Hemodialysis treatment in patients with severe electrolyte disorders: Management of hyperkalemia and hyponatremia

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Abstract

Significant deviations of serum potassium and sodium levels are frequently observed in hospitalized patients and are both associated with increased all‐cause and cardiovascular mortality. The presence of acute or chronic renal failure facilitates the pathogenesis and complicates the clinical management. In the absence of reliable outcome data in the context of dialysis prescription, requirement of renal replacement therapy in patients with severe electrolyte disturbances constitutes a therapeutic challenge. Recommendations for intradialytic management are based on pathophysiologic reasoning and clinical observations only, and as such, heterogeneous and limited to expert opinion level. This article reviews current strategies for the management of severe hyperkalemia and hyponatremia in hemodialysis patients.

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Most cited references 45

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Serum and dialysate potassium concentrations and survival in hemodialysis patients.

Csaba P. Kovesdy, Kamyar Kalantar-Zadeh, Joel D. Kopple … (2007)

Controlling serum potassium is an important goal in maintenance hemodialysis patients. We examined the achievement of potassium balance through hemodialysis treatments and the associated fluctuations in serum potassium. A 3-yr (July 2001 to June 2004) cohort of 81,013 maintenance hemodialysis patients from all DaVita dialysis clinics across the United States were studied. Nine quarterly-averaged serum potassium groups ( or = 6.3 mEq/L and seven increments in-between) and four dialysate potassium concentration groups were created in each of the 12 calendar quarters. The death risk associated with predialysis potassium level and dialysate potassium concentration was examined using unadjusted, case-mix adjusted, and malnutrition-inflammation-adjusted time-dependent survival models. Serum potassium correlated with nutritional markers. Serum potassium between 4.6 and 5.3 mEq/L was associated with the greatest survival, whereas potassium or = 5.6 mEq/L was associated with increased mortality. The death risk of serum potassium > or = 5.6 mEq/L remained consistent after adjustments. Higher dialysate potassium concentration was associated with increased mortality in hyperkalemic patients with predialysis serum potassium > or = 5.0 mEq/L. A predialysis serum potassium of 4.6 to 5.3 mEq/L is associated with the greatest survival in maintenance hemodialysis patients. Hyperkalemic patients who undergo maintenance hemodialysis against lower dialysate bath may have better survival. Limitations of observational studies including confounding by indication should be considered when interpreting these results.

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Cardiac arrest and sudden death in dialysis units.

J Lazarus, C Dubinsky, M Herget … (2001)

For patients with end-stage renal disease and their providers, dialysis unit-based cardiac arrest is the most feared complication of hemodialysis. However, relatively little is known regarding its frequency or epidemiology, or whether a fraction of these events could be prevented. To explore clinical correlates of dialysis unit-based cardiac arrest, 400 reported arrests over a nine-month period from October 1998 through June 1999 were reviewed in detail. Clinical characteristics of patients who suffered cardiac arrest were compared with a nationally representative cohort of> 77,000 hemodialysis patients dialyzed at Fresenius Medical Care North America-affiliated facilities. The cardiac arrest rate was 400 out of 5,744,708, corresponding to a rate of 7 per 100,000 hemodialysis sessions. Cardiac arrest was more frequent during Monday dialysis sessions than on other days of the week. Case patients were nearly twice as likely to have been dialyzed against a 0 or 1.0 mEq/L potassium dialysate on the day of cardiac arrest (17.1 vs. 8.8%). Patients who suffered a cardiac arrest were on average older (66.3 +/- 12.9 vs. 60.2 +/- 15.4 years), more likely to have diabetes (61.8 vs. 46.8%), and more likely to use a catheter for vascular access (34.1 vs. 27.8%) than the general hemodialysis population. Sixteen percent of patients experienced a drop in systolic pressure of 30 mm Hg or more prior to the arrest. Thirty-seven percent of patients who suffered cardiac arrest had been hospitalized within the past 30 days. Sixty percent of patients died within 48 hours of the arrest, including 13% while in the dialysis unit. Cardiac arrest is a relatively infrequent but devastating complication of hemodialysis. To reduce the risk of adverse cardiac events on hemodialysis, the dialysate prescription should be evaluated and modified on an ongoing basis, especially following hospitalization in high-risk patients.

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Dialysate Potassium, Serum Potassium, Mortality, and Arrhythmia Events in Hemodialysis: Results From the Dialysis Outcomes and Practice Patterns Study (DOPPS)

Jarcy Zee, Steven M. Brunelli, Len Usvyat … (2017)

Background Sudden death is a leading cause of death in patients on maintenance hemodialysis (HD). During HD sessions, the gradient between serum and dialysate levels results in rapid electrolytes shifts, which may contribute to arrhythmias and sudden death. Controversies exist on the optimal electrolyte concentration in the dialysate; specifically, it is unclear whether patient outcomes differ among those treated with dialysate potassium (DK) concentration of 3 mEq/L compared to 2 mEq/L. Study Design Prospective cohort study Setting & Participants 55,183 patients from 20 countries in the Dialysis Outcomes and Practice Patterns Study phases 1–5 (1996–2015). Predictor DK at study entry. Outcomes Cox regression was used to estimate the association between DK and both all-cause mortality and an arrhythmia composite outcome (arrhythmia-related hospitalization or sudden death), adjusting for potential confounders. Results During a median follow-up of 16.5 months, 24% of patients died and 7% had an arrhythmia composite outcome. No meaningful difference in clinical outcomes were observed for patients treated with DK 3 vs. 2 mEq/L; the adjusted hazard ratio (95% CI) was 0.96 (0.91, 1.01) for mortality and 0.98 (0.88, 1.08) for the arrhythmia composite. Results were similar across pre-dialysis serum potassium (SK) levels. As in prior studies, higher SK was associated with adverse outcomes. However, DK only had minimal impact on SK measured pre-dialysis (+0.09 mEq/L SK per 1 mEq/L DK; 95% CI: 0.05, 0.14). Limitations Data were not available on delivered (vs. prescribed) DK and post-dialysis SK; possible unmeasured confounding. Conclusions In combination, these results suggest that approaches other than altering DK concentration (e.g., education on dietary K sources, prescription of K-binding medications) may merit further attention to reduce risks associated with high SK.

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Author and article information

Contributors

Markus Pirklbauer:

ORCID: https://orcid.org/0000-0002-1211-0253

markus.pirklbauer@i-med.ac.at

Journal

Journal ID (nlm-ta): Hemodial Int

Journal ID (iso-abbrev): Hemodial Int

Journal ID (doi): 10.1111/(ISSN)1542-4758

Journal ID (publisher-id): HDI

Title: Hemodialysis International. International Symposium on Home Hemodialysis

Publisher: John Wiley & Sons, Inc. (Hoboken, USA )

ISSN (Print): 1492-7535

ISSN (Electronic): 1542-4758

Publication date (Electronic): 20 May 2020

Publication date (Print): July 2020

Volume: 24

Issue: 3 ( doiID: 10.1111/hdi.v24.3 )

Pages: 282-289

Affiliations

[ ¹ ] Department of Internal Medicine IV—Nephrology and Hypertension Medical University Innsbruck Innsbruck Austria

Author notes

[*] [* ]Correspondence to: M. Pirklbauer, MD, PhD, Department of Internal Medicine IV—Nephrology and Hypertension, Medical University Innsbruck, Anichstrasse 35, Innsbruck, Austria. E‐mail: markus.pirklbauer@ 123456i-med.ac.at

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Markus Pirklbauer https://orcid.org/0000-0002-1211-0253

Article

Publisher ID: HDI12845

DOI: 10.1111/hdi.12845

PMC ID: 7496587

PubMed ID: 32436307

SO-VID: d73d20d4-a933-4652-8e22-bfd6b152d3ad

License:

This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

History

Date received : 15 February 2020

Date revision received : 02 May 2020

Date accepted : 05 May 2020

Page count

Figures: 0, Tables: 3, Pages: 8, Words: 5367

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cover-date July 2020

details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:5.9.0 mode:remove_FC converted:11.09.2020

Hemodialysis treatment in patients with severe electrolyte disorders: Management of hyperkalemia and hyponatremia

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Most cited references 45

Serum and dialysate potassium concentrations and survival in hemodialysis patients.

Cardiac arrest and sudden death in dialysis units.

Dialysate Potassium, Serum Potassium, Mortality, and Arrhythmia Events in Hemodialysis: Results From the Dialysis Outcomes and Practice Patterns Study (DOPPS)

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