Real-world insights into hyperkalemia burden and RAASi discontinuation: a cohort study

BACKGROUND: Hyperkalemia is a common and clinically significant complication among patients receiving renin-angiotensin-aldosterone system inhibitors (RAASi). Despite their well-established cardiovascular and renal benefits, RAASi use is often limited by hyperkalemia, leading to treatment modification or discontinuation. Real-world adherence to potassium management strategies remains inconsistent, particularly in high-risk populations. OBJECTIVE: This study aimed to determine the incidence and severity of hyperkalemia among RAASi users, identify associated risk groups, and assess its influence on clinical decisions and patient outcomes. METHODS: We conducted a retrospective cohort study involving 905 adult patients attending outpatient clinics at King Abdulaziz Medical City, Jeddah. All patients were on RAASi therapy and followed for a mean duration of 29.8 months. RESULTS: ≥5.1 mmol/L) was observed in 295 patients, yielding an overall incidence of 32.8% (95% CI: 30-36%). Most cases were mild (74.6%), with moderate and severe hyperkalemia accounting for 19.0% and 6.4%, respectively. Recurrence occurred in over half of the affected patients, with decreasing intervals between successive episodes. Risk factors significantly associated with hyperkalemia included age ≥75 years, diabetes, congestive heart failure, and reduced eGFR. RAASi therapy was discontinued in 6.2%, and down-titrated in 4.5% of patients due to hyperkalemia. Adverse clinical events included emergency visits (2.1%), hospitalizations (1.7%), arrhythmias (0.3%), and dialysis (0.2%). CONCLUSION: Hyperkalemia affects nearly one-third of RAASi users, often prompting de-escalation of therapy. Proactive monitoring and management strategies are necessary to maintain the benefits of RAAS inhibition, especially in high-risk groups.