Cardiometabolic Medicine

@cardiomet_CE on Twitter

1) Welcome to our #accredited #tweetorial on optimal mgt of #hyperkalemia in the patient with #CKD. Earn 0.5h #CME/CE credit by following this thread. I am Sourabh Sharma MD DNB FASN 🇮🇳 @iamnephrologist & u have found the ONLY source for CE credit delivered entirely on Twitter!

2) This program is supported by educational grants from AstraZeneca, Bayer, & Chiesi & is intended for #healthcare providers. See faculty disclosures Educational credit for #physicians #physicianassociate #nurses #nursepractitioners #pharmacists 🇺🇸🇨🇦🇪🇺🇬🇧

3) Potassium first isolated by Humphry Davy in 1807 by electrolysis (Coined word from “Potash” [Dutch]). The periodic table symbol K was derived from kali (alkali) [Arabic].
#NephroNotes #NephPearls #FOAMed #MedEd @MedTweetorials #CardioTwitter

4) Re potassium #homeostasis: 98% of the body's K lies in intracellular space➡️ helping determine resting membrane potential & intracellular electronegativity.
10% of K secretion is via the colon (↑significantly in advancing CKD) 🔓 #NephroNotes

5) There is debate abt the definition of hyperK (>5? >5.5?), but it is classified by serum K & ECG. Mortality risk is independent of symptoms, but not ECG findings, as bradycardia/junctional rhythm/QRS widening→Poor outcome.

6) Arrhythmia in Hyperkalemia
Moderate HyperK: Fast Na channel activation; ↑excitability/conduction velocity: Peaked T
Severe HyperK: Fast Na channel inactivation/Inwardly rectifying K channel activation: Wide QRS/Conduction block

7) There are multiple causes of #hyperkalemia:
a. Pseudohyperkalemia
b. Redistribution
c. Excess intake
d. Impaired renal K secretion
In #CKD, relative risk of hyperK approximately doubles for every⬇️in eGFR of 15 mL/min
#NephroNotes #NephPearls #MedEd

8) Because it may be unexpected, we must be especially cautious of drug-induced hyperkalemia
#NephroNotes #NephPearls #FOAMed #MedEd

9) So let's focus on #hyperkalemia in #CKD ➡️adverse outcomes, as it restricts RAASi & MRA usage. #CKD patients have multiple risk factors for hyperkalemia. For those on dialysis, long interdialytic gap ↑hyperkalemia chances
#NephroNotes #NephPearls

10) This table is a nice summary of causes and treatment of hyperkalemia across continuum of kidney function, from 🔓
#NephroNotes #NephPearls #FOAMed #MedEd

11) A low-K diet is generally recommended in advanced #CKD, but @goKDIGO suggests interventional trials to determine optimal recommendations, as there is no direct evidence to link dietary K & serum K, and the benefits of K can’t be ignored

12) Guidelines for use of #RAAS inhibitors are intertwined with K homeostasis. Strive for maximum tolerated RAASi therapy! Treat hyperkalemia & reinitiate RAASi after resolution, then reassess K level within 1 wk

13) Patient education is🔑:
@nkf recommends⬆️patient awareness of hyperK
👉Educational tools
👉Lifestyle change
👉Dietary modification
👉Involve allied healthcare professionals
Hyperkalemia is often asymptomatic; regular K monitoring needed!🔓

14) The National Institute for Health and Care Excellence #NICE offers a systematic Treatment Approach to #hyperkalemia
👉Account for clinical priorities
👉↑patient outcome
👉↓adverse events
#NephroNotes #NephPearls #FOAMed #MedEd

15) So when hyperK happens, how is it treated? Acutely:
👉IV calcium ↓cardiac membrane excitation (1-3 min)
👉Insulin/glucose & β agonist redistribute K to ICS (30-60 min) but not ↓total body K
👉β Agonists: short duration of effect (2-4hrs)
👉Sodium bicarbonate ↑K elimination

16) #Hemodialysis increases total K elimination & is used for resistant acute hyperkalemia
#NephroNotes #NephPearls #FOAMed #MedEd

17) So among acute treatment options, different medications have rapid, intermediate or delayed onset of action
Rapidly & intermediately acting medications are required in acute hyperkalemia management
#NephroNotes #NephPearls #FOAMed #MedEd

18) So let's look at drug administration & safety of different emergency use medications
IV Calcium preparation
👉Calcium Chloride
👉Calcium Gluconate
#NephroNotes #NephPearls

19) Insulin/Glucose Infusion: Consider
👉Drug administration & safety
👉Alternative glucose preparations
#NephroNotes #NephPearls #FOAMed #MedEd

20) #Salbutamol: Drug administration & safety
Effective but more likely to produce side effects
#NephroNotes #NephPearls #FOAMed #MedEd

21) So now let's look at oral potassium binders, which are more useful in chronic mgt & can help facilitate #RAASi optimization. Which of the following binders has the most rapid onset of action after oral administration?

22) Mark your best response & return TOMORROW for the correct answer and the remainder of this program! 👏to @sibgokcay @dr_nikhilshah @kdjhaveri @proychaudhuryMD @divyaa24 @arvindcanchi @priti899 @vjha126 @NephPrasad @Gawad_Nephro @SmeetaSinha @Priyasinghbmc @Joe_Vassalotti

23) Welcome back! I am @iamnephrologist and we're talking about #hyperkalemia in #CKD and what to do about it! You are earning🆓CE/#CME, #physicians #physicianassistants #nursepractitioners #pharmacists #nurses. Shout-outs to @vipvargh @gudnephron @SwastiThinks @docanjuyadav

24) We were about to start talking about the oral K binders. (BTW earn MORE CE/#CME on this topic at Yes, prune juice is a K binder, but it's not quick, and it may make a bigger mess than Na polystyrene sulfonate. So the correct answer was D.

Phil Hartman Ed Mc Mahon Snl GIF

25) So these oral potassium binders are to be considered in chronic #hyperkalemia despite diuretic therapy/corrected metabolic acidosis. They potentially allow continuation/optimization of RAASi/ MRA
#NephroNotes #NephPearls #FOAMed #MedEd

26) So in the K binder🌎, there is old and there is new.
New binders have opened new horizons for treatment & prevention of hyperkalemia
#NephroNotes #NephPearls #FOAMed #MedEd

27) Start w/the old. Sodium/Calcium Polysterene Sulfonate clinical studies:
👉Limited evidence for effectiveness/safety
👉With sorbitol, can cause colonic necrosis
👉Nonselective for K, with affinity for Ca/Mg ions
👉Caution: Na & volume overload

28) And then the new. First, #patiromer sorbitex calcium clinical studies:
👉Efficacy established in randomized, placebo-controlled, phase 2 and 3 trials (CKD/ HF/RAASi)
👉Onset of action~ 7 hours
👉No serious AEs
#NephPearls #FOAMed #MedEd

29) Sodium Zirconium Cyclosilicate (#SZC) clinical studies:
👉Efficacy & safety established in Ph 2 & 3 trials (#CKD/#HF/#DM/#RAASi)
👉assoc'd w/ ↑Bicarbonate
👉High selectivity for K & ammonium ions
👉fast onset, starts in small bowel
👉No serious AEs

30) Summary: Clinical trials of oral potassium binders
#NephroNotes #NephPearls #FOAMed #MedEd

31) Treatment of #Hyperkalemia in #hemodialysis patients:
👉Hyperkalaemia contributes to mortality in HD (3-5% deaths)
👉K ⤴️is most common immediately post 3-day weekend break
👉Adjust dialysate K as per 🔓

32) In summary, the treatment of hyperkalemia is likely to evolve in the coming years with the availability of novel drugs & the development of new strategies to improve safety. Clinical decisions on when to treat & how aggressively to treat require a pt-centered approach …

33) … guided by the clinical setting and rate of change in serum K+ level. Patients with moderate levels of hyperkalemia pose the greatest dilemma, especially when acuity is low, but warrant intervention to avoid deterioration.

34) Severe hyperkalemia risks arrhythmias & cardiac arrest, therefore prompt recognition and intervention is required. How big a problem is it? In-hospital mortality is significantly higher in patients w/ hyperkalaemia (X%) hypokalaemia (Y%) vs normokalaemia (Z%). What are X,Y,Z?

35) Per NICE guidelines, the correct answer is B, more exactly hyperkalemia (18.1%) compared to those with hypokalemia (5.0%) or normokalemia (3.9%). Pts with severe hyperK (> 6.5 mmol/l) are most at risk & in one report (🔓, hospital mortality was 30.7%.

36) And that's it! You made it! Go grab your CE/#CME certificate at I am @iamnephrologist and I hope you'll FOLLOW @cardiomet_CE AND @ckd_ce for more #accredited #tweetorials from expert authors all over the 🌎🌍🌏!

Originally tweeted by cardio-met (@cardiomet_CE) on April 20, 2022.