Mitigating Hyperkalemia While Maintaining Optimal RAASi Therapy, with Wei Ling Lau, MD

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Wei Ling Lau, MD, explains how to enable optimal RAASi therapy while reducing hyperkalemia risk.

Renin–angiotensin–aldosterone system inhibitors (RAASi) medications have long been established as the standard of care for reducing cardiovascular events and mortality in various patient groups, including those with chronic kidney disease, diabetes, heart failure, and hypertension. However, the primary challenge associated with these medications has always been the risk of hyperkalemia, a condition characterized by elevated blood potassium levels, which can lead to severe arrhythmias and sudden cardiac arrest. This potential side effect has significantly limited the optimization of RAASi therapy due to safety concerns.

In an interview with HCPLive, Wei Ling Lau, MD, interim chief in the Division of Nephrology, Hypertension & Kidney Transplantation at the University of California, Irvine, discusses her session on enabling optimal RAASi therapy, presented at the National Kidney Foundation (NKF) 2024 Spring Clinical Meeting.

RAASi medications encompass several subgroups, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and mineralocorticoid receptor antagonists (MRAs). Both ACE inhibitors and ARBs are considered excellent choices, with no compelling evidence favoring one over the other. However, Lau noted patients may switch between these agents if they experience side effects such as a dry cough. MRAs, such as spironolactone and the newer agent finerenone, are particularly beneficial for patients with diabetes who have persistent proteinuria.

Mitigating hyperkalemia while maintaining optimal RAASi therapy poses a significant clinical challenge. Traditionally, dietary restrictions targeting high-potassium foods like bananas, avocados, and potatoes have been recommended. However, implementing such restrictions can be challenging, as many of these foods are essential components of a heart-healthy diet rich in fruits and vegetables. Additionally, restricting potassium-rich foods may inadvertently lead to decreased fiber intake, exacerbating issues like constipation, particularly in the kidney disease population.

Alternative strategies for managing hyperkalemia include the use of diuretics to increase urinary potassium excretion and sodium-glucose cotransporter-2 (SGLT2) inhibitors, which have shown potential in lowering blood potassium levels.

Historically, dialysis patients have been managed with lower potassium concentrations during dialysis sessions, but this approach has fallen out of favor due to associated mortality risks. The introduction of newer oral potassium binders, such as patiromer and sodium zirconium cyclosilicate, has revolutionized hyperkalemia management, allowing for long-term potassium control while enabling patients to maintain optimal RAASi therapy and dietary flexibility.

Disclosures: Lau has no relevant disclosures to report.

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