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Review
. 2025 Mar;30(2):271-286.
doi: 10.1007/s10741-024-10461-3. Epub 2024 Nov 27.

Hyperkalemia management: a multidisciplinary expert panel's perspective on the role of new potassium binders

Cândida Fonseca  1   2 , Cristina Garagarza  3   4 , Gil Silva  5 , Graça Caires  6 , Irene Marques  7   8 , José António Lopes  4   9 , Patrícia Branco  10 , Rui Alves  11   12 , Aníbal Ferreira  13   14
Affiliations
Review

Hyperkalemia management: a multidisciplinary expert panel's perspective on the role of new potassium binders

Cândida Fonseca et al. Heart Fail Rev. 2025 Mar.

Abstract

Hyperkalemia is a potentially life-threatening condition frequently encountered in clinical practice, particularly among patients with chronic kidney disease, heart failure, diabetes, and hypertension and those undergoing treatment with renin-angiotensin-aldosterone system inhibitors (RAASi). The management of chronic and acute hyperkalemia is complex and requires timely intervention to prevent severe complications such as cardiac arrhythmias and sudden death. Traditional therapeutic approaches to chronic hyperkalemia, including dietary potassium restriction, use of diuretics, and administration of cation-exchange resins like sodium polystyrene sulfonate, often suffer from limitations like gastrointestinal side effects, variable efficacy, delayed onset of action, and RAASi treatment discontinuation. In recent years, the development of new potassium binders, specifically patiromer and sodium zirconium cyclosilicate (SZC), has revolutionized the management of hyperkalemia. Patiromer, a non-absorbed polymer, binds potassium in the gastrointestinal tract in exchange for calcium, thus facilitating its excretion. SZC operates by exchanging sodium and hydrogen ions for potassium, leading to efficient potassium removal. Both agents have demonstrated rapid and sustained reductions in serum potassium levels, coupled with favorable safety and tolerability profiles, in multiple clinical trials. This review article, authored by a multidisciplinary group of Portuguese experts in hyperkalemia management, provides an in-depth analysis of the efficacy and safety of current therapeutic strategies and highlights the clinical potential of new potassium binders. The introduction of patiromer and SZC offers significant advantages over traditional therapies, providing effective and better-tolerated options for patients. The review highlights the role of these novel agents in contemporary hyperkalemia management and calls for ongoing research to further refine treatment protocols and improve patient outcomes.

Keywords: Chronic kidney disease; Heart failure; Hyperkalemia; Patiromer; RAASi therapy; Sodium zirconium cyclosilicate.

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Conflict of interest statement

Declarations. Ethics approval: Not applicable. Consent for publication: All the authors have read and approved the final version of the manuscript and gave their consent for publication. Competing interests: C.F received consultancy fees, lectures, or sponsorship of scientific meetings from AstraZeneca, Bayer, Bial, Boehringer Ingelheim, Novartis, Novo Nordisk, Pfizer, Roche Diagnosis, Servier, CSL Vifor, companies that research and commercialize drugs for the treatment of heart failure patients. G.C. received speaking fees from Servier, Novartis, CSL Vifor, and Boehringer. C.G. is employed by Fresenius Medical Care as Head of the Nutrition Department. G.S. received speaking fees from CSL Vifor, AstraZeneca, Alnylam and Baxter. I.M. received speaking fees from AstraZeneca, Bayer, Bial, CSL Vifor, Daiichi-Sankyo, Novartis, Pfizer, Roche Diagnostics, and Servier. I.M. served on advisory boards for AstraZeneca, Bayer, Bial, CSL Vifor, Novartis, Novo Nordisk, and Servier. A.F. received Advisory Board and consultancy fees, lectures, or sponsorship of scientific meetings from AstraZeneca, Astellas, CSL Vifor, Fresenius Medical Care, MSD-Merck Sharp & Dohme companies.

Figures

Fig. 1
Fig. 1
Management approaches for acute and chronic hyperkalemia. *The implementation of these measures will allow the optimization of RAASi therapy. IV, intravenous; K+, potassium; RAASi, renin–angiotensin–aldosterone system inhibitors
See this image and copyright information in PMC

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