No impact of hyperkalaemia with renin-angiotensin system blockades in maintenance haemodialysis patients

Abstract

Background. Renin-angiotensin system (RAS) blockades, angiotensin converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are well accepted for the cardiorenal-protective benefits added to antihypertensive effects in chronic kidney diseases (CKD), but associated with an increased risk of hyperkalaemia. However, few studies have investigated the effect of RAS blockades on serum potassium in dialysis patients. Methods. Hyperkalaemia associated with RAS blockades by ACEI and/or ARB was evaluated in 69 patients on maintenance haemodialysis, who underwent a three-period crossover study in four groups (no exposure to RAS blockades, ACEI or ARB alone and ACEI plus ARB treatments), lasting one month in each period. Results. Sixty-two patients completed this prospective 3-month study, and no one stopped the study because of the development of hyperkalaemia and/or complications. Mean serum K was similar among the four periods (no exposure, 5.54 AE 0.67 mmol/l; ACEI alone, 5.54 AE 0.75 mmol/l; ARB alone, 5.50 AE 0.66 mmol/l; ACEI þ ARB combination, 5.42 AE 0.66 mmol/l) and was also equal when compared between the two groups with and without exposure to RAS blockades (5.48 AE 0.68 vs 5.54 AE 0.67 mmol/l, P ¼ NS). The incidence of severe hyperkalaemic episodes (>6.0 mmol/l) upon monthly predialysis serum K determination was 25.8% with no exposure to RAS blockades, 29.8% for ACEI alone, 19.6% for ARB alone and 17.7% for ACEI þ ARB combination without statistically significant differences among the four periods (P ¼ NS). Among covariables, the degree of Kt/V, intakes of other medications interfering with potassium homeostasis and diabetes mellitus did not result in any significant hyperkalaemic changes during the 3-month study period except anuric patients compared with non-anuric patients (5.58 AE 0.69 vs 5.19 AE 0.65 mmol/l, P < 0.001). Conclusion. Neither monotherapy (ACEI or ARB) nor combination therapy (ACEI plus ARB) is associated with the additional risk of hyperkalaemia in patients on maintenance haemodialysis. However, those patients with anuria on RAS blockades warrant the cautious monitoring of serum K to prevent hyperkalaemia.

Renin-Angiotensin System Blockade Is Not Associated with Hyperkalemia in Chronic Hemodialysis Patients

“…[4] However, another one published in 2007 found that neither monotherapy (ACEI or ARB) nor combination therapy (ACEI plus ARB) was associated with the risk of hyperkaliemia in chronic HD patients. [5] Our study also demonstrated that RASB (ACE-I or ARB) was not associated with hyperkalemia in chronic HD patients. In our study, we defined hyperkalemia as prehemodialysis serum K ≥ 5.3 meq/L because of blood sampling by two-day interval (on Wednesday or Thursday) but not by three-day interval (on Monday or Tuesday).…”

“…However, few studies have investigated the relationship between renin-angiotensin system blockade (RASB) and hyperkalemia in chronic HD patients, and the results remain controversial. [4,5] In general, many factors, including dietary intake, DM, urine output, stool passage, KT/V, serum HCO 3 − level, and drugs such as RASB, heparin, furosemide, b-blocker, NSAID, and insulin may be related to hyperkalemia in chronic HD patients. [6] To examine the relationship between RASB and hyperkalemia in the present clinical practice for chronic HD patients, we conducted the observational study in 200 chronic HD patients.…”

Pharmacotherapy in Chronic Kidney Disease Patients Presenting With Acute Coronary Syndrome

“…The use of ACE inhibitors or ARBs in patients undergoing chronic dialysis has been associated with an increased risk of hyperkalemia, although study results have been variable. [113][114][115] Most of the large randomized controlled trials evaluating the effectiveness of ACE inhibitors or ARBs in post-MI patients with left ventricular dysfunction have excluded patients with ESRD, with SCr cut offs ranging from 2 to 3.4 mg/dL. Nonetheless, the ability of these agents to prevent ventricular dilation and to significantly improve mortality for patients with compromised cardiac function should not be underestimated.…”

Impact of serum potassium on therapeutic prognosis of maintenance hemodialysis patients on angiotensin receptor antagonists

“…Knoll et al reported that the risk for hyperkalemia in dialysis patients increased 2.1-2.3 times due to the use of RAS inhibitors [16]. In other literature, the relationship between the use of ARB and changes in serum K was not shown in dialysis patients [17,18]. This present study was observational and based on our dialysis database; in addition, patients who were on ARB at the time of registration to the database were assigned to the ARB group.…”