Management of hyperkalemia in Nephrology and Cardiology clinics: reality and perspectives

Abstract

Chronic kidney disease (CKD) and chronic heart failure (CHF) are two entities that share several aspects: (i) these are two chronic conditions associated with poor prognosis; (ii) they involve frailty patients who need strict monitoring in terms of visits and treatment; (iii) both CKD and CHF patients benefit from renin-angiotensin-aldosterone system inhibitors (RAASI). RAASI proved effective in significantly reducing the risk for cardiovascular events, mortality and end-stage renal disease in CKD and CHF patients. Notwithstanding, RAASI use may induce hyperkalemia. High serum potassium (≥5.0 mEq/l) is, per se, responsible for higher risk for end-stage renal disease, arrhythmias and mortality. This risk is even reinforced when patients who develop hyperkalemia withdraw or reduce RAASI treatment, thus losing nephro- and cardioprotective effects. Current available strategies aimed at reducing hyperkalemia include dietary restriction, loop diuretics, potassium binders, namely sodium/calcium polystyrene sulfonate (SPS/CPS), patiromer, and sodium zirconium cyclosilicate (SZC). SPS and CPS have shown low safety/efficacy and several drug-drug interactions, these being major limitations to their use. Patiromer and SZC were found to reduce potassium with less side effects. These findings combined provide strong support that management of hyperkalemia is crucial for cardiologists and nephrologists to improve prognosis among CKD and CHF patients.