血管紧张素系统抑制剂在无尿血液透析患者中增加血钾。
Use of Renin-Angiotensin System Blockers Increases Serum Potassium in Anuric Hemodialysis Patients.
出版信息
Am J Nephrol. 2018;48(2):79-86. doi: 10.1159/000491552. Epub 2018 Aug 2.
BACKGROUND
Angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) are increasingly used in uremic patients (pts). However, their effect on serum potassium (sK) concentrations in anuric pts on chronic hemodialysis treatment (HD) is controversial. The aim of the study was to evaluate sK before and after the start of ACEi/ARB therapy.
METHODS
In the period 1/1/2015 - 31/12/2015, 112 out of 240 prevalent HD pts on thrice weekly HD treatment followed at our institution started the ACEi/ARB therapy. The mean age was 67 ± 14 years, 67/112 were men, dialysis vintage was 6-212 months. In the 3 months before (PRE; N° 36 HD sessions) and after (POST; N° 36 HD sessions) the start of ACEi/ARB therapy, the following variables were evaluated in pre dialysis after the long interdialysis interval: sK (mean of 12 determinations; mmol/L), maximum sK (maximum K value observed during observations; sKmax; mmol/L), serum sodium (sNa; mmol/L), pre dialysis systolic blood pressure (SBP; mm Hg) and diastolic blood pressure (DBP; mm Hg), body weight (BW; Kg), interdialytic weight gain (IWG; Kg), Kt/V, serum bicarbonate concentrations (sBic; mmol/L), protein catabolic rate (PCRn; g/KgBW/day). SBP, DBP, IWG are the mean of the 24 HD sessions. Out of 112 patients, 102 were on antihypertensive therapy. The duration of HD and blood and dialysate flow rates were kept constant. Data are expressed as mean ± SD. Student t test for paired and unpaired data for normally distributed variables, Mann-Whitney test for medians, χ2 test for categorical data were employed to compare groups. A significant difference was defined as p < 0.05.
RESULTS
sK increased from 5.0 ± 0.4 mmol/L PRE to 5.7 ± 0.5 mmol/L POST (p < 0.0001). sKmax increased from 5.3 ± 0.5 mmol/L PRE to 6.2 ± 0.6 mmol/L POST (p < 0.0001). The percentage of pts with normal sK concentrations decreased from 82% PRE to 29% POST (p < 0.0001). Mild hyperkalemia increased from 18 to 52% (p < 0.001); in 31% of the patients, it was necessary to reduce the K dialysate concentration. None of the patients had severe hyperkalemia PRE, but 19% developed severe hyperkalemia POST (p < 0.0001) necessitating treatment withdrawal. Mean sK in these pts varied from 5.2 ± 0.3 mmol/L PRE to 6.5 ± 0.2 mmol/L at the moment of withdrawal (p < 0.0001) and sKmax from 5.5 ± mmol/L PRE to 6.9 ± 0.3 mmol/L (p< 0.0001). After withdrawal of ACEi/ARB, sK and sKmax concentrations decreased to basal levels within 1 month. There were no significant changes of BW, IWG, SBP, DBP, Na, Hb, Kt/V, sBic, and PCRn in both periods.
CONCLUSIONS
ACEi/ARB therapy is associated with an increased risk of hyperkalemia in anuric hemodialysis patients. The proportion of patients with normal sK concentrations decreased from 82 to 29% and with mild hyperkalemia increased from 18 to 52%. Severe hyperkalemia necessitating the interruption of ACEi/ARB therapy developed in 19% of patients. This suggests great caution in the widest utilization of this class of drugs in HD patients.
背景
血管紧张素转换酶抑制剂（ACEi）和血管紧张素受体阻滞剂（ARB）在尿毒症患者（pts）中的应用越来越广泛。然而，它们对接受慢性血液透析治疗（HD）的无尿患者血清钾（sK）浓度的影响仍存在争议。本研究的目的是评估 ACEi/ARB 治疗开始前后的 sK。
方法
在 2015 年 1 月 1 日至 12 月 31 日期间，我院接受每周三次 HD 治疗的 240 例持续性 HD 患者中有 112 例开始接受 ACEi/ARB 治疗。平均年龄为 67 ± 14 岁，67/112 例为男性，透析龄为 6-212 个月。在 ACEi/ARB 治疗开始前（PRE；N°36 次 HD 治疗）和开始后（POST；N°36 次 HD 治疗）的 3 个月内，评估了长透析间期后预透析时的以下变量：sK（12 次测定的平均值；mmol/L）、最大 sK（观察期间观察到的最大 K 值；sKmax；mmol/L）、血清钠（sNa；mmol/L）、预透析收缩压（SBP；mmHg）和舒张压（DBP；mmHg）、体重（BW；kg）、透析间期体重增加（IWG；kg）、Kt/V、血清碳酸氢盐浓度（sBic；mmol/L）、蛋白分解率（PCRn；g/kgBW/天）。SBP、DBP、IWG 为 24 次 HD 治疗的平均值。在 112 例患者中，有 102 例正在接受降压治疗。HD 时间、血液和透析液流量保持不变。数据表示为平均值 ± SD。对于正态分布变量，采用配对和非配对学生 t 检验，对于中位数，采用曼-惠特尼检验，对于分类数据，采用卡方检验来比较组间差异。定义差异有统计学意义为 p<0.05。
结果
sK 从 PRE 的 5.0 ± 0.4 mmol/L 增加到 POST 的 5.7 ± 0.5 mmol/L（p<0.0001）。sKmax 从 PRE 的 5.3 ± 0.5 mmol/L 增加到 POST 的 6.2 ± 0.6 mmol/L（p<0.0001）。sK 正常浓度的患者比例从 PRE 的 82%下降到 POST 的 29%（p<0.0001）。轻度高钾血症的比例从 18%增加到 52%（p<0.001）；在 31%的患者中，需要降低透析液中 K 的浓度。在 PRE 没有患者出现严重高钾血症，但有 19%的患者在 POST 出现严重高钾血症（p<0.0001），需要停止治疗。在这些患者中，有 19%的患者在停止 ACEi/ARB 治疗后，sK 从 PRE 的 5.2 ± 0.3 mmol/L 增加到 POST 的 6.5 ± 0.2 mmol/L（p<0.0001），sKmax 从 PRE 的 5.5 ± mmol/L 增加到 POST 的 6.9 ± 0.3 mmol/L（p<0.0001）。停止 ACEi/ARB 治疗后，sK 和 sKmax 浓度在 1 个月内降至基础水平。在两个时期，BW、IWG、SBP、DBP、Na、Hb、Kt/V、sBic 和 PCRn 均无显著变化。
结论
ACEi/ARB 治疗与无尿血液透析患者高钾血症风险增加相关。sK 正常浓度患者的比例从 82%下降到 29%，轻度高钾血症的比例从 18%增加到 52%。有 19%的患者出现需要中断 ACEi/ARB 治疗的严重高钾血症。这表明在 HD 患者中广泛使用这类药物时需要非常谨慎。
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