Hyperkalemia is one of the main
electrolyte disorders in patients with
chronic kidney disease (CKD). The prevalence of
hyperkalemia increases as the Glomerular Filtration Rate (GFR) declines. Although chronic
hyperkalemia is not a medical emergency, it can have negative consequences for the adequate cardio-renal management in the medium and long term.
Hyperkalemia is common in patients on renin-angiotensin-aldosterone system inhibitors (RAASi) or
Mineralocorticoid Receptor Antagonists (MRAs) and can affect treatment optimization for
hypertension,
diabetes mellitus,
heart failure (HF), and CKD. Mortality rates are higher with suboptimal dosing among patients with CKD, diabetes or HF compared with full RAASi dosing, and are the highest among patients who discontinue RAASis. The treatment of chronic
hyperkalemia is still challenging. Therefore, in the real world, discontinuation or reduction of RAASi
therapy may lead to adverse cardiorenal outcomes, and current guidelines differ with regard to recommendations on RAASi
therapy to enhance cardio and reno-protective effects. Treatment options for
hyperkalemia have not changed much since the introduction of the
cation exchange resin over 50 years ago. Nowadays, two new
potassium binders,
Patiromer Sorbitex
Calcium, and
Sodium Zirconium Cyclosilicate (SZC) already approved by FDA and by the European Medicines Agency, have demonstrated their clinical efficacy in reducing serum
potassium with a good safety profile. The use of the newer
potassium binders may allow continuing and optimizing RAASi
therapy in patients with
hyperkalemia keeping the cardio-renal protective effect in patients with CKD and
cardiovascular disease. However, further research is needed to address some questions related to
potassium disorders (definition of chronic
hyperkalemia, monitoring strategies, prediction score for
hyperkalemia or length for treatment).