Did you know what special meaning May 1 has besides International Labor Day?
In 2021, initiated by the American Association of Nephrologists (AAKP), High Potassium Awareness Day was established on May 1, and many promotions were carried out with the theme of "Are U OK+", aiming to involve kidney patients, medical professionals, kidney friends, and the general public to recognize the harm of hyperkalemia and actively intervene, and call on patients to control their blood potassium concentration at 5.1mmol/ for a long time. L or less (potassium target range 3.5 to 5 mmol/L) [1]. Today, this activity is also carried out for the first time in mainland China, so let's start with the origin of hyperkalemia and gain an in-depth understanding of this silent but serious disease.
What should I pay attention to: What is hyperkalemia and what are the harms?
Potassium ion is an ion in the human body, which cannot be seen or touched, but it is one of the electrolytes necessary for the body to maintain normal physiological functions. Potassium ions are directly involved in metabolic activities inside and outside cells, including maintaining cell metabolism, regulating fluid osmotic pressure, maintaining acid-base balance, and maintaining cellular stress function. To put it simply, potassium is inseparable from heart beating, nerve conduction and sensation are inseparable from potassium, potassium is indispensable for maintaining acid-base balance in the blood, and important biochemical reactions such as protein synthesis, carbohydrate metabolism and cellular energy production are also inseparable from potassium.
However, hyperkalemia occurs when potassium concentrations exceed the normal range [1], which is a dangerous condition. Imagine a sudden and large increase in the level of ions responsible for the heart's beating, and the heart is obviously unable to adapt right away, whether it is beating too fast, too slowly, or irregularly, which can have serious consequences, and severe cardiac arrest or ventricular fibrillation can even be fatal. In addition to cardiac symptoms, possible effects of high potassium include neuromuscular symptoms and gastrointestinal symptoms such as nausea, vomiting, and abdominal pain. Potassium is related to nerve conduction in the body, and in the early stage of hyperkalemia, there are often numbness in the limbs and around the mouth, extreme fatigue, muscle aches, and paleness and clammy limbs. When the serum potassium concentration reaches 7 mmol/L, numbness and paralysis of the limbs may occur, first to the trunk and then to the limbs, and finally to affect the respiratory muscles and cause asphyxia. Patients may also experience irritability, confusion, etc. Therefore, hyperkalemia is a harmful disease, but the initial symptoms of the disease are often atypical, so it has a certain degree of insidiousness.
In fact, data from relevant databases in mainland China show that the diagnosis rate of hyperkalemia is 2.53% in the outpatient population, and the prevalence of hyperkalemia in patients with chronic kidney disease (CKD) is as high as 22.89% [2]. An observational retrospective cohort study using the Japanese Hospital Claims Database [3] showed that the prevalence of hyperkalemia in patients with CKD stage 3a, stage 3b, stage 4, and stage 5 was as high as 9.2%, 21.0%, 51.7%, and 66.2%, respectively. In addition to the high morbidity, hyperkalaemia is prone to recurrence, with an analysis of 364955 subjects in a large Swedish healthcare system [4] suggesting a recurrence rate of up to 35.7%.
In summary, hyperkalemia is not uncommon, especially in patients with CKD. Moreover, the disease is not easy to detect and is harmful, so more attention should be paid to it.
Why does hyperkalemia occur?
The causes of hyperkalemia are varied, but for memory purposes, they can be summarized into four main causes [1].
Excessive potassium intake/production
Hyperkalemia is not usually caused by the intake of potassium-rich foods in normal people, and we even encourage hypertensive patients with normal kidney function to consume potassium-rich low-sodium salts to reduce sodium intake and control blood pressure. However, patients with chronic kidney disease (CKD) have a higher risk of hyperkalemia than the general population due to impaired renal function and significantly reduced potassium excretion. Intake of potassium-rich vegetables, fruits, food additives and Chinese patent medicines can lead to the occurrence of hyperkalemia in CKD patients.
Potassium excretion is too low
The kidneys are important organs for the excretion of potassium in the body, and once kidney function declines, potassium excretion may become problematic, leading to hyperkalemia. Patients with cardiovascular disease, especially heart failure, may also have reduced renal blood attention due to heart pumping problems, inducing hyperkalemia.
Drug effects
Hyperkalemia may be caused by a number of commonly used clinical drugs, such as antihypertensive drugs such as angiotensin-converting enzyme inhibitors (ACE inhibitors)/angiotensin-II receptor antagonists (ARBs), potassium-sparing diuretics, nonsteroidal anti-inflammatory drugs, digoxin, cyclosporine A, and tacrolimus, which are more common in patients with CKD. It should be noted that due to the cardiorenal protective effect of some antihypertensive drugs, it is not recommended to discontinue the drug arbitrarily in order to reduce serum potassium.
There is an imbalance in the distribution of potassium
Certain pathological conditions in the human body, such as metabolic acidosis, diabetic hyperosmolar state, etc., may lead to the transfer of potassium ions from inside the cell to the outside of the cell, thus causing hyperkalemia.
How does a multi-pronged approach intervene in hyperkalemia?
Disease interventions are inseparable from risk factor control, lifestyle management, and pharmacological interventions, as well as hyperkalemia, and the following are specific interventions.
Diet management
Reducing potassium intake appears to be a good way to control hyperkalemia, and common foods high in potassium include beans such as soybeans, black beans, and mung beans, dried fruits and nuts such as raisins, peanuts, and dried red dates, dried foods such as dried shiitake mushrooms and enoki cabbage, condiments and pickled products such as soy sauce, vinegar, mustard, and shrimp skin, and vegetables such as red amaranth and spinach (Table 1). In order to control potassium in the blood, it is generally recommended to prohibit special table salts such as low-sodium salts and balanced salts, to use less condiments such as soy sauce, and to soak or blanch vegetables with high potassium content to remove potassium ions before cooking [1]. However, because potassium is present in a variety of foods, it is often difficult for patients to identify, and a low-potassium diet may lead to constipation and an increased risk of cardiovascular disease [1].
Table 1: Table of potassium per 100g of common foods [5]
Correction of precipitating factors
When diagnosing hyperkalemia, the patient should first be evaluated for and corrected for precipitating factors, such as drug use that interferes with renal potassium excretion, inadequate dialysis, and the presence of metabolic acidosis. Drugs that may cause hyperkalemia, such as nonsteroidal anti-inflammatory drugs and traditional Chinese medicine preparations, should be avoided. Renin⁃angiotensin⁃aldosterone system (RAAS) inhibitors are commonly used in patients with CKD and are commonly used to elevate serum potassium in patients. However, it is important to note that since the cardiorenal protective effects of RAAS inhibitors have been recommended by several guidelines, it is recommended to avoid discontinuation or reduction of such drugs with aggressive potassium control in order to ensure maximum survival benefit. For people at high risk of hyperkalemia, the addition of potassium-lowering drugs to the continuation of medication may be considered to avoid the development of severe hyperkalemia.
Pharmacological interventions
Oral medications are also important measures to lower serum potassium, including potassium-excreting diuretics, cation exchange resins, and new oral potassium-lowering drugs. It is important to note that the use of potassium-wasting diuretics requires close monitoring of the patient's weight, blood pressure, and serum creatinine to avoid hypovolemia and decreased glomerular filtration rate. Although cation exchange resins have been shown to be effective in short-term clinical trials, there is a lack of evidence from long-term prospective clinical trials. In recent years, the role of new oral potassium-lowering drugs in lowering and maintaining serum potassium has also been confirmed. Rational selection of drug intervention regimens can help optimize the use of RAAS inhibitors in CKD and enable patients to achieve continuous cardiorenal benefits [1].
summary
The first hyperkalemia day is approaching to allow us to learn more about hyperkalemia and reduce the risk of its occurrence and the consequent risk of adverse events such as malignant arrhythmias through lifestyle management and timely pharmacological intervention. We look forward to more attention to hyperkalemia and a better tomorrow for patients!
Disclaimer: For the information of healthcare professionals only, not to be forwarded or shared by non-healthcare professionals. Not to be used for promotional purposes. This article was written/published with support from AstraZeneca. Approval number: CN-133751, expiration date: 2025-04-18