Patiromer in a Patient with Severe Hyperkalemia on Incremental Hemodialysis with 1 Session per Week: A Case Report and Literature Review

Hyperkalemia is common in patients with ESRD, undergoing hemodialysis (HD), and is associated with an increase in hospitalization and mortality. Residual kidney function in long-term dialysis patients is associated with lower morbidity and mortality in HD patients. Although the 2015 National Kidney Foundation-Kidney Disease Outcomes Quality Initiate (NKD-KDOQI) guidelines allow the reduction in the weekly HD dose for patients with a residual kidney urea clearance (Kur) >3 mL/min/1.73 m<sup>2</sup>, very few centers adjust the dialysis dose based on these criteria. In our center, the pattern of incremental hemodialysis (iHD) with once-a-week schedule (1 HD/W) has been an option for a group of patients showing very good results. This pattern is maintained as long as residual diuresis is >1,000 mL/24 h, Kur is >4 mL/min, and there is no presence of edema or volume overload, as well as no analytical parameters persistently outside the advisable range (serum phosphorus >6 mg/dL or potassium [K<sup>+</sup>] >6.5 mmol/L). Management of hyperkalemia in HD patients includes reduction of dietary intake, dosing of medications that contribute to hyperkalemia, and use of cation-exchange resins such as calcium or sodium polystyrene sulfonate. Two newer potassium binders, patiromer sorbitex calcium and sodium zirconium cyclosilicate, have been safely used for potassium imbalance treatment in patients with ESRD in HD with a conventional regimen of thrice weekly, but has not yet been studied in 1 HD/W schedules. We present the case of a 76-year-old woman in iHD (1 HD/W) treated with patiromer for severe HK and describe her clinical characteristics and outcomes. In addition, we review the corresponding literature. Based on these data, it can be anticipated that the use of patiromer may overcome the risk of hyperkalemia in patients with incident ESRD treated with less-frequent HD regimens.

Download Full-text

Potassium-lowering agents for the treatment of nonemergent hyperkalemia: pharmacology, dosing and comparative efficacy

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfz223 ◽

2019 ◽

Vol 34 (Supplement_3) ◽

pp. iii45-iii50 ◽

Cited By ~ 1

Author(s):

Mary Barna Bridgeman ◽

Milisha Shah ◽

Edward Foote

Keyword(s):

Heart Failure ◽

Elevated Serum ◽

Severe Heart Failure ◽

Sodium Polystyrene Sulfonate ◽

Potential Safety ◽

Urinary Potassium ◽

Patients With Heart Failure ◽

Cation Exchange Resins ◽

Exchange Resins ◽

Sodium Zirconium Cyclosilicate

Abstract Hyperkalemia represents a common and potentially life-threating electrolyte abnormality, a complication frequently observed in patients with heart failure, kidney disease, diabetes or in those receiving drug therapies influencing the renin–angiotensin–aldosterone system. Elevated serum potassium levels are often the result of impaired urinary potassium elimination, inadequate or reduced cellular potassium uptake, severe heart failure, use of medications influencing potassium levels in the circulation, or, more commonly, a combination of these factors. Strategies for the treatment of nonemergent hyperkalemia include the use of cation-exchange resins, polymers or other novel mechanisms of potassium trapping, including sodium polystyrene sulfonate, patiromer and sodium zirconium cyclosilicate. These agents differ in their pharmacology and mechanism of action, clinical efficacy, including onset and extent of potassium-lowering effect, dosage and administration, and potential safety and adverse effect profiles. In this review, an evaluation of these characteristics, including clinical evidence and safety concerns, in the management of nonemergent hyperkalemia will be explored.

Download Full-text

Potassium binders

ESC CardioMed ◽

10.1093/med/9780198784906.003.0042_update_001 ◽

2018 ◽

pp. 218-221

Author(s):

Keld P. Kjeldsen ◽

Juan Tamargo ◽

Thomas A. Schmidt

Keyword(s):

United States ◽

Clinical Pharmacology ◽

Gastrointestinal Tract ◽

The United States ◽

European Medicines Agency ◽

Sodium Polystyrene Sulfonate ◽

United States Food ◽

States Food ◽

Potassium Binders ◽

Sodium Zirconium Cyclosilicate

Potassium binders are used for the treatment of and prophylaxis against hyperkalaemia. Already in 1958, the United States Food and Drug Administration (FDA) approved sodium polystyrene sulfonate, a potassium binder exchanging sodium for potassium in the gastrointestinal tract. In 2015, the FDA approved a new potassium binder, patiromer sorbitex calcium (Veltassa®), exchanging calcium for potassium, and in 2017, it was approved by the European Medicines Agency (EMA). Furthermore, in 2018, the FDA and the EMA approved another new potassium binder, sodium zirconium cyclosilicate (Lokelma®), exchanging sodium for potassium. The clinical pharmacology aspects of potassium binders are reviewed in this chapter.

Download Full-text

Potassium binders

ESC CardioMed ◽

10.1093/med/9780198784906.003.0042 ◽

2018 ◽

pp. 218-221

Author(s):

Keld P. Kjeldsen ◽

Juan Tamargo ◽

Thomas A. Schmidt

Keyword(s):

United States ◽

Clinical Pharmacology ◽

Gastrointestinal Tract ◽

The United States ◽

European Medicines Agency ◽

Sodium Polystyrene Sulfonate ◽

United States Food ◽

States Food ◽

Potassium Binders ◽

Sodium Zirconium Cyclosilicate

Potassium binders are used for the treatment of and prophylaxis against hyperkalaemia. Already in 1958, the United States Food and Drug Administration (FDA) approved sodium polystyrene sulfonate, a potassium binder exchanging sodium for potassium in the gastrointestinal tract. In 2015, the FDA approved a new potassium binder, patiromer sorbitex calcium (Veltassa®), exchanging calcium for potassium, and in 2017, it was approved by the European Medicines Agency (EMA). Furthermore, in January 2018 approval by the FDA of another new potassium binder, sodium zirconium cyclosilicate (ZS-9®), exchanging sodium for potassium, is pending. The clinical pharmacology aspects of potassium binders are reviewed in this chapter.

Download Full-text

Kayexalate-Induced Esophageal Ulceration in a Patient with Decompensated Cirrhosis: A Review of the Literature

Case Reports in Gastrointestinal Medicine ◽

10.1155/2021/8831814 ◽

2021 ◽

Vol 2021 ◽

pp. 1-4

Author(s):

Kishore Kumar ◽

Harish Patel ◽

Muhammad Saad ◽

Ahmed Baiomi ◽

Anil Dev

Keyword(s):

Clinical Medicine ◽

The Body ◽

Decompensated Cirrhosis ◽

Sodium Polystyrene Sulfonate ◽

Esophageal Ulcer ◽

Polystyrene Sulfonate ◽

Colonic Necrosis ◽

Cation Exchange Resins ◽

Gastrointestinal Side Effects ◽

Exchange Resins

Hyperkalemia is one of the most common electrolyte abnormalities encountered in clinical practice. The treatment of hyperkalemia includes removal of excess potassium from the body using cation exchange resins, e.g., sodium polystyrene sulfonate (Kayexalate) is one of the most practiced modalities in clinical medicine. Colonic mucosal necrosis and perforation are the serious gastrointestinal side effects associated with sodium polystyrene sulfonate (SPS) use, which have been reported with or without concomitant use of sorbitol. However, the catastrophic bleeding esophageal ulcer has been rarely described in our literature search. Due to the risk of colonic necrosis, the FDA has issued a warning to avoid concomitant sorbitol use with Kayexalate. We present an individual with acute hematemesis due to bleeding esophageal ulcer immediately after treatment with Kayexalate therapy. Though the exact mechanism by which Kayexalate causes esophageal ulcer to be elucidated, nonetheless it is worthwhile to be vigilant about its potential adverse effects. Our case highlights the rare but certainly the life-threatening complication of Kayexalate therapy.

Download Full-text

Hyperkalemia in patients with chronic renal failure

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfz231 ◽

2019 ◽

Vol 34 (Supplement_3) ◽

pp. iii12-iii18

Author(s):

Stephen L Seliger

Keyword(s):

Sodium Polystyrene Sulfonate ◽

Cardiovascular Morbidity And Mortality ◽

Increased Risk ◽

Binding Agents ◽

All Cause Mortality ◽

Multicenter Clinical Trials ◽

Potassium Binding ◽

Sodium Zirconium Cyclosilicate

Abstract Although hyperkalemia is much more common in patients with chronic kidney disease (CKD), the reported frequency of hyperkalemia varies markedly across studies, primarily due to differences in the ascertainment of hyperkalemia and the severity of CKD. Major risk factors for hyperkalemia among CKD patients include lower estimated glomerular filtration rate (eGFR), use of renin–angiotensin–aldosterone system inhibitors (RAASis), diabetes, older age and male gender. The use of two drugs to inhibit RAAS in diabetic CKD markedly increases the risk of hyperkalemia, as demonstrated in large multicenter clinical trials. Hyperkalemia has consistently been associated with an increased risk of adverse events compared with normokalemia, including all-cause mortality and cardiovascular morbidity and mortality. This risk is not explained by differences in comorbidity or estimated GFR, nor concomitant metabolic abnormalities such as acidosis among those with hyperkalemia. Sodium polystyrene sulfonate has been used commonly for decades to treat hyperkalemia in CKD patients, but without any high-quality clinical data to support its efficacy and with an increased risk of rare but serious colonic complications. The newer oral potassium-binding agents, patiromer and sodium zirconium cyclosilicate, have been shown to be effective and safe for the non-emergent treatment of hyperkalemia in CKD patients, including patients treated with RAASis. Although the long-term use of these medications may permit continuation of RAASis in CKD patients with hyperkalemia, the overall impact of this approach (as compared with down-titration of RAASis and/or up-titration of diuretics) on long-term morbidity, mortality and quality of life remains uncertain.

Download Full-text

Increased colonic K+ excretion through inhibition of the H,K-ATPase type 2 helps reduce plasma K+ level in a murine model of nephronic reduction

Scientific Reports ◽

10.1038/s41598-021-81388-0 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Christine Walter ◽

Chloé Rafael ◽

Anthony Genna ◽

Stéphanie Baron ◽

Gilles Crambert

Keyword(s):

Enzyme Inhibitor ◽

Specific Method ◽

Proof Of Concept ◽

Cation Exchange Resins ◽

Severe Hyperkalemia ◽

Dependent Absorption ◽

Targeted Inhibition ◽

Exchange Resins ◽

End Stage

AbstractHyperkalemia is frequently observed in patients at the end-stage of chronic kidney disease (CKD), and has possible harmful consequences on cardiac function. Many strategies are currently used to manage hyperkalemia, one consisting of increasing fecal K+ excretion through the administration of cation-exchange resins. In this study, we explored another more specific method of increasing intestinal K+ secretion by inhibiting the H,K-ATPase type 2 (HKA2), which is the main colonic K+ reabsorptive pathway. We hypothetised that the absence of this pump could impede the increase of plasma K+ levels following nephronic reduction (N5/6) by favoring fecal K+ secretion. In N5/6 WT and HKA2KO mice under normal K+ intake, the plasma K+ level remained within the normal range, however, a load of K+ induced strong hyperkalemia in N5/6 WT mice (9.1 ± 0.5 mM), which was significantly less pronounced in N5/6 HKA2KO mice (7.9 ± 0.4 mM, p < 0.01). This was correlated to a higher capacity of HKA2KO mice to excrete K+ in their feces. The absence of HKA2 also increased fecal Na+ excretion by inhibiting its colonic ENaC-dependent absorption. We also showed that angiotensin-converting-enzyme inhibitor like enalapril, used to treat hypertension during CKD, induced a less severe hyperkalemia in N5/6 HKA2KO than in N5/6 WT mice. This study therefore provides the proof of concept that the targeted inhibition of HKA2 could be a specific therapeutic maneuver to reduce plasma K+ levels in CKD patients.

Download Full-text

▼Patiromer for the management of hyperkalaemia

Drug and Therapeutics Bulletin ◽

10.1136/dtb.2018.1.0575 ◽

2018 ◽

Vol 56 (1) ◽

pp. 6-9

Keyword(s):

Cation Exchange ◽

Sodium Polystyrene Sulfonate ◽

Potassium Ions ◽

Polystyrene Sulfonate ◽

Efficacy And Safety ◽

High Concentration ◽

Threatening Condition ◽

Cation Exchange Resins ◽

Life Threatening ◽

Exchange Resins

Hyperkalaemia is a potentially life-threatening condition, in which there is an abnormally high concentration of potassium ions in the blood.1,2 Cation-exchange resins (e.g. calcium or sodium polystyrene sulfonate) that bind potassium in the gastrointestinal tract to increase faecal elimination have been used as part of the management of hyperkalaemia but they have some serious adverse effects, including potentially fatal gastrointestinal necrosis.3,4 Patiromer (▼Veltassa – Vifor Fresenius) is a cation-exchange polymer that is licensed for the treatment of hyperkalaemia in adults and, unlike other exchange resins, its licence is not restricted to people with anuria, severe oliguria or those requiring or undergoing dialysis.5,6 Here, we review the evidence for the efficacy and safety of patiromer and consider its place in the management of hyperkalaemia.

Download Full-text