Hyperkalemia and renin-angiotensin aldosterone system inhibitor therapy in chronic kidney disease: A general practice-based, observational study

Data on hyperkalemia frequency among chronic kidney disease (CKD) patients receiving renin-angiotensin aldosterone system inhibitors (RAASis) and its impact on subsequent RAASi treatment are limited. This population-based cohort study sought to assess the incidence of clinically significant hyperkalemia among adult CKD patients who were prescribed a RAASi and the proportion of patients with RAASi medication change after experiencing incident hyperkalemia. We conducted a retrospective, population-based cohort study (1 January 2013–30 June 2017) using Australian national general practice data from the NPS MedicineWise’s MedicineInsight program. The study included adults aged ≥18 years who received ≥1 RAASi prescription during the study period and had CKD (estimated glomerular filtration rate [eGFR] <60 ml/min/1.73m2). Study outcomes included incident clinically significant hyperkalemia (serum potassium >6 mmol/L or a record of hyperkalemia diagnosis) and among patients who experienced incident hyperkalemia, the proportion who had RAASi medication changes (cessation or dose reduction during the 210-day period after the incident hyperkalemia event). Among 20,184 CKD patients with a median follow-up of 3.9 years, 1,992 (9.9%) patients experienced an episode of hyperkalemia. The overall incidence rate was 3.1 (95% CI: 2.9–3.2) per 100 person-years. Rates progressively increased with worsening eGFR (e.g. 3.5-fold increase in patients with eGFR <15 vs. 45–59 ml/min/1.73m2). Among patients who experienced incident hyperkalemia, 46.6% had changes made to their RAASi treatment regimen following the first occurrence of hyperkalemia (discontinuation: 36.6% and dose reduction: 10.0%). In this analysis of adult RAASi users with CKD, hyperkalemia and subsequent RAASi treatment changes were common. Further assessment of strategies for hyperkalemia management and optimal RAASi use among people with CKD are warranted.

目前关于接受肾素-血管紧张素-醛固酮系统抑制剂（RAASis）治疗的慢性肾脏病（CKD）患者高钾血症的发生频率，及其对后续RAASi治疗的影响相关数据较为匮乏。本项基于人群的队列研究拟评估开具RAASi处方的成年CKD患者中临床显著性高钾血症的发生率，以及发生新发高钾血症后调整RAASi用药方案的患者比例。本研究依托NPS MedicineWise的MedicineInsight项目，利用澳大利亚国家全科医疗数据，开展了2013年1月1日至2017年6月30日的回顾性基于人群队列研究。研究纳入标准为年龄≥18岁、在研究期间接受≥1次RAASi处方且确诊CKD（估算肾小球滤过率（estimated glomerular filtration rate, eGFR）<60 ml/min/1.73m²）的成年患者。本研究的结局指标包括：①临床显著性高钾血症新发事件（血清钾＞6 mmol/L或存在高钾血症诊断记录）；②在发生新发高钾血症的患者中，于事件发生后210天内调整RAASi用药方案（停药或减量）的患者比例。在20184名中位随访时长3.9年的CKD患者中，共1992名（9.9%）患者发生高钾血症事件，总体发生率为3.1例/100人年（95%置信区间：2.9~3.2）。发生率随eGFR水平下降逐步升高：例如eGFR＜15 ml/min/1.73m²的患者，其发生率较eGFR 45~59 ml/min/1.73m²的患者升高3.5倍。在发生新发高钾血症的患者中，46.6%的患者在首次高钾血症事件后调整了RAASi治疗方案（其中停药占36.6%，减量占10.0%）。本项针对成年CKD且使用RAASi患者的分析显示，高钾血症及其后续RAASi治疗调整的情况较为普遍。未来仍需进一步评估CKD患者高钾血症管理策略及RAASi最优使用方案。