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Review
. 2024 Mar;19(2):295-306.
doi: 10.1007/s11739-023-03427-0. Epub 2023 Sep 29.

Recommendations for the management of hyperkalemia in patients receiving renin-angiotensin-aldosterone system inhibitors

Luca De Nicola  1 , Pietro Manuel Ferraro  2   3   4 , Andrea Montagnani  5 , Roberto Pontremoli  6   7 , Francesco Dentali  8 , Giorgio Sesti  9
Affiliations
Review

Recommendations for the management of hyperkalemia in patients receiving renin-angiotensin-aldosterone system inhibitors

Luca De Nicola et al. Intern Emerg Med. 2024 Mar.

Abstract

Hyperkalemia is common in clinical practice and can be caused by medications used to treat cardiovascular diseases, particularly renin-angiotensin-aldosterone system inhibitors (RAASis). This narrative review discusses the epidemiology, etiology, and consequences of hyperkalemia, and recommends strategies for the prevention and management of hyperkalemia, mainly focusing on guideline recommendations, while recognizing the gaps or differences between the guidelines. Available evidence emphasizes the importance of healthcare professionals (HCPs) taking a proactive approach to hyperkalemia management by prioritizing patient identification and acknowledging that hyperkalemia is often a long-term condition requiring ongoing treatment. Given the risk of hyperkalemia during RAASi treatment, it is advisable to monitor serum potassium levels prior to initiating these treatments, and then regularly throughout treatment. If RAASi therapy is indicated in patients with cardiorenal disease, HCPs should first treat chronic hyperkalemia before reducing the dose or discontinuing RAASis, as reduction or interruption of RAASi treatment can increase the risk of adverse cardiovascular and renal outcomes or death. Moreover, management of hyperkalemia should involve the use of newer potassium binders, such as sodium zirconium cyclosilicate or patiromer, as these agents can effectively enable optimal RAASi treatment. Finally, patients should receive education regarding hyperkalemia, the risks of discontinuing their current treatments, and need to avoid excessive dietary potassium intake.

Keywords: Cardiovascular disease; Chronic kidney disease; Hyperkalemia; Patient-centered care; Potassium binders; Renin–angiotensin–aldosterone inhibitors.

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Conflict of interest statement

Luca De Nicola has received consultancy or lecture fees from Astellas, AstraZeneca, Novo Nordisk, and CSL Vifor. Pietro Manuel Ferraro has received research grants, consultancy fees, or other support from Allena Pharmaceuticals, Alnylam, Amgen, AstraZeneca, BioHealth Italia, Gilead, Otsuka Pharmaceuticals, Rocchetta, and CSL Vifor; and royalties as an author from UpToDate. Andrea Montagnani has received consultancy or lecture fees from BMS, Pfizer, Bayer, Boehringer Ingelheim, AstraZeneca, and CSL Vifor. Roberto Pontremoli has received consultancy or lecture fees from AstraZeneca, Boehringer Ingelheim, Lilly, MSD, Novartis, Menarini, Bayer, Recordati International, Alfasigma, Novo Nordisk, and CSL Vifor. Giorgio Sesti has received speaker fees from Novo Nordisk, Eli Lilly, AstraZeneca, Teva, MSD, Sanofi, Daiichi Sankyo, Sobi, Janssen, and Servier. Francesco Dentali declares no conflicts of interest.

Figures

Fig. 1
Fig. 1
Pragmatic step-by-step intervention for the treatment of hyperkalemia in patients with hyperkalemia. ECG electrocardiogram, IV intravenous, MRA mineralocorticoid receptor antagonist, NSAID non-steroidal anti-inflammatory drug, RAASi renin–angiotensin–aldosterone system inhibitor, sK serum potassium, SGLT2i sodium-glucose cotransporter 2 inhibitor, SZC sodium zirconium cyclosilicate
See this image and copyright information in PMC

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