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Hyperkalemia, an update
1. Conflicts of interest
• ZS Pharma honorarium*
• Relypsa bought me breakfast*
• Astute speaker bureau
• Alexis honorarium
• Astellas travel honorarium
• Davita partner in multiple dialysis units and a vascular access center
2. 66 year old white male
CC: cough and fever
Started on TMP-SMX 3 days ago
PMHx: CKD 3, DM2, Hypertension
140
5.7
110
21 1.4
18
124
3. 66 year old white male
CC: cough and fever
Started on TMP-SMX 3 days ago
PMHx: CKD 3, DM2, Hypertension
140
5.7
110
21 1.4
18
124
How would you manage the potassium
a. You call that hyperkalemia? Do nothing
b. Stop the ACEi/ARB and TMP-SMX
c. Some combination of IV calcium,
nebulized albuterol, insulin and glucose
d. 30 grams oral kayexalate
e. answers b, c and d
http://bit.ly/HyperK
4.
5. 66 year old white male
CC: cough and fever
Started on TMP-SMX 3 days ago
PMHx: CKD 3, DM2, Hypertension
140
5.7
110
21 1.4
18
124
How would you manage the potassium
a. You call that hyperka-
lemia? Do nothing.
b. Stop the ACEi/ARB and TMP-SMX
c. Some combination of IV calcium,
nebulized albuterol, insulin and glucose
d. 30 grams oral kayexalate
e. answers b, c and d
http://bit.ly/HyperK
6. Fralick M, Macdonald EM, Gomes T, et al. Co-trimoxazole and
sudden death in patients receiving inhibitors of renin-angiotensin
system: population based study. BMJ. 2014;349:g6196.
7. Ontario residents
Age ≥ 66
On an ACE or ARB
Over 17 years 39,000
cases of sudden death
1,110 within 7 days of
being prescribed an
antibiotic
14. dct
ccd
K +
3 Na+ 2 K+
ATPase
+
Principal cell
S o d i u m f l o w s d o w n a
c h e m i c a l g r a d i e n t
15. dct
ccd
K +
3 Na+ 2 K+
ATPase
+
+–
+–
+–
Principal cell
S o d i u m f l o w s d o w n a
c h e m i c a l g r a d i e n t
G e n e r a t e s a n e g a t i v e
c h a rg e i n t h e t u b u l e
16. dct
ccd
K +
3 Na+ 2 K+
ATPase
+
+–
+–
+–
Principal cell
S o d i u m f l o w s d o w n a
c h e m i c a l g r a d i e n t
G e n e r a t e s a n e g a t i v e
c h a rg e i n t h e t u b u l e
P o t a s s i u m s e c re t i o n
17. dct
ccd
K +
3 Na+ 2 K+
ATPase
+
+–
+–
+–
Principal cell
A n y p ro c e s s t h a t b l o c k s
t h e e N a C c h a n n e l c a n
c a u s e h y p e r k a l e m i a
D r u g s
• Tr i a m t e re n e
• A m i l o r i d e
• Tr i m e t h o p r i m ( a b x )
D i s e a s e s
• Ty p e 1 RTA
( e l e c t ro g e n i c )
• P s e u d o h y p o a l d o -
s t e ro n i s m t y p e 1
STOP
18. dct
ccd
K +
3 Na+ 2 K+
ATPase
+
+–
+–
+–
Principal cell
A n y p ro c e s s t h a t b l o c k s
t h e e N a C c h a n n e l c a n
c a u s e h y p e r k a l e m i a
D r u g s
• Tr i a m t e re n e
• A m i l o r i d e
• Tr i m e t h o p r i m ( a b x )
D i s e a s e s
• Ty p e 1 RTA
( e l e c t ro g e n i c )
• P s e u d o h y p o a l d o -
s t e ro n i s m t y p e 1
STOP
19. But what if we ignore TMP/SMX…how dangerous is a potassium of 5.5 to 6.5?
24. 5,945 patients died within 1 day of a potassium
measurement, odds ratio of death based on potassium
OddsRatioofdeathin1day
0
10
20
30
40
No CKD CKD 3 CKD 4 CKD 5
8.0
11.6
19.5
31.6
2.3
5.75.4
10.3
1.31.01.11.0
K < 5.5 K 5.5-6.0 K ≥ 6.0
Einhorn LM, Zhan M, Hsu VD, et al. The frequency of hyperkalemia and its significance
in chronic kidney disease. Arch Intern Med. 2009;169(12):1156-62.
25. 5,945 patients died within 1 day of a potassium
measurement, odds ratio of death based on potassium
OddsRatioofdeathin1day
0
10
20
30
40
No CKD CKD 3 CKD 4 CKD 5
8.0
11.6
19.5
31.6
2.3
5.75.4
10.3
1.31.01.11.0
K < 5.5 K 5.5-6.0 K ≥ 6.0
Einhorn LM, Zhan M, Hsu VD, et al. The frequency of hyperkalemia and its significance
in chronic kidney disease. Arch Intern Med. 2009;169(12):1156-62.
26. 5,945 patients died within 1 day of a potassium
measurement, % deaths for K and CKD status%ofpotassiumwithadeathin24hours
0
10
K < 5.5 K 5.5-6.0 K ≥ 6.0
4.8%
1.8%
0.4%
8.6%
3.2%
0.3%
No CKD CKD
Einhorn LM, Zhan M, Hsu VD, et al. The frequency of hyperkalemia and its significance
in chronic kidney disease. Arch Intern Med. 2009;169(12):1156-62.
27. 5,945 patients died within 1 day of a potassium
measurement, % deaths for K and CKD status%ofpotassiumwithadeathin24hours
0
10
K < 5.5 K 5.5-6.0 K ≥ 6.0
4.8%
1.8%
0.4%
8.6%
3.2%
0.3%
No CKD CKD
Einhorn LM, Zhan M, Hsu VD, et al. The frequency of hyperkalemia and its significance
in chronic kidney disease. Arch Intern Med. 2009;169(12):1156-62.
The odds of death increased with
severity of hyperkalemia; however,
the risk of death was greater in the
absence of CKD than in the presence
of CKD.
31. p l a c e b o 1 . 2 5 & 2 . 5 g 5 & 1 0 g
AT R I A L F I B 0 0 1
AT R I A L F L U T T E R 0 1 0
B R A D Y C A R D I A 0 0 1
PA L P I TAT I O N S 0 0 1
S I N U S
TA C H Y C A R D I A
0 0 1
V E N T R I C U L A R
E X T R A S Y S T O L E
0 0 1
32. p l a c e b o 1 . 2 5 & 2 . 5 g 5 & 1 0 g
AT R I A L F I B 1 0 1
L E F T B B B 0 1 0
B R A D Y C A R D I A 0 0 1
C H F 1 0 0
C V D I S O R D E R 1 0 0
D I A S T O L I C
D Y S F U N C T I O N
0 0 1
L O N G Q T 0 0 1
34. 2 patients during the initial
treatment phase and 1 in the
patiromer group during the
randomized withdrawal phase
had ECG changes consistent
with hyperkalemia
35. How about some prospective data?
Disagreement between the retrospective
view from 30,000 feet and carefully
collected prospective data.
36.
37. P o t a s s i u m 8 . 5 m m o l / L d u e t o r h a b d o m y o l y s i s
38. P o t a s s i u m o f 9 . 9 , h e m o l y z e d s p e c i m e n
39. 66 year old white male
CC: cough and fever
Started on TMP-SMX 3 days ago
PMHx: CKD 3, DM2, Hypertension
140
5.7
110
21 1.4
18
124
How would you manage the potassium
a. You call that hyperkalemia? Do nothing
b. Stop the ACEi/ARB and TMP-SMX
c. Some combination of IV calcium,
nebulized albuterol, insulin and glucose
d. 30 grams oral
kayexalate
http://bit.ly/HyperK
56. 32 patients
SPS 20-60 grams a day
23 oliguric
AKI
9 CKD
everyone was treated, no controls
30 patients treated between 1 and 6 days
2 treated for 35 and 280 days respectively
64. Potassium 5.0-5.9 mmol/L
GFR < 40 mL/min
PlaceboSPS 30 g qD
Primary outcome: mean difference in potassium from
baseline to the day after the last dose of study drug
7 days 7 days
69. Five patients received kayexalate and
sorbitol enemas for hyperkalemia
Lillemoe KD, Romolo JL, Hamilton SR, Pennington LR, Burdick JF, Williams GM. Intestinal necrosis due to sodium polystyrene (Kayexalate) in sorbitol enemas: clinical and
experimental support for the hypothesis. Surgery. 1987;101(3):267-72.
70. Five patients received kayexalate and
sorbitol enemas for hyperkalemia
Lillemoe KD, Romolo JL, Hamilton SR, Pennington LR, Burdick JF, Williams GM. Intestinal necrosis due to sodium polystyrene (Kayexalate) in sorbitol enemas: clinical and
experimental support for the hypothesis. Surgery. 1987;101(3):267-72.
71. Five patients received kayexalate and
sorbitol enemas for hyperkalemia
all five of them developed colonic
necrosis and four died
Lillemoe KD, Romolo JL, Hamilton SR, Pennington LR, Burdick JF, Williams GM. Intestinal necrosis due to sodium polystyrene (Kayexalate) in sorbitol enemas: clinical and
experimental support for the hypothesis. Surgery. 1987;101(3):267-72.
72. Harel Z, Harel S, Shah PS, Wald R, Perl J, Bell CM. Gastrointestinal adverse events with sodium
polystyrene sulfonate (Kayexalate) use: a systematic review. Am J Med. 2013;126(3):264.e9-24.
75. 23 case reports
30 articles
7 case series
58 cases
0
10
20
30
40
Before 1990 1990-2000 After 2000
31
24
3
76. 23 case reports
30 articles
7 case series
58 cases
0
10
20
30
40
Before 1990 1990-2000 After 2000
31
24
3
mean age 58 years
77. 23 case reports
30 articles
7 case series
58 cases
0
10
20
30
40
Before 1990 1990-2000 After 2000
31
24
3
women
men
mean age 58 years
78. 23 case reports
30 articles
7 case series
58 cases
0
10
20
30
40
Before 1990 1990-2000 After 2000
31
24
3
women
men
mean age 58 years
No CKD
ESRD
CKD
79. 23 case reports
30 articles
7 case series
58 cases
0
10
20
30
40
Before 1990 1990-2000 After 2000
31
24
3
women
men
mean age 58 years
No CKD
ESRD
CKD
Chronic
Acute
80. 23 case reports
30 articles
7 case series
58 cases
0
10
20
30
40
Before 1990 1990-2000 After 2000
31
24
3
women
men
mean age 58 years
No CKD
ESRD
CKD
Chronic
Acute
SPS
SPS+Sorbitol
81. 23 case reports
30 articles
7 case series
58 cases
0
10
20
30
40
Before 1990 1990-2000 After 2000
31
24
3
women
men
mean age 58 years
No CKD
ESRD
CKD
Chronic
Acute
20% Sorbitol
70% Sorbitol
SPS
SPS+Sorbitol
84. 58 cases of gastrointestinal ischemia from 1973 to 2013 is 9 kg of kayexalate
(guessing 5 doses per episode)
58 cases
is that a lot
85. 5 million doses of kayexalate used per year
58 cases of gastrointestinal ischemia from 1973 to 2013 is 9 kg of kayexalate
(guessing 5 doses per episode)
58 cases
is that a lot
86. 5 million doses of kayexalate used per year
150,000 kg of kayexalate
58 cases of gastrointestinal ischemia from 1973 to 2013 is 9 kg of kayexalate
(guessing 5 doses per episode)
58 cases
is that a lot
87. 5 million doses of kayexalate used per year
150,000 kg of kayexalate
58 cases of gastrointestinal ischemia from 1973 to 2013 is 9 kg of kayexalate
(guessing 5 doses per episode)
58 cases
is that a lot
88. 5 million doses of kayexalate used per year
150,000 kg of kayexalate
58 cases of gastrointestinal ischemia from 1973 to 2013 is 9 kg of kayexalate
(guessing 5 doses per episode)
58 cases
is that a lot
89. avoid kayexalate in patients with sick bowels
(infection, constipation, ischemic disease, GI bleed)
avoid kayexalate in post transplant patients
avoid kayexalate enemas
90. 66 year old white male
CC: cough and fever
Started on TMP-SMX 3 days ago
PMHx: CKD 3, DM2, Hypertension
140
5.7
110
21 1.4
18
124
How would you manage the potassium
a. You call that hyperkalemia? Do nothing
b. Stop the ACEi/ARB and TMP-SMX
c. Some combination of IV
calcium, nebulized albu-
terol, insulin and glucose
d. 30 grams oral kayexalate
91. Allon Et al. Annals of Int Med; 1989: 110, 426-429
inhaled beta-agonists are effective
92. • 8 studies show this works
• 20 mg works better than 10 mg
• IV administration is no better than nebulized
• additive to insulin
• may be repeated after 2 hours
Allon Et al. Annals of Int Med; 1989: 110, 426-429
inhaled beta-agonists are effective
93. Allon Et al. Annals of Int Med; 1989: 110, 426-429
inhaled beta-agonists are effective
94. • give regular insulin intravenously rather than subcutaneously
Blumberg Et al. Amer J Med; 1988: 85, 507-512.
as is intravenous insulin
95. Blumberg Et al. Amer J Med; 1988: 85, 507-512.
but sodium bicarbonate is not
96. Blumberg Et al. Amer J Med; 1988: 85, 507-512.
but sodium bicarbonate is not
97. Blumberg Et al. Amer J Med; 1988: 85, 507-512.
but sodium bicarbonate is not
98. Blumberg Et al. Amer J Med; 1988: 85, 507-512.
Blumberg Et al. Kidney International; 1992: 41, 369-374.
99. • 4 mmol/min for 1 hour
• 240 mmol of NaHCO3
• 0.5 mmol/min for 5 hours
• 150 mmol of NaHCO3
• Total 390 mmol NaHCO3
(8 amps) in 1140 mL
Blumberg Et al. Amer J Med; 1988: 85, 507-512.
Blumberg Et al. Kidney International; 1992: 41, 369-374.
102. insulin and glucose
Maximum hypoglycemic
effect at 100microUnits/mL
Maximum hypokalemic effect
at 500 microUnits/mL
Theoretical maximum
transport of 134 mmol/min
103. insulin and glucose
Maximum hypoglycemic
effect at 100microUnits/mL
Maximum hypokalemic effect
at 500 microUnits/mL
Theoretical maximum
transport of 134 mmol/min
104. insulin and glucose
Maximum hypoglycemic
effect at 100microUnits/mL
Maximum hypokalemic effect
at 500 microUnits/mL
Theoretical maximum
transport of 134 mmol/min
109. 29 of the 221 (13%) episodes resulted in hypoglycemia.
Glucose 51–60 mg/dL in 16 episodes
Glucose ≤ 50 mg/dL in 13 episodes
All patients with hypoglycemic episodes received 25 g of
dextrose with insulin.
Hypoglycemia occurred at a median of 2 h and persisted
for a median of 2 h
110. Albuterol lowers the potassium independent
and additively with insulin glucose
Guhan AR, Cooper S, Oborne J, Lewis S, Bennett J, Tattersfield AE. Systemic effects of formoterol
and salmeterol: a dose-response comparison in healthy subjects. Thorax. 2000;55(8):650-6.
Albuterol stimulates
glucosegenesis
111. 66 year old white male
CC: cough and fever
Started on TMP-SMX 3 days ago
PMHx: CKD 3, DM2, Hypertension
140
5.7
110
21 1.4
18
124
How would you manage the potassium
a. You call that hyperkalemia? Do nothing
b. Stop the ACEi/ARB and TMP-SMX
c. Some combination of IV calcium,
nebulized albuterol, insulin and glucose
d. 30 grams oral kayexalate
e. answers b, c and d
http://bit.ly/HyperK
113. Patiromer for Oral Suspension
(FOS) is a high capacity, non-
absorbed, oral potassium
binder.
Patiromer is a dry, odorless
powder for suspension in small
amounts of water.
Patiromer is insoluble in typical
solvents and passes through
the GI tract without being
metabolized or broken down.
114. CKD stage 3 or 4 Potassium 5.1–6.5 RAAS inhibitor
4 week single group
phase
8 week single blind
placebo controlled
withdrawal phase
• 52 on placebo
• 55 on patiromer
K 5.1-5.5
4.2 g bid
n=92
K 5.5-6.5
8.4 g bid
n=151
K 3.8-5.0
115.
116.
117.
118.
119.
120. How would you manage the potassium
a. You call that hyperkalemia? Do nothing
b. Stop the ACEi/ARB and TMP-SMX
c. Some combination of IV calcium,
nebulized albuterol, insulin and glucose
d. 30 grams oral kayexalate
e. Patiromer (Veltassa)
e. answers b, c and d