A Retrospective Analysis of Patients Presenting with Acute Hyperkalemia in an Emergency Care Setting.

Objective: We aimed to analyze the clinical characteristics and prognostic factors of patients with severe hyperkalemia in the emergency department. Methods: This retrospective cohort study included adult patients diagnosed with severe hyperkalemia who sought medical care at the emergency department of Aerospace Center Hospital between January 2018 and May 2022. Clinical data, including demographics, comorbidities, laboratory findings, and outcomes, were systematically collected. Patients were categorized into survival and deceased groups based on in-hospital mortality. Comparative analysis between these groups identified significant differences, highlighting key clinically covariates. Binary logistic regression was employed to determine the primary factors influencing patient outcomes. Results: Of 90 patients diagnosed with severe hyperkalemia, 64 were in the survival group, and 26 in the deceased group. Binary logistic regression identified several significant predictors of mortality, including higher APACHE II scores (odds ratio [OR] 1.41, P = 0.02), widened QRS wave on electrocardiogram (ECG) (OR 79.39, P = 0.04), and elevated serum potassium levels (OR 1.3, P = 0.04). In contrast, emergency blood purification was associated with a reduced mortality rate (OR 0.29, P = 0.03). Conclusion: Key risk factors for mortality in patients with severe hyperkalemia include widened QRS wave on ECG, elevated APACHE II score, and high serum potassium level. Timely correction of hyperkalemia through emergency blood purification significantly improves patient outcomes.

Risk and predictors of severe hyperkalemia after total parathyroidectomy without auto-transplantation in patients with secondary hyperparathyroidism.

Objective: To identify the risk factors of postoperative severe hyperkalemia after total parathyroidectomy (TPTX) without auto-transplantation in patients with secondary hyperparathyroidism (SHPT). Methods: Data on 406 consecutive patients who underwent TPTX without auto-transplantation for secondary hyperparathyroidism at the General Hospital of Northern Theater Command between January 2013 and January 2023, were prospectively collected. Then, patients were divided into the training set (n=203) and the validation set (n=203) in a ratio of 1:1 by timeline. The patients were divided into severe hyperkalemia group and non-hyperkalemia group according to the postoperative serum kalium level >6.0 mmol/L with ECG changes or serum kalium level ≥6.5 mmol/L. Univariate and multivariate logistic regression analyses were used to evaluate the possible risk factors associated with postoperative severe hyperkalemia after TPTX. The predictive performance was evaluated with receiver operating characteristic (ROC) curves with the areas under the ROC curve (AUC) and calibration curve. Decision curve and clinical impact curve analyses were used to validate the clinical application of the value. Results: The incidence of postoperative severe hyperkalemia was 15.5% in all patients, 17.2% and 13.8% in the training and validation cohorts, respectively. The risk factors associated with postoperative severe hyperkalemia was higher preoperative kalium level. The optimal cut-off value for preoperative serum kalium level was 5.0mmol/L according to the ROC curve. The area under the curve (AUC) achieved good concordance indexes of 0.845 (95%CI, 0.776-0.914) in the training cohort. The sensitivities were 0.829 (95%CI: 0.663-0.934) and 0.857 (95%CI: 0.673-0.960) in the training and validation cohorts, respectively. The specificities were 0.798 (95%CI: 0.729-0.856) and 0.720 (95%CI:0.647-0.785) in the training and validation cohorts, respectively. Calibration curve exhibited a good consistency between actual observations and predicted severe hyperkalemia in the training and validation cohorts. Conclusions: Our study found that the preoperative kalium levels is only a risk factor for postoperative severe hyperkalemia in patients undergoing TPTX for secondary hyperparathyroidism. The threshold for preoperative serum kalium levels is 5.0mmol/L that can serve as a useful indicator for identifying patients with severe hyperkalemia after surgery. These results provide valuable suggestion for clinical practice.

Sodium Zirconium Cyclosilicate for Renin-Angiotensin-Aldosterone System Inhibitor Optimization in Patients with Heart Failure with Reduced Ejection Fraction: A Retrospective Analysis.

INTRODUCTION: In this retrospective analysis, we evaluate the effectiveness of the potassium (K+) binder sodium zirconium cyclosilicate (SZC) in maintaining normokalemia and facilitating the initiation, optimization, and maintenance of renin-angiotensin-aldosterone system inhibitors (RAASi) in patients with heart failure (HF) with reduced ejection fraction (HFrEF). METHODS: A total of 44 patients with HFrEF and a history of hyperkalemia who were receiving SZC to enable the prescription of RAASi were identified from two district general hospital sites. Retrospective analysis was performed to determine biochemical response, alterations in pharmacotherapy, and subsequent HF outcomes following initiation of SZC. RESULTS: Mean K+ was reduced by 0.9 mmol/L within 1 month of initiation of SZC; mean K+ after 12 months of treatment was 4.8 mmol/L with a median (interquartile range) duration of treatment of 13 (8.4-15.1) months. Following SZC treatment, 100% of patients received an angiotensin receptor-neprilysin inhibitor (18% increase) and 93% received a mineralocorticoid receptor antagonist (41% increase), with 59% and 37% achieving guideline-recommended dosing, respectively. Ninety-one percent of patients were able to receive triple or quadruple therapy with the addition of a beta-blocker and a sodium glucose co-transporter 2 inhibitor. Reduced rates of hospitalization for HF (HHF) were observed with 12 episodes per 100 patient-years recorded (reduced from 21) in addition to improvements in mean left ventricular ejection fraction (29-36%) and median N-terminal pro-B-type natriuretic peptide (3458-2055 ng/L, 45% median reduction). Renal function (creatinine clearance increased from 48.4 to 49.3 ml/min) and systolic blood pressure (decreased from 124 to 122 mmHg) were similar following optimization, and no tolerability issues were identified. CONCLUSIONS: Extended real-world treatment with the K+ binder SZC was effective at maintaining normokalemia, and was associated with a greater uptake of RAASi, a reduced rate of HHF, and improvements in cardiac biomarkers in patients with HFrEF.

Cardiovascular events in crush syndrome: on-site therapeutic strategies and pharmacological investigations.

Crush syndrome often occurs after severe crush injury caused by disasters or accidents, and is associated with high mortality and poor prognosis. Cardiovascular complications, such as cardiac arrest, hypovolemic shock, and hyperkalemia-related cardiac dysfunction, are the primary causes of on-site death in crush syndrome. Prehospital evaluation, together with timely and correct treatment, is of great benefit to crush syndrome patients, which is difficult in most cases due to limited conditions. Based on current data and studies, early fluid resuscitation remains the most important on-site treatment for crush syndrome. Novel solutions and drugs used in fluid resuscitation have been investigated for their effectiveness and benefits. Several drugs have proven effective for the prevention or treatment of cardiovascular complications in crush syndrome, such as hypovolemic shock, hyperkalemia-induced cardiac complications, myocardial ischemia/reperfusion injury, ventricular dysfunction, and coagulation disorder experimentally. Moreover, these drugs are beneficial for other complications of crush syndrome, such as renal dysfunction. In this review, we will summarize the existing on-site treatments for crush syndrome and discuss the potential pharmacological interventions for cardiovascular complications to provide clues for clinical therapy of crush syndrome.

Mortality Risk Stratification Utilizing Artificial Intelligence Electrocardiogram for Hyperkalemia in Cardiac Intensive Care Unit Patients.

Background: Hyperkalemia has been associated with increased mortality in cardiac intensive care unit (CICU) patients. An artificial intelligence (AI) enhanced electrocardiogram (ECG) can predict hyperkalemia, and other AI-ECG algorithms have demonstrated mortality risk-stratification in CICU patients. Objectives: The authors hypothesized that the AI-ECG hyperkalemia algorithm could stratify mortality risk beyond laboratory serum potassium measurement alone. Methods: We included 11,234 unique Mayo Clinic CICU patients admitted from 2007 to 2018 with a 12-lead ECG and blood potassium (K) level obtained at admission with K ≥5 mEq/L defining hyperkalemia. ECGs underwent AI evaluation for the probability of hyperkalemia (probability >0.5 defined as positive). Hospital mortality was analyzed using logistic regression, and survival to 1 year was estimated using Kaplan-Meier and Cox analysis. Results: In the final cohort (n = 11,234), the mean age was 69.6 ± 10.5 years, 37.8% were females, and 92.4% were White. Chronic kidney disease was present in 20.2%. The mean laboratory potassium value for the cohort was 4.2 ± 0.3 mEq/L. The AI-ECG predicted hyperkalemia in 33.9% (n = 3,810) of CICU patients and 12.9% (n = 1,451) of patients had laboratory-confirmed hyperkalemia (K ≥5 mEq/L). In-hospital mortality increased in false-positive, false-negative, and true-positive patients, respectively (P < 0.001), and each of these patient groups had successively lower survival out to 1 year. Conclusions: AI-ECG-based prediction of hyperkalemia, even with a normal laboratory potassium value, was associated with higher in-hospital mortality and lower 1-year survival in CICU patients. This study demonstrated that AI-ECG probability of hyperkalemia may enable rapid individualized risk stratification in critically ill patients beyond laboratory value alone.

Management of hyperkalemia: Expert consensus from Kuwait - a Modified Delphi Approach.

Introduction: Hyperkalemia is common in heart failure (HF) patients on renin angiotensin aldosterone inhibitors (RAASi), in chronic kidney disease (CKD), and in hemodialysis, and it negatively impacts their management. New potassium binders, such as sodium zirconium cyclosilicate (SZC), are effective in management of acute and chronic hyperkalemia. However, guidelines inconsistencies and lack of standardized treatment protocols are hindering proper and wider use of such agents. Therefore, an expert panel from Kuwait developed a consensus statement to address hyperkalemia management in acute settings, in HF, in CKD, and in hemodialysis. Methods: A three-step modified Delphi method was adopted to develop the present consensus, which consisted of two rounds of voting and in-between a virtual meeting. Twelve experts from Kuwait participated in this consensus. Statements were developed and shared with experts for voting. A meeting was held to discuss statements that did not reach consensus at the first round and then the remaining statements were shared for final voting. Results: The consensus consists of 44 statements involving an introduction to and the management of hyperkalemia in acute settings, HF, CKD, and hemodialysis. Thirty-six statements approved unanimously in the first vote. In the second vote, four statements were removed and four were approved after editing. Conclusion: Hyperkalemia management lacks standardized definitions, treatment thresholds and consistent guidelines and laboratory practices. This consensus is in response to lack of standardized treatment in the Arabian Gulf, and it aims to establish guidance on hyperkalemia management for healthcare practitioners in Kuwait and highlight future needs.

Hyperkalemia and maintenance of renin-angiotensin system inhibitor therapy after initiating SGLT-2 or DPP-4 inhibitors.

BACKGROUND: Post-hoc analyses of clinical trials suggest that sodium-glucose cotransporter-2 inhibitors (SGLT-2i) lower the risk of hyperkalemia and facilitate the use of renin-angiotensin system inhibitors (RASi) in people with type 2 diabetes. Whether this is also observed in routine care is unclear. We investigated whether SGLT-2i lowered the risk of hyperkalemia and RASi discontinuation as compared to dipeptidyl peptidase 4 inhibitors (DPP-4i). METHODS: Using the target trial emulation framework, we studied adults with type 2 diabetes (T2D) who started SGLT-2i or DPP-4i in Stockholm, Sweden (2014-2021). The outcomes were incident hyperkalaemia (potassium > 5.0 mmol/L), mild hyperkalemia (potassium > 5-≤5.5 mmol/L) and moderate to severe hyperkalemia (potassium > 5.5 mmol/L). Among RASi users, we studied time to RASi discontinuation through evaluation of pharmacy fills. Cox regression with inverse probability of treatment weighting was used to estimate per-protocol hazard ratios (HRs). RESULTS: 29 849 individuals (15 326 SGLT-2i and 14 523 DPP-4i initiators) were included (mean age 66 years, 37% women). About one third of participants in each arm discontinued treatment within a year. Compared with DPP-4i, SGLT-2i use was associated with a lower rate of hyperkalemia (HR 0.77; 95% CI: 0.64-0.93), including both mild (0.76; 0.62-0.93) and moderate/severe (0.53; 0.40-0.69) hyperkalemia events. Of 19.116 participants that used RASi at baseline, 7% discontinued therapy. Initiation of SGLT-2i vs. DPP-4i was not associated with the rate of RASi discontinuation (0.97; 0.83-1.14). Results were consistent in intention-to-treat analyses and across strata of age, sex, cardiovascular comorbidity, and baseline kidney function. CONCLUSIONS: In patients with diabetes managed in routine clinical care, the use of SGLT-2i was associated with lower rates of hyperkalemia compared with DPP-4i. Possibly because of a relatively high rate of treatment discontinuations, this was not accompanied by higher persistence on RASi therapy.

Serum Potassium Monitoring Using AI-Enabled Smartwatch Electrocardiograms.

BACKGROUND: Hyperkalemia, characterized by elevated serum potassium levels, heightens the risk of sudden cardiac death, particularly increasing risk for individuals with chronic kidney disease and end-stage renal disease (ESRD). Traditional laboratory test monitoring is resource-heavy, invasive, and unable to provide continuous tracking. Wearable technologies like smartwatches with electrocardiogram (ECG) capabilities are emerging as valuable tools for remote monitoring, potentially allowing for personalized monitoring with artificial intelligence (AI)-ECG interpretation. OBJECTIVES: The purpose of this study was to develop an AI-ECG algorithm to predict serum potassium level in ESRD patients with smartwatch-generated ECG waveforms. METHODS: A cohort of 152,508 patients with 293,557 ECGs paired serum potassium levels obtained within 1 hour at Cedars Sinai Medical Center was used to train an AI-ECG model ("Kardio-Net") to predict serum potassium level. The model was further fine-tuned on 4,337 ECGs from 1,463 patients with ESRD using inputs from 12- and single-lead ECGs. Kardio-Net was evaluated in held-out test cohorts from Cedars Sinai Medical Center and Stanford Healthcare (SHC) as well as a prospective international cohort of 40 ESRD patients with smartwatch ECGs at Chang Gung Memorial Hospital. RESULTS: The Kardio-Net, when applied to 12-lead ECGs, identified severe hyperkalemia (>6.5 mEq/L) with an AUC of 0.852 (95% CI: 0.745-0.956) and a mean absolute error (MAE) of 0.527 mEq/L. In external validation at SHC, the model achieved an AUC of 0.849 (95% CI: 0.823-0.875) and an MAE of 0.599 mEq/L. For single-lead ECGs, Kardio-Net detected severe hyperkalemia with an AUC of 0.876 (95% CI: 0.765-0.987) in the primary cohort and had an MAE of 0.575 mEq/L. In the external SHC validation, the AUC was 0.807 (95% CI: 0.778-0.835) with an MAE of 0.740 mEq/L. Using prospectively obtained smartwatch data, the AUC was 0.831 (95% CI: 0.693-0.975), with an MAE of 0.580 mEq/L. CONCLUSIONS: We validate a deep learning model to predict serum potassium levels from both 12-lead ECGs and single-lead smartwatch data, demonstrating its utility for remote monitoring of hyperkalemia.

Corrigendum: Effectiveness, safety, and treatment pattern of sodium zirconium cyclosilicate in Chinese patients with hyperkalemia: interim analysis from a multicenter, prospective, real-world study (Actualize Study).

[This corrects the article DOI: 10.3389/fphar.2024.1398953.].

Rapid onset severe hyperkalemia during robotic radical cystectomy: a case report.

Radical cystectomy is a preferred treatment for muscle-invasive bladder cancer.  Despite known complications, rapid onset, severe hyperkalemia necessitating abortion of surgery has not been reported.  In this case report, a patient with end stage renal disease (ESRD) undergoing attempted cystectomy developed severe intraoperative hyperkalemia and acidosis that led to abortion of surgery and transfer to the medical intensive care unit for emergent hemodialysis.  The multifactorial etiology was related to respiratory acidosis, ESRD, patient positioning, clipping of ureters, and body habitus, as well as an idiopathic element.  Knowledge of hyperkalemia etiologies can assist in diagnosis and treatment of this serious condition.

Finerenone's Impact on Major Adverse Cardiovascular Events in Chronic Kidney Disease and Type 2 Diabetes Mellitus: A Systematic Review.

Chronic kidney disease (CKD) impacts about 10% of adults globally and substantially elevates the risk of major adverse cardiovascular events (MACE), such as heart attacks, strokes, cardiovascular-related deaths, and hospital admissions due to heart failure. The interplay between CKD and cardiovascular disease (CVD) leads to poor health outcomes. Nevertheless, there is a scarcity of systematic reviews focusing on the effectiveness of finerenone, a new non-steroidal mineralocorticoid receptor antagonist (MRA), in lowering these risks. In this systematic review, we aim to evaluate the impact of finerenone on reducing MACE in individuals with CKD and type 2 diabetes mellitus (T2DM). CKD pathophysiology involves hyperglycemia, hypertension, and dyslipidemia, leading to glomerular hyperfiltration, inflammation, and fibrosis. Traditional treatments, including angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARBs), and sodium-glucose cotransporter-2 inhibitors (SGLT2i), often fall short in preventing cardiovascular events. Steroidal MRAs like spironolactone and eplerenone, while effective in reducing proteinuria, are limited by hyperkalemia risks. Finerenone offers a more selective mechanism, reducing sodium retention, inflammation, and fibrosis, with a lower risk of hyperkalemia. We searched five electronic databases comprehensively, identifying studies consistently demonstrating that finerenone significantly reduces MACE and improves renal outcomes by reducing albuminuria and slowing the fall in estimated glomerular filtration rate (eGFR). However, limitations include study heterogeneity, short follow-up periods, and potential publication bias. In conclusion, finerenone shows promise as a therapeutic option for CKD and T2DM, reducing MACE and improving renal outcomes. Further research is needed to understand its long-term benefits and safety across diverse populations.

Cost-effectiveness of sodium zirconium cyclosilicate for the treatment of hyperkalemia in patients with chronic kidney disease or heart failure in Spain.

BACKGROUND AND OBJECTIVE: Hyperkalemia (HK) is an electrolyte disturbance in the concentration of potassium ions (K+), whose risk increases in patients with chronic kidney disease (CKD) or heart failure (HF) and/or in patients being treated with renin-angiotensin-aldosterone system inhibitors (RAASi). The new oral K+ chelators offer a safe and effective treatment to maintain normokalemia in these patients. The objective of the analysis is to estimate the cost-effectiveness of sodium zirconium cyclosilicate (SZC) for the treatment of chronic HK in patients with CKD or HF versus standard treatment (calcium polystyrene sulfonate and lifestyle modifications) from the perspective of the Spanish National Health System. MATERIALS AND METHODS: Two microsimulation models reflecting the natural history of CKD and HF were used. In both models, K+ levels were simulated individually. Based on efficacy (reduction of K+ levels), quality of life of patients (utilities according to health states, and disutilities of events derived from each pathology and adverse events [AEs] of treatment) and costs considered (cost of treatment for HK, of RAASi treatment and its modification, health states, management of events derived from each pathology, HK episodes, and AEs treatment) (€, 2022), clinical benefit (quality-adjusted life years [QALYs]) and cost results were obtained. A time horizon of the patient's lifetime was used and a discount rate of 3% was applied for costs and outcomes. RESULTS: SZC is a more effective option in both pathologies, with a difference in QALYs of 0.476 in CKD and 0.978 in HF compared to standard treatment, and it represents an incremental cost of € 3,616 and € 14,749, respectively, obtaining an incremental cost-utility ratio of € 7,605/QALY in CKD and € 15,078/QALY in HF. CONCLUSIONS: SZC is a cost-effective alternative for the treatment of HK in patients with CKD or HF, taking into account the reference efficiency values commonly used in Spain.

Prevalence of Hyperkalemia and Familial Hyperkalemic Hypertension in 5100 Patients Referred to a Tertiary Hypertension Unit.

BACKGROUND: Hyperkalemia is a frequent electrolyte alteration whose prevalence varies widely, depending on the adopted cutoff, the setting (inpatients versus outpatients), and the characteristics of the study population. Familial hyperkalemic hypertension (FHH) is a rare cause of hypertension, hyperkalemia, and hyperchloremic metabolic acidosis. METHODS: In this retrospective observational study, we investigated the prevalence of hyperkalemia (serum K+ >5.2 mmol/L on 2 repeated measurements) in 5100 referred patients affected by arterial hypertension, the potential causes, and the associated cardiovascular risk profile. RESULTS: Overall, 374 (7.3%) patients had hyperkalemia. This was associated with drugs known to increase K+ levels (74.6%), chronic kidney disease (33.7%), or both (24.3%). Among the 60 patients with unexplained hyperkalemia, 3 displayed a clinical and biochemical phenotype suggestive of FHH that was genetically confirmed in 2 of them (0.04% in the entire cohort). FHH prevalence rose to 3.3% in patients with unexplained hyperkalemia and up to 29% (2/7) if they had serum K+>5.8 mmol/L. The genetic cause of FHH was a missense variant affecting the acidic motif of WNK1 in 1 family and a rare CUL3 splicing variant, whose functional significance was confirmed by a minigene assay, in another. Finally, we observed a significant association between hyperkalemia and the occurrence of cardiovascular events, metabolic syndrome, and organ damage, independent of potential confounding factors. CONCLUSIONS: The identification of hyperkalemia in patients with hypertension has prognostic implications. A timely diagnosis of FHH is important for effective management of hypertension, electrolyte imbalance correction with tailored treatment, and genetic counseling.

Electrolyte and Acid-Base Abnormalities After Kidney Transplantation.

Kidney transplantation is the optimal therapeutic approach for individuals with end-stage kidney disease. The Scientific Registry of Transplant Recipients has reported a continuous rise in the total number of kidney transplants performed in the United States, with 25,500 new kidney recipients in 2022 alone. Despite an improved glomerular filtration rate, the post-transplant period introduces a unique set of electrolyte abnormalities that differ from those encountered in chronic kidney disease. A variety of factors contribute to the high prevalence of hypomagnesemia, hyperkalemia, metabolic acidosis, hypercalcemia, and hypophosphatemia seen after kidney transplantation. These include the degree of allograft function, immunosuppressive medications and their diverse mechanisms of action, and metabolic changes after transplant. This article aims to provide a comprehensive review of the key aspects surrounding the most commonly encountered electrolyte and acid-base abnormalities in the post-transplant setting.

Rare electrocardiographic findings in a young woman with acute barium poisoning: A case report.

Background: Barium, as a heavy divalent alkaline earth metal, can be found in various products such as rodenticides, insecticides, depilatories, and fireworks. Barium can be highly toxic upon both acute and chronic exposure. The toxicity of barium compounds is dependent on their solubility. Both suicidal and accidental exposures to soluble barium can cause toxicity. Case summary: We report a case characterized by two different wide QRS complex tachycardia in a patient with acute barium poisoning, one due to barium-induced ventricular tachycardia (VT) under hypokalemia and, subsequently, sino-ventricular conduction with intraventricular conduction delay due to hyperkalemia after aggressive potassium supplementation. The latter may be misdiagnosed as VT for the history of acute barium poisoning and the absence of peaked T wave in hyperkalemia. Of note, another hemodynamically unstable VT and profound hypokalemia occurred during the potassium-lowering therapy, which, in addition to barium poisoning, may also be due to the iatrogenic hypokalemia. We also observed the prominent T-U waves at serum potassium of 4.6 mM 12 hours after admission, which may indicate that barium had not been completely cleared from the plasma at that moment. There are some parallels to the Andersen-Tawil syndrome with prominent T-U waves and risk of ventricular tachycardias. To our knowledge, this is the first case report of conversion from hypokalemia to hyperkalemia, and in a short moment, from hyperkalemia to hypokalemia, in acute barium poisoning. Conclusion: In addition to profound hypokalemia secondary to acute barium poisoning, hyperkalemia may also occur after aggressive potassium supplementation. A more careful rather than too aggressive potassium supplementation may be suitable in these cases of hypokalemia due to an intracellular shift of potassium. And a iatrogenic hypokalemia risk in the treatment of rebound hyperkalemia in barium poisoning must be considered.

Effectiveness and safety of finerenone in diabetic kidney disease patients: a real-world observational study from China.

AIMS: Finerenone has been approved for treating diabetic kidney disease (DKD) with reducing cardiorenal risk. Real-world data on finerenone treatment for the management of DKD are presently lacking. This study aimed to investigate the effect of finerenone on the renal parameters of the Chinese DKD population in the real-world medical setting for the first time, especially in combination with renin-angiotensin system inhibitors (RASi) and sodium-glucose cotransporter 2 inhibitors (SGLT2i). METHODS: Forty-two DKD patients were selected and completed a 6-month finerenone treatment. Renal parameters and adverse effects were collected at every visit. RESULTS: The median urine albumin-to-creatinine ratio (UACR) was 1426.11 (755.42, 3638.23) mg/g. Among them, the proportion of patients with a UACR of 300-5000 mg/g was 76.2%, and the proportion of patients with a UACR of >5000 mg/g was 14.3%. The median estimated glomerular filtration rate (eGFR) was 54.50 (34.16, 81.73) mL/min/1.73 m2. Finerenone decreased the UACR significantly throughout the study period (p < .05). The maximal decline of UACR at month 6 was 73%. Moreover, the proportion of patients with a 30% or greater reduction in UACR was 68.42% in month 6. There was a smaller decline (9-11%) in the eGFR after initiating finerenone (p > .05). One patient each discontinued finerenone due to hyperkalemia (2.4%) and acute kidney injury (2.4%). No patient reported hypotension, breast pain, and gynecomastia. CONCLUSIONS: This study from China first demonstrated finerenone decreased UACR with manageable safety in real-world DKD treatment. A triple regimen of RASi, SGLT2i, and finerenone may be a promising treatment strategy for lowering albuminuria and reducing hyperkalemia risk in advanced DKD patients.

Efficacy of anti-hyperkalemic agents during cardiopulmonary resuscitation in out-of-hospital cardiac arrest.

Aim: We assessed the efficacy of anti-hyperkalemic agents for alleviating hyperkalemia and improving clinical outcomes in patients with out-of-hospital cardiac arrest (OHCA). Methods: This was a single-center, retrospective observational study of OHCA patients treated at tertiary hospitals between 2010 and 2020. Adult patients aged 18 or older who were in cardiac arrest at the time of arrival and had records of potassium levels measured during cardiac arrest were included. A linear regression model was used to evaluate the relationship between changes in potassium levels and use of anti-hyperkalemic medications. Cox proportional hazards regression analysis was performed to analyze the relationship between the use of anti-hyperkalemic agents and the achievement of return of spontaneous circulation (ROSC). Results: Among 839 episodes, 465 patients received anti-hyperkalemic medication before ROSC. The rate of ROSC was higher in the no anti-hyperkalemic group than in the anti-hyperkalemic group (55.9 % vs 47.7 %, P = 0.019). The decrease in potassium level in the anti-hyperkalemic group from pre-ROSC to post-ROSC was significantly greater than that in the no anti-hyperkalemic group (coefficient 0.38, 95 % confidence interval [CI], 0.13-0.64, P = 0.003). In Cox proportional hazards regression analysis, the use of anti-hyperkalemic medication was related to a decreased ROSC rate in the overall group (adjusted hazard ratio [aHR] 0.66, 95 % CI, 0.54-0.81, P < 0.001), but there were no differences among subgroups classified according to initial potassium levels. Conclusions: Anti-hyperkalemic agents were associated with substantial decreases in potassium levels in OHCA patients. However, administration of anti-hyperkalemic agents did not affect the achievement of ROSC.

Comparison of Metabolic, Ionic, and Electrolyte Responses to Exhaustive Low-Load Strength Training With and Without Blood Flow Restriction and High-Load Resistance Training.

Low-load blood-flow-restriction resistance training (LL-BFR-RT) is gaining popularity, but its physiological effects remain unclear. This study aimed to compare LL-BFR-RT with low-load resistance exercise (LL-RT) and high-load resistance exercise (HL-RT) on metabolism, electrolytes, and ions in the lower extremities by invasive catheter measurements, which are crucial for risk assessment. Ten healthy men (27.6 ± 6.4 years) completed three trials of knee-extensor exercises with LL-RT (30% 1RM), LL-BFR-RT (30% 1RM, 50% limb occlusion pressure), and HL-RT (75% 1RM). The exercise protocol consisted of four sets to voluntary muscle failure with 1 min of rest between sets. Blood gas analysis was collected before, during, and after each trial through intravenous catheters at the exercising leg. LL-BFR-RT had lower total workload (1274 ± 237 kg, mean ± SD) compared to LL-RT (1745 ± 604 kg), and HL-RT (1847 ± 367 kg, p < 0.01), with no difference between LL-RT and HL-RT. Pain perception did not differ significantly. Exercise-induced drop in oxygen partial pressure, lactate accumulation and electrolyte shifts (with increased [K+]) occurred during under all conditions (p < 0.001). Creatine kinase and lactate dehydrogenase increased significantly 24- and 48-h postexercise under all three conditions (p < 0.001). This study, using invasive catheter measurements, found no significant differences in metabolic, ionic, and electrolyte responses among LL-BFR-RT, LL-RT, and HL-RT when exercised to voluntary muscular failure. LL-BFR-RT reduced time to failure without specific physiological responses.

Stone heart syndrome: A curious case of digoxin toxicity and calcium infusion.

Stone heart syndrome has a complex interaction with digoxin toxicity, where, theoretically, the administration of intravenous calcium can worsen a patient's condition. Research on this subject is conflicting, so it is imperative to approach it cautiously.