In the treatment of non-severe hyperkalemia, for patients with CKD, dietary guidance should be carried out by a team of nutritionists to identify and replace foods rich in potassium and improve adherence to the dietary plan. It is worth mentioning that in patients with CKD, the inadequate restriction of vegetable, fruit, and liquid intake can cause or aggravate intestinal constipation, which results in increased intestinal absorption of potassium 6 6.
Nutritional treatment of advanced CKD: twenty consensus statements. Drugs associated with increased serum levels of potassium, such as beta-blockers, mineralocorticoids receptor antagonists, calcineurin, nonsteroidal anti-inflammatories, trimethoprim, and heparin should be adjusted or replaced in the occurrence of this complication 10 Special attention should be taken regarding RAAS inhibitors.
As described above, these classes of drugs have a fundamental role in cardiac-renal protection, and their suspension should take into account the benefits of their use and the unfavorable outcomes that may occur after their suspension or reduction 21 Some patients, after the initial measures, still maintain a high level of potassium. For these, it is indicated to associate pharmacological approaches, such as the use of sodium bicarbonate and the introduction or increase of diuretics.
The sodium bicarbonate dose varies between grams per day and is indicated only in patients with metabolic acidosis. It is worth noting that this measure is poorly tolerated in patients with CKD patients in advanced stages due to the risk of increased blood pressure and fluid retention 23 The prescription of diuretics should be made with caution and strict control to prevent hypovolemia, hypotension, decreased GFR, and, consequently, the recurrence of hyperkalemia 24 Chronic kidney disease, fluid overload and diuretics: a complicated triangle.
In addition, exchange resins can be used calcium polystyrene sulfonate; sodium polystyrene sulfonate; patiromer; sodium zirconium cyclosilicate. Sodium polystyrene sulfonate is a resin that exchanges sodium for potassium, calcium, and ammonia and acts on the distal portion of the colon.
The administration is via oral or rectal route, through laxatives and enemas, respectively. Clinical trials show that this resin is effective in the treatment of mild hyperkalemia in patients with CDK in the early stages. Doses between grams lead to the fall of potassium serum levels by 0. In addition to this delay of the therapeutic effect, the medication has frequent side effects, such as gastrointestinal intolerance, hypocalcemia, and magnesium deficiency.
Also, to a lesser incidence, intestinal necrosis can occur. Thus, the use of this medication in CKD patients is questionable due to its uncertain efficacy, delayed effect, and the restricted use to mild hyperkalemia 25 Kim GH. Pharmacologic treatment of chronic hyperkalemia in patients with chronic kidney disease.
Electrolyte Blood Press. Calcium polystyrene sulfonate is another resin that exchanges calcium for potassium. It also acts in the intestine and is administered via the oral route. The drug information leaflet makes reference to a rectal use by diluting it in sorbitol or methylcellulose. Its main side effect is constipation, but there have also been reported occurrences of hypercalcemia and hypercalciuria 25 Long-term efficacy of oral calcium polystyrene sulfonate for hyperkalemia in CKD patients.
Wang et al. Calcium-polystyrene sulfonate decreases inter-dialytic hyperkalemia in patients undergoing maintenance hemodialysis: a prospective, randomized, crossover study. Ther Apher Dial. Similar to calcium polystyrene sulfonate, patiromer is a resin that acts in the colon, exchanging potassium for calcium.
It is a new medication for the treatment of chronic hyperkalemia in CKD patients, and studies have demonstrated a good response to treatment. Like other ion exchange resins, the main side effect described is constipation. In addition to that, there have also been reports of mild hypomagnesemia 5 5. The patients were stratified into mild and moderate hyperkalemia according to the serum level of potassium at the beginning of the study.
The dose ranged from 4. In the group classified as mild, the reduction of the serum level of potassium ranged between 0. In patients of the moderate group, the reduction was 0. The reduction in both groups was dose-dependent. In this study, they found a rate of 9. The authors cannot say whether this adverse event was secondary to the effect of drugs, an inherent progression of CKD, or due to the increased doses of the RAAS inhibiting drugs used in the treatment group 28 ESC Heart Fail.
All patients used patiromer for four weeks, with doses ranging between 4. After this stage, the patients were divided into two groups, placebo and medication, for 8 more weeks of follow-up. In the patiromer group, there was a reduction in serum levels of potassium and an increased number of patients who were able to continue the use of RAAS inhibitors during the study period.
Patiromer in patients with kidney disease and hyperkalemia receiving RAAS inhibitors. A small study with patients on hemodialysis demonstrated that the use of patiromer decreased serum levels of potassium and phosphorus and increased potassium in the stool. The reported that no adverse effect was observed during the study period 30 Patiromer decreases serum potassium and phosphate levels in patients on hemodialysis.
Am J Nephrol. Sodium zirconium cyclosilicate is a non-absorbable compound of zirconium silicate that acts as a selective exchanger of potassium and sodium for ammonia and hydrogen in the gastrointestinal tract, thus increasing the stool excretion of potassium. The recommended initial dose is 10 grams, three times a day.
Normokalemia is achieved in a period of hours, and it is recommended that the dose is reduced to maintain an optimal serum level of potassium 25 A stage 3 study included patients who had potassium levels between 5. After 48 hours, there was a decrease in the level of potassium in the group that used sodium zirconium cyclosilicate, and the decrease rate was dose-dependent. In the maintenance stage, the potassium level remained within the range of normality in patients from the medication group.
Diarrhea was the most common complication reported by the authors 31 Sodium zirconium cyclosilicate in hyperkalemia. N Eng J Med. Contributing factors include both defects in the host immune response, both due to AKI per se and to underlying morbidity, and as a result of the multiple breaches of muccocutaneous barriers eg, intravascular catheters including dialysis catheters, bladder catheters, endotracheal intubation for mechanical ventilation required for therapeutic management of the seriously ill patient.
Nat Rev Nephrol. A concise review summarizing the relationship between fluid balance and outcomes in patients with acute kidney injury. Kidney Int. Am J Kidney Dis. A retrospective analysis of pediatric data demonstrating increased mortality associated with increasing severity of volume overload in critically ill chrildren with AKI.
A retrospective post hoc analysis demonstrating an increased mortality risk after propensity score adjustment in patients with AKI treated with diuretics. The increased mortality risk, however, appeared to be predominantly in patients unresponsive to diuretic administration. Clin J Am Soc Nephrol. A post hoc analysis of data from the ARDS Network FACTT study demonstrating improved survival in patients with acute lung injury and AKI associated with both negative fluid balance and with diuretic use, with the benefit of diuretics mediated through the effect on volume balance.
Evans, KJ, Greenberg, A. J Intensive Care Med. A review of the etiologies and management of hyperkalemia. Semin Nephrol. A review of electrolyte disturbances associated with acute kidney injury in patients with malignancy-associated AKI.
A review of the current diagnositic criteria and management strategies for prevention and treatment of tumor lysis syndrome. Arch Int Med. A description of the use of the urine uric acid to creatinine ratio to differentiate between hyperurecemia due to acute kidney injury and AKI due to acute urate nephropathy. A description of gastrointenstinal hemorrhage in patients with AKI.
Druml, W. J Ren Nutr. A review of nutritional management in patients with AKI. Crit Care Med. A review of causes and outcomes of AKI in critically ill patients with data on the infectious complications seen in this population.
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Registration is free. Register for free and gain unlimited access to:. Does this patient have complications associated with acute kidney injury? Introduction Acute kidney injury AKI is often associated with systemic complications including volume overload; electrolyte and acid-base disturbances, particularly hyponatremia, hyperkalemia and metabolic acidosis; nutritional and gastrointestinal disturbances; anemia and bleeding diatheses, and increased risk of infection. What tests to perform?
See reviews of specific conditions below for appropriate tests, if any. Jump to Section Does this patient have complications associated with acute kidney injury? Introduction What tests to perform? How should patients with complications associated with AKI be managed?
How to utilize team care? Ask if there is a medicine that could help. Medicines called potassium binders might be able to help you if diet is not enough.
Ask your healthcare team if potassium binders could be an option for you. Educational content made possible by Vifor Pharma and AstraZeneca. Donate Now. Give Monthly Give In Honor. High potassium hyperkalemia. What do you know about high potassium and kidney disease? Take a quick quiz to find out! Take the quiz. Manage your potassium levels with diet and treatment. Explore Kidney Kitchen. Frequently asked questions about hyperkalemia What causes high potassium? The most common cause of high potassium is kidney disease.
Other causes of high potassium include: Dehydration Some medicines Uncontrolled diabetes Injuries that cause severe bleeding Some rare diseases If you have kidney disease, you are at risk for high potassium because your kidneys cannot remove the extra potassium in your blood.
What are the symptoms of high potassium? If you do feel symptoms, some of the most common are: Feeling tired or weak Feeling sick to the stomach nausea Muscle pains or cramps Trouble breathing, unusual heartbeat, chest pains If you have trouble breathing or think there could be a problem with your heart, call for emergency help. What are the complications of high potassium?
If you think you are having a heart attack, call for emergency help. Some of the most common signs of heart attack are: Feelings of pressure, pain, or squeezing in your chest or arms Stomach pain or nausea Shortness of breath Breaking into a cold sweat Sudden feelings of dizziness.
What are the tests for high potassium? What are the treatments for high potassium? Potassium binders Medicines for high potassium are called potassium binders.
Follow these tips to keep your potassium at the right level: Avoid salt substitutes because they are usually high in potassium. Do not forget about drinks. Many fruit juices, like orange and tomato, have high potassium.
Potassium can also be found in other drinks including coconut water. Pay attention to serving sizes. Use measuring cups and measuring spoons to make sure you know how many servings you are eating or drinking. Remember that if you eat two servings of a food with potassium, you are eating twice as much potassium!
To manage your potassium intake, you need to know how much potassium is in your food and drinks. Packaged foods must have nutrition labels, but potassium is not always listed on the label.
If you do not see potassium listed on the nutrition label, check the list of ingredients on the package. Starting in July , potassium values will be listed on food nutrition labels.
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