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American Journal of Kidney Diseases

Dialysate and Serum Potassium in Hemodialysis

Published:March 28, 2015DOI:https://doi.org/10.1053/j.ajkd.2015.02.322
      Most patients with end-stage renal disease depend on intermittent hemodialysis to maintain levels of serum potassium and other electrolytes within a normal range. However, one of the challenges has been the safety of using a low-potassium dialysate to achieve that goal, given the concern about the effects that rapid and/or large changes in serum potassium concentrations may have on cardiac electrophysiology and arrhythmia. Additionally, in this patient population, there is a high prevalence of structural cardiac changes and ischemic heart disease, making them even more susceptible to acute arrhythmogenic triggers. This concern is highlighted by the knowledge that about two-thirds of all cardiac deaths in dialysis are due to sudden cardiac death and that sudden cardiac death accounts for 25% of the overall death for end-stage renal disease. Developing new approaches and practice standards for potassium removal during dialysis, as well as understanding other modifiable triggers of sudden cardiac death, such as other electrolyte components of the dialysate (magnesium and calcium), rapid ultrafiltration rates, and safety of a number of medications (ie, drugs that prolong the QT interval or use of digoxin), are critical in order to decrease the unacceptably high cardiac mortality experienced by hemodialysis-dependent patients.

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      References

        • Collins A.J.
        • Foley R.N.
        • Chavers B.
        • et al.
        US Renal Data System 2013 Annual Data Report.
        Am J Kidney Dis. 2014; 63 (A7): e1-e420
        • Wanner C.
        • Krane V.
        • Marz W.
        • et al.
        Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis.
        N Engl J Med. 2005; 353: 238-248
        • Chiu D.Y.
        • Sinha S.
        • Kalra P.A.
        • Green D.
        Sudden cardiac death in haemodialysis patients—preventative options.
        Nephrology (Carlton). 2014; 19: 740-749
        • Ohtake T.
        • Kobayashi S.
        • Moriya H.
        • et al.
        High prevalence of occult coronary artery stenosis in patients with chronic kidney disease at the initiation of renal replacement therapy: an angiographic examination.
        J Am Soc Nephrol. 2005; 16: 1141-1148
        • Bleyer A.J.
        • Hartman J.
        • Brannon P.C.
        • Reeves-Daniel A.
        • Satko S.G.
        • Russell G.
        Characteristics of sudden death in hemodialysis patients.
        Kidney Int. 2006; 69: 2268-2273
        • Foley R.N.
        • Curtis B.M.
        • Randell E.W.
        • Parfrey P.S.
        Left ventricular hypertrophy in new hemodialysis patients without symptomatic cardiac disease.
        Clin J Am Soc Nephrol. 2010; 5: 805-813
        • Bleyer A.J.
        • Russell G.B.
        • Satko S.G.
        Sudden and cardiac death rates in hemodialysis patients.
        Kidney Int. 1999; 55: 1553-1559
        • Beaubien E.R.
        • Pylypchuk G.B.
        • Akhtar J.
        • Biem H.J.
        Value of corrected QT interval dispersion in identifying patients initiating dialysis at increased risk of total and cardiovascular mortality.
        Am J Kidney Dis. 2002; 39: 834-842
        • Buemi M.
        • Aloisi E.
        • Coppolino G.
        • et al.
        The effect of two different protocols of potassium haemodiafiltration on QT dispersion.
        Nephrol Dial Transplant. 2005; 20: 1148-1154
        • Genovesi S.
        • Dossi C.
        • Vigano M.R.
        • et al.
        Electrolyte concentration during haemodialysis and QT interval prolongation in uraemic patients.
        Europace. 2008; 10: 771-777
        • Foley R.N.
        • Gilbertson D.T.
        • Murray T.
        • Collins A.J.
        Long interdialytic interval and mortality among patients receiving hemodialysis.
        N Engl J Med. 2011; 365: 1099-1107
        • Jadoul M.
        • Thumma J.
        • Fuller D.S.
        • et al.
        Modifiable practices associated with sudden death among hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study.
        Clin J Am Soc Nephrol. 2012; 7: 765-774
        • Kovesdy C.P.
        • Regidor D.L.
        • Mehrotra R.
        • et al.
        Serum and dialysate potassium concentrations and survival in hemodialysis patients.
        Clin J Am Soc Nephrol. 2007; 2: 999-1007
        • Pun P.H.
        • Lehrich R.W.
        • Honeycutt E.F.
        • Herzog C.A.
        • Middleton J.P.
        Modifiable risk factors associated with sudden cardiac arrest within hemodialysis clinics.
        Kidney Int. 2011; 79: 218-227
        • Karnik J.A.
        • Young B.S.
        • Lew N.L.
        • et al.
        Cardiac arrest and sudden death in dialysis units.
        Kidney Int. 2001; 60: 350-357
        • Buiten M.S.
        • de Bie M.K.
        • Rotmans J.I.
        • et al.
        The dialysis procedure as a trigger for atrial fibrillation: new insights in the development of atrial fibrillation in dialysis patients.
        Heart. 2014; 100: 685-690
        • Santoro A.
        • Mancini E.
        • London G.
        • et al.
        Patients with complex arrhythmias during and after haemodialysis suffer from different regimens of potassium removal.
        Nephrol Dial Transplant. 2008; 23: 1415-1421
        • Morrison G.
        • Michelson E.L.
        • Brown S.
        • Morganroth J.
        Mechanism and prevention of cardiac arrhythmias in chronic hemodialysis patients.
        Kidney Int. 1980; 17: 811-819
        • Pani A.
        • Floris M.
        • Rosner M.H.
        • Ronco C.
        Hyperkalemia in hemodialysis patients.
        Semin Dial. 2014; 27: 571-576
        • Blumberg A.
        • Roser H.W.
        • Zehnder C.
        • Muller-Brand J.
        Plasma potassium in patients with terminal renal failure during and after haemodialysis; relationship with dialytic potassium removal and total body potassium.
        Nephrol Dial Transplant. 1997; 12: 1629-1634
        • Genovesi S.
        • Valsecchi M.G.
        • Rossi E.
        • et al.
        Sudden death and associated factors in a historical cohort of chronic haemodialysis patients.
        Nephrol Dial Transplant. 2009; 24: 2529-2536
        • Heguilen R.M.
        • Sciurano C.
        • Bellusci A.D.
        • et al.
        The faster potassium-lowering effect of high dialysate bicarbonate concentrations in chronic haemodialysis patients.
        Nephrol Dial Transplant. 2005; 20: 591-597
        • Redaelli B.
        • Locatelli F.
        • Limido D.
        • et al.
        Effect of a new model of hemodialysis potassium removal on the control of ventricular arrhythmias.
        Kidney Int. 1996; 50: 609-617
        • Severi S.
        • Bolasco P.
        • Badiali F.
        • et al.
        Calcium profiling in hemodiafiltration: a new way to reduce the calcium overload risk without compromising cardiovascular stability.
        Int J Artif Organs. 2014; 37: 206-214
        • Packham D.K.
        • Rasmussen H.S.
        • Lavin P.T.
        • et al.
        Sodium zirconium cyclosilicate in hyperkalemia.
        N Engl J Med. 2015; 372: 222-231
        • Weir M.R.
        • Bakris G.L.
        • Bushinsky D.A.
        • et al.
        Patiromer in patients with kidney disease and hyperkalemia receiving RAAS inhibitors.
        N Engl J Med. 2015; 372: 211-221
        • Averbukh Z.
        • Rosenberg R.
        • Galperin E.
        • et al.
        Cell-associated magnesium and QT dispersion in hemodialysis patients.
        Am J Kidney Dis. 2003; 41: 196-202
        • Sakaguchi Y.
        • Fujii N.
        • Shoji T.
        • Hayashi T.
        • Rakugi H.
        • Isaka Y.
        Hypomagnesemia is a significant predictor of cardiovascular and non-cardiovascular mortality in patients undergoing hemodialysis.
        Kidney Int. 2014; 85: 174-181
        • Pun P.H.
        • Horton J.R.
        • Middleton J.P.
        Dialysate calcium concentration and the risk of sudden cardiac arrest in hemodialysis patients.
        Clin J Am Soc Nephrol. 2013; 8: 797-803
        • McIntyre C.W.
        • Burton J.O.
        • Selby N.M.
        • et al.
        Hemodialysis-induced cardiac dysfunction is associated with an acute reduction in global and segmental myocardial blood flow.
        Clin J Am Soc Nephrol. 2008; 3: 19-26
        • Burton J.O.
        • Jefferies H.J.
        • Selby N.M.
        • McIntyre C.W.
        Hemodialysis-induced cardiac injury: determinants and associated outcomes.
        Clin J Am Soc Nephrol. 2009; 4: 914-920
        • Flythe J.E.
        • Kimmel S.E.
        • Brunelli S.M.
        Rapid fluid removal during dialysis is associated with cardiovascular morbidity and mortality.
        Kidney Int. 2011; 79: 250-257
        • Chan K.E.
        • Lazarus J.M.
        • Hakim R.M.
        Digoxin associates with mortality in ESRD.
        J Am Soc Nephrol. 2010; 21: 1550-1559
        • Chugh S.S.
        • Reinier K.
        • Singh T.
        • et al.
        Determinants of prolonged QT interval and their contribution to sudden death risk in coronary artery disease: the Oregon Sudden Unexpected Death Study.
        Circulation. 2009; 119: 663-670
        • Ray W.A.
        • Murray K.T.
        • Hall K.
        • Arbogast P.G.
        • Stein C.M.
        Azithromycin and the risk of cardiovascular death.
        N Engl J Med. 2012; 366: 1881-1890
        • Ray W.A.
        • Murray K.T.
        • Meredith S.
        • Narasimhulu S.S.
        • Hall K.
        • Stein C.M.
        Oral erythromycin and the risk of sudden death from cardiac causes.
        N Engl J Med. 2004; 351: 1089-1096

      Linked Article

      • Erratum Regarding “Dialysate and Serum Potassium in Hemodialysis” (Am J Kidney Dis. 2015;66[1]:125-132)
        American Journal of Kidney DiseasesVol. 66Issue 5
        • Preview
          In the In Practice article entitled “Dialysate and Serum Potassium in Hemodialysis” that appeared in the July 2015 issue of AJKD (Hung & Hakim, volume 66, issue 1, pages 125-132), there were errors in the description, dose information, and reported results for 2 new oral agents for the treatment of hyperkalemia.
        • Full-Text
        • PDF
      • Dialysate and Serum Potassium in Hemodialysis
        American Journal of Kidney DiseasesVol. 67Issue 1
        • Preview
          Hung and Hakim1 described factors associated with sudden cardiac death in patients on hemodialysis therapy, using a sample case in which a patient had cardiac arrest in the second half of dialysis and basing the subsequent discussion on possible factors that could have contributed to this outcome. Given the article topic, the authors focus on potassium balance and note that normal or slightly elevated predialysis serum potassium levels and using a lower dialysate potassium concentration in patients with hyperkalemia have been associated with the greater likelihood of survival.
        • Full-Text
        • PDF