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Prediction and Management of Hyperkalemia Across the Spectrum of Chronic Kidney Disease
Abstract
Hyperkalemia commonly limits optimizing treatment to slow stage 3 or higher chronic kidney disease (CKD) progression. The risk of hyperkalemia is linked to dietary potassium intake, level of kidney function, concomitant diseases that may affect potassium balance such as diabetes, and use of medications that influence potassium excretion. The risk predictors for developing hyperkalemia are an estimated glomerular filtration rate of less than 45 mL/min/1.73 m(2) and a serum potassium level greater than 4.5 mEq/L in the absence of blockers of the renin-angiotensin-aldosterone system (RAAS). Generally, monotherapy with RAAS blockers does not increase risk substantially unless hypotension or volume depletion occur. Dual RAAS blockade involving any combination of an angiotensin-converting enzyme inhibitor, angiotensin-receptor blocker, renin inhibition, or aldosterone-receptor blocker markedly increases the risk of hyperkalemia in patients with stage 3 or higher CKD. Moreover, dual RAAS blockade further reduces albuminuria by 25% to 30% compared with monotherapy, it has failed to show a benefit on CKD progression or cardiovascular outcome, and thus is not indicated in such patients because of its marked increase in hyperkalemia potential. Although sodium polystyrene resins exist to manage hyperkalemia in patients requiring therapy that increases serum potassium levels, they are not well tolerated. Newer, more predictable, better-tolerated polymers to bind potassium are on the horizon and may be approved within the next 1 to 2 years.
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“However, the use of spironolactone as a fourth drug is limited by tolerability issues in some patients, including the development of hyperkalemia in those with CKD with an eGFR <45 mL⋅min−1⋅1.73 m−2 or baseline serum potassium >4.5 mEq/L.378”
From Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association (2018) · cites this paper as [378]
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Metadata
- Authors
- Lazich, I., & Bakris, G. L.
- Affiliations
- University of Chicago (US)
- Corresponding author
- Bakris, George L.
- ORCID
- Bakris, George L.
- Venue
- Seminars in Nephrology
- Publisher
- Elsevier BV
- Published
- 2014-05
- Volume
- 34
- Issue
- 3
- Pages
- 333-339
- ISSN
- 0270-9295 (ISSN-L)
- OpenAlex
- W2072577267
- Cited by
- 164
- References
- 71
- Citations by year
- 2026: 2 · 2025: 6 · 2024: 5 · 2023: 15 · 2022: 10 · 2021: 26 · 2020: 28 · 2019: 16 · 2018: 16 · 2017: 14 · 2016: 15 · 2015: 10 · 2014: 1
- FWCI
- 2.28
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Seminars in Nephrology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Nephrology › Potassium and Related Disorders
- Health Sciences › Medicine › Nephrology › Chronic Kidney Disease and Diabetes
- Health Sciences › Medicine › Nephrology › Parathyroid Disorders and Treatments
- Keywords
- hyperkalemia, chronic kidney disease, risk prediction, potassium intake, renin-angiotensin-aldosterone system inhibitors, albuminuria, estimated glomerular filtration rate, chronic kidney disease progression
- MeSH terms
- Mineralocorticoid Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Glomerular Filtration Rate, Humans, Hyperkalemia, Potassium, Renal Insufficiency, Chronic, Angiotensin Receptor Antagonists
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