Welcome to que digo conversations in Nephrology this
episode is titled management of disc elimi has for disclosure
information. Please go to que digo dot org,
slash podcasts. Here's your host dr.
Roberto Papua filho. Hello and welcome to the KT book
conversations and in frolla G I am dr.
Gilberto pakhlava video on a frolla gist and Senior research
scientist at Arbor research. Liability for health, and a
professor of medicine at the pontifical Catholic University
of America, joining me to talk about the management of this
Columbia is dr. Chuck, Herzog, professor of
medicine at the University of Minnesota in a cardiologist, at
the Hennepin Health Care, Chuck. Welcome to the program.
Thanks very much Roberto. I'm very delighted to be here
with you virtually. So check, let's Dive Right In.
Let me ask you a basic. Good question.
What is the definition you use for this Colima?
So it's been arbitrary and it's a partially based on population
sampling. But acute hyperkalemia is
defined and by the que digo group to be greater than 5.0,
millimoles per liter, or above the reference range of the
laboratory. If there is a reference range
available which to me is not terribly helpful as a standalone
threshold. And I'd like to just review the
que digo classification scheme related to hyper Caitlin which I
think is a bit better. Hypokalemia is attractive, less
attention is arbitrarily defined as less than 3.5 million moles
per liter in the que digo, Miami consensus conference, which you
and I both participated in the group came up with a
classification scheme that both reflects plasma levels and the
presence or absence of electrocardiographic changes.
So mild hypokalemia was defined to be 5 to 5 .9, but at the same
levels changed with ECG changes suggested.
Active of hyperkalemia defined to be moderate and consistent
with this. A six to six point four was
defined to be moderate without tcga changes and severe in the
presence of changes, attributed to a hyperkalemia.
And any patient with a value of 6, point 5 or higher acutely, to
be considered to be a severe acute hyperkalemia.
You are an experienced and seasoned clinician and see
patients with hypo and hyperkalemia all the time.
Right? Check.
And I wonder what is the thing? That just see as a biggest
challenge that, in clinical, practice in the management of
this, this Colinas. But do I think the biggest
challenge is being able to Monitor and respond,
appropriately in real time both to hyper and hypokalemia once
available management algorithms, which are embedded in
electronic. Medical records can be helpful
and they should be evaluated by East Institution for the safety
and efficacy for the platform, being used on your own Campus,
of course, many countries do not have Have electronic medical
records, but you can do the same thing without an EMR.
Using, you know, paper orders or even verbal orders.
It's just takes a little longer to implement the carry them out,
but the same algorithmic approach for treatment.
Can be applied across the board, no matter where you are.
It's just a question of what the platform is, and what is the
most important consequence of this episodes of hypo and
hyperkalemia? That you see will ignore the
noncardiac ones. The most important ones are
arrhythmia both hyper and hypokalemia Don't lead to lethal
arithmetic events such as torsade de Pointes degenerating
into ventricular fibrillation, hypokalemia patients and also
asystole in severe. Hypokalemia people with severe
hypokalemia besides having asystole can also develop a
ventricular fibrillation. My personal experience, I would
say in the setting of hypokalemia particularly in the
Intensive Care Unit or an acute illness, I think that it also
contributes to other rhythmic. Events, which are magnified by
the comorbid conditions of whatever going on with the
patient. Particularly one of those
arrhythmias is atrial fibrillation.
So sometimes we see patients who come in with acute illness.
Now, the question comes up is is the arrhythmia related to this
case, atrial fibrillation is related to the low potassium
levels, or is it just a coincidence?
So in this type of setting, The normal range with self defined
as 3.5 or higher 3.5. And actually might be too low
because been electric physiologic standpoint, the
ideals serum potassium. I actually might be closer to
four point five to 50 but this can be very hard to implement
safely because if you think about clinical setting, there
has to be a margin of safety on the upper end to acute
hyperkalemia practice, we sort of aim for a sweet spot and our
own EMR driven algorithms, the Spot is probably in the range of
four point zero two four point three totally arbitrary.
But that seems to be a reasonable place to be because
it gives safety on the high end. I think it is associated with
better results than just shooting for 3.5.
My own experience, is that not unusual to replace people's
potassium levels? It come in with acute atrial
fibrillation in the setting of acute illness.
You correct the potassium and then they go into sinus rhythm.
Now, whether that's causal or coincidental, it's very hard to
determine that, but I have to say this Just an observation
that if I had a choice on where potassium levels going to be in
a hospitalized patient, it's probably going to be a naming a
goal of somewhere in the 4.0 to 4.2 or 4.3 range arbitrary but
pretty much experience based. Well, thanks so much chuck.
I really think that those tips are pretty useful in the daily
management of this patients. We see all the time, Chuck.
You mentioned that being able to Monitor and respond quickly to
disclaimers in real time is a special challenge.
Challenge for us clinicians. It sounds like you had something
minor. Yes, I think you can divide it
into two parts. First is appropriate treatment,
which is probably actually the easier one because there are
good treatment algorithms for acute hyperkalemia, and I would
just refer the audience back to the que digo controversies
conference document, which has a very nice flow diagram, which
summarizes evidence-based therapy is.
So, hypokalemia is actually attracted lesson.
Engine in the literature. And in my own institution, we
have an EMR based treatment algorithm which actually
predates, the electronic medical record and we started with
old-fashioned paper charts. This was a literally, a
five-year project. I spent time working with one of
our Cardiology inpatient, pharmacist and the algorithm
takes into account, both the dose of potassium and the timing
and frequency of monitoring related to real time, serum
potassium. A sium, egfr concomitant
medications, affecting potassium, levels, and type of
IV access or ability to receive oral potassium replacement.
I've also encourage clinicians dealing with patients, who are
thickly those treating patients with acute, be compensated,
heart failure, where there's a fairly large, diuresis and a
concomitant Kelly erases to use the urine output and spot.
You're in potassium as a Of anticipating ongoing, potassium
replacement requirements. So to spot Buren potassium's, 12
hours apart, take the average. And multiply times the 24 hour
urine output. You have sort of a general
reasonable idea of what what the patient lost in that 24 hour to
period of time. And what they might perhaps
would need in the next 24 hours. I do encourage clinicians to
think about this process because I think it's inherently safer to
be doing this in a algorithmic approach rather than to just
Just to do ad. Hoc, you know, or potassium
orders were somebody has a low potassium and they get a, they
just sort of the middle and I get a call and it's okay.
We'll just do the potassium x amount of potassium, and that's
not likely to be as safe or accurate in that proper
procedure. So, each Hospital needs to have
its own approach, and hopefully it's been tested to, to make
sure it works in the individual institution.
Yeah, and I fully agree with you, that the hypokalemia has
not received enough attention, despite being a big big.
Clinical problem. Now, remember this generated
interesting discussions in the Miami meeting during our que
digo controversies meeting on the management of hypokalemia.
And by the way, just reminding our audience that the report of
the meeting is available in a publication that came out on
King International and is free for access at the KD website.
So, for those turning in just now, you're listening to the que
digo conversations in frolla G Today's episode is on management
of disclaimers. I am Hobart to pick waffle you
and here with me, is dr. Chuck Herzog.
Okay, so let's shift to the other side of the spectrum of
the scalia's and talk about hyperkalemia.
What are your thoughts about big challenges in patients
presenting with high potassium levels?
Thank you. That's a good question.
It's also a little more complicated.
I think the most challenging issue is what I would refer to
as the unexpected trajectory of acute hyperkalemia.
Hospitalized patients, James wedmore.
And I recently published a paper in the American Heart journal on
hypokalemia and hyperkalemia. In hospitalized patients at our
own institution, using our electronic medical record.
The paper covered five years of hospitalizations 2012 through
2016 and we actually had at our disposal nearly 100,000
admissions where it's a serum potassium was done and then to
be make this Methods, a little more rigorous we randomly picked
one unique hospitalization, at a patient level, so that we were
not affected by Survivor bias by having people with multiple
potassium levels over different hospitalizations.
So we had a sample of 47,000 unique hospitalizations over
five years, where a potassium value was available randomly
selected from all hospitalizations.
And in this study 1.3 percent of those 47 thousand patients and a
potassium value of at least 60. Fire and a little over 4% had a
potassium value of a below 3.5. So it's not something that's
frequent but it's enough to be of concern.
One of the things about the analysis, which struck me as
being quite important, was that in some of the patients with
hyperkalemia, there was an unusually rapid trajectory and I
would use the analogy of commercial Aviation to think
about this where, if a pilot does not realize how fast a
plane might be descending. Being and responds to late with
dire consequences, like the plane crashes because they
actually didn't know how fast they were following.
The same thing sort of strikes me as being similar with the
acute hyperkalemia example, where it's the clinicians, don't
realize how fast the potassium value is rising.
They will be caught unawares, and with very potentially dire
consequences to the patient, because they didn't have enough
time to respond to the rapidly changing value.
And to start treatment, I would refer the audience.
To the paper to take a look because it's fairly dense, but I
think it's an interesting study because it's very difficult to
construct these type of temporally driven studies
without a good EMR. So let's take a look.
If you have a chance. So the take-home message is
potassium levels can rise faster than you might think is a cute
hypokalemia really only a problem for hospitalized
patients. Chuck?
Well, no, not really, of course not but you know, it It is
presented question. If we actually don't monitor
outpatients closely, then acute or chronic hyperkalemia can
cause out-of-hospital sudden cardiac death and how would we
know that was the reason if we weren't actually monitoring
them. So it's it may be more of a
monitoring issue. There's also a widely held
perception that I think is really unique to the Nephrology
world that chronic hyperkalemia is.
Well, tolerated, including the belief and I say it's a belief,
it's not really based on any Ones that are hyperkalemic,
patient with no ECG changes related.
To hyperkalemia is not a pressing clinical issue.
I try to actually look this up one time before the conference,
and I went back actually 50 years.
But I couldn't find a paper that actually, you know, verify this,
I would say is sort of a perception that really is not
evidence based. So, a couple of practical
issues, we may not actually have ready access to the patient's
Baseline electrocardiogram anyway and left.
Ventricular hypertrophy and other causes of repolarization
abnormality, they confuse the issue of what is actually a
normal electric cardiogram for the individual patient.
Also, a single electrocardiogram is a snapshot in time, and what
happens hours, or even minutes might look different.
So, when we see a patient with a single ECG, and a single web
value, we don't have the ability to see the trajectory of
hyperkalemia prospectively. We don't know what's going to
happen for hours in the Sure. So another issue unique to the
Nephrology world is conventional hemodialysis patients who are
hyperkalemic. Only a certain times
particularly after the long enter dialectic interval on say
Monday morning. If they dialyze Monday,
Wednesday or Friday, or Tuesday morning, if they dialyze
Tuesday, Thursday or Saturday, it's really a type of cyclic
hyperkalemia with a rapid drop occurring.
During the Asus run and the large Delta K which occurs
during the dialysis run is also likely an incubator for certain
type of arrhythmias, particularly paroxysmal atrial
fibrillation. So when the patient develops
hyperkalemia, they may be at risk for other types of revenues
to not just ventricular fibrillation but there's also
the issue of their have a high potassium and then they suddenly
have a low potassium. This topic by the way is now the
subject of a Tseebo controlled randomized, double-blind
prospective trial, in hemodialysis patients with
chronic hyperkalemia. The trial is called dialyze
outcomes. It is just started.
And I would again, if anyone's interested in, go to trials.gov
to check it out. But it's testing the efficacy of
a potassium binder versus placebo.
For reducing cardiovascular events, and hyperkalemic,
hemodialysis patients. Check as it is, a Cardiology you
probably. We do a lot of Echoes In the
evaluation of transplant candidates.
Do you see particular challenges in that group of patients, great
question, Roberto? Because this is something that I
like to rail about. With my colleagues.
They don't like to hear it because, you know, it's like
certain things. It's just go away.
My biggest personal headache with outpatient hyperkalemia
because of my unusual practice is in the setting of cardiac
stress testing in kidney transplant candidates who in the
u.s. either are on dialysis or have a need.
You're far less than 20 to be transplant eligible.
Some of our patients can may come from as far as 300
kilometers away and we may not have recent lab testing for
either electrolytes, including potassium, or even a baseline
electrocardiogram. And I might add that when it
actually comes to the practice of doing stress testing in the
u.s. at least there are no societal guidelines related to
what a potassium value should be for a stress test nor are there
ones for hemoglobin or serum glucose.
It's more do - don't tell. So a not infrequent occurrence
for me is when an outpatient shows up with ECG changes that
are sort of nondescript. Can't really tell what they if
they might be newer old. And we don't have a recent
potassium. So as you can imagine, trying to
figure out, if somebody has a potassium value in the mid 6
range, and this has happened to be on multiple occasions.
It is not good for our workflow to have to deal with a patient
with severe hypokalemia and then try to Manage them in the Echo
lab because that's not what they're there for.
I did actually present one of these cases that ASN kidney week
in 2019. So the topic is not totally
unknown. But I would say it's something
that it's like, it's just another thing that people don't
want to hear about, because it just like it complicates life
and people don't want their lives to be complicated any more
than it has to be. So don't ask don't tell is sort
of been the informal recommendations for this
particular issue but as you can imagine Roberto I I'm never
comfortable with not asking questions and not answering
questions. Now, do you have an opinion
about the use of Ro potassium? Binders in hospitalized patients
and also in those in transition to outpatient care, that's a
real interesting and somewhat. Controversial question.
If you look at the que digo diagram in the, in the
manuscript about the treatment of acute hyperkalemia, there is
a suggestion of consider all potassium binders, and I think
Mitch therapy in hospitalized patients, but we definitely have
used it at our own institution, even example, where it might
help. And then episode occurs at three
in the morning and you're using doing everything else that
works. Including redistribute of
therapies, you still may have a problem where the trajectory of
hyperkalemia puts you into very dangerous territory and you
would like something to slow it down just a little bit if
possible. So you see what, why not?
Just put the patient on a cute. Dialysis, the answer is well
three of them. Morning, sometimes that's not a
five-minute procedure. And a lot of institutions in
Minnesota, we have big snowstorm.
So sometimes the ability even to do a cute, dialysis might be
affected by, you know, the weather, and things like that,
in terms of availability of emergency technical staff.
So the the oral potassium binder might buy you a little time,
it's not going to prevent dialysis, it's not going to make
the person necessarily normal Kaylee make, but it might buy a
little extra time before you get into the lethal.
In your range. There isn't much downside.
So I think it's sort of a niche therapy by the clinicians and
it's usually something you would do really in an acute setting.
And it's not instead of dialysis, dialysis is still the
main therapy for removing potassium from the body and it's
going to be the Mainstay of therapy for a Nephrology
practice, but it might help be a little bit of a buffer to give
the patient a little more time to get to the point where they
can safely and initiating a cute.
Dialysis. And then sometimes the patient
to develops acute hyperkalemia might transition to Chronic
therapy when they leave the hospital.
So if the thought is that they're likely to be at risk for
the episode again, that it makes sense to continue the therapy,
but I think the bottom line is these decisions have to be
individualized at a particular edit.
The edit individual patient level.
I would say, it's not routine, practice to be giving patients
in hospital for to oral potassium, binders.
It's kind of a niche therapy. Well, that's all we have for A
thank you for listening and I hope you enjoyed program and
thank you Chuck for joining me and sharing all those very
valuable insights. It was a true pleasure speaking
with you today. Thanks Roberto.
It's been a pleasure being on this podcast with you and always
good to be working with JD go. I'm dr.
Roberto Cavalli, and to access this and other episodes of the
series visit Katie google.org / podcast, thanks for listening.
This episode was provided by by KD go and supported by V4
Pharma.