Severe Hyperkalaemia (>8.0 mmol/L) in the Non-Dialysed Patient

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Severe Hyperkalaemia (gt8.0 mmol/L) in the
Non-Dialysed Patient

• A. Davison, P. S. Williams, K. Mahawish, T. Hine.
  Departments of Clinical Biochemistry and
  Nephrology, Royal Liverpool University Hospital,
  Prescot St, Liverpool.
• Ian Ward Members Papers Meeting
  28th January 2005

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Hyperkalaemia

• Why is it dangerous?
• Cardiac arrest

• What are the signs?
• Paraesthesia
• Muscle weakness
• Natriuresis

http//www.emedu.org/ecg/images/ans/2k_2a.jpg
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Causes of Hyperkalaemia
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N Engl J Med 2004 351 585-592
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Randomised Aldactone Evaluation Study (RALES)

• Doubled blinded randomised study, 1663 patients.
• 822 patients 25mg Spironolactone vs. 841
  patients placebo
• Severe HF and LVEF ?35.
• Primary end point - death in all cases.
• On ACE inhibitor and loop diuretic Digoxin.
• Discontinued prematurely - interim analysis
  showed Spironolactone and significantly
  improve the outcome in patients with severe HF.
• Minimal hyperkalaemia.
• Median gt 0.3 mmol/L
• Severe hyperkalaemia (gt6 mmol/L) 10/667 placebo
  and 14/674 25mg Spironolactone

Am J Cardiol 1996 78902-907 N Engl J Med
1999 341 709-717
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Hyperkalaemia after publication of RALES

• Population based time series analysis.
• 1.3 million adults 66 yrs in Ontario, Canada
  from 1994-2001.
• Spironolactone prescription rate was 34/1000
  (1994) ? 149/1000 (2001).
• Hospitalisation rate for hyperkalaemia rose from
  2.4/1000 (1994) ? 11/1000 (2001) and associated
  mortality increased from 0.2/1000 ? 2/1000.
• Publication of RALES was associated with abrupt
  increases in prescription rate for Spironolactone
  and in hyperkalaemia associated morbidity and
  mortality.

N Engl J Med 2004 351 534-551
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Audit

• Retrospective audit of hyperkalaemia gt8 mmol/L in
  non dialysis dependent patients.
• May 1999 May 2004.
• Data retrieved from patient case notes and
  Telepath database.
• All spurious hyperkalaemia (e.g. K EDTA, IV drip
  contamination etc.) were excluded.

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Audit Results

• 49 Patients, Median age 76yrs (29-99 years)
• Median plasma Potassium 8.4 mmol/L
• (8.0 10.1 mmol/ L)
• Creatinine 365 ?mol/L, (123-2418 ?mol/L)
• Urea 38.25 mmol/L (10.7-112 mmol/L )
• Bicarbonate 14.0 mmol/L (3-26 mmol/L ).

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Audit Results Distribution of Data
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Audit Results

• Biochemistry results were available for 35/49
  patients up to 6 months prior to hyperkalaemia
• Median plasma Potassium 4.5 mmol/L
• (2.8-6.1 mmol/ L)
• Creatinine 127 ?mol/L, (61-1445 ?mol/L)
• Urea 8.8 mmol/L (3.1-36.6 mmol/L )
• Bicarbonate 24 mmol/L (10-33 mmol/L ).

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Audit Results Distribution of Data up to 6
months Before Acute Event
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Significant Past Medical History
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Pharmacological Agents Associated with
Hyperkalaemia
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Out of 28 Patients on Pharmacological Agents
Associated with Hyperkalaemia

• Single agent 15
• Two agents 8
• Three agents 5

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Treatment
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Factors that may have Precipitated Hyperkalaemia

• Sepsis observed in 20 patients.
• e.g. Urinary tract infection, pneumonia
• Hypovolaemia observed in 10 patients.
• e.g. Vomiting, haemorrhage, reduced oral intake

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Outcome

• All 30/49 patients died.
• 20 during acute episode/during hospital admission
  (lt24h)
• 10 later during hospital admission

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Conclusions

• Outcome is extremely poor.
• Many pharmacological agents contribute
  significantly to hyperkalaemia.
• Spironolactone was not a significant contributor
  to hyperkalaemia in patients with CCF
• COX II inhibitors and NSAIDs are a greatly under
• appreciated contributor to hyperkalaemia

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• Very small proportion of patients referred for
  dialysis.
• A combination of deteriorating renal function,
  potassium-sparing drugs and sepsis were
  responsible for the majority of cases of
  hyperkalaemia.
• Plasma U E should be monitored regularly in any
  individual at risk of severe hyperkalaemia.
• Contamination should always be considered to
  minimise inappropriate patient management.