Advances in treatment of hyperkalemia in chronic kidney disease

Introduction: Hyperkalemia is a frequent electrolyte disorder associated with life-threatening cardiac arrhythmias and sudden death. Patients prone to hyperkalemia have chronic kidney disease (CKD) either alone or in conjunction with diabetes or heart failure (HF). Although agents inhibiting the renin–angiotensin–aldosterone–system (RAAS) are currently the first-line treatments toward cardio- and nephroprotection, their administration often leads to potassium elevation in such patients and results in high rates of treatment discontinuation. Areas covered: This article provides an overview of factors interfering with potassium homeostasis and discusses emerging potassium-lowering therapies for long-term management of hyperkalemia. Expert opinion: In recent randomized clinical studies, two new oral potassium-exchanging compounds, patiromer and sodium zirconium cyclosilicate, were shown to effectively normalize elevated serum potassium and chronically maintain potassium homeostasis in hyperkalemic patients treated with RAAS blockers. Both agents exhibit good tolerability and were not associated with serious adverse effects. Although additional research is required, these drugs are promising for lowering the risk of incident hyperkalemia associated with RAAS blockade use in people with diabetes or HF who have CKD. They also provide the opportunity to test whether patients who could not previously receive RAAS blockade may benefit from their cardio- and renoprotective effects.