Doctoral Degrees (Nephrology)


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    Improving the emergency management of hyperkalaemia
    (Stellenbosch : Stellenbosch University, 2022-08) Chothia, Mogamat-Yazied; Davids, Mogamat Razeen; Chikte, Usuf; Faculty of Medicine and Health Sciences. Dept. of Medicine. Division of Nephrology.
    ENGLISH ABSTRACT: Hyperkalaemia is a common electrolyte disorder in hospitalised adult patients and is associated with life-threatening muscle weakness and cardiac arrhythmias if left untreated. The central theme of this project was to improve the emergency management of hyperkalaemia by contributing data to fill important knowledge gaps and shed light on areas of the management where there is still controversy. We investigated the epidemiology, diagnostic aspects, treatment-related adverse effects, the knowledge of medical specialists regarding managing hyperkalaemia and we tested a novel treatment option. Our retrospective cohort study is the largest African study to report on the frequency, risk factors and outcome of hospitalised adult patients with hyperkalaemia. In-hospital death was high (29%) and acute kidney injury was the strongest predictor of mortality. Fourteen percent of our patients with hyperkalaemia were HIV positive. There was no difference in mortality based on HIV status. Future research should investigate whether the earlier identification and treatment of patients with hyperkalaemia in association with AKI will improve outcomes. Our scoping review on the adverse effects of insulin therapy for hyperkalaemia is the first comprehensive review of the topic. The prevalence of hypoglycaemia was 17%. Lower insulin doses were associated with a reduced prevalence of severe hypoglycaemia, and continuous infusion of dextrose was associated with a lower overall prevalence. There were no differences in the prevalence of hypoglycaemia by insulin dose, type, rate of administration or timing relative to dextrose. There was also no difference related to dextrose dose. The most important predictor of hypoglycaemia was lower pre-treatment serum glucose concentrations. In our survey, which tested the knowledge of medical specialists on the emergency management of hyperkalaemia, we found wide variations in their knowledge and practice. Knowledge gaps were identified in all facets of management, particularly around the optimal and safe use of insulin-based therapies. Our findings should be useful in informing the development of consensus-based guidelines and educational materials. To improve the diagnosis of hyperkalaemia in the emergency department, we performed a method comparison study between point-of-care blood gas analyser (POC-BGA) and laboratory auto-analyser potassium concentrations ([K+]). We found a systematic negative bias of -0.4 mmol/L, with the difference remaining relatively constant across the hyperkalaemic range. We recommend that POC-BGA measurements of [K+] can therefore be used, with adjustment for this bias, allowing for rapid diagnosis and the prompt initiation of treatment. To address the risk of hypoglycaemia after insulin therapy, we investigated a novel treatment for the management of hyperkalaemia. In a randomised, cross-over trial, stable patients on chronic haemodialysis received treatment with either an intravenous dextrose-only bolus or standard insulin-plus-dextrose therapy. In the dextrose-only group, a clinically significant decrease of 0.5 mmol/L in the [K+] was found, without any episodes of hypoglycaemia. Although the decrease in the [K+] was greater in the insulin-plus-dextrose group, 20% of the participants developed hypoglycaemia. A dextrose-only bolus is therefore an attractive treatment option especially in busy, resource-limited emergency departments where careful and frequent monitoring of the blood glucose concentration may not be possible. These studies have highlighted the importance of hyperkalaemia in hospitalised patients and contributed to improvements in the diagnosis and emergency management of this condition. We anticipate that our findings will inform treatment guidelines and inform the training of healthcare workers and students.