Kidney Week 2025 Annual Meeting-Management of RAAS Inhibitor Therapy After Hyperkalemia in Patients with CKD and Heart Failure

Video Transcription

Video Summary

The symposium focuses on managing renin–angiotensin system (RAS) inhibitor therapy after hyperkalemia in patients with CKD and heart failure. The moderator reviews the history and major cardio-renal benefits of ACE inhibitors and ARBs, noting that despite strong guideline recommendations, hyperkalemia remains a key barrier to optimal use.<br /><br />Dr. Sabe (Csaba) Kovesdy explains that RAS inhibition is foundational in CKD and heart failure, but risk of hyperkalemia rises as RAAS blockade intensifies (especially with dual therapy and steroidal MRAs). Large observational cohorts show that after hyperkalemia, clinicians often down-titrate or discontinue RAS inhibitors, particularly in advanced CKD. However, discontinuation or submaximal dosing is consistently associated with worse outcomes, including higher all-cause and cardiovascular mortality and more kidney events. Data also suggest that restarting RAS inhibitors after discontinuation improves outcomes, with only modest increases in recurrent hyperkalemia.<br /><br />Dr. Matt Weir discusses practical hyperkalemia management, emphasizing individualized thresholds and recurrence risk. Chronic strategies include optimizing diuretics, stopping contributing drugs, maintaining bowel function, and using potassium binders. He contrasts older sodium polystyrene sulfonate (poor tolerability, GI risks) with newer agents patiromer and sodium zirconium cyclosilicate, which reliably lower potassium (~1 mEq/L) and can enable continued guideline-directed RAAS therapy. Q&A addresses emergency department use, sodium load concerns, diet, SGLT2 inhibitors, transplant considerations, pediatrics, and cost-driven intermittent dosing.

Asset Subtitle

Moderator(s): Rita McGill, Benjamin Ko

Presentation(s):

Introduction - Rita McGill
Clinical Impact of Suboptimal RAAS Inhibitor Therapy After Hyperkalemia - Csaba Kovesdy
Management of Hyperkalemia and RAAS Inhibitors - Matthew Weir

Support is provided by an educational grant from AstraZeneca.

Meta Tag

Date 11/8/2025

Pathway 1 CKD Non-Dialysis

Session ID 520634

Keywords

renin–angiotensin system inhibitors

hyperkalemia management

chronic kidney disease

heart failure

ACE inhibitors and ARBs

RAAS inhibitor discontinuation and restart

mineralocorticoid receptor antagonists

potassium binders (patiromer, sodium zirconium cyclosilicate)

guideline-directed medical therapy