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Optimally managing hyperkalemia in patients with cardiorenal syndrome
1Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China.
Insights
Hyperkalemia (HK) often forces discontinuation of renin-angiotensin-aldosterone system inhibitors (RAASi) in heart failure (HF) patients. Novel therapies are needed to manage HK, allowing continued RAASi use for better cardiovascular outcomes.
Area of Science:
- Cardiology
- Nephrology
- Pharmacology
Background:
- Renin-angiotensin-aldosterone system inhibitors (RAASi) are crucial for cardiovascular disease and heart failure (HF) management.
- RAASi, particularly with mineralocorticoid receptor antagonists, increase hyperkalemia (HK) risk, especially in patients with reduced kidney function.
- Discontinuation of RAASi due to HK in HF patients is linked to increased mortality and rehospitalization.
Purpose of the Study:
- To review the prevalence and significance of hyperkalemia in cardiorenal syndrome.
- To discuss the optimal management of hyperkalemia in patients with heart failure and reduced kidney disease.
- To highlight recent novel therapies for managing hyperkalemia and enabling continued RAASi treatment.
Main Methods:
- Literature review of studies on RAASi, hyperkalemia, heart failure, and cardiorenal syndrome.
- Analysis of the impact of RAASi discontinuation on patient outcomes.
- Evaluation of current and emerging therapeutic strategies for hyperkalemia management.
Main Results:
- Hyperkalemia is a significant complication of RAASi therapy in HF patients, often leading to treatment cessation.
- RAASi discontinuation negatively impacts mortality and rehospitalization rates in HF patients.
- Effective hyperkalemia management is essential for maintaining RAASi therapy and its associated benefits.
Conclusions:
- Managing hyperkalemia is critical for patients with heart failure and cardiorenal syndrome on RAASi therapy.
- Novel treatment approaches are needed to address hyperkalemia and allow for optimal RAASi utilization.
- Maintaining normokalemia enables patients to receive the full benefits of RAASi, improving cardiovascular outcomes.
Abstract:
Renin-angiotensin-aldosterone system inhibitors (RAASi) are now a standard treatment in most patients with cardiovascular disease, especially in those with heart failure (HF). The European Society of Cardiology and the American College of Cardiology/American Heart Association gave a Class IA recommendation for the use of RAASi in the treatment of Classes II-IV symptomatic HF with reduced ejection fraction (HFREF), based on their strong clinical benefits of lowering all-cause mortality and HF hospitalizations in these subjects. However, RAASi therapy or adding mineralocorticoid receptor antagonists in subjects receiving background angiotensin-converting enzyme inhibitors or angiotensin receptor blockers may be associated with an increased risk of hyperkalemia (HK), especially in those with reduced kidney function. As a result, a significant proportion of these subjects either have RAASi dose reduced or more often discontinued when they develop HK. Discontinuation of RAASi in patients hospitalized with HFREF was associated with higher postdischarge mortality and rehospitalization rates, while optimal dosing of RAASi significantly reduced median hospital stays, outpatient visits and related costs. Thus, effective treatment is required to lower potassium level and maintain normokalemia in subjects with HF and reduced kidney disease who develop or are at risk of HK, thus enabling them to continue their RAASi therapy and maximize benefits from RAASi. In this review, we provide an up-to-date review of the prevalence and significance of HK in patients with cardiorenal syndrome, as well as their optimal management of HK with recent novel therapies.