Hyperkalemia and chronic kidney disease

S.V. Kushnirenko


Chronic hyperkalemia is a major complication of chronic kidney disease (CKD) that occurs frequently, heralds poor prognosis, and necessitates careful management by the nephrologist. Current strategies aimed at prevention and treatment of hyperkalemia are still suboptimal, as evidenced by the relatively high prevalence of hyperkalemia in patients under stable nephrology care, and even in the ideal setting of randomized trials where best treatment and monitoring are mandatory. The aim of this review was to identify and discuss a range of unresolved issues related to the management of chronic hyperkalemia in CKD. The following topics of clinical interest were addressed: diagnosis, relationship with main comorbidities of CKD, therapy with renin-angiotensin-aldosterone system inhibitors, efficacy of current dietary and pharmacological treatment, and the potential role of the new generation of potassium binders.


hyperkalemia; chronic kidney disease; potassium binders; review


Abuelo JG. Treatment of severe hyperkalemia: confronting 4 fallacies. Kidney Int Rep. 2017 Oct 7;3(1):47-55. doi: 10.1016/j.ekir.2017.10.001.

Anker SD, Kosiborod M, Zannad F, et al. Maintenance of serum potassium with sodium zirconium cyclosilicate (ZS‐9) in heart failure patients: results from a phase 3 randomized, double‐blind, placebo‐controlled trial Eur J Heart Fail. 2015 Oct;17(10):1050-6. doi: 10.1002/ejhf.300.

Asirvatham JR, Moses V, Bjornson L. Errors in potassium measurement: a laboratory perspective for the clinician. N Am J Med Sci. 2013 Apr;5(4):255-9. doi: 10.4103/1947-2714.110426.

Bakris GL, Pitt B, Weir MR, et al. Effect of patiromer on serum potassium level in patients with hyperkalemia and diabetic kidney disease: the AMETHYST-DN randomized clinical trial. JAMA. 2015 Jul 14;314(2):151-61. doi: 10.1001/jama.2015.7446.

Batterink J, Lin J, Au-Yeung SH, Cessford T. Effectiveness of sodium polystyrene sulfonate for short-term treatment of hyperkalemia. Can J Hosp Pharm. 2015 Jul-Aug;68(4):296-303.

NKF. Best Practices in Managing Hyperkalemia in Chronic Kidney Disease. 2016. Available from:

Betts KA, Woolley JM, Mu F, Tang W, Wang Y, Wu E. Prevalence of Hyperkalemia in Medicare Patients. American Society of Nephrology - Kidney Week Abstract Details. 2018. ABSTRACT: SA-PO430.

Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001 Sep 20;345(12):861-9. DOI: 10.1056/NEJMoa011161.

Chaitman M, Dixit D, Bridgeman MB. Potassium-binding agents for the clinical management of hyperkalemia. P T. 2016 Jan;41(1):43-50.

Chang AR, Sang Y, Leddy J, et al. Antihypertensive medications and the prevalence of hyperkalemia in a large health system. Hypertension. 2016 Jun;67(6):1181-8. doi: 10.1161/HYPERTENSIONAHA.116.07363.

Collins AJ, Pitt B, Reaven N, et al. Association of serum potassium with all-cause mortality in patients with and without heart failure, chronic kidney disease, and/or diabetes. Am J Nephrol. 2017;46(3):213-221. doi: 10.1159/000479802.

De Nicola L, Di Lullo L, Paoletti E, Cupisti A, Bianchi S. Chronic Hyperkalemia in non-dialysis CKD: controversial issues in nephrology practice. J Nephrol. 2018 Jun 7. doi: 10.1007/s40620-018-0502-6.

De Nicola L, Provenzano M, Chiodini P, et al. Epidemiology of low-proteinuric chronic kidney disease in renal clinics. PLoS One. 2017 Feb 17;12(2):e0172241. doi: 10.1371/journal.pone.0172241.

Drawz PE, Babineau DC, Rahman M. Metabolic complications in elderly adults with chronic kidney disease. J Am Geriatr Soc. 2012 Feb;60(2):310-5. doi: 10.1111/j.1532-5415.2011.03818.x.

Dunn JD, Benton WW, Orozco-Torrentera E, Adamson RT. The burden of hyperkalemia in patients with cardiovascular and renal disease. Am J Manag Care. 2015 Nov;21(15 Suppl):s307-15.

Durfey N, Lehnhof B, Bergeson A, et al. Severe hyperkalemia: can the electrocardiogram risk stratify for short-term adverse events? West J Emerg Med. 2017 Aug;18(5):963-971. doi: 10.5811/westjem.2017.6.33033.

Fitch K, Woolley JM, Engel T, Blumen H. The Clinical and economic burden of hyperkalemia on medicare and commercial payers. Am Health Drug Benefits. 2017 Jun;10(4):202-210.

Fried LF, Emanuele N, Zhang JH, et al. Combined angiotensin inhibition for the treatment of diabetic nephropathy N Engl J Med. 2013 Nov 14;369(20):1892-903. doi: 10.1056/NEJMoa1303154.

Georgianos PI, Liampas I, Kyriakou A, et al. Evaluation of the tolerability and efficacy of sodium polystyrene sulfonate for long-term management of hyperkalemia in patients with chronic kidney disease. Int Urol Nephrol. 2017 Dec;49(12):2217-2221. doi: 10.1007/s11255-017-1717-5.

Georgianos PI, Agarwal R. Revisiting RAAS blockade in CKD with newer potassium-binding drugs. Kidney Int. 2018 Feb;93(2):325-334. doi: 10.1016/j.kint.2017.08.038.

Hayes J, Kalantar-Zadeh K, Lu JL, Turban S, Anderson JE, Kovesdy CP. Association of hypo- and hyperkalemia with disease progression and mortality in males with chronic kidney disease: the role of race. Nephron Clin Pract. 2012;120(1):c8-16. doi: 10.1159/000329511.

Heerspink HJ, Kröpelin TF, Hoekman J, et al. Drug-induced reduction in albuminuria is associated with subsequent renoprotection: a meta-analysis J Am Soc Nephrol. 2015 Aug;26(8):2055-64. doi: 10.1681/ASN.2014070688.

Hughes-Austin JM, Rifkin DE, Beben T, et al. The relation of serum potassium concentration with cardiovascular events and mortality in community-living individuals. Clin J Am Soc Nephrol. 2017 Feb 7;12(2):245-252. doi: 10.2215/CJN.06290616.

Ibsen H, Olsen MH, Wachtell K, et al. Reduction in albuminuria translates to reduction in cardiovascular events in hypertensive patients: losartan intervention for endpoint reduction in hypertension study. Hypertension. 2005 Feb;45(2):198-202. doi: 10.1161/01.HYP.0000154082.72286.2a.

Kalantar-Zadeh K, Fouque D. Nutritional management of chronic kidney disease. N Engl J Med. 2017 Nov 2;377(18):1765-1776. doi: 10.1056/NEJMra1700312.

Clinical practice guidelines for nutrition in chronic renal failure. Am J Kidney Dis. 2000 Jun;35(6 Suppl 2):S1-140.

Kloner RA, Gross C, Yuan J, Conrad A, Pergola PE. Effect of patiromer in hyperkalemic patients taking and not taking RAAS inhibitors J Cardiovasc Pharmacol Ther. 2018 Nov;23(6):524-531. doi: 10.1177/1074248418788334.

Kovesdy CP. Epidemiology of hyperkalemia: an update. Kidney Int Suppl (2011). 2016 Apr;6(1):3-6. doi: 10.1016/j.kisu.2016.01.002.

Kovesdy CP, Matsushita K, Sang Y, et al. Serum potassium and adverse outcomes across the range of kidney function: a CKD Prognosis Consortium meta-analysis. Eur Heart J. 2018 May 1;39(17):1535-1542. doi: 10.1093/eurheartj/ehy100.

Kovesdy CP. Updates in hyperkalemia: Outcomes and therapeutic strategies. Rev Endocr Metab Disord. 2017 Mar;18(1):41-47. doi: 10.1007/s11154-016-9384-x.

Lazich I, Bakris GL. Prediction and management of hyperkalemia across the spectrum of chronic kidney disease Semin Nephrol. 2014 May;34(3):333-9. doi: 10.1016/j.semnephrol.2014.04.008.

Lepage L, Dufour AC, Doiron J, et al. Randomized clinical trial of sodium polystyrene sulfonate for the treatment of mild hyperkalemia in CKD. Clin J Am Soc Nephrol. 2015 Dec 7;10(12):2136-42. doi: 10.2215/CJN.03640415.

Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001 Sep 20;345(12):851-60. doi: 10.1056/NEJMoa011303.

Luo J, Brunelli SM, Jensen DE, Yang A. Association between serum potassium and outcomes in patients with reduced kidney function Clin J Am Soc Nephrol. 2016 Jan 7;11(1):90-100. doi: 10.2215/CJN.01730215.

McIntyre WF, Femenía F, Arce M, Pérez-Riera AR, Baranchuk A. Importance of early electrocardiographic recognition and timely management of hyperkalemia in geriatric patients Exp Clin Cardiol. 2011 Summer;16(2):47-50.

Mann JF, Schmieder RE, McQueen M, et al. Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double-blind, controlled trial. Lancet. 2008 Aug 16;372(9638):547-53. doi: 10.1016/S0140-6736(08)61236-2.

Mistry M, Shea A, Giguère P, Nguyen ML. Evaluation of sodium polystyrene sulfonate dosing strategies in the inpatient management of hyperkalemia. Ann Pharmacother. 2016 Jun;50(6):455-62. doi: 10.1177/1060028016641427.

Molnar MZ, Kalantar-Zadeh K, Lott EH, et al. Angiotensin-converting enzyme inhibitor, angiotensin receptor blocker use, and mortality in patients with chronic kidney disease. J Am Coll Cardiol. 2014 Feb 25;63(7):650-658. doi: 10.1016/j.jacc.2013.10.050.

Montford JR, Linas S. How dangerous is hyperkalemia. J Am Soc Nephrol. 2017 Nov;28(11):3155-3165. doi: 10.1681/ASN.2016121344.

Nakamura T, Fujisaki T, Miyazono M, et al. Risk and benefits of sodium polystyrene sulfonate for hyperkalemia in patients on maintenance hemodialysis. Drugs R D. 2018 Sep;18(3):231-235. doi: 10.1007/s40268-018-0244-x.

Nakayama Y, Ueda K, Yamagishi SI, et al. Compared effects of calcium and sodium polystyrene sulfonate on mineral and bone metabolism and volume overload in pre-dialysis patients with hyperkalemia. Clin Exp Nephrol. 2018 Feb;22(1):35-44. doi: 10.1007/s10157-017-1412-y.

Nakhoul GN, Huang H, Arrigain S, et al. Serum potassium, end-stage renal disease and mortality in chronic kidney disease. Am J Nephrol. 2015;41(6):456-63. doi: 10.1159/000437151.

Núñez J, Bayés-Genís A, Zannad F, et al. Long-term potassium monitoring and dynamics in heart failure and risk of mortality. Circulation. 2018 Mar 27;137(13):1320-1330. doi: 10.1161/CIRCULATIONAHA.117.030576.

Parving HH, Brenner BM, McMurray JJ, et al. Cardiorenal end points in a trial of aliskiren for type 2 diabetes. N Engl J Med. 2012 Dec 6;367(23):2204-13. doi: 10.1056/NEJMoa1208799.

Pergola PE, Spiegel DM, Warren S, Yuan J, Weir MR. Patiromer lowers serum potassium when taken without food: comparison to dosing with food from an open-label, randomized, parallel group hyperkalemia study. Am J Nephrol. 2017;46(4):323-332. doi: 10.1159/000481270.

Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016 Jul 14;37(27):2129-2200. doi: 10.1093/eurheartj/ehw128.

Roscioni SS, Heerspink HJ, de Zeeuw D. The effect of RAAS blockade on the progression of diabetic nephropathy. Nat Rev Nephrol. 2014 Feb;10(2):77-87. doi: 10.1038/nrneph.2013.251.

Sarafidis PA, Blacklock R, Wood E, et al. Prevalence and factors associated with hyperkalemia in predialysis patients followed in a low-clearance clinic. Clin J Am Soc Nephrol. 2012 Aug;7(8):1234-41. doi: 10.2215/CJN.01150112.

Schmidt M, Mansfield KE, Bhaskaran K, et al. Serum creatinine elevation after renin–angiotensin system blockade and long term cardiorenal risks: cohort study. BMJ. 2017 Mar 9;356:j791. doi: 10.1136/bmj.j791.

Sterns RH, Grieff M, Bernstein PL. Treatment of hyperkalemia: something old, something new. Kidney Int. 2016 Mar;89(3):546-54. doi: 10.1016/j.kint.2015.11.018.

Viera AJ, Wouk N. Potassium disorders: hypokalemia and hyperkalemia. Am Fam Physician. 2015 Sep 15;92(6):487-495.

Weir MR, Bakris GL, Bushinsky DA, et al. Patiromer in patients with kidney disease and hyperkalemia receiving RAAS inhibitors. N Engl J Med. 2015 Jan 15;372(3):211-21. doi: 10.1056/NEJMoa1410853.

Wright JT, Bakris G, Greene T, et al. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA. 2002 Nov 20;288(19):2421-31.

Xie X, Liu Y, Perkovic V, et al. Renin–angiotensin system inhibitors and kidney and cardiovascular outcomes in patients with CKD: a Bayesian network meta-analysis of randomized clinical trials. Am J Kidney Dis. 2016 May;67(5):728-41. doi: 10.1053/j.ajkd.2015.10.011.

Yu MY, Yeo JH, Park JS, Lee CH, Kim GH. Long-term efficacy of oral calcium polystyrene sulfonate for hyperkalemia in CKD patients. PLoS One. 2017 Mar 22;12(3):e0173542. doi: 10.1371/journal.pone.0173542.

Papaian AV. Savenkova ND. Klinicheskaia nefrologiia detskogo vozrasta: Rukovodstvo dlia vrachei [Clinical nephrology of childhood. A guide for doctors]. SPb: Levsha. Sankt-Peterburg; 2008. 600 p.

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