Updates in hyperkalemia: Outcomes and therapeutic strategies

Abstract

Hyperkalemia is a frequent clinical abnormality in patients with chronic kidney disease, and it is associated with higher risk of mortality and malignant arrhythmias. Severe hyperkalemia is a medical emergency, which requires immediate therapies, followed by interventions aimed at preventing its recurrence. Current treatment paradigms for chronic hyperkalemia management are focused on eliminating predisposing factors, such as high potassium intake in diets or supplements, and the use of medications known to raise potassium level. Among the latter, inhibitors of the renin-angiotensin aldosterone system are some of the most commonly involved medications, and their discontinuation is often the first step taken by clinicians to prevent the recurrence of hyperkalemia. While this strategy is usually successful, it also deprives patients of the recognized benefits of this class, such as their renoprotective effects. The development of novel potassium binders has ushered in a new era of hyperkalemia management, with a focus on chronic therapy while maintaining the use of beneficial, but hyperkalemia-inducing medications such as renin-angiotensin aldosterone system inhibitors. This review article examines the incidence and clinical consequences of hyperkalemia, and its various treatment options, with special emphasis on novel therapeutic agents and the potential benefits of their application.

Keywords: Chronic kidney disease; Glomerular filtration rate; Hyperkalemia; Mortality; Renin-angiotensin-aldosterone system; Serum potassium.

Figure 1

Mechanisms of action of the development of hyperkalemia in patients with chronic kidney disease and associated comorbid conditions. AKI, acute kidney injury; CKD, chronic kidney disease; CVD, cardiovascular disease; DM, diabetes mellitus; GFR, glomerular filtration rate; RAAS, renin-angiotensin-aldosterone system Reprinted with permission from Kovesdy CP, Am J Med 128:1281–1287, 2015

Figure 2

Association of serum potassium level with all-cause mortality. Reprinted with permission from Hayes J et al, Nephron Clin Pract 120:c8–16, 2012