Biff F. Palmer’s research while affiliated with The University of Texas at El Paso and other places

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Publications (183)


EMCREG-International Multidisciplinary Consensus Panel on Management of Hyperkalemia in Chronic Kidney Disease (CKD) and Heart Failure
  • Literature Review

January 2025

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5 Reads

CardioRenal Medicine

Natalie Kreitzer

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Alpesh N Amin

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Background: Hyperkalemia, generally defined as serum potassium levels greater than 5.0 mEq/L, poses significant clinical risks, including cardiac toxicity and muscle weakness. Its prevalence and severity increase in patients with chronic kidney disease (CKD), diabetes mellitus, and heart failure (HF), particularly when compounded by medications like Angiotensin converting inhibitors, Angiotensin receptor blockers, and potassium sparing diuretics. Hyperkalemia arises from disruptions in potassium regulation involving intake, excretion, and intracellular-extracellular distribution. In CKD and acute kidney injury, these regulatory mechanisms are impaired, leading to heightened risk. The management of chronic hyperkalemia presents a challenge due to the necessity of balancing effective cardiovascular and renal therapies against the risk of elevated potassium levels. Summary: The emergency department management of acute hyperkalemia focuses on preventing cardiac complications through strategies that stabilize cellular membranes and shift potassium intracellularly. Chronic management often involves dietary interventions and pharmacological treatments. Pharmacological management of acute hyperkalemia includes diuretics, which enhance kaliuresis, and potassium binders such as patiromer and sodium zirconium cyclosilicate (SZC), which facilitate fecal excretion of potassium. While diuretics are commonly used, they carry risks of volume contraction and renal function deterioration. The newer potassium binders have shown efficacy in lowering chronically elevated potassium levels in CKD and HF patients, offering an alternative to diuretics and other older agents such as sodium polystyrene sulfonate , which has significant adverse effects and limited evidence for chronic use. Key Messages: We convened a consensus panel to describe the optimal management across multiple clinical settings when caring for patients with hyperkalemia. This consensus emphasizes a multidisciplinary approach to managing hyperkalemia, particularly in patients with cardiovascular kidney metabolic (CKM) syndrome, to avoid fragmentation of care and ensure comprehensive treatment strategies. The primary goal of this manuscript is to describe strategies to maintain cardiovascular benefits of essential medications while effectively managing potassium levels.



Metabolic Alkalosis Treatment Standard

September 2024

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28 Reads

Nephrology Dialysis Transplantation

The kidney is poised to defend against development of metabolic alkalosis through non-adaptive mechanisms in the proximal nephron and adaptive processes in the distal nephron. Despite a prodigious capacity to excrete base, metabolic alkalosis is the most common acid-base disturbance in hospitalized patients. Development of this disorder requires pathophysiologic changes leading to generation of new HCO3- combined with an augmentation in the capacity of the kidney to reclaim filtered HCO3-. The initial approach to these patients is careful assessment of effective arterial blood volume focusing on the physical examination and urine electrolytes. Identifying the mechanisms by which the kidney's ability to correct alkalosis are perturbed provides an understanding of the clinical approach to differential diagnosis and appropriate treatment. While metabolic alkalosis is frequently not dangerous, in certain settings, metabolic alkalosis may contribute to mortality and should be aggressively managed.


Management of Hyperkalemia in RAASi: Strategies to Maintain Chronic Kidney Disease Patients with Type II Diabetes on Therapy

March 2024

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4 Reads

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3 Citations

CardioRenal Medicine

Background: According to the Centers for Disease Control and Prevention (CDC), diabetes affects approximately 37.3 million individuals in the USA, with another estimated 96 million people having a prediabetic state. Furthermore, one or two out of three adult Americans exhibit metabolic syndrome or an insulin-resistant state, depending on their age group. Summary: Chronic kidney disease (CKD) represents a complication often associated with type II diabetes or the insulin-resistant condition, typically identifiable through proteinuria. Proteinuria serves as both a marker and a contributing factor to kidney damage, and it significantly heightens the risk of cardiovascular (CV) events, including atherosclerosis, heart attacks, and strokes. Renin-angiotensin-aldosterone system inhibitors (RAASis) have demonstrated clinical efficacy in lowering blood pressure, reducing proteinuria, and slowing CKD progression. However, hyperkalemia is a common and serious adverse effect associated with using RAASi. Key messages: It is imperative to establish personalized management strategies to enable patients to continue RAASi therapy while effectively addressing hyperkalemia risk. Healthcare professionals must be careful not to inadvertently create a low renal perfusion state, which can reduce distal nephron luminal flow or luminal sodium concentration while using RAASi. Nonsteroidal mineralocorticoid receptor antagonists (nsMRAs), such as finerenone, are demonstrated to delay CKD progression and reduce CV complications, all while mitigating the risk of hyperkalemia. Additionally, maintaining a routine monitoring regimen for serum potassium levels among at-risk patients, making dietary adjustments, and considering the adoption of newer potassium-binding agents hold promise for optimizing RAASi therapy and achieving more effective hyperkalemia management.


Hyperkalemia treatment Standard

February 2024

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29 Reads

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5 Citations

Nephrology Dialysis Transplantation

Hyperkalemia is a common electrolyte disturbance in both inpatient and outpatient clinical practice. The severity and associated risk depends on the underlying cause and rate of potassium (K+) increase. Acute hyperkalemia requires immediate attention due to potentially life-threatening manifestations resulting from the rapid increase in plasma K+ concentration. Treatment is initially focused on stabilizing the cardiac membrane, followed by maneuvers to shift K+ into the cells, and ultimately initiating strategies to decrease total body K+ content. Chronic hyperkalemia develops over a more extended period of time and manifestations tend to be less severe. Nevertheless, the disorder is not benign since chronic hyperkalemia is associated with increased morbidity and mortality. The approach to patients with chronic hyperkalemia begins with a review of medications potentially responsible for the disorder, ensuring effective diuretic therapy and correcting metabolic acidosis if present. The practice of restricting foods high in K+ to manage hyperkalemia is being reassessed since the evidence supporting the effectiveness of this strategy is lacking. Rather, dietary restriction should be more nuanced, focusing on reducing the intake of nonplant sources of K+. Down-titration and/or discontinuation of renin–angiotensin–aldosterone inhibitors should be discouraged since these drugs improve outcomes in patients with heart failure and proteinuric kidney disease. In addition to other conservative measures, K+ binding drugs and sodium–glucose cotransporter 2 inhibitors can assist in maintaining the use of these drugs.


Non-steroidal mineralocorticoid antagonists and hyperkalemia monitoring in chronic kidney disease patients associated with type II diabetes: a narrative review

February 2024

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13 Reads

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2 Citations

Chronic kidney disease (CKD) is a prevalent complication of Type II diabetes (T2D). The coexistence of CKD with T2D is comparable to cardiovascular disease (CVD) when the estimated glomerular filtration rate declines below 60 ml/min/1.73 m2. Screening and early detection of people with high risk for CKD would be beneficial in managing CKD progress and the associated complications such as CV complications. Renin-angiotensin-aldosterone system inhibitors (RAASi) have demonstrated beneficial effects in delaying CKD progression, but they carry the risk of hyperkalemia. Nonsteroidal mineralocorticoid antagonists (nsMRA), such as finerenone, exhibit considerable efficacy in their anti-inflammatory, antifibrotic, and renal protective effects with demonstrable reductions in CV complications. In addition, nsMRAs do not cause significant changes in serum potassium levels compared to traditional steroidal MRA. Ongoing research explores the capacity of the sodium-glucose transport protein 2 inhibitors (SGLT-2i), combined with nsMRA, to produce synergistic renal protective effects and reduce the risk of hyperkalemia. Also, a dedicated renal outcomes study (FLOW study) involving a once-weekly injectable Glucagon-like peptide-1 receptor agonist, semaglutide, was halted early by the data monitoring committee due to having achieved the predefined efficacy endpoint and considerations related to renal disease. In CKD patients with T2D on nsMRA, hyperkalemia management requires a comprehensive approach involving lifestyle adjustments, dietary modifications, regular serum potassium level monitoring, and potassium binders, if necessary. Withholding or down-titration of nsMRAs with close monitoring of serum potassium levels may be required in patients with concerning potassium levels. In light of the current state of knowledge, this review article explores the perspectives and approaches that HCPs may consider when monitoring and managing hyperkalemia in CKD patients with T2D.


Estrogens, Adipose Tissues, and Environmental Exposures Influence Obesity and Diabetes Across the Lifecycle

February 2024

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28 Reads

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4 Citations

Proceedings of The Nutrition Society

Endogenous estrogens regulate essential functions to include menstrual cycles, energy balance, adipose tissue distribution, pancreatic β-cell function, insulin sensitivity, and lipid homeostasis. Estrogens are a family of hormones which include estradiol (E2), estrone (E1), and estriol (E3). Estrogens function by binding and activating estrogen receptors (ERs). Phytoestrogens are plant-derived compounds which exhibit estrogenic-like activity and can bind to ERs. Phytoestrogens exert potential estrogenic-like benefits; however, their effects are context-dependent and require cautious consideration regarding generalized health benefits. Xenoestrogens are synthetic compounds which have been determined to disrupt endocrine function through binding to ERs. Xenoestrogens enter the body through various routes and given their chemical structure they can accumulate, posing long-term health risks. Xenoestrogens interfere with endogenous estrogens and their functions contributing to conditions like cancer, infertility, and metabolic disorders. Understanding the interplay between endogenous and exogenous estrogens is critical in order to determine their potential health consequences and requires further investigation. This manuscript provides a summary of the role endogenous estrogens have in regulating metabolic functions. Additionally, we discuss the impact phytoestrogens and synthetic xenoestrogens have on biological systems across various life stages. We highlight their mechanisms of action, potential benefits, risks, and discuss the need for further research to bridge gaps in understanding and mitigate exposure-related health risks.



SGLT2 Inhibition and Kidney Potassium Homeostasis

August 2023

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30 Reads

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14 Citations

Clinical Journal of the American Society of Nephrology

Pharmacologic inhibition of the Na+-glucose transporter 2 in the proximal tubule brings about physiologic changes predicted to both increase and decrease kidney K+ excretion. Despite these effects, disorders of plasma K+ concentration are an uncommon occurrence. If anything, these drugs either cause no effect or a slight reduction in plasma K+ concentration in patients with normal kidney function but seem to exert a protective effect against hyperkalemia in the setting of reduced kidney function or when given with drugs that block the renin-angiotensin-aldosterone axis. In this review, we discuss the changes in kidney physiology following administration of SGLT2 inhibitors predicted to cause both hypokalemia and hyperkalemia. We conclude these factors offset one another explaining the uncommon occurrence of dyskalemias with these drugs. Careful human studies focusing on determinants of kidney K+ handling are needed to fully understand how these drugs attenuate the risk of hyperkalemia and yet rarely cause hypokalemia.


Amlodipine in the current management of hypertension
  • Literature Review
  • Full-text available

August 2023

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333 Reads

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27 Citations

Hypertension is the leading cause of death worldwide, affecting 1.4 billion people. Treatment options include the widely used calcium channel blockers, among which amlodipine, a dihydropyridine, has unique characteristics that distinguish it from other drugs within this class. This review aims to provide an updated overview of the evidence supporting the use of amlodipine over the past 30 years and highlights its cardiovascular benefits in current hypertension management. Amlodipine has low renal clearance (7 mL/min/mg) and long half-life (35-50 h) and duration of action, which allows it to sustain its anti-hypertensive effect for more than 24 h following a single dose. Additionally, blood pressure (BP) control is maintained even when a dose has been missed, providing continuous protection in case of incidental noncompliance. It has proven to reduce BP variability and successfully lower BP. Amlodipine also controls BP in patients with a systolic/diastolic BP of 130/80 mm Hg or higher, diabetes, or chronic kidney disease without worsening glycemic or kidney function. Additionally, amlodipine is a wise choice for older adults due to its ability to control BP and protect against stroke and myocardial infarction. Side effects of amlodipine include edema, palpitations, dizziness, and flushing, which are more common with the higher dose of 10 mg. Amlodipine is cost effective and predicted to be cost saving when compared with usual care.

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Citations (86)


... 64 These medications work through different mechanisms: GLP-1 receptor agonists reduce blood sugar levels and help with weight loss by suppressing appetite and enhancing the feeling of fullness, while also significantly lowering the risk of cardiovascular events. 65 On the other hand, SGLT2 inhibitors promote weight loss by increasing glucose excretion through urine and reduce the risk of heart failure and chronic kidney disease progression. Widely used in diabetic patients with cardiovascular risk, these two classes of drugs offer multiple health benefits beyond blood sugar management. ...

Reference:

Advances in Understanding Diabetic Kidney Disease Progression and the Mechanisms of Acupuncture Intervention
Non-steroidal mineralocorticoid antagonists and hyperkalemia monitoring in chronic kidney disease patients associated with type II diabetes: a narrative review
  • Citing Article
  • February 2024

... Additionally, our study revealed a stronger correlation between CVAI and SO in females, possibly attributable to the influence of hormonal factors. A significant decline in estrogen levels associated with female menopause has been linked to impaired skeletal muscle function and lipid metabolism disorder, which ultimately leads to the development of SO (40,41). ...

Estrogens, Adipose Tissues, and Environmental Exposures Influence Obesity and Diabetes Across the Lifecycle
  • Citing Article
  • February 2024

Proceedings of The Nutrition Society

... Glucose tubular transport, coupled with sodium reuptake, takes place in cortical proximal tubular segments by SGLT1 and SGLT2 transporters. SGLT inhibition reduces renal cortical oxygen expenditure for tubular transport not only by blocking sodium/glucose co-transport, but also through the inhibition of e Na1-H1 antiporter (NHE3) [43]. The dual transport inhibition reduces cortical oxygen consumption and improves ambient pO 2 [5], as shown in rodents following the non-selective inhibition of SGLT [22]. ...

SGLT2 Inhibition and Tubular Sodium Handling
  • Citing Article
  • December 2023

Journal of the American Society of Nephrology

... The authors found that treatment with empagliflozin inhibits proximal tubule NHE3 activity, augments natriuresis, and increases diuretic and natriuretic responses to a saline challenge in both hypertensive and normotensive rats. They also showed that just in normotensive animals, empagliflozin upregulates NCC function via transcriptional and post-translational mechanisms and lowers BP only in hypertensive but not in normotensive rats [176]. In line with this finding, other authors, in cell lines and animal models showed that SGLT2i, through the stimulus of the Ca 2+ -sensing receptor in the distal convoluted tubule and consequent glycosuria, caused increased activity of NCC. ...

SGLT2 Inhibition and Kidney Potassium Homeostasis
  • Citing Article
  • August 2023

Clinical Journal of the American Society of Nephrology

... The ongoing KBindER randomized study, expected to be completed by December 2024, aims to compare oral potassium binders in the treatment of acute HK and will hopefully inform decision-making guidelines on this matter [46]. Another important field of research is to determine the efficacy of recommending dietary restriction of potassium-rich foods in patients with CKD or HF, specifically from plantbased sources, as these foods also provide cardiometabolic health benefits [48,90]. Clinical trials are needed to test the validity of dietary potassium intake from different food sources, both alone and in combination with gut-targeted interventions, for optimal potassium management. ...

New Insights Into Dietary Approaches to Potassium Management in Chronic Kidney Disease
  • Citing Article
  • August 2023

Journal of Renal Nutrition

... It is mostly characterized by high consumption of vegetables, legumes, and fruits (also known as plant-based food), providing a high amounts of K and a low amounts of sodium. The Med diet also requires high consumption of cereals, fish and dairy products, the use of olive oil for cooking as a source of fat, and low consumption of refined carbohydrates and animal proteins [25]. ...

The Role of Dietary Potassium in the Cardiovascular Protective Effects of Plant-Based Diets
  • Citing Article
  • August 2023

Seminars in Nephrology

... Studies indicate that changes in the distribution pattern of alpha and beta estrogen receptors disrupt their signaling pathways, resulting in increased estrogen release. [15][16][17] This hormonal surge initiates a cascade of metabolic changes, including activation of PPARγ receptors, increased uptake of glucose and free fatty acids, and increased angiogenesis. Simultaneously, there are reductions in lipolysis and formation of new mitochondria. ...

The evolutionary impact and influence of oestrogens on adipose tissue structure and function

... It has also been reported to cause insulin resistance in skeletal muscle cells and increase the risk of developing cancer and cardiovascular disease 9 . On the other hand, an increase of blood pH to be > 7.45 due to metabolic and respiratory disorders is defined as alkalosis, affecting homeostasis 13,14 . As described above, cell behavior is related to pH in the in vivo microenvironment, but a detailed understanding of the relationship has not been achieved. ...

Respiratory Acidosis and Respiratory Alkalosis: Core Curriculum 2023
  • Citing Article
  • June 2023

American Journal of Kidney Diseases

... The primary distinction between AKI and CKD in each of these criteria is the duration and rate of time at which renal function declined, with CKD characterized by functional and structural disturbances that persist longer than 3 months 53,69,70 . Renal morphology and function often improve as a consequence of AKI repair mechanisms, whereas CKD repair mechanisms lead to aberrant cell proliferation, cell hypertrophy, and increased extracellular matrix (ECM) accumulation 71 . ...

Acquired Disorders of Hypomagnesemia
  • Citing Article
  • March 2023

Mayo Clinic Proceedings