Debunking the myths of acute hyperkalemia treatment
DOI:
https://doi.org/10.32782/2415-8127.2022.66.24Keywords:
hyperkalemia, intensive care, treatment algorithms.Abstract
The article provides an overview of the world data on modern approaches to the treatment of patients with hyperkalemia according to the principles of evidence-based medicine. Hyperkalemia is a common and potentially fatal condition that affects millions of people throughout their lives. Despite the prevalence and severity of this condition, there are no consensus recommendations for the treatment of hyperkalemia. The authors noted that a standard approach would likely improve outcomes. Further complicating the situation is that there is not even a universal definition of hyperkalemia. Historically, approaches to the treatment of acute hyperkalemia have been based on three concepts: «stabilization» of the cardiac depolarization threshold, intracellular displacement of serum potassium, and elimination of total potassium in the body. The urgency of these actions is often determined by ECG findings, as life-threatening dysrhythmias can occur over a wide range of serum potassium concentrations. Because of the difficult nature of prospectively assessing a life-threatening condition, many of these ideas have been entrenched for generations despite a lack of evidence to support them. Objective. To review information sources devoted to modern approaches to the management of patients with acute hyperkalemia, modern diagnostics, modern treatment protocols in order to establish optimal methods of treatment of patients, prevention of complications and early recovery and development of recommendations in Ukrainian. The article provides a brief overview of the most significant errors encountered in emergency care in hyperkalemia, reviews the currently available literature and discusses the practical aspects of several methods of hyperkalemia treatment. Misconceptions and disagreements about its treatment have led to controversial treatment strategies. The article reviews four of the most common myths and provides recommendations based on the interpretation of the available data. At the end of each section, recommendations from open sources are provided to help emergency physicians, internists, nephrologists, and anesthesiologists make safe and effective choices in the treatment of acute hyperkalemia. Conclusion. Hyperkalemia is a common and potentially life-threatening electrolyte disorder. Misconceptions and disagreements about its treatment have led to controversial treatment strategies. This article reviews four of the most common myths and provides recommendations based on the interpretation of the available evidence. We recommend that clinicians continue to evaluate the available evidence and make treatment decisions based on the balance between the potential benefits and harms of each of these interventions.
References
Aggarwal S, Topaloglu H, Kumar SS. Trends in emergency room visits due to hyperkalemia in the United States. Value Health. 2015;18:386.
Mu F, Betts KA, Woolley JM, et al. Prevalence and economic burden of hyperkalemia in the United States medicare population. Curr Med Res Opin. 2020;36:1333–41.
Betts KA, Woolley JM, Mu F, Xiang C, Tang W, Wu EQ. The Cost of Hyperkalemia in the United States. Kidney Int Reports. 2018;3:385–93. 4. Collins AJ, Bertram P, Reaven N, et al. Association of serum potassium with all-cause mortality in patients with and without heart failure, chronic kidney disease, and/or diabetes. Am J Nephrol. 2017;46:213–21.
Peacock WF, Rafique Z, Clark CL, et al. Real world evidence for treatment of hyperkalemia in the emergency department (REVEAL–ED): a multicenter, prospective, observational study. J Emerg Med. 2018;55:741–50.
Rafique Z, Chouihed T, Mebazaa A, Peacock WF. Current treatment and unmet needs of hyperkalemia in the emergency department. Eur Heart J Suppl: J Eur Soc Cardiol. 2019;21:A12–9.
Tintinalli JE, Ma OJ. Tintinalli’s emergency medicine: a comprehensive study guide. Ninth edition. ed. New York: McGraw- Hill; 2020.
Evans BM, Jones NC, Milne MD, Yellowlees H. Ion-exchange resins in the treatment of anuria. Lancet (London, England). 1953:265.
Flinn RB, Merrill JP, Welzant WR. Treatment of the Oliguric Patient with a New Sodium-Exchange Resin and Sorbitol, vol. 264; 1961; 111–5. https://doi.org/10. 1056/NEJM196101192640302.
Scherr L, Ogden DA, Mead AW, Spritz N, Rubin AL. Management of Hyperkalemia with a Cation-Exchange Resin; 1961. https://doi.org/10.1056/NEJM196101192640303.
Junod SW. FDA and Clinical Drug Trials: A Short History. A Quick Guide to Clinical Trials. Washington: Bioplan, Inc; 2008.
Gruy-Kapral C, Emmett M, Ana CA Santa, Porter JL, Fordtran JS, Fine KD. Effect of single dose resin-cathartic therapy on serum potassium concentration in patients with end-stage renal disease. J Am Soc Nephrol: JASN. 1998;9.
Nasir Kiran, Ahmad Aasim. Treatment of hyperkalemia in patients with chronic kidney disease: a comparison of calcium polystyrene sulphonate and sodium polystyrene sulphonate. J Ayub Med Coll Abbottabad: JAMC. 2014;26.
Lepage Laurence, Dufour Anne-Claude, Doiron Jessica, et al. Randomized clinical trial of sodium polystyrene sulfonate for the treatment of mild hyperkalemia in CKD. Clin J Am Soc Nephrol: CJASN. 2015;10.
Nakayama Y, Ueda K, Yamagishi S-i, et al. Compared effects of calcium and sodium polystyrene sulfonate on mineral and bone metabolism and volume overload in pre-dialysis patients with hyperkalemia. Clin Exp Nephrol. 2017;22:35–44.
Wong SWS, Zhang G, Norman P, Welihinda H, Wijeratne DT. polysulfonate resins in hyperkalemia: a systematic review. Can J Kidney Health Dis. 2020;7:1–19.
Mahoney BA, Smith WA, Lo D, Tsoi K, Tonelli M, Clase C. Emergency interventions for hyperkalaemia. Cochrane Database Syst Rev. 2005(2):6–38 Art. No.: CD003235.
Batterink J, Cessford TA, Taylor RA. Pharmacological interventions for the acute management of hyperkalaemia in adults - Batterink, J - 2015|Cochrane Library. Cochrane Database Syst Rev. 2015(10):11–2 Art. No.: CD010344.
Natale Patrizia, Palmer Suetonia C, Ruospo Marinella, Saglimbene Valeria M, Strippoli Giovanni Fm. Potassium binders for chronic hyperkalaemia in people with chronic kidney disease. Cochrane Database Syst Reviews. 2020:6.
Noel J Ariana, Bota Sarah E, Petrcich William, et al. Risk of hospitalization for serious adverse gastrointestinal events associated with sodium polystyrene sulfonate use in patients of advanced age. JAMA Intern Med. 2019;179.
Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: adult basic and advanced life support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142.
Rossignol P, Legrand M, Kosiborod M, et al. Emergency management of severe hyperkalemia: guideline for best practice and opportunities for the future. Pharmacol Res. 2016;113:585–91.
Self WH, Semler MW, Wanderer JP, et al. Balanced crystalloids versus saline in noncritically ill adults. N Engl J Med. 2018;378(9):819–28. https://doi.org/10. 1056/NEJMoa1711586.
Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018;378:829–39.
Farkas J. Myth-busting: Lactated Ringers is safe in hyperkalemia, and is superior to NS. www.emcrit.org2014.
Scheingraber S, Rehm M, Sehmisch C, Finsterer U. Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery. Anesthesiology. 1999;90:1265–70.
Oster JR, Perez GO, Vaamonde CA. Relationship between blood pH and potassium and phosphorus during acute metabolic acidosis. Am J Phys. 1978;235:345–51.
Fisch C, Feigenbaum H, Bowers JA. The effect of potassium on atrioventricular conduction of normal dogs. Am J Cardiol. 1963;11:487–92.
Lanari A, Chait LO, Capurro C, CAPURRO C. Electrocardiographic effects of potassium. I. Perfusion through the coronary bed. Am Heart J. 1964;67:357–63.
Dittrich KL, Walls RM. Hyperkalemia: ECG manifestations and clinical considerations. J Emerg Med. 1986;4:449–55.
Parham WA, Mehdirad AA, Biermann KM, Fredman CS. Hyperkalemia revisited. Tex Heart Inst J. 2006;33:40–7.
Ettinger PO, Regan TJ, Oldewurtel HA. Hyperkalemia, cardiac conduction, and the electrocardiogram: a review. Am Heart J. 1974;88:360–71.
Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. 2000;18:721–9.
Szerlip HM, Weiss J, Singer I. Profound hyperkalemia without electrocardiographic manifestations. Am J Kidney Dis. 1986;7:461–5.
Yu AS. Atypical electrocardiographic changes in severe hyperkalemia. Am J Cardiol. 1996;77:906–8.
Khattak HK, Khalid S, Manzoor K, Stein PK. Recurrent life-threatening hyperkalemia without typical electrocardiographic changes. J Electrocardiol. 2014;47:95–7.
Martinez-Vea A, Bardají A, Garcia C, Oliver JA. Severe hyperkalemia with minimal electrocardiographic manifestations: a report of seven cases. J Electrocardiol. 1999; 32:45–9.
Acker CG, Johnson JP, Palevsky PM, Greenberg A. Hyperkalemia in hospitalized patients: causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines. Arch Intern Med. 1998;158: 917–24.
Fordjour KN, Walton T, Doran JJ. Management of hyperkalemia in hospitalized patients. Am J Med Sci. 2014;347:93–100.
Durfey N, Lehnhof B, Bergeson A, et al. Severe hyperkalemia: can the electrocardiogram risk stratify for short-term adverse events? West J Emerg Med. 2017;18: 963–71.
Merrill JP, Levine HD, Somerville W, Smith S. Clinical recognition and treatment of acute potassium intoxication. Ann Intern Med. 1950;33:797.
Chamberlain MJ, Birm MB. Emergency treatment of hyperkalaemia. Lancet. 1964; 283:464–7.
Heckler FR, McCraw JB. Calcium-related cutaneous necrosis. Surg Forum. 1976;27: 553–5.
Semple P, Booth C. Calcium chloride; a reminder. Anaesthesia. 1996;51:93.
Pacheco Compaña FJ, Midón Míguez J, de Toro Santos FJ. Lesions associated with calcium gluconate extravasation: presentation of 5 clinical cases and analysis of cases published. Ann Plast Surg. 2017;79:444–9.
Alfonzo A, Soar J, MacTier R, et al. Clinical practice guidelines: treatment of acute hyperkalaemia in adults. UK Renal Assoc. 2014;147:59–77.
Alfonzo AV, Isles C, Geddes C, Deighan C. Potassium disorders–clinical spectrum and emergency management. Resuscitation. 2006;70:10–25.
Truhlář A, Deakin CD, Soar J, et al. European resuscitation council guidelines for resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation. 2015;95:148–201.
Martin TJ, Kang Y, Robertson KM, Virji MA, Marquez JM. Ionization and hemodynamic effects of calcium chloride and calcium gluconate in the absence of hepatic function. Anesthesiology. 1990;73:62–
Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 8: advanced challenges in resuscitation: section 1: life-threatening electrolyte abnormalities. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation. 2000;102:I217–22.
