Hyperkalemia incidence and recurrence among patients with heart failure - predictors and temporal trends
F Lindberg, L Benson, J J Carrero, G SavareseAbstract
Background
Actual but also perceived risk of hyperkalemia represents a major barrier to renin-angiotensin-system-inhibitors (RAASi) treatment implementation in heart failure (HF), and is associated with adverse outcomes. Assessing the risk of hyperkalemia incidence and recurrence is central to guide the need of follow-up, use of potassium binders, and ensure maintanance of HF pharmacotherapy.
Purpose
To estimate incidence rates, temporal trends, and independent predictors of incident and recurrent hyperkalemia among patients with HF.
Methods
All adults in Region Stockholm with a diagnosis of HF between 2009 and 2021 were included. All potassium measurements in routine care were obtained from the Stockholm CREAtinine Measurements (SCREAM) project. Incident hyperkalemia was defined as serum potassium >5.5 mmol/L. Patients with an incident hyperkalemia event were subsequently followed for hyperkalemia recurrence. A set of 36 demographic factors, laboratory variables, comorbodities, and treatments were selected based on clinical relevance and assessed for independent associations with incident and recurrent hyperkalemia.
Results
Among 50’710 individuals with a new diagnosis of HF, the median age was 79 (interquartile range 70-86) years, and 47% were women. Following a HF diagnosis, the 1-year incidence of hyperkalemia was 6.8 (95% confidence interval [95% CI] 6.6-7.1) per 100 patient-years. Strong independent predictors (adjusted odds ratio [aOR] ≥1.50) of incident hyperkalemia were potassium binder use (aOR 3.67, 95% CI 2.94-4.57), chronic kidney disease (aOR 2.05, 95% CI 1.89-2.23), anemia (aOR 2.01, 95% CI 1.86-2.17), liver disease (aOR 1.69, 95% CI 1.43-1.99), diabetes mellitus (aOR 1.56, 95% CI 1.44-1.68), and use of mineralocorticoid receptor antagonists (aOR 1.56, 95% CI 1.45-1.69). Crude incidence of hyperkalemia declined between 2009 and 2021 from 8.12 (95% CI 7.61-8.67) to 6.29 (5.94-6.66) events per 100 patient-years (estimated annual percent change -2.23, 95% CI -2.94 to -1.51). Following a hyperkalemia event, the 1-year incidence of recurrent hyperkalemia was 51.0 (95% CI 48.9-53.2) per 100 patient-years. The only strong independent predictors of recurrent hyperkalemia were use of cyclosporine/tacrolimus (aOR 1.50, 95% CI 1.09-2.09) and potassium binders (aOR 1.56, 95% CI 1.30-1.88).
Conclusion
The incidence of hyperkalemia following a diagnosis of HF has declined over the past 15 years, but recurrence rates remain high. Several strong predictors of incident hyperkalemia did not meaningfully predict recurrence, which might suggest that following a first event reversible causes were likely addressed and strategies for mitigating the risk, e.g. use of potassium binders and changes in RAASi therapy, were adopted. These findings underscore the need for better tools to gauge the risk of recurrent hyperkalemia to guide follow-up and preventive measures.Figure 1For image description, please refer to the figure legend and surrounding text.