A PROTOCOL-DRIVEN APPROACH FOR POTASSIUM SUPPLEMENTATION TO ADDRESS PERSISTANT HYPOKALEMIA IN PATIENTS UNDERGOING HEMODIALYSIS

Cardiac arrhythmias remain a significant contributor to sudden death among patients receiving maintenance hemodialysis, linked to both high and low pre-dialysis potassium (K) levels. While hypokalemia is commonly found in patients undergoing peritoneal dialysis (PD), it is rarely observed in those on hemodialysis, resulting in a lack of established guidelines for intervention when pre-dialysis K levels are consistently below 4 mEq/L. Generally, these patients are transitioned to a dialysate with a K concentration of 3 mmol/L and advised to follow a potassium-rich diet. Nevertheless, there are instances where these standard strategies prove inadequate. As a result, we implemented a novel approach to maintain pre-dialysis K levels above 4 mEq/L, particularly in situations where hypokalemia does not respond to traditional treatments. This approach entails the oral administration of potassium chloride supplementation three times a week on dialysis days, with the with the primary objective of sustaining mid-monthly pre-dialysis K levels between 4 and 6 mEq/L. The current study aims to evaluate the effectiveness and safety of this oral potassium replacement protocol.

This study was a retrospective audit conducted at a single centre. It included all adult patients undergoing hemodialysis (aged over 18 years) who had monthly pre-dialysis potassium levels below 4 mEq/L for more than three months, despite receiving K 3 mmol dialysate and potassium-rich dietary supplements. Patients who were suspected of having potassium-losing tubulopathy, low serum magnesium levels, or chronic diarrhoea were excluded from the analysis. Patients with pre-dialysis potassium levels ranging from 3.5 to 3.9 mEq/L were administered 10 mmol of potassium chloride orally. In cases where the potassium level fell below 3.5 mEq/L, an oral dose of 20 mmol of potassium chloride was provided. This regimen was maintained three times a week, immediately before dialysis, under the direct supervision of the dialysis medical personnel. The pre-dialysis potassium levels were verified through point-of-care blood tests to ensure they were below 4 mEq/L before the dosing. Additionally, the pre-dialysis potassium levels were monitored bi-monthly through laboratory testing.

Five patients satisfied the inclusion criteria. All participants receiving oral potassium chloride supplementation three times a week successfully maintained their pre-dialysis potassium levels above 4 mEq/L throughout the 3-month follow-up period, with no occurrences of hyperkalemia. On average, more than a hundred doses of oral potassium chloride were administered monthly over the past three months, with no reports of adverse events or intolerability. The graph below depicts their median potassium levels prior to and following the intervention.

The immediate outcomes of our intervention proved to be both effective and reassuringly safe. This indicates that methods beyond modifying dialysate potassium concentration and dietary potassium supplementation deserve additional consideration to mitigate risks linked to chronic hypokalemia in hemodialysis. Nevertheless, we advise further validation prior to making more definitive conclusions regarding this method. It is crucial to acknowledge that the study has certain limitations, as it is a retrospective analysis and the sample size is relatively small.