Background: Hyperkalaemia is a potentially life-threatening electrolyte disturbance which may lead to cardiac arrhythmias and death. Renal replacement therapy is known to be effective in treating hyperkalaemia, but safe and effective pharmacological interventions are needed to prevent dialysis or avoid the complications of hyperkalaemia until dialysis is performed. Objectives: This review looked at the benefits and harms of pharmacological treatments used in the acute management of hyperkalaemia in adults. This review evaluated the therapies that reduce serum potassium as well as those that prevent complications of hyperkalaemia. Search methods: We searched Cochrane Kidney and Transplant's Specialised Register to 18 August 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. Selection criteria: All randomised controlled trials (RCTs) and quasi-RCTs looking at any pharmacological intervention for the acute management of hyperkalaemia in adults were included in this review. Non-standard study designs such as cross-over studies were also included. Eligible studies enrolled adults (aged 18 years and over) with hyperkalaemia, defined as serum potassium concentration = 4.9 mmol/L, to receive pharmacological therapy to reduce serum potassium or to prevent arrhythmias. Patients with artificially induced hyperkalaemia were excluded from this review. Data collection and analysis: All three authors screened titles and abstracts, and data extraction and risk of bias assessment was performed independently by at least two authors. Studies reported in non-English language journals were translated before assessment. Authors were contacted when information about results or study methodology was missing from the original publication. Although we planned to group all studies of a particular pharmacological therapy regardless of administration route or dose for analysis, we were unable to conduct meta-analyses because of the small numbers of studies evaluating any given treatment. For continuous data we reported mean difference (MD) and 95% confidence intervals (CI). Main results: We included seven studies (241 participants) in this review. Meta-analysis of these seven included studies was not possible due to heterogeneity of the treatments and because many of the studies did not provide sufficient statistical information with their results. Allocation and blinding methodology was poorly described in most studies. No study evaluated the efficacy of pharmacological interventions for preventing clinically relevant outcomes such as mortality and cardiac arrhythmias; however there is evidence that several commonly used therapies effectively reduce serum potassium levels. Salbutamol administered via either nebulizer or metered-dose inhaler (MDI) significantly reduced serum potassium compared with placebo. The peak effect of 10 mg nebulised salbutamol was seen at 120 minutes (MD -1.29 mmol/L, 95% CI -1.64 to -0.94) and at 90 minutes for 20 mg nebulised salbutamol (1 study: MD -1.18 mmol/L, 95% CI -1.54 to -0.82). One study reported 1.2 mg salbutamol via MDI 1.2 mg produced a significant decrease in serum potassium beginning at 10 minutes (MD -0.20 mmol/L, P < 0.05) and a maximal decrease at 60 minutes (MD -0.34 mmol/L, P < 0.0001). Intravenous (IV) and nebulised salbutamol produced comparable effects (2 studies). When compared to other interventions, salbutamol had similar effect to insulin-dextrose (2 studies) but was more effective than bicarbonate at 60 minutes (MD -0.46 mmol/L, 95% CI -0.82 to -0.10; 1 study). Insulin-dextrose was more effective than IV bicarbonate (1 study) and aminophylline (1 study). Insulin-dextrose, bicarbonate and aminophylline were not studied in any placebo-controlled studies. None of the included studies evaluated the effect of IV calcium or potassium binding resins in the treatment of hyperkalaemia. Authors' conclusions: Evidence for the acute pharmacological management of hyperkalaemia is limited, with no clinical studies demonstrating a reduction in adverse patient outcomes. Of the studied agents, salbutamol via any route and IV insulin-dextrose appear to be most effective at reducing serum potassium. There is limited evidence to support the use of other interventions, such as IV sodium bicarbonate or aminophylline. The effectiveness of potassium binding resins and IV calcium salts has not been tested in RCTs and requires further study before firm recommendations for clinical practice can be made.
Un examen raccourci a été réalisée pour déterminer si levalbuterol nébulisée est supérieure ou équivalente à l'albutérol pour abaisser la kaliémie. Sept documents ont été trouvés en utilisant la recherche signalés, dont trois ont présenté la meilleure preuve pour répondre à la question clinique. L'auteur, date et pays de publication, le groupe de patients étudiés, le type d'étude, les résultats pertinents, les résultats et les faiblesses de l'étude de ces meilleurs papiers sont totalisées. Une ligne en bas clinique est indiqué.
CONTEXTE: L'hyperkaliémie survient chez des patients externes et chez 1 à 10 % des patients hospitalisés. Lorsqu'elle est sévère, elle peut aboutir à une arythmie ou au décès.
OBJECTIFS: Réviser les preuves randomisées concernant la gestion urgente (c.-à-d. aiguë plutôt que chronique) de l'hyperkaliémie
STRATÉGIE DE RECHERCHE DOCUMENTAIRE: MEDLINE (1966-2003), EMBASE (1980-2003), La librairie Cochrane (numéro 4, 2003) et SciSearch ont été consultés à l'aide des mots de textes hyperkal* ou hyperpotass* (* indique une coupure). Une sélection de revues et de résumés de réunions a également été consultée. Des références bibliographiques d'articles de revue récents, des ouvrages et des articles pertinents ont été révisés pour de potentiels titres pertinents supplémentaires.
CRITÈRES DE SÉLECTION: Toute la sélection a été faite en double. Les articles étaient considérés comme pertinents s'il s'agissait d'essais randomisés, quasi-randomisés ou randomisés croisés d'interventions pharmacologiques ou non pour traiter les humains non néonatals souffrant d'hyperkaliémie ; les articles devaient signaler les résultats cliniquement importants ou la kaliémie au cours des six premières heures d'administration.
RECUEIL ET ANALYSE DES DONNÉES: L'extraction des données a été effectuée en double. Les informations relatives à la qualité, les détails sur la population de patients et les valeurs de potassium de départ et pendant l'intervention et le suivi. Les informations relatives aux arythmies, à la mortalité et aux effets indésirables ont été extraites. Dans la mesure du possible, une méta-analyse a été effectuée au moyen de modèles à effets aléatoires.
RÉSULTATS PRINCIPAUX: Aucune des études d'hyperkaliémie cliniquement pertinentes n'a rapporté de mortalité ou d'arythmies cardiaques. Les rapports se concentraient sur les taux de potassium sérique. Bon nombre des études étaient de petite envergure et certains groupes expérimentaux ne présentaient pas assez de données pour permettre d'effectuer une méta-analyse. Selon les petites études, les béta-agonistes inhalés, les béta-agonistes nébulisés et l'insuline-glucose par voie intraveineuse (IV) se sont tous montrés efficaces, et l'association de béta-agonistes nébulisés avec l'insuline-glucose par voie IV étaient plus efficaces que l'un des autres agents seul. La dialyse est efficace. Les résultats étaient équivoques en ce qui concerne le biocarbonate par IV. La résine d'absorption de potassium (K) ne s'est pas avérée efficace après quatre heures, et les ECR n'ont pas fourni de données de suivi plus long sur cette intervention.
CONCLUSIONS DES AUTEURS: Le salbutamol nébulisé ou inhalé, ou l'insuline-glucose par voie IV sont les traitements de première intention pour la gestion d'urgence de l'hyperkaliémie étant les mieux étayés par les preuves. Leur association peut être plus efficace que tout autre agent seul, et elle devrait être envisagée dans le cas d'une hyperkaliémie sévère. En cas d'arythmie, une abondance de données non confirmées ou provenant d'études réalisées sur des animaux suggèrent que le calcium par voie IV est efficace pour traiter l'arythmie. D'autres études sur l'utilisation optimale des traitements combinés et sur les effets indésirables des traitements sont nécessaires.
Background: Hyperkalaemia is a potentially life-threatening electrolyte disturbance which may lead to cardiac arrhythmias and death. Renal replacement therapy is known to be effective in treating hyperkalaemia, but safe and effective pharmacological interventions are needed to prevent dialysis or avoid the complications of hyperkalaemia until dialysis is performed. Objectives: This review looked at the benefits and harms of pharmacological treatments used in the acute management of hyperkalaemia in adults. This review evaluated the therapies that reduce serum potassium as well as those that prevent complications of hyperkalaemia. Search methods: We searched Cochrane Kidney and Transplant's Specialised Register to 18 August 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. Selection criteria: All randomised controlled trials (RCTs) and quasi-RCTs looking at any pharmacological intervention for the acute management of hyperkalaemia in adults were included in this review. Non-standard study designs such as cross-over studies were also included. Eligible studies enrolled adults (aged 18 years and over) with hyperkalaemia, defined as serum potassium concentration = 4.9 mmol/L, to receive pharmacological therapy to reduce serum potassium or to prevent arrhythmias. Patients with artificially induced hyperkalaemia were excluded from this review. Data collection and analysis: All three authors screened titles and abstracts, and data extraction and risk of bias assessment was performed independently by at least two authors. Studies reported in non-English language journals were translated before assessment. Authors were contacted when information about results or study methodology was missing from the original publication. Although we planned to group all studies of a particular pharmacological therapy regardless of administration route or dose for analysis, we were unable to conduct meta-analyses because of the small numbers of studies evaluating any given treatment. For continuous data we reported mean difference (MD) and 95% confidence intervals (CI). Main results: We included seven studies (241 participants) in this review. Meta-analysis of these seven included studies was not possible due to heterogeneity of the treatments and because many of the studies did not provide sufficient statistical information with their results. Allocation and blinding methodology was poorly described in most studies. No study evaluated the efficacy of pharmacological interventions for preventing clinically relevant outcomes such as mortality and cardiac arrhythmias; however there is evidence that several commonly used therapies effectively reduce serum potassium levels. Salbutamol administered via either nebulizer or metered-dose inhaler (MDI) significantly reduced serum potassium compared with placebo. The peak effect of 10 mg nebulised salbutamol was seen at 120 minutes (MD -1.29 mmol/L, 95% CI -1.64 to -0.94) and at 90 minutes for 20 mg nebulised salbutamol (1 study: MD -1.18 mmol/L, 95% CI -1.54 to -0.82). One study reported 1.2 mg salbutamol via MDI 1.2 mg produced a significant decrease in serum potassium beginning at 10 minutes (MD -0.20 mmol/L, P < 0.05) and a maximal decrease at 60 minutes (MD -0.34 mmol/L, P < 0.0001). Intravenous (IV) and nebulised salbutamol produced comparable effects (2 studies). When compared to other interventions, salbutamol had similar effect to insulin-dextrose (2 studies) but was more effective than bicarbonate at 60 minutes (MD -0.46 mmol/L, 95% CI -0.82 to -0.10; 1 study). Insulin-dextrose was more effective than IV bicarbonate (1 study) and aminophylline (1 study). Insulin-dextrose, bicarbonate and aminophylline were not studied in any placebo-controlled studies. None of the included studies evaluated the effect of IV calcium or potassium binding resins in the treatment of hyperkalaemia. Authors' conclusions: Evidence for the acute pharmacological management of hyperkalaemia is limited, with no clinical studies demonstrating a reduction in adverse patient outcomes. Of the studied agents, salbutamol via any route and IV insulin-dextrose appear to be most effective at reducing serum potassium. There is limited evidence to support the use of other interventions, such as IV sodium bicarbonate or aminophylline. The effectiveness of potassium binding resins and IV calcium salts has not been tested in RCTs and requires further study before firm recommendations for clinical practice can be made.
Systematic Review Question»Systematic review of interventions
