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Hyperkalemia After Initiating Renin-Angiotensin System Blockade: The Stockholm Creatinine Measurements (SCREAM) Project.
J Am Heart Assoc. 2017 Jul 19; 6(7)JA

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 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 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.

Authors+Show Affiliations

Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD.Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.Division of Nephrology, Geisinger Health System, Danville, PA.Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.Department of Medical Sciences, Cardiovascular Epidemiology, Uppsala University, Uppsala, Sweden. School of Health and Social Studies, Dalarna University, Falun, Sweden.Unit of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.Division of Nephrology, Tufts Medical Center, Boston, MA.Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD mgrams2@jhmi.edu. Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.

Pub Type(s)

Journal Article
Validation Study

Language

eng

PubMed ID

28724651

Citation

Bandak, Ghassan, et al. "Hyperkalemia After Initiating Renin-Angiotensin System Blockade: the Stockholm Creatinine Measurements (SCREAM) Project." Journal of the American Heart Association, vol. 6, no. 7, 2017.
Bandak G, Sang Y, Gasparini A, et al. Hyperkalemia After Initiating Renin-Angiotensin System Blockade: The Stockholm Creatinine Measurements (SCREAM) Project. J Am Heart Assoc. 2017;6(7).
Bandak, G., Sang, Y., Gasparini, A., Chang, A. R., Ballew, S. H., Evans, M., Arnlov, J., Lund, L. H., Inker, L. A., Coresh, J., Carrero, J. J., & Grams, M. E. (2017). Hyperkalemia After Initiating Renin-Angiotensin System Blockade: The Stockholm Creatinine Measurements (SCREAM) Project. Journal of the American Heart Association, 6(7). https://doi.org/10.1161/JAHA.116.005428
Bandak G, et al. Hyperkalemia After Initiating Renin-Angiotensin System Blockade: the Stockholm Creatinine Measurements (SCREAM) Project. J Am Heart Assoc. 2017 Jul 19;6(7) PubMed PMID: 28724651.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Hyperkalemia After Initiating Renin-Angiotensin System Blockade: The Stockholm Creatinine Measurements (SCREAM) Project. AU - Bandak,Ghassan, AU - Sang,Yingying, AU - Gasparini,Alessandro, AU - Chang,Alex R, AU - Ballew,Shoshana H, AU - Evans,Marie, AU - Arnlov,Johan, AU - Lund,Lars H, AU - Inker,Lesley A, AU - Coresh,Josef, AU - Carrero,Juan-Jesus, AU - Grams,Morgan E, Y1 - 2017/07/19/ PY - 2017/7/21/entrez PY - 2017/7/21/pubmed PY - 2018/4/25/medline KW - angiotensin receptor blockers KW - angiotensin‐converting enzyme inhibition KW - angiotensin‐converting enzyme inhibitors KW - chronic kidney disease KW - hyperkalemia KW - potassium KW - risk score JF - Journal of the American Heart Association JO - J Am Heart Assoc VL - 6 IS - 7 N2 - 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 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 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. SN - 2047-9980 UR - https://www.unboundmedicine.com/medline/citation/28724651/Hyperkalemia_After_Initiating_Renin_Angiotensin_System_Blockade:_The_Stockholm_Creatinine_Measurements__SCREAM__Project_ L2 - https://www.ahajournals.org/doi/10.1161/JAHA.116.005428?url_ver=Z39.88-2003&amp;rfr_id=ori:rid:crossref.org&amp;rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -