Discussion On The Treatment Of Hyperkalemia in Chronic Kidney Disease Treated By Traditional Chinese Medicine

Clinical application of traditional Chinese medicine in patients with chronic kidney disease

Chronic kidney disease (CKD) is a highly prevalent disease worldwide. According to a 2012 study, the prevalence of CKD in my country was 10.8%. Due to the lack of effective treatment drugs, about 10% of patients progressed to end-stage renal disease (end-stage renal disease). stage renal disease, ESRD)[1], seriously affecting the survival and quality of life of patients. Traditional Chinese medicine is a great creation of the Chinese nation, a treasure of ancient Chinese science, and a key to unlocking the treasure house of Chinese civilization. Traditional medicine in my country, traditional Chinese medicine plays a pivotal role in the treatment of CKD. A multi-center RCT study showed that, compared with ACEI inhibitors (Benazepril), traditional Chinese medicine can significantly improve the renal function of patients with CKD stage 3, and has fewer side effects [2]. Other studies have shown that traditional Chinese medicine is effective in improving the clinical symptoms of CKD patients and correcting the imbalance of calcium/phosphorus metabolism[3,4]. In 2022, a large data study in Taiwan showed that patients who used traditional Chinese medicine (Astragalus-Angelica-Rhubarb-Danshen) had significantly reduced progression to ESRD and mortality [5]. A retrospective cohort study in Hong Kong showed that the addition of traditional Chinese medicine treatment can better maintain stable renal function in CKD patients than Western medicine alone, but the incidence of hyperkalemia increased (8.1% vs. 2.7%) [6].

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It can be seen that traditional Chinese medicine has a positive effect on CKD, and can prolong the time for CKD to enter ESRD for renal replacement therapy. However, hyperkalemia is a problem that needs to be paid attention to during the treatment of CKD with traditional Chinese medicine.

Potassium ions are important electrolytes in the body and play an important role in maintaining the normal functions of nerves, muscles, and cardiomyocytes. The emergence of hyperkalemia has serious harm to the body, and malignant arrhythmia or even cardiac arrest may occur, which is life-threatening. The traditional view is that hyperkalemia refers to serum potassium ion concentration >5.5mmol/L. With the gradual improvement of research on the relationship between blood potassium levels and cardiovascular events, death risk, etc., there are currently relevant guidelines and expert consensus at home and abroad, such as "KDIGO Kidney Disease Symposium Consensus on Abnormal Blood Potassium Management" (2019 edition), "Chinese Chronic Kidney Disease The Expert Consensus on Serum Potassium Management Practice in Patients (2020), "China Peridialytic Chronic Kidney Disease Management Standards" (2021 Edition) [7-9], etc., all suggest that the serum potassium management window be moved forward to 5.0mmol/L, That is, serum potassium >5.0mmol/L is defined as hyperkalemia, which makes the goal of serum potassium management more stringent.

Different studies have different opinions on the use of traditional Chinese medicine and the occurrence of hyperkalemia in CKD patients, so the relationship between the two needs further analysis and research. With the advancement of modern Chinese medicine research techniques and methods, the potassium content and mechanism of action of Chinese medicine are gradually revealed, which will better guide the application of Chinese medicine in CKD patients.

Analysis of the Causes of Hyperkalemia Caused by Traditional Chinese Medicine

①Analysis of potassium content in traditional Chinese medicine

The detection methods of potassium in traditional Chinese medicine samples include atomic absorption spectrometry and plasma spectrometry. Different detection methods and different shapes, origins, and parts of samples all affect the potassium content of traditional Chinese medicines[10,11]. Wang Yuhui et al. [12] tested the potassium content of 308 traditional Chinese medicine decoctions, showing that Chinese medicines with high potassium content (>0.5mmol/), including Daqingye, purslane, white cardamom powder, capillary, dry Lotus grass, commelina, lobelia, viola, desmodium, dandelion, Asarum, light bamboo leaves, safflower (sorted from high to low potassium content); most potassium content is 0.01-0.19mmol/g Between; Chinese medicines with potassium content <0.01mmol/g include cyanite, stone cassia, mother-of-pearl, tianzhuhuang, amethyst, cicada slough, magnet, amber, ocher, keel, pumice stone, Poria cocos (containing potassium are sorted from low to high). The study also showed that the potassium content of traditional Chinese medicine varies with different parts of the material. The potassium content of traditional Chinese medicine used as whole grass, flowers, and leaves is higher, and the potassium content of roots, stems, animal insects, minerals, etc. is lower. Lowest in potassium.

② Potassium-sparing diuretic effect of traditional Chinese medicine

Some traditional Chinese medicines, such as Alisma, motherwort, and Poria cocos, have diuretic and swelling effects and are often used clinically for patients with edema. As the pharmacological studies of traditional Chinese medicine have shown, they have a spironolactone-like potassium-sparing diuretic effect that causes elevated blood potassium [13]. Alisma can act directly on the collecting duct of the renal tubules to inhibit the excretion of potassium ions and at the same time inhibit the reabsorption of sodium ions to produce a diuretic effect [14]. The main components of motherwort are stachydrine and other urine. These two alkaloids can increase the excretion of Na + and reduce the excretion of K +, suggesting that motherwort has a potassium-sparing and diuretic effect [15]. The main active ingredient of Poria cocos is pachygyria, which can compete for aldosterone receptors in vitro, and can reverse the aldosterone effect in vivo without affecting the synthesis of aldosterone, thereby preserving potassium and excreting sodium and drainage[16].

③ Chinese medicine decoction affects potassium content in water decoction

Studies have shown that different decoction methods have no significant effect on the potassium content of traditional Chinese medicine decoctions such as fruits and minerals; they have statistically significant effects on the potassium content of traditional Chinese medicine decoctions such as flowers and plants [12], among which decoctions of traditional Chinese medicine Potassium levels from low to high are as follows: 10 minutes after soaking < soaking solution < 30 minutes on high heat < long-term decoction < decoction twice. Therefore, for patients who are prone to hyperkalemia, it is recommended that when decocting traditional Chinese medicine, the decoction pieces of flowers and herbs should be boiled for 10 minutes. There are no relevant reports on the effects of different decoction methods of traditional Chinese medicine on the blood potassium level of patients.

④Factors causing hyperkalemia other than traditional Chinese medicine

Several recent studies have shown that hyperkalemia occurs in some patients taking traditional Chinese medicine, which is related to the combination of western medicine. The latter include nonselective beta-blockers, intravenous amino acids, an overdose of digoxin, nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists, calcium Neurophosphatase inhibitors, potassium-sparing diuretics, etc. [17-18]. In addition, low aldosterone function, cell destruction caused by high-dose tumor chemotherapy drugs, and large-scale infusion of banked blood are also factors that cause hyperkalemia.

Potassium-lowering drugs escort traditional Chinese medicine in the treatment of CKD

The 2020 "Expert Consensus on Serum Potassium Management in Patients with Chronic Kidney Disease in China" [8] pointed out that the main drugs used to lower blood potassium are:

① Diuretics: By promoting renal potassium excretion, they have limited effect on patients with severe CKD, and may easily cause hypovolemia and aggravate the progress of the renal function.

②Cation exchange resin: Sodium polystyrene sulfonate (SPS) and calcium polystyrene sulfonate (CPS) are commonly used clinically at present. Through the exchange of sodium or calcium ions and potassium ions in the colon, potassium ions are promoted from the feces. discharge. These drugs are prone to constipation, and there is a risk of intestinal obstruction and intestinal perforation.

③A new type of potassium ion binder sodium zirconium cyclosilicate: Can capture potassium ions with high selectivity by displacing sodium/hydrogen ions in the whole intestinal tract, reducing the absorption of potassium ions in the intestinal tract, thereby quickly and effectively reducing blood potassium concentration, and can be stable for a long time Potassium and good safety.

Traditional Chinese medicine is an important measure for the treatment of chronic kidney disease. To avoid the risk of hyperkalemia, blood potassium needs to be monitored monthly. If necessary, new potassium ion binders can be used for long-term blood potassium management. With the popularization of the concept of long-term blood potassium management and more clinical experience in the long-term use of oral potassium-lowering drugs, there will be more solutions to the problem of hyperkalemia caused by traditional Chinese medicine, which can take into account the benefits of traditional Chinese medicine for CKD patients and also It can reduce the risk brought by high potassium, further promote the application of traditional Chinese medicine in CKD patients, and benefit more patients.

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