Mono-therapy versus dual-therapy as transcellualr K shifting agents for acute therapy of hyperkalemia on maintenance hemodialysis

Kim, Byoung Hun; Yang, Suck Chul; Kim, Ho Jung

Abstract

OBJECTIVES
We evaluate the efficacy of transcellualr K-lowering effect at 1 hour following mono-therapy compared to that of dual-therapy , and aimed to find the sage and rapid method for acute therapy of hyperkalemia before dialysis in 10 ESRD patients with maintenance hemodialysis. METHOD: For ten patients of end stage renal failure with body weight between 55 and 65 Kg and a predialysis plasma potassium greater than 5.5 mEq/L, we studied in three separated phases separated from one another by at least 1 week. After 1 hour following mono-therapy (2mEq/Kg of NaHCO3 in interavenous infusion, 10 units of regular insulin with 50ml of 50% glucose in i.v. push, or 15mg of salbutamol in nebulizer) or dual therapy(NaHCO3 + Insulin with glucose, NaHCO3 + salbutamol, or salbutamol + insulin with glucose) for hyperkalemia, we compared the efficacy and safety of each transcellular K shifting methods.
RESULTS
Bicarbonate infusion induced a signigicant raise in plasma bicarbonate and pH from baseline values in both mono-therapy and dual-therapy without any significant difference each other. Among mono-therapeutic regimens, bicarbonate alone failed to lower plasme K from baseline levels (-0.1+/-0.15 mEq/L, P=NS) whereas two other regimens effectively lowered plasma K (-0.62+/-0.06 mEq/L in insulin with glucose, -0.57+/-0.04 mEq/L in salbutamol, P vs. basal <0.05 in both). The K-lowering effects in the three combined regimeds of dual therapy were more prominent as compared to that of three regimens of monotherapy (-0.96+/-0.08 mEq/L in NaHCO3 + salbutamol, -1.20+/-0.6 mEq/L in NaHCO3 + insulin with glucose, and -1.20+/-0.10 mEq/L in salbutamol + insulin with glucose, respectively)(P<0.05). Two patients in monotherapy with salbutamol alone were resistant to the hypokalemic effect, however in dual therapy with simultaneous administration of salbutamol and bicarbonate resolved it. Also, hypoglycemia (<60mg/dL of fasting glucose) was noted in 4 patients in mon-therapy of insuli with glucose alone, 2 in dual-therapy of insulin with glucose + NaHCO3, but none in insulin with glucose + salbutamol.
CONCLUSION
Dudal-therapeutic regimens lowered plasma potassium more effectively than mono-therapeutic regimens, and among them, the combination of insulin with glucose plus salbutamol could be recommended as an efficacious and safe modality in the acute therapy of hyperkalimia in ESRD patients.