What is the treatment for hyperkalemia (elevated potassium levels) in a patient with Chronic Kidney Disease (CKD)?

From the Guidelines

For hyperkalemia in a patient with chronic kidney disease (CKD), immediate treatment is recommended, starting with dietary potassium restriction and review of medications that may contribute to hyperkalemia, such as ACE inhibitors, ARBs, potassium-sparing diuretics, and NSAIDs, which should be discontinued if possible. The management of hyperkalemia in CKD patients requires a multifaceted approach, considering both acute and long-term strategies to mitigate the risks associated with elevated potassium levels. According to the most recent and highest quality study 1, the risk of mortality, cardiovascular morbidity, progression of CKD, and hospitalization is increased in patients with hyperkalemia, especially those with CKD, heart failure, and diabetes.

Acute Management

For acute management, the following interventions are recommended:

• Administer sodium polystyrene sulfonate (Kayexalate) 15-30 g orally or rectally, or patiromer (Veltassa) 8.4 g once daily with food, as supported by 1 and 1.
• If symptoms of hyperkalemia are present or ECG changes are noted, more urgent interventions are needed: intravenous calcium gluconate 10% (10 mL over 2-3 minutes) to stabilize cardiac membranes, followed by insulin (10 units regular insulin IV) with glucose (25-50 g IV) to shift potassium intracellularly, as recommended by 1.
• Loop diuretics like furosemide 40-80 mg IV can help increase potassium excretion if residual kidney function exists, as suggested by 1 and 1.

Long-term Management

For long-term management, consider a potassium binder such as patiromer or sodium zirconium cyclosilicate (Lokelma) for ongoing control, as recommended by 1. Regular monitoring of serum potassium levels is essential, with frequency based on the severity of CKD and previous potassium values. This approach addresses both immediate safety concerns and long-term management of hyperkalemia in CKD patients, where impaired potassium excretion is a common problem.

Key considerations in the management of hyperkalemia in CKD patients include:

• The use of renin-angiotensin-aldosterone system inhibitors (RAASi) should be carefully managed, as they can increase potassium levels, but are crucial for the treatment of cardiovascular diseases and CKD, as highlighted by 1 and 1.
• The selection of potassium binders should be based on individual patient needs and the severity of hyperkalemia, with consideration of the costs and benefits of newer agents like patiromer and sodium zirconium cyclosilicate, as discussed in 1.

From the FDA Drug Label

The dose of Veltassa was titrated, as needed, based on the serum potassium level, assessed starting on Day 3 and then at weekly visits (Weeks 1,2 and 3) to the end of the 4-week treatment period, with the aim of maintaining serum potassium in the target range (3.8 mEq/L to < 5.1 mEq/L). For the Part A secondary endpoint, 76% (95% CI: 70%, 81%) of patients had a serum potassium in the target range of 3.8 mEq/L to < 5.1 mEq/L at Week 4. The mean daily doses of Veltassa were 13 grams and 21 grams in patients with serum potassium of 5.1 to < 5.5 mEq/L and 5.5 to < 6.5 mEq/L, respectively.

The treatment for hyperkalemia (elevated potassium levels) in a patient with Chronic Kidney Disease (CKD) is Veltassa (patiromer), with a starting dose of 8.4 grams per day for patients with a baseline serum potassium of 5.1 mEq/L to < 5.5 mEq/L, and 16.8 grams per day for patients with a baseline serum potassium of 5.5 mEq/L to < 6.5 mEq/L. The dose should be titrated as needed to maintain serum potassium in the target range of 3.8 mEq/L to < 5.1 mEq/L 2.

From the Research

Treatment Strategies for Hyperkalemia in CKD Patients

The treatment for hyperkalemia (elevated potassium levels) in patients with Chronic Kidney Disease (CKD) involves several strategies, including:

• Limiting dietary potassium intake 3, 4, 5
• Avoiding medications that may impair renal potassium excretion 3
• Using kaliuretic diuretics and correcting metabolic acidosis as a therapeutic strategy 3
• Employing potassium binders, such as patiromer and sodium zirconium cyclosilicate (SZC), to maintain normokalemia in patients who previously developed hyperkalemia on renin-angiotensin-aldosterone blockers 6, 3, 7
• Using other potassium binders, such as sodium polystyrene sulfonate (SPS) and calcium polystyrene sulfonate (CPS), to enhance fecal potassium excretion 7

Management of Hyperkalemia

The management of hyperkalemia includes:

• Orientation of low potassium diets and monitoring of patients' adherence to this procedure 4
• Knowing the medications in use and the presence of comorbidities to guide dose reduction or even temporary withdrawal of any of the potassium retention-related drugs 4
• Using potassium binders in both acute episodes and chronic hyperkalemia 4

Importance of Controlling Hyperkalemia

Controlling hyperkalemia is essential for reducing the mortality rate in CKD patients, as hyperkalemia increases the risk of cardiac arrhythmia episodes and sudden death 4, 5. The adoption of new hypokalaemic agents, such as patiromer and SZC, can allow patients with heart failure and chronic renal failure to continue to benefit from renin-angiotensin-aldosterone system inhibitor (RAASi) therapy 6.