Background Sodium and calcium polystyrene sulfonate (SPS/CPS) cation-exchange resins have had long-standing clinical use for hyperkalemia in patients with chronic kidney disease (CKD). However, uncertainty exists regarding the real-world usage of SPS/CPS for acute and chronic management of hyperkalemia. We evaluated the prescription patterns of SPS/CPS and their impact on renin angiotensin aldosterone system inhibitor (RAASi) treatment in patients with CKD Stages G3-G5 after an episode of de novo hyperkalemia. Methods We conducted a retrospective cohort study using population-level administrative databases in Manitoba, Canada, which included adults with CKD and a RAASi prescription who had an episode of de novo hyperkalemia (≥5.5 mmol/L) between January 2007 and December 2017. Results A total of 10,009 individuals were included in our study cohort. Among the study population, 4% received an SPS/CPS prescription within 30 days of their hyperkalemia episode. Of those, 22% received a 1-day supply of SPS/CPS and 7% received a prescription for more than 30 days. There were 8,145 patients using RAASi at baseline who survived 90 days after their first hyperkalemia episode. Of those, 1,447 (18%) discontinued their RAAS inhibitor and 339 (5%) received a prescription of SPS/CPS. Also, the proportion of patients who discontinued their RAASi was similar among those who did and did not receive a prescription of SPS/CPS. Conclusion In patients with CKD receiving RAASi therapy, there is a low frequency of SPS/CPS prescription after an episode of hyperkalemia. RAASi discontinuation or down-titration is the most used pharmacologic approach for the management of hyperkalemia, a strategy which deprives patients of the cardiac and renal protective benefits of RAASI. New options for management of hyperkalemia in this population are needed.
38-year-old man from Manitoba with diabetes and hypertension presented to the emergency department with a 5-month history of a progressively painful right shoulder mass. He also reported 3 weeks of fever, dyspnea, cough, night sweats and weight loss. The patient had mildly increased work of breathing and tachycardia, but was normotensive and normoxemic. He had a tender 15 x 15 cm fluctuant mass overlying the right posterior scapula. Chest radiographs showed a diffuse micronodular pattern and extensive lysis of the right scapula (Appendix 1, available at www.cmaj.ca/lookup /doi/10.1503/cmaj.201177/tab-related -content). Further imaging showed a multifocal, lobulated mass causing invasion and destruction of the right scapula, and diffuse bilateral miliary lesions (Figure 1 and Appendix 1). Our differential diagnosis included tuberculosis, viral pneumonitis, disseminated fungal disease and metastatic malignancy. We also suspected blastomycosis, as the patient frequented an endemic area in Northwestern Ontario (Kenora), where the annual incidence of blastomycosis is 17 cases per 100 000 people. 1 Bronchoalveolar lavage and aspiration of the shoulder mass showed broad-based budding yeast consistent with Blastomyces dermatitidis. We prescribed continuous liposomal amphotericin B infusion and the patient had ultrasound-guided drainage of the shoulder abscess. Two days into treatment, he briefly required bilevel positive airway pressure to treat hypoxemic respiratory failure. After a week, we switched his amphotericin B to oral voriconazole for a total treatment course of 12 months, and he has made a good functional recovery with the ongoing help of physiotherapy. 2 Extrapulmonary manifestations of blastomycosis occur in 25%-40% of patients with pulmonary disease, and most commonly involve the skin and bones. 2,3 Risk factors for respiratory failure requiring mechanical ventilation among these patients include diabetes and diffuse pulmonary disease. 3,4 Our case emphasizes the importance of considering blastomycosis in patients with destructive osteomyelitis of any bone, especially when patients have travelled to regions with endemic blastomycosis.
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