2) This #accredited #tweetorial series on #kidneydisease #hyperkalemia is supported by an independent educational grant from AstraZeneca and is intended for healthcare providers. Accreditation statement & faculty disclosures are at https://t.co/TZMHIW237D.
— @CKD_ce (@ckd_ce) July 19, 2022
4) Consequences of acute, severe #hyperkalemia are well recognized, most notably increasing risk of fatal #arrhythmias, including ventricular fibrillation, #asystole and #cardiac_arrest.
— @CKD_ce (@ckd_ce) July 19, 2022
🔓 https://t.co/kDy791e5ny pic.twitter.com/WqbkadPDur
6) Hyperkalemia is defined as
— @CKD_ce (@ckd_ce) July 19, 2022
👉Mild ≥5mmol/L
👉Moderate 5.0-6.4mmol/L
👉Severe ≥6.5mmol/L
🔓https://t.co/QIpv3HMjqH pic.twitter.com/NtWxXwWvk4
8) Which of these medications is/are NOT associated with hyperkalemia?
— @CKD_ce (@ckd_ce) July 19, 2022
a. heparin & beta-blockers
b. spironolactone
c. losartan and Bactrim
d. none of the above
10) Medications at highest risk of hyperK+
— @CKD_ce (@ckd_ce) July 19, 2022
👉#RAASi – #ACEi, #ARB, #ARNI (angiotensin receptor neprilysin inhibitors)
👉Mineralocorticoid receptor antagonists #MRA#NSAIDs
👉Calcineurin inhibitors #CNI
Full list & mechanisms below
🔓https://t.co/dmCd30IQoM pic.twitter.com/TjD6eGtwmc
12) Mechanisms of #hyperkalemia in #CKD
— @CKD_ce (@ckd_ce) July 19, 2022
👉Reduced #GFR
👉Associated metabolic acidosis
👉Use of disease specific populations that interfere with RAAS axishttps://t.co/RNqjT84vkw pic.twitter.com/IB10ujRQfQ
14) Mechanisms of #hyperkalemia in #heartfailure
— @CKD_ce (@ckd_ce) July 19, 2022
👉 Decreased tubular sodium delivery
👉 Use of medications that interfere with #RAAS axis pic.twitter.com/HfYS0jzyRn
16) This propensity-matched large observational study from @kireports revealed ⬆️risk of CV events, hospital admissions & #ICU admissions even at mild levels of #hyperkalemia. 🔓https://t.co/ifM2PHQRhW pic.twitter.com/59Zl2btRpZ
— @CKD_ce (@ckd_ce) July 19, 2022
18) First, among the countless observational studies on #hyperkalemia and #mortality, it is impossible to control for confounders that may impact outcomes i.e., acute cause of hyperkalemia and use of sodium polystyrene sulfonate #SPS with known bowel necrosis/perforation risk.
— @CKD_ce (@ckd_ce) July 19, 2022
20) However, disease states at greatest risk of developing #hyperkalemia also stand to benefit most from #RAASi and #MRAs treatment, which include;
— @CKD_ce (@ckd_ce) July 19, 2022
👉 Albuminuric kidney disease
👉diabetic kidney disease
👉 Heart failure with reduced ejection fraction #HFrEF
22) The below figure demonstrates worsening mortality risk due to #hyperkalemia as stratified by #T2D, #HF, and #CKD. The full combination of all 3⃣ reveals the highest hyperkalemia-associated #mortality risk
— @CKD_ce (@ckd_ce) July 19, 2022
🔓https://t.co/1AtGTuI26d pic.twitter.com/JgVzWqLOXb
24) While you ponder the choice of the red pill vs the blue pill, we’ll take a break. RETURN TOMORROW to continue this program. You’re well on your way to 0.75h 🆓CE/#CME credit!
— @CKD_ce (@ckd_ce) July 19, 2022
26) So yesterday we asked, is the mortality risk attributed to ⬆️K+ due to #hyperkalemia itself OR is it related to the discontinuation of cardio & renoprotective #RAASi and #MRA agents in those which benefit from them most?
— @CKD_ce (@ckd_ce) July 20, 2022
28) The cardioprotective effects of #RAASi and #MRAs are well known in #HFrEF, a mainstay in #GDMT
— @CKD_ce (@ckd_ce) July 20, 2022
🔓https://t.co/rpac6rI2RF
🔓https://t.co/iKMdwxhZeA pic.twitter.com/s6PCjalJGG
30) If RAASi and MRAs are so ‘protective’, what data exist to support the theory that much of the associated mortality may be attributable to the discontinuation of said medications? pic.twitter.com/En24c5Q6KH
— @CKD_ce (@ckd_ce) July 20, 2022
32) Next, we know the percent mortality goes up in #CKD, #HF, #T2D in those for whom #RAASi was discontinued or on submaximal doses.
— @CKD_ce (@ckd_ce) July 20, 2022
🔓 https://t.co/H0ACCmw3RF pic.twitter.com/baefkHI5uk
34) Among those with #heartfailure and #CKD, there is increased all-cause & cardiovascular mortality & increased risk of dialysis initiation in those for whom #RAASi is discontinued for hyperkalemia https://t.co/Go0Zkhy5O0 pic.twitter.com/0miNn6nnfC
— @CKD_ce (@ckd_ce) July 20, 2022
36) #NKF at https://t.co/ji8NPgzOTt offers a masterclass that discusses pathogenesis, evaluation and management of #hyperkalemia, designed to guide management and/or prevention hyperkalemia while maintaining our #cardiovascular protective medshttps://t.co/dpTjIYqPQU pic.twitter.com/qdP2DiaAQ7
— @CKD_ce (@ckd_ce) July 20, 2022
38) Welcome back! It's Day 3⃣ and Day FINAL of our tour through the world of #hyperkalemia and how it can derail #guidelines-concordant #cardiorenal care. I am @sophia_kidney from @CUAnschutz. This is your ONLY source for #accredited #serialized CE/#CME by #tweetorial!
— @CKD_ce (@ckd_ce) July 21, 2022
40) In acute, life threatening #hyperkalemia with #ECG changes, what do you think is the most appropriate order of management?
— @CKD_ce (@ckd_ce) July 21, 2022
1) IV calcium, insulin & D50
2) Consult nephrology for dialysis and place temporary dialysis catheter
3) give IV loop diuretic
4) Start K+ binder
42) Tweet 40? Best answer is B. First, stabilize the #myocardium with calcium gluconate then insulin with D50 to shift potassium intracellularly. Below, review mechanism, onset & duration summary of hyperkalemia management
— @CKD_ce (@ckd_ce) July 21, 2022
🔓https://t.co/5tVGzqpckt pic.twitter.com/hxP8YLEhdw
44) So, how do we prevent #hyperkalemia while maintaining #GDMT?? Let’s consider a case. pic.twitter.com/YIDTj0TqmC
— @CKD_ce (@ckd_ce) July 21, 2022
46) How will you manage this patient’s potassium and need for increased #RAASi?
— @CKD_ce (@ckd_ce) July 21, 2022
a) Make no changes, potassium is 5.2
b) Start chlorthalidone, recheck potassium, then up-titrate lisinopril
c) Start potassium binder
d) restrict K+ in diet
48) In chronic hyperK+/advanced #CKD (eGFR <30ml/min/1.73m2): dietary counseling, cautious #RAASi initiation & titration, diuretics, sodium bicarb and K+ binders are options
— @CKD_ce (@ckd_ce) July 21, 2022
Goal: Stabilize hyperkalemia, resume/up-titrate RAASi & reassess K+.
🔓https://t.co/kp31gI2pYY pic.twitter.com/IP2PPexCTz
50) Similar practices should be extended for the use of steroidal and nonsteroidal MRAs, especially considering the rise of finerenone included in #DKD and #HFrEF #GDMT
— @CKD_ce (@ckd_ce) July 21, 2022
52) The introduction of #diuretics can be an effective measure, preferably loop diuretics or thiazides. The #CLICK trial demonstrated that #thiazide diuretics are effective in advanced #CKD.https://t.co/PiZNiNiiXG
— @CKD_ce (@ckd_ce) July 21, 2022
54) Sodium polystyrene sulfonate #SPS #kayexalate, approved in 1958, is a cation-exchange resin where sodium & hydrogen ions are exchanged for free potassium ions in large intestine pic.twitter.com/u00dXzVcfy
— @CKD_ce (@ckd_ce) July 21, 2022
56) Sodium zirconium cyclosilicate #SZC is the fastest acting binder (within 1 hour), a crystalline structure, non-systemically absorbed compound. H+ and K+ are exchanged specifically for K+. Works throughout the entire gut (not just colon) pic.twitter.com/ZDU0aQQoX2
— @CKD_ce (@ckd_ce) July 21, 2022
58) #SZC in Heart failure demonstrated reduction in #hyperkalemia. This figure also demonstrates the rapid onset of potassium reduction associated with SZC compared to placebo, which makes it the preferred K+ binder in acute, life threatening hyperkalemia pic.twitter.com/KVxjasqDfH
— @CKD_ce (@ckd_ce) July 21, 2022
60) #OPAL-HK, #AMBER and #AMETHYST-DN trials all revealed reduction of #hyperkalemia with patiromer compared with placebo pic.twitter.com/XHe8sC7HQX
— @CKD_ce (@ckd_ce) July 21, 2022
62b) … risk of serious hyperkalemia in those with T2D on SGLT2i was decreased by 16% (HR 0.84 [95% CI 0.76-0.93]). See 🔓https://t.co/ouheB3dwje pic.twitter.com/6zMkf8xDTc
— @CKD_ce (@ckd_ce) July 21, 2022
63) Back to the case… a 65 YO patient with PMH #htn #T2D #DKD with UACR 1.2g/g. Meds: lisinopril 20mg QD. Pt adheres to low K+ diet. BP 142/80. sCr 2.0. sK 5.2. On exam, there's trace LE edema.
— @CKD_ce (@ckd_ce) July 21, 2022
How will you manage this patient’s potassium and need for increased #RAASi?
65) This patient would also benefit from an #SGLT2i. Based on the above data, early efforts to #flozinate (add SGLT2i) will have #cardiovascular and #renal protective benefits and potentially reduce hyperkalemic risk.
— @CKD_ce (@ckd_ce) July 21, 2022
67) And that's it! #Physicians #pharmacists #nurses #nursepractitioners #physicianassociates go claim your 🆓0.75hr CE/#CME at https://t.co/ea0b53CvzH. I am @sophia_kidney and I encourage you to FOLLOW @ckd_ce and @cardiomet_ce for more outstanding education here on Twitter!
— @CKD_ce (@ckd_ce) July 21, 2022