For patients with progressive kidney disease, hyperkalemia is a chronic risk that may require a long-term approach to management1

As we learn more about risk of recurrent hyperkalemia in patients with CKD and heart failure, we are beginning to better understand the increasing importance of managing the condition over the long term.

In patients with CKD, as kidney function continues to deteriorate, hyperkalemic events may continue to recur.2 Furthermore, hyperkalemia is often asymptomatic and therefore may not be detected until serum K+ levels have increased to concerning levels, possibly resulting in multiple ER visits and hospitalizations. Patients at risk for recurrent hyperkalemia may benefit from a different approach, in which normokalemia is maintained on a regular basis as part of overall patient management.3,4

While treatments are available to acutely lower elevated serum potassium and reduce the risk of a life-threatening event, there are no treatments designed to be used on a long-term daily basis for the ongoing management of hyperkalemia.1

Following aggressive treatment of an acute hyperkalemia event, ongoing monitoring to detect a recurrence of hyperkalemia is a crucial component of long-term management. In addition, it is important to identify the underlying causes or ancillary factors that contributed to the acute hyperkalemic event. Other common management strategies are diet modification to reduce K+ and withdrawal or titration of therapies that may be exacerbating the hyperkalemia (eg, RAASi).5 (See more on how medications can increase hyperkalemia)

Withdrawal of RAASi to manage K+ levels creates potential trade-offs in care

With limited treatment options to manage K+ on a daily, ongoing basis, the standard practice is to withhold or down-titrate the RAASi therapy. For instance, Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommend that RAASi therapy should be reduced or stopped when hyperkalemia develops.6-11

Although discontinuation of RAAS inhibitors usually restores normokalemia in patients with CKD, implementation of alternative treatments that allow for the continuation of these medications would be desirable.12

This table outlines recommended modifications to RAASi use for patients with high serum potassium levels. With limited treatment options to manage serum potassium on a daily, ongoing basis, the standard practice is to withhold or down-titrate the RAASi therapy.

aNICE/CKD = National Institute for Health and Clinical Excellence/Chronic Kidney Disease.

bKDOQI = Kidney Disease Outcomes Quality Initiative.

cKDIGO = Kidney Disease: Improving Global Outcomes.

dESH/ESC = European Society of Hypertension/European Society of Cardiology.

eESC = European Society of Cardiology.

fHFSA = Heart Failure Society of America.

gACCF/AHA = American College of Cardiology Foundation/American Heart Association.