Hyperkalemia After Initiating Renin–Angiotensin System Blockade: The Stockholm Creatinine Measurements (SCREAM) Project

Abstract

BackgroundConcerns about hyperkalemia limit the use of angiotensin‐converting enzyme inhibitors (ACE‐I) and angiotensin receptor blockers (ARBs), but guidelines conflict regarding potassium‐monitoring protocols. We quantified hyperkalemia monitoring and risks after ACE‐I/ARB initiation and developed and validated a hyperkalemia susceptibility score. Methods and ResultsWe evaluated 69 426 new users of ACE‐I/ARB therapy in the Stockholm Creatinine Measurements (SCREAM) project with medication initiation from January 1, 2007 to December 31, 2010, and follow‐up for 1 year thereafter. Three fourths (76%) of SCREAM patients had potassium checked within the first year. Potassium >5 and >5.5 mmol/L occurred in 5.6% and 1.7%, respectively. As a comparison, we propensity‐matched new ACE‐I/ARB users to 20 186 new β‐blocker users in SCREAM: 64% had potassium checked. The occurrence of elevated potassium levels was similar between new β‐blocker and ACE‐I/ARB users without kidney disease; only at estimated glomerular filtration rate 60 mL/min per 1.73 m2, but rates were much higher with lower estimated glomerular filtration rate. Use of the hyperkalemia susceptibility score may help guide laboratory monitoring and prescribing strategies.

Keywords

• angiotensin‐converting enzyme inhibitors
• angiotensin receptor blockers
• angiotensin‐converting enzyme inhibition
• chronic kidney disease
• hyperkalemia
• potassium