Chronic hyperkalemia in non-dialysis CKD: controversial issues in nephrology practice

Abstract

Chronic hyperkalemia is a major complication of chronic kidney disease (CKD) that occurs frequently, heralds poor prognosis, and necessitates careful management by the nephrologist. Current strategies aimed at prevention and treatment of hyperkalemia are still suboptimal, as evidenced by the relatively high prevalence of hyperkalemia in patients under stable nephrology care, and even in the ideal setting of randomized trials where best treatment and monitoring are mandatory. The aim of this review was to identify and discuss a range of unresolved issues related to the management of chronic hyperkalemia in non-dialysis CKD. The following topics of clinical interest were addressed: diagnosis, relationship with main comorbidities of CKD, therapy with inhibitors of the renin-angiotensin-aldosterone system, efficacy of current dietary and pharmacological treatment, and the potential role of the new generation of potassium binders. Opinion-based answers are provided for each of these controversial issues.

Keywords: Anti-RAAS; Chronic kidney disease; Hyperkalemia; Potassium binder.

Fig. 1

Changes in electrocardiogram following progressive increases in potassium levels

Fig. 2

Stepwise approach to hyperkalemia in CKD patients under nephrology care. K potassium, sK serum potassium (mEq/l), anti-RAAS antagonists of renin–angiotensin–aldosterone system, iv intravenous, ECG electrocardiogram