Prevention and management of hyperkalemia in patients treated with renin-angiotensin-aldosterone system inhibitors

Hyperkalemia, defined as a serum potassium level of 5.0 mmol/L or greater, can lead to severe electrophysiological disturbances, including cardiac arrythmias, that increase morbidity and risk of death.1 It is common in patients with conditions that impair potassium excretion by the kidneys, such as chronic kidney disease (CKD), heart failure, hypertension that is difficult to control, diabetes or combinations of these conditions.1,2 These patients are commonly treated with renin-angiotensin-aldosterone system (RAAS) inhibitors to help lower their risk of CKD progression and cardiovascular events.3 However, these medications may trigger or exacerbate hyperkalemia.4-7 Some guidelines now recommend initiating and up-titrating these medications to the highest approved dose that the patient can tolerate to optimize clinical outcomes.8,9 Therefore, anticipation and prompt management of hyperkalemia is crucial for patients prescribed these medications. We discuss strategies to mitigate the risk of chronic hyperkalemia and to optimize care of patients being treated for CKD, heart failure or associated conditions, as informed by original research, reviews and clinical practice guidelines (Box 1). © 2021 Canadian Medical Association. All rights reserved.