Management of Hyperkalemia in Chronic Kidney Disease

Hyperkalemia, defined as a serum potassium concentration above 5.0 mmol/L, is a frequent and potentially life-threatening complication of chronic kidney disease (CKD). As glomerular filtration rate declines, the kidney’s capacity for potassium excretion diminishes, and factors such as diabetes, metabolic acidosis and use of renin–angiotensin–aldosterone system inhibitors (RAASi) further exacerbate risk. Acute elevation of potassium may precipitate cardiac arrhythmias, neuromuscular dysfunction and renal tubular acidosis, whereas chronic or recurrent mild hyperkalemia often leads clinicians to reduce or discontinue nephroprotective therapies. Management strategies encompass dietary potassium restriction, optimisation of diuretic therapy and correction of acidosis, together with pharmacological interventions. In chronic settings, novel non-absorbed potassium binders have emerged to maintain normokalemia and enable continuation of RAASi without undue risk. Extracorporeal treatments remain indispensable for severe or refractory hyperkalemia, whilst emerging algorithms integrate patient-specific risk factors to tailor long-term care. The global burden of CKD and the widespread use of RAASi underscore the practical and public-health importance of effective, safe potassium control.

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Management of Hyperkalemia in Chronic Kidney Disease publication trend

The graph below shows the total number of articles in management of hyperkalemia in chronic kidney disease across all publications each year (not limited to Nature Index journals).

Technical terms

Hyperkalemia: Elevated serum potassium concentration, typically >5.0 mmol/L, with potential cardiac and neuromuscular consequences.

Chronic kidney disease (CKD): Progressive loss of renal function over months to years, characterised by reduced glomerular filtration rate and altered electrolyte handling.

Renin–angiotensin–aldosterone system inhibitors (RAASi): Medications (including ACE inhibitors, angiotensin receptor blockers and mineralocorticoid receptor antagonists) that lower blood pressure and protect renal function but may raise serum potassium.

Patiromer: A non-absorbed, polymeric potassium binder that exchanges calcium for potassium in the gastrointestinal tract, used to lower serum potassium in CKD.

Sodium zirconium cyclosilicate (SZC): A crystalline, inorganic compound that selectively traps potassium ions in the gut, facilitating potassium excretion and management of hyperkalemia.

References

1. Characterization of Structure and Function of ZS-9, a K+ Selective Ion Trap. PLOS ONE (2014).
2. Hyperkalemia: pathophysiology, risk factors and consequences. Nephrology Dialysis Transplantation (2019).
3. Real‐World Associations of Renin–Angiotensin–Aldosterone System Inhibitor Dose, Hyperkalemia, and Adverse Clinical Outcomes in a Cohort of Patients With New‐Onset Chronic Kidney Disease or Heart Failure in the United Kingdom. Journal of the American Heart Association (2019).
4. Patiromer induces rapid and sustained potassium lowering in patients with chronic kidney disease and hyperkalemia. Kidney International (2015).
5. Management of hyperkalemia in patients with kidney disease: a position paper endorsed by the Italian Society of Nephrology. Journal of Nephrology (2019).
6. Management of hyperkalemia in the acutely ill patient. Annals of Intensive Care (2019).