamilton, Canada
| | - Marie Evans
- Department of Clinical Science Intervention and Technology, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Tamara Popov
- Medical Affairs, Vifor Pharma Group, Glattbrugg, Switzerland
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
| | - Arvid Sjölander
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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13
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Valdivielso JM, Balafa O, Ekart R, Ferro CJ, Mallamaci F, Mark PB, Rossignol P, Sarafidis P, Del Vecchio L, Ortiz A. Hyperkalemia in Chronic Kidney Disease in the New Era of Kidney Protection Therapies. Drugs 2021; 81:1467-1489. [PMID: 34313978 DOI: 10.1007/s40265-021-01555-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 12/20/2022]
Abstract
Despite recent therapeutic advances, chronic kidney disease (CKD) is one of the fastest growing global causes of death. This illustrates limitations of current therapeutic approaches and, potentially, unidentified knowledge gaps. For decades, renin-angiotensin-aldosterone system (RAAS) blockers have been the mainstay of therapy for CKD. However, they favor the development of hyperkalemia, which is already common in CKD patients due to the CKD-associated decrease in urinary potassium (K+) excretion and metabolic acidosis. Hyperkalemia may itself be life-threatening as it may trigger potentially lethal arrhythmia, and additionally may limit the prescription of RAAS blockers and lead to low-K+ diets associated to low dietary fiber intake. Indeed, hyperkalemia is associated with adverse kidney, cardiovascular, and survival outcomes. Recently, novel kidney protective therapies, ranging from sodium/glucose cotransporter 2 (SGLT2) inhibitors to new mineralocorticoid receptor antagonists have shown efficacy in clinical trials. Herein, we review K+ pathophysiology and the clinical impact and management of hyperkalemia considering these developments and the availability of the novel K+ binders patiromer and sodium zirconium cyclosilicate, recent results from clinical trials targeting metabolic acidosis (sodium bicarbonate, veverimer), and an increasing understanding of the role of the gut microbiota in health and disease.
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Affiliation(s)
- José M Valdivielso
- Vascular and Renal Translational Research Group, UDETMA, REDinREN del ISCIII, IRBLleida, Lleida, Spain.
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Robert Ekart
- Clinic for Internal Medicine, Department of Dialysis, University Medical Center Maribor, Maribor, Slovenia
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases, Ospedali Riuniti, 89124, Reggio Calabria, Italy
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Patrick Rossignol
- Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116 and FCRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Alberto Ortiz
- School of Medicine, IIS-Fundacion Jimenez Diaz, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
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14
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Association between hyperkalemia, RAASi non-adherence and outcomes in chronic kidney disease. J Nephrol 2021; 35:463-472. [PMID: 34115311 PMCID: PMC8927011 DOI: 10.1007/s40620-021-01070-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 05/09/2021] [Indexed: 11/21/2022]
Abstract
Background Hyperkalemia is relatively frequent in CKD patients treated with renin-angiotensin-aldosterone-system inhibitors (RAASi). Aim The aim of the present study was to estimate the increased risk of cardiovascular events and mortality due to sub-optimal adherence to RAASi in CKD patients with hyperkalemia. Methods An observational retrospective cohort study was conducted, based on administrative and laboratory databases of five Local Health Units. Adult patients discharged from the hospital with a diagnosis of CKD, who were prescribed RAASi between January 2010 and December 2017, were included. We evaluated the appearance of documented episodes of hyperkalemia, RAASi therapy adherence and the effects of these two variables on cardiovascular events, death and dialysis inception for study patients. Results Of the 9241 selected patients, 4451 met all the criteria for study inclusion. Among them, 1071 had at least one documented episode of hyperkalemia, while 3380 did not. After propensity score matching based on several variables we obtained 2 groups of patients. The appearance of hyperkalemia caused treatment discontinuation in 21.8% of patients previously on RAASi therapy, and sub-optimal adherence (proportion of days covered < 80%) in 33.6% of them. Non-adherence to RAASi therapy among hyperkalemia patients was associated with a higher risk of cardiovascular events (hazard ratio [HR] 1.45, confidence interval [CI] 1.02–2.08; p < 0.05). Moreover, in non-adherent hyperkalemia patients, the risk of death increased by 126% (HR 2.26, CI 1.62–3.15; p < 0.001) compared with adherent patients. Conclusions In a large cohort of CKD patients treated with RAASi, we observed that following hyperkalemia onset, non-adherence to RAASi medication can result in an increased risk of cardiovascular events and death. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s40620-021-01070-6.
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15
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Morales E, Cravedi P, Manrique J. Management of Chronic Hyperkalemia in Patients With Chronic Kidney Disease: An Old Problem With News Options. Front Med (Lausanne) 2021; 8:653634. [PMID: 34150795 PMCID: PMC8213200 DOI: 10.3389/fmed.2021.653634] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 05/04/2021] [Indexed: 12/11/2022] Open
Abstract
Hyperkalemia is one of the main electrolyte disorders in patients with chronic kidney disease (CKD). The prevalence of hyperkalemia increases as the Glomerular Filtration Rate (GFR) declines. Although chronic hyperkalemia is not a medical emergency, it can have negative consequences for the adequate cardio-renal management in the medium and long term. Hyperkalemia is common in patients on renin-angiotensin-aldosterone system inhibitors (RAASi) or Mineralocorticoid Receptor Antagonists (MRAs) and can affect treatment optimization for hypertension, diabetes mellitus, heart failure (HF), and CKD. Mortality rates are higher with suboptimal dosing among patients with CKD, diabetes or HF compared with full RAASi dosing, and are the highest among patients who discontinue RAASis. The treatment of chronic hyperkalemia is still challenging. Therefore, in the real world, discontinuation or reduction of RAASi therapy may lead to adverse cardiorenal outcomes, and current guidelines differ with regard to recommendations on RAASi therapy to enhance cardio and reno-protective effects. Treatment options for hyperkalemia have not changed much since the introduction of the cation exchange resin over 50 years ago. Nowadays, two new potassium binders, Patiromer Sorbitex Calcium, and Sodium Zirconium Cyclosilicate (SZC) already approved by FDA and by the European Medicines Agency, have demonstrated their clinical efficacy in reducing serum potassium with a good safety profile. The use of the newer potassium binders may allow continuing and optimizing RAASi therapy in patients with hyperkalemia keeping the cardio-renal protective effect in patients with CKD and cardiovascular disease. However, further research is needed to address some questions related to potassium disorders (definition of chronic hyperkalemia, monitoring strategies, prediction score for hyperkalemia or length for treatment).
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Affiliation(s)
- Enrique Morales
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
- Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Paolo Cravedi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Joaquin Manrique
- Nephrology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
- Navarra Institute for Health Research, IdiSNA, Pamplona, Spain
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16
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Current Management of Hyperkalemia in Non-Dialysis CKD: Longitudinal Study of Patients Receiving Stable Nephrology Care. Nutrients 2021; 13:nu13030942. [PMID: 33804015 PMCID: PMC8000881 DOI: 10.3390/nu13030942] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/08/2021] [Accepted: 03/11/2021] [Indexed: 02/06/2023] Open
Abstract
Background: No study has explored the limitations of current long-term management of hyperkalemia (HK) in outpatient CKD clinics. Methods: We evaluated the association between current therapeutic options and control of serum K (sK) during 12-month follow up in ND-CKD patients stratified in four groups by HK (sK ≥ 5.0 mEq/L) at baseline and month 12: Absent (no-no), Resolving (yes-no), New Onset (no-yes), Persistent (yes-yes). Results: We studied 562 patients (age 66.2 ± 14.5 y; 61% males; eGFR 39.8 ± 21.8 mL/min/1.73 m2, RAASI 76.2%). HK was “absent” in 50.7%, “resolving” in 15.6%, “new onset” in 16.6%, and “persistent” in 17.1%. Twenty-four hour urinary measurements testified adherence to nutritional recommendations in the four groups at either visit. We detected increased prescription from baseline to month 12 of bicarbonate supplements (from 5.0 to 14.1%, p < 0.0001), K-binders (from 2.0 to 7.7%, p < 0.0001), and non-K sparing diuretics (from 34.3 to 41.5%, p < 0.001); these changes were consistent across groups. Similar results were obtained when using higher sK level (≥5.5 mEq/L) to stratify patients. Mixed-effects regression analysis showed that higher sK over time was associated with eGFR < 60, diabetes, lower serum bicarbonate, lower use of non-K sparing diuretics, bicarbonate supplementation, and K-binder use. Treatment-by-time interaction showed that sK decreased in HK patients given bicarbonate (p = 0.003) and K-binders (p = 0.005). Conclusions: This observational study discloses that one-third of ND-CKD patients under nephrology care remain with or develop HK during a 12-month period despite low K intake and increased use of sK-lowering drugs.
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Gallieni M, Buskermolen M, Boggio A, De Salvo C, Camerotto C. Plant-based kidney diets prescribed in nutrition clinics: clinical advantages with low risks of hyperkalemia. Intern Emerg Med 2021; 16:23-24. [PMID: 32399955 DOI: 10.1007/s11739-020-02363-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Maurizio Gallieni
- Department of Biomedical and Clinical Sciences "Luigi Sacco", Università Di Milano, Via G.B. Grassi, 74, 20157, Milan, Italy.
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Milan, Italy.
| | | | - Anna Boggio
- Nutritional Service, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Cristina De Salvo
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Carla Camerotto
- Nutritional Service, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
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18
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D'Alessandro C, Cumetti A, Pardini E, Mannucci C, Serio P, Morganti R, Cupisti A. Prevalence and correlates of hyperkalemia in a renal nutrition clinic. Intern Emerg Med 2021; 16:125-132. [PMID: 32382848 DOI: 10.1007/s11739-020-02353-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 04/21/2020] [Indexed: 12/18/2022]
Abstract
Hyperkalemia (HK) is a frequent complication of chronic kidney disease (CKD). Vegetable-based renal diets are considered at risk due to the high potassium (K) content. The aim of this study was to describe the prevalence and correlates of chronic hyperkalemia (HK) in CKD patients on nutritional care, and in particular, the risk of HK in patients on plant-based versus animal-based low-protein diets. We recruited adult patients affected by CKD not on dialysis, afferent to our renal nutrition clinic from November 2014 to May 2019. We evaluated a total of 870 accesses in 219 patients (172 m, 47 f, age 67 ± 13 years). HK was defined as mild when K serum level was 5.1-5.9 mEq/l, moderate when K serum level was 6.0-6.9 mEq/l, and severe HK when K serum level was ≥ 7 mEq/l. Biochemical, anthropometric data and medications were recorded. The prevalence of HK in all the renal nutrition visits was 26.1%; all but six cases were mild HK, whereas no severe HK was observed. The prevalence of HK was associated with decreased eGFR, up to 36.5% for eGFR < 20 ml/min. Medications were similar in hyperkalemic and normokalemic patients, RAASi being present in up to 85% of patients. In a follow-up of 40 ± 14 months, no association was found between HK and mortality, whereas HK, at the start of follow-up, showed a trend to increased ESRD risk. Serum potassium levels and prevalence of HK were not different between patients on animal-based low-protein diet and plant-based low-protein diet. In conclusion, chronic HK is quite prevalent in a renal nutrition clinic, especially when eGFR falls down below 60 ml/min, thereby reaching the highest prevalence in CKD stage 4. Hyperkalemia is mostly mild, being moderate to severe HK quite infrequent. Hyperkalemia was not associated with higher risk of mortality, whereas a trend, although not statistically significant, was observed for lower ESRD-free survival. Plant-based low-protein diet is not associated with significant higher prevalence of HK with respect to animal-based LPD at the same residual kidney function.
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Affiliation(s)
- Claudia D'Alessandro
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Andrea Cumetti
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Erica Pardini
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Claudia Mannucci
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Piera Serio
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | | | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, Italy.
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Lindner G, Burdmann EA, Clase CM, Hemmelgarn BR, Herzog CA, Małyszko J, Nagahama M, Pecoits-Filho R, Rafique Z, Rossignol P, Singer AJ. Acute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference. Eur J Emerg Med 2020; 27:329-337. [PMID: 32852924 PMCID: PMC7448835 DOI: 10.1097/mej.0000000000000691] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/17/2020] [Indexed: 11/30/2022]
Abstract
Hyperkalemia is a common electrolyte disorder observed in the emergency department. It is often associated with underlying predisposing conditions, such as moderate or severe kidney disease, heart failure, diabetes mellitus, or significant tissue trauma. Additionally, medications, such as inhibitors of the renin-angiotensin-aldosterone system, potassium-sparing diuretics, nonsteroidal anti-inflammatory drugs, succinylcholine, and digitalis, are associated with hyperkalemia. To this end, Kidney Disease: Improving Global Outcomes (KDIGO) convened a conference in 2018 to identify evidence and address controversies on potassium management in kidney disease. This review summarizes the deliberations and clinical guidance for the evaluation and management of acute hyperkalemia in this setting. The toxic effects of hyperkalemia on the cardiac conduction system are potentially lethal. The ECG is a mainstay in managing hyperkalemia. Membrane stabilization by calcium salts and potassium-shifting agents, such as insulin and salbutamol, is the cornerstone in the acute management of hyperkalemia. However, only dialysis, potassium-binding agents, and loop diuretics remove potassium from the body. Frequent reevaluation of potassium concentrations is recommended to assess treatment success and to monitor for recurrence of hyperkalemia.
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Affiliation(s)
- Gregor Lindner
- Department of Internal and Emergency Medicine, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Emmanuel A. Burdmann
- LIM 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | | | - Brenda R. Hemmelgarn
- Departments of Community Health Sciences and Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Charles A. Herzog
- Division of Cardiology, Department of Medicine, Hennepin Healthcare/University of Minnesota, Minneapolis, Minnesota, USA
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Poland
| | - Masahiko Nagahama
- Division of Nephrology, Department of Internal Medicine, St. Luke’s International Hospital, Tokyo, Japan
| | - Roberto Pecoits-Filho
- Pontificia Universidade Catolica do Paraná, Curitiba, Brazil and Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Zubaid Rafique
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Patrick Rossignol
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques-Plurithématique 14-33 and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Adam J. Singer
- Department of Emergency Medicine, Stony Brook University, Stony Brook, New York, USA
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Haas JS, Krinke KS, Maas C, Hardt T, Barck I, Braun S. The burden of hyperkalemia in Germany - a real world evidence study assessing the treatment and costs of hyperkalemia. BMC Nephrol 2020; 21:332. [PMID: 32770956 PMCID: PMC7414716 DOI: 10.1186/s12882-020-01942-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/12/2020] [Indexed: 11/10/2022] Open
Abstract
Background Hyperkalemia (HK) can affect health outcomes and quality of life, as it is referred to as a potentially life-threatening condition caused by an increased serum potassium concentration in the blood. Patients suffering from heart failure or chronic kidney diseases are at a higher risk of HK, which can further be amplified by the treatment received. To date, data on HK prevalence is lacking for Germany and the aims of this study were to assess HK and compare health-relevant outcomes and healthcare costs between HK patients and non-HK patients. Methods The InGef research database containing healthcare claims of over 4 million individuals in Germany was utilized for this retrospective, matched cohort analysis. Patients with non-acute outpatient treated and a subgroup of patients with chronic HK, were identified in 2015 with an individual 1 year pre- and post-index period, taking the first observable HK diagnosis/treatment in 2015 into account as the index event. To identify non-acute outpatient treated HK patients, at least two ICD-10-GM diagnosis codes E87.5 “Hyperkalemia” and/or prescriptions of polystyrene sulfonate were required. Chronic HK patients had additional diagnoses and/or prescriptions in all quarters following the first observable HK diagnosis. Patients without HK were matched 1:1 to the respective HK cohorts. Results In the year 2015, 3333 patients with non-acute outpatient treated HK were identified of which 1693 were patients with chronic HK. After matching, 3191 and 1664 HK patients and controls were available for analysis. A significantly higher number of hospitalizations was observed for both HK cohorts in comparison to their matched controls. Dialysis initiation as well as the healthcare costs were higher for both HK cohorts when compared to their matched counterparts. Conclusions The disease burden was higher for patients with HK, based on a higher proportion of patients with dialysis initiation and higher healthcare costs.
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Affiliation(s)
| | | | | | - Thomas Hardt
- Vifor Pharma Gruppe, Pharma Deutschland GmbH, Baierbrunner Str. 29, 81379, Munich, Germany
| | - Isabella Barck
- Vifor Pharma Gruppe, Pharma Deutschland GmbH, Baierbrunner Str. 29, 81379, Munich, Germany
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Li G, Lian L, Huang S, Miao J, Cao H, Zuo C, Liu X, Zhu Z. Nomograms to predict 2-year overall survival and advanced schistosomiasis-specific survival after discharge: a competing risk analysis. J Transl Med 2020; 18:187. [PMID: 32375846 PMCID: PMC7201698 DOI: 10.1186/s12967-020-02353-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 04/25/2020] [Indexed: 02/07/2023] Open
Abstract
Background The prognosis of patients with advanced schistosomiasis is poor. Pre-existing prognosis studies did not differentiate the causes of the deaths. The objectives were to evaluate the 2-year overall survival (OS) and advanced schistosomiasis-specific survival (ASS) in patients with advanced schistosomiasis after discharge through competing risk analysis and to build predictive nomograms. Methods Data was extracted from a previously constructed database from Hubei province. Patients were enrolled from September 2014 to January 2015, with follow up to January 2017. OS and ASS were primary outcome measures. Nomograms for estimating 2-year OS and ASS rates after discharge were established based on univariate and multivariate Cox regression model and Fine and Gray’s model. Their predictive performances were evaluated using C-index and validated in both internal and external validation cohorts. Results The training cohort included 1487 patients with advanced schistosomiasis. Two-year mortality rate of the training cohort was 8.27% (123/1487). Competing events accounted for 26.83% (33/123). Older age, splemomegaly clinical classification, abnormal serum DBil, AST, ALP and positive HBsAg were significantly associated with 2-year OS. Older age, splemomegaly clinical classification, abnormal serum AST, ALP and positive HBsAg were significantly associated with 2-year ASS. The established nomograms were well calibrated, and had good discriminative ability, with a C-index of 0.813 (95% CI 0.803–0.823) for 2-year OS prediction and 0.834 (95% CI 0.824–0.844) for 2-year ASS prediction. Their predictive performances were well validated in both internal and external validation cohorts. Conclusion The effective predictors of 2-year OS and ASS were discovered through competing risk analysis. The nomograms could be used as convenient predictive tools in clinical practice to guide follow-up and aid accurate prognostic assessment.
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Affiliation(s)
- Guo Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, Hubei, 430030, China
| | - Lifei Lian
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, Hubei, 430030, China
| | - Shanshan Huang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, Hubei, 430030, China
| | - Jinfeng Miao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, Hubei, 430030, China
| | - Huan Cao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, Hubei, 430030, China
| | - Chengchao Zuo
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, Hubei, 430030, China
| | - Xiaoyan Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, Hubei, 430030, China.
| | - Zhou Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, Hubei, 430030, China.
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22
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Provenzano M, De Francesco M, Iannazzo S, Garofalo C, Andreucci M, Genualdo R, Borrelli S, Minutolo R, Conte G, De Nicola L. Cost-analysis of persistent hyperkalaemia in non-dialysis chronic kidney disease patients under nephrology care in Italy. Int J Clin Pract 2020; 74:e13475. [PMID: 31909866 DOI: 10.1111/ijcp.13475] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/19/2019] [Accepted: 01/06/2020] [Indexed: 12/21/2022] Open
Abstract
AIM In patients with chronic kidney disease (CKD), hyperkalaemia (HK) (potassium level ≥ 5.0 mEq/L) is associated with poor clinical outcomes. This study provides novel insights by comparing management costs of CKD patients with normokalaemia vs those with persistent HK regularly followed in renal clinics in Italy. METHODS To this aim, a Markov model over life-time horizon was developed. Time to end-stage renal disease (ESRD) and time to death in CKD patients were derived from an observational multi-centre database including 1665 patients with non-dialysis CKD stage 1-5 under nephrology care in Italy (15 years follow-up). Resource use for CKD and HK management was obtained from the observational database, KDIGO international guidelines, and clinical expert opinion. RESULTS Results showed that patients with normokalaemia vs persistent HK brought an average per patient lifetime cost-saving of €16 059 besides delayed onset of ESRD by 2.29 years and increased survival by 1.79 years with increment in total survival and dialysis-free survival in normokalaemia that decreased from early to advanced disease. Cost-saving related to normokalaemia increased at more advanced CKD; however, it was already evident at early stage (3388.97€ at stage 1-3a). OWSA confirmed cost-saving associated with normokalaemia across all parameter variations. DISCUSSION AND CONCLUSION This model is the first to simulate the impact of HK in non-dialysis CKD patients on economic and clinical outcomes using real-world data from nephrology clinics. In these patients, persistent HK results into higher lifetime costs, besides poorer clinical outcomes, that are evident since the early stages of CKD. Maintaining normokalaemia should therefore be of main concern in CKD treatment planning to improve long-term economic and clinical outcomes.
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Affiliation(s)
- Michele Provenzano
- Nephrology and Dialysis Division, University Magna Graecia in Catanzaro, Catanzaro, Italy
| | | | | | - Carlo Garofalo
- Division of Nephrology, Department of Advanced Medical and Surgical Sciences, Nephrology Unit - University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Michele Andreucci
- Nephrology and Dialysis Division, University Magna Graecia in Catanzaro, Catanzaro, Italy
| | - Raffaele Genualdo
- Nephrology and Dialysis Unit, Pellegrini Hospital, ASL NA1 Centro, Naples, Italy
| | - Silvio Borrelli
- Division of Nephrology, Department of Advanced Medical and Surgical Sciences, Nephrology Unit - University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Roberto Minutolo
- Division of Nephrology, Department of Advanced Medical and Surgical Sciences, Nephrology Unit - University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giuseppe Conte
- Division of Nephrology, Department of Advanced Medical and Surgical Sciences, Nephrology Unit - University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Luca De Nicola
- Division of Nephrology, Department of Advanced Medical and Surgical Sciences, Nephrology Unit - University of Campania "Luigi Vanvitelli", Naples, Italy
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23
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Chronic Kidney Disease: The Silent Epidemy. J Clin Med 2019; 8:jcm8111795. [PMID: 31717778 PMCID: PMC6912263 DOI: 10.3390/jcm8111795] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 12/19/2022] Open
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24
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Bianchi S, Aucella F, De Nicola L, Genovesi S, Paoletti E, Regolisti G. Management of hyperkalemia in patients with kidney disease: a position paper endorsed by the Italian Society of Nephrology. J Nephrol 2019; 32:499-516. [PMID: 31119681 PMCID: PMC6588653 DOI: 10.1007/s40620-019-00617-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 05/05/2019] [Indexed: 12/11/2022]
Abstract
Hyperkalemia (HK) is the most common electrolyte disturbance observed in patients with kidney disease, particularly in those in whom diabetes and heart failure are present or are on treatment with renin-angiotensin-aldosterone system inhibitors (RAASIs). HK is recognised as a major risk of potentially life threatening cardiac arrhythmic complications. When an acute reduction of renal function manifests, both in patients with chronic kidney disease (CKD) and in those with previously normal renal function, HK is the main indication for the execution of urgent medical treatment and the recourse to extracorporeal replacement therapies. In patients with end-stage renal disease, the presence of HK not responsive to medical therapy is an indication at the beginning of chronic renal replacement therapy. HK can also be associated indirectly with the progression of CKD, because the finding of high potassium values leads to withdrawal of treatment with RAASIs, which constitute the first choice nephro-protective treatment. It is therefore essential to identify patients at risk of developing HK, and to implement therapeutic interventions aimed at preventing and treating this dangerous complication of kidney disease. Current strategies aimed at the prevention and treatment of HK are still unsatisfactory, as evidenced by the relatively high prevalence of HK also in patients under stable nephrology care, and even in the ideal setting of randomized clinical trials where optimal treatment and monitoring are mandatory. This position paper will review the main therapeutic interventions to be implemented for the prevention, detection and treatment of HK in patients with CKD on conservative care, in those on dialysis, in patients in whom renal disease is associated with diabetes, heart failure, resistant hypertension and who are on treatment with RAASIs, and finally in those presenting with severe acute HK.
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Affiliation(s)
- Stefano Bianchi
- Nephrology and Dialysis Unit, Department of Internal Medicine, Azienda ASL Toscana Nord Ovest, Livorno, Italy
| | - Filippo Aucella
- Nephrology and Dialysis Unit, IRCCS “Casa Sollievo della Sofferenza” Scientific Institute for Research and Health Care, San Giovanni Rotondo, Italy
| | - Luca De Nicola
- Division of Nephrology, University of Campania, Naples, Italy
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milano - Bicocca San Gerardo Hospital, Nephrology Unit, Monza, Italy
| | - Ernesto Paoletti
- Nephrology, Dialysis and Transplantation, University of Genoa and Policlinico, San Martino Genoa, Italy
| | - Giuseppe Regolisti
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
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25
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Di Micco L, Di Lullo L, Bellasi A, Di Iorio BR. Very Low Protein Diet for Patients with Chronic Kidney Disease: Recent Insights. J Clin Med 2019; 8:jcm8050718. [PMID: 31137545 PMCID: PMC6572310 DOI: 10.3390/jcm8050718] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 05/17/2019] [Accepted: 05/17/2019] [Indexed: 12/30/2022] Open
Abstract
Use of nutritional therapy (NT) in chronic kidney disease (CKD) patients is still debated among nephrologists, but it represents a fundamental point in the conservative treatment of CKD. It has been used for years and it has new goals today, such as (1) the reduction of edema, diuretics, and blood pressure values with a low sodium-content diet; (2) the dose reduction of phosphate levels and phosphate binders; (3) the administration of bicarbonate with vegetables in order to correct metabolic acidosis and delay CKD progression; (4) the reduction of the number and the doses of drugs and chemical substances; and (5) the lowering of urea levels, the cure of intestinal microbioma, and the reduction of cyanates levels (such as indoxyl-sulphate and p-cresol sulphate), which are the most recent known advantages achievable with NT. In conclusion, NT and especially very low protein diet (VLPD) have several beneficial effects in CKD patients and slows the progression of CKD.
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Affiliation(s)
- Lucia Di Micco
- Nefrology and Dialysis, AORN "San Giuseppe Moscati, 83100 Avellino AV, Italy.
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Rome, Italy.
| | - Antonio Bellasi
- Department of Research, Innovation and Brand Reputation, ASST Papa Giovanni XXIII, 24127 Bergamo BG, Italy.
| | - Biagio R Di Iorio
- Nephrology and Dialysis, AORN "Antonio Cardarelli", 80131 Napoli, Italy.
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