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Stadt MM, Layton AT. A modeling analysis of whole body potassium regulation on a high-potassium diet: proximal tubule and tubuloglomerular feedback effects. Am J Physiol Regul Integr Comp Physiol 2024; 326:R401-R415. [PMID: 38465401 DOI: 10.1152/ajpregu.00283.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/15/2024] [Accepted: 03/05/2024] [Indexed: 03/12/2024]
Abstract
Potassium (K+) is an essential electrolyte that plays a key role in many physiological processes, including mineralcorticoid action, systemic blood-pressure regulation, and hormone secretion and action. Indeed, maintaining K+ balance is critical for normal cell function, as too high or too low K+ levels can have serious and potentially deadly health consequences. K+ homeostasis is achieved by an intricate balance between the intracellular and extracellular fluid as well as balance between K+ intake and excretion. This is achieved via the coordinated actions of regulatory mechanisms such as the gastrointestinal feedforward effect, insulin and aldosterone upregulation of Na+-K+-ATPase uptake, and hormone and electrolyte impacts on renal K+ handling. We recently developed a mathematical model of whole body K+ regulation to unravel the individual impacts of these regulatory mechanisms. In this study, we extend our mathematical model to incorporate recent experimental findings that showed decreased fractional proximal tubule reabsorption under a high-K+ diet. We conducted model simulations and sensitivity analyses to investigate how these renal alterations impact whole body K+ regulation. Model predictions quantify the sensitivity of K+ regulation to various levels of proximal tubule K+ reabsorption adaptation and tubuloglomerular feedback. Our results suggest that the reduced proximal tubule K+ reabsorption under a high-K+ diet could achieve K+ balance in isolation, but the resulting tubuloglomerular feedback reduces filtration rate and thus K+ excretion.NEW & NOTEWORTHY Potassium homeostasis is maintained in the body by a complex system of regulatory mechanisms. This system, when healthy, maintains a small extracellular potassium concentration, despite large fluctuations of dietary potassium. The complexities of the system make this problem well suited for investigation with mathematical modeling. In this study, we extend our mathematical model to consider recent experimental results on renal potassium handling on a high potassium diet and investigate the impacts from a whole body perspective.
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Affiliation(s)
- Melissa M Stadt
- Department of Applied Mathematics, University of Waterloo, Waterloo, Ontario, Canada
| | - Anita T Layton
- Department of Applied Mathematics, University of Waterloo, Waterloo, Ontario, Canada
- Cheriton School of Computer Science, University of Waterloo, Waterloo, Ontario, Canada
- Department of Biology, University of Waterloo, Waterloo, Ontario, Canada
- Department of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
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2
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Johnston JG, Welch AK, Cain BD, Sayeski PP, Gumz ML, Wingo CS. Aldosterone: Renal Action and Physiological Effects. Compr Physiol 2023; 13:4409-4491. [PMID: 36994769 DOI: 10.1002/cphy.c190043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Aldosterone exerts profound effects on renal and cardiovascular physiology. In the kidney, aldosterone acts to preserve electrolyte and acid-base balance in response to changes in dietary sodium (Na+ ) or potassium (K+ ) intake. These physiological actions, principally through activation of mineralocorticoid receptors (MRs), have important effects particularly in patients with renal and cardiovascular disease as demonstrated by multiple clinical trials. Multiple factors, be they genetic, humoral, dietary, or otherwise, can play a role in influencing the rate of aldosterone synthesis and secretion from the adrenal cortex. Normally, aldosterone secretion and action respond to dietary Na+ intake. In the kidney, the distal nephron and collecting duct are the main targets of aldosterone and MR action, which stimulates Na+ absorption in part via the epithelial Na+ channel (ENaC), the principal channel responsible for the fine-tuning of Na+ balance. Our understanding of the regulatory factors that allow aldosterone, via multiple signaling pathways, to function properly clearly implicates this hormone as central to many pathophysiological effects that become dysfunctional in disease states. Numerous pathologies that affect blood pressure (BP), electrolyte balance, and overall cardiovascular health are due to abnormal secretion of aldosterone, mutations in MR, ENaC, or effectors and modulators of their action. Study of the mechanisms of these pathologies has allowed researchers and clinicians to create novel dietary and pharmacological targets to improve human health. This article covers the regulation of aldosterone synthesis and secretion, receptors, effector molecules, and signaling pathways that modulate its action in the kidney. We also consider the role of aldosterone in disease and the benefit of mineralocorticoid antagonists. © 2023 American Physiological Society. Compr Physiol 13:4409-4491, 2023.
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Affiliation(s)
- Jermaine G Johnston
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida, USA
- Nephrology Section, Veteran Administration Medical Center, North Florida/South Georgia Malcom Randall Department of Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - Amanda K Welch
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
- Nephrology Section, Veteran Administration Medical Center, North Florida/South Georgia Malcom Randall Department of Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - Brian D Cain
- Department of Biochemistry and Molecular Biology, University of Florida, Gainesville, Florida, USA
| | - Peter P Sayeski
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida, USA
| | - Michelle L Gumz
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida, USA
- Department of Biochemistry and Molecular Biology, University of Florida, Gainesville, Florida, USA
- Nephrology Section, Veteran Administration Medical Center, North Florida/South Georgia Malcom Randall Department of Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - Charles S Wingo
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida, USA
- Nephrology Section, Veteran Administration Medical Center, North Florida/South Georgia Malcom Randall Department of Veterans Affairs Medical Center, Gainesville, Florida, USA
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Guo L, Fu B, Liu Y, Hao N, Ji Y, Yang H. Diuretic resistance in patients with kidney disease: Challenges and opportunities. Biomed Pharmacother 2023; 157:114058. [PMID: 36473405 DOI: 10.1016/j.biopha.2022.114058] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 11/15/2022] [Accepted: 11/27/2022] [Indexed: 12/10/2022] Open
Abstract
Edema caused by kidney disease is called renal edema. Edema is a common symptom of many human kidney diseases. Patients with renal edema often need to take diuretics.However, After taking diuretics, patients with kidney diseases are prone to kidney congestion, decreased renal perfusion, decreased diuretics secreted by renal tubules, neuroendocrine system abnormalities, abnormal ion transporter transport, drug interaction, electrolyte disorder, and hypoproteinemia, which lead to ineffective or weakened diuretic use and increase readmission rate and mortality. The main causes and coping strategies of diuretic resistance in patients with kidney diseases were described in detail in this report. The common causes of DR included poor diet (electrolyte disturbance and hypoproteinemia due to patients' failure to limit diet according to correct sodium, chlorine, potassium, and protein level) and poor drug compliance (the patient did not take adequate doses of diuretics. true resistance occurs only if the patient takes adequate doses of diuretics, but they are not effective), changes in pharmacokinetics and pharmacodynamics, electrolyte disorders, changes in renal adaptation, functional nephron reduction, and decreased renal blood flow. Common treatment measures include increasing in the diuretic dose and/or frequency, sequential nephron blockade,using new diuretics, ultrafiltration treatment, etc. In clinical work, measures should be taken to prevent or delay the occurrence and development of DR in patients with kidney diseases according to the actual situation of patients and the mechanism of various causes. Currently, there are many studies on DR in patients with heart diseases. Although the phenomenon of DR in patients with kidney diseases is common, there is a relatively little overview of the mechanism and treatment strategy of DR in patients with kidney diseases. Therefore, this paper hopes to show the information on DR in patients with kidney diseases to clinicians and researchers and broaden the research direction and ideas to a certain extent.
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Affiliation(s)
- Luxuan Guo
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Baohui Fu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Yang Liu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Na Hao
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Yue Ji
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Hongtao Yang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China.
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Stadt MM, Leete J, Devinyak S, Layton AT. A mathematical model of potassium homeostasis: Effect of feedforward and feedback controls. PLoS Comput Biol 2022; 18:e1010607. [PMID: 36538563 PMCID: PMC9812337 DOI: 10.1371/journal.pcbi.1010607] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/04/2023] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
Maintaining normal potassium (K+) concentrations in the extra- and intracellular fluid is critical for cell function. K+ homeostasis is achieved by ensuring proper distribution between extra- and intracellular fluid compartments and by matching K+ excretion with intake. The Na+-K+-ATPase pump facilitates K+ uptake into the skeletal muscle, where most K+ is stored. Na+-K+-ATPase activity is stimulated by insulin and aldosterone. The kidneys regulate long term K+ homeostasis by controlling the amount of K+ excreted through urine. Renal handling of K+ is mediated by a number of regulatory mechanisms, including an aldosterone-mediated feedback control, in which high extracellular K+ concentration stimulates aldosterone secretion, which enhances urine K+ excretion, and a gastrointestinal feedforward control mechanism, in which dietary K+ intake increases K+ excretion. Recently, a muscle-kidney cross talk signal has been hypothesized, where the K+ concentration in skeletal muscle cells directly affects urine K+ excretion without changes in extracellular K+ concentration. To understand how these mechanisms coordinate under different K+ challenges, we have developed a compartmental model of whole-body K+ regulation. The model represents the intra- and extracellular fluid compartments in a human (male) as well as a detailed kidney compartment. We included (i) the gastrointestinal feedforward control mechanism, (ii) the effect of insulin and (iii) aldosterone on Na+-K+-ATPase K+ uptake, and (iv) aldosterone stimulation of renal K+ secretion. We used this model to investigate the impact of regulatory mechanisms on K+ homeostasis. Model predictions showed how the regulatory mechanisms synthesize to ensure that the extra- and intracelluller fluid K+ concentrations remain in normal range in times of K+ loading and fasting. Additionally, we predict that without the hypothesized muscle-kidney cross talk signal, the model was unable to predict a return to normal extracellular K+ concentration after a period of high K+ loading or depletion.
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Affiliation(s)
- Melissa M. Stadt
- Department of Applied Mathematics, University of Waterloo, Waterloo, Ontario, Canada
- * E-mail:
| | - Jessica Leete
- Computational Biology and Bioinformatics Program, Duke University, Durham, North Carolina, United States of America
| | - Sophia Devinyak
- Department of Physics and Astronomy, University of Waterloo, Waterloo, Ontario, Canada
| | - Anita T. Layton
- Department of Applied Mathematics, University of Waterloo, Waterloo, Ontario, Canada
- Cheriton School of Computer Science, University of Waterloo, Waterloo, Ontario, Canada
- Department of Biology, University of Waterloo, Waterloo, Ontario, Canada
- Department of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
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5
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McDonough AA, Fenton RA. Potassium homeostasis: sensors, mediators, and targets. Pflugers Arch 2022; 474:853-867. [PMID: 35727363 PMCID: PMC10163916 DOI: 10.1007/s00424-022-02718-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 06/08/2022] [Accepted: 06/12/2022] [Indexed: 12/16/2022]
Abstract
Transmembrane potassium (K) gradients are key determinants of membrane potential that can modulate action potentials, control muscle contractility, and influence ion channel and transporter activity. Daily K intake is normally equal to the amount of K in the entire extracellular fluid (ECF) creating a critical challenge - how to maintain ECF [K] and membrane potential in a narrow range during feast and famine. Adaptations to maintain ECF [K] include sensing the K intake, sensing ECF [K] vs. desired set-point and activating mediators that regulate K distribution between ECF and ICF, and regulate renal K excretion. In this focused review, we discuss the basis of these adaptions, including (1) potential mechanisms for rapid feedforward signaling to kidney and muscle after a meal (before a rise in ECF [K]), (2) how skeletal muscles sense and respond to changes in ECF [K], (3) effects of K on aldosterone biosynthesis, and (4) how the kidney responds to changes in ECF [K] to modify K excretion. The concepts of sexual dimorphisms in renal K handling adaptation are introduced, and the molecular mechanisms that can account for the benefits of a K-rich diet to maintain cardiovascular health are discussed. Although the big picture of K homeostasis is becoming more clear, we also highlight significant pieces of the puzzle that remain to be solved, including knowledge gaps in our understanding of initiating signals, sensors and their connection to homeostatic adjustments of ECF [K].
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Affiliation(s)
- Alicia A McDonough
- Department of Physiology and Neuroscience, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.
| | - Robert A Fenton
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
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Scicchitano P, Iacoviello M, Massari F, De Palo M, Caldarola P, Mannarini A, Passantino A, Ciccone MM, Magnesa M. Optimizing Therapies in Heart Failure: The Role of Potassium Binders. Biomedicines 2022; 10:biomedicines10071721. [PMID: 35885026 PMCID: PMC9313061 DOI: 10.3390/biomedicines10071721] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/12/2022] [Accepted: 07/15/2022] [Indexed: 11/21/2022] Open
Abstract
Heart failure (HF) is a worrisome cardiac pandemic with a negative prognostic impact on the overall survival of individuals. International guidelines recommend up-titration of standardized therapies in order to reduce symptoms, hospitalization rates, and cardiac death. Hyperkalemia (HK) has been identified in 3–18% of HF patients from randomized controlled trials and over 25% of HF patients in the “real world” setting. Pharmacological treatments and/or cardio-renal syndrome, as well as chronic kidney disease may be responsible for HK in HF patients. These conditions can prevent the upgrade of pharmacological treatments, thus, negatively impacting on the overall prognosis of patients. Potassium binders may be the best option in patients with HK in order to reduce serum concentrations of K+ and to promote correct upgrades of therapies. In addition to the well-established use of sodium polystyrene sulfonate (SPS), two novel drugs have been recently introduced: sodium zirconium cyclosilicate (SZC) and patiromer. SZC and patiromer are gaining a central role for the treatment of chronic HK. SZC has been shown to reduce K+ levels within 48 h, with guaranteed maintenance of normokalemia for up to12 months. Patiromer has resulted in a statistically significant decrease in serum potassium for up to 52 weeks. Therefore, long-term results seemed to positively promote the implementation of these compounds in clinical practice due to their low rate side effects. The aim of this narrative review is to delineate the impact of new potassium binders in the treatment of patients with HF by providing a critical reappraisal for daily application of novel therapies for hyperkalemia in the HF setting.
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Affiliation(s)
- Pietro Scicchitano
- Cardiology Section, Hospital “F. Perinei” Altamura (BA), 70022 Altamura, Italy;
- Correspondence: ; Tel.: +39-0803108286
| | - Massimo Iacoviello
- Cardiology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (M.I.); (M.M.)
| | - Francesco Massari
- Cardiology Section, Hospital “F. Perinei” Altamura (BA), 70022 Altamura, Italy;
| | - Micaela De Palo
- Cardiac Surgery Unit, Azienda Ospedaliero-Universitaria Policlinico Bari, 70124 Bari, Italy;
| | | | - Antonia Mannarini
- Division of University Cardiology, Cardiothoracic Department, Policlinic University Hospital, 70124 Bari, Italy;
| | - Andrea Passantino
- Division of Cardiology and Cardiac Rehabilitation, Scientific Clinical Institutes Maugeri, IRCCS Institute of Bari, 70124 Bari, Italy;
| | - Marco Matteo Ciccone
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, 70124 Bari, Italy;
| | - Michele Magnesa
- Cardiology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (M.I.); (M.M.)
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Bamgbola OF. Review of the Pathophysiologic and Clinical Aspects of Hypokalemia in Children and Young Adults: an Update. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2022; 8:96-114. [PMID: 37521171 PMCID: PMC9115742 DOI: 10.1007/s40746-022-00240-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 11/28/2022]
Abstract
This article examines the regulatory function of the skeletal muscle, renal, and adrenergic systems in potassium homeostasis. The pathophysiologic bases of hypokalemia, systematic approach for an early diagnosis, and therapeutic strategy to avert life-threatening complications are highlighted. By promoting skeletal muscle uptake, intense physical exercise (post), severe trauma, and several toxins produce profound hypokalemia. Hypovolemia due to renal and extra-renal fluid losses and ineffective circulation activate secondary aldosteronism causing urinary potassium wasting. In addition to hypokalemic alkalosis, primary aldosteronism causes low-renin hypertension. Non-aldosterone mineralocorticoid activation leading to low-renin and low-aldosterone hypertension occurs in Liddle's syndrome and apparent mineralocorticoid excess. Although there is enzymatic inhibition of cortisol synthesis in congenital adrenal hyperplasia, precursors of aldosterone produce low-renin hypokalemic hypertension. In addition to the glucocorticoid effect, hypercortisolism activates mineralocorticoid receptors in Cushing's syndrome. Genetic mutations involving furosemide-sensitive Na+-K+-2Cl- co-transporters and thiazide-sensitive Na+-Cl- transporters result in (non-hypertensive) salt-wasting nephropathy. Proximal and distal renal tubular acidosis is associated with hypokalemia. Eating disorders causing hypokalemia include bulimia, laxative abuse, and diuretic misuse. Low urinary potassium (<15 mmol/day) and/or low urinary chloride (<20 mol/L) suggest a gastrointestinal pathology. Co-morbidity of hypokalemia with chronic pulmonary and cardiovascular diseases may increase the fatality rate.
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Affiliation(s)
- Oluwatoyin Fatai Bamgbola
- Division of Pediatric Nephrology, SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203 USA
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Leete J, Wang C, López-Hernández FJ, Layton AT. Determining risk factors for triple whammy acute kidney injury. Math Biosci 2022; 347:108809. [PMID: 35390421 DOI: 10.1016/j.mbs.2022.108809] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/08/2022] [Accepted: 03/22/2022] [Indexed: 01/03/2023]
Abstract
Concurrent use of a diuretic, a renin-angiotensin system (RAS) inhibitor, and a non-steroidal anti-inflammatory drug (NSAID) significantly increases the risk of acute kidney injury (AKI). This phenomenon is known as "triple whammy". Diuretics and RAS inhibitors, such as an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker, are often prescribed in tandem for the treatment of hypertension, whereas some NSAIDs, such as ibuprofen, are available over the counter. As such, concurrent treatment with all three drugs is common. The goals of this study are to better understand the mechanisms underlying the development of triple whammy AKI and to identify physiological factors that may increase an individual's susceptibility. To accomplish these goals, we utilize sex-specific computational models of long-term blood pressure regulation. These models include variables describing the heart and circulation, kidney function, sodium and water reabsorption in the nephron and the RAS and are parameterized separately for men and women. Hypertension is modeled as overactive renal sympathetic nervous activity. Model simulations suggest that low water intake, the myogenic response, and drug sensitivity may predispose patients with hypertension to develop triple whammy-induced AKI. Triple treatment involving an ACE inhibitor, furosemide, and NSAID results in blood pressure levels similar to double treatment with ACEI and furosemide. Additionally, the male and female hypertensive models act similarly in most situations, except for the ACE inhibitor and NSAID double treatment.
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Affiliation(s)
- Jessica Leete
- Computational Biology and Bioinformatics Program, Duke University, Durham, NC, USA
| | - Carolyn Wang
- Faculty of Mathematics, University of Waterloo, Waterloo, Ontario, Canada
| | | | - Anita T Layton
- Departments of Applied Mathematics and Biology, Cheriton School of Computer Science, and School of Pharmacology, University of Waterloo, Waterloo Ontario, N2L 3G1, Canada.
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Al-Qusairi L, Grimm PR, Zapf AM, Welling PA. Rapid development of vasopressin resistance in dietary K + deficiency. Am J Physiol Renal Physiol 2021; 320:F748-F760. [PMID: 33749322 PMCID: PMC8174811 DOI: 10.1152/ajprenal.00655.2020] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/15/2021] [Accepted: 03/15/2021] [Indexed: 12/27/2022] Open
Abstract
The association between diabetes insipidus (DI) and chronic dietary K+ deprivation is well known, but it remains uncertain how the disorder develops and whether it is influenced by the sexual dimorphism in K+ handling. Here, we determined the plasma K+ (PK) threshold for DI in male and female mice and ascertained if DI is initiated by polydipsia or by a central or nephrogenic defect. C57BL6J mice were randomized to a control diet or to graded reductions in dietary K+ for 8 days, and kidney function and transporters involved in water balance were characterized. We found that male and female mice develop polyuria and secondary polydipsia. Altered water balance coincided with a decrease in aquaporin-2 (AQP2) phosphorylation and apical localization despite increased levels of the vasopressin surrogate marker copeptin. No change in the protein abundance of urea transporter-A1 was observed. The Na+-K+-2Cl- cotransporter decreased only in males. Desmopressin treatment failed to reverse water diuresis in K+-restricted mice. These findings indicate that even a small fall in PK is associated with nephrogenic DI (NDI), coincident with the development of altered AQP2 regulation, implicating low PK as a causal trigger of NDI. We found that PK decreased more in females, and, consequently, females were more prone to develop NDI. Together, these data indicate that AQP2 regulation is disrupted by a small decrease in PK and that the response is influenced by sexual dimorphism in K+ handling. These findings provide new insights into the mechanisms linking water and K+ balances and support defining the disorder as "potassium-dependent NDI."NEW & NOTEWORTHY This study shows that aquaporin-2 regulation is disrupted by a small fall in plasma potassium levels and the response is influenced by sexual dimorphism in renal potassium handling. The findings provided new insights into the mechanisms by which water balance is altered in dietary potassium deficiency and support defining the disorder as "potassium-dependent nephrogenic diabetes insipidus."
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Affiliation(s)
- Lama Al-Qusairi
- Departments of Medicine, Nephrology, and Physiology, Johns Hopkins University Medical School, Baltimore, Maryland
| | - P Richard Grimm
- Departments of Medicine, Nephrology, and Physiology, Johns Hopkins University Medical School, Baltimore, Maryland
| | - Ava M Zapf
- Graduate Program in Life Sciences, University of Maryland, Baltimore, Maryland
| | - Paul A Welling
- Departments of Medicine, Nephrology, and Physiology, Johns Hopkins University Medical School, Baltimore, Maryland
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Hoppe LK, Muhlack DC, Koenig W, Brenner H, Schöttker B. The Associations of Diuretics and Laxatives Use with Cardiovascular Mortality. An Individual Patient-Data Meta-analysis of Two Large Cohort Studies. Cardiovasc Drugs Ther 2020; 33:567-579. [PMID: 31375970 PMCID: PMC6904395 DOI: 10.1007/s10557-019-06894-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose To investigate the associations of diuretics overall, non-potassium-sparing diuretics in specific, and laxative use with cardiovascular mortality (CVM) in subjects with antihypertensive treatment. Methods Analyses included 4253 participants, aged 50 to 75 years, from the German ESTHER cohort and 105,359 participants, aged 50 to 69 years, from the UK Biobank. Cox proportional hazard regression models were applied in both studies, and then results were pooled using random-effects model meta-analyses. Results During 14 and 7 years of follow-up, 476 and 1616 CVM cases were observed in the ESTHER study and the UK Biobank, respectively. Compared to non-users, a 1.6-fold (hazard ratio [95% confidence interval] 1.57 [1.29; 1.90]), a 1.4-fold (1.39 [1.26; 1.53]), and no statistically significantly increased (1.13 [0.94; 1.36]) CVM were observed in users of diuretics overall, non-potassium-sparing diuretics in specific, and laxatives, respectively. Concurrent use of non-potassium-sparing diuretics and laxatives was associated with a 2-fold increased CVM (2.05 [1.55; 2.71]) when compared to users of neither diuretics nor laxatives. However, a test for interaction slightly missed statistical significance (p = 0.075). Conclusions These consistent results from two large cohort studies imply that more research is needed on the safety of diuretics in routine care. Although not statistically significant in this study, a drug-drug interaction of non-potassium-sparing diuretics and laxatives appears plausible. Physicians and pharmacists are advised to clarify additional laxative use in users of non-potassium-sparing diuretics and inform about the risk of concurrent use. Moreover, closer potassium monitoring intervals (e.g., every 3 months) might be indicated in concurrent users to prevent fatal cardiovascular events. Electronic supplementary material The online version of this article (10.1007/s10557-019-06894-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Liesa Katharina Hoppe
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Im Neuenheimer Feld 581, 69120, Heidelberg, Germany
- Network Aging Research, University of Heidelberg, Bergheimer Straße 20, 69115, Heidelberg, Germany
| | - Dana Clarissa Muhlack
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Im Neuenheimer Feld 581, 69120, Heidelberg, Germany
- Network Aging Research, University of Heidelberg, Bergheimer Straße 20, 69115, Heidelberg, Germany
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, Lazarettstraße 36, 80636, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Pettenkoferstraße 8a & 9, 80336, Munich, Germany
- Institute of Epidemiology and Medical Biometry, University of Ulm, Helmholtzstraße 22, 89081, Ulm, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Im Neuenheimer Feld 581, 69120, Heidelberg, Germany
- Network Aging Research, University of Heidelberg, Bergheimer Straße 20, 69115, Heidelberg, Germany
| | - Ben Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Im Neuenheimer Feld 581, 69120, Heidelberg, Germany.
- Network Aging Research, University of Heidelberg, Bergheimer Straße 20, 69115, Heidelberg, Germany.
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11
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Lin CS, Lin C, Fang WH, Hsu CJ, Chen SJ, Huang KH, Lin WS, Tsai CS, Kuo CC, Chau T, Yang SJ, Lin SH. A Deep-Learning Algorithm (ECG12Net) for Detecting Hypokalemia and Hyperkalemia by Electrocardiography: Algorithm Development. JMIR Med Inform 2020; 8:e15931. [PMID: 32134388 PMCID: PMC7082733 DOI: 10.2196/15931] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/28/2019] [Accepted: 12/15/2019] [Indexed: 01/17/2023] Open
Abstract
Background The detection of dyskalemias—hypokalemia and hyperkalemia—currently depends on laboratory tests. Since cardiac tissue is very sensitive to dyskalemia, electrocardiography (ECG) may be able to uncover clinically important dyskalemias before laboratory results. Objective Our study aimed to develop a deep-learning model, ECG12Net, to detect dyskalemias based on ECG presentations and to evaluate the logic and performance of this model. Methods Spanning from May 2011 to December 2016, 66,321 ECG records with corresponding serum potassium (K+) concentrations were obtained from 40,180 patients admitted to the emergency department. ECG12Net is an 82-layer convolutional neural network that estimates serum K+ concentration. Six clinicians—three emergency physicians and three cardiologists—participated in human-machine competition. Sensitivity, specificity, and balance accuracy were used to evaluate the performance of ECG12Net with that of these physicians. Results In a human-machine competition including 300 ECGs of different serum K+ concentrations, the area under the curve for detecting hypokalemia and hyperkalemia with ECG12Net was 0.926 and 0.958, respectively, which was significantly better than that of our best clinicians. Moreover, in detecting hypokalemia and hyperkalemia, the sensitivities were 96.7% and 83.3%, respectively, and the specificities were 93.3% and 97.8%, respectively. In a test set including 13,222 ECGs, ECG12Net had a similar performance in terms of sensitivity for severe hypokalemia (95.6%) and severe hyperkalemia (84.5%), with a mean absolute error of 0.531. The specificities for detecting hypokalemia and hyperkalemia were 81.6% and 96.0%, respectively. Conclusions A deep-learning model based on a 12-lead ECG may help physicians promptly recognize severe dyskalemias and thereby potentially reduce cardiac events.
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Affiliation(s)
- Chin-Sheng Lin
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin Lin
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan.,School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Department of Research and Development, National Defense Medical Center, Taipei, Taiwan
| | - Wen-Hui Fang
- Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Jung Hsu
- Planning and Management Office, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Sy-Jou Chen
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Injury Prevention and Control, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan
| | - Kuo-Hua Huang
- Planning and Management Office, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Shiang Lin
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Sung Tsai
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Chun Kuo
- Department of Electrical Engineering, National Taiwan University, Taipei, Taiwan
| | - Tom Chau
- Department of Medicine, Providence St Vincent Medical Center, Portland, OR, United States
| | - Stephen Jh Yang
- Department of Computer Science and Information Engineering, National Central University, Taoyuan, Taiwan
| | - Shih-Hua Lin
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan.,Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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12
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Lisi F, Parisi G, Gioia M, Amato L, Bellino M, Grande D, Massari F, Caldarola P, Ciccone M, Iacoviello M. Mineralcorticoid Receptor Antagonist Withdrawal for Hyperkalemia and Mortality in Patients with Heart Failure. Cardiorenal Med 2020; 10:145-153. [DOI: 10.1159/000505286] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/06/2019] [Indexed: 11/19/2022] Open
Abstract
Background: Hyperkalemia is one of the most frequent side effects related to renin-angiotensin-aldosterone system (RAAS) inhibition, and can influence optimization of heart failure (HF) therapy. Aim: To evaluate the occurrence of hyperkalemia in a series of outpatients with chronic HF and its relationship with RAAS inhibitor therapy. Method: We evaluated consecutive outpatients with HF and a reduced left ventricular ejection fraction. The incidence of hyperkalemia and consequent changes in RAAS inhibitor therapy were evaluated for each patient. Results: A history of hyperkalemia or at least 1 episode of hyperkalemia during follow-up was observed in 104 of 351 patients. Hyperkalemia mainly influenced mineralocorticoid receptor antagonist (MRA) therapy and, among patients with hyperkalemia, not taking MRA was associated with a greater risk of death on univariate analysis (HR = 6.39; 95% CI 2.76–14.79, p < 0.001) and multivariate analysis (HR = 5.24; 95% CI 1.87–14.72, p = 0.002) after correction for age, ischemic cardiomyopathy, diabetes, systolic arterial pressure, New York Heart Association class 3, left ventricular ejection fraction, presence of hyponatremia, glomerular filtration rate calculated by the EPI formula, and presence of N-terminal pro-B-type natriuretic peptide >1,000 pg/mL. Conclusion: The occurrence of hyperkalemia is common among outpatients with HF and it is the main cause of MRA withdrawal, which is associated with a worse prognosis. In this setting, the possibility of managing hyperkalemia using new classes of drugs could allow continuation of MRA therapy.
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13
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Recent insights into sodium and potassium handling by the aldosterone-sensitive distal nephron: a review of the relevant physiology. J Nephrol 2020; 33:431-445. [DOI: 10.1007/s40620-019-00684-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 12/02/2019] [Indexed: 02/07/2023]
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14
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Hoorn EJ, Gritter M, Cuevas CA, Fenton RA. Regulation of the Renal NaCl Cotransporter and Its Role in Potassium Homeostasis. Physiol Rev 2020; 100:321-356. [DOI: 10.1152/physrev.00044.2018] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Daily dietary potassium (K+) intake may be as large as the extracellular K+ pool. To avoid acute hyperkalemia, rapid removal of K+ from the extracellular space is essential. This is achieved by translocating K+ into cells and increasing urinary K+ excretion. Emerging data now indicate that the renal thiazide-sensitive NaCl cotransporter (NCC) is critically involved in this homeostatic kaliuretic response. This suggests that the early distal convoluted tubule (DCT) is a K+ sensor that can modify sodium (Na+) delivery to downstream segments to promote or limit K+ secretion. K+ sensing is mediated by the basolateral K+ channels Kir4.1/5.1, a capacity that the DCT likely shares with other nephron segments. Thus, next to K+-induced aldosterone secretion, K+ sensing by renal epithelial cells represents a second feedback mechanism to control K+ balance. NCC’s role in K+ homeostasis has both physiological and pathophysiological implications. During hypovolemia, NCC activation by the renin-angiotensin system stimulates Na+ reabsorption while preventing K+ secretion. Conversely, NCC inactivation by high dietary K+ intake maximizes kaliuresis and limits Na+ retention, despite high aldosterone levels. NCC activation by a low-K+ diet contributes to salt-sensitive hypertension. K+-induced natriuresis through NCC offers a novel explanation for the antihypertensive effects of a high-K+ diet. A possible role for K+ in chronic kidney disease is also emerging, as epidemiological data reveal associations between higher urinary K+ excretion and improved renal outcomes. This comprehensive review will embed these novel insights on NCC regulation into existing concepts of K+ homeostasis in health and disease.
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Affiliation(s)
- Ewout J. Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands; and Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Martin Gritter
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands; and Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Catherina A. Cuevas
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands; and Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Robert A. Fenton
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands; and Department of Biomedicine, Aarhus University, Aarhus, Denmark
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15
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Tomilin V, Mamenko M, Zaika O, Wingo CS, Pochynyuk O. TRPV4 deletion protects against hypokalemia during systemic K + deficiency. Am J Physiol Renal Physiol 2019; 316:F948-F956. [PMID: 30838874 DOI: 10.1152/ajprenal.00043.2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Tight regulation of K+ balance is fundamental for normal physiology. Reduced dietary K+ intake, which is common in Western diets, often leads to hypokalemia and associated cardiovascular- and kidney-related pathologies. The distal nephron, and, specifically, the collecting duct (CD), is the major site of controlled K+ reabsorption via H+-K+-ATPase in the state of dietary K+ deficiency. We (Mamenko MV, Boukelmoune N, Tomilin VN, Zaika OL, Jensen VB, O'Neil RG, Pochynyuk OM. Kidney Int 91: 1398-1409, 2017) have previously demonstrated that the transient receptor potential vanilloid type 4 (TRPV4) Ca2+ channel, abundantly expressed in the CD, contributes to renal K+ handling by promoting flow-induced K+ secretion. Here, we investigated a potential role of TRPV4 in controlling H+-K+-ATPase-dependent K+ reabsorption in the CD. Treatment with a K+-deficient diet (<0.01% K+) for 7 days reduced serum K+ levels in wild-type (WT) mice from 4.3 ± 0.2 to 3.3 ± 0.2 mM but not in TRPV4-/- mice (4.3 ± 0.1 and 4.2 ± 0.3 mM, respectively). Furthermore, we detected a significant reduction in 24-h urinary K+ levels in TRPV4-/- compared with WT mice upon switching to K+-deficient diet. TRPV4-/- animals also had significantly more acidic urine on a low-K+ diet, but not on a regular (0.9% K+) or high-K+ (5% K+) diet, which is consistent with increased H+-K+-ATPase activity. Moreover, we detected a greatly accelerated H+-K+-ATPase-dependent intracellular pH extrusion in freshly isolated CDs from TRPV4-/- compared with WT mice fed a K+-deficient diet. Overall, our results demonstrate a novel kaliuretic role of TRPV4 by inhibiting H+-K+-ATPase-dependent K+ reabsorption in the CD. We propose that TRPV4 inhibition could be a novel strategy to manage certain hypokalemic states in clinical settings.
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Affiliation(s)
- Viktor Tomilin
- Department of Integrative Biology and Pharmacology, University of Texas Health Science Center at Houston , Houston, Texas
| | - Mykola Mamenko
- Department of Physiology, Medical College of Georgia, Augusta University , Augusta, Georgia
| | - Oleg Zaika
- Department of Integrative Biology and Pharmacology, University of Texas Health Science Center at Houston , Houston, Texas
| | - Charles S Wingo
- Division of Nephrology, Hypertension and Transplantation, Department of Medicine, University of Florida , Gainesville, Florida.,North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - Oleh Pochynyuk
- Department of Integrative Biology and Pharmacology, University of Texas Health Science Center at Houston , Houston, Texas
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16
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Di Lullo L, Ronco C, Granata A, Paoletti E, Barbera V, Cozzolino M, Ravera M, Fusaro M, Bellasi A. Chronic Hyperkalemia in Cardiorenal Patients: Risk Factors, Diagnosis, and New Treatment Options. Cardiorenal Med 2018; 9:8-21. [DOI: 10.1159/000493395] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 08/30/2018] [Indexed: 11/19/2022] Open
Abstract
Chronic hyperkalemia (HK) is a serious medical condition that often manifests in patients with chronic kidney disease (CKD) and heart failure (HF) leading to poor outcomes and necessitating careful management by cardionephrologists. CKD, HF, diabetes, and renin-angiotensin-aldosterone system inhibitors use is known to induce HK. Current therapeutic options are not optimal, as pointed out by a large number of CKD and HF patients with HK. The following review will focus on the main risk factors for developing HK and also aims to provide a guide for a correct diagnosis and present new approaches to therapy.
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17
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Abstract
OBJECTIVE The retrospective study aimed to estimate prevalence of hyperkalemia using a large US commercial claims database. METHODS Adults with serum potassium lab data (2010 to 2014) and ≥1 calendar year of data were included from a large US commercial claims database. Hyperkalemia was defined as ≥2 serum potassium measurements >5.0 mEq/L or one hyperkalemia diagnosis code (ICD-9-CM, 276.7) or one sodium polystyrene sulfonate fill. Hyperkalemia prevalence was estimated for the overall population and subgroups with hyperkalemia-related comorbidities by calendar year. Hyperkalemia prevalence was also standardized to the US population to estimate the number of US adults with hyperkalemia. RESULTS The analysis included 2,270,635 patients (2010-2014). The annual prevalence of hyperkalemia in the overall population was 1.57% in 2014, with higher rates observed in patients with chronic kidney disease (CKD), heart failure, diabetes and hypertension. Among patients with CKD and/or heart failure, the 2014 annual prevalence was 6.35%. Among patients with hyperkalemia, 48.43% had CKD and/or heart failure in 2014. The prevalence of hyperkalemia was higher in patients with more severe CKD, as well as older patients and men. Extrapolating those results to the US population supports that 1.55% or 3.7 million US adults had hyperkalemia in 2014. CONCLUSIONS An estimated 3.7 million US adults had hyperkalemia in 2014, and this prevalence rate has increased since 2010. In patients with CKD and/or heart failure, the annual prevalence of hyperkalemia was 6.35% in 2014, and about half of all patients with hyperkalemia have either CKD and/or heart failure.
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Affiliation(s)
| | - J Michael Woolley
- b ZS Pharma, a member of the AstraZeneca Group , San Mateo , CA , USA
| | - Fan Mu
- a Analysis Group Inc. , Boston , MA , USA
| | | | - Wenxi Tang
- a Analysis Group Inc. , Boston , MA , USA
| | - Eric Q Wu
- a Analysis Group Inc. , Boston , MA , USA
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18
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Cook BM, Carter DM, Dell'Orfano H, Matta L. Potassium Chloride Sustained Release Dosing Pathway in an Academic Medical Center. Crit Pathw Cardiol 2017; 16:158-160. [PMID: 29135624 DOI: 10.1097/hpc.0000000000000134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Potassium supplementation can be administered intravenously or orally with either immediate release or sustained release formulations. Sustained release potassium chloride allows for delayed absorption and peak effects. In the inpatient setting, it is important to monitor and prevent both hypokalemia and hyperkalemia. Our tertiary-care academic hospital created a clinical pathway for sustained release potassium chloride supplementation in the inpatient population. Our clinical pathway for sustained release potassium chloride creates dosing restrictions designed to prevent hyperkalemia, while allowing exceptions for patients with high requirements.
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Affiliation(s)
- Bryan M Cook
- From the Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
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19
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Berg M, Plöntzke J, Leonhard-Marek S, Müller K, Röblitz S. A dynamic model to simulate potassium balance in dairy cows. J Dairy Sci 2017; 100:9799-9814. [DOI: 10.3168/jds.2016-12443] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 08/14/2017] [Indexed: 11/19/2022]
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20
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21
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Sarwar CMS, Papadimitriou L, Pitt B, Piña I, Zannad F, Anker SD, Gheorghiade M, Butler J. Hyperkalemia in Heart Failure. J Am Coll Cardiol 2017; 68:1575-89. [PMID: 27687200 DOI: 10.1016/j.jacc.2016.06.060] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 06/28/2016] [Indexed: 01/14/2023]
Abstract
Disorders of potassium homeostasis can potentiate the already elevated risk of arrhythmia in heart failure. Heart failure patients have a high prevalence of chronic kidney disease, which further heightens the risk of hyperkalemia, especially when renin-angiotensin-aldosterone system inhibitors are used. Acute treatment for hyperkalemia may not be tolerated in the long term. Recent data for patiromer and sodium zirconium cyclosilicate, used to treat and prevent high serum potassium levels on a more chronic basis, have sparked interest in the treatment of hyperkalemia, as well as the potential use of renin-angiotensin-aldosterone system inhibitors in patients who were previously unable to take these drugs or tolerated only low doses. This review discusses the epidemiology, pathophysiology, and outcomes of hyperkalemia in heart failure; provides an overview of traditional and novel ways to approach management of hyperkalemia; and discusses the need for further research to optimally treat heart failure.
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Affiliation(s)
| | | | - Bertram Pitt
- Cardiology Division, University of Michigan, Ann Arbor, Michigan
| | - Ileana Piña
- Cardiology Division, Albert Einstein College of Medicine; Bronx, New York
| | - Faiez Zannad
- INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Université de Lorraine, Nancy, France
| | - Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center, Göttingen, Germany
| | - Mihai Gheorghiade
- Center for Cardiovascular Drug Development and Innovation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Javed Butler
- Cardiology Division, Stony Brook University, Stony Brook, New York.
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22
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Al-Qusairi L, Basquin D, Roy A, Rajaram RD, Maillard MP, Subramanya AR, Staub O. Renal Tubular Ubiquitin-Protein Ligase NEDD4-2 Is Required for Renal Adaptation during Long-Term Potassium Depletion. J Am Soc Nephrol 2017; 28:2431-2442. [PMID: 28289184 DOI: 10.1681/asn.2016070732] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 02/01/2017] [Indexed: 11/03/2022] Open
Abstract
Adaptation of the organism to potassium (K+) deficiency requires precise coordination among organs involved in K+ homeostasis, including muscle, liver, and kidney. How the latter performs functional and molecular changes to ensure K+ retention is not well understood. Here, we investigated the role of ubiquitin-protein ligase NEDD4-2, which negatively regulates the epithelial sodium channel (ENaC), Na+/Cl- cotransporter (NCC), and with no-lysine-kinase 1 (WNK1). After dietary K+ restriction for 2 weeks, compared with control littermates, inducible renal tubular NEDD4-2 knockout (Nedd4LPax8/LC1 ) mice exhibited severe hypokalemia and urinary K+ wasting. Notably, expression of the ROMK K+ channel did not change in the distal convoluted tubule and decreased slightly in the cortical/medullary collecting duct, whereas BK channel abundance increased in principal cells of the connecting tubule/collecting ducts. However, K+ restriction also enhanced ENaC expression in Nedd4LPax8/LC1 mice, and treatment with the ENaC inhibitor, benzamil, reversed excessive K+ wasting. Moreover, K+ restriction increased WNK1 and WNK4 expression and enhanced SPAK-mediated NCC phosphorylation in Nedd4LPax8/LC1 mice, with no change in total NCC. We propose a mechanism in which NEDD4-2 deficiency exacerbates hypokalemia during dietary K+ restriction primarily through direct upregulation of ENaC, whereas increased BK channel expression has a less significant role. These changes outweigh the compensatory antikaliuretic effects of diminished ROMK expression, increased NCC phosphorylation, and enhanced WNK pathway activity in the distal convoluted tubule. Thus, NEDD4-2 has a crucial role in K+ conservation through direct and indirect effects on ENaC, distal nephron K+ channels, and WNK signaling.
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Affiliation(s)
- Lama Al-Qusairi
- Department of Pharmacology and Toxicology, University of Lausanne, Lausanne, Switzerland.,National Centre of Competence in Research "Kidney.ch", Zurich, Switzerland
| | - Denis Basquin
- Department of Pharmacology and Toxicology, University of Lausanne, Lausanne, Switzerland.,National Centre of Competence in Research "Kidney.ch", Zurich, Switzerland
| | - Ankita Roy
- Department of Medicine, University of Pittsburgh School of Medicine and VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; and
| | - Renuga Devi Rajaram
- Department of Pharmacology and Toxicology, University of Lausanne, Lausanne, Switzerland.,National Centre of Competence in Research "Kidney.ch", Zurich, Switzerland
| | - Marc P Maillard
- Service of Nephrology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Arohan R Subramanya
- Department of Medicine, University of Pittsburgh School of Medicine and VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; and
| | - Olivier Staub
- Department of Pharmacology and Toxicology, University of Lausanne, Lausanne, Switzerland; .,National Centre of Competence in Research "Kidney.ch", Zurich, Switzerland
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23
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Corsi C, Cortesi M, Callisesi G, De Bie J, Napolitano C, Santoro A, Mortara D, Severi S. Noninvasive quantification of blood potassium concentration from ECG in hemodialysis patients. Sci Rep 2017; 7:42492. [PMID: 28198403 PMCID: PMC5309791 DOI: 10.1038/srep42492] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 01/11/2017] [Indexed: 11/29/2022] Open
Abstract
Blood potassium concentration ([K+]) influences the electrocardiogram (ECG), particularly T-wave morphology. We developed a new method to quantify [K+] from T-wave analysis and tested its clinical applicability on data from dialysis patients, in whom [K+] varies significantly during the therapy. To elucidate the mechanism linking [K+] and T-wave, we also analysed data from long QT syndrome type 2 (LQT2) patients, testing the hypothesis that our method would have underestimated [K+] in these patients. Moreover, a computational model was used to explore the physiological processes underlying our estimator at the cellular level. We analysed 12-lead ECGs from 45 haemodialysis and 12 LQT2 patients. T-wave amplitude and downslope were calculated from the first two eigenleads. The T-wave slope-to-amplitude ratio (TS/A) was used as starting point for an ECG-based [K+] estimate (KECG). Leave-one-out cross-validation was performed. Agreement between KECG and reference [K+] from blood samples was promising (error: −0.09 ± 0.59 mM, absolute error: 0.46 ± 0.39 mM). The analysis on LQT2 patients, also supported by the outcome of computational analysis, reinforces our interpretation that, at the cellular level, delayed-rectifier potassium current is a main contributor of KECG correlation to blood [K+]. Following a comprehensive validation, this method could be effectively applied to monitor patients at risk for hyper/hypokalemia.
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Affiliation(s)
- Cristiana Corsi
- Department of Electrical, Electronic and Information Engineering "Guglielmo Marconi", University of Bologna, Cesena, Italy.,Health Sciences and Technology Interdepartmental Center for Industrial Research, University of Bologna, Cesena, Italy
| | - Marilisa Cortesi
- Department of Electrical, Electronic and Information Engineering "Guglielmo Marconi", University of Bologna, Cesena, Italy
| | - Giulia Callisesi
- Department of Electrical, Electronic and Information Engineering "Guglielmo Marconi", University of Bologna, Cesena, Italy
| | | | - Carlo Napolitano
- Molecular Cardiology, IRCCS Fondazione Salvatore Maugeri, Pavia, Italy
| | - Antonio Santoro
- Nephrology Dialysis, Hypertension Unit, Hospital Policlinico S.Orsola-Malpighi, Bologna, Italy
| | | | - Stefano Severi
- Department of Electrical, Electronic and Information Engineering "Guglielmo Marconi", University of Bologna, Cesena, Italy.,Health Sciences and Technology Interdepartmental Center for Industrial Research, University of Bologna, Cesena, Italy
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24
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The renal TRPV4 channel is essential for adaptation to increased dietary potassium. Kidney Int 2017; 91:1398-1409. [PMID: 28187982 DOI: 10.1016/j.kint.2016.12.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/22/2016] [Accepted: 12/08/2016] [Indexed: 12/11/2022]
Abstract
To maintain potassium homeostasis, kidneys exert flow-dependent potassium secretion to facilitate kaliuresis in response to elevated dietary potassium intake. This process involves stimulation of calcium-activated large conductance maxi-K (BK) channels in the distal nephron, namely the connecting tubule and the collecting duct. Recent evidence suggests that the TRPV4 channel is a critical determinant of flow-dependent intracellular calcium elevations in these segments of the renal tubule. Here, we demonstrate that elevated dietary potassium intake (five percent potassium) increases renal TRPV4 mRNA and protein levels in an aldosterone-dependent manner and causes redistribution of the channel to the apical plasma membrane in native collecting duct cells. This, in turn, leads to augmented TRPV4-mediated flow-dependent calcium ion responses in freshly isolated split-opened collecting ducts from mice fed the high potassium diet. Genetic TRPV4 ablation greatly diminished BK channel activity in collecting duct cells pointing to a reduced capacity to excrete potassium. Consistently, elevated potassium intake induced hyperkalemia in TRPV4 knockout mice due to deficient renal potassium excretion. Thus, regulation of TRPV4 activity in the distal nephron by dietary potassium is an indispensable component of whole body potassium balance.
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25
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26
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Bankir L, Bouby N, Blondeau B, Crambert G. Glucagon actions on the kidney revisited: possible role in potassium homeostasis. Am J Physiol Renal Physiol 2016; 311:F469-86. [DOI: 10.1152/ajprenal.00560.2015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 03/31/2016] [Indexed: 12/25/2022] Open
Abstract
It is now recognized that the metabolic disorders observed in diabetes are not, or not only due to the lack of insulin or insulin resistance, but also to elevated glucagon secretion. Accordingly, selective glucagon receptor antagonists are now proposed as a novel strategy for the treatment of diabetes. However, besides its metabolic actions, glucagon also influences kidney function. The glucagon receptor is expressed in the thick ascending limb, distal tubule, and collecting duct, and glucagon regulates the transepithelial transport of several solutes in these nephron segments. Moreover, it also influences solute transport in the proximal tubule, possibly by an indirect mechanism. This review summarizes the knowledge accumulated over the last 30 years about the influence of glucagon on the renal handling of electrolytes and urea. It also describes a possible novel role of glucagon in the short-term regulation of potassium homeostasis. Several original findings suggest that pancreatic α-cells may express a “potassium sensor” sensitive to changes in plasma K concentration and could respond by adapting glucagon secretion that, in turn, would regulate urinary K excretion. By their combined actions, glucagon and insulin, working in a combinatory mode, could ensure an independent regulation of both plasma glucose and plasma K concentrations. The results and hypotheses reviewed here suggest that the use of glucagon receptor antagonists for the treatment of diabetes should take into account their potential consequences on electrolyte handling by the kidney.
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Affiliation(s)
- Lise Bankir
- INSERM UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
- Université Pierre et Marie Curie, Paris, France; and
| | - Nadine Bouby
- INSERM UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
- Université Pierre et Marie Curie, Paris, France; and
- Université Paris-Descartes, Paris, France
| | - Bertrand Blondeau
- INSERM UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
- Université Pierre et Marie Curie, Paris, France; and
| | - Gilles Crambert
- INSERM UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
- Université Pierre et Marie Curie, Paris, France; and
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Zhang Y, D'Argenio DZ. Feedback control indirect response models. J Pharmacokinet Pharmacodyn 2016; 43:343-58. [PMID: 27394724 DOI: 10.1007/s10928-016-9479-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 06/13/2016] [Indexed: 11/29/2022]
Abstract
A general framework is introduced for modeling pharmacodynamic processes that are subject to autoregulation, which combines the indirect response (IDR) model approach with methods from classical feedback control of engineered systems. The canonical IDR models are modified to incorporate linear combinations of feedback control terms related to the time course of the difference (the error signal) between the pharmacodynamic response and its basal value. Following the well-established approach of traditional engineering control theory, the proposed feedback control indirect response models incorporate terms proportional to the error signal itself, the integral of the error signal, the derivative of the error signal or combinations thereof. Simulations are presented to illustrate the types of responses produced by the proposed feedback control indirect response model framework, and to illustrate comparisons with other PK/PD modeling approaches incorporating feedback. In addition, four examples from literature are used to illustrate the implementation and applicability of the proposed feedback control framework. The examples reflect each of the four mechanisms of drug action as modeled by each of the four canonical IDR models and include: selective serotonin reuptake inhibitors and extracellular serotonin; histamine H2-receptor antagonists and gastric acid; growth hormone secretagogues and circulating growth hormone; β2-selective adrenergic agonists and potassium. The proposed feedback control indirect response approach may serve as an exploratory modeling tool and may provide a bridge for development of more mechanistic systems pharmacology models.
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Affiliation(s)
- Yaping Zhang
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, 90089, USA
| | - David Z D'Argenio
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, 90089, USA.
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Khositseth S, Uawithya P, Somparn P, Charngkaew K, Thippamom N, Hoffert JD, Saeed F, Michael Payne D, Chen SH, Fenton RA, Pisitkun T. Autophagic degradation of aquaporin-2 is an early event in hypokalemia-induced nephrogenic diabetes insipidus. Sci Rep 2015; 5:18311. [PMID: 26674602 PMCID: PMC4682130 DOI: 10.1038/srep18311] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 11/16/2015] [Indexed: 12/19/2022] Open
Abstract
Hypokalemia (low serum potassium level) is a common electrolyte imbalance that can cause a defect in urinary concentrating ability, i.e., nephrogenic diabetes insipidus (NDI), but the molecular mechanism is unknown. We employed proteomic analysis of inner medullary collecting ducts (IMCD) from rats fed with a potassium-free diet for 1 day. IMCD protein quantification was performed by mass spectrometry using a label-free methodology. A total of 131 proteins, including the water channel AQP2, exhibited significant changes in abundance, most of which were decreased. Bioinformatic analysis revealed that many of the down-regulated proteins were associated with the biological processes of generation of precursor metabolites and energy, actin cytoskeleton organization, and cell-cell adhesion. Targeted LC-MS/MS and immunoblotting studies further confirmed the down regulation of 18 selected proteins. Electron microscopy showed autophagosomes/autophagolysosomes in the IMCD cells of rats deprived of potassium for only 1 day. An increased number of autophagosomes was also confirmed by immunofluorescence, demonstrating co-localization of LC3 and Lamp1 with AQP2 and several other down-regulated proteins in IMCD cells. AQP2 was also detected in autophagosomes in IMCD cells of potassium-deprived rats by immunogold electron microscopy. Thus, enhanced autophagic degradation of proteins, most notably including AQP2, is an early event in hypokalemia-induced NDI.
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Affiliation(s)
- Sookkasem Khositseth
- Department of Pediatrics, Faculty of Medicine, Thammasat University Klong Luang, Pathumthani, 12120, Thailand
| | - Panapat Uawithya
- Department of Physiology, Faculty of Medicine Siriraj Hospital, Mahidol University Bangkok, 10700, Thailand
| | - Poorichaya Somparn
- Systems Biology Center, Research Affairs, Faculty of Medicine, Chulalongkorn University 1873 Rama 4 Road, Pathumwan, Bangkok, 10330, Thailand
| | - Komgrid Charngkaew
- Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University Bangkok, 10700, Thailand
| | - Nattakan Thippamom
- Department of Pediatrics, Faculty of Medicine, Thammasat University Klong Luang, Pathumthani, 12120, Thailand
| | - Jason D. Hoffert
- National Institute of Diabetes and Digestive and Kidney, Bethesda MD 20892, United States
| | - Fahad Saeed
- Department of Electrical & Computer Engineering and Department of Computer Science, Western Michigan University Kalamazoo, 49008, United States
| | - D. Michael Payne
- Systems Biology Center, Research Affairs, Faculty of Medicine, Chulalongkorn University 1873 Rama 4 Road, Pathumwan, Bangkok, 10330, Thailand
| | - Shu-Hui Chen
- Department of Chemistry, National Cheng Kung University, Tainan City, 701, Taiwan
| | - Robert A. Fenton
- Department of Biomedicine and Center for Interactions of Proteins in Epithelial Transport, Aarhus University, Aarhus, 8000, Denmark
| | - Trairak Pisitkun
- Systems Biology Center, Research Affairs, Faculty of Medicine, Chulalongkorn University 1873 Rama 4 Road, Pathumwan, Bangkok, 10330, Thailand
- Department of Biomedicine and Center for Interactions of Proteins in Epithelial Transport, Aarhus University, Aarhus, 8000, Denmark
- Epithelial Systems Biology Laboratory, National Heart, Lung, and Blood Institute, Bethesda MD 20892, United States
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Evidence for a gastrointestinal–renal kaliuretic signaling axis in humans. Kidney Int 2015; 88:1383-1391. [DOI: 10.1038/ki.2015.243] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 06/18/2015] [Accepted: 06/18/2015] [Indexed: 01/20/2023]
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Li C, Zhou X, Han W, Jiang X, Liu J, Fang L, Wang H, Guan Q, Gao L, Zhao J, Xu J, Xu C. Identification of two novel mutations in SLC12A3 gene in two Chinese pedigrees with Gitelman syndrome and review of literature. Clin Endocrinol (Oxf) 2015; 83:985-93. [PMID: 25990047 DOI: 10.1111/cen.12820] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 03/19/2015] [Accepted: 05/13/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Gitelman syndrome (GS) is one of the most common causes of inherited hypokalaemia. As it was caused by mutations in the SLC12A3 gene, GS is a highly heterogeneous disease. Here, we aimed to investigate the clinical and genetic characteristics of two Chinese pedigrees and summarize the advance in GS genetics, diagnosis and management. SUBJECTS AND METHODS Two three-generation families with GS were identified and screened for mutations in the SLC12A3 gene. Genotype-phenotype correlations were analysed. RESULTS The two probands (A and B) were characterized by hypokalaemia, hypomagnesaemia and hypocalciuria without hypertension. Complete DNA sequencing of the SLC12A3 gene revealed two novel compound heterozygous mutations (c.179C>T and c.234delG; c.486-490delTACGGinsA and c.1925G>A), which are predicted to drastically affect normal protein structure. The female members of the pedigrees showed mild-to-no phenotype, although they carried the same mutations as the probands. Moreover, proband B presented with more severe symptoms than did proband A, which might be related to a lower serum magnesium level. During the 1-year follow-up, both probands showed satisfactory symptom improvement following the use of potassium and magnesium supplements. CONCLUSION Our findings strongly suggested that the two novel mutations in the SLC12A3 gene are the causative agents of GS, which may provide further insights into the function of this gene and help clinicians better understand this disorder.
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Affiliation(s)
- Congcong Li
- Department of Endocrinology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
- Institute of Endocrinology and Metabolism, Shandong Academy of Clinical Medicine, Jinan, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, Shandong, China
| | - Xinli Zhou
- Department of Endocrinology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
- Institute of Endocrinology and Metabolism, Shandong Academy of Clinical Medicine, Jinan, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, Shandong, China
| | - Wenxia Han
- Department of Endocrinology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
- Institute of Endocrinology and Metabolism, Shandong Academy of Clinical Medicine, Jinan, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, Shandong, China
| | - Xiuyun Jiang
- Department of Endocrinology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
- Institute of Endocrinology and Metabolism, Shandong Academy of Clinical Medicine, Jinan, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, Shandong, China
| | - Jia Liu
- Department of Endocrinology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
- Institute of Endocrinology and Metabolism, Shandong Academy of Clinical Medicine, Jinan, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, Shandong, China
| | - Li Fang
- Department of Endocrinology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
- Institute of Endocrinology and Metabolism, Shandong Academy of Clinical Medicine, Jinan, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, Shandong, China
| | - Hai Wang
- Department of Endocrinology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
- Institute of Endocrinology and Metabolism, Shandong Academy of Clinical Medicine, Jinan, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, Shandong, China
| | - Qingbo Guan
- Department of Endocrinology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
- Institute of Endocrinology and Metabolism, Shandong Academy of Clinical Medicine, Jinan, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, Shandong, China
| | - Ling Gao
- Institute of Endocrinology and Metabolism, Shandong Academy of Clinical Medicine, Jinan, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, Shandong, China
- Scientific Center, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
| | - Jiajun Zhao
- Department of Endocrinology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
- Institute of Endocrinology and Metabolism, Shandong Academy of Clinical Medicine, Jinan, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, Shandong, China
| | - Jin Xu
- Department of Endocrinology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
- Institute of Endocrinology and Metabolism, Shandong Academy of Clinical Medicine, Jinan, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, Shandong, China
| | - Chao Xu
- Department of Endocrinology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
- Institute of Endocrinology and Metabolism, Shandong Academy of Clinical Medicine, Jinan, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, Shandong, China
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Johnston CT, Maish GO, Minard G, Croce MA, Dickerson RN. Evaluation of an Intravenous Potassium Dosing Algorithm for Hypokalemic Critically Ill Patients. JPEN J Parenter Enteral Nutr 2015; 41:796-804. [PMID: 26304602 DOI: 10.1177/0148607115602885] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The intent of this study was to evaluate the safety and efficacy of an intravenous (IV) potassium (K) dosing algorithm for hypokalemic critically ill trauma patients. METHODS Adult patients, admitted to the trauma intensive care unit from June 2010 to October 2012 and who received IV K therapy according to a standardized dosing algorithm, were retrospectively evaluated. Patients who received IV K during resuscitation or following initiation of nutrition therapy, IV fluids containing >20 mEq/L of potassium, or medications known to alter K homeostasis or those with an arterial pH change >0.1, diarrhea, hypomagnesemia, renal impairment, or morbid obesity were excluded. RESULTS In total, 715 patients were reviewed to obtain 100 evaluable patients. Serum K for patients with mild depletion (serum K, 3.5-3.9 mEq/L, n = 74) remained unchanged at 0.0 ± 0.3 mEq/L ( P = ns) following 46 ± 8 mEq. Serum K increased by 0.4 ± 0.3 mEq/L ( P = .001) following 78 ± 18 mEq during moderate depletion (serum K, 3-3.4 mEq/L). None of the patients experienced hyperkalemia (serum K, >5.2 mEq/L) postinfusion. The presence of traumatic brain injury (TBI) blunted the response to IV K for mild K depletion as only 26% had an increase in serum K compared with 55% of patients without TBI ( P = .025). CONCLUSIONS The Nutrition Support Service-guided IV K dosing algorithm was safe for patients with mild and moderate hypokalemia and efficacious for those with moderate hypokalemia. Further study in patients with severe hypokalemia (serum K, <3 mEq/L) is warranted.
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Affiliation(s)
- Corry T Johnston
- 1 Department of Pharmacy, University of Maryland Baltimore Washington Medical Center, Baltimore, Maryland, USA
| | - George O Maish
- 2 Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Gayle Minard
- 2 Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Martin A Croce
- 2 Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Roland N Dickerson
- 3 Department of Clinical Pharmacy, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
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Penton D, Czogalla J, Loffing J. Dietary potassium and the renal control of salt balance and blood pressure. Pflugers Arch 2015; 467:513-30. [PMID: 25559844 DOI: 10.1007/s00424-014-1673-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 12/10/2014] [Accepted: 12/11/2014] [Indexed: 01/09/2023]
Abstract
Dietary potassium (K(+)) intake has antihypertensive effects, prevents strokes, and improves cardiovascular outcomes. The underlying mechanism for these beneficial effects of high K(+) diets may include vasodilation, enhanced urine flow, reduced renal renin release, and negative sodium (Na(+)) balance. Indeed, several studies demonstrate that dietary K(+) intake induces renal Na(+) loss despite elevated plasma aldosterone. This review briefly highlights the epidemiological and experimental evidences for the effects of dietary K(+) on arterial blood pressure. It discusses the pivotal role of the renal distal tubule for the regulation of urinary K(+) and Na(+) excretion and blood pressure and highlights that it depends on the coordinated interaction of different nephron portions, epithelial cell types, and various ion channels, transporters, and ATPases. Moreover, we discuss the relevance of aldosterone and aldosterone-independent factors in mediating the effects of an altered K(+) intake on renal K(+) and Na(+) handling. Particular focus is given to findings suggesting that an aldosterone-independent downregulation of the thiazide-sensitive NaCl cotransporter significantly contributes to the natriuretic and antihypertensive effect of a K(+)-rich diet. Last but not least, we refer to the complex signaling pathways enabling the kidney to adapt its function to the homeostatic needs in response to an altered K(+) intake. Future work will have to further address the underlying cellular and molecular mechanism and to elucidate, among others, how an altered dietary K(+) intake is sensed and how this signal is transmitted to the different epithelial cells lining the distal tubule.
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Affiliation(s)
- David Penton
- Institute of Anatomy, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland
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Scurati-Manzoni E, Fossali EF, Agostoni C, Riva E, Simonetti GD, Zanolari-Calderari M, Bianchetti MG, Lava SAG. Electrolyte abnormalities in cystic fibrosis: systematic review of the literature. Pediatr Nephrol 2014; 29:1015-23. [PMID: 24326787 DOI: 10.1007/s00467-013-2712-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 11/12/2013] [Accepted: 11/18/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cystic fibrosis per se can sometimes lead to hyponatremia, hypokalemia, hypochloremia or hyperbicarbonatemia. This tendency was first documented 60 years ago and has subsequently been confirmed in single case reports or small case series, most of which were retrospective. However, this issue has not been addressed analytically. We have therefore systematically reviewed and analyzed the available literature on this subject. METHODS This was a systematic review of the literature. RESULTS The reports included in this review cover 172 subacute and 90 chronic cases of electrolyte imbalances in patients with cystic fibrosis. The male:female ratio was 1.57. Electrolyte abnormalities were mostly associated with clinically inapparent fluid volume depletion, mainly affected patients aged ≤2.5 years, frequently tended to recur and often were found before the diagnosis of cystic fibrosis was established. Subacute presentation often included an history of heat exposure, vomiting, excessive sweating and pulmonary infection. History of chronic presentation, in contrast, was often inconspicuous. The tendency to hypochloremia, hypokalemia and metabolic alkalosis was similar between subacute and chronic patients, with hyponatremia being more pronounced (P < 0.02) in subacute compared to chronic presentations. Subacute cases were treated parenterally; chronic ones were usually managed with oral salt supplementation. Retention of urea and creatinine was documented in 38 % of subacute cases. CONCLUSIONS The findings of our review suggest that physicians should be aware that electrolyte abnormalities can occur both as a presenting and a recurring feature of cystic fibrosis.
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Affiliation(s)
- Elisabetta Scurati-Manzoni
- Pediatric Emergency Unit, De Marchi Hospital, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Abstract
It has been known for decades that urinary potassium excretion varies with a circadian pattern. In this review, we consider the historical evidence for this phenomenon and present an overview of recent developments in the field. Extensive evidence from the latter part of the past century clearly shows that circadian potassium excretion does not depend on endogenous aldosterone. Of note is the recent discovery that the expression of several renal potassium transporters varies with a circadian pattern that appears to be consistent with substantial clinical data regarding daily fluctuations in urinary potassium levels. We propose the circadian clock mechanism as a key regulator of renal potassium transporters, and consequently renal potassium excretion. Further investigation into the regulation mechanism of renal potassium transport by the circadian clock is warranted to increase our understanding of the clinical relevance of circadian rhythms to potassium homeostasis.
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Affiliation(s)
- Michelle L Gumz
- Department of Medicine, Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, FL, USA.
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Constable PD, Hiew MWH, Tinkler S, Townsend J. Efficacy of oral potassium chloride administration in treating lactating dairy cows with experimentally induced hypokalemia, hypochloremia, and alkalemia. J Dairy Sci 2013; 97:1413-26. [PMID: 24377802 DOI: 10.3168/jds.2013-6982] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 10/03/2013] [Indexed: 11/19/2022]
Abstract
Hypokalemia occurs commonly in lactating dairy cows. The objectives of this study were to determine (1) whether a 24-h oral KCl dose of 0.4 g/kg of body weight (BW) was effective and safe in hypokalemic cattle; (2) whether potassium was best administered as 2 large doses or multiple smaller doses over a 24-h period; and (3) the effect of oral KCl administration on plasma Mg concentration and urine Mg excretion in fasted lactating dairy cattle. Plasma K and Cl concentrations were decreased, and blood pH increased, in 15 lactating Holstein-Friesian cows by administering 2 intramuscular (i.m.) 10-mg injections of isoflupredone acetate 24h apart followed by 2 i.m. injections of furosemide (1mg/kg of BW) 8h apart and by decreasing feed intake. Cows were randomly assigned to 1 of 3 treatment groups with 5 cows/group: untreated control (group C); oral administration of KCl at 0.05 g/kg of BW 8 times at 3-h intervals (group K3); and oral administration of KCl at 0.2g/kg of BW twice at 12-h intervals (group K12). A 24-h KCl dose rate of 0.4 g/kg of BW increased plasma and milk K concentration and plasma Cl concentration, and corrected the metabolic alkalosis and alkalemia, with no clinically significant difference between 2 large doses (group K12) or multiple small doses (group K3) of KCl over 24 h. Oral KCl administration decreased peripheral fat mobilization in cattle with experimentally induced hypokalemia, as measured by changes in plasma nonesterified fatty acid concentration, and slightly augmented the fasting-induced decrease in plasma Mg concentration. Our findings support recommendations for a 24-h oral KCl dose of 0.4 g/kg of BW for treating moderately hypokalemic cattle. Additional Mg may need to be administered to inappetant lactating dairy cattle being treated with oral KCl to minimize K-induced decreases in magnesium absorption.
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Affiliation(s)
- P D Constable
- Department of Veterinary Clinical Sciences, Purdue University, West Lafayette, IN 47907.
| | - M W H Hiew
- Department of Veterinary Clinical Sciences, Purdue University, West Lafayette, IN 47907
| | - S Tinkler
- Department of Veterinary Clinical Sciences, Purdue University, West Lafayette, IN 47907
| | - J Townsend
- Department of Veterinary Clinical Sciences, Purdue University, West Lafayette, IN 47907
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Ali A, Masood Q, Yaqub S, Kashif W. A case of Gitelman syndrome with severe hyponatraemia and hypophosphataemia. Singapore Med J 2013; 54:e18-20. [PMID: 23338926 DOI: 10.11622/smedj.2013020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Gitelman syndrome (GS) is a renal tubular disorder of the thiazide-sensitive sodium chloride cotransporter, which is located in the distal tubule of the loop of Henle. We present a rare case of GS complicated by severe hyponatraemia and hypophosphataemia. A 17-year-old boy was admitted to our institution with fever and lethargy. The workup revealed typical features of GS, i.e. hypokalaemia, hypomagnesaemia and metabolic alkalosis. In this report, we discuss the differential diagnoses and rationale for accepting GS as the most likely diagnosis. This case was complicated by severe hyponatraemia (115 mmol/L) and hypophosphataemia (0.32 mmol/L). We concluded that the syndrome of inappropriate secretion of antidiuretic hormones could not be ruled out and that respiratory alkalosis was the most likely aetiology of hypophosphataemia. This case report also generates an interesting discussion on water and electrolyte metabolism.
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Affiliation(s)
- Absar Ali
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.
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van der Lubbe N, Moes AD, Rosenbaek LL, Schoep S, Meima ME, Danser AHJ, Fenton RA, Zietse R, Hoorn EJ. K+-induced natriuresis is preserved during Na+ depletion and accompanied by inhibition of the Na+-Cl- cotransporter. Am J Physiol Renal Physiol 2013; 305:F1177-88. [PMID: 23986520 DOI: 10.1152/ajprenal.00201.2013] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
During hypovolemia and hyperkalemia, the kidneys defend homeostasis by Na(+) retention and K(+) secretion, respectively. Aldosterone mediates both effects, but it is unclear how the same hormone can evoke such different responses. To address this, we mimicked hypovolemia and hyperkalemia in four groups of rats with a control diet, low-Na(+) diet, high-K(+) diet, or combined diet. The low-Na(+) and combined diets increased plasma and kidney ANG II. The low-Na(+) and high-K(+) diets increased plasma aldosterone to a similar degree (3-fold), whereas the combined diet increased aldosterone to a greater extent (10-fold). Despite similar Na(+) intake and higher aldosterone, the high-K(+) and combined diets caused a greater natriuresis than the control and low-Na(+) diets, respectively (P < 0.001 for both). This K(+)-induced natriuresis was accompanied by a decreased abundance but not phosphorylation of the Na(+)-Cl(-) cotransporter (NCC). In contrast, the epithelial Na(+) channel (ENaC) increased in parallel with aldosterone, showing the highest expression with the combined diet. The high-K(+) and combined diets also increased WNK4 but decreased Nedd4-2 in the kidney. Total and phosphorylated Ste-20-related kinase were also increased but were retained in the cytoplasm of distal convoluted tubule cells. In summary, high dietary K(+) overrides the effects of ANG II and aldosterone on NCC to deliver sufficient Na(+) to ENaC for K(+) secretion. K(+) may inhibit NCC through WNK4 and help activate ENaC through Nedd4-2.
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Wingo CS. Introduction: potassium homeostasis in humans: our current understanding. Semin Nephrol 2013; 33:205-6. [PMID: 23953796 DOI: 10.1016/j.semnephrol.2013.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Asmar A, Mohandas R, Wingo CS. A physiologic-based approach to the treatment of a patient with hypokalemia. Am J Kidney Dis 2012; 60:492-7. [PMID: 22901631 DOI: 10.1053/j.ajkd.2012.01.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 01/31/2012] [Indexed: 01/15/2023]
Abstract
Hypokalemia is common and can be associated with serious adverse consequences, including paralysis, ileus, cardiac arrhythmias, and death. As a result, the body maintains serum potassium concentration within very narrow limits by tightly regulated feedback and feed-forward systems. Whereas the consequences of symptomatic hypokalemia and severe potassium depletion are well appreciated, chronic mild hypokalemia can accelerate the progression of chronic kidney disease, exacerbate systemic hypertension, and increase mortality. Persistent hypokalemia may reflect total-body potassium depletion or increased renal potassium clearance. In a patient with simple potassium depletion, potassium replacement therapy should correct serum potassium concentration, but may have little effect when renal potassium clearance is abnormally increased from potassium wasting. In such cases, the addition of potassium-sparing diuretics might be helpful. Serum potassium concentration is an inaccurate marker of total-body potassium deficit. Mild hypokalemia may be associated with significant total-body potassium deficits and conversely, total-body potassium stores can be normal in patients with hypokalemia due to redistribution. The speed and extent of potassium replacement should be dictated by the clinical picture and guided by frequent reassessment of serum potassium concentration(.) The goals of therapy should be to correct a potassium deficit, if present, without provoking hyperkalemia. Oral replacement is preferred except when there is no functioning bowel or in the setting of electrocardiogram changes, neurologic symptoms, cardiac ischemia, or digitalis therapy.
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Affiliation(s)
- Abdo Asmar
- Division of Nephrology, Hypertension, and Transplantation, University of Florida, College of Medicine, Gainesville, FL 32610-0224, USA
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Abstract
The adrenal cortex synthesizes many steroids, but the mineralocorticoid aldosterone and the glucocorticoids cortisol and corticosteroid have been viewed as the principal steroids responsible for regulation of renal electrolyte excretion. A study by Elabida et al. challenges that paradigm and suggests that progesterone, classically viewed as a sex steroid, also participates in renal electrolyte balance.
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Affiliation(s)
- Charles S Wingo
- Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA.
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Unwin RJ, Luft FC, Shirley DG. Pathophysiology and management of hypokalemia: a clinical perspective. Nat Rev Nephrol 2011; 7:75-84. [PMID: 21278718 DOI: 10.1038/nrneph.2010.175] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Potassium (K(+)) ions are the predominant intracellular cations. K(+) homeostasis depends on external balance (dietary intake [typically 100 mmol per day] versus excretion [95% via the kidney; 5% via the colon]) and internal balance (the distribution of K(+) between intracellular and extracellular fluid compartments). The uneven distribution of K(+) across cell membranes means that a mere 1% shift in its distribution can cause a 50% change in plasma K(+) concentration. Hormonal mechanisms (involving insulin, β-adrenergic agonists and aldosterone) modulate K(+) distribution by promoting rapid transfer of K(+) across the plasma membrane. Extrarenal K(+) losses from the body are usually small, but can be marked in individuals with chronic diarrhea, severe burns or prolonged sweating. Under normal circumstances, the kidney's distal nephron secretes K(+) and determines final urinary excretion. In patients with hypokalemia (plasma K(+) concentration <3.5 mmol/l), after the exclusion of extrarenal causes, alterations in sodium ion delivery to the distal nephron, mineralocorticoid status, or a specific inherited or acquired defect in distal nephron function (each of which affects distal nephron K(+) secretion), should be considered. Clinical management of hypokalemia should establish the underlying cause and alleviate the primary disorder. This Review aims to inform clinicians about the pathophysiology and appropriate treatment for hypokalemia.
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Affiliation(s)
- Robert J Unwin
- Centre for Nephrology, Royal Free Hospital, University College London, Rowland Hill Street, London NW3 2PF, UK.
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Abnormalities of serum potassium concentration in dialysis-associated hyperglycemia and their correction with insulin: a unique clinical/physiologic exercise in internal potassium balance. Int Urol Nephrol 2010; 42:1015-22. [PMID: 20853142 DOI: 10.1007/s11255-010-9831-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Accepted: 08/21/2010] [Indexed: 12/21/2022]
Abstract
The absence of significant losses of potassium in the urine makes dialysis-associated hyperglycemia (DH) a model for the study of the internal potassium balance. Studies of DH have revealed that hyperkalemia is frequent at presentation, insulin infusion is usually the only treatment required, and the magnitude of the decrease in serum potassium concentration (K(+)) during treatment of DH with insulin depends on the starting serum K(+) level, the decreases in serum glucose concentration and tonicity, and the increase in serum total carbon dioxide level. We present an analysis of these findings based on previously studied actions of insulin. Calculations of transcellular potassium shifts based on the combined effects of insulin-the increase in the electrical potential differences (hyperpolarization) of the cell membranes and the correction of the hyperglycemic intracellular dehydration through decrease in serum glucose concentration-produced quantitative predictions of the decrease in serum K(+) similar to the reported changes in serum K(+) during treatment of DH with insulin. The lessons from analyzing serum K(+) changes during treatment of DH with insulin are applicable to other conditions where internal potassium balance is called upon to protect serum K(+), such as the postprandial state. The main questions related to internal potassium balance in DH that await clarification include the structure and function of cell membrane potassium channels, the effect of insulin on these channels, and the mechanisms of feedforward potassium regulation.
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Wolak T, Sergienko R, Wiznitzer A, Ben Shlush L, Paran E, Sheiner E. Low potassium level during the first half of pregnancy is associated with lower risk for the development of gestational diabetes mellitus and severe pre-eclampsia. J Matern Fetal Neonatal Med 2010; 23:994-8. [DOI: 10.3109/14767050903544736] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Mahato M, Pal P, Kamilya T, Sarkar R, Chaudhuri A, Talapatra GB. Influence of KCl on the interfacial activity and conformation of hemoglobin studied by Langmuir–Blodgett technique. Phys Chem Chem Phys 2010; 12:12997-3006. [DOI: 10.1039/c0cp00344a] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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