From the Guidelines
Chronic hyperkalemia should be managed with a combination of dietary potassium restriction, pharmacological treatment with loop diuretics or potassium binders, and regular monitoring of potassium levels and kidney function, as evidenced by the most recent study in 2025 1. The management of chronic hyperkalemia typically begins with dietary potassium restriction, limiting high-potassium foods like bananas, oranges, and potatoes, and addressing underlying causes such as medication side effects from ACE inhibitors, ARBs, or potassium-sparing diuretics. For pharmacological management, loop diuretics like furosemide (20-80 mg daily) or thiazide diuretics such as hydrochlorothiazide (12.5-50 mg daily) can increase potassium excretion. Sodium polystyrene sulfonate (15-60 g daily), patiromer (8.4-25.2 g daily), or sodium zirconium cyclosilicate (5-15 g daily) are potassium binders that can be used for ongoing management. In patients with chronic kidney disease, adjusting medications and possibly reducing doses of renin-angiotensin-aldosterone system inhibitors may be necessary, as suggested by the European Heart Journal study in 2018 1. Regular monitoring of potassium levels, kidney function, and acid-base status is essential, with testing frequency based on severity (typically every 1-3 months once stable), as recommended by the Mayo Clinic Proceedings study in 2021 1. Chronic hyperkalemia requires attention because sustained elevation increases risk of dangerous cardiac arrhythmias, as potassium plays a crucial role in cardiac electrical conduction and muscle contraction. Some key points to consider in the management of chronic hyperkalemia include:
- Dietary potassium restriction
- Pharmacological treatment with loop diuretics or potassium binders
- Regular monitoring of potassium levels and kidney function
- Adjusting medications and possibly reducing doses of renin-angiotensin-aldosterone system inhibitors in patients with chronic kidney disease
- Considering the use of new potassium binders, such as patiromer or sodium zirconium cyclosilicate, as evidenced by the European Heart Journal study in 2018 1.
From the Research
Definition and Prevalence of Chronic Hyperkalemia
- Chronic hyperkalemia is a potentially life-threatening complication of chronic kidney disease (CKD) 2, 3, 4.
- The management of CKD requires balancing the benefits of specific treatments, which may exacerbate the potential for hyperkalemia, with the risks of hyperkalemia itself 2.
Risk Factors for Chronic Hyperkalemia
- High potassium intake, advanced age, diabetes mellitus, congestive heart failure, and medications such as renin-angiotensin-aldosterone system (RAAS) blockades increase the risk of hyperkalemia in patients with CKD 3, 5, 4.
- Diabetes mellitus and metabolic acidosis are associated with hyperkalemia in non-dialysis-dependent CKD patients 5.
- Diabetes mellitus and serum creatinine are predictors of hyperkalemia in hemodialysis patients 5.
Treatment and Management of Chronic Hyperkalemia
- Potassium binders, such as patiromer and sodium zirconium cyclosilicate, have emerged as new options to enhance fecal potassium excretion and reduce serum potassium levels in CKD patients 2, 3, 4.
- These agents offer alternatives to sodium polystyrene sulfonate, which is associated with serious gastrointestinal adverse effects 2, 3.
- Dietary potassium restriction is often recommended, but dietary potassium intake was not associated with serum potassium or hyperkalemia in CKD patients 5, 6.
- Other potential clinical factors related to serum potassium balance should be considered in the management of hyperkalemia in CKD, rather than solely restricting dietary potassium 5.
Pharmacologic Treatment of Chronic Hyperkalemia
- RAAS blockers are first-line treatments for cardio- and nephroprotection, but their use is often limited due to K+ elevation, resulting in high rates of discontinuation 4.
- Newer therapeutic agents, such as sodium/glucose-cotransporter-2 inhibitors and mineralocorticoid-receptor-antagonists, have shown promising results in clinical trials 4.
- Patiromer and sodium-zirconium-cyclosilicate are novel orally administered K+-exchanging compounds that effectively reduce elevated serum K+ and maintain chronically K+ balance within the normal range with excellent tolerability and no serious adverse events 4.