Hyperkalemia in patients with stage 5 chronic kidney disease (CKD) increases the risk for early death, whether or not patients initiate hemodialysis, investigators reported at Kidney Week 2022, the annual meeting of the American Society of Nephrology, in Orlando, Florida.

Using the US Veterans Affairs database, investigators identified 5063 patients who initiated hemodialysis and 9618 patients who did not but had an estimated glomerular filtration rate (eGFR) less than 10 mL/min/1.73 m2.

Overall, 8548 patients (58.2%) experienced at least 1 hyperkalemia episode, defined as serum potassium greater than 5.0 mEq/L, in the year prior to the index date. Baseline hyperkalemia affected a greater proportion of the group initiating than not initiating hemodialysis: 69.6% and 52.3%.

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The 1-year all-cause mortality rate was higher among patients with than without baseline hyperkalemia: 21.9% vs 11.0%, Elani Streja, MPH, PhD, of the University of California Irvine, reported on behalf of her team. Baseline hyperkalemia was significantly associated with a 50% increased risk of 1-year all-cause mortality compared with no baseline hyperkalemia. She noted that they are currently examining whether the number and/or severity of hyperkalemia episodes influenced the magnitude of these associations.

In addition, the investigators considered a possible relationship between hyperkalemia, hemodialysis initiation, and death. They found that the 1-year all-cause mortality rate was lower in the group receiving than not receiving hemodialysis: 11.3% vs 20.5%. Hemodialysis was significantly associated with a 60% lower risk of 1-year all-cause mortality compared with no hemodialysis, after accounting for baseline hyperkalemia and eGFR, demographic characteristics, comorbidities, and medication use.

According to the investigators, patients with stage 5 CKD (or end-stage kidney disease) that is managed conservatively without hemodialysis likely have less control of hyperkalemia than those receiving hemodialysis.

“Our results suggest that patients who transition to hemodialysis may have better management of their potassium which may mediate improved survival in these patients,” Dr Streja said in an interview with Renal & Urology News. “Stage 5 CKD patients with baseline hyperkalemia who elect non-dialytic kidney management may benefit from potassium-lowering agents.”

Coauthor Kamyar Kalantar-Zadeh, MD, PhD, MPH, of the University of California Irvine added, “These data have important implications in the new era where delaying dialysis initiation is a priority goal by means of continued conservative management of hyperkalemia.”

Disclosure: This research was supported by AstraZeneca. Please see the original reference for a full list of disclosures.


Streja E, Hsiung JT, Agiro A, Fawaz S, Westfall Laura, Oluwatosin Y, Kalantar-Zadeh K. Impact of hyperkalemia on mortality in patients with advanced kidney disease with and without hemodialysis: Implications for deferring hemodialysis initiation under value-based models. Presented at: Kidney Week 2022; November 3-6, Orlando, Florida. Abstract FR-PO544.