Svensson Maria K, Fischereder Michael, Kalra Paul R, Sánchez Lázaro Ignacio José, Lesén Eva, Franzén Stefan, Allum Alaster, Cars Thomas, Kossack Nils, Breitbart Philipp, Arroyo David
Department of Medical Sciences, Renal Medicine, Uppsala University, Uppsala, Sweden.
Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden.
Kidney360. 2024 Dec 1;5(12):1813-1823. doi: 10.34067/KID.0000000000000561. Epub 2024 Aug 21.
Renin-angiotensin-aldosterone system inhibitor (RAASi) therapy is frequently downtitrated or discontinued after a hyperkalemia episode. Reducing RAASi therapy after a hyperkalemia episode is associated with increased risk of hospitalization compared with maintaining RAASi. Our data suggest that a hospitalization within 6 months could be avoided if 25 patients maintained instead of reduced their RAASi therapy.
Renin-angiotensin-aldosterone system inhibitor (RAASi) therapy provides cardiorenal protection but is often downtitrated or discontinued after a hyperkalemia episode. This observational study describes the extent of hyperkalemia-related RAASi reduction in patients with CKD and/or heart failure (HF) and estimates the number needed to treat (NNT) to avoid a first hospitalization if RAASi had been maintained at the prior dose.
Health care registers and claims data from Germany, Spain, Sweden, and the United Kingdom were used to identify nondialysis patients with CKD and/or HF who had a hyperkalemia episode while on RAASi. Patients whose RAASi therapy was reduced (downtitrated/discontinued) after the hyperkalemia episode were propensity score matched to those with maintained RAASi, and their risks of a hospitalization within 6 months were estimated using the Kaplan–Meier method. On the basis of the absolute difference in this 6-month risk, the NNT framework was applied to estimate the number of patients who needed to have maintained instead of reduced their RAASi to avoid a first hospitalization during this period.
Overall, 40,059 patients from Germany, Spain, Sweden, and the United Kingdom were included. Presence of CKD at baseline was similar across countries (72%–92%), while HF was less common in Spain (18%) versus other countries (32%–71%). After the hyperkalemia episode, RAASi was reduced in 25%–57% of patients. After propensity score matching, the 6-month risk of hospitalization was consistently higher in those with reduced versus maintained RAASi; the absolute risk difference ranged from 2.7% to 7.3%. Applying the NNT framework, these data suggest that a first hospitalization within 6 months could potentially have been avoided if 25 patients had maintained instead of reduced their RAASi.
Our findings suggest a potential for avoiding a first hospitalization, even within a short time frame, by increasing adherence to guidelines to maintain instead of reduce RAASi after a hyperkalemia episode.
高钾血症发作后，肾素-血管紧张素-醛固酮系统抑制剂（RAASi）治疗常常会减量或停药。与维持RAASi治疗相比，高钾血症发作后减少RAASi治疗与住院风险增加相关。我们的数据表明，如果25名患者维持而非减少RAASi治疗，那么6个月内可避免住院。
肾素-血管紧张素-醛固酮系统抑制剂（RAASi）治疗可提供心肾保护，但在高钾血症发作后常被减量或停用。这项观察性研究描述了慢性肾脏病（CKD）和/或心力衰竭（HF）患者中与高钾血症相关的RAASi减量情况，并估计了若将RAASi维持在先前剂量以避免首次住院所需的治疗人数（NNT）。
利用德国、西班牙、瑞典和英国的医疗保健登记和索赔数据，识别在接受RAASi治疗期间发生高钾血症发作的非透析CKD和/或HF患者。高钾血症发作后RAASi治疗减量（减量/停药）的患者与维持RAASi治疗的患者进行倾向评分匹配，并使用Kaplan-Meier方法估计他们6个月内的住院风险。基于这6个月风险的绝对差异，应用NNT框架来估计为避免在此期间首次住院而需要维持而非减少RAASi治疗的患者人数。
总体而言，纳入了来自德国、西班牙、瑞典和英国的40059名患者。各国基线时CKD的存在情况相似（72% - 92%），而西班牙HF的发生率较低（18%），其他国家为（32% - 71%）。高钾血症发作后，25% - 57%的患者RAASi治疗减量。倾向评分匹配后，RAASi治疗减量的患者6个月内的住院风险始终高于维持治疗的患者；绝对风险差异在2.7%至7.3%之间。应用NNT框架，这些数据表明，如果25名患者维持而非减少RAASi治疗，那么6个月内可能避免首次住院。
我们的研究结果表明，通过提高对指南的依从性，在高钾血症发作后维持而非减少RAASi治疗，即使在短时间内也有可能避免首次住院。
