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Management of hyperkalaemia in chronic kidney disease

Nature Reviews Nephrology volume 10, pages 653–662 (2014)Cite this article

Subjects

Key Points

  • Hyperkalaemia is common in patients with chronic kidney disease (CKD), especially when CKD is accompanied by exacerbating factors

  • Hyperkalaemia is associated with adverse outcomes in patients with CKD, and can restrict the use of beneficial medications, such as renin–angiotensin–aldosterone-system (RAAS) inhibitors

  • Current therapeutic paradigms for hyperkalaemia emphasize intermittent acute interventions and the elimination of exacerbating factors (including RAAS inhibitors)

  • Proactive treatment strategies to prevent the development of hyperkalaemia could also benefit patients by enabling more liberal use of RAAS inhibitors

  • The emergence of new potassium binders may result in more widespread implementation of strategies for hyperkalaemia prevention

Abstract

Hyperkalaemia is common in patients with chronic kidney disease (CKD), in part because of the effects of kidney dysfunction on potassium homeostasis and in part because of the cluster of comorbidities (and their associated treatments) that occur in patients with CKD. Owing to its electrophysiological effects, severe hyperkalaemia represents a medical emergency that usually requires prompt intervention, whereas the prevention of hazardous hyperkalaemic episodes in at-risk patients requires measures aimed at the long-term normalization of potassium homeostasis. The options for effective and safe medical interventions to restore chronic potassium balance are few, and long-term management of hyperkalaemia is primarily limited to the correction of modifiable exacerbating factors. This situation can result in a difficult trade-off in patients with CKD, because drugs that are beneficial to these patients (for example, renin–angiotensin–aldosterone-system antagonists) are often the most prominent cause of their hyperkalaemia. Maintaining the use of these beneficial medications while implementing various strategies to control potassium balance is desirable; however, discontinuation rates remain high. The emergence of new medications that specifically target hyperkalaemia could lead to a therapeutic paradigm shift, emphasizing preventive management over ad hoc treatment of incidentally discovered elevations in serum potassium levels.

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Figure 1: Mechanisms contributing to the development of hyperkalaemia in patients with chronic kidney disease and associated comorbidities.

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Acknowledgements

C.P.K. is supported by grants RO1 DK096920 and UO1DK102163 from the US NIH-NIDDK. He is an employee of the US Department of Veterans Affairs. Opinions expressed in this paper are those of the author and do not necessarily represent those of the Department of Veterans Affairs.

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  1. University of Tennessee Health Science Center, University of Tennessee, 956 Court Avenue, Memphis, 38163, TN, USA

    Csaba P. Kovesdy

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Kovesdy, C. Management of hyperkalaemia in chronic kidney disease. Nat Rev Nephrol 10, 653–662 (2014). https://doi.org/10.1038/nrneph.2014.168

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