Plasma potassium ranges associated with mortality across stages of chronic kidney disease: the Stockholm CREAtinine Measurements (SCREAM) project

Background. Small-scale studies suggest that hyperkalaemia is a less threatening condition in chronic kidney disease (CKD), arguing adaptation/tolerance to potassium (K+) retention. This study formally evaluates this hypothesis by estimating the distribution of plasma K+ and its association with mortality across CKD stages. Methods. This observational study included all patients undergoing plasma K+ testing in Stockholmduring 2006-11. We randomly selected one K+ measurement per patient and constructed a cross-sectional cohort with mortality follow-up. Covariates included demographics, comorbidities, medications and estimated glomerular filtration rate (eGFR). We estimated K+ distribution and defined K+ ranges associated with 90-, 180- and 365-day mortality. Results. Included were 831 760 participants, of which 70 403 (8.5%) had CKD G3 (eGFR<60-30 mL/min) and 8594 (1.1%) had CKD G4-G5 (eGFR<30 mL/min). About 66 317 deaths occurred within a year. Adjusted plasma K+ increased across worse CKD stages: from median 3.98 (95% confidence interval 3.49-4.59) for eGFR>90 to 4.43 (3.22-5.65) mmol/L for eGFR <= 15 mL/min/1.73 m(2). The association between K+ and mortality was U-shaped, but it flattened at lower eGFR strata and shifted upwards. For instance, the range where the 90-day mortality risk increased by no more than 100% was 3.45-4.94 mmol/L in eGFR>60 mL/min, but was 3.36-5.18 in G3 and 3.26-5.53 mmol/L in G4-G5. In conclusion, CKD stage modifies K+ distribution and the ranges that predictmortality in the community. Conclusion. Although this study supports the view that hyperkalaemia is better tolerated with worse CKD, it challenges the current use of a single optimal K+ range for all patients.