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Management of Hyperkalemia in CKD patients

Management of Hyperkalemia in CKD patients. Dr. Overview. Introduction Hyperkalemia in CKD Incidence Significance Causes Management Summary and conclusions. Introduction. CKD Common disease Affecting a growing number of population across globe

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Management of Hyperkalemia in CKD patients

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  1. Management of Hyperkalemia in CKD patients Dr

  2. Overview • Introduction • Hyperkalemia in CKD • Incidence • Significance • Causes • Management • Summary and conclusions

  3. Introduction • CKD • Common disease • Affecting a growing number of population across globe • May be associated with a variety of electrolyte disturbances • Such as hyperkalemia Arch Intern Med. 2009;169(12):1156-1162

  4. Introduction • CKD - Hyperkalemia • Great concern to nephrologists because of • Possible implications for patient safety related to the potential for associated adverse cardiac outcomes Arch Intern Med. 2009;169(12):1156-1162

  5. Hyperkalemia in CKD • Hyperkalemia is usually defined as • Plasma potassium (K+ ) > 5.0 mEq/L, even though exact cut-off is arbitrary • The incidence of hyperkalemia in hospitalized patients varies from • 1.4% to 10% depending on the arbitrary level of potassium Electrolyte & Blood Pressure 2005; 3:71-78.

  6. Hyperkalemia in CKD • Hyperkalemia • Prevalence in ESRD • 5% to 10% • Contributes to 1.9% to 5% of deaths among patients with ESRD ESRD: End stage renal disease Electrolyte & Blood Pressure 2005; 3:71-78.

  7. Hyperkalemia in CKD: Incidence Arch Intern Med. 2009;169(12):1156-1162

  8. Hyperkalemia in CKD: Significance • CKD - Hyperkalemia • One study determined the incidence of hyperkalemia in CKD and whether it is associated with excess mortality • Results: • Of the 66 259 hyperkalemic events (3.2% of records), more occurred as inpatient events (n=34 937 [52.7%]) than as outpatient events (n=31 322 [47.3%]). • The adjusted rate of hyperkalemia was higher in patients with CKD than in those without CKD among individuals treated with RAAS blockers (7.67 vs 2.30 per 100 patient-months; P.001) and those without RAAS blocker treatment (8.22 vs 1.77 per 100 patient months; P.001). Arch Intern Med. 2009;169(12):1156-1162

  9. Hyperkalemia in CKD: Significance • CKD – Hyperkalemia • Study results continued • The adjusted odds ratio (OR) of death with a moderate (K+, 5.5 and 6.0 mEq/L [to convert to mmol/L, multiply by 1.0]) and severe (K+ , 6.0 mEq/L) hyperkalemic event was highest with no CKD (OR, 10.32 and 31.64, respectively) vs stage 3 (OR, 5.35 and 19.52, respectively), stage 4 (OR, 5.73 and 11.56, respectively), or stage 5 (OR, 2.31 and 8.02, respectively) CKD, with all P.001 vs normokalemia and no CKD. Arch Intern Med. 2009;169(12):1156-1162

  10. Hyperkalemia in CKD: Significance • CKD – Hyperkalemia • Study Conclusions • The risk of hyperkalemia is increased with CKD, and its occurrence increases the odds of mortality within 1 day of the event • These findings underscore the importance of this metabolic disturbance as a threat to patient safety in CKD Arch Intern Med. 2009;169(12):1156-1162

  11. Hyperkalemia in CKD: Causes • CKD – hyperkalemia: • Causes • An impaired GFR combined with a frequently high dietary K+ intake relative to residual renal function Arch Intern Med. 2009;169(12):1156-1162

  12. Hyperkalemia in CKD: Causes Pediatr Nephrol Published online 22 December 2010

  13. Hyperkalemia in CKD: Causes • If potassium intake is normal, CKD does not produce significant hyper- kalemia until the GFR is • < 5 ml/min Electrolyte & Blood Pressure 2005; 3:71-78.

  14. Hyperkalemia in CKD: Causes • CKD – hyperkalemia: • Causes • Commonly observed extracellular shift of K+ caused by the metabolic acidosis of renal failure • Under almost all conditions, • Hyperkalemia not due to redistribution of potassium is related to impaired renal potassium excretion Arch Intern Med. 2009;169(12):1156-1162

  15. Hyperkalemia in CKD: Causes • CKD – hyperkalemia: • Causes • Most importantly, recommended treatment with renin angiotensin- aldosterone system (RAAS) blockers that inhibit renal K+ excretion Arch Intern Med. 2009;169(12):1156-1162

  16. Hyperkalemia in CKD: Causes Am J Kidney Dis 2010;56:387-393.

  17. Hyperkalemia in CKD: Causes Pediatr Nephrol Published online 22 December 2010

  18. Hyperkalemia in CKD • Preservation of normokalemia results from • An adaptive increase in K+ excretion by remnant nephrons and increased bowel loss • However, hyperkalemia may be an early feature of renal failure in patients with • (hyperchloremic) metabolic acidosis and hyporeninemic hypoaldosteronism, which occur particularly in patients with • Tubulointerstitial disease and diabetes mellitus Electrolyte & Blood Pressure 2005; 3:71-78.

  19. Hyperkalemia in CKD • Clinical management for hyperkalemia in patients with CKD requires • Exclusion of pseudohyperkalemia, • Assessmemt of the urgency for treatment, and • Appropriate acute and chronic therapy Electrolyte & Blood Pressure 2005; 3:71-78.

  20. Hyperkalemia in CKD • Pseudohyperkalemia • Important to avoid unnecessary treatment • The most common cause of pseudohyperkalemia is hemolysis, which is usually • Easily noted due to a pink tinge to the plasma resulting from release of hemoglobin from damaged red blood cells • Alternatively, an excessively tight tourniquet surrounding an exercising extremity (e.g., opening and closing a hand) can increase plasma K+ by > 2 mEq/L) • Excessive numbers of either leukocytes > 70,000/cm3, or platelets > 1,000,000/cm3 also can lead to pseudohyperkalemia Electrolyte & Blood Pressure 2005; 3:71-78.

  21. Hyperkalemia in CKD • Pseudohyperkalemia • When the serum K+ is >0.3 mEq/L as compared with a simultaneous plasma K+ , • Pseudohyperkalemia should be diagnosed • Plasma K+ can be measured by obtaining a heparinized blood specimen • If pseudohyperkalemia exists, • All further K+ levels should be measured using plasma Electrolyte & Blood Pressure 2005; 3:71-78.

  22. Hyperkalemia in CKD • Clinical manifestations of hyperkalemia • May be asymptomatic or life-threatening • The main danger of hyperkalemia is a • Cardiac arrhythmia • ECGs • Considered to be sensitive indicators of the presence of hyperkalemia • ECG abnormalities consistent with hyperkalemia in the hospitalized hyperkalemia patients were observed in only 14% of episodes • Serum K+ levels > 8 mEq/L are almost invariably associated with ECG abnormalities • However, minimal or atypical ECG changes have been observed in some cases of severe hyperkalemia Electrolyte & Blood Pressure 2005; 3:71-78.

  23. Hyperkalemia in CKD • Clinical manifestations of hyperkalemia • Minor ECG abnormalities (tall-peaked T waves) may be the first indication of hyperkalaemia but • By the time serious changes occur, the patient usually complains of muscle weakness, paresthesia, and lethargy • Severe hyperkalemia • Can cause bilateral flaccid paralysis of extremities, and weakness of repiratory muscles • However unlike hypokalemia, complete paralysis is uncommon. Electrolyte & Blood Pressure 2005; 3:71-78.

  24. Hyperkalemia in CKD: Treatment • Acute / emergency treatment of hyperkalemia • Acute reduction of serum K+ is required at levels exceeding 7.0 mEq/L, because of the risk of cardiac arrest • For acute therapy of hyperkalemia in an urgent situation, regardless of the underlying cause, following treatments have been recommended Electrolyte & Blood Pressure 2005; 3:71-78.

  25. Hyperkalemia in CKD: Treatment • Acute / emergency treatment of hyperkalemia • Emergency treatment should be started by the administration of calcium (10-30 mL of 10% calcium gluconate over 10 min intravenously) • Intravenous infusion of calcium is the most rapid and effective way to antagonize the myocardial toxic effects of hyperkalemia Electrolyte & Blood Pressure 2005; 3:71-78.

  26. Hyperkalemia in CKD: Treatment • Acute / emergency treatment of hyperkalemia • Furthermore, intravenous glucose (50 mL dextrose 50 %, preferably by central venous infusion) should be given followed by or combined with 10 units of short-acting regular insulin, because • Combined administration of glucose and insulin results in a greater decline in serum K+ levels • Intravenous insulin rapidly stimulates uptake of K+ into cells, primarily the muscle and liver Electrolyte & Blood Pressure 2005; 3:71-78.

  27. Hyperkalemia in CKD: Treatment • Acute / emergency treatment of hyperkalemia • β2-adrenergic agonists, • which also induce cellular K+ uptake, are useful for the acute therapy of hyperkalemia • A direct comparison between • Intravenous (0.5 mg) and nebulized (10 mg) albuterol (salbutamol) in ESRD patients revealed a similar potassium-lowering Electrolyte & Blood Pressure 2005; 3:71-78.

  28. Hyperkalemia in CKD: Treatment • Acute / emergency treatment of hyperkalemia • However, 20-40% of ESRD patients are refractory to the K+ -lowering effect of albuterol and • Not possible to predict non-responders • Combined use of • β2-adrenergic agonists with glucose and insulin • will maximize the reduction in serum K+ Electrolyte & Blood Pressure 2005; 3:71-78.

  29. Hyperkalemia in CKD: Treatment • Acute / emergency treatment of hyperkalemia • When especially used alone, bicarbonate is probably less effective than either β2-agonist or insulin in the acute treatment of hyperkalemia • Recent studies show conflicting evidences whether bicarbonate can act in a synergistic fashion with either insulin or β2 -adrenergic agonists Electrolyte & Blood Pressure 2005; 3:71-78.

  30. Hyperkalemia in CKD: Treatment • Acute / emergency treatment of hyperkalemia • Dialysis should be considered the primary method of K+ removal when hyperkalemia is persistent or severe • Hemodialysis is the most rapid method of K+ removal • Removal rates of K+ can approximate 35 mEq/hr with a dialysate bath potassium concentration of 1-2 mEq/L • A glucose free dialysate is preferable to minimize a glucose-induced shift of K+ into cell, lessening the removal of K+ Electrolyte & Blood Pressure 2005; 3:71-78.

  31. Hyperkalemia in CKD: Treatment • Acute / emergency treatment of hyperkalemia • Peritoneal dialysis and chronic hemodiafiltration are effective in chronic hyperkalemia, but • Do not remove K+ fast enough to be recommended for use in acute, severe hyperkalemia • Although dialysis is the most rapid method available to treat most cases of hyperkalemia, • other modes of treatment should not be delayed while waiting to institute dialysis Electrolyte & Blood Pressure 2005; 3:71-78.

  32. Hyperkalemia in CKD: Treatment • Chronic treatment of hyperkalemia in CKD • Important to determine underlying causes for hyperkalemia. • One should find modifiable causes of hyperkalemia in CKD patients • Common modifiable causes are • Concomitant medications and • Excessive dietary intake • A careful history on the dietary habit and the medication is necessary Electrolyte & Blood Pressure 2005; 3:71-78.

  33. Hyperkalemia in CKD: Treatment • Chronic treatment of hyperkalemia in CKD • 3 general categories (1) to avoid or replace drugs that cause hyperkalemia; (2) to prescribe a low-potassium diet and avoid constipation, and (3) to enhance potassium excretion by residual functioning nephrons or to remove it more efficiently by dialysis and/or by the gastrointestinal tract Electrolyte & Blood Pressure 2005; 3:71-78.

  34. Hyperkalemia in CKD: Treatment • Chronic treatment of hyperkalemia in CKD • Follow-up should be in 2 weeks if serum K+ >5.1 mEq/L for outpatients management of CKD • If mild hyperkalemia develops after medications, • Reduce the dose of medications that interfere K+ balance by 50% and • Reassess the serum K+ every 5 to 7 days until serum K+ has returned to baseline • If serum K+ does not return to baseline within 2 to 4 weeks, • Discontinue that medications and select an alternate medication Electrolyte & Blood Pressure 2005; 3:71-78.

  35. Hyperkalemia in CKD: Treatment • Chronic treatment of hyperkalemia in CKD • Target potassium intake of a “low potassium diet” is • <2 to 3 g/d (approximately 50 to 75 mEq/d) • The DASH diet should not be routinely recommended to patients with CKD stage 3, 4 and 5 (GFR<60 mL/min/1.73 m2) because of its high content of fruits and vegetables • Salt substitutes should not be recommended in CKD Electrolyte & Blood Pressure 2005; 3:71-78.

  36. Hyperkalemia in CKD: Treatment • Chronic treatment of hyperkalemia in CKD • Beside excess potassium dietary intake and constipation, it is also important to look for prolonged fasting • Overnight fasting in preparation for surgery in dialysis patients may induce hyperkalemia due to a fall in the concentration of insulin • This can be avoided by continuous infusion of 10% glucose at 50 mL/h mixed with or without regular insulin Electrolyte & Blood Pressure 2005; 3:71-78.

  37. Hyperkalemia in CKD: Treatment • Chronic treatment of hyperkalemia in CKD • Promoting diuresis with a loop diuretic can control chronic, mild hyperkalemia Electrolyte & Blood Pressure 2005; 3:71-78.

  38. Hyperkalemia in CKD: Treatment • Chronic treatment of hyperkalemia in CKD • Thiazide and loop diuretics increase the delivery of sodium to the distal tubule, thereby increasing urinary potassium excretion • This may be a useful side-effect in CKD, especially in patients treated with an ACE inhibitor or ARB • However, most of thiazides are effective in kaliuresis in patients with GFR > approx. 30 mL/min/1.73 m2 Electrolyte & Blood Pressure 2005; 3:71-78.

  39. Hyperkalemia in CKD: Treatment • Chronic treatment of hyperkalemia in CKD • An active component of licorice, • Glycyrrhetinic acid might be considered as one of the therapeutic agents for chronically hyperkalemic patients on maintenance hemodialysis Electrolyte & Blood Pressure 2005; 3:71-78.

  40. Hyperkalemia in CKD: Treatment • Either after acute hyperkalemia has been corrected or in chronic management of less severe hyperkalemia in CKD patients, the more slowly acting • Cation exchange resin may be given orally or rectally (e.g. sodium/calcium polystyrene sulfonate 15-30 g, with an equal amount of sorbitol to prevent fecal impaction) • Cation exchange resin may be given in order to prevent a further increase in serum K+ Electrolyte & Blood Pressure 2005; 3:71-78.

  41. Potassium binding resins in hyperkalemia • Hot topic in Nephrology • Recent editorial • Damned If You Do, Damned If You Don’t: Potassium Binding Resins in Hyperkalemia CJASN ePress. Published on August 26, 2010

  42. Potassium binding resins in hyperkalemia • SPS resins increase stool potassium excretion in normokalemic subjects, but proportionately more potassium excreted due to cathartics when the two are combined • In hyperkalemic patients, oral SPS mixed in water significantly decreases serum potassium within 24 hours CJASN ePress. Published on August 26, 2010

  43. Potassium binding resins in hyperkalemia • SPS/sorbitol-associated colonic necrosis is most commonly seen in patients • who have received enemas in the setting of recent abdominal surgery, bowel injury, or intestinal dysfunction • It is a rare event, • on the order of 0.2 to 0.3%, almost exclusively present in patients at risk CJASN ePress. Published on August 26, 2010

  44. Potassium binding resins in hyperkalemia • Authors concluded • SPS ion-exchange resins are the only agents, • other than dialysis and diuretics, • Available to increase K+excretion in hyperkalemia, and • when used appropriately, • they appear to be • Clinically effective and reasonably safe CJASN ePress. Published on August 26, 2010

  45. Summary: Drugs for hyperkalemia Pediatr Nephrol Published online 22 December 2010

  46. Hyperkalemia in CKD: Treatment • Either asymptomatic and mild hyperkalemia or chronic hyperkalemia in CKD patients is common Electrolyte & Blood Pressure 2005; 3:71-78.

  47. Conclusions • Hyperkalemia is common and life threatening complication of CKD • The effective and rapid diagnosis and management of acute and chronic hyperkalemia is clinically relevant and can be life-saving • In treatment of moderate to severe hyperkalemia, the combination of medications with different therapeutic approaches is usually effective, and often methods of blood purification can be avoided.

  48. Conclusions • In patients with severe hyperkalemia and major ECG abnormalities, conservative efforts should be initiated immediately to stabilize the patient, but management should include rapid facilitation of renal replacement treatment

  49. Thank You!

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