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

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.

• Authors: Ghassan Bandak, Yingying Sang, Alessandro Gasparini, Alex R Chang, Shoshana H Ballew, Marie Evans, Johan Arnlov, Lars H Lund, Lesley A Inker, Josef Coresh, Juan-Jesus Carrero, Morgan E Grams
• Journal: Journal of the American Heart Association (J Am Heart Assoc) Vol. 6 Issue 7 (Jul 19 2017) ISSN: 2047-9980 [Electronic] England
• PMID: 28724651 (Publication Type: Journal Article, Validation Study)
• Copyright: © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Chemical References

• Angiotensin II Type 1 Receptor Blockers
• Angiotensin-Converting Enzyme Inhibitors
• Biomarkers
• Creatinine
• Potassium

Topics

• Adult
• Aged
• Angiotensin II Type 1 Receptor Blockers (adverse effects)
• Angiotensin-Converting Enzyme Inhibitors (adverse effects)
• Biomarkers (blood)
• Creatinine (blood)
• Databases, Factual
• Drug Monitoring (methods, standards)
• Female
• Glomerular Filtration Rate (drug effects)
• Humans
• Hyperkalemia (blood, chemically induced, diagnosis)
• Kidney (drug effects, metabolism, physiopathology)
• Logistic Models
• Male
• Middle Aged
• Potassium (blood)
• Predictive Value of Tests
• Propensity Score
• Renin-Angiotensin System (drug effects)
• Reproducibility of Results
• Risk Factors
• Sweden
• Time Factors
• Treatment Outcome