HYPERKALAEMIA AND CO-MORBID CONDITIONS

Some comorbid conditions increase a patient’s risk of developing hyperkalaemia1-3

Although patients with hyperkalaemia are typically asymptomatic, the condition can become life-threatening if left untreated.1

Body figure with vascular network and pancreas highlighted
Body figure with vascular network and pancreas highlighted
Blue clipboard icon
Blue clipboard icon

To increase the chance of early diagnosis and treatment, it’s important to be able to identify patients at high risk of developing hyperkalaemia.1

In addition to patients with chronic kidney disease (CKD) and heart failure (HF) high-risk patients include individuals with:1

  • Resistant hypertension1
  • Diabetic nephropathy2,3

  1. Renal Association Clinical Practice Guidelines 2014. 
  2. Kovesdy, CP. Nat. Rev. Nephrol. 2014; 10: 653–662. 
  3. Liamis G et al. World J Clin Cases. 2014; 2: 488-496.

HYPERKALAEMIA AND CO-MORBID CONDITIONS

Individuals with diabetes have a higher incidence rate of hyperkalaemia*1

In an observational study in Sweden ~15% of adult patients with diabetes developed hyperkalaemia within 3 years.1

ADJUSTED
OR 1.73

for hyperkalaemia
in patients with
diabetes.*1

*Reference group: patients without diabetes

References:

  1. Nilsson E, et al. ERA-EDTA, Madrid, 2017. Poster presentation SP313.

HYPERKALAEMIA AND CO-MORBID CONDITIONS

Mechanism of diabetes that could lead to hyperkalaemia

Diabetes is strongly associated with microvascular complications, which causes damage to small blood vessels in the kidney, thus reducing renal function and impairing potassium excretion. This can be exacerbated by some diabetes medication.1

A lack of insulin also limits the body’s ability to regulate the shift of potassium into the cell.2

Schematic of a skeletal cell to show the effect of insulin and catecholamine binding on cation exchange through the cell membrane
Schematic of a skeletal cell to show the effect of insulin and catecholamine binding on cation exchange through the cell membrane

Adapted from Palmer BF. Clin Am J Soc Nephrol. 2015; 10: 1050-60.3

Mechanism of hypertension that could lead to hyperkalaemia

Certain blood pressure lowering drugs interfere with the RAAS, which results in decreased aldosterone production and subsequent impaired potassium excretion.3,5,6

Diagram to show how different pharmacological interventions can disrupt the renin–angiotensin–aldosterone system and its effects on the kidneys, resulting in hyperkalaemia
Diagram to show how different pharmacological interventions can disrupt the renin–angiotensin–aldosterone system and its effects on the kidneys, resulting in hyperkalaemia

Adapted from Palmer BF. N Engl J Med. 2004;351:585-92.4

  1. Liamis G et al. World J Clin Cases. 2014;2:488-496.
  2. Zacchia M et al. Kidney Dis. 2016;2:72–79.
  3. Palmer BF. Clin Am J Soc Nephrol. 2015; 10: 1050-60.
  4. Palmer BF. N Engl J Med. 2004;351:585-92.
  5. National Kidney Foundation. 2014. Clinical update on hyperkalemia.
  6. Viera AJ. J Am Board Fam Med. 2012;25:487-495.

HYPERKALAEMIA AND CO-MORBID CONDITIONS

There is a need for additional treatment options for hyperkalaemia1

The goal of long-term control of serum potassium is to prevent recurrence of hyperkalaemia1

 

Critical care management of hyperkalaemia

Many hyperkalaemia patients are treated in the acute setting, where the main goal is to restore normal membrane potential and prevent cardiac arrhythmia.1 

Protect the heart:2

  • Intravenous calcium salts

Shift potassium into cells:2

  • Sodium bicarbonate
  • Insulin/glucose
  • β2 agonists

Remove excess potassium from the body:2

  • Diuretics
  • Cation exchange resin (mild-moderate hyperkalaemia)
  • Dialysis

 

Long-term management of hyperkalaemia

Hyperkalaemia is episodic and may represent a chronic problem for patients with diabetes, hypertension, HF or CKD. Ongoing monitoring and long-term maintenance therapy may be necessary to avoid further risk of recurrent hyperkalaemia.3,4

Historically, there have been number of therapeutic options available, both pharmacological and non-pharmacological. Whilst they are associated with some benefits, treatment options are still limited.

PHARMALOGICAL THERAPIES

Cation exchange resins

  • Cases of intestinal injury have been reported in association with calcium polystyrene sulfonate (CPS) and sodium polystyrene sulfonate (SPS)5-8
  • Lack of clinical data to support use beyond 7 days of treatment9-12
  • Intestinal intolerance has been reported in association with CPS and SPS, including nausea, vomiting, gastric irritation, constipation and diarrhoea5-8

Patiromer

  • Indicated in the treatment of hyperkalaemia, but should not replace emergency treatment for life-threatening hyperkalaemia13

NON-PHARMALOGICAL THERAPIES

Low potassium diet

  • Doesn’t tackle the underlying cause of hyperkalaemia and has limited effectiveness and variable patient compliance14,15

OTHER OPTIONS

Renin-angiotensin-aldosterone system inhibition (RAASi) dose reduction

  • RAASi is beneficial for the preservation of cardio-renal function, and dose reduction is associated with an increased risk of mortality*16,17

*Compared to patients on maximum doses of RAASi

References:

  1. National Kidney Foundation, 2014. Clinical Update on Hyperkalaemia.
  2. Renal Association Clinical Practice Guidelines 2014. Treatment of Acute Hyperkalemia in Adults.
  3. Einhorn LM et al. Arch Intern Med. 2009; 169: 1156-62.
  4. Sarwar CMS et al. J Am Coll Cardiol. 2016; 68: 1575-89.
  5. Sanofi-Aventis. Calcium resonium® Summary of Product Characteristics.
  6. Sanofi-Aventis. Resonium A® Summary of Product Characteristics.
  7. Sanofi-Aventis. Calcium resonium® Prescribing information.
  8. Sanofi-Aventis. Kayexalate® Prescribing information.
  9. Lepage L et al. Clin J Am Soc Nephrol. 2015;10:2136-42.
  10. Nasir K & Ahmad A. J Ayub Coll Abbottabad. 2014; 26:455-8.
  11. Gruy-Kapral C et al. J Am Soc Nephrol. 1998;9:1924-30.
  12. Emmett M et al. Gastroenterol. 1995 Mar;108:752-60.
  13. Vifor Pharma. Veltessa (patiromer) summary of product characteristics.
  14. Packham DK & Kosiborod M. Am J Cardiovasc Drugs. 2016;16:19-31.
  15. Sanghavis S et al. Semin Dial. 2013;26:597-603.
  16. Epstein M et al. Am J Manag Care 2015; 21: S212-S220.
  17. Maggioni AP et al. Eur J Heart Fail. 2013;15:1173-84.

HYPERKALAEMIA AND CO-MORBID CONDITIONS

Summary

Some comorbid conditions increase a patient’s risk of developing hyperkalaemia1-3

In addition to patients with CKD and HF, patients at risk of hyperkalaemia include individuals with resistant hypertension and diabetic nephropathy1-3

Individuals with diabetes have a higher incidence rate of hyperkalaemia*4 

To discover the clinical burden of hyperkalaemia in CKD or HF patients, take a look at the following pages:

*Compared to those without diabetes among adult healthcare users in an observational study.

References:

  1. Renal Association Clinical Practice Guidelines 2014.
  2. Kovesdy, CP. Nat. Rev. Nephrol. 2014; 10: 653–662.
  3. Liamis G et al. World J Clin Cases. 2014;2:488-496.
  4. Nilsson E, et al. ERA-EDTA, Madrid, 2017. Poster presentation SP313.