Preventing Hypoglycemia Following Treatment of Hyperkalemia in Hospitalized Patients

Abstract

H yperkalemia is common in hospitalized patients, with an estimated prevalence of 1%-10%. 1,2 Hyperkalemia can lead to life-threatening cardiac arrhythmias. The risk of arrhythmias increases with serum potassium values >6.5 mmol/L, and hyperkalemia is associated with increased in-hospital mortality. 3 Treatment for hyperkalemia is indicated by a combination of the absolute serum potassium level, the rate of change of potassium level, and the presence of electrocardiogram abnormalities.Intravenous insulin stimulates the sodium/potassium-ATP pump, leading to intracellular uptake of potassium. Recommendations vary regarding the optimal dosing of insulin and dextrose for the treatment of hyperkalemia. 4 Hypoglycemia is a common complication following treatment of hyperkalemia with insulin/dextrose. The reported incidence in hospitalized patients ranges from 6% to 75% depending on the population studied, the doses of insulin/ dextrose administered, and the definition of hypoglycemia. [5][6][7][8] Hypoglycemia itself is associated with increased morbidity and mortality in hospitalized patients. 9 The aims of this study were to describe the incidence of hypoglycemia following hyperkalemia treatment with intra-venous insulin/dextrose in inpatients in a large (900-bed) UK teaching hospital and to determine the risk factors predisposing to hypoglycemia.

Decreasing Hypoglycemia following Insulin Administration for Inpatient Hyperkalemia

“…Without standardized blood glucose measurement protocols, retrospective studies have reported posttreatment hypoglycemia rates of 8.7%-17.5% among all patients with hyperkalemia, 5,6 and 13% among patients with end-stage renal disease. 4 These estimates likely underestimate the true hypoglycemia rates as they measure blood glucose sporadically and are often outside the three-hour window of highest risk after insulin administration.…”

The Association of Insulin-dextrose Treatment with Hypoglycemia in Patients with Hyperkalemia

“…Not all previous studies have analyzed body weight but there is evidence supporting this association. Boughton et al reported that patients who experienced hypoglycemia were on average 15 kg lighter than patients who did not have hypoglycemia 3 . Schafer et al noted an ordinal relationship between a lower body weight and the severity of hypoglycemia 4 .…”

“…IDT can be complicated by hypoglycemia, which is associated with increased morbidity and mortality. The estimated incidence of hypoglycemia ranges from 6 to 21% [3][4][5][6] . The variability in estimates is likely due to differences in the population studied, clinical setting, protocol for IDT, and the definition of hypoglycemia used.…”

“…The variability in estimates is likely due to differences in the population studied, clinical setting, protocol for IDT, and the definition of hypoglycemia used. Previously identified risk factors for hypoglycemia have included age, body weight, history of diabetes and pretreatment glucose 3,7 . It was also suggested that acute kidney injury (AKI) and chronic kidney disease (CKD) may be contributing factors as well 4 .…”

In Reference to: “Preventing Hypoglycemia Following Treatment of Hyperkalemia in Hospitalized Patients”

“…

B oughton et al 1 reported a high incidence of hypoglycemia resulting from glucose-with-insulin (GwI) infusion used to treat acute hyperkalemia. This has been reported by other investigators-particularly in subjects without preexisting diabetes 2 and resonates with the experiences of clinicians practicing in Internal Medicine or Diabetes.The authors suggested that patients at risk of hypoglycemia be identified and offered a regimen containing less insulin.

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