Kidney Week Educational Symposia-Hyperkalemia in Diabetes and Heart Failure: Optimizing Management to Mitigate Risk

Video Transcription

Video Summary

This symposium session focused on hyperkalemia risk in the “trifecta” of chronic kidney disease (CKD), diabetes, and heart failure, and how to mitigate potassium elevations while preserving guideline-directed therapies. Wendy St. Peter reviewed epidemiology showing hyperkalemia prevalence rises with worsening eGFR and albuminuria, and is higher when diabetes and heart failure coexist. She emphasized the clinical challenge of balancing optimal renin–angiotensin system inhibitors (RASi) and mineralocorticoid receptor antagonists (MRAs)—therapies that improve kidney and cardiovascular outcomes—against hyperkalemia, which often leads to underuse, dose reduction, or discontinuation. Potassium levels show a U-shaped relationship with adverse outcomes, with lowest risk around 4–5 mmol/L.<br /><br />David Mount addressed mechanisms in diabetic kidney disease, highlighting hyporeninemic hypoaldosteronism/type 4 RTA and volume expansion/ANP effects. He described BRASH syndrome (bradycardia, renal failure, AV nodal blocker, shock/hyperkalemia), often occurring even with modest potassium elevations. He reviewed evidence that dual ACEi+ARB increases AKI and hyperkalemia, while finerenone increases hyperkalemia risk but not AKI; hyperkalemia mitigation requires close monitoring and dose adjustment. SGLT2 inhibitors reduce hyperkalemia risk without causing hypokalemia and may synergize with MRAs in reducing albuminuria. He noted binder considerations: patiromer (drug interactions, hypomagnesemia; may lower phosphate) and sodium zirconium cyclosilicate (rapid onset; possible edema; may raise bicarbonate via ammonium binding).<br /><br />Angela Wang reviewed heart failure data showing hyperkalemia is common, recurrent, increases hospitalizations, arrhythmias, mortality, and costs. She stressed that stopping/down-titrating RASi worsens outcomes and advocated managing potassium first (diet review, medication review, diuretics, binders) using toolkits and cross-specialty collaboration. Q&A discussed finerenone vs spironolactone hyperkalemia risk, and the real-world affordability of binders versus dietary interventions.

Asset Subtitle

Moderator(s): Wendy St. Peter

Presentation(s):

Introduction - Wendy St. Peter
Hyperkalemia in the Patient with Diabetic Kidney Disease - David Mount
Hyperkalemia in the Patient with Heart Failure - Angela Yee Moon Wang

Support is provided by an educational grant from AstraZeneca.

Meta Tag

Date 11/3/2023

Pathway 1 CKD Non-Dialysis

Pathway 2 Diabetic Kidney Disease

Session ID 466412

Session Type ES - Educational Symposium

Keywords

hyperkalemia

chronic kidney disease (CKD)

diabetes mellitus

heart failure

renin–angiotensin system inhibitors (RASi)

mineralocorticoid receptor antagonists (MRAs)

finerenone

SGLT2 inhibitors

patiromer

sodium zirconium cyclosilicate (SZC)