Management of hyperkalaemia in the Italian clinical practice: impact of diverse potassium binders on outcomes and costs in patients with chronic kidney disease and heart failure

INTRODUCTION: Hyperkalemia is a common and clinically relevant condition in patients with chronic kidney disease (CKD) and heart failure (HF), often limiting optimal use of renin-angiotensin-aldosterone system inhibitors (RAASi). METHODS: This real-world study evaluated adherence, clinical outcomes, and healthcare costs among Italian patients initiating patiromer, sodium zirconium cyclosilicate (SZC), or sodium polystyrene sulfonate (SPS) between January 2022 and June 2024. RESULTS: Administrative data covering about 10% of the Italian population identified 1953 patients: 249 on patiromer, 387 on SZC, and 1317 on SPS. After full matching, 67.5% of patiromer patients were adherent at 6 months, compared with 20.4% for SZC and 0.5% for SPS (p < 0.001). Over the total follow-up, adherence remained higher with patiromer (42.5% vs 13.4% and 0.5%). During the first 6 months, HF-related hospitalization rates were lower with patiromer versus SZC (5.4 vs 12.8 events per 100 person-years; p = 0.079), becoming significant over overall follow-up (5.3 vs 15.7; p = 0.003). Composite HF outcomes at 6 months were also lower with patiromer compared with SZC (5.3 vs 17.4; p = 0.012) and SPS (3.4 vs 24.8; p = 0.005). At 12 months, total healthcare costs were significantly lower with patiromer than with SZC and SPS (€5645 vs €8500 and €4736 vs €6234; p < 0.001). Overall, patiromer use was associated with better adherence, fewer HF-related events, and reduced healthcare expenditure. CONCLUSIONS: These findings suggest a patiromer potential role for sustained potassium binder therapy in supporting RAASi optimization and improving clinical management in routine practice, but confirmation through direct comparative prospective randomized trials is needed.