Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Hypokalemia and hyperkalemia in patients on peritoneal dialysis: incidence and associated factors

  • 57 Accesses

Abstract

Background

Hypokalemia is a well-described electrolyte disturbance in patients on peritoneal dialysis (PD). Hyperkalemia, however, is still overlooked, although it also represents a risk factor for mortality. Angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers (ACE/ARB), diuretics, and proton pump inhibitor (PPI) can interfere with potassium levels in these patients.

Methods

This is a retrospective study that evaluated monthly serum potassium in a 5-year period. Serum potassium disturbances were evaluated as time-average and number of hypo- and hyperkalemia episodes per patient. Prescribed medication such as ACE/ARB, diuretics, and omeprazole were recorded.

Results

We evaluated 2025 potassium measurements obtained from 146 patients on PD. Serum potassium ranged from 2.5 to 8.3 mEq/L with an average of 4.72 ± 0.74 mEq/L. Hypokalemia was found in 59 measurements (2.9%) obtained from 35 patients (23.9%) whereas hyperkalemia was demonstrated in 269 (13.3%) measurements obtained from 74 patients (50.7%). Hypokalemia was associated with low albumin (p = 0.022), and omeprazole use (p = 0.024). Black race was a protector factor (p = 0.031). Omeprazole-associated hypokalemia was seen only in non-anuric patients and remained an independent risk factor even after adjustments. Patients who had hyperkalemia were more likely to be anuric (p = 0.001) and in use of furosemide (p = 0.0001).

Conclusion

Hyperkalemia and hypokalemia are very frequent in patients on PD and should be closely monitored. Interventional studies should address the impact of discontinuing omeprazole in the levels of potassium.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2

References

  1. 1.

    Ribeiro SC, Figueiredo AE, Barretti P, Pecoits-Filho R, de Moraes TP, All centers that contributed to BIIs (2015) Low serum potassium levels increase the infectious-caused mortality in peritoneal dialysis patients: a propensity-matched score study. PLoS ONE 10(6):e0127453. https://doi.org/10.1371/journal.pone.0127453

  2. 2.

    Xu Q, Xu F, Fan L, Xiong L, Li H, Cao S, Lin X, Zheng Z, Yu X, Mao H (2014) Serum potassium levels and its variability in incident peritoneal dialysis patients: associations with mortality. PLoS ONE 9(1):e86750. https://doi.org/10.1371/journal.pone.0086750

  3. 3.

    Chuang YW, Shu KH, Yu TM, Cheng CH, Chen CH (2009) Hypokalaemia: an independent risk factor of Enterobacteriaceae peritonitis in CAPD patients. Nephrol Dial Transplant 24(5):1603–1608. https://doi.org/10.1093/ndt/gfn709

  4. 4.

    Jung JY, Chang JH, Lee HH, Chung W, Kim S (2009) De novo hypokalemia in incident peritoneal dialysis patients: a 1-year observational study. Electrolyte Blood Press 7(2):73–78. https://doi.org/10.5049/EBP.2009.7.2.73

  5. 5.

    Yu HL, Lu XH, Su CY, Tang W, Wang T (2014) Potassium metabolism in continuous ambulatory peritoneal dialysis patients. Ren Fail 36(5):748–754. https://doi.org/10.3109/0886022X.2014.884379

  6. 6.

    Fulop T, Zsom L, Rodriguez B, Afshan S, Davidson JV, Szarvas T, Dixit MP, Tapolyai MB, Rosivall L (2017) Clinical utility of potassium-sparing diuretics to maintain normal serum potassium in peritoneal dialysis patients. Perit Dial Int 37(1):63–69. https://doi.org/10.3747/pdi.2016.00022

  7. 7.

    Torlen K, Kalantar-Zadeh K, Molnar MZ, Vashistha T, Mehrotra R (2012) Serum potassium and cause-specific mortality in a large peritoneal dialysis cohort. Clin J Am Soc Nephrol 7(8):1272–1284. https://doi.org/10.2215/CJN.00960112

  8. 8.

    Kim HW, Chang JH, Park SY, Moon SJ, Kim DK, Lee JE, Han SH, Kim BS, Kang SW, Choi KH, Lee HY, Han DS (2007) Factors associated with hypokalemia in continuous ambulatory peritoneal dialysis patients. Electrolyte Blood Press 5(2):102–110. https://doi.org/10.5049/EBP.2007.5.2.102

  9. 9.

    Szeto CC, Chow KM, Kwan BC, Leung CB, Chung KY, Law MC, Li PK (2005) Hypokalemia in Chinese peritoneal dialysis patients: prevalence and prognostic implication. Am J Kidney Dis 46(1):128–135

  10. 10.

    Salenger PV (2019) Sudden cardiac death in end-stage renal disease. Cardiol Clin 37(3):319–326. https://doi.org/10.1016/j.ccl.2019.04.010

  11. 11.

    Poulikakos D, Hnatkova K, Skampardoni S, Green D, Kalra P, Malik M (2019) Sudden cardiac death in dialysis: arrhythmic mechanisms and the value of non-invasive electrophysiology. Front Physiol 10:144. https://doi.org/10.3389/fphys.2019.00144

  12. 12.

    Wang AY, Brimble KS, Brunier G, Holt SG, Jha V, Johnson DW, Kang SW, Kooman JP, Lambie M, McIntyre C, Mehrotra R, Pecoits-Filho R (2015) ISPD Cardiovascular and metabolic guidelines in adult peritoneal dialysis patients part II—management of various cardiovascular complications. Perit Dial Int 35(4):388–396. https://doi.org/10.3747/pdi.2014.00278

  13. 13.

    Franczyk-Skora B, Gluba-Brzozka A, Wranicz JK, Banach M, Olszewski R, Rysz J (2015) Sudden cardiac death in CKD patients. Int Urol Nephrol 47(6):971–982. https://doi.org/10.1007/s11255-015-0994-0

  14. 14.

    Palmer BF, Clegg DJ (2018) Hyperkalemia across the continuum of kidney function. Clin J Am Soc Nephrol 13(1):155–157. https://doi.org/10.2215/CJN.09340817

  15. 15.

    Ribeiro SC, Figueiredo AE, Barretti P, Pecoits-Filho R, de Moraes TP, Investigators B (2017) Impact of renin-angiotensin aldosterone system inhibition on serum potassium levels among peritoneal dialysis patients. Am J Nephrol 46(2):150–155. https://doi.org/10.1159/000479011

  16. 16.

    Garthwaite E, Bhandari S (2009) The effects of angiotensin converting enzyme inhibitors on potassium homeostasis in dialysis patients with and without residual renal function. Artif Organs 33(8):641–647. https://doi.org/10.1111/j.1525-1594.2009.00790.x

  17. 17.

    Phakdeekitcharoen B, Leelasa-nguan P (2004) Effects of an ACE inhibitor or angiotensin receptor blocker on potassium in CAPD patients. Am J Kidney Dis 44(4):738–746

  18. 18.

    Wong CM, O'Connor DT, Martinez JA, Kailasam MT, Parmer RJ (2003) Diminished renal kallikrein responses to mineralocorticoid stimulation in African Americans: determinants of an intermediate phenotype for hypertension. Am J Hypertens 16(4):281–289. https://doi.org/10.1016/s0895-7061(03)00002-5

  19. 19.

    Chen Y, Sang Y, Ballew SH, Tin A, Chang AR, Matsushita K, Coresh J, Kalantar-Zadeh K, Molnar MZ, Grams ME (2017) Race, serum potassium, and associations with ESRD and mortality. Am J Kidney Dis 70(2):244–251. https://doi.org/10.1053/j.ajkd.2017.01.044

  20. 20.

    Hayes J, Kalantar-Zadeh K, Lu JL, Turban S, Anderson JE, Kovesdy CP (2012) Association of hypo- and hyperkalemia with disease progression and mortality in males with chronic kidney disease: the role of race. Nephron Clin Pract 120(1):c8–16. https://doi.org/10.1159/000329511

  21. 21.

    Vavruk AM, Martins C, Nascimento MM, Hayashi SY, Riella MC (2012) Association between hypokalemia, malnutrition and mortality in peritoneal dialysis patients. J Bras Nefrol 34(4):349–354

  22. 22.

    Zanger R (2010) Hyponatremia and hypokalemia in patients on peritoneal dialysis. Semin Dial 23(6):575–580. https://doi.org/10.1111/j.1525-139X.2010.00789.x

  23. 23.

    Jaynes M, Kumar AB (2019) The risks of long-term use of proton pump inhibitors: a critical review. Ther Adv Drug Saf 10:2042098618809927. https://doi.org/10.1177/2042098618809927

  24. 24.

    Epstein M, McGrath S, Law F (2006) Proton-pump inhibitors and hypomagnesemic hypoparathyroidism. N Engl J Med 355(17):1834–1836. https://doi.org/10.1056/NEJMc066308

  25. 25.

    Cundy T, Dissanayake A (2008) Severe hypomagnesaemia in long-term users of proton-pump inhibitors. Clin Endocrinol (Oxf) 69(2):338–341. https://doi.org/10.1111/j.1365-2265.2008.03194.x

  26. 26.

    Francois M, Levy-Bohbot N, Caron J, Durlach V (2008) Chronic use of proton-pump inhibitors associated with giardiasis: a rare cause of hypomagnesemic hypoparathyroidism? Ann Endocrinol (Paris) 69(5):446–448. https://doi.org/10.1016/j.ando.2008.03.003

  27. 27.

    Fatuzzo P, Portale G, Scollo V, Zanoli L, Granata A (2017) Proton pump inhibitors and symptomatic hypomagnesemic hypoparathyroidism. J Nephrol 30(2):297–301. https://doi.org/10.1007/s40620-016-0319-0

  28. 28.

    Maeda Y, Kojima N, Araki Y, Uno T, Nishigaki K, Inaba N (2011) Does a proton pump inhibitor cause hypokalemia? Intern Med 50(9):1045–1050. https://doi.org/10.2169/internalmedicine.50.4877

Download references

Acknowledgements

We thank Fatima Libanio for her assistance with electronic data collection.

Funding

RMAM and RME are supported by CNPq, Conselho Nacional de Desenvolvimento Científico e Tecnológico (Grant Numbers 304249/2013-0 and 305106/2018-0, respectively). This financial support had no role in study design; collection, analysis and interpretation of data; writing the report; and the decision to submit the report for publication.

Author information

Contributions to the conception and study design: FAG and RME; Data collection and analysis: RME. Data interpretation: RME, RMAM. Drafting of the manuscript: RME, RMAM. Revising manuscript content and approval of the final version of the manuscript: FAG, LCC, LC, MCTP, LKRPA, CSW, BCS, BJP, RMAM and RME. RME takes responsibility for the integrity of the data analysis.

Correspondence to Rosilene M. Elias.

Ethics declarations

Conflict of interest

We have read and understood Peritoneal Dialysis International’s policy on disclosing conflicts of interest and declare that we have none.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Goncalves, F.A., de Jesus, J.S., Cordeiro, L. et al. Hypokalemia and hyperkalemia in patients on peritoneal dialysis: incidence and associated factors. Int Urol Nephrol 52, 393–398 (2020). https://doi.org/10.1007/s11255-020-02385-2

Download citation

Keywords

  • Hyperkalemia
  • Potassium
  • Proton-pump inhibitor
  • Black race
  • Anuria