Out of sight, out of mind, but at high risk: incidence, timing and risk factors for hyperkalemia after liver transplant discharge
- 1Division of Transplant, Department of Surgery, University of California, San Francisco
- 2University of California, San Francisco School of Medicine
- 3Department of Anesthesia and Perioperative Care, University of California, San Francisco
Abstract
Background: Hyperkalemia occurs in liver transplant (LT) recipients due to calcineurin inhibitor initiation and post-operative renal dysfunction and is associated with significant patient morbidity and resource expenditures. Little is known about the prevalence and timing of hyperkalemia after LT discharge.
Methods: Adults undergoing LT between 1/2022-12/2024 at a single transplant center were included, excluding simultaneous heart-liver transplant recipients and patients who died before discharge. The primary exposure was time to hyperkalemia (serum potassium > 5.0 mmol/L) within three months of LT discharge. Univariable and multivariable Cox proportional hazards regression was used to identify predictors of hyperkalemia.
Results: Of 544 patients, 268 (49%) developed hyperkalemia within three months following LT discharge. Compared to patients without hyperkalemia, those who developed hyperkalemia were more likely to have diabetes mellitus (30% vs 20%, p=0.01) and higher laboratory MELD scores (29 vs 24, p=0.02). The median time to the first hyperkalemia episode was 11 days (IQR 5-28) after LT discharge, with the highest incidence occurring during the first week after discharge. 110 patients (20%) had hyperkalemia documented during readmission. On multivariable Cox regression, CKD stages 3a (aHR 1.63, 95% CI 1.11-2.40), 3b (aHR 2.38, 95% CI 1.51-3.74), and 5 (aHR 2.01, 95% CI 1.32–3.06); one week pre-transplant potassium (aHR 1.52, 95% CI 1.24-1.84); and discharge potassium (aHR 1.63, 95% CI 1.24-2.16) were independently associated with hyperkalemia.
Conclusion: Hyperkalemia is common within the first three months following LT discharge. These findings support the development of risk-stratified surveillance and management guidelines to reduce hyperkalemia-related morbidity and healthcare utilization. Given the cost and access barriers associated with outpatient hyperkalemia treatment, targeted interventions are needed to safeguard patients after discharge.
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BibTeX
@article{crest2026sight,
title = {{Out of sight, out of mind, but at high risk: incidence, timing and risk factors for hyperkalemia after liver transplant discharge}},
author = {Peyton Crest and Holland Stacey and Akshara Vykunta and Ella Atsavapranee and Kevin Kachi Ogbonna and Kara Ushijima and Liliana Espinosa and Nathan Robbins and Dieter Adelmann and Garrett R. Roll},
journal = {Frontiers in Immunology},
year = {2026},
month = oct,
doi = {10.3389/fimmu.2026.1924687},
url = {https://www.frontiersin.org/articles/10.3389/fimmu.2026.1924687/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Out of sight, out of mind, but at high risk: incidence, timing and risk factors for hyperkalemia after liver transplant discharge
AU - Peyton Crest
AU - Holland Stacey
AU - Akshara Vykunta
AU - Ella Atsavapranee
AU - Kevin Kachi Ogbonna
AU - Kara Ushijima
AU - Liliana Espinosa
AU - Nathan Robbins
AU - Dieter Adelmann
AU - Garrett R. Roll
PY - 2026
DA - 2026/10/07
JO - Frontiers in Immunology
DO - 10.3389/fimmu.2026.1924687
UR - https://www.frontiersin.org/articles/10.3389/fimmu.2026.1924687/full
AB - Background: Hyperkalemia occurs in liver transplant (LT) recipients due to calcineurin inhibitor initiation and post-operative renal dysfunction and is associated with significant patient morbidity and resource expenditures. Little is known about the prevalence and timing of hyperkalemia after LT discharge. Methods: Adults undergoing LT between 1/2022-12/2024 at a single transplant center were included, excluding simultaneous heart-liver transplant recipients and patients who died before discharge. The primary exposure was time to hyperkalemia (serum potassium > 5.0 mmol/L) within three months of LT discharge. Univariable and multivariable Cox proportional hazards regression was used to identify predictors of hyperkalemia. Results: Of 544 patients, 268 (49%) developed hyperkalemia within three months following LT discharge. Compared to patients without hyperkalemia, those who developed hyperkalemia were more likely to have diabetes mellitus (30% vs 20%, p=0.01) and higher laboratory MELD scores (29 vs 24, p=0.02). The median time to the first hyperkalemia episode was 11 days (IQR 5-28) after LT discharge, with the highest incidence occurring during the first week after discharge. 110 patients (20%) had hyperkalemia documented during readmission. On multivariable Cox regression, CKD stages 3a (aHR 1.63, 95% CI 1.11-2.40), 3b (aHR 2.38, 95% CI 1.51-3.74), and 5 (aHR 2.01, 95% CI 1.32–3.06); one week pre-transplant potassium (aHR 1.52, 95% CI 1.24-1.84); and discharge potassium (aHR 1.63, 95% CI 1.24-2.16) were independently associated with hyperkalemia. Conclusion: Hyperkalemia is common within the first three months following LT discharge. These findings support the development of risk-stratified surveillance and management guidelines to reduce hyperkalemia-related morbidity and healthcare utilization. Given the cost and access barriers associated with outpatient hyperkalemia treatment, targeted interventions are needed to safeguard patients after discharge.
SN - 1664-3224
ER -