维持性血液透析患者血钾水平及其对预后影响

doi:10.3969/j.issn.1674-8115.2023.04.015

摘要/Abstract

摘要：

维持性血液透析是终末期肾病患者肾脏替代治疗的方式之一，血钾异常是维持性血液透析患者常见的代谢并发症，透析前高钾血症、透析期间和透析后低钾血症均可能与维持性血透患者全因死亡、心血管事件死亡有关。目前，血钾波动对患者预后的影响受到广泛关注，因维持性血液透析的间歇性治疗特点，患者经历更频繁的血钾波动，血钾变异性能较好地反映患者血钾稳态情况，血钾变异性大是维持性血液透析患者不良预后的潜在危险因素。此外，透析过程中患者血钾水平的急性变化易增加患者恶性心律失常、心源性猝死和其他不良预后的发生风险。血清-透析液钾浓度梯度是影响钾清除的重要因素，其他透析液成分同样影响血钾清除。因此，加强患者血钾水平的监测和管理，选择适宜的透析液钾浓度，个体化制定透析处方有利于维持性血液透析患者维持钾稳态，减少血钾异常发生，改善预后。该文简要阐述维持性血液透析患者血钾水平的变化特点，讨论维持性血液透析患者血钾水平对预后的影响，强调血钾变异与患者预后的关系以及透析液成分对血钾水平稳定的影响。

关键词: 维持性血液透析, 钾, 变异性, 透析液钾, 预后

Abstract:

Maintenance hemodialysis is one of the renal replacement therapy that end-stage renal disease patients mainly rely on. Dyskalemia is one of the most common metabolic complications in patients undergoing maintenance hemodialysis. Both pre-dialysis hyperkalemia and hypokalemia during and after dialysis may contribute to a higher risk of all-cause mortality, cardiovascular mortality in hemodialysis patients. The impact of serum potassium fluctuation has attracted widespread attention in recent years. Due to the intermittent nature of maintenance hemodialysis, patients are prone to frequent fluctuations of serum potassium. Potassium variability may be a better indicator to reflect potassium homeostasis, and large variability of potassiun is recognized as a potential risk factor for poor outcomes. In addition, the rapid fluctuation of serum potassium concentration during hemodialysis may increase the risk of malignant arrhythmia, sudden cardiac death and other poor outcomes. The gradient of serum and dialysate potassium is an important factor that influence the removal of potassium, which is also affected by other dialysate components. Therefore, strengthening the monitoring and management of serum potassium, selecting appropriate dialysate potassium concentration and individualizing dialysate prescription may be beneficial to maintain potassium homeostasis, reduce dyskalemia and improve prognosis. This review briefly expounds the feature of serum potassium level and discusses its effect on outcomes in patients with maintenance hemodialysis, emphasizing the relevance of potassium variation and prognosis in patients with maintenance hemodialysis and the impact of dialysate composition on potassium homeostasis.

Key words: maintenance hemodialysis, potassium, variability, dialysate potassium, prognosis

中图分类号:

R459.5

门如, 朱旻霞, 张伟明. 维持性血液透析患者血钾水平及其对预后影响[J]. 上海交通大学学报（医学版）, 2023, 43(4): 507-513.

MEN Ru, ZHU Minxia, ZHANG Weiming. Serum potassium level in maintenance hemodialysis patients and its effect on outcome[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2023, 43(4): 507-513.

参考文献 50

1	KOVESDY C P. Management of hyperkalaemia in chronic kidney disease[J]. Nat Rev Nephrol, 2014, 10(11): 653-662.
2	边佳明, 左力, 赵厚宇, 等. 中国门诊患者高钾血症分布及诊疗现状的流行病学研究[J].中国血液净化, 2020, 19(11): 726-729, 746.
	BIAN J M, ZUO L, ZHAO H Y, et al. Epidemiology and treatment pattern of hyperkalemia among outpatients in China: a descriptive study using an administrative database in China[J]. Chinese Journal of Blood Purification, 2020, 19(11): 726-729, 746.
3	AGAR B U, CULLETON B F, FLUCK R, et al. Potassium kinetics during hemodialysis[J]. Hemodial Int, 2015, 19(1): 23-32.
4	BLUMBERG A, ROSER H W, ZENHNDER C, et al. Plasma potassium in patients with terminal renal failure during and after haemodialysis; relationship with dialytic potassium removal and total body potassium[J]. Nephrol Dial Transplant, 1997, 12(8): 1629-1634.
5	KOVESDY C P. Fluctuations in plasma potassium in patients on dialysis[J]. Nephrol Dial Transplant, 2019, 34(Suppl 3): iii19-iii25.
6	MERCADAL L, LAMBERT O, COUCHOUD C, et al. Prescription patterns of dialysate potassium and potassium binders and survival on haemodialysis: the French Renal Epidemiology and Information Network registry[J]. Nephrol Dial Transplant, 2021, 36(1): 151-159.
7	HE H D, WU J J, LU W, et al. A multicenter study of hemodialysis using individualized dialysate potassium concentrations[J]. Ann Palliat Med, 2021, 10(12): 12218-12229.
8	SHIBATA S, UCHIDA S. Hyperkalemia in patients undergoing hemodialysis: its pathophysiology and management[J]. Ther Apher Dial, 2022, 26(1): 3-14.
9	BANSAL S, PERGOLA P E. Current management of hyperkalemia in patients on dialysis[J]. Kidney Int Rep, 2020, 5(6): 779-789.
10	EPSTEIN M, LIFSCHITZ M D. The unappreciated role of extrarenal and gut sensors in modulating renal potassium handling: implications for diagnosis of dyskalemias and interpreting clinical trials[J]. Kidney Int Rep, 2016, 1(1): 43-56.
11	PALMER B F, CLEGG D J. Diagnosis and treatment of hyperkalemia[J]. Cleve Clin J Med, 2017, 84(12): 934-942.
12	PUN P H, MIDDLETON J P. Dialysate potassium, dialysate magnesium, and hemodialysis risk[J]. J Am Soc Nephrol, 2017, 28(12): 3441-3451.
13	FEIG P U, SHOOK A, STERNS R H. Effect of potassium removal during hemodialysis on the plasma potassium concentration[J]. Nephron, 1981, 27(1): 25-30.
14	SANDLE G I, GAIGER E, TAPSTER S, et al. Evidence for large intestinal control of potassium homoeostasis in uraemic patients undergoing long-term dialysis[J]. Clin Sci (Lond), 1987, 73(3): 247-252.
15	CUPISTI A, KOVESDY C P, D'ALESSANDRO C, et al. Dietary approach to recurrent or chronic hyperkalaemia in patients with decreased kidney function[J]. Nutrients, 2018, 10(3): 261.
16	United States Renal Data System. 2021 USRDS Annual Data Report: Epidemiology of kidney disease in the United States[EB/OL]. (2023-01-08) [2022-06-01]. https://adr.usrds.org/2021.
17	赵新菊, 甘良英, 牛庆雨, 等. 中国血液透析患者死亡原因及特点分析: DOPPS研究的启示[J].中国血液净化, 2022, 21(2): 89-93.
	ZHAO X J, GAN L Y, NIU Q Y, et al. The cause of death and its related information in hemodialysis patients in China: enlightenment from the DOPPS study[J]. Chinese Journal of Blood Purification, 2022, 21(2): 89-93.
18	黄耀禹, 王静, 王宁宁, 等. 维持性血液透析患者高钾血症及其反复发作的相关因素[J].中华医学杂志, 2021, 101(42): 3484-3489.
	HUANG Y Y, WANG J, WANG N N, et al. Related factors for hyperkalemia and its recurrence in maintenance hemodialysis patients[J]. National Medical Journal of China, 2021, 101(42): 3484-3489.
19	ROSSIGNOL P, LAMIRAL Z, FRIMAT L, et al. Hyperkalaemia prevalence, recurrence and management in chronic haemodialysis: a prospective multicentre French regional registry 2-year survey[J]. Nephrol Dial Transplant, 2017, 32(12): 2112-2118.
20	HOPPE L K, MUHLACK D C, KOENIG W, et al. Association of abnormal serum potassium levels with arrhythmias and cardiovascular mortality: a systematic review and meta-analysis of observational studies[J]. Cardiovasc Drugs Ther, 2018, 32(2): 197-212.
21	KARABOYAS A, ZEE J, BRUNELLI S M, et al. Dialysate potassium, serum potassium, mortality, and arrhythmia events in hemodialysis: results from the dialysis outcomes and practice-patterns study (DOPPS)[J]. Am J Kidney Dis, 2017, 69(2): 266-277.
22	KARABOYAS A, ROBINSON B M, JAMES G, et al. Hyperkalemia excursions are associated with an increased risk of mortality and hospitalizations in hemodialysis patients[J]. Clin Kidney J, 2020, 14(7): 1760-1769.
23	赵新菊, 牛庆雨, 甘良英, 等. 基于DOPPS研究分析中国血液透析患者高钾血症的患病率及相关影响因素[J]. 中国血液净化, 2021, 20(3): 145-150, 156.
	ZHAO X J, NIU Q Y, GAN L Y, et al. The prevalence and risk factors of hyperkalemia in Chinese hemodialysis patients based on the China Dialysis Outcomes and Practice Patterns Study[J]. Chinese Journal of Blood Purification, 2021, 20(3): 145-150, 156.
24	FERRARO P M, BOLIGNANO D, AUCELLA F, et al. Hyperkalemia excursions and risk of mortality and hospitalizations in hemodialysis patients: results from DOPPS-Italy[J]. J Nephrol, 2022, 35(2): 707-709.
25	KOVESDY C P, REGIDOR D L, MEHROTRA R, et al. Serum and dialysate potassium concentrations and survival in hemodialysis patients[J]. Clin J Am Soc Nephrol, 2007, 2(5): 999-1007.
26	YUSUF A A, HU Y, SINGH B, et al. Serum potassium levels and mortality in hemodialysis patients: a retrospective cohort study[J]. Am J Nephrol, 2016, 44(3): 179-186.
27	TAFESSE E, HURST M, SUGRUE D, et al. Serum potassium as a predictor of adverse clinical outcomes in patients with increasing comorbidity burden[J]. Eur Heart J Qual Care Clin Outcomes, 2022, 8(1): 61-69.
28	DE ROOIJ E N M, DEKKER F W, LE CESSIE S, et al. Serum potassium and mortality risk in hemodialysis patients: a cohort study[J]. Kidney Med, 2022, 4(1): 100379.
29	PUN P H, LEHRICH R W, HONEYCUTT E F, et al. Modifiable risk factors associated with sudden cardiac arrest within hemodialysis clinics[J]. Kidney Int, 2011, 79(2): 218-227.
30	LEE S, KANG E, YOO K D, et al. Lower serum potassium associated with increased mortality in dialysis patients: a nationwide prospective observational cohort study in Korea[J]. PLoS One, 2017, 12(3): e0171842.
31	TORLÉN K, KALANTAR-ZADEH K, MOLNAR M Z, et al. Serum potassium and cause-specific mortality in a large peritoneal dialysis cohort[J]. Clin J Am Soc Nephrol, 2012, 7(8): 1272-1284.
32	OHNISHI T, KIMACHI M, FUKUMA S, et al. Postdialysis hypokalemia and all-cause mortality in patients undergoing maintenance hemodialysis[J]. Clin J Am Soc Nephrol, 2019, 14(6): 873-881.
33	HESSELS L, HOEKSTRA M, MIJZEN L J, et al. The relationship between serum potassium, potassium variability and in-hospital mortality in critically ill patients and a before-after analysis on the impact of computer-assisted potassium control[J]. Crit Care, 2015, 19(1): 4.
34	ENGELHARDT L J, BALZER F, MÜLLER M C, et al. Association between potassium concentrations, variability and supplementation, and in-hospital mortality in ICU patients: a retrospective analysis[J]. Ann Intensive Care, 2019, 9(1): 100.
35	LOMBARDI G, GAMBARO G, FERRARO P M. Serum potassium variability is associated with increased mortality in a large cohort of hospitalized patients[J]. Nephrol Dial Transplant, 2022, 37(8): 1482-1487.
36	XU Q D, XU F H, FAN L, et al. Serum potassium levels and its variability in incident peritoneal dialysis patients: associations with mortality[J]. PLoS One, 2014, 9(1): e86750.
37	LI S H, XIE J T, LONG H B, et al. Time-averaged serum potassium levels and its fluctuation associate with 5-year survival of peritoneal dialysis patients: two-center based study[J]. Sci Rep, 2015. 5: 15743.
38	DASHPUTRE A A, POTUKUCHI P K, SUMIDA K, et al. Predialysis potassium variability and postdialysis mortality in patients with advanced CKD[J]. Kidney Int Rep, 2021, 6(2): 366-380.
39	BUEMI M, ALOISI E, COPPOLINO G, et al. The effect of two different protocols of potassium haemodiafiltration on QT dispersion[J]. Nephrol Dial Transplant, 2005, 20(6): 1148-1154.
40	MORRISON G, MICHELSON E L, BROWN S, et al. Mechanism and prevention of cardiac arrhythmias in chronic hemodialysis patients[J]. Kidney Int, 1980, 17(6): 811-819.
41	SANTORO A, MANCINI E, LONDON G, et al. Patients with complex arrhythmias during and after haemodialysis suffer from different regimens of potassium removal[J]. Nephrol Dial Transplant, 2008, 23(4): 1415-1421.
42	ABUELO J G. Low dialysate potassium concentration: an overrated risk factor for cardiac arrhythmia?[J]. Semin Dial, 2015, 28(3): 266-275.
43	JADOUL M, THUMMA J, FULLER D S, et al. Modifiable practices associated with sudden death among hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study[J]. Clin J Am Soc Nephrol, 2012, 7(5): 765-774.
44	FERREY A, YOU A S, KOVESDY C P, et al. Dialysate potassium and mortality in a prospective hemodialysis cohort[J]. Am J Nephrol, 2018, 47(6): 415-423.
45	ADROGUÉ H J, MADIAS N E. Changes in plasma potassium concentration during acute acid-base disturbances[J]. Am J Med, 1981, 71(3): 456-467.
46	HEGUILÉN R M, SCIURANO C, BELLUSCI A D, et al. The faster potassium-lowering effect of high dialysate bicarbonate concentrations in chronic haemodialysis patients[J]. Nephrol Dial Transplant, 2005, 20(3): 591-597.
47	ALHOSAINI M, LEEHEY D J. Magnesium and dialysis: the neglected cation[J]. Am J Kidney Dis, 2015, 66(3): 523-531.
48	MCGILL R L, WEINER D E. Dialysate composition for hemodialysis: changes and changing risk[J]. Semin Dial, 2017, 30(2): 112-120.
49	PALMER B F, CARRERO J J, CLEGG D J, et al. Clinical management of hyperkalemia[J]. Mayo Clin Proc, 2021, 96(3): 744-762.
50	SHERMAN R A, HWANG E R, BERNHOLC A S, et al. Variability in potassium removal by hemodialysis[J]. Am J Nephrol, 1986, 6(4): 284-288.

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