Kidney disease, chronic hyperkalemia

Potassium-sparing diuretics may cause hyperkalemia, especially in patients with chronic kidney disease or diabetes, and in patients receiving concurrent treatment with an ACE inhibitor, ARB, NSAID, or potassium supplement. Eplerenone has an increased risk for hyperkalemia and is contraindicated in patients with impaired renal function or type 2 diabetes with proteinuria. Spironolactone may cause gynecomastia in up to 10% of patients, but this effect occurs rarely with eplerenone. 

ACE inhibitors decrease aldosterone and can increase serum potassium concentrations. Hyperkalemia occurs primarily in patients with chronic kidney disease or diabetes and in those also taking ARBs, NSAIDs, potassium supplements, or potassium-sparing diuretics. 

ACE inhibitors are well tolerated in most patients but are not absent of side effects. ACE inhibitors decrease aldosterone and can increase potassium serum concentrations. Usually the increase in potassium is small, but hyperkalemia is possible. It is seen primarily in patients with chronic kidney disease or diabetes mellitus and in those on concomitant ARBs, nonsteroidal anti-inflammatory drugs, potassium supplements, or potassium-sparing diuretics. Judicious monitoring of potassium and serum creatinine values within 4 weeks of starting or increasing the dose of an ACE inhibitor often can identify these abnormalities before they evolve into more serious complications. 

Hyperkalemia commonly results in patients with acute or chronic kidney disease. 

Hyperkalemia is much less common than hypokalemia. In facf if all patients with acute and chronic kidney disease were excluded, the true prevalence of hyperkalemia would be insignificant. Indeed, the incidence of hyperkalemia in hospitalized patients has been estimated to be 1.4% to 0% Most cases of hypokalemia are the result of overcorrection of hypokalemia with potassium supplements. Severe hyperkalemia occurs more commonly in elderly patients with renal insufficiency who receive potassium supplementation. ... 

Electrolyte balance Concern about the risk of hyperkalemia associated with ACE inhibitors in patients with chronic kidney disease probably inhibits their use in such patients despite the beneficial effects of ACE inhibitors on progression of chronic kidney disease. In 1094 non-diabetic African-American adults with hypertensive chronic kidney disease, hyperkalemia was associated with increasing age, baseline protein excretion, glomerular filtration rate (GFR), and baseline potassium concentrations. Use of a potassium-wasting diuretic reduced the risk of hyperkalemia [36 ]. 

Johnson ES, Weinstein JR, Thorp ML, Platt RW, Petrik AF, Yang X, Anderson S, Smith DH. Predicting the risk of hyperkalemia in patients with chronic kidney disease starting lisinopril. Pharma-coepidemiol Drug Saf 2010 19 266-72. 

Renal disease Spironolactone is more likely to cause hyperkalemia in patients with chronic renal disease. In a retrospective cohort study, 88 patients (34 patients with chronic kidney disease, GFR bellow 45 ml/ minute) were given spironolactone 12.5-25 mg/day for hypertension [29 ]. There was a non-significant mean increase in the plasma potassium concentration of 0.5 mmol/1 in those with chronic kidney disease compared with 0.3 mmol/1 in those with normal renal function. Three patients with chronic kidney disease changed therapy because of hyperkalemia spironolactone was withdrawn in two patients, but continued in the third because another medication was withdrawn instead. The mean rise in the potassium concentration from baseline in these three patients was 0.9 mmol/1. No patient required hospitalization for hyperkalemia. Multivariate analysis showed that a GFR below 45 ml/minute was a significant predictor of a significant (greater than 0.5 mmol/1) rise in potassium (OR=7.9). 

In an analysis of the Valsartan in Heart Failure Trial (Val-HeFT), focusing on chronic kidney disease, the benefits and harms of dual blockade of the RAAS have been explored [29. Compared with the addition of placebo to ACE inhibition, the addition of valsartan led to higher rates of discontinuation and hyperkalemia in those with chronic kidney disease at baseline. However, the authors argued that the overall benefits of combined therapy would outweigh the risks even in those with chronic kidney disease. 

In an open, randomized, crossover trial in 18 patients with chronic non-diabetic proteinuric kidney disease, double blockade with telmisartan and cilazapril plus hydrochlorothiazide was compared with triple blockade (the addition of spironolactone) [32 ]. Plasma renin activity and proteinuria were reduced, but the risk of hyperkalemia increased. 

The deficiency of potassium develops chronic diseases with malnutrition, gastro intestinal losses and alkalosis. In most of these cases intracellular potassium is transferred to extra cellular fluids which is quickly removed by kidneys. Symptoms of hyperkalemia include muscular weeikness, paralysis and dilation of heart. 

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