Real-world insights into hyperkalemia burden and RAASi discontinuation: a cohort study

Hyperkalemia is a common and clinically significant complication among patients receiving renin-angiotensin-aldosterone system inhibitors (RAASi). Despite their well-established cardiovascular and renal benefits, RAASi use is often limited by hyperkalemia, leading to treatment modification or discontinuation. Real-world adherence to potassium management strategies remains inconsistent, particularly in high-risk populations.

This study aimed to determine the incidence and severity of hyperkalemia among RAASi users, identify associated risk groups, and assess its influence on clinical decisions and patient outcomes.

We conducted a retrospective cohort study involving 905 adult patients attending outpatient clinics at King Abdulaziz Medical City, Jeddah. All patients were on RAASi therapy and followed for a mean duration of 29.8 months.

Hyperkalemia (K⁺ ≥5.1 mmol/L) was observed in 295 patients, yielding an overall incidence of 32.8% (95% CI: 30-36%). Most cases were mild (74.6%), with moderate and severe hyperkalemia accounting for 19.0% and 6.4%, respectively. Recurrence occurred in over half of the affected patients, with decreasing intervals between successive episodes. Risk factors significantly associated with hyperkalemia included age ≥75 years, diabetes, congestive heart failure, and reduced eGFR. RAASi therapy was discontinued in 6.2%, and down-titrated in 4.5% of patients due to hyperkalemia. Adverse clinical events included emergency visits (2.1%), hospitalizations (1.7%), arrhythmias (0.3%), and dialysis (0.2%).

Hyperkalemia affects nearly one-third of RAASi users, often prompting de-escalation of therapy. Proactive monitoring and management strategies are necessary to maintain the benefits of RAAS inhibition, especially in high-risk groups.