What adjustments should be made to the treatment plan of a patient with a history of type 2 diabetes mellitus (T2DM), hypertension (HTN), stage 4 sacral ulcer, and chronic kidney disease (CKD) who has been readmitted with acute kidney injury (AKI), hyperkalemia, and metabolic acidosis, and is currently taking medications including insulin, nebulized therapy, and Lokelma (sodium zirconium cyclosilicate)?

Treatment Plan Adjustments for Recurrent AKI with Hyperkalemia

Immediately discontinue or temporarily hold ACE inhibitors/ARBs if the patient is taking them, as uncontrolled hyperkalemia (K+ 5.7 mmol/L) requiring emergent dialysis represents a clear indication to reduce or stop these medications per KDIGO guidelines. 1

Immediate Management Priorities

Hyperkalemia Management

• Continue Lokelma (sodium zirconium cyclosilicate) at 10g three times daily for up to 48 hours for acute hyperkalemia treatment, then transition to 10g once daily for maintenance after dialysis stabilizes potassium levels 2
• Administer all other oral medications at least 2 hours before or after Lokelma to avoid drug interactions 2
• Proceed with emergent hemodialysis as planned for definitive hyperkalemia management and AKI treatment 3, 4

Medication Review and Adjustments

ACE inhibitor/ARB Management:

• Reduce dose or discontinue ACE inhibitor/ARB therapy given uncontrolled hyperkalemia despite medical treatment (K+ 5.7 mmol/L requiring emergent dialysis) 1
• This represents a Practice Point 1.2.6 scenario: uncontrolled hyperkalemia despite medical treatment outlined in prior guidelines 1
• Critical caveat: While KDIGO recommends attempting to maintain these medications when possible, emergent dialysis for hyperkalemia indicates failure of conservative measures 3

Insulin Regimen:

• Review and adjust insulin doses based on current renal function, as insulin requirements typically decrease with worsening kidney function due to reduced renal insulin clearance 1
• Monitor blood glucose closely given AKI and potential changes in insulin metabolism 1

Other Medications to Review:

• Discontinue any NSAIDs if present in medication list, as these worsen hyperkalemia and AKI 1
• Review and potentially discontinue potassium-sparing diuretics (spironolactone, eplerenone, amiloride, triamterene) if present 1
• Avoid potassium-containing salt substitutes and educate patient on hidden dietary potassium sources 3, 5

Post-Dialysis Management Strategy

Monitoring Protocol

• Monitor serum potassium and creatinine within 2-4 weeks after any medication adjustments 1
• Check potassium levels weekly during active hyperkalemia treatment phase 3
• Assess for volume status and blood pressure changes with each dialysis session 1

Dietary Modifications

• Implement strict dietary potassium restriction with consultation from renal dietitian, focusing on reducing processed foods high in bioavailable potassium 3, 5
• Target dietary potassium intake appropriate for dialysis-dependent patients 6, 5
• Educate on avoiding herbal remedies as hidden potassium sources 5

Lokelma Dosing for Dialysis Patients

• Once on chronic hemodialysis, administer Lokelma only on non-dialysis days at 5-10g once daily depending on pre-dialysis potassium levels 2
• For K+ >6.5 mEq/L, consider 10g once daily on non-dialysis days 2
• Adjust dose based on pre-dialysis potassium values after the long interdialytic interval 2

Addressing Underlying Contributors

Metabolic Acidosis Management

• Consider sodium bicarbonate supplementation if metabolic acidosis persists, as this promotes potassium excretion and counters acidosis-induced potassium release from cells 7
• Dialysis prescription should address acid-base balance adequately 7

Sacral Ulcer Considerations

• Ensure adequate nutrition for wound healing while maintaining potassium restrictions 5
• Monitor for infection which can worsen hyperkalemia through tissue breakdown 4

Algorithm for ACE Inhibitor/ARB Resumption

After dialysis stabilization and if patient does NOT require chronic dialysis:

1. Wait until potassium normalizes (K+ <5.0 mmol/L) for at least 1 week 1
2. Ensure adequate urine output (>600 mL/day) and eGFR >15 mL/min 5
3. Restart at 50% of previous dose with close monitoring 1
4. Recheck potassium and creatinine in 2-4 weeks 1
5. If K+ rises >5.5 mmol/L or creatinine increases >30%, implement the following sequence before discontinuing:
   • Review concurrent medications for potassium-retaining drugs 1
   • Moderate dietary potassium intake further 1
   • Consider loop diuretics if not contraindicated 1
   • Optimize Lokelma dosing (up to 15g daily) 2
   • Only reduce or stop ACE inhibitor/ARB as last resort 1, 3

If patient requires chronic hemodialysis:

• ACE inhibitor/ARB can potentially be continued at reduced doses with careful monitoring, as cardiovascular benefits may outweigh risks in dialysis patients 1, 3
• Decision should weigh cardiovascular protection against hyperkalemia risk 3, 4

Critical Pitfalls to Avoid

• Do not permanently discontinue ACE inhibitors/ARBs without attempting potassium-lowering strategies first in patients with diabetic nephropathy, as this increases mortality and accelerates disease progression 3
• Do not combine ACE inhibitors with ARBs or direct renin inhibitors, as this triples hyperkalemia risk without additional benefit 1
• Do not use mineralocorticoid receptor antagonists (spironolactone, eplerenone) in this patient given recurrent severe hyperkalemia and advanced CKD 1
• Monitor for edema with Lokelma use, as each 5g dose contains approximately 400mg sodium; adjust diuretics as needed 2
• Avoid Lokelma if severe constipation or bowel obstruction develops, particularly concerning given stage 4 sacral ulcer 2