Background: Our standard Hypoglycemia Protocol primarily utilizes juice to treat hypoglycemia. The system currently allows both the Hypoglycemia Protocol and a renal diet to be active simultaneously. This algorithm has no restrictions on administering orange juice to treat hypoglycemia for patients despite exclusion of orange juice for patients on a renal diet. Considering anecdotal instances of hyperkalemia in patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD) that were thought to be secondary to orange juice consumption for hypoglycemia treatment, we sought to review the Hypoglycemia Protocol and implement changes with a goal of reducing the incidence of this iatrogenic side effect by 50% over a six-month period.Per the current Hypoglycemia Protocol, for blood glucose 50-69 g/dL, nursing is to give 118 mL of apple/orange/cranberry juice and for blood glucose below 50 g/dL, nursing is to give 237 mL of apple/orange/cranberry juice. Solutions with dextrose in water are available for intravenous injections as part of the protocol, but are reserved for patients unsafe for oral intake. Although glucose gel is an alternative, the expense is prohibitive, limiting treatment options. Based on the labels of the 118-mL juices at our facility, potassium content is 150 mg in orange juice,125 mg in apple juice, and 0 mg in cranberry juice.
Methods: Our inclusion criteria included hospitalized adult patients from January to June 2023 with documented diagnosis of CKD or ESRD, and on a renal diet. For our analysis, we defined hypoglycemia as blood glucose less than 70 g/dL and hyperkalemia as potassium 5.3 mmol/L or more. We utilized ICD coding and orders for renal diet to generate this cohort and manually reviewed each electronic medical record to identify hypoglycemic episodes with subsequent hyperkalemia.
Results: Of the 401 patients who met inclusion criteria, there were 17 hypoglycemic episodes with subsequent hyperkalemia. Expressed as a percentage, this is 4.24%.
Conclusions: Our investigation showed that there is a possibility that the juices used for the Hypoglycemia Protocol may be causing or exacerbating hyperkalemia in CKD/ESRD patients. There is no mechanism in place to restrict orange juice administration to patients on a renal diet who require hypoglycemia treatment. Although other factors can contribute to hyperkalemia in the CKD/ESRD patient population, such as a missed day of hemodialysis, the administration of orange juice should be eliminated as a possible contributing factor. Given its negligible potassium content, cranberry juice would be the best for patients on a renal diet.We proposed 3 possible solutions: (1) Modify the Hypoglycemia Protocol to limit patients on a renal diet to either cranberry or apple juice, (2) modify the protocol to eliminate orange juice altogether, or (3) purchase glucose gel, eliminating juices from the protocol. We presented our findings to the Inpatient/Critical Care Division Committee who preferred to modify the protocol to eliminate orange juice altogether for any patient regardless of diet order with the additional modification of listing cranberry juice as first-line in the protocol.Once the revised protocol is executed, another 6 months of data, preferably from the months of January to July, will be analyzed to determine whether the changes made a significant difference. We plan to evaluate other risk factors with regression analysis or comparative cohort.