Sterns Richard H, Grieff Marvin, Bernstein Paul L
Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, Rochester General Hospital, Rochester, New York, USA.
Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, Rochester General Hospital, Rochester, New York, USA.
Kidney Int. 2016 Mar;89(3):546-54. doi: 10.1016/j.kint.2015.11.018. Epub 2016 Feb 2.
Treatment options for hyperkalemia have not changed much since the introduction of the cation exchange resin, sodium polystyrene sulfonate (Kayexalate, Covis Pharmaceuticals, Cary, NC), over 50 years ago. Although clinicians of that era did not have ready access to hemodialysis or loop diuretics, the other tools that we use today-calcium, insulin, and bicarbonate-were well known to them. Currently recommended insulin regimens provide too little insulin to achieve blood levels with a maximal kalemic effect and too little glucose to avoid hypoglycemia. Short-acting insulins have theoretical advantages over regular insulin in patients with severe kidney disease. Although bicarbonate is no longer recommended for acute management, it may be useful in patients with metabolic acidosis or intact kidney function. Kayexalate is not effective as acute therapy, but a new randomized controlled trial suggests that it is effective when given more chronically. Gastrointestinal side effects and safety concerns about Kayexalate remain. New investigational potassium binders are likely to be approved in the coming year. Although there are some concerns about hypomagnesemia and positive calcium balance from patiromer, and sodium overload from ZS-9 (ZS Pharma, Coppell, TX), both agents have been shown to be effective and well tolerated when taken chronically. ZS-9 shows promise in the acute treatment of hyperkalemia and may make it possible to avoid or postpone the most effective therapy, emergency hemodialysis.
自50多年前引入阳离子交换树脂聚苯乙烯磺酸钠（降钾树脂，Covis制药公司，北卡罗来纳州卡里）以来，高钾血症的治疗选择并没有太大变化。尽管那个时代的临床医生无法随时进行血液透析或使用袢利尿剂，但我们如今使用的其他工具——钙、胰岛素和碳酸氢盐——对他们来说并不陌生。目前推荐的胰岛素治疗方案提供的胰岛素量过少，无法达到具有最大降钾效果的血药浓度，且提供的葡萄糖量过少，无法避免低血糖。对于重症肾病患者，短效胰岛素在理论上比常规胰岛素更具优势。尽管碳酸氢盐不再推荐用于急性处理，但对于代谢性酸中毒患者或肾功能正常的患者可能有用。降钾树脂作为急性治疗无效，但一项新的随机对照试验表明，长期使用时它是有效的。降钾树脂的胃肠道副作用和安全性问题依然存在。新型研究性钾结合剂可能在明年获批。尽管对帕替罗姆导致的低镁血症和正钙平衡以及ZS-9（ZS制药公司，得克萨斯州科佩尔）导致的钠过载存在一些担忧，但这两种药物在长期服用时均已证明有效且耐受性良好。ZS-9在高钾血症的急性治疗中显示出前景，可能使避免或推迟最有效的治疗方法——紧急血液透析——成为可能。
