Hyperpotassemia secondary to the combined use of an ACEI or ARB II with spironolactone

Abstract

Introduction and Objective: To determine the clinical characteristics and evolution of patients with hyperkalemia due to chronic prescription of angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACE inhibition/ARBs), plus spironolactone, documented in Internal Medicine-Nephrology outpatient service, inter-consultation, or recent hospitalization discharge report. Materials and Methods: Patients over 18 years of age were included, in whom serum potassium levels over 5.5 mEq/l were documented, associated with combined treatment of an ACE inhibitors or ARBs plus spironolactone. In addition, patients were grouped due to base diseases, predisposing factors, and previous medications related to the risk of hyperkalemia. The serum potassium and creatinine laboratory variables were included at the entrance and follow-up at 30 days. Additionally, the type of outpatient and hospitable management patients received, and interventions practiced were recorded. The statistical analysis was conducted with the SPSS 25.0V statistical program in Spanish licensed for the University of Caldas. Results: The study spanned 13 years. Seventy-two patients were identified, of whom 41 met the inclusion criteria, 3.15 patients per year: 22 women (54%), with a mean age of 74. The main reason for the combination prescription was difficult to manage arterial hypertension, followed by heart failure. Regarding medications, 54% were ACE inhibitors, enalapril the most common, with an average dose of 27.75 mg/d, ARBs losartan 105.5 mg/d, and spironolactone 35.37 mg/d. Other prescribed medications associated with hyperkalemia were Beta-blockers, NSAIDs, heparin, and no use of trimethoprim sulfa. The main precipitating for which hyperkalemia was triggered was decompensated heart failure (low cardiac output) and acute renal failure of various origins. None in 13 outpatients (32%), required further hospitalization, improving just with treatment discontinuation. In hospitalized patients, hemodialysis was required in five patients (12.2%), with an average of 2.4, performed every 24 hours. No patient died. Creatinine significantly declined over 30 days, changing GFR from a baseline average value of 27.82 mL/minute to 46.16 mL/minute at 30 days. In hospitalized patients, various interventions were chosen suspension of the causal medication, intravenous furosemide, B2 agonists, ion exchange resins, calcium gluconate, glucose-insulin infusion, and intravenous bicarbonate. Conclusions: Severe hyperkalemia associated with combined ACE inhibitors/ARBs + spironolactone therapy is a pathology that continues to occur. Therefore, hydration status, renal function, and serum potassium should be monitored in frequent recipients. Elderly individuals with heart failure and renal failure are the highest-risk population. Henceforward, if possible, do not try to escalate to very high doses of medications when prescribing this combination.