Optimizing hyperkalemia management in CKD: real-world nephrologist strategies and impact on patient outcomes

BACKGROUND: Hyperkalemia is a common complication in chronic kidney disease (CKD), requiring management to maintain cardiovascular benefits of renin-angiotensin-aldosterone system and mineralocorticoid receptors (RAASi/MRA) therapy. This study evaluated hyperkalemia management and recurrence in CKD patients. METHODS: A prospective, multicenter observational study was conducted across 15 hospitals, enrolling 429 patients with serum potassium > 5.5 mmol/L. Patients were managed per usual practice, and data on recurrence, RAASi/MRA changes, cardiovascular events, and renal function were collected over 2 years. RESULTS: Cohort (mean age 71.5 years, 71.3% male, 88.6% hypertension, 55.9% diabetes) presented with mild, moderate (19.1%), and severe (3.7%) hyperkalemia. Post-event, dietary modifications increased by 39.9%, bicarbonate use by 7.9%, resin use by 2.6%, patiromer use by 10.9%, and sodium zirconium cyclosilicate (SZC) use by 24.6%. Modifications on RAA Si/MRA therapy were as follows: angiotensin-converting enzyme inhibitors reduced in 12% and suspended in 6.8%; angiotensin II receptor blockers reduced in 5.49% and suspended in 7.32%; and MRA reduced in 12.73% and suspended in 21.82%. Recurrence occurred in 43.8%, with higher rates in patients with baseline estimated glomerular filtration rate <30 ml/min (49.1% vs 38.8%, P = 0.03). Recurrent hyperkalemia was associated with faster eGFR decline (-2.4 ml/min/year, P < 0.001). Kaplan-Meier analysis showed no differences in overall survival between patients with and without recurrence. The study found no significant difference between patiromer/SZC and resins in efficacy (recurrence rates). CONCLUSION: Integrating potassium binders into CKD therapeutic strategies may improve hyperkalemia management and allow sustained RAASi/MRA use. Recurrence remains significant, impacting renal function, although causality is unclear. The mortality difference requires further study.