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Association between hyperkalemia at critical care initiation and mortality

Gearoid M. McMahon| Mallika L. Mendu| Fiona K. Gibbons| Kenneth B. Christopher
Original
Volume 38, Issue 11 / November , 2012

Pages 1834 - 1842

Abstract

Purpose

To investigate the association between potassium concentration at the initiation of critical care and all-cause mortality.

Methods

We performed a retrospective observational study on 39,705 patients, age ≥18 years, who received critical care between 1997 and 2007 in two tertiary care hospitals in Boston, Massachusetts. The exposure of interest was the highest potassium concentration on the day of critical care initiation and categorized a priori as 4.0–4.5, 4.5–5.0, 5.0–5.5, 5.5–6.0, 6.0–6.5, or ≥6.5 mEq/l. Logistic regression examined death by days 30, 90, and 365 post-critical care initiation, and in-hospital mortality. Adjusted odds ratios were estimated by multivariable logistic regression models.

Results

The potassium concentration was a strong predictor of all-cause mortality 30 days following critical care initiation with a significant risk gradient across potassium groups following multivariable adjustment: K = 4.5–5.0 mEq/l OR 1.25 (95 % CI, 1.16–1.35; P < 0.0001); K = 5.0–5.5 mEq/l OR 1.42 (95 % CI, 1.29–1.56; P < 0.0001); K = 5.5–6.0 mEq/l OR 1.67 (95 % CI, 1.47–1.89; P < 0.0001); K = 6.0–6.5 mEq/l OR 1.63 (95 % CI, 1.36–1.95; P < 0.0001); K > 6.5 mEq/l OR 1.72 (95 % CI, 1.49–1.99; P < 0.0001); all relative to patients with K = 4.0–4.5 mEq/l. Similar significant associations post multivariable adjustments are seen with in-hospital mortality and death by days 90 and 365 post-critical care initiation. In patients whose hyperkalemia decreases ≥1 mEq/l in 48 h post-critical care initiation, the association between high potassium levels and mortality is no longer significant.

Conclusions

Our study demonstrates that a patient's potassium level at critical care initiation is robustly associated with the risk of death even at moderate increases above normal.

Keywords

References

  1. Gennari F (1997) Disorders of potassium metabolism. In: Suki W, Massry S (eds) Therapy of renal diseases. Kluwer, Boston, pp 53–84
  2. Gennari FJ (2002) Disorders of potassium homeostasis. Hypokalemia and hyperkalemia. Crit Care Clin 18:273–288vi
  3. Acker CG, Johnson JP, Palevsky PM, Greenberg A (1998) Hyperkalemia in hospitalized patients: causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines. Arch Intern Med 158:917–924
    • View reference on PubMed
    • View reference on publisher's website
  4. Moore ML, Bailey RR (1989) Hyperkalaemia in patients in hospital. N Z Med J 102:557–558
    • View reference on PubMed
  5. Borra S, Shaker R, Kleinfeld M (1988) Hyperkalemia in an adult hospitalized population. Mt Sinai J Med 55:226–229
    • View reference on PubMed
  6. Shemer J, Modan M, Ezra D, Cabili S (1983) Incidence of hyperkalemia in hospitalized patients. Isr J Med Sci 19:659–661
    • View reference on PubMed
  7. Paice B, Gray JM, McBride D, Donnelly T, Lawson DH (1983) Hyperkalaemia in patients in hospital. Br Med J (Clin Res Ed) 286:1189–1192
    • View reference on publisher's website
  8. Shapiro S, Slone D, Lewis GP, Jick H (1971) Fatal drug reactions among medical inpatients. JAMA 216:467–472
    • View reference on PubMed
    • View reference on publisher's website
  9. Topf J, Asplin J (2006) Disorders of potassium homeostasis. In: Murray P, Brady H, Hall J (eds) Intensive care in nephrology. Taylor & Francis, London, pp 363–382
  10. Murphy SN, Chueh HC (2002) A security architecture for query tools used to access large biomedical databases. In: Proceedings of AMIA symposium, pp 552–556
  11. Zager S, Mendu ML, Chang D, Bazick HS, Braun AB, Gibbons FK, Christopher KB (2011) Neighborhood poverty rate and mortality in patients receiving critical care in the academic medical center setting. Chest 139:1368–1379
    • View reference on PubMed
    • View reference on publisher's website
  12. Braun A, Chang D, Mahadevappa K, Gibbons FK, Liu Y, Giovannucci E, Christopher KB (2011) Association of low serum 25-hydroxyvitamin D levels and mortality in the critically ill. Crit Care Med 39:671–677
    • View reference on PubMed
    • View reference on publisher's website
  13. Hivert MF, Grant RW, Shrader P, Meigs JB (2009) Identifying primary care patients at risk for future diabetes and cardiovascular disease using electronic health records. BMC Health Serv Res 9:170
    • View reference on PubMed
    • View reference on publisher's website
  14. Hug BL, Lipsitz SR, Seger DL, Karson AS, Wright SC, Bates DW (2009) Mortality and drug exposure in a 5-year cohort of patients with chronic liver disease. Swiss Med Wkly 139:737–746
    • View reference on PubMed
  15. Linder JA, Bates DW, Williams DH, Connolly MA, Middleton B (2006) Acute infections in primary care: accuracy of electronic diagnoses and electronic antibiotic prescribing. J Am Med Inform Assoc 13:61–66
    • View reference on PubMed
    • View reference on publisher's website
  16. Braun AB, Gibbons FK, Litonjua AA, Giovannucci E, Christopher KB (2012) Low serum 25-hydroxyvitamin D at critical care initiation is associated with increased mortality. Crit Care Med 40:63–72
    • View reference on PubMed
    • View reference on publisher's website
  17. Bellevue R, Dosik H, Spergel G, Gussoff BD (1975) Pseudohyperkalemia and extreme leukocytosis. J Lab Clin Med 85:660–664
    • View reference on PubMed
  18. Howard MR, Ashwell S, Bond LR, Holbrook I (2000) Artefactual serum hyperkalaemia and hypercalcaemia in essential thrombocythaemia. J Clin Pathol 53:105–109
    • View reference on PubMed
    • View reference on publisher's website
  19. Einhorn LM, Zhan M, Hsu VD, Walker LD, Moen MF, Seliger SL, Weir MR, Fink JC (2009) The frequency of hyperkalemia and its significance in chronic kidney disease. Arch Intern Med 169:1156–1162
    • View reference on PubMed
    • View reference on publisher's website
  20. Kaplan E, Meier P (1958) Nonparametric estimation from incomplete observations. J Am Stat Assoc 53:457–481
    • View reference on publisher's website
  21. Rapoport J, Gehlbach S, Lemeshow S, Teres D (1992) Resource utilization among intensive care patients. Managed care vs traditional insurance. Arch Intern Med 152:2207–2212
    • View reference on PubMed
    • View reference on publisher's website
  22. Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi JC, Saunders LD, Beck CA, Feasby TE, Ghali WA (2005) Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 43:1130–1139
    • View reference on PubMed
    • View reference on publisher's website
  23. Trespalacios FC, Taylor AJ, Agodoa LY, Abbott KC (2002) Incident acute coronary syndromes in chronic dialysis patients in the United States. Kidney Int 62:1799–1805
    • View reference on PubMed
    • View reference on publisher's website
  24. Martin GS, Mannino DM, Eaton S, Moss M (2003) The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 348:1546–1554
    • View reference on PubMed
    • View reference on publisher's website
  25. Meduri GU, Golden E, Freire AX, Taylor E, Zaman M, Carson SJ, Gibson M, Umberger R (2007) Methylprednisolone infusion in early severe ARDS: results of a randomized controlled trial. Chest 131:954–963
    • View reference on PubMed
    • View reference on publisher's website
  26. Waikar SS, Wald R, Chertow GM, Curhan GC, Winkelmayer WC, Liangos O, Sosa MA, Jaber BL (2006) Validity of international classification of diseases, ninth revision, clinical modification codes for acute renal failure. J Am Soc Nephrol 17:1688–1694
    • View reference on PubMed
    • View reference on publisher's website
  27. Beier K, Eppanapally S, Bazick HS, Chang D, Mahadevappa K, Gibbons FK, Christopher KB (2011) Elevation of blood urea nitrogen is predictive of long-term mortality in critically ill patients independent of “normal” creatinine. Crit Care Med 39:305–313
    • View reference on PubMed
    • View reference on publisher's website
  28. Logic JR (1973) Enhancement of the vulnerability of the ventricle to fibrillation (VF) by regional hyperkalaemia. Cardiovasc Res 7:501–507
    • View reference on PubMed
    • View reference on publisher's website
  29. Wingo C, Weiner I (2000) Disorders of potassium balance. In: Brenner B (ed) The kidney. WB Saunders Co., Philadelphia, pp 998–1035
  30. Surawicz B (1967) Relationship between electrocardiogram and electrolytes. Am Heart J 73:814–834
    • View reference on PubMed
    • View reference on publisher's website
  31. Fisch C (1973) Relation of electrolyte disturbances to cardiac arrhythmias. Circulation 47:408–419
    • View reference on PubMed
    • View reference on publisher's website
  32. Hultgren HN, Swenson R, Wettach G (1975) Cardiac arrest due to oral potassium administration. Am J Med 58:139–142
    • View reference on PubMed
    • View reference on publisher's website
  33. Chen G, Khan N, Walker R, Quan H (2010) Validating ICD coding algorithms for diabetes mellitus from administrative data. Diabetes Res Clin Pract 89:189–195
    • View reference on PubMed
    • View reference on publisher's website
  34. Zgibor JC, Orchard TJ, Saul M, Piatt G, Ruppert K, Stewart A, Siminerio LM (2007) Developing and validating a diabetes database in a large health system. Diabetes Res Clin Pract 75:313–319
    • View reference on PubMed
    • View reference on publisher's website
  35. Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829
    • View reference on PubMed
    • View reference on publisher's website
  36. Quach S, Hennessy DA, Faris P, Fong A, Quan H, Doig C (2009) A comparison between the APACHE II and Charlson Index Score for predicting hospital mortality in critically ill patients. BMC Health Serv Res 9:129
    • View reference on PubMed
    • View reference on publisher's website
  37. Meehl P (1967) Theory testing in psychology and physics: a methodological paradox. Philos Sci 16:103–115
    • View reference on publisher's website
  38. Sawyer A (1982) Statistical power and effect size in consumer research. In: Mitchell A (ed) Advances in consumer research. Association for Consumer Research, Ann Arbor, pp 1–7

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