Understanding Hyperkalemia and Chronic Kidney Disease [transcript][audio]

Guest: Dr. Joseph Vassalotti

Presenter: Neal Howard

Guest Bio: Dr. Vassalotti is the Chief Medical Officer of the National Kidney Foundation (NKF) and Associate Clinical Professor of Medicine in the Division of Nephrology, at Icahn School of Medicine at Mount Sinai. He received his medical degree with Distinction in Research from the SUNY Stony Brook School of Medicine and completed an Internal Medicine Residency and Nephrology Fellowship at the Johns Hopkins Hospital. At NKF, his major focus is implementation of evidence-based clinical practice guidelines on chronic kidney disease (CKD), including the NKF’s Kidney Disease Outcomes Quality Initiative (KDOQI), particularly through guidance of the NKF’s primary care initiative, called CKD intercept. He has served as co-PI for the CDC Demonstration Project “CKD Health Evaluation and Risk Information Sharing (CHERISH)”, which aimed to identify individuals at high risk for CKD in the U.S. and as an investigator for the NIH-sponsored clustered practice randomized trial entitled, evidenced-based primary care for CKD. Leadership also includes multiple roles over the last decade with the CMS Fistula First national quality  improvement initiative for hemodialysis, including as Lead Physician Consultant from 2013 through 2015. He has served on numerous committees that shape innovation and health policy in kidney disease for the CDC, the NIH and CMS. Dr. Vassalotti has over 80 publications in peer-reviewed journals and has been featured in Castle Connolly’s Top Doctors and Best Doctors in America.

Segment Overview: Dr. Joseph Vassalotti, chief medical officer of the National Kidney Foundation, talks about the importance of understanding the seriousness of hyperkalemia (elevated potassium levels in the blood), especially for people living with chronic kidney disease (CKD), and ways to manage it.

Transcript

Neal Howard: Hello and welcome to the program. I’m your host Neal Howard here on Health Professional Radio. What is ‘Hyperkalemia’ and why are patients with kidney disease often at risk of developing it? Our guest in studio today is Dr. Joseph Vassalotti and he’s with us today to talk about a new survey of people with chronic kidney disease as the Chief Medical Officer of the National Kidney Foundation. Welcome to Health Professional Radio Dr. Vassalotti.

Dr. Joseph Vassalotti: Great. Thank you for having me.

N: Before we get into topic, give our listeners a little bit of background about yourself being the Chief Medical Officer there at the National Kidney Foundation.

V: So I’m a nephrologist and I’m also on the clinical faculty at Icahn School of Medicine at Mount Sinai and I’m an Associate Professor there or a CPH as well. We train the pharmacy fellows there. Those are residents who were going into nephrology.

N: This new study, this survey of people that are suffering with chronic kidney disease, what was the purpose of the study in the first place?

V: Well, hyperkalemia as the audience knows is an important complication of chronic kidney disease. And the purpose of the study was to have an understanding about the awareness of chronic kidney disease, hyperkalemia in patients with chronic kidney disease and the full spectrum of disease, the patients who are treated with dialysis, patients have a kidney transplant and patients with much earlier stages of kidney disease. In fact, patients with all the stages of kidney disease were included in this survey. And then moreover, what the patients understand potassium means in the blood. The patients know their potassium level in their blood and do they know about how hyperkalemia can be treated.

N: So in your opinion, it’s a lack of awareness that is contributing to this hyperkalemia. People not knowing exactly what they need to do about. Is it just a lack of awareness?

V: It’s not surprising that hyperkalemia has low awareness because chronic kidney disease itself has low awareness and only about 10% of people in the US who have chronic kidney disease are aware of the condition. So unfortunately, it makes sense that awareness of a complication is low. But I think we can start to change the dynamic a little bit and we can start to help prevent hyperkalemia and help patients better understand what it means and better manage it when they have it. And I think that the opportunity for the practicing clinician is to think about the patient who might develop hyperkalemia in advance. In my opinion, most patients only learn about hyperkalemia because doctors and how the healthcare professionals start to talk about it once they have an elevated potassium level in the blood. So I think by increasing awareness for patients of hyperkalemia, we can start to move those conversations up.
N: So what are some of the the symptoms of hyperkalemia? And once those symptoms have been identified by either the patient or the practitioner, how is it actually properly diagnosed?

V: Unfortunately, hyperkalemia is often asymptomatic. So patients may feel well and the first problem they have with it is could be quite severe. It could be a heart rhythm problem if the hyperkalemia is severe. So I think that’s important and that’s why it’s very important to have your blood monitored for potassium if you have chronic kidney disease to detect hyperkalemia. In my days, I’ve seen some patients with extremely elevated potassium and sometimes, patients also have muscle weakness that goes along with hyperkalemia because the potassium affects conduction in the heart, it can also affect skeletal muscle contractions. So for that reason, I think that’s why patients experience that. I think the most important thing for people to know is that they may be completely symptom free with a high potassium level.

N: Well, that’s extremely problematic in the first place being asymptomatic. But you mentioned managing the condition once it’s been diagnosed, what are some of the challenges other than the high levels of potassium and the things that go along with it that would prevent someone from managing their potassium levels effectively?

V: Well I think by far the most important risk for hyperkalemia is impaired kidney function. So patients should know that just because they have kidney function, they’re at risk for hyperkalemia. The other thing that patients should know is that unfortunately, a lot of the medicines that are used to treat chronic kidney disease can raise the potassium level such as ACE inhibitors or Angiotensin Receptor Blockers that we use for treating hypertension and Albuminuria, Proteinuria. Those drugs reduce the risk of kidney failure.They reduce the risk of mortality. So they’re really important drugs for us to use. But unfortunately, they have the risk of hyperkalemia. I think one thing for clinicians to do is to think about what the passing level is before they start those therapies. And then there are certain kinds of diuretic, potassium sparing diuretics like Spironolactone and Eplerenone that also increase potassium that are sometimes used for patients who also have heart failure or who have liver disease and those also can raise the potassium. For the individual patient, it’s really complicated. There are diet issues that patients have to deal with, unfortunately, diet is very challenging for patients with hyperkalemia. A lot of the foods patients like to eat are high in potassium, the fruits and the vegetables. I use the ABCT approach very simply, Avocados, Bananas, Citrus fruits, juices and Tomatoes, tomato products. We can learn more about the diet if you look at the NKF website, there’s a very nice description of that. Also it’s important to tell people what they can eat. In general apples and cherries are relatively low in potassium and you may want to have a dietitian involved to help patients navigate low potassium restricted diet. The other aspect is that potassium is often beneficial for people with blood pressure that’s elevated and that’s unfortunately, it’s something that we have to deal with our kidney disease patients that we have to restrict it. I did discuss the kidney protective medications and then there may be other medications that we can use that reduce potassium like diuretics – the Thiazide diuretics or the Loop diuretics. Sometimes, if the patient has metabolic alkalosis, we can treat that with alkali and then there may be other therapies potassium binders that can be used to treat the potassium in the blood.

N: Now where can we go and get some more information online about the survey and also about hyperkalemia?

V: The National Kidney Foundation website is www.kidney.org, that has a lot of information. There’s a potassium and your CKD diet and the A to Z health guide that is very useful for both patients and clinicians to refer their patients to. There is the survey is available there. In addition there’s CME for healthcare professionals regarding CKD and hyperkalemia approaches to diagnosis and management.

N: Well I appreciate you coming in today a Dr. Vassalotti and I’m hoping that you’ll come back with us in future segments and give us some updates.

V: Okay, great. Thank you for having us and thank you for discussing this very important topic.

N: You’ve been listening to Health Professional Radio. I’m your host Neal Howard. Transcripts and audio of the program are available at hpr.fm. You can subscribe to the podcast on iTunes, listen in and download at SoundCloud and be sure and visit our affiliates page at healthprofessionalradio.com.au and also at hpr.fm.

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