Association of Serum Potassium with All-Cause Mortality in Patients with and without Heart Failure, Chronic Kidney Disease, and/or Diabetes

Am J Nephrol. 2017;46(3):213-221. doi: 10.1159/000479802. Epub 2017 Sep 2.


Background: The relationship between serum potassium, mortality, and conditions commonly associated with dyskalemias, such as heart failure (HF), chronic kidney disease (CKD), and/or diabetes mellitus (DM) is largely unknown.

Methods: We reviewed electronic medical record data from a geographically diverse population (n = 911,698) receiving medical care, determined the distribution of serum potassium, and the relationship between an index potassium value and mortality over an 18-month period in those with and without HF, CKD, and/or DM. We examined the association between all-cause mortality and potassium using a cubic spline regression analysis in the total population, a control group, and in HF, CKD, DM, and a combined cohort.

Results: 27.6% had a potassium <4.0 mEq/L, and 5.7% had a value ≥5.0 mEq/L. A U-shaped association was noted between serum potassium and mortality in all groups, with lowest all-cause mortality in controls with potassium values between 4.0 and <5.0 mEq/L. All-cause mortality rates per index potassium between 2.5 and 8.0 mEq/L were consistently greater with HF 22%, CKD 16.6%, and DM 6.6% vs. controls 1.2%, and highest in the combined cohort 29.7%. Higher mortality rates were noted in those aged ≥65 vs. 50-64 years. In an adjusted model, all-cause mortality was significantly elevated for every 0.1 mEq/L change in potassium <4.0 mEq/L and ≥5.0 mEq/L. Diuretics and renin-angiotensin-aldosterone system inhibitors were related to hypokalemia and hyperkalemia respectively.

Conclusion: Mortality risk progressively increased with dyskalemia and was differentially greater in those with HF, CKD, or DM.

Keywords: Chronic kidney disease; Diabetes; Heart failure; Hyperkalemia; Hypokalemia; Mortality.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Age Factors
  • Aged
  • Angiotensin-Converting Enzyme Inhibitors / adverse effects
  • Cause of Death
  • Diabetes Mellitus / blood*
  • Diabetes Mellitus / drug therapy
  • Diabetes Mellitus / epidemiology
  • Diuretics / adverse effects
  • Electronic Health Records / statistics & numerical data
  • Female
  • Follow-Up Studies
  • Glomerular Filtration Rate
  • Heart Failure / blood*
  • Heart Failure / drug therapy
  • Heart Failure / epidemiology
  • Humans
  • Hyperkalemia / blood
  • Hyperkalemia / chemically induced
  • Hyperkalemia / mortality*
  • Hypokalemia / blood
  • Hypokalemia / chemically induced
  • Hypokalemia / mortality*
  • Male
  • Middle Aged
  • Potassium / blood*
  • Prevalence
  • Renal Insufficiency, Chronic / blood*
  • Renal Insufficiency, Chronic / drug therapy
  • Renal Insufficiency, Chronic / epidemiology


  • Angiotensin-Converting Enzyme Inhibitors
  • Diuretics
  • Potassium