Oral potassium supplementation reduces Peritonitis risk in hypokalemic peritoneal dialysis patients

Thailand: A study published in the American Journal of Kidney diseases has concluded that protocol-based oral potassium supplementation is safe and maintains serum potassium levels in the range of 4-5 mEq/L. This supplementation also reduces the peritonitis risk in hypokalemic peritoneal dialysis (PD) patients compared to the reactive potassium supplementation, where the serum potassium level is below 3.5 mEq/L.

It is already known that the number of kidney failure cases treated with kidney replacement therapy (KRT) is rising, and these numbers will be doubled between 2020 and 2030.

Hypokalemia complicates PD (serum potassium concentration below 3.5 mEq/L) and has a high prevalence ranging from 3 to 47 %, as per Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS).

The literature mentions the studies reporting an association between hypokalemia and an increased peritonitis risk. When serum potassium concentration is in range of 4-5 mEq/L, the peritonitis risk is lowest.

Hypokalemia correction through potassium supplementation mitigates peritonitis risk. Clinical trials have yet to evaluate this.

Considering this, a study was conducted by DrWatthikorn Pichitporn from the Division of Nephrology, Department of Medicine from Chulalongkorn University, Bangkok, Thailand, with a team of researchers to evaluate the safety and effectiveness of protocol-based potassium treatment over 12 months and determine whether it reduces peritonitis in hypokalemic PD patients.

The conclusive points of the study are:

• The nature of the study was multicenter, open-label, stratified RCT.

• The study participants were enrolled on six peritoneal dialysis centres in Thailand.

• The other settings and participants are N = 167 adults aged ≥18 years, PD > 3 months and K < 3.5 mEq/L.

• The intervention included Protocol-based K Treatment vs usual care or reactive K treatment.

• In Protocol-based K treatment, 85 participants were given titrate sustained-release KCL tablets to maintain serum potassium concentrations between 4-5 mEq/L.

• In the conventional treatment group, 82 participants were given potassium supplements;here serum potassium level fell below 3.5 mEq/L.

• The intervention period was 52 weeks.

• Diet counselling was given to both groups related to adequate potassium intake.

• The treatment groups were compared using intention-to-treat analyses implemented using Cox proportional hazards regression.

• The primary and secondary outcomes were measured.

• Time to first peritonitis episode was the primary outcome measured.

• CV mortality, all-cause mortality, hospitalisation and hemodialysis transfer were the secondary outcomes measured.

• The median follow-up was 401 days.

• In the protocol-based K treatment group, the time to first peritonitis was 233 days with a Hazard ratio of 0.47. The value of P was 0.029

• The time to first peritonitis in usual care K treatment was 133 days.

• There was an increase in serum potassium levels to 4.36 ± 0.70 mEq/L in the protocol-based treatment group.

• In the conventional treatment group, serum potassium levels were 3.57 ± 0.65 mEq/L.

• The mean difference was 0.66 with a P value of < 0.001.

• The secondary outcomes were not significant.

They said we reported increased Serum potassium levels, from 3.32 ± 0.27 mEq/L (baseline ) to 4.04 ± 0.62 mEq/L(first month follow-up)in the intervention group . This value remained in the target range of 4-5 mEq/L throughout the study, which has been associated with the lowest adverse PD patient outcomes (peritonitis, cardiovascular mortality, all-cause mortality) according to previous studies. Our study is the first to demonstrate how effective potassium supplementation is in preventing PD-associated peritonitis.

The dosage of Potassium chloride tablets, 25 ± 13 mEq/d, which we used in our study, has promising efficacy and relatively few side effects.

The potential mechanisms of this beneficial effect include improvement of gut motility, muscle strength, cellular function, etc.

This was the first RCT evaluating the potassium treatment effectiveness on outcomes of peritonitis.

The Ratchadapiseksompotch Fund and others supported the study, as acknowledged.

Further reading:

Efficacy of Potassium Supplementation in Hypokalemic Patients Receiving Peritoneal Dialysis: A Randomized Controlled Trial Watthikorn Pichitporn et al.