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Serum and Dialysate Potassium Concentrations and Survival in Hemodialysis Patients

Csaba P. Kovesdy^*, Deborah L. Regidor^,,, Rajnish Mehrotra, Jennie Jing, Charles J. McAllister^||, Sander Greenland, Joel D. Kopple^,, and Kamyar Kalantar-Zadeh^,

^* Division of Nephrology, Salem Veterans Affairs Medical Center, Salem, and Department of Medicine, University of Virginia, Charlottesville, Virginia; and Harold Simmons Center for Kidney Disease Research and Epidemiology and Division of Nephrology and Hypertension, Los Angeles Biomedical Institute at Harbor-UCLA Medical Center, Torrance, School of Public Health, University of California, Los Angeles, and ^|| DaVita, Inc., El Segundo, California

Address correspondence to: Dr. Kamyar Kalantar-Zadeh, Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, LA BioMed at Harbor-UCLA Medical Center, 1124 West Carson Street, Torrance, CA 90502. Phone: 310-222-3891; Fax: 310-782-1837; E-mail: kamkal{at}ucla.edu

Background and objectives: Controlling serum potassium is an important goal in maintenance hemodialysis patients. We examined the achievement of potassium balance through hemodialysis treatments and the associated fluctuations in serum potassium.

Design, setting, participants, & measurements: A 3-yr (July 2001 to June 2004) cohort of 81,013 maintenance hemodialysis patients from all DaVita dialysis clinics across the United States were studied. Nine quarterly-averaged serum potassium groups (<4.0, 6.3 mEq/L and seven increments in-between) and four dialysate potassium concentration groups were created in each of the 12 calendar quarters. The death risk associated with predialysis potassium level and dialysate potassium concentration was examined using unadjusted, case-mix adjusted, and malnutrition-inflammation–adjusted time-dependent survival models.

Results: Serum potassium correlated with nutritional markers. Serum potassium between 4.6 and 5.3 mEq/L was associated with the greatest survival, whereas potassium <4.0 or 5.6 mEq/L was associated with increased mortality. The death risk of serum potassium 5.6 mEq/L remained consistent after adjustments. Higher dialysate potassium concentration was associated with increased mortality in hyperkalemic patients with predialysis serum potassium 5.0 mEq/L.

Conclusions: A predialysis serum potassium of 4.6 to 5.3 mEq/L is associated with the greatest survival in maintenance hemodialysis patients. Hyperkalemic patients who undergo maintenance hemodialysis against lower dialysate bath may have better survival. Limitations of observational studies including confounding by indication should be considered when interpreting these results.

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