Welcome to que digo conversations in.
Nephrology this episode is titled approaches to rassi
optimization for disclosure information.
Please go to que digo dot org, slash podcasts.
Here's your host dr. Roberto Pourquoi.
Filho. Hello and welcome to the
cadyville conversations in biology.
I am dr. Roberto Pavilion, senior
research scientist. Just at the arbor research
collaborative. Health professor of medicine at
the pontifical Catholic University of Montana on the
program, with me today to discuss, approaches to the
optimization of raining, and the tensing of those turn system.
In addition is dr. Patrick row.
Single doctor rosie. No is a nephrologist.
Vascular medicine specialist. So certainly the perfect gas for
our topic today. Patrick welcome to the program.
Thank you very much for Berto. Delighted to be here.
That's okay. It looks like as ears go by
therapies that inhibit the renin-angiotensin system or
rassi as I'll refer to this from now on the continue to be
important tools in the management of patients with CKD.
See you in the real world. Listen, struggle to align with
recommendation. What is your approach to rassi
optimization or SEO titration is indeed desirable throughout the
quadrant? The Continuum as universally
emphasized by International guidelines.
This is true in chronic kidney disease patients without without
hypertension as emphasized Again by the latest 221 que digo
guidelines on blood pressure Management in CKD.
For instance, stating that resi s Inhibitors or are bees should
be administered using the highest approved dose.
That is tolerated to achieve the benefits described because the
proven benefits were achieved in Trials using these doses.
This is also true in patients with heart failure on reduced,
ejection fraction. That's confirmed by the latest.
European Cardiology guidelines published in August to 21.
Importantly, CKD must redefine us egfr below 60 million per
minute per 1.73. M2 is a highly prevalent
condition in patients. With acute on chronic heart
failure, approximately one-third recording to a meta-analysis
published some Years Ago by cave in demand in the European.
Aldrin are in 2013 of 57 studies.
Comprising, more than 1 million patients.
In both settings, especially in elderly patients on in patients
with diabetes, hyperkalemia was found the true world or toward
rescue optimization in the art. Fair setting, we on orders?
We plotted that hyperkalemia is one of the main triggers of
received, no news, underdosing on discontinuation.
Thereby leading to deep rib, our patients for this category, no
protective agent. It's on partly mediating, The
observed association between hyperkalemia on two outcomes.
Intel urinal patients, looking at the conversations in the
biology and Cardiology seems like the community has finally
decided to approach the problem or hyperkalemia.
In a more proactive approach, don't you think so?
Yes, indeed. So, let us 221.
Can you go guide lines and blood pressure Management in CKD
stated that I procured in your associate We use of recipe can
often be managed by measures to reduce the serum potassium
levels, rather than decreasing the dose of stopping resi.
On that potassium. Restriction discontinuation of
potassium supplements, certain salt substitutes on
hyperkalemic, drugs, adding potassium, wasting diuretics and
or potassium. Binders in CKD.
Patients receiving receipt, we develop hyperkalemia.
The letter can be controlled with newer or potassium, binders
in many. A patients with the effects that
Pharisee can be continued as a recommended dose.
Furthermore, the latest 2021 is here for your guylines stated
that administration of the catering agents, fetch your
mother or sodium zirconium Sacra silicate, may allow any
uncertainty reduction system inhibitor initiation or up
titration in the literature. Proportion of patients.
That's really interesting. Patrick, so you were an
experienced clinician and you probably treat patients with
these therapies a lot. Not in a daily basis.
Can you provide the nor audience with your approach to monitoring
measures impatient studying and long-term Russell therapies?
Well, it is universally acknowledged that creatinine and
potassium must be adequately. Monitored in cked on or off for
your patience. Why the proper monitoring was
unfortunately reported to be poor after mineral particular
receptor. Antagonist.
Initiation in heart failure, patients both in the US and in
Europe. The latest 221 cadigal
guidelines on blood pressure Management in CKD stated that
changes in blood pressure serum creatinine, turn potassium
should be checked within two to four weeks of initiation or
increasing the dose of resi. C, depending on the current
differ on serum potassium. Furthermore, in patients at risk
for iplock alinea, measuring serum potassium before on at one
to two weeks after initiation, of recipe is recommended.
Patients should also be monitored for symptomatic.
Hypotension. I broke a linear on serum
creatinine within two to four weeks after initiating or
changing the dose of the drug with the time interval depending
on Baseline blood pressure, serum creatinine, some potassium
on, only the shorter time. Interval is indicated, is a
baseline serum creatinine is I or some potassium is already a
normal, or is, there is a history of I Academia or an
acute rise in some creatinine with blood pressure lowering or
raising as far as the easiest federal guidelines concern.
So let us is Jeffrey. Guidelines repeatedly stated
that in advisor on reduce ejection fraction.
Firstly after s Inhibitors are be initiation.
Recheck, blood chemistry. In other words urea be un
creatinine, potassium one to two weeks after initiation on one to
two weeks. After final dose titration,
monitor blood, chemistry for monthly thereafter, The syrup
potassium monitoring is warranted in patients.
Treated with an Metacritic, restore antagonist, check blood
chemistry are torn on for weeks after starting increasing those
on that 8 and 12 weeks 69 on 12 months, four months he's after.
So don't the close protection, monitoring is warranted under
potassium, lowering agents for those just joining us.
This is que digo conversations in virology, I'm dr.
Gilberto topography And I'm speaking with dr.
Patrick real signal on approaches to Rossi
optimization, Patrick, the guidelines are providing a clear
message in terms of the importance of keeping patients
on this life-saving therapies. However, it's not really an easy
task to optimize patients. And this requires a diversity of
strategies different phases of treatment acute, or chronic
hospital or ambulatory. Can you provide some tips on how
to optimize that? Therapies.
Well Roberto it should be emphasized that as yet no
monitoring regime and has been prospectively.
Evaluated in patients initiating a potassium boring agent for the
treatment of I Britannia in editorial.
Bertram. Didn't I published a couple of
years ago? In pharmacological research,
2017 we are ever suggested the following regimen based upon the
experience in initiating. These agents in the pivotal
clinical trials. On our own experience on resi
under etic management, as a basis for discussion on further
prospective evaluation. First serum potassium should be
measured before. Initiation of potassium boring
agent on should be above 50 minimal per liter on a known
immunized, blood sample in patients without
life-threatening, I practically Nia, it will be prudent to
repeat the measurement on to confirm that their own
potassium, is truly above. Five me.
Immortality before initiating, your potassium roaring agent
one, should also measure some magnesium bicarbonate on access
when I'll function with the egfr.
Second after initiating, you put a silver ring.
Agent serum potassium should be measured within 48 to 72 hours
on repeated at one week. If at one rig, the sun
protection remains above five, millimoles per liter
consideration. Should be given to increasing
the dose of the potassium. Boring agent on tour.
Check some potassium? No, l.
And one week later, Once the same potential is below 5
minimal pollinator, it would appear reasonable to based upon
the experience in the pivotal Trials of procurement on a sec
to measure some potassium at one month on then every three to six
months at regular follow-up. Visits.
Importantly, any time that the change in electrolyzed Staters
is suspected such as during an episode of diarrhea.
The or vomiting or after each recipe or directly to change
some potassium and creatinine should be remeasured on the
monitoring sequence. Repeated, I'm sure that there
are different Regional realities and really the, the
fragmentation of care and problems with the communication
between Specialties that take care of the patients is really
difficult. Don't you think why do you think
is Of chemical education is exist, especially between
Cardiology Nephrology emergency medicine.
Why. Roberto in my view is the
workload is certainly a measure or do Lashley along with some
inconsistencies between Nephrology and Cardiology
guidelines. For instance, regarding
thresholds to discontinue, don't die traitor.
SE in the presence of a rational function on or I truck anemia,
and I'm fully agree with that. Patrick Well, any final advice
to clinicians sure. Please don't hesitate to titrate
for a see as much as you can which monitoring creatinine and
potassium closely and be ready to introduce a new petition
binder to enable resi as repeatedly.
Demonstrated whispered. Shermer, for instance, in the on
betrayal, I was involved in the steering committee in patients
with Advanced, chronic kidney disease on resistant
hypertension. A tumor compared to Placebo,
enables a more persistent shoes of the steroidal.
Emery spironolactone, the primary endpoint of this Phase 2
trial. Well, that, take away in mind, I
want to thank my guest, dr. Patrick Rocio for joining me and
discussed the different approaches to Rossi
optimization. Patrick was great having you on
the program, my pleasure rattle, I am Doctor Who bear to people
are feeling to access this and other episodes in the series.
Series please. Visit KD V Dot org slash
podcast. Thanks for listening.
This episode was provided by KD go and supported by V4 Pharma.
Series please. Visit KD V Dot org slash
podcast. Thanks for listening.
This episode was provided by KD go and supported by V4 Pharma.