2) This #accredited #tweetorial series on #kidneydisease #hyperkalemia is supported by an independent educational grant from AstraZeneca and is intended for healthcare providers. Accreditation statement & faculty disclosures are at https://t.co/gvXca4G9Xm.
— cardio-met (@cardiomet_CE) June 21, 2022
4) Consequences of acute, severe #hyperkalemia are well recognized, most notably increasing risk of fatal #arrhythmias, including ventricular fibrillation, #asystole and #cardiac_arrest.
— cardio-met (@cardiomet_CE) June 21, 2022
🔓 https://t.co/YUcIhZaI3I pic.twitter.com/jE2AoCLQUO
6) Hyperkalemia is defined as
— cardio-met (@cardiomet_CE) June 21, 2022
👉Mild ≥5mmol/L
👉Moderate 5.0-6.4mmol/L
👉Severe ≥6.5mmol/L
🔓https://t.co/Xb8jMzaN04 pic.twitter.com/4GpfYCSrWk
8) Which of these medications is/are NOT associated with hyperkalemia?
— cardio-met (@cardiomet_CE) June 21, 2022
a. heparin & beta-blockers
b. spironolactone
c. losartan and Bactrim
d. none of the above
10) Medications at highest risk of hyperK+
— cardio-met (@cardiomet_CE) June 21, 2022
👉#RAASi – #ACEi, #ARB, #ARNI (angiotensin receptor neprilysin inhibitors)
👉Mineralocorticoid receptor antagonists #MRA#NSAIDs
👉Calcineurin inhibitors #CNI
Full list & mechanisms below
🔓https://t.co/gxCv9Sha0k pic.twitter.com/eGb3bxR9k0
12) Mechanisms of #hyperkalemia in #CKD
— cardio-met (@cardiomet_CE) June 21, 2022
👉Reduced #GFR
👉Associated metabolic acidosis
👉Use of disease specific populations that interfere with RAAS axishttps://t.co/pAsv2KXdik pic.twitter.com/wd9seuNZbV
14) Mechanisms of #hyperkalemia in #heartfailure
— cardio-met (@cardiomet_CE) June 21, 2022
👉 Decreased tubular sodium delivery
👉 Use of medications that interfere with #RAAS axis pic.twitter.com/zYePvvDhSW
16) This propensity-matched large observational study from @kireports revealed ⬆️risk of CV events, hospital admissions & #ICU admissions even at mild levels of #hyperkalemia. 🔓https://t.co/UL5FeQyVEW pic.twitter.com/f04bWg3p73
— cardio-met (@cardiomet_CE) June 21, 2022
18) First, among the countless observational studies on #hyperkalemia and #mortality, it is impossible to control for confounders that may impact outcomes i.e., acute cause of hyperkalemia and use of sodium polysteryene sulfonate #SPS with known bowel necrosis/perforation risk.
— cardio-met (@cardiomet_CE) June 21, 2022
20) However, disease states at greatest risk of developing #hyperkalemia also stand to benefit most from #RAASi and #MRAs treatment, which include;
— cardio-met (@cardiomet_CE) June 21, 2022
👉 Albuminuric kidney disease
👉diabetic kidney disease
👉 Heart failure with reduced ejection fraction #HFrEF
22) The below figure demonstrates worsening mortality risk due to #hyperkalemia as stratified by #T2D, #HF, and #CKD. The full combination of all 3⃣ reveals the highest hyperkalemia-associated #mortality risk
— cardio-met (@cardiomet_CE) June 21, 2022
🔓https://t.co/i5ytAJEzUs pic.twitter.com/5a4MgSZ7Vz
24) While you ponder the choice of the red pill vs the blue pill, we’ll take a break. RETURN TOMORROW to continue this program. You’re well on your way to 0.75h 🆓CE/#CME credit!
— cardio-met (@cardiomet_CE) June 21, 2022
26) So yesterday we asked, is the mortality risk attributed to ⬆️K+ due to #hyperkalemia itself OR is it related to the discontinuation of cardio & renoprotective #RAASi and #MRA agents in those which benefit from them most?
— cardio-met (@cardiomet_CE) June 22, 2022
28) The cardioprotective effects of #RAASi and #MRAs are well known in #HFrEF, a mainstay in #GDMT
— cardio-met (@cardiomet_CE) June 22, 2022
🔓https://t.co/RVQHiBBKPi
🔓https://t.co/J8Np1C5ioP pic.twitter.com/9F8xGYlKJT
30) If #RAASi and #MRAs are so ‘protective’, what data exist to support the theory that much of the associated #mortality may be attributable to the discontinuation of said medications? pic.twitter.com/h8mHmU1wn8
— cardio-met (@cardiomet_CE) June 22, 2022
32) Next, we know the percent mortality goes up in #CKD, #HF, #T2D in those for whom #RAASi was discontinued or on submaximal doses.
— cardio-met (@cardiomet_CE) June 22, 2022
🔓 https://t.co/8USxto3Be3 pic.twitter.com/HHtJrQmzz5
34) Among those with #heartfailure and #CKD, there is increased all-cause & cardiovascular mortality & increased risk of dialysis initiation in those for whom #RAASi is discontinued for hyperkalemia https://t.co/3xqf2qpyLq pic.twitter.com/JKU7XY0Sc3
— cardio-met (@cardiomet_CE) June 22, 2022
36) NKF at https://t.co/oytUmoCOjs offers a masterclass that discusses pathogenesis, evaluation and management of #hyperkalemia, designed to guide management and/or prevention hyperkalemia while maintaining our #cardiovascular protective medshttps://t.co/eseM8eHEHD pic.twitter.com/ACJqPLOQrX
— cardio-met (@cardiomet_CE) June 22, 2022
38) Welcome back! It’s Day 3⃣ and Day FINAL of our tour through the world of #hyperkalemia and how it can derail #guidelines-concordant #cardiorenal care. I am @sophia_kidney from @CUAnschutz. This is your ONLY source for #accredited #serialized CE/#CME by #tweetorial!
— cardio-met (@cardiomet_CE) June 23, 2022
40) In acute, life threatening #hyperkalemia with #ECG changes, what do you think is the most appropriate order of management?
— cardio-met (@cardiomet_CE) June 23, 2022
1) IV calcium, insulin & D50
2) Consult nephrology for dialysis and place temporary dialysis catheter
3) give IV loop diuretic
4) Start K+ binder
42) Tweet 40? Best answer is B. First, stabilize the #myocardium with calcium gluconate then insulin with D50 to shift potassium intracellularly. Below, review mechanism, onset & duration summary of hyperkalemia management
— cardio-met (@cardiomet_CE) June 23, 2022
🔓https://t.co/6uox2kCZLW pic.twitter.com/bQAK0F0DE5
44) So, how do we prevent #hyperkalemia while maintaining #GDMT?? Let’s consider a case. pic.twitter.com/l7fTCW9D1X
— cardio-met (@cardiomet_CE) June 23, 2022
46) How will you manage this patient’s potassium and need for increased #RAASi?
— cardio-met (@cardiomet_CE) June 23, 2022
a) Make no changes, potassium is 5.2
b) Start chlorthalidone, recheck potassium, then uptitrate lisinopril
c) Start potassium binder
d) restrict K+ in diet
48) In chronic hyperK+/advanced #CKD (eGFR <30ml/min/1.73m2): dietary counseling, cautious #RAASi initiation & titration, diuretics, sodium bicarb and K+ binders are options
— cardio-met (@cardiomet_CE) June 23, 2022
Goal: Stabilize hyperkalemia, resume/uptitrate RAASi & reassess K+.
🔓https://t.co/QtW6pKVLn8 pic.twitter.com/iZUDra4LCR
50) Similar practices should be extended for the use of steroidal and nonsteroidal MRAs, especially considering the rise of finerenone included in #DKD and #HFrEF #GDMT
— cardio-met (@cardiomet_CE) June 23, 2022
52) The introduction of #diuretics can be an effective measure, preferably loop diuretics or thiazides. The CLICK trial demonstrated that #thiazide diuretics are effective in advanced #CKD.https://t.co/x15vaMaGPN
— cardio-met (@cardiomet_CE) June 23, 2022
54) Sodium polystyrene sulfonate #SPS #kayexalate, approved in 1958, is a cation-exchange resin where sodium & hydrogen ions are exchanged for free potassium ions in large intestine pic.twitter.com/Mbzvd3z1aQ
— cardio-met (@cardiomet_CE) June 23, 2022
56) Sodium zirconium cyclosilicate #SZC is the fastest acting binder (within 1 hour), a crystalline structure, non-systemically absorbed compound. H+ and K+ are exchanged specifically for K+. Works throughout the entire gut (not just colon) pic.twitter.com/PCH1hiTwf7
— cardio-met (@cardiomet_CE) June 23, 2022
58) #SZC in #heartfailure demonstrated reduction in hyperkalemia. This figure also demonstrates the rapid onset of potassium reduction associated with SZC compared to placebo, which makes it the preferred K+ binder in acute, life threatening hyperkalemia pic.twitter.com/ndhReQrxFU
— cardio-met (@cardiomet_CE) June 23, 2022
60) #OPAL-HK, #AMBER and #AMETHYST-DN trials all revealed reduction of #hyperkalemia with patiromer compared with placebo pic.twitter.com/LyCaE16DmZ
— cardio-met (@cardiomet_CE) June 23, 2022
62) These data may support that we should abandon the practice of maximizing #RAASi before starting an #SGLT2i. Rather, an SGLT2i should be started in tandem with low dose or while uptitrating RAASi with the benefit of potentially reducing the risk of #hyperkalemia.
— cardio-met (@cardiomet_CE) June 23, 2022
64) So, let’s come full🔄. The answer to the question in tweet 41 is B. As this patient is still hypertensive & has edema, chlorthalidone is a good option. If K+ remains elevated despite the addition of a diuretic, you can consider one of the newer K+ binders we have discussed.
— cardio-met (@cardiomet_CE) June 23, 2022
66) In conclusion, hyperK+ is associated with increased mortality. However, the discontinuation or reduction of #RAASi and #MRA contributes substantially to this mortality risk. Efforts should be made to maintain RAASi/MRA therapies while maintaining normokalemia. pic.twitter.com/qVphQlFEQG
— cardio-met (@cardiomet_CE) June 23, 2022
67) And that’s it! #Physicians #pharmacists #nurses #nursepractitioners #physicianassociates go claim your 🆓0.75hr CE/#CME at https://t.co/oNeVMvjKX9. I am @sophia_kidney and I encourage you to FOLLOW @cardiomet_ce and @ckd_ce for more outstanding education here on Twitter!
— cardio-met (@cardiomet_CE) June 23, 2022