1 00:00:03,500 --> 00:00:06,800 Welcome to que digo conversations in Nephrology this 2 00:00:06,800 --> 00:00:10,800 episode is titled management of disc elimi has for disclosure 3 00:00:10,800 --> 00:00:13,500 information. Please go to que digo dot org, 4 00:00:13,600 --> 00:00:16,700 slash podcasts. Here's your host dr. 5 00:00:16,700 --> 00:00:21,200 Roberto Papua filho. Hello and welcome to the KT book 6 00:00:21,200 --> 00:00:24,600 conversations and in frolla G I am dr. 7 00:00:24,600 --> 00:00:28,300 Gilberto pakhlava video on a frolla gist and Senior research 8 00:00:28,300 --> 00:00:32,100 scientist at Arbor research. Liability for health, and a 9 00:00:32,108 --> 00:00:35,200 professor of medicine at the pontifical Catholic University 10 00:00:35,200 --> 00:00:39,200 of America, joining me to talk about the management of this 11 00:00:39,200 --> 00:00:42,700 Columbia is dr. Chuck, Herzog, professor of 12 00:00:42,700 --> 00:00:47,000 medicine at the University of Minnesota in a cardiologist, at 13 00:00:47,000 --> 00:00:50,500 the Hennepin Health Care, Chuck. Welcome to the program. 14 00:00:51,200 --> 00:00:54,000 Thanks very much Roberto. I'm very delighted to be here 15 00:00:54,000 --> 00:00:58,300 with you virtually. So check, let's Dive Right In. 16 00:00:58,600 --> 00:01:01,100 Let me ask you a basic. Good question. 17 00:01:01,500 --> 00:01:04,500 What is the definition you use for this Colima? 18 00:01:05,000 --> 00:01:09,000 So it's been arbitrary and it's a partially based on population 19 00:01:09,000 --> 00:01:11,100 sampling. But acute hyperkalemia is 20 00:01:11,100 --> 00:01:15,800 defined and by the que digo group to be greater than 5.0, 21 00:01:15,800 --> 00:01:18,800 millimoles per liter, or above the reference range of the 22 00:01:18,800 --> 00:01:20,800 laboratory. If there is a reference range 23 00:01:20,800 --> 00:01:23,700 available which to me is not terribly helpful as a standalone 24 00:01:23,700 --> 00:01:25,700 threshold. And I'd like to just review the 25 00:01:25,700 --> 00:01:29,000 que digo classification scheme related to hyper Caitlin which I 26 00:01:29,000 --> 00:01:32,200 think is a bit better. Hypokalemia is attractive, less 27 00:01:32,200 --> 00:01:35,700 attention is arbitrarily defined as less than 3.5 million moles 28 00:01:35,700 --> 00:01:39,600 per liter in the que digo, Miami consensus conference, which you 29 00:01:39,600 --> 00:01:43,600 and I both participated in the group came up with a 30 00:01:43,600 --> 00:01:48,700 classification scheme that both reflects plasma levels and the 31 00:01:49,000 --> 00:01:51,500 presence or absence of electrocardiographic changes. 32 00:01:51,500 --> 00:01:57,800 So mild hypokalemia was defined to be 5 to 5 .9, but at the same 33 00:01:57,800 --> 00:02:00,000 levels changed with ECG changes suggested. 34 00:02:00,100 --> 00:02:04,000 Active of hyperkalemia defined to be moderate and consistent 35 00:02:04,000 --> 00:02:06,700 with this. A six to six point four was 36 00:02:06,700 --> 00:02:10,300 defined to be moderate without tcga changes and severe in the 37 00:02:10,300 --> 00:02:13,300 presence of changes, attributed to a hyperkalemia. 38 00:02:13,800 --> 00:02:17,700 And any patient with a value of 6, point 5 or higher acutely, to 39 00:02:17,700 --> 00:02:20,100 be considered to be a severe acute hyperkalemia. 40 00:02:20,400 --> 00:02:23,300 You are an experienced and seasoned clinician and see 41 00:02:23,300 --> 00:02:26,400 patients with hypo and hyperkalemia all the time. 42 00:02:26,400 --> 00:02:27,200 Right? Check. 43 00:02:27,800 --> 00:02:31,700 And I wonder what is the thing? That just see as a biggest 44 00:02:31,700 --> 00:02:35,100 challenge that, in clinical, practice in the management of 45 00:02:35,100 --> 00:02:38,100 this, this Colinas. But do I think the biggest 46 00:02:38,100 --> 00:02:40,400 challenge is being able to Monitor and respond, 47 00:02:40,400 --> 00:02:45,400 appropriately in real time both to hyper and hypokalemia once 48 00:02:45,400 --> 00:02:48,900 available management algorithms, which are embedded in 49 00:02:48,900 --> 00:02:51,100 electronic. Medical records can be helpful 50 00:02:51,300 --> 00:02:54,900 and they should be evaluated by East Institution for the safety 51 00:02:54,900 --> 00:02:58,100 and efficacy for the platform, being used on your own Campus, 52 00:02:58,600 --> 00:03:01,100 of course, many countries do not have Have electronic medical 53 00:03:01,100 --> 00:03:04,700 records, but you can do the same thing without an EMR. 54 00:03:04,800 --> 00:03:07,900 Using, you know, paper orders or even verbal orders. 55 00:03:07,900 --> 00:03:10,500 It's just takes a little longer to implement the carry them out, 56 00:03:10,500 --> 00:03:13,800 but the same algorithmic approach for treatment. 57 00:03:13,800 --> 00:03:16,000 Can be applied across the board, no matter where you are. 58 00:03:16,000 --> 00:03:18,800 It's just a question of what the platform is, and what is the 59 00:03:18,800 --> 00:03:22,900 most important consequence of this episodes of hypo and 60 00:03:22,900 --> 00:03:25,200 hyperkalemia? That you see will ignore the 61 00:03:25,200 --> 00:03:27,600 noncardiac ones. The most important ones are 62 00:03:27,600 --> 00:03:31,100 arrhythmia both hyper and hypokalemia Don't lead to lethal 63 00:03:31,100 --> 00:03:35,100 arithmetic events such as torsade de Pointes degenerating 64 00:03:35,100 --> 00:03:40,200 into ventricular fibrillation, hypokalemia patients and also 65 00:03:40,300 --> 00:03:44,300 asystole in severe. Hypokalemia people with severe 66 00:03:44,300 --> 00:03:47,400 hypokalemia besides having asystole can also develop a 67 00:03:47,400 --> 00:03:50,800 ventricular fibrillation. My personal experience, I would 68 00:03:50,800 --> 00:03:54,000 say in the setting of hypokalemia particularly in the 69 00:03:54,000 --> 00:03:58,600 Intensive Care Unit or an acute illness, I think that it also 70 00:03:58,600 --> 00:04:01,800 contributes to other rhythmic. Events, which are magnified by 71 00:04:01,800 --> 00:04:04,600 the comorbid conditions of whatever going on with the 72 00:04:04,600 --> 00:04:06,900 patient. Particularly one of those 73 00:04:06,900 --> 00:04:10,000 arrhythmias is atrial fibrillation. 74 00:04:10,700 --> 00:04:14,200 So sometimes we see patients who come in with acute illness. 75 00:04:14,200 --> 00:04:17,899 Now, the question comes up is is the arrhythmia related to this 76 00:04:17,899 --> 00:04:20,600 case, atrial fibrillation is related to the low potassium 77 00:04:20,600 --> 00:04:23,200 levels, or is it just a coincidence? 78 00:04:23,200 --> 00:04:28,200 So in this type of setting, The normal range with self defined 79 00:04:28,200 --> 00:04:32,300 as 3.5 or higher 3.5. And actually might be too low 80 00:04:32,900 --> 00:04:35,000 because been electric physiologic standpoint, the 81 00:04:35,000 --> 00:04:38,400 ideals serum potassium. I actually might be closer to 82 00:04:38,400 --> 00:04:42,600 four point five to 50 but this can be very hard to implement 83 00:04:42,600 --> 00:04:45,500 safely because if you think about clinical setting, there 84 00:04:45,508 --> 00:04:48,500 has to be a margin of safety on the upper end to acute 85 00:04:48,500 --> 00:04:52,800 hyperkalemia practice, we sort of aim for a sweet spot and our 86 00:04:52,800 --> 00:04:56,900 own EMR driven algorithms, the Spot is probably in the range of 87 00:04:56,900 --> 00:05:00,300 four point zero two four point three totally arbitrary. 88 00:05:00,300 --> 00:05:02,800 But that seems to be a reasonable place to be because 89 00:05:02,800 --> 00:05:06,800 it gives safety on the high end. I think it is associated with 90 00:05:06,800 --> 00:05:09,800 better results than just shooting for 3.5. 91 00:05:10,300 --> 00:05:13,500 My own experience, is that not unusual to replace people's 92 00:05:13,500 --> 00:05:15,600 potassium levels? It come in with acute atrial 93 00:05:15,600 --> 00:05:17,700 fibrillation in the setting of acute illness. 94 00:05:18,100 --> 00:05:20,600 You correct the potassium and then they go into sinus rhythm. 95 00:05:20,600 --> 00:05:23,900 Now, whether that's causal or coincidental, it's very hard to 96 00:05:23,907 --> 00:05:26,400 determine that, but I have to say this Just an observation 97 00:05:26,400 --> 00:05:29,700 that if I had a choice on where potassium levels going to be in 98 00:05:29,700 --> 00:05:32,800 a hospitalized patient, it's probably going to be a naming a 99 00:05:32,808 --> 00:05:37,900 goal of somewhere in the 4.0 to 4.2 or 4.3 range arbitrary but 100 00:05:38,400 --> 00:05:41,800 pretty much experience based. Well, thanks so much chuck. 101 00:05:41,800 --> 00:05:44,700 I really think that those tips are pretty useful in the daily 102 00:05:44,700 --> 00:05:47,800 management of this patients. We see all the time, Chuck. 103 00:05:47,800 --> 00:05:52,500 You mentioned that being able to Monitor and respond quickly to 104 00:05:52,500 --> 00:05:55,300 disclaimers in real time is a special challenge. 105 00:05:55,400 --> 00:05:59,100 Challenge for us clinicians. It sounds like you had something 106 00:05:59,100 --> 00:06:02,100 minor. Yes, I think you can divide it 107 00:06:02,100 --> 00:06:06,300 into two parts. First is appropriate treatment, 108 00:06:06,700 --> 00:06:09,100 which is probably actually the easier one because there are 109 00:06:09,108 --> 00:06:12,000 good treatment algorithms for acute hyperkalemia, and I would 110 00:06:12,000 --> 00:06:15,400 just refer the audience back to the que digo controversies 111 00:06:15,600 --> 00:06:19,500 conference document, which has a very nice flow diagram, which 112 00:06:19,500 --> 00:06:21,400 summarizes evidence-based therapy is. 113 00:06:21,900 --> 00:06:25,300 So, hypokalemia is actually attracted lesson. 114 00:06:25,500 --> 00:06:28,900 Engine in the literature. And in my own institution, we 115 00:06:28,900 --> 00:06:31,400 have an EMR based treatment algorithm which actually 116 00:06:31,400 --> 00:06:34,800 predates, the electronic medical record and we started with 117 00:06:35,000 --> 00:06:39,000 old-fashioned paper charts. This was a literally, a 118 00:06:39,000 --> 00:06:41,700 five-year project. I spent time working with one of 119 00:06:41,700 --> 00:06:46,600 our Cardiology inpatient, pharmacist and the algorithm 120 00:06:47,200 --> 00:06:51,500 takes into account, both the dose of potassium and the timing 121 00:06:51,500 --> 00:06:55,100 and frequency of monitoring related to real time, serum 122 00:06:55,100 --> 00:06:58,200 potassium. A sium, egfr concomitant 123 00:06:58,200 --> 00:07:02,100 medications, affecting potassium, levels, and type of 124 00:07:02,100 --> 00:07:05,700 IV access or ability to receive oral potassium replacement. 125 00:07:06,200 --> 00:07:09,500 I've also encourage clinicians dealing with patients, who are 126 00:07:10,300 --> 00:07:13,900 thickly those treating patients with acute, be compensated, 127 00:07:13,900 --> 00:07:18,000 heart failure, where there's a fairly large, diuresis and a 128 00:07:18,008 --> 00:07:23,200 concomitant Kelly erases to use the urine output and spot. 129 00:07:23,200 --> 00:07:27,400 You're in potassium as a Of anticipating ongoing, potassium 130 00:07:27,400 --> 00:07:31,100 replacement requirements. So to spot Buren potassium's, 12 131 00:07:31,100 --> 00:07:34,800 hours apart, take the average. And multiply times the 24 hour 132 00:07:34,800 --> 00:07:36,900 urine output. You have sort of a general 133 00:07:36,900 --> 00:07:40,800 reasonable idea of what what the patient lost in that 24 hour to 134 00:07:40,808 --> 00:07:42,800 period of time. And what they might perhaps 135 00:07:42,800 --> 00:07:46,400 would need in the next 24 hours. I do encourage clinicians to 136 00:07:46,400 --> 00:07:51,200 think about this process because I think it's inherently safer to 137 00:07:51,200 --> 00:07:55,300 be doing this in a algorithmic approach rather than to just 138 00:07:55,400 --> 00:07:58,300 Just to do ad. Hoc, you know, or potassium 139 00:07:58,300 --> 00:08:01,500 orders were somebody has a low potassium and they get a, they 140 00:08:01,500 --> 00:08:03,200 just sort of the middle and I get a call and it's okay. 141 00:08:03,200 --> 00:08:06,300 We'll just do the potassium x amount of potassium, and that's 142 00:08:06,300 --> 00:08:09,400 not likely to be as safe or accurate in that proper 143 00:08:09,500 --> 00:08:12,900 procedure. So, each Hospital needs to have 144 00:08:12,900 --> 00:08:16,000 its own approach, and hopefully it's been tested to, to make 145 00:08:16,000 --> 00:08:17,900 sure it works in the individual institution. 146 00:08:18,300 --> 00:08:22,000 Yeah, and I fully agree with you, that the hypokalemia has 147 00:08:22,000 --> 00:08:25,300 not received enough attention, despite being a big big. 148 00:08:25,500 --> 00:08:28,400 Clinical problem. Now, remember this generated 149 00:08:28,400 --> 00:08:32,100 interesting discussions in the Miami meeting during our que 150 00:08:32,100 --> 00:08:35,700 digo controversies meeting on the management of hypokalemia. 151 00:08:36,799 --> 00:08:40,900 And by the way, just reminding our audience that the report of 152 00:08:40,900 --> 00:08:44,600 the meeting is available in a publication that came out on 153 00:08:44,600 --> 00:08:49,000 King International and is free for access at the KD website. 154 00:08:49,500 --> 00:08:52,800 So, for those turning in just now, you're listening to the que 155 00:08:52,800 --> 00:08:57,300 digo conversations in frolla G Today's episode is on management 156 00:08:57,300 --> 00:09:00,500 of disclaimers. I am Hobart to pick waffle you 157 00:09:00,500 --> 00:09:03,500 and here with me, is dr. Chuck Herzog. 158 00:09:03,900 --> 00:09:06,600 Okay, so let's shift to the other side of the spectrum of 159 00:09:06,600 --> 00:09:08,900 the scalia's and talk about hyperkalemia. 160 00:09:09,700 --> 00:09:12,100 What are your thoughts about big challenges in patients 161 00:09:12,100 --> 00:09:14,500 presenting with high potassium levels? 162 00:09:14,800 --> 00:09:16,500 Thank you. That's a good question. 163 00:09:16,700 --> 00:09:18,800 It's also a little more complicated. 164 00:09:19,100 --> 00:09:22,100 I think the most challenging issue is what I would refer to 165 00:09:22,100 --> 00:09:25,300 as the unexpected trajectory of acute hyperkalemia. 166 00:09:25,400 --> 00:09:27,900 Hospitalized patients, James wedmore. 167 00:09:27,900 --> 00:09:31,800 And I recently published a paper in the American Heart journal on 168 00:09:31,800 --> 00:09:35,800 hypokalemia and hyperkalemia. In hospitalized patients at our 169 00:09:35,800 --> 00:09:38,700 own institution, using our electronic medical record. 170 00:09:39,500 --> 00:09:43,900 The paper covered five years of hospitalizations 2012 through 171 00:09:43,900 --> 00:09:50,000 2016 and we actually had at our disposal nearly 100,000 172 00:09:50,000 --> 00:09:54,300 admissions where it's a serum potassium was done and then to 173 00:09:54,300 --> 00:09:58,500 be make this Methods, a little more rigorous we randomly picked 174 00:09:58,500 --> 00:10:01,500 one unique hospitalization, at a patient level, so that we were 175 00:10:01,500 --> 00:10:05,000 not affected by Survivor bias by having people with multiple 176 00:10:05,000 --> 00:10:07,400 potassium levels over different hospitalizations. 177 00:10:07,800 --> 00:10:12,000 So we had a sample of 47,000 unique hospitalizations over 178 00:10:12,000 --> 00:10:15,600 five years, where a potassium value was available randomly 179 00:10:15,600 --> 00:10:17,600 selected from all hospitalizations. 180 00:10:18,400 --> 00:10:23,500 And in this study 1.3 percent of those 47 thousand patients and a 181 00:10:23,500 --> 00:10:28,100 potassium value of at least 60. Fire and a little over 4% had a 182 00:10:28,108 --> 00:10:32,900 potassium value of a below 3.5. So it's not something that's 183 00:10:33,500 --> 00:10:36,100 frequent but it's enough to be of concern. 184 00:10:36,300 --> 00:10:38,900 One of the things about the analysis, which struck me as 185 00:10:38,900 --> 00:10:42,300 being quite important, was that in some of the patients with 186 00:10:42,300 --> 00:10:46,800 hyperkalemia, there was an unusually rapid trajectory and I 187 00:10:46,800 --> 00:10:50,200 would use the analogy of commercial Aviation to think 188 00:10:50,200 --> 00:10:54,000 about this where, if a pilot does not realize how fast a 189 00:10:54,008 --> 00:10:57,500 plane might be descending. Being and responds to late with 190 00:10:57,500 --> 00:11:00,900 dire consequences, like the plane crashes because they 191 00:11:00,900 --> 00:11:02,600 actually didn't know how fast they were following. 192 00:11:02,600 --> 00:11:05,300 The same thing sort of strikes me as being similar with the 193 00:11:05,300 --> 00:11:08,700 acute hyperkalemia example, where it's the clinicians, don't 194 00:11:08,700 --> 00:11:11,300 realize how fast the potassium value is rising. 195 00:11:11,800 --> 00:11:15,800 They will be caught unawares, and with very potentially dire 196 00:11:15,800 --> 00:11:19,600 consequences to the patient, because they didn't have enough 197 00:11:19,600 --> 00:11:22,300 time to respond to the rapidly changing value. 198 00:11:22,300 --> 00:11:25,200 And to start treatment, I would refer the audience. 199 00:11:25,700 --> 00:11:30,400 To the paper to take a look because it's fairly dense, but I 200 00:11:30,400 --> 00:11:33,800 think it's an interesting study because it's very difficult to 201 00:11:33,800 --> 00:11:36,400 construct these type of temporally driven studies 202 00:11:36,400 --> 00:11:39,400 without a good EMR. So let's take a look. 203 00:11:39,400 --> 00:11:42,500 If you have a chance. So the take-home message is 204 00:11:42,600 --> 00:11:47,300 potassium levels can rise faster than you might think is a cute 205 00:11:47,300 --> 00:11:50,200 hypokalemia really only a problem for hospitalized 206 00:11:50,200 --> 00:11:51,400 patients. Chuck? 207 00:11:51,800 --> 00:11:55,600 Well, no, not really, of course not but you know, it It is 208 00:11:55,600 --> 00:11:58,100 presented question. If we actually don't monitor 209 00:11:58,100 --> 00:12:02,500 outpatients closely, then acute or chronic hyperkalemia can 210 00:12:02,500 --> 00:12:05,700 cause out-of-hospital sudden cardiac death and how would we 211 00:12:05,700 --> 00:12:08,200 know that was the reason if we weren't actually monitoring 212 00:12:08,200 --> 00:12:10,000 them. So it's it may be more of a 213 00:12:10,000 --> 00:12:13,200 monitoring issue. There's also a widely held 214 00:12:13,200 --> 00:12:16,300 perception that I think is really unique to the Nephrology 215 00:12:16,300 --> 00:12:19,200 world that chronic hyperkalemia is. 216 00:12:19,200 --> 00:12:23,200 Well, tolerated, including the belief and I say it's a belief, 217 00:12:23,200 --> 00:12:27,400 it's not really based on any Ones that are hyperkalemic, 218 00:12:27,400 --> 00:12:30,100 patient with no ECG changes related. 219 00:12:30,100 --> 00:12:32,800 To hyperkalemia is not a pressing clinical issue. 220 00:12:33,400 --> 00:12:36,500 I try to actually look this up one time before the conference, 221 00:12:37,100 --> 00:12:39,200 and I went back actually 50 years. 222 00:12:39,200 --> 00:12:42,100 But I couldn't find a paper that actually, you know, verify this, 223 00:12:42,100 --> 00:12:46,800 I would say is sort of a perception that really is not 224 00:12:46,900 --> 00:12:49,500 evidence based. So, a couple of practical 225 00:12:49,500 --> 00:12:52,300 issues, we may not actually have ready access to the patient's 226 00:12:52,300 --> 00:12:55,200 Baseline electrocardiogram anyway and left. 227 00:12:55,300 --> 00:12:58,100 Ventricular hypertrophy and other causes of repolarization 228 00:12:58,100 --> 00:13:01,500 abnormality, they confuse the issue of what is actually a 229 00:13:01,500 --> 00:13:03,800 normal electric cardiogram for the individual patient. 230 00:13:03,800 --> 00:13:10,100 Also, a single electrocardiogram is a snapshot in time, and what 231 00:13:10,100 --> 00:13:13,100 happens hours, or even minutes might look different. 232 00:13:13,100 --> 00:13:17,500 So, when we see a patient with a single ECG, and a single web 233 00:13:17,500 --> 00:13:20,700 value, we don't have the ability to see the trajectory of 234 00:13:20,700 --> 00:13:23,800 hyperkalemia prospectively. We don't know what's going to 235 00:13:23,800 --> 00:13:29,600 happen for hours in the Sure. So another issue unique to the 236 00:13:29,600 --> 00:13:34,400 Nephrology world is conventional hemodialysis patients who are 237 00:13:34,400 --> 00:13:36,900 hyperkalemic. Only a certain times 238 00:13:36,900 --> 00:13:40,800 particularly after the long enter dialectic interval on say 239 00:13:40,800 --> 00:13:43,700 Monday morning. If they dialyze Monday, 240 00:13:43,700 --> 00:13:47,800 Wednesday or Friday, or Tuesday morning, if they dialyze 241 00:13:47,800 --> 00:13:51,800 Tuesday, Thursday or Saturday, it's really a type of cyclic 242 00:13:51,800 --> 00:13:54,300 hyperkalemia with a rapid drop occurring. 243 00:13:54,300 --> 00:13:58,800 During the Asus run and the large Delta K which occurs 244 00:13:59,000 --> 00:14:03,000 during the dialysis run is also likely an incubator for certain 245 00:14:03,000 --> 00:14:06,300 type of arrhythmias, particularly paroxysmal atrial 246 00:14:06,300 --> 00:14:09,900 fibrillation. So when the patient develops 247 00:14:09,900 --> 00:14:13,600 hyperkalemia, they may be at risk for other types of revenues 248 00:14:13,600 --> 00:14:17,100 to not just ventricular fibrillation but there's also 249 00:14:17,100 --> 00:14:20,000 the issue of their have a high potassium and then they suddenly 250 00:14:20,000 --> 00:14:23,600 have a low potassium. This topic by the way is now the 251 00:14:23,600 --> 00:14:27,600 subject of a Tseebo controlled randomized, double-blind 252 00:14:27,600 --> 00:14:31,700 prospective trial, in hemodialysis patients with 253 00:14:31,700 --> 00:14:36,200 chronic hyperkalemia. The trial is called dialyze 254 00:14:36,200 --> 00:14:38,600 outcomes. It is just started. 255 00:14:38,600 --> 00:14:42,400 And I would again, if anyone's interested in, go to trials.gov 256 00:14:42,400 --> 00:14:46,200 to check it out. But it's testing the efficacy of 257 00:14:46,200 --> 00:14:48,400 a potassium binder versus placebo. 258 00:14:48,400 --> 00:14:51,000 For reducing cardiovascular events, and hyperkalemic, 259 00:14:51,000 --> 00:14:54,500 hemodialysis patients. Check as it is, a Cardiology you 260 00:14:54,500 --> 00:14:57,300 probably. We do a lot of Echoes In the 261 00:14:57,308 --> 00:14:59,900 evaluation of transplant candidates. 262 00:15:00,100 --> 00:15:04,300 Do you see particular challenges in that group of patients, great 263 00:15:04,300 --> 00:15:07,100 question, Roberto? Because this is something that I 264 00:15:07,100 --> 00:15:09,000 like to rail about. With my colleagues. 265 00:15:09,000 --> 00:15:11,400 They don't like to hear it because, you know, it's like 266 00:15:11,400 --> 00:15:13,000 certain things. It's just go away. 267 00:15:13,100 --> 00:15:16,100 My biggest personal headache with outpatient hyperkalemia 268 00:15:16,500 --> 00:15:19,100 because of my unusual practice is in the setting of cardiac 269 00:15:19,100 --> 00:15:22,700 stress testing in kidney transplant candidates who in the 270 00:15:22,700 --> 00:15:25,200 u.s. either are on dialysis or have a need. 271 00:15:25,300 --> 00:15:28,300 You're far less than 20 to be transplant eligible. 272 00:15:28,900 --> 00:15:31,600 Some of our patients can may come from as far as 300 273 00:15:31,600 --> 00:15:35,400 kilometers away and we may not have recent lab testing for 274 00:15:35,400 --> 00:15:38,400 either electrolytes, including potassium, or even a baseline 275 00:15:38,400 --> 00:15:41,400 electrocardiogram. And I might add that when it 276 00:15:41,400 --> 00:15:44,000 actually comes to the practice of doing stress testing in the 277 00:15:44,000 --> 00:15:48,600 u.s. at least there are no societal guidelines related to 278 00:15:49,100 --> 00:15:52,700 what a potassium value should be for a stress test nor are there 279 00:15:52,700 --> 00:15:54,500 ones for hemoglobin or serum glucose. 280 00:15:54,500 --> 00:15:59,300 It's more do - don't tell. So a not infrequent occurrence 281 00:15:59,300 --> 00:16:04,300 for me is when an outpatient shows up with ECG changes that 282 00:16:04,300 --> 00:16:06,600 are sort of nondescript. Can't really tell what they if 283 00:16:06,600 --> 00:16:09,200 they might be newer old. And we don't have a recent 284 00:16:09,200 --> 00:16:12,300 potassium. So as you can imagine, trying to 285 00:16:12,300 --> 00:16:15,900 figure out, if somebody has a potassium value in the mid 6 286 00:16:15,900 --> 00:16:18,800 range, and this has happened to be on multiple occasions. 287 00:16:18,800 --> 00:16:21,800 It is not good for our workflow to have to deal with a patient 288 00:16:21,800 --> 00:16:26,700 with severe hypokalemia and then try to Manage them in the Echo 289 00:16:26,700 --> 00:16:28,600 lab because that's not what they're there for. 290 00:16:29,100 --> 00:16:32,300 I did actually present one of these cases that ASN kidney week 291 00:16:32,400 --> 00:16:36,900 in 2019. So the topic is not totally 292 00:16:37,700 --> 00:16:39,300 unknown. But I would say it's something 293 00:16:39,300 --> 00:16:41,800 that it's like, it's just another thing that people don't 294 00:16:41,800 --> 00:16:44,900 want to hear about, because it just like it complicates life 295 00:16:44,900 --> 00:16:47,200 and people don't want their lives to be complicated any more 296 00:16:47,200 --> 00:16:50,200 than it has to be. So don't ask don't tell is sort 297 00:16:50,200 --> 00:16:52,000 of been the informal recommendations for this 298 00:16:52,000 --> 00:16:55,600 particular issue but as you can imagine Roberto I I'm never 299 00:16:55,600 --> 00:16:58,600 comfortable with not asking questions and not answering 300 00:16:58,600 --> 00:17:00,400 questions. Now, do you have an opinion 301 00:17:00,400 --> 00:17:04,500 about the use of Ro potassium? Binders in hospitalized patients 302 00:17:04,500 --> 00:17:08,099 and also in those in transition to outpatient care, that's a 303 00:17:08,099 --> 00:17:11,400 real interesting and somewhat. Controversial question. 304 00:17:11,599 --> 00:17:15,900 If you look at the que digo diagram in the, in the 305 00:17:16,000 --> 00:17:20,000 manuscript about the treatment of acute hyperkalemia, there is 306 00:17:20,000 --> 00:17:25,000 a suggestion of consider all potassium binders, and I think 307 00:17:25,300 --> 00:17:28,099 Mitch therapy in hospitalized patients, but we definitely have 308 00:17:28,099 --> 00:17:31,400 used it at our own institution, even example, where it might 309 00:17:31,400 --> 00:17:34,000 help. And then episode occurs at three 310 00:17:34,000 --> 00:17:37,100 in the morning and you're using doing everything else that 311 00:17:37,500 --> 00:17:39,100 works. Including redistribute of 312 00:17:39,100 --> 00:17:42,200 therapies, you still may have a problem where the trajectory of 313 00:17:42,200 --> 00:17:46,200 hyperkalemia puts you into very dangerous territory and you 314 00:17:46,200 --> 00:17:49,200 would like something to slow it down just a little bit if 315 00:17:49,200 --> 00:17:52,100 possible. So you see what, why not? 316 00:17:52,100 --> 00:17:54,700 Just put the patient on a cute. Dialysis, the answer is well 317 00:17:54,700 --> 00:17:56,700 three of them. Morning, sometimes that's not a 318 00:17:56,700 --> 00:17:59,700 five-minute procedure. And a lot of institutions in 319 00:17:59,700 --> 00:18:01,700 Minnesota, we have big snowstorm. 320 00:18:01,700 --> 00:18:05,300 So sometimes the ability even to do a cute, dialysis might be 321 00:18:05,300 --> 00:18:07,900 affected by, you know, the weather, and things like that, 322 00:18:07,900 --> 00:18:11,900 in terms of availability of emergency technical staff. 323 00:18:11,900 --> 00:18:16,600 So the the oral potassium binder might buy you a little time, 324 00:18:16,600 --> 00:18:20,100 it's not going to prevent dialysis, it's not going to make 325 00:18:20,100 --> 00:18:22,800 the person necessarily normal Kaylee make, but it might buy a 326 00:18:22,808 --> 00:18:24,700 little extra time before you get into the lethal. 327 00:18:25,300 --> 00:18:27,700 In your range. There isn't much downside. 328 00:18:27,700 --> 00:18:31,600 So I think it's sort of a niche therapy by the clinicians and 329 00:18:31,600 --> 00:18:35,300 it's usually something you would do really in an acute setting. 330 00:18:35,700 --> 00:18:40,000 And it's not instead of dialysis, dialysis is still the 331 00:18:40,000 --> 00:18:44,200 main therapy for removing potassium from the body and it's 332 00:18:44,200 --> 00:18:46,600 going to be the Mainstay of therapy for a Nephrology 333 00:18:46,600 --> 00:18:50,800 practice, but it might help be a little bit of a buffer to give 334 00:18:50,800 --> 00:18:53,400 the patient a little more time to get to the point where they 335 00:18:53,400 --> 00:18:55,000 can safely and initiating a cute. 336 00:18:55,200 --> 00:18:58,700 Dialysis. And then sometimes the patient 337 00:18:58,700 --> 00:19:02,400 to develops acute hyperkalemia might transition to Chronic 338 00:19:02,400 --> 00:19:03,700 therapy when they leave the hospital. 339 00:19:03,700 --> 00:19:05,800 So if the thought is that they're likely to be at risk for 340 00:19:05,800 --> 00:19:09,300 the episode again, that it makes sense to continue the therapy, 341 00:19:09,700 --> 00:19:12,000 but I think the bottom line is these decisions have to be 342 00:19:12,000 --> 00:19:13,900 individualized at a particular edit. 343 00:19:13,900 --> 00:19:15,400 The edit individual patient level. 344 00:19:15,800 --> 00:19:18,300 I would say, it's not routine, practice to be giving patients 345 00:19:18,300 --> 00:19:20,800 in hospital for to oral potassium, binders. 346 00:19:20,800 --> 00:19:25,500 It's kind of a niche therapy. Well, that's all we have for A 347 00:19:25,900 --> 00:19:29,800 thank you for listening and I hope you enjoyed program and 348 00:19:29,800 --> 00:19:33,100 thank you Chuck for joining me and sharing all those very 349 00:19:33,100 --> 00:19:36,200 valuable insights. It was a true pleasure speaking 350 00:19:36,200 --> 00:19:38,000 with you today. Thanks Roberto. 351 00:19:38,000 --> 00:19:41,700 It's been a pleasure being on this podcast with you and always 352 00:19:41,700 --> 00:19:44,200 good to be working with JD go. I'm dr. 353 00:19:44,200 --> 00:19:47,900 Roberto Cavalli, and to access this and other episodes of the 354 00:19:47,900 --> 00:19:53,000 series visit Katie google.org / podcast, thanks for listening. 355 00:19:53,700 --> 00:19:58,000 This episode was provided by by KD go and supported by V4 356 00:19:58,000 --> 00:19:58,600 Pharma.