Management of hyperkalemia in patients with kidney disease: a position paper endorsed by the Italian Society of Nephrology

Abstract

Hyperkalemia (HK) is the most common electrolyte disturbance observed in patients with kidney disease, particularly in those in whom diabetes and heart failure are present or are on treatment with renin-angiotensin-aldosterone system inhibitors (RAASIs). HK is recognised as a major risk of potentially life threatening cardiac arrhythmic complications. When an acute reduction of renal function manifests, both in patients with chronic kidney disease (CKD) and in those with previously normal renal function, HK is the main indication for the execution of urgent medical treatment and the recourse to extracorporeal replacement therapies. In patients with end-stage renal disease, the presence of HK not responsive to medical therapy is an indication at the beginning of chronic renal replacement therapy. HK can also be associated indirectly with the progression of CKD, because the finding of high potassium values leads to withdrawal of treatment with RAASIs, which constitute the first choice nephro-protective treatment. It is therefore essential to identify patients at risk of developing HK, and to implement therapeutic interventions aimed at preventing and treating this dangerous complication of kidney disease. Current strategies aimed at the prevention and treatment of HK are still unsatisfactory, as evidenced by the relatively high prevalence of HK also in patients under stable nephrology care, and even in the ideal setting of randomized clinical trials where optimal treatment and monitoring are mandatory. This position paper will review the main therapeutic interventions to be implemented for the prevention, detection and treatment of HK in patients with CKD on conservative care, in those on dialysis, in patients in whom renal disease is associated with diabetes, heart failure, resistant hypertension and who are on treatment with RAASIs, and finally in those presenting with severe acute HK.

Cost‐analysis of persistent hyperkalaemia in non‐dialysis chronic kidney disease patients under nephrology care in Italy

“…In our cohort, persistent HK affected one out of three patients despite regular nephrology care including traditional K binders. This finding adds real‐wold evidence to the notion that HK management remains a major unmet need in nephrology practice . Indeed, data on effectiveness, in terms of efficacy and safety, of potassium‐binding agents today available have been scarce and ambiguous despite the long‐standing use …”

“…This finding adds real-wold evidence to the notion that HK management remains a major unmet need in nephrology practice. 8,36 Indeed, data on effectiveness, in terms of efficacy and safety, of potassium-binding agents today available have been scarce and ambiguous despite the long-standing use. [37][38][39][40] The current study is limited to inclusion of costs from the perspective of the NHS in Italy, thus non-medical and indirect costs were not included.…”

“…Current treatment of HK still remains inadequate . This holds true even in the ideal setting of tertiary nephrology care, as testified by the high prevalence of sK ≥ 5.0 mEq/L in renal clinics .…”

“…2,7 Current treatment of HK still remains inadequate. 8 This holds true even in the ideal setting of tertiary nephrology care, as testified by the high prevalence of sK ≥ 5.0 mEq/L in renal clinics. 5 This picture will change in the near future because of the introduction of two novel binders of potassium, patiromer and sodium zirconium cyclosilicate, that may likely allow to overcome the current HK-related barrier to optimal RAASI therapy in chronic renal and cardiovascular disease.…”

“…5 This picture will change in the near future because of the introduction of two novel binders of potassium, patiromer and sodium zirconium cyclosilicate, that may likely allow to overcome the current HK-related barrier to optimal RAASI therapy in chronic renal and cardiovascular disease. 8,9 When considering this future perspective, attaining a cost analysis of HK is preliminary and functional to the best implementation of the new anti-hyperkaliaemic agents. Few studies have evidenced that HK is a costly event; these studies were however based on retrospective analyses in unselected populations either derived from commercial or insurance databases [10][11][12] or from databases covering primary and secondary care.…”