Bandak Ghassan, Sang Yingying, Gasparini Alessandro, Chang Alex R, Ballew Shoshana H, Evans Marie, Arnlov Johan, Lund Lars H, Inker Lesley A, Coresh Josef, Carrero Juan-Jesus, Grams Morgan E
Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD.
Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.
J Am Heart Assoc. 2017 Jul 19;6(7):e005428. doi: 10.1161/JAHA.116.005428.
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.
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 m 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.
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 m, 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.
对高钾血症的担忧限制了血管紧张素转换酶抑制剂（ACE-I）和血管紧张素受体阻滞剂（ARB）的使用，但关于钾监测方案的指南存在冲突。我们对ACE-I/ARB起始治疗后的高钾血症监测及风险进行了量化，并开发和验证了高钾血症易感性评分。
我们在斯德哥尔摩肌酐测量（SCREAM）项目中评估了69426名新使用ACE-I/ARB治疗的患者，这些患者于2007年1月1日至2010年12月31日开始用药，并在之后进行了1年的随访。四分之三（76%）的SCREAM患者在第一年进行了血钾检查。血钾>5 mmol/L和>5.5 mmol/L的发生率分别为5.6%和1.7%。作为对照，我们将SCREAM中新使用ACE-I/ARB的患者与20186名新使用β受体阻滞剂的患者进行倾向评分匹配：64%的β受体阻滞剂使用者进行了血钾检查。在无肾脏疾病的新β受体阻滞剂使用者和ACE-I/ARB使用者中，血钾升高的发生率相似；仅在估算肾小球滤过率<60 mL/（min·1.73 m²）时，ACE-I/ARB使用者的风险更高。我们开发了一种高钾血症易感性评分，纳入了新使用ACE-I/ARB患者的估算肾小球滤过率、基线血钾水平、性别、糖尿病、心力衰竭以及同时使用保钾利尿剂的情况；该评分准确预测了SCREAM队列中1年高钾血症风险（曲线下面积，0.845，95%CI：0.840 - 0.869）以及美国盖辛格医疗系统验证队列（N = 19524；曲线下面积，0.818，95%CI：0.794 - 0.841）中的风险，且校准良好。
在估算肾小球滤过率>60 mL/（min·1.73 m²）的人群中，ACE-I/ARB治疗第一年的高钾血症相对不常见，但估算肾小球滤过率较低时发生率要高得多。使用高钾血症易感性评分可能有助于指导实验室监测和处方策略。
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