October 28, 2019
Hyperkalemia—a common but serious adverse effect that can occur in patients with chronic kidney disease (CKD)—can often complicate the management and treatment of CKD, especially in the context of comorbid cardiometabolic disease.
James J. Matera, DO, nephrologist and vice president of Medical Affairs at CentraState Medical Center in Freehold, New Jersey, recently discussed the challenges of managing hyperkalemia in patients with comorbid CKD and cardiometabolic disease, as well as new approaches to managing hyperkalemia that could help optimize outcomes in this patient population.
What are some challenges that come with managing hyperkalemia in patients with cardiometabolic disease?
This is an excellent question, as hyperkalemia can be a very serious adverse effect and oftentimes necessitates a reduction or adjustment in medications thought to have caused the patient’s hyperkalemia. Many of these medications are essential in controlling disease states like diabetes, cardiovascular disease, and congestive heart failure. These would include agents like angiotensin receptor blockers (ARBs), angiotensin-converting enzyme (ACE) inhibitors, and mineral or corticoid antagonists. All of these have been have been shown to have a positive impact on these disease states. However, when hyperkalemia ensues and these medications often subsequently have to be reduced or adjusted, this could have a negative impact on the patient’s underlying disease state.
The newer novel binding agents that are available may allow us to continue some of these medications, as they are targeted at improving the underlying disease state, but come with less worry of potential hyperkalemia. Certainly, I have a great respect for hyperkalemia, as I have often seen many significant and sometimes fatal events that occur when potassium levels are not well-controlled. Since it is primarily an intracellular cation, the presence in the serum indicates a very narrow range of therapeutic and adverse activity.
Could you describe some of the new approaches to managing hyperkalemia in patients with cardiometabolic disease?
We have long struggled to manage hyperkalemia effectively, and I am glad to see that in 2019, we have some better weapons in our arsenal to combat this. Previously, only 1 agent was truly available for reducing potassium (namely sodium polystyrene), and that agent has significant colonic and gastrointestinal adverse effects that make its use much less palatable.
The recent advance of novel binding agents such as patiromer and sodium zirconium cyclosilicate have shown to be potentially better agents that we can use in an attempt to keep patients’ potassium levels under control. This is extremely important when we want to maximize the benefits of some of the medications I mentioned earlier and thus have a positive impact on cardiovascular disease states. If we are unable to do this, oftentimes we have to reduce or even discontinue these medications because due to hyperkalemia, and we lose the effectiveness and potential positive impact that these agents would have.
We, of course, always have to temper our decision-making when it comes to risks and benefits depending on the patient's status, concurrent medications, and underlying risk factors for cardiovascular disease. I think that these agents will become more widely used as time goes on, particularly if we can demonstrate their added benefit for maximizing other therapies.
What key message do you hope physicians take away from this?
My key takeaways are as follows:
- Recognize CKD as an important disease state that often coexists with many of the conditions that you see in your patients on a daily basis.
- Understand that it is not the CKD per se, but the adverse cardiovascular risks, that will lead to increasing morbidity and mortality.
- Adhering to guidelines such as the American Diabetes Association’s recommended hemoglobin A1c targets and the American Heart Association and American College of Cardiology’s 2017 hypertension guidelines, as well as using specific medications (such as ACE inhibitors, ARBs, and perhaps sodium-glucose co-transporter-2 inhibitors), may all have a positive impact on CKD.
- A working collaboration between primary care physicians and nephrologists is of utmost importance in order to optimize care of CKD.
- Again, recognition of CKD progression and the need for education, with a focus on a transition to home modalities (if dialysis is necessary), will have a positive impact on patient outcomes.
- Lastly, utilizing population health tools, programs, health coaching, and management for not only CKD, but other aspects of care such as diabetes management, hypertension understanding and control, and obesity-related health issues, is really where we need to be focusing our efforts in the upcoming years.
Matera JJ. New approaches to managing hyperkalemia in patients with cardiometabolic disease. Presented at: Cardiometabolic Risk Summit 2019; October 24-26, 2019; Orlando, FL.