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Predicting the risk of hyperkalemia in patients with chronic kidney disease starting lisinopril†

  1. Eric S Johnson PhD1,*,
  2. Jessica R Weinstein MD2,
  3. Micah L Thorp DO, MPH3,
  4. Robert W Platt PhD4,
  5. Amanda F Petrik MS1,
  6. Xiuhai Yang MS1,
  7. Sharon Anderson MD2,5,
  8. David H Smith RPh, PhD1

Article first published online: 29 JAN 2010

DOI: 10.1002/pds.1923

Issue

Pharmacoepidemiology and Drug Safety

Pharmacoepidemiology and Drug Safety

Volume 19, Issue 3, pages 266–272, March 2010

Additional Information

How to Cite

Johnson, E. S., Weinstein, J. R., Thorp, M. L., Platt, R. W., Petrik, A. F., Yang, X., Anderson, S. and Smith, D. H. (2010), Predicting the risk of hyperkalemia in patients with chronic kidney disease starting lisinopril. Pharmacoepidem. Drug Safe., 19: 266–272. doi: 10.1002/pds.1923

Author Information

  1. 1

    The Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA

  2. 2

    Division of Nephrology and Hypertension, Department of Medicine, Oregon Health & Science University, Portland, OR, USA

  3. 3

    Department of Nephrology, Kaiser Permanente Northwest, Portland, OR, USA

  4. 4

    Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada

  5. 5

    Portland Veterans Affairs Medical Center, Portland, OR, USA

*The Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Avenue, Portland, OR 97227, USA.

  1. †

    The authors declare no conflicts of interest.

Publication History

  1. Issue published online: 24 FEB 2010
  2. Article first published online: 29 JAN 2010
  3. Manuscript Accepted: 15 DEC 2009
  4. Manuscript Revised: 24 NOV 2009
  5. Manuscript Received: 1 JUL 2009

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Keywords:

  • hyperkalemia;
  • chronic kidney disease;
  • ACE-inhibitors;
  • risk score;
  • cohort study;
  • adverse effects

Abstract

Purpose

Angiotensin-converting enzyme (ACE) inhibitors are recommended for patients with chronic kidney disease (CKD) because they slow disease progression. But physicians' concerns about the risk of hyperkalemia (elevated serum potassium level), a potentially fatal adverse effect, may limit optimal management with ACE-inhibitors. We synthesized known predictors of hyperkalemia into a prognostic risk score to predict the risk of hyperkalemia.

Methods

We assembled a retrospective cohort of adult patients with possible CKD (at least one estimated glomerular filtration rate (eGFR) value less than 60 ml/min/1.73 m2) who started an ACE-inhibitor (i.e., incident users) between 1998 and 2006 at a health maintenance organization. We followed patients for hyperkalemia: (1) potassium value >5.5 mmol/L; or (2) diagnosis code for hyperkalemia. Cox regression synthesized a priori predictors recorded in the electronic medical record into a risk score.

Results

We followed 5171 patients and 145 experienced hyperkalemia, a 90-day risk of 2.8%. Predictors included: age, eGFR, diabetes, heart failure, potassium supplements, potassium-sparing diuretics, and a high dose for the ACE-inhibitor (lisinopril). The risk score separated high-risk patients (top quintile, observed risk of 6.9%) from low-risk patients (bottom quintile, observed risk of 0.7%). Predicted and observed risks agreed within 1% for each quintile. The risk increased gradually in relation to declining eGFR with no apparent threshold for contraindicating ACE-inhibitors.

Conclusions

The risk score separated high-risk patients (who may need more intensive laboratory monitoring) from low-risk patients. The risk score should be validated in other populations before it is ready for use in clinical practice. Copyright © 2010 John Wiley & Sons, Ltd.

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