Serum Potassium in Stage 5 CKD Patients on their first Presentation
in a Dialysis Service of a County Hospital in Western Romania
GH. GLUHOVSCHI1,2, ANCA MATEŞ3, CRISTINA GLUHOVSCHI2,4, O. GOLEA3, FLORICA GĂDĂLEAN2,4,
MARIA SOMAI3, ILEANA ENE2, LIGIA PETRICA2,4, SILVIA VELCIOV2,4
1Romanian Academy of Medical Sciences
2Division of Nephrology, Emergency County Hospital Timişoara, Romania
3The Dialysis Centre of the Emergency County Hospital Timişoara, Romania
4“V. Babeş” University of Medicine and Pharmacy Timişoara, Romania
CKD patients present deficient elimination of potassium.
Ambulatory treatment with hypotensors, mainly angiotensin-renin system inhibitors, can be
associated in these patients with potassium retention and risk of hyperkalemia.
In pre-dialysis stage-5 CKD patients, the use of medication accompanied by hyperkalemia
increases risks of developing it.
Using diuretics like spironolactone also increases this risk. Serum potassium can also increase
in case of inappropriate consumption of potassium-rich food (bananas).
Since ambulatory care does not always rigorously control hyperkalemia in CKD patients we
consider it is useful to screen patients when they are referred to dialysis services. The screening can
reflect the management of ambulatory CKD patients under treatment with ACE-I and ARB hypotensors.
We remark that beta-blockers are attributed a (limited) role in increasing the values of serum K.
Material and Method. We studied a group of 477 stage-5 CKD patients referred for dialysis
to The Dialysis Centre of the Emergency County Hospital Timişoara. The average age of the patients
was 57.41 ± 14.26 years. 260 were males and 217 females.
All were stage-5 CKD with GFR < 15 mL/min/1.73 m2 , with a group average value of eGFR
of 5.72 ± 2.81 mL/min/1.73m2.
Our investigations showed hypokalemia in 14 patients (2.93%). Hyperkalemia was found in
179 patients. Of these, 124 had mild hyperkalemia (5.5–6.4 mEq/L), 45 patients had medium hyper-
kalemia (6.5–7.5 mEq/L) and 10 (2.09%) had severe hyperkalemia (K > 7.5 mEq/L).
Discussion. Hyperkalemia was more frequent in patients who had been treated with blockers
of the renin-angiotensin system than in patients who had used other hypotensors or who had not
needed hypotensors and had not taken diuretics.
Severe hyperkalemia (K > 7.5 mEq/L) was present both in patients treated with blockers of the
renin-angiotensin system and in those treated with other hypotensors and in 1 case without hypotensor
or diuretic treatment.
2 cases treated with blockers of the renin-angiotensin-aldosterone system with severe hyper-
potassemia associated antialdosteronic diuretics, cumulating hyperpotassemic effects.
Diuretic treatments with loop diuretics influenced the values of serum K of most patients.
Hyperkalemia represents an important problem in nephrology because of the risks it induces in
the treatment of pre-dialysis CKD patients and it requires attentive monitoring.
Key words: potassium, CKD-chronic kidney disease, ACE-I-angiotension converting inhibitors.
Hypotensor treatments bring into discussion
potassium retention that can be caused by some
hypotensors frequently used in practice.
Angiotensin converting enzyme inhibitors
(ACE-I) and angiotensin receptor blockers (ARB)
are most often involved. Antialdosteronic diuretics
and direct inhibitors of renin, like aliskiren, play a
That is why therapy with these substances is
to be monitored by periodic determinations of
Other hypotensors, like beta-blockers, also
increase serum potassium, but much less significantly.
Chronic kidney disease (CKD) is associated
especially in stage-5 with disturbances of renal
elimination of potassium. The organism reacts pre-
senting phenomena of adaptability, trying to restore
potassium homeostasis. Thus, increased values of
serum potassium facilitate its elimination.
However, numerous stage-5 CKD patients
present hyperkalemia in pre-dialysis stages
(Palmer, Sarafidis et al.) [1, 2].
ROM. J. INTERN. MED., 2014, 52, 1, 30–38
2 Serum potassium in Stage 5 CKD patients 31
Administration of blockers of the renin-
angiotensin aldosterone system to patients with
CKD stages 1–4 can contribute to hyperkalemia.
The body adapts itself to this situation increasing
In pre-dialysis stage-5 adaptative phenomena
are not always able to eliminate excess serum
potassium, so risks of hyperkalemia appear.
Stage-5 CKD patients are vulnerable to any-
thing that leads to serum potassium increases:
potassium-rich food, for example bananas, and
medicines like inhibitors of the renin-angiotensin-
aldosterone system, in which can intervene, together
with ACE-I and ARB hypotensors, diuretics like
aldosterone inhibitors, for example spironolactones.
The objective of the present paper is to
analyse the activity of a dialysis centre in the
western part of our country with regard to the
values of serum potassium in the following groups
of patients referred to that centre:
– patients treated ± ACE-I and ARB ±
– patients treated ± beta-blockers ± diuretics
– patients treated with ACE-I and ARB +
other hypotensors± diuretic treatment
– a group of stage-5 CKD patients without
hypertension, consequently without hypotensor
treatment or treatment with diuretics.
MATERIAL AND METHOD
We studied a group of 477 pre-dialysis stage-
5 CKD patients referred to the dialysis centre of the
Timişoara Emergency County Hospital between
2008–2013. The ages of the patients were 57.41 ±
14.26 years. 260 persons were males, 217 were
These patients underwent complex clinical,
biological, functional, and paraclinical investigations
in order to be evaluated for admission into a
The present paper aims at assessing the
values of serum K at presentation and hypotensor
and diuretic treatments used in relationship with the
renal function, respectively with GFR calculated
according to MDRD 4.
We also analysed separately the values of
serum K in patients with diabetes mellitus and
chronic tubulointerstitial nephritis.
The results we obtained are presented in
Tables I and II.
In the group we studied the average value of
serum creatinine = 9.57 ± 3.70 mg/dL; eGFR = 5.72 ±
2.81 mL/min/1.73 m2 (CKD-EPI formula), respectively
the average value of serum K = 5.13 ± 1.04 mmol/L.
Hyperkalemia is present in 37.51% (n = 179)
patients. Normokalemia is present in 59.53%
(n = 284) patients and hypokalemia in 2.93% (n =
10 patients with CKD had values of serum K
higher than 7.5 mmol/L, which required emergency
Our study found in the 477 patients with CKD
in pre-dialysis stage 5 the following data about the
level of serum potassium:
– cases with hyporkalemia – 14 patients
(2.93% of the total). Only 4 patients of 14 had been
administered diuretic treatment .This could not be
incriminated in the other 10 cases in the production
Korgaonkar et al.  find that patients with
CKD stages 3–5 have hypokalemia in 5–12% cases.
The distribution of serium potassium in patients with CKD stage V-predialysis
GROUP A –
(n = 142p)
(n = 1p)
54.22% (n = 77p) 63.83% (n = 150p)
29.57% (n = 42p)
11.97% (n = 17p)
(n = 5p)
100% (n = 142p)
GROUP B –
(n = 235p)
GROUP C –
AH (n = 100)
P1 (group A
vs group B)
P2 (group A
vs group C)
P3 (group B
vs group C)
K < 3.5 mmol/L
(n = 9p)
(n = 4p)
57% (n = 57p)
29% (n = 29p)
9% (n = 9p)
n = 14p 0.097 0.162 1
K [3.5–5.4 mmol/L]
K [5.5–6.4 mmol/L]
K [6.5–7.5 mmol/L]
n = 284p
n = 124p
n = 45p
22.55% (n = 53p)
8.08% (n = 19p)
K > 7.5 mmol/L 1.70% (n = 4p) 1.00% (n = 1p) n = 10p 0.306 0.405 1
TOTAL 100% (n = 235p) 100% (n = 100p)477p
32 Gh. Gluhovschi et al. 3
The patients with CKD stage V-predialysis in relationship with diuretic medication
2 / 0
ACE-I ARB+other hypotens/
ACE-I+ARB+other hypotens+D ACE-I + other
ARB+ other hypotens+D DIURETIC
Without AH and D
K < 3.5 mmol/L
K [3.5 – 5.4 mmol/L]
K [5.5–6.4 mmol/L]
K [6.5–7.5 mmol/L]
K > 7.5 mmol/L
The incidence of hyperkalemia is, according
to Espinal et al. , 2% in patients with normal
renal functions. It increases to 42% if GFR decreases
to 20 mL/minute/1.73 m2 body area.
Specialised literature records variable incidence
of hyperkalemia in CKD patients. Abdel Kader
et al.  finds hyperkalemia in stage 3b–5 CKD.
Other authors, like Gennari and Segal, consider
that the prevalence of hyperkalemia could occur in
more than 50% cases of renal insufficiency .
According to Sarafidis , hyperkalemia, res-
pectively K > 5.5 mEq/L is 31.5% in pre-dialysis
patients when GFR is 15 mL/min/1.72 m2.
We have to mention that in our study we used
as reference points values of serum K of: K ≥
5.5 mEq/L (Lehnhardt and Kemper/Bakris et al.) [7, 8].
Comparing the results of our study, that found
in pre-dialysis stage-5 CKD patients a 37.51%
incidence of hyperkalemia, with that of Sarafidis
(who assessed hyperkalemia in a group of patients
in the same stage CKD in pre-dialysis and found an
incidence of 31.5%) we note that hyperkalemia is
met in pre-dialysis in numerous patients with GFR
< 15 mL/min/1.73 m2 .
An important number of patients (284) with
normal values of serum K were investigated by us
(59.53%). This is very important, since it was
found that normal values of potassium in pre-
dialysis have favourable effects in CKD patients.
Thus, according to Kovesdy et al. , pre-dialysis
potassium values between 4.6 and 5.3 mEq/L are
associated with longer survival periods in main-
tenance haemodialysis patients.
– cases with normal-kalemia – 284 patients,
– cases with hyperkalemia – 179 patients,
Diets with potassium in excess can represent
an important factor for hyperkalemia production.
Serum potassium is to be maintained within
strict limits in the body (Hsieh) .
Permanent re-balancing of the values of
potassium in the body is necessary in order to
maintain them as constant as possible.
Both low and very high values of serum K
represent important risk factors, impairing cardiac
functions. They can induce arrhythmias and they
can become death factors in pre-dialysis patients
Treatments with ACE-I or BRA can determine
important hyperkalemia and so can treatments
Physiologically, eliminations of K occur at
distal tube level. Stage-5 patients are particularly
vulnerable to inhibiting effects of ACE-I . This
effect is significant in stage-5.
The effects of ACE-inhibitors on glomerular
filtration rate were found to act on potassium excretion
as well .
Hyperkalemia possesses an adaptative me-
chanism in CRI (chronic renal insufficiency).
It activates increases of extra-cellular K, which
leads to stimulation of potassium releases at distal
The effect of this new adaptation is an increase
of the values of serum K, that is a new level,
corresponding to the new situation.
This adaptation will persist until new conditions
intervene to alter it: nutrition excesses, diminutions
of the filtration rate, medication .
The adaptative mechanism is influenced
(according to Palmer) by factors like: adequate
distal delivery of Na, normal mineral corticoid
level, intact adequate distal function .
4 Serum potassium in Stage 5 CKD patients 33
The regulation of serum K is also influenced
by mechanisms of extra-renal disposal of potassium
(gastrointestinal excretion and cellular uptake).
These mechanisms play an important part in
balancing the potassium in the organism [5, 12].
It is to be noted that in patients with peri-
toneal dialysis hyperkalemia represents a risk
It is also a risk factor for dialysed patients
whose high potassium level has to remain constant .
As far as hypokalemia is concerned, we found
its presence in 14 cases representing 2.51% of the
The diuretic treatment could not be incriminated
since only 2 patients had been administered such
treatment before their serum potassium was deter-
Korgaonkar et al. highlighted an important
observation. In a cohort study (220 patients) they
found that hypokalemia is present in CKD patients.
Their study suggests that patients with low or very
low normal kalemia present higher risks of death
than those with mild to moderate hyperkalemia .
The risk of hypokalemia in CKD patients
could be related to the fact that it can have serious
effects, especially cardiovascular ones, that can
even cause death (Korgaonkar et al.) .
We have to mention that hyperkalemia
patients undergo adaptative reactions of the body
that allow the functionality of the heart and of other
organs, phenomena which are absent from hypo-
Hyperkalemia represents in pre-dialysis,
respectively when GFR is low, an important factor
of risk, especially a cardiovascular one. It is
responsible for rhythm disturbances, even very
severe ones. Cardiovascular pathology is the most
important pathology associated with CKD. In this
situation it is essential to hyperkalemia.
High incidence of hyperkalemia is associated
with excess mortality. It represents a threat for the
safety of the patient.
Korgaonkar appreciates that hyperkalemia
could contribute to 2–5% deaths of ESRD (end
stage renal disease) patients .
According to Bakris et al., some medicines
that could increase serum potassium would be:
– medicines that cause redistribution of
potassium: beta adrenergic, beta 2 blockers, succinyl-
choline, digitalis overdose, manitol hypertonic;
– medicines that act by impairing potassium
excretion NSAIDs, inhibitors of the renin-angio-
tensin – aldosterone system, heparin.
In act, according to Bakris et al., hyper-
kalemia would limit the treatment with medicines
of that type, especially with ACE-I and ARB, in
persons who had previously had increases of serum
potassium and/or kidney insufficiency .
Korgaonkar also found that hyperkalemia is
more frequent in patients with CKD consecutive to
diabetes mellitus and tubulointerstitial nephro-
At present, there are discussions whether
hyperkalemia is caused by disturbed entry of K into
cells or whether it is related to an increase of intra-
cellular K stores .
Increased serum K values could stimulate
potassium excretion in the distal tube. When
ingestion followed by intestinal absorption increases
there appears a signal for kidneys to increase
potassium elimination. Gennari and Segal  bring
into discussion a kaliuretic neuroenteric reflex that
incriminates a splahnic sensor which detects
increased values of K in the diet and stimulates
tubular K secretion.
In fact, the diminished number of nephrons
caused by the signal given by hyperkalemia could
activate Na+ K+ ATP-ase of tubular cells and
increased density of the K channels, facilitating
K excretion .
Angiotensin converting enzyme inhibitors
(ACE-I) and angiotensin receptor blockers
Pre-dialysis stage-5 CKD patients use ACE-I
and ARB during treatment for hypertension (AH).
These medicines can determine during evolution
potassium retention with hyperkalemia. In fact,
hyperkalemia consecutive to ACE-I has been
described (Weinberg)  in these patients for
inappropriate consumption of potassium-rich food,
that could cause arrhythmia, sometimes followed
Because the use of ACE-I and ARB can
induce hyperkalemia in pre-dialysis patients one
must have in view that in stage-5 CKD there is low
elimination of potassium, its level being often high.
However, the use of diuretics like spirono-
lactone is often accompanied by increased values
of serum K caused by the fact that the tubular
action of aldosterone is blocked.
Our studies found ACE-I and ARB were used
in 142 patients (29.76%) of the pre-dialysis stage-5
CKD cases. Of these, 1 patient presented hypo-
kalemia without diuretic consumption and 77
patients (representing 54.22% of the total number
of patients who had consumed ACE-I and ARB)
presented normal values of serum potassium.
34 Gh. Gluhovschi et al. 5
We found that hyperkalemia is not
constantly met in pre-dialysis CKD patients who
had been administered this medication. 64 patients
(45.07% of the patients who had used ACE-I and
ARB) had increased values of serum K.
The CKD patients treated with blockers of
the renin-angiotensin aldosterone system have
higher hyperkalemia than individuals without CKD
treated with this medication (Einhorn et al.) .
Both ACE-I and ARB increase potassium con-
centrations in CKD patients (Espinel et al.). It is to
be noted that in kidney insufficiency angiotensin
receptor blockers (e.g. valsartan) could produce an
increase to that caused by ACE-I .
Espinel et al. found in a randomised study
that hyperkalemia > 5mEq/L in patients with CKD
stage-3 is not different from that of patients treated
with enalapril and olmesartan (Espinel et al.) .
We note that 5 of 60 patients presented values
of serum K higher than 7.5 mEq/L, a condition that
requires emergency dialysis. Two of these 5 patients
had used antialdosteronic medication (1 verospirone,
1 spironolactone), which is associated with potassium
retention. 2 patients associated furosemid and 1 did
not use diuretics.
Only 1 of the 5 patients used ACE-I associated
with ARB, associated with another hypotensor and
It is well known in fact that the association of
ACE-I and ARB increases the risk of hyper-
kalemia and association with an aldosterone
inhibitor further increases risks.
This requires avoidance of such associations
in CKD patients since they highly increase risks of
hyperkalemia, with various consequences and
17 patients of the other 55 patients with
hyperkalemia, who had used ACE-I and/or ARB,
presented values ranging between 6.5–7.5 mEq/L,
which indicates high risk, and 38 patients had
values between 5.5–6.4 mEq/L, which indicates
In fact other authors also note the presence of
numerous patients with mild kalemia among stage-
According to Weinberg ACE-I can determine
increased values of potassium, impairing renal
excretion and affecting production and/or aldosterone
excretion. Hyperkalemia is estimated to occur in
about 10% of the patients who had used an ACE-I.
Weinberg, who had analysed African American
Study of Kidney Disease and Hypertension found
that hyperkalemia in patients treated with ACE-I is
low, when GFR is higher than 40mL/min/1.73 m2
Comparing the values of serum K with those
of stage 5 CKD patients who had used beta-
blockers ± blockers of calcium channels ± other
hypotensors ± diuretics. To this group of patients
from the 9 persons who presented hypokalemia,
4 had used associated diuretics. As compared to the
patients with ACE-I and ARB treatment, we note
that hyperkalemia is more frequent in this group
of patients, but this phenomenon can be associated
with the use of diuretics only in 4 patients.
It is important to note that 1 of the 39 patients
with hyperkalemia had used neither hypo-tensors
nor diuretics. Hence, the conclusion that very
serious hyperkalemia can occur in CKD patients.
Patients who had used hypotensors other than
ACE-I and ARB presented with normal kalemia in
150 cases (63.83%) and hyperkalemia in 76 cases
In patients who had used neither hypotensors
nor diuretics, normal kalemia is much more
frequent than hyperkalemia in pre-dialysis stage-5
CKD patients. We found that 57 (57%) pre-dialysis
CKD patients had normal kalemia and 39 patients
(39%) had hyperkalemia.
If we compare the two groups we find
hyperkalemia in 43.73% of the patients who had
used ACE-I and ARB and in 33.01% and 41.83%
patients who had used other hypotensors (no ARB
and ACE-I) we notice differences.
Taking into account these observations one
could bring into discussion the use of other
hypotensors than ACE-I and ARB in CKD patients.
This observation is to be considered with
reticence and it brings into discussion individual
methods of regulating eliminations of K, partially
independent of the hypotensor used.
According to Weinberg, beta-blockers can be
associated with hyperkalemia because of a potassium
re-distribution from intracellular compartments to
extra-cellular compartments and as a result of a
blockade of beta 2 receptor-mediated cellular
potassium uptake .
Serum potassium in pre-dialysis stage-5
CKD patients treated with other hypo-
tensors except renin-angiotensin system
230 (48.22%) of 477 patients treated for
hypertension (AH) were treated with this medication.
9 of these patients presented hypokalemia, 4 of
them having had associated diuretic treatments.
6 Serum potassium in Stage 5 CKD patients 35
The therapy of 8 patients had included beta-
blockers, in 4 cases associating diuretics as well.
Beta-blockers can induce mild hyperkalemia.
Diuretic medication could have caused the
hyperkalemia of the 4 patients who had been using
it but we do not possess an explanation for the
191 of these patients were treated with beta-
blockers ± blockers of calcium channels ± diuretic
medication, 16 patients with blockers of calcium
channels and 30 patients with blockers of calcium
channels ± other hypotensors/without ACE-/ARB
and beta-blockers ± diuretic medication.
Normal values of kalemia were present in
145 patients, of whom 56 (34.86%) had associated
diuretic medication, but this fact participated in
causing hyperkalemia only in few cases.
Of the 61 cases with hyperkalemia, 31 cases
had used diuretic medication. Although K diminishes
serum potassium, numerous cases remained hyper-
kalemic and 4 of the patients presented hyper-
kalemia > 7.5 mEq/L. Three of these 4 patients had
used loop diuretics.
Our study does not provide convincing evidence
for the role of diuretic medication in patients
treated with other hypotensors and/or diuretics.
Treatments with hypotensors associated
with diuretics in CKD patients treated with
IEC and ARB and other hypotensors
It is well-known that loop diuretics increase
urinary elimination of serum K. In case they are
associated with IEC or ARB hypotensors they can
decrease the values of serum potassium, diminishing
the risk of kalemia. Loop diuretics could have the
same effect if associated with other hypotensors
that have milder correction effects of serum K than
It is to be noted that tiasidic diuretics are not
used in this stage of the disease as their efficiency
is low in case of GFR < 30 mL/minute. Weinberg
et al. consider that diuretics diminish risks of hyper-
In patients treated with ACE-I and ARB
associated or not with other hypotensors, with
values of serum K within normal limits (between
3.5 and 5.4), the association was of only 34%, the
part it played in the normokalemia of these patients
being irrelevant. In those who used other
hypotensors, diuretic medication was associated in
27.5% cases. Its participation to the normo-
kalemia of these patients has to be taken into
Having in view that the pre-dialysis CKD
patients in our group represented 56.27% of those
with hypotensor medication with ARB and ACE-I
and 65.99% of those treated with other hypo-
tensors, as compared to patients without hypotensor
and diuretic treatments (57%), the role of hypotensor
medication in producing normokalemia does not
seem to be significant.
Diuretic medication seems to play a decisive
part in cases of pre-dialysis stage-5 CKD patients,
4 of 7 patients having used this type of medication.
Of the 9 patients with K > 7.5, 6 had used
diuretics – 4 had used loop diuretics and 2 antialdo-
steronics. We can conclude that loop diuretics do
not always prevent severe hyperkalemia, but it is
highly probable that their association with
antialdosteronics should have its role in this respect. It
is to be noted that only 1 of 41 cases treated with
ACE-I and ARB, with K values between 5.5 and
6.4 mEq/L had used diuretic medication and only
2 of 17 patients with hyperkalemia between
6.5–7.5 mEq/L had used diuretic medication.
Our study could indicate that the absence of
association with loop diuretics could represent a
factor that facilitates hyperkalemia in pre-dialysis
stage-5 CKD patients.
The patients with hypotensor medication who
had been administered other hypotensors than
ACE-I and ARB had normokalemia – 145 patients
(35.86%) had used associated hypotensor medi-
Diuretic medication was associated in 36.04%
of the 86 patients who used hypotensors different
from ACE-I and ARB. We can conclude that diuretic
medication does not seem to influence visibly the
values of serum potassium.
In fact only 2 of the 9 patients with
hypokalemia and 2 of the 4 patients with K >
7.5 mEq/L had used diuretic medication. In these
cases diuretic medication does not seem to play a
decisive role in the values of serum potassium.
The 5 pre-dialysis stage 5 CKD patients were
treated only with diuretics, 4 with loop diuretics
and 1 with diurex. All presented normal values of
serum K, which indicated good control of these
Pre-dialysis stage-5 CKD patients without
hypertension-respectively without diuretic
The values of serum K in this group of
patients were neither due to the use of medication
that can increase the values of serum K, like
36 Gh. Gluhovschi et al. 7
inhibitors of the renin-angiotensin system, nor to
beta-blockers or aldosterone blockers used for
Our observations found that 100 (20.97) of
477 pre-dialysis stage-5 CKD patients used neither
ACE-I or ARB, nor spironolactone or its derivatives.
57 (57%) of 100 patients in this group presented
normal kalemia, which indicates the existence of a
balance between K intake and elimination, when
the capacity of eliminating K of the kidney is
reduced because of a diminished number of nephrons
and of elimination disturbances at (mainly distal)
Digestive potassium elimination, a well-
known compensatory mechanism, might play an
important part in this process.
Hyperkalemia was present only in 39 of the
100 patients who had used neither ACE-I/ARB nor
It is notable that 45% the patients who had
used in the pre-dialysis stage-5 of CKD inhibitors
of conversion enzymes and/or ARB presented
hyperkalemia. If we exclude the 11 patients who
had been administered associated diuretic medication,
we are left with 59 patients (37.39) treated with
ICE ± ARB ± other hypotensors who presented
It is to be noted that most (29) of the 39 CKD
patients with hyperkalemia, without ARB/IEC or
diuretic treatment, presented mild hyperkalemia,
9 had more severe (6.00–7.5 mEq/L) hyper-
kalemia and only 1 had very severe kalemia >
It results that, although pre-dialysis stage-5
CKD patients without ACE/ARB treatment present
La bolnavii cu boală cronică de rinichi (BCR) există o eliminare deficitară a
potasiului. Tratamentul cu hipotensoare în ambulatoriu, în principal cu inhibitori
ai sistemului renină angiotensină se poate însoţi de retenţie de potasiu cu riscul
unei hiperkalemii la aceşti bolnavi.
La bolnavi cu BCR stadiul V predialitic utilizarea medicamentelor care se
însoţesc de hiperkalemie creşte riscul acesteia. Utilizarea de diuretice de tipul
spironolactonei creşte acest risc. La fel, potasiul seric poate creşte la un consum
intempestiv de alimente bogate în potasiu (exemplu, banane).
Întrucât în practica ambulatorie nu totdeauna există un control riguros al
potasemiei la bolnavii cu BCR, am considerat util un screening al acesteia la
prezentarea în serviciul de dializă, acesta putând reflecta managementul
bolnavilor cu BCR în ambulatoriu sub tratament cu hipotensoare de tipul
inhibitorilor de enzimă de conversie (IECA) şi blocanţi de receptor de angio-
tensină (BRA). Menţionăm că betablocantelor li se atribuie un rol e drept redus de
creştere a valorilor K seric, ca de altfel şi altor medicamente.
lower risk of hyperkalemia, they need monitoring
as, in individual cases, some of them can present
high values of serum potassium and high risk.
Hyperkalemia is an important element in pre-
dialysis stage 5 CKD. It represents a risk factor for
Our studies detected the presence of hyper-
kalemia in 179 of 477 patients. It was present in all
categories of patients treated with hypotensors.
Hyperkalemia was more frequent in patients
who had been treated with blockers of the renin-
angiotensin system than in patients who had used
other hypotensors, who had not needed hypotensors
or who had not been administered diuretics.
Few cases (14–2.93%) presented hypo-
kalemia. This could be related to diuretic medication in
Very severe hyperkalemia (7.5 mEq/L) was
present in few (10) cases (2.9%). It occurred both
in patients treated with blockers of the renin-
angiotensin-aldosterone system and in patients
treated with other hypotensors. In 2 cases treated
with ACE-I/ARB this medication was associated
with antialdosteronic diuretics that cumulated
In pre-dialysis stage-5 CKD patients hyper-
potassemia requires monitoring and cautious use of
It is necessary to individualize hypotensor
therapy and serum potassium monitoring.
8 Serum potassium in Stage 5 CKD patients 37
Material şi metodă. S-au luat în studiu un lot de 477 bolnavi cu BCR stadiul
V care s-au prezentat în vederea dializei la Centrul de Dializă al Spitalului Clinic
Judeţean Timişoara. Pe lotul studiat, vârsta medie = 57,41 ± 14,26 ani, 260 fiind
bărbaţi iar 217 fiind femei. Toţi pacienţii se aflau în stadiu V al BCR, cu RFG <
15 ml/min/1,73 m2 cu o medie pe întregul lot al e GFR de 5,72 ± 2,81 ml/min/1,73m2.
Investigaţiile noastre au evidenţiat o hipokaliemie la 14 pacienţi (2,93%).
Hiperkaliemia a fost prezentă la 179 de bolnavi. Dintre aceştia 124 au prezentat o
hiperkalemie uşoară (K seric între 5,5–6,4 mEq/L), hiperkaliemie medie
(K seric între 6,5–7,5 mEq/L) la 45 de bolnavi şi hiperkaliemie severă (K seric >
7,5 mEq/L) la 10 bolnavi (2,09%).
Hiperkaliemia a fost mai frecventă la bolnavi care au urmat tratament cu
blocanţi ai sistemului renină-angiotensină comparativ cu cei care au utilizat alte
hipotensoare sau nu au necesitat hipotensoare şi nu au utilizat diuretice.
Hiperkaliemia severă > 7,5 mEq/L a fost prezentă atât la bolnavii cu tratament
cu blocant ai sistemului renină-angiotensină, cât şi la cei trataţi cu alte hipotensoare
şi la 1 caz fără tratament cu hipotensoare sau diuretice.
Două cazuri tratate cu blocanţi ai sistemului renină-angiotensină aldosteron
cu hiperkaliemie severă au asociat şi diuretice antialdosteronice, cumulând efecte
Tratamentul diuretic cu diuretice de ansă a influenţat majoritatea cazurilor
la care s-au aplicat valorile K seric.
Hiperkaliemia reprezintă o problemă importantă în nefrologie datorită
riscului pe care îl induce în tratamentul bolnavilor cu BCR în predializă, fapt ce
impune o bună monitorizare.
Corresponding author: Prof. Gh. Gluhovschi,
Calea Alexandru Ioan Cuza No. 8 Ap. 16
300088 Timişoara, Romania
Phone: 0040-256-435950; Fax: 0040-256-486967
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Received January 28, 2014