Dialysate Potassium, Serum Potassium, Mortality, and Arrhythmia Events in Hemodialysis: Results From the Dialysis Outcomes and Practice Patterns Study (DOPPS)

Abstract

Background Sudden death is a leading cause of death in patients on maintenance hemodialysis (HD). During HD sessions, the gradient between serum and dialysate levels results in rapid electrolytes shifts, which may contribute to arrhythmias and sudden death. Controversies exist on the optimal electrolyte concentration in the dialysate; specifically, it is unclear whether patient outcomes differ among those treated with dialysate potassium (DK) concentration of 3 mEq/L compared to 2 mEq/L. Study Design Prospective cohort study Setting & Participants 55,183 patients from 20 countries in the Dialysis Outcomes and Practice Patterns Study phases 1–5 (1996–2015). Predictor DK at study entry. Outcomes Cox regression was used to estimate the association between DK and both all-cause mortality and an arrhythmia composite outcome (arrhythmia-related hospitalization or sudden death), adjusting for potential confounders. Results During a median follow-up of 16.5 months, 24% of patients died and 7% had an arrhythmia composite outcome. No meaningful difference in clinical outcomes were observed for patients treated with DK 3 vs. 2 mEq/L; the adjusted hazard ratio (95% CI) was 0.96 (0.91, 1.01) for mortality and 0.98 (0.88, 1.08) for the arrhythmia composite. Results were similar across pre-dialysis serum potassium (SK) levels. As in prior studies, higher SK was associated with adverse outcomes. However, DK only had minimal impact on SK measured pre-dialysis (+0.09 mEq/L SK per 1 mEq/L DK; 95% CI: 0.05, 0.14). Limitations Data were not available on delivered (vs. prescribed) DK and post-dialysis SK; possible unmeasured confounding. Conclusions In combination, these results suggest that approaches other than altering DK concentration (e.g., education on dietary K sources, prescription of K-binding medications) may merit further attention to reduce risks associated with high SK.

Use of Renin-Angiotensin System Blockers Increases Serum Potassium in Anuric Hemodialysis Patients

“…As such, their clinical use is very common even in HD patients. However, data concerning the side effect of hyperkalemia in patients on regular HD are still controversial [16]. For this reason, we conducted this observational study with the aim of evaluating the pre HD serum K concentrations after the introduction of an ACEi or an ARB as part of standard antihypertensive therapy in prevalent anuric HD patients.…”

Low dialysate potassium concentration is associated with prolonged recovery time

“…Perhaps more importantly, it was associated with shorter recovery time and lower risk for first hospitalization and mortality. The use of dialysate potassium concentrations <2.0 mEq/L may pose a significant risk for cardiac arrhythmia and sudden death . We are unaware of any previous descriptions of an association of dialysate potassium with prolonged recovery time.…”

The Effect of Nutrition Education Program on Biochemical Parameters Among Patients With Chronic Kidney Disease Undergoing Hemodialysis

“…This disorder leads to complications in heart rhythm and finally heart failure. Therefore, it is well known as a risk factor for sudden death and mortality of patients under hemodialysis, and any education on adherence to low potassium level can be effective in decreasing this risk (19). Also, sodium, as one of the important extracellular fluid components, has a crucial role in creating serum osmolality.…”