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Managing Acute & Chronic Hyperkalemia

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MANAGING ACUTE AND CHRONIC HYPERKALEMIA: SOLVING THE PUZZLE Matthew R. Weir, MD Professor and Chief Division of Nephrology University of Maryland School of Medicine Disclosure Slide Scientific Advisor: Janssen, Astra, BI, MSD, Akebia, Relypsa, Boston Scientific, Lexicon, Bayer, Vifor, CareDx Grant Funding: NIDDK: R01DK066013, U01DK116095,and U01DK106102; NHLBI: R01HL127422, R01HL132732 Outline • Recognition: Review prevalence and risk factors for hyperkaleMia • Management: Review current ManageMent strategies • Treatment: • Describe current approaches for the treatment of hyperkalemia both acutely and chronically • Highlight new option to treat hyperkalemia in patients on renoprotective therapies Overview: Epidemiology of Hyperkalemia • Prevalence in hospitalized patients ranges froM 1%-10% depending on the definition of hyperkaleMia1 • Prevalence in patients with CKD ranges froM 5%-50%, increasing as kidney function declines2 • HyperkaleMia is More coMMon in patients with3 • Reduced kidney function • Multiple medications (especially RAAS inhibitors) • Older age • Diabetes mellitus 1. Hollander-Rodriguez JC, Calvert JF Jr. Hyperkalemia. Am Fam Phys. 2006;73(2):283-290. 2. Reardon LC, Macpherson DS. Arch Intern Med. 1998;158(1):26-32. 3. Lazich I, Bakris G., Semin Nephrol 2014; 34:333-339. Hyperkalemia Varies Widely in Studies and Guidelines • The upper liMit of norMal (ULN) for seruM K+ levels varies across guidelines and publications1-6 Hyperkalemia • Serum K+ levels of 5.0, 5.5, or 6.0 mEq/L are 6.0 commonly used cutoffs for ULN 5.5 • Some studies differentiate hyperkalemia by severity1 + 5.0 • Serum K+ levels ≥5.5-<6.0 mEq/L defined as Normal moderate + (mEq/L) Target Range: K =3.5-5.0 + Serum K 4.0 • Serum K levels ≥6.0 mEq/L defined as severe 3.5 3.0 Hypokalemia K+: potassiuM 1. Einhorn LM, et al. Arch Intern Med. 2009;169(12):1156-1162. 2. Yancy CW, et al. J Am Coll Cardiol. 2017 Apr 21. pii: S0735-1097(17)37087-0. doi: 10.1016/j.jacc.2017.04.025. [Epub ahead of print]. 3. Ponikowski P., et al., Eur Heart J. 2016 Jul 14;37(27):2129-200. 4. National Kidney Foundation. Guideline 11: Use of angiotensin-converting enzyMe inhibitors and angiotensin receptor blockers in CKD. In: K/DOQI Clinical Practice GuidelineS on HypertenSion and AntihypertenSive AgentS in Chronic Kidney DiSeaSe. 2002. http://www2.kidney.org/professionals/kdoqi/guidelines_bp/guide_11.htm. Accessed February 17, 2015. 5. National Institute for Health and Clinical Excellence (NICE) [UK]. Chronic kidney disease (CG73): Early identification and Management of chronic kidney disease in adults in priMary and secondary care. 2008. http://www.nice.org.uk/CG73. 6. Heart Failure Society of AMerica, Lindenfeld J, et al. J Card Fail. 2010;16(6):475-539. Overview: Epidemiology of Hyperkalemia • Prevalence in hospitalized patients ranges froM 1%-10% depending on the definition of hyperkaleMia1 • Prevalence in patients with CKD ranges froM 5%-50%, increasing as kidney function declines2 • HyperkaleMia is More coMMon in patients with3 • Reduced kidney function • Multiple medications (especially RAAS inhibitors) • Older age • Diabetes mellitus 1. Hollander-Rodriguez JC, Calvert JF Jr. Hyperkalemia. Am Fam Phys. 2006;73(2):283-290. 2. Reardon LC, Macpherson DS. Arch Intern Med. 1998;158(1):26-32. 3. Lazich I, Bakris G., Semin Nephrol 2014; 34:333-339. Prevalence of Hyperkalemia Defined as Serum Potassium >5 mEq/l and/or Sodium Polystyrene Use in Diabetic and Non-diabetic Patients with CKD Stages 2, 3 and 4 Loutradis C, et.al. Am J Nephrol 2015;42:351-360 Hyperkalemia Rates in RAASi-Treated Patients in Randomized Trials Patient Population # of Patients Definition Rate AASK1: 417 ≥5.5 7.2% non-diabetic CKD J-LIGHT2: 58 >5.1 ≤6.9 5.2% HTN-CKD RENAAL3: 751 ≥5.5 10.8% diabetic nephropathy IDNT4: 579 >6 18.6 diabetic nephropathy 1. Weinberg JM, et al. Arch Intern Med. 2009;169(17):1587-1594. 2. Iino Y, et al. Hypertens Res. 2004;27(1):21-30. 3. Miao Y, et al. Diabetologia. 2011;54(1):44-50. 4. Avapro [package insert]. Bridgewater, NJ: sanofi-aventis U.S. LLC. 2012. Predictors of Hyperkalemia Before Starting Therapy • eGFR <45 ml/min/1.73m2 • serum potassium of >4.5 mEq/L • eGFR <45 ml/min/1.73m2 + serum [K+] >4.5 mEq/L (HIGHEST PREDICTOR) in the absence of RAAS blockers Lazich I and Bakris G. Sem Nephrol 2014;34:333-339; Khosla N et.al. Am J Nephrol 2009;30:418-423 Hyperkalemia: A Significant Risk Marker for Mortality Spline Analysis Adjusted for Covariates, Showing Serum Potassium as a Continuous Variable with All-Cause Mortality Collins AJ, et al. Am J Nephrol 2017;46:213-221. Serum K+ Concentrations and Survival in Hemodialysis Patients 2.5 Unadjusted Unadjusted Case-mix 2 Case-mix Case-mix and Case-mix and 2 MICS MICS Both incident and Only prevalent* MHD patients prevalent* MHD patients (vintage ≥6 months) n=74,219 1.5 n=53,206 1.5 Ratio 1 Cause Mortality HazardRatio CauseMortality - 1 Cardiovascular Mortality Hazard Mortality Cardiovascular All 0.8 <4.0 4.29 4.59 4.99 5.29 5.59 5.99 6.29 ≥6.3 – – – – – – – <4.0 – 4.29 – 4.59 – 4.99 – 5.29 – 5.59 – 5.99 – 6.29 ≥6.3 4.0 4.3 4.6 5.0 5.3 5.6 6.0 4.0 4.4 4.6 5.0 5.3 5.6 6.0 Potassium (mEq/L) Potassium (mEq/L) Predialysis serum K+ categories in 74,219 Predialysis serum K+ categories in 53,206 MHD patients observed for up to 3 years prevalent MHD patients observed for up to 3 years MHD: maintenance hemodialysis; MICS: malnutrition inflammation complex syndrome. Kovesdy CP, et al. Clin J Am Soc Nephrol. 2007;2:999-1007. Admission Serum K+ Levels and In-Hospital Mortality among CKD Patients With and Without CVD Analysis of 73,983 patients admitted to Mayo Clinic Rochester. A U-shaped curve showed higher in-hospital mortality associated with both hypo- and hyperkalemia 12 10.2 10 7.9 8 6.3 6.3 6 4.1 4.1 4 3.1 3.3 2.8 2.8 3 2.7 hospital Mortality hospital (%) 1.9 - 2 1.7 In 0 <3.0 3.0-<3.5 3.5-<4.0 4.0-<4.5 4.5-<5.0 5.0-<5.5 ≥5.5 Cardiovascular disease Non-cardiovascular disease Serum Potassium at Hospital Admission (mEq/L) Odds Ratio for in-hospital mortality 3.26 2.40 1.38 1 1.13 1.89 3.62 after adjusting for (95%CI 2.03-4.98) (95%CI 1.89-3.04) (95%CI 1.15-1.66) (REFERENCE) (95% CI 0.94-1.37) (95% CI 1.49-2.38) (95%CI 2.73-4.76) potential cofounders* * Adjusted for age, sex, race, GFR, principal diagnosis, Charlson comorbidity score, CAD, CHF, PVD, stroke, DM, COPD, cirrhosis, use of ACEI/ARB, diuretics and potassium supplements CVD = cardiovascular disease Cheungpasitporn W., et al., QJM. 2017 Jun 16. doi: 10.1093/qjmed/hcx118. [Epub ahead of print] Traditional Treatment Options for Hyperkalemia Traditional Treatment Options for Hyperkalemia Membrane stabilization Calcium + Insulin1 K redistribution gluconate salt1 K+ elimination ᵦ-andrenoreceptor Removal/reduction of drugs that ↑ serum K+ agonists1 RAASi Dialysis1 SPS1 reduction2 Sodium Loop diuretics1 Dialysis1 Low K+ diet2 bicarbonate1 Therapy Emergent Intermediate Maintenance Acute management RAASi: renin-angiotensin-aldosterone system inhibitor, SPS: sodium polystyrene sulfonate 1. Weisberg L. Crit Care Med. 2008;36(12):3246-3251. 2. PalMer BF, et al. N Engl J Med. 2004;351(6):585-592. Standard Care of CHRONIC Hyperkalemia • Review medication history • Titrate or discontinue RAAS inhibitors • Diuretic therapy • Potassium binder therapy National Kidney Foundation. Am J Kidney Dis. 2002;39(suppl 1):S76-S110. Palmer BF. N Engl J Med. 2004;351:585-592. Modifiable Risk Factors for Hyperkalemia in Patients on RAAS • Reduce potassium intake: – Low potassium diet – Avoid potassium supplements, including salt substitutes and certain herbs • Avoid Drugs That Concomitantly Interfere With Renal K+ Excretion: – Nonsteroidal antiinflammatory drugs – Beta-blockers – Calcineurin inhibitors: cyclosporine, tacrolimus – Heparin – Ketoconazole – Potassium-sparing diuretics: spironolactone, – eplerenone, amiloride, triamterene – Trimethoprim – Pentamidine Palmer B, N Engl J Med. 2004 Aug 5;351(6):585-92. Medications Associated With Hyperkalemia Class Mechanism Example Inhibit conversion of angiotensin I to ACE inhibitor Captopril, lisinopril, etc. angiotensin II Inhibit activation of angiotensin I receptor by ARB Losartan, irbesartan, etc. angiotensin II Aldosterone Spironolactone, Block aldosterone receptor activation antagonist eplerenone β-Adrenergic Propranolol, metoprolol, Inhibit renin release receptor blocker atenolol Digitalis Inhibit Na+-K+-ATPase; necessary for K+ Digoxin glycoside secretion Heparin Reduces production of aldosterone Heparin sodium K+-sparing Block collecting duct apical Na+ channel, Amiloride, triamterene diuretic decreasing gradient for K+ secretion Inhibit synthesis of prostaglandin E and NSAIDs Ibuprofen prostacyclin, inhibiting renin release Block collecting duct apical Na+ channel, Trimethoprim, Other decreasing gradient for K+ secretion pentamidine Weiner ID, et al. Comprehensive Clinical Nephrology 2015;111-123. Limitations of Diuretic Therapy • Diuretic therapy is commonly used to treat hyperkalemia but has limited effectiveness in patients with advanced CKD • Diuretic-induced kaliuresis is dependent on kidney function, adequate extracellular voluMe, and delivery of sodiuM to the cortical collecting tubule, all of which May be iMpaired in patients with advanced renal insufficiency and/or heart failure • Syncope, orthostatic hypotension, gout, ototoxicity, and increasing azotemia secondary to volume depletion can limit the use of diuretics, especially in high doses or as coMbination strategies • Please consult the reference list in the source article, Weir et al, for background information in the literature. Do not use fludrocortisone! • VoluMe overload • Toxin for MyocardiuM, kidney and vascular beds Low Potassium Diet K+ Quiz Dairy Products Ice cream Yoghurt Cheddar Advising Your Patient About K+ Intake 1.None of these are high in potassium 2.Yoghurt > Ice cream > Cheddar 3.Ice cream > Yoghurt > Cheddar 4.Cheddar > Ice cream > Yoghurt 5.Ice cream > Cheddar > Yoghurt Dairy Products Food Per Serving mEqs Cheddar cheese 1.5 oz.
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  • Evaluating and Managing Electrolyte Disbalances in the Outpatient Setting Disclosure

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    EVALUATING AND MANAGING ELECTROLYTE DISBALANCES IN THE OUTPATIENT SETTING DISCLOSURE There are no conflicts of interest Homeostasis • Potassium • Water Evaluation and Management of Electrolyte TO BE DISCUSSED Disbalances • Hyperkalemia • Hypokalemia • Hypernatremia • Hyponatremia Summary DISORDERS OF POTASSIUM BALANCE: HYPERKALEMIA AND HYPOKALEMIA POTASSIUM HOMEOSTASIS • Aldosterone • High Na+ delivery to distal tubule Increase (diuretics) Renal K+ • High urine flow (osmotic diuresis) Excretion • High serum K+ level • Delivery bicarbonate to distal tubule • Absence, or very low aldosterone • Low Na+ delivery to the distal Decrease tubule Renal K+ • Low urine flow Excretion • Low serum K+ level • Kidney Injury MORTALITY IN DYSKALEMIA Collins et al Am J Nephrol 2017;46:213- 221 HYPERKALEMIA MY PATIENT HAS HYPERKALEMIA, WHAT SHOULD I DO? H&P and Check other medication causes •Changes? Treat review •Send home •Symptoms? Treat •Metabolic acidosis •Obstruction •Hyperosmolarity •K+ increasing meds •CKD Pseudohyperkale EKG and BMP mia CAUSES OF HYPERKALEMIA Increased potassium release from Reduced urinary potassium excretion cells • Pseudohyperkalemia • Acute and chronic kidney disease • Fist clenching • Reduced aldosterone secretion or • Tourniquet use response to aldosterone • Metabolic acidosis • Reduced distal sodium and water • Insulin deficiency, hyperglycemia, delivery and hyperosmolality • Drugs • Increased tissue catabolism • Drugs • Hyperkalemic Periodic Palasysis Biff Palmer A Physiologic-Based Approach to the Evaluation of a Patient