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J Am Heart Assoc. 2017 Jul 19;6(7). pii: e005428. doi: 10.1161/JAHA.116.005428.

Hyperkalemia After Initiating Renin-Angiotensin System Blockade: The Stockholm Creatinine Measurements (SCREAM) Project.

Author information

1
Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD.
2
Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.
3
Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
4
Division of Nephrology, Geisinger Health System, Danville, PA.
5
Department of Medical Sciences, Cardiovascular Epidemiology, Uppsala University, Uppsala, Sweden.
6
School of Health and Social Studies, Dalarna University, Falun, Sweden.
7
Unit of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
8
Division of Nephrology, Tufts Medical Center, Boston, MA.
9
Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD mgrams2@jhmi.edu.

Abstract

BACKGROUND:

Concerns about hyperkalemia limit the use of angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARBs), but guidelines conflict regarding potassium-monitoring protocols. We quantified hyperkalemia monitoring and risks after ACE-I/ARB initiation and developed and validated a hyperkalemia susceptibility score.

METHODS AND RESULTS:

We evaluated 69 426 new users of ACE-I/ARB therapy in the Stockholm Creatinine Measurements (SCREAM) project with medication initiation from January 1, 2007 to December 31, 2010, and follow-up for 1 year thereafter. Three fourths (76%) of SCREAM patients had potassium checked within the first year. Potassium >5 and >5.5 mmol/L occurred in 5.6% and 1.7%, respectively. As a comparison, we propensity-matched new ACE-I/ARB users to 20 186 new β-blocker users in SCREAM: 64% had potassium checked. The occurrence of elevated potassium levels was similar between new β-blocker and ACE-I/ARB users without kidney disease; only at estimated glomerular filtration rate <60 mL/min per 1.73 m2 were risks higher among ACE-I/ARB users. We developed a hyperkalemia susceptibility score that incorporated estimated glomerular filtration rate, baseline potassium level, sex, diabetes mellitus, heart failure, and the concomitant use of potassium-sparing diuretics in new ACE-I/ARB users; this score accurately predicted 1-year hyperkalemia risk in the SCREAM cohort (area under the curve, 0.845, 95% CI: 0.840-0.869) and in a validation cohort from the US-based Geisinger Health System (N=19 524; area under the curve, 0.818, 95% CI: 0.794-0.841), with good calibration.

CONCLUSIONS:

Hyperkalemia within the first year of ACE-I/ARB therapy was relatively uncommon among people with estimated glomerular filtration rate >60 mL/min per 1.73 m2, but rates were much higher with lower estimated glomerular filtration rate. Use of the hyperkalemia susceptibility score may help guide laboratory monitoring and prescribing strategies.

KEYWORDS:

angiotensin receptor blockers; angiotensin‐converting enzyme inhibition; angiotensin‐converting enzyme inhibitors; chronic kidney disease; hyperkalemia; potassium; risk score

PMID:
28724651
PMCID:
PMC5586281
DOI:
10.1161/JAHA.116.005428
[Indexed for MEDLINE]
Free PMC Article

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