Hyperkalemia after initiating renin-angiotensin system blockade: The Stockholm Creatinine Measurements (SCREAM) project

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

Research output: Contribution to journalArticle

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 b-blocker users in SCREAM: 64% had potassium checked. The occurrence of elevated potassium levels was similar between new b-blocker and ACEI/ 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.

Original languageEnglish (US)
Article numbere005428
JournalJournal of the American Heart Association
Volume6
Issue number7
DOIs
StatePublished - Jul 1 2017

Keywords

  • Angiotensin receptor blockers
  • Angiotensin-converting enzyme inhibition
  • Angiotensin-converting enzyme inhibitors
  • Chronic kidney disease
  • Hyperkalemia
  • Potassium
  • Risk score

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

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