Hypokalemia in Peritoneal Dialysis: A Systematic Review and Meta-analysis of Prevalence, Treatment, and Outcomes

Rationale & Objective

Hypokalemia is common and potentially life-threatening in patients undergoing peritoneal dialysis (PD). However, the current literature has produced varying results. This study aimed to evaluate the prevalence and adverse outcomes of hypokalemia and the role of potassium supplementation in patients receiving PD.

Study Design

Systematic review and meta-analysis of randomized controlled trials and observational studies.

Setting & Study Populations

Adults receiving maintenance PD.

Selection Criteria for Studies

Studies that investigated the prevalence and adverse outcomes of hypokalemia and the effect of potassium supplementation.

Data Extraction

Two independent reviewers evaluated studies for eligibility and extracted relevant data.

Analytical Approach

Random effects meta-analysis was conducted to pool hazard ratios (HRs) and 95% CIs for the outcomes of interest. The certainty of findings was rated according to the Grading of Recommendations Assessment, Development and Evaluation criteria.

Results

Of 3,632 reports identified, 24 studies involving 60,313 participants met the inclusion criteria. The prevalence of hypokalemia was 37.9% (95% CI, 27.2%-52.7%), 17.7% (95% CI, 12.0%-25.9%), and 4.4% (95% CI, 1.9%-10.2%) in patients with potassium level <4.0, 3.5, and 3.0 mmol/L, respectively. Hypokalemia, according to the study’s definition, was associated with increased risks of all-cause mortality (HR, 1.49; 95% CI, 1.18-1.89), cardiovascular mortality (HR, 1.50; 95% CI, 1.19-1.88), and PD-associated peritonitis (HR, 1.42; 95% CI, 1.17-1.73). These associations were consistent but with low to very low certainty. The effect of correcting hypokalemia with potassium supplementation in patients undergoing PD remains uncertain.

Limitations

Heterogeneity persisted across most of the examined subgroups, and observational studies preclude causation.

Conclusions

Hypokalemia is common and portends poorer survival and a higher risk of peritonitis among patients undergoing PD. Further research into the optimal prevention and treatment strategies for hypokalemia is warranted to improve outcomes.

Registration

Registered at PROSPERO with registration number CRD42022358236.

Plain-Language Summary

Hypokalemia is common and can be fatal in patients undergoing peritoneal dialysis (PD). The reported prevalence of hypokalemia in patients undergoing PD varies significantly across studies, and there is inconsistency regarding the relationship between hypokalemia and adverse outcomes. This systematic review and meta-analysis showed that hypokalemia is prevalent and associated with decreased survival rates and higher risk of peritonitis among patients undergoing PD. Standardized definitions and thresholds for hypokalemia are essential for future research in this field. The results underscore that maintaining potassium homeostasis should be a clinical priority in managing patients undergoing PD to improve patient outcomes. Further research into the optimal prevention and treatment strategies for hypokalemia is warranted to improve outcomes.