Consensus Statement on Hyperkalemia Management in the Asia–Pacific Region

Hyperkalemia is a common problem among patients with chronic kidney disease (CKD). The incidence of hyperkalemia in Asia is 10.4%, which is higher than the worldwide incidence of 6.3% (95% CI, 5.8%-6.8%).

Risk of hyperkalemia is heightened by the use of renin-angiotensin-aldosterone system (RAAS) inhibitors, which are common in CKD treatment. Providers treating hyperkalemia in patients with CKD face a dilemma because both hyperkalemia and stoppage of RAAS inhibitor therapy put patients at higher risk of cardiovascular events, hospitalizations, and death.

To help guide health care providers in the Asia–Pacific region, a panel of experts led by Desmond Y.H. Yap, MD, PhD, collaborated to review the published literature, share clinical experiences, and develop 25 consensus statements on the management of hyperkalemia in the region. The statements, which were published in Nephrology, cover three clinical areas: (1) risk factors of hyperkalemia and risk stratification in susceptible patients; (2) prevention of hyperkalemia for at-risk individuals; and (3) correction of hyperkalemia for at-risk individuals with cardiorenal disease.

The group’s statements about risk factors and risk stratification focused largely on RAAS inhibitors.

Unsurprisingly, the authors found that RAAS inhibitors, and also potassium-sparing diuretics, nonsteroidal anti-inflammatory drugs, beta-blockers, and trimethoprim, are common medications associated with hyperkalemia. For example, a retrospective study in Hong Kong showed that the prevalence of hyperkalemia is 28% among people who receive treatment with RAAS blockade.

They further determined that hyperkalemia is a major limiting factor for the dosing of RAAS inhibitor therapy for patients with CKD, heart failure, or diabetes, and that dose interruptions of RAAS inhibitors due to treatment-related hyperkalemia are associated with adverse cardiorenal outcomes, disease progression, and increased mortality. One registry-based cohort study in Hong Kong found that 17% (1766/10,400) of patients with type 2 diabetes discontinued treatment with RAAS inhibitors within 6 months, which was associated with higher risks of major adverse cardiovascular events, heart failure, and end-stage renal disease (hazard ratios, 1.27 [95% CI, 1.08-1.49], 1.85 [1.53-2.25], and 1.30 [1.17-1.43], respectively) compared with those who continued to receive RAAS inhibitors. The authors recommended that RAAS inhibitors be continued for cardiorenal benefits as long as possible when managing mild-to-moderate hyperkalemia in patients with CKD, heart failure, or diabetes.

Several of the authors’ statements related to prevention of hyperkalemia for at-risk individuals focused on patient monitoring. “Real-world data from routine clinical practice in the [United States] revealed that patients who received RAAS inhibitors were generally tested for [hyperkalemia] no less than once annually, with more frequent monitoring (no less than three times annually) in those with an [estimated glomerular filtration rate] <30 mL/min/1.73 m². Additionally, detection of [hyperkalemia] was increased with frequency of testing,” they stated. They also suggested alternative preventive measures, including dietary modifications, avoiding medications associated with hyperkalemia, and using approved oral potassium binders such as sodium zirconium cyclosilicate (SZC). The HARMONIZE trial showed that SZC 10 g three times daily reduced the mean serum potassium level among patients with hyperkalemia (serum potassium ≥5.1 mmol/L) from 5.6 mmol/L at baseline to 4.5 mmol/L at 48 h; compared with placebo (5.1 mmol/L), all three doses of SZC resulted in significantly lower mean serum potassium levels during days 8 to 29 (4.8, 4.5. and 4.4 mmol/L for 5, 10, and 15 g, respectively; all P<.001).

Finally, the authors provided several recommendations regarding correction of hyperkalemia for at-risk individuals with cardiorenal disease. Broadly, these included excluding pseudo-hyperkalemia, using electrocardiographic changes and serum potassium level severity to guide treatment, and taking a stepwise approach to treat acute hyperkalemia, involving stabilization of the cardiac membrane, redistribution of potassium, and elimination of potassium.

In summary, the authors said, “These statements were expected to serve as useful guidance in the management of [hyperkalemia] for health care providers in the region.”

Source: Nephrology