Potassium Binders for Hyperkalemia in Chronic Kidney Disease—Diet, Renin-Angiotensin-Aldosterone System Inhibitor Therapy, and Hemodialysis

Abstract

Hyperkalemia is a potentially life-threatening complication of chronic kidney disease (CKD). The management of CKD requires balancing the benefits of specific treatments, which may exacerbate the potential for hyperkalemia, with the risks of hyperkalemia itself. Renin-angiotensin-aldosterone system (RAAS) inhibitors, which slow CKD progression and improve cardiovascular outcomes, are often discontinued if hyperkalemia develops. Patients with hyperkalemia are frequently advised to restrict dietary potassium (K þ), depriving these patients of many heart-healthy foods. Patients receiving hemodialysis are particularly susceptible to hyperkalemia during long interdialytic intervals, and managing this risk without causing hypokalemia can be challenging. Recently, 2 K þ-binding agents were approved for the treatment of hyperkalemia: sodium zirconium cyclosilicate and patiromer. These agents offer alternatives to sodium polystyrene sulfonate, which is associated with serious gastrointestinal adverse effects. For this review, PubMed was searched for English-language articles published in 2014-2018 using the terms patiromer, sodium zirconium cyclosilicate, sodium polystyrene sulfonate, hyperkalemia, renin-angiotensin-aldosterone, diet, and dialysis. In randomized controlled studies of patients with hyperkalemia, sodium zirconium cyclosilicate and patiromer effectively reduced serum K þ and were generally well tolerated. Furthermore, patients in these studies could maintain RAAS inhibitor therapy and, in some studies, were not required to limit dietary K þ. There may also be a role for these agents in preventing hyperkalemia in patients receiving hemodialysis. Thus, K þ-binding agents may allow patients with CKD at risk for hyperkalemia to optimize RAAS inhibitor therapy, receive benefits of a K þ-rich diet, and experience improved hemodialysis outcomes. Additional longterm studies are necessary to confirm these effects.

A Whole Food Plant-Based Diet With a Novel Potassium-Binding Resin in a Patient With Advanced Chronic Kidney Disease

“…A potential use of new potassium binders is to ease dietary potassium restrictions in patients with CKD. 6 This case report demonstrates the ability and safety to recommend a whole food plant-based diet to patients with advanced CKD, while maintained on ACE inhibitor or angiotensin II receptor blockers (ARBs), with the adequate control of serum potassium levels using a potassium binding resin. We believe the benefits of a whole food plant-based diet should be extended to the broad range of patient with CKD, including those with advanced stages.…”

“…2 Limiting dietary potassium presents a clinical challenge because it can lead to patients not receiving enough micronutrients and a heart healthy diet. 6 Patiromer and SZC are newly Food and Drug Administrationapproved agents to treat hyperkalemia and have been studied in patients with CKD and patients receiving renin angiotensin aldosterone system (RAAS) inhibitors. 7 Some of the studies of potassium binders required patients to follow a potassium restricted diet whereas others did not leading to inconclusive data.…”

“…2,3 There is concern among nephrologists in prescribing such diets to patients with advanced CKD due, in part, to concerns over their high potassium content and the risk for hyperkalemia, 4,5 depriving these patients of many heart-healthy foods. 6 Recently and Drug Administration approved for the treatment of hyperkalemia. 7 Thus far, studies of SZC and Patiromer do not systematically control for diet leading to inconclusive data.…”

“…7 Thus far, studies of SZC and Patiromer do not systematically control for diet leading to inconclusive data. 6 We report a case of a patient with advanced CKD and hyperkalemia who was able to gain the advantages of a whole-food plant-based diet while safely controlling the serum potassium with the use of an oral potassium-binding agent.…”

The potassium regulator patiromer affects serum and stool electrolytes in patients receiving hemodialysis

“…There is a call for preemptive treatment with K binders to enable liberalization of diet and use of angiotensinconverting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) in CKD patients. 13 The results from this study are especially important in HD patients receiving long-term treatment with patiromer for the treatment of hyperkalemia.…”