Morales Enrique, Cravedi Paolo, Manrique Joaquin
Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain.
Instituto de Investigación Hospital Universitario 12 de Octubre (imas12), Madrid, Spain.
Front Med (Lausanne). 2021 Jun 4;8:653634. doi: 10.3389/fmed.2021.653634. eCollection 2021.
Hyperkalemia is one of the main electrolyte disorders in patients with chronic kidney disease (CKD). The prevalence of hyperkalemia increases as the Glomerular Filtration Rate (GFR) declines. Although chronic hyperkalemia is not a medical emergency, it can have negative consequences for the adequate cardio-renal management in the medium and long term. Hyperkalemia is common in patients on renin-angiotensin-aldosterone system inhibitors (RAASi) or Mineralocorticoid Receptor Antagonists (MRAs) and can affect treatment optimization for hypertension, diabetes mellitus, heart failure (HF), and CKD. Mortality rates are higher with suboptimal dosing among patients with CKD, diabetes or HF compared with full RAASi dosing, and are the highest among patients who discontinue RAASis. The treatment of chronic hyperkalemia is still challenging. Therefore, in the real world, discontinuation or reduction of RAASi therapy may lead to adverse cardiorenal outcomes, and current guidelines differ with regard to recommendations on RAASi therapy to enhance cardio and reno-protective effects. Treatment options for hyperkalemia have not changed much since the introduction of the cation exchange resin over 50 years ago. Nowadays, two new potassium binders, Patiromer Sorbitex Calcium, and Sodium Zirconium Cyclosilicate (SZC) already approved by FDA and by the European Medicines Agency, have demonstrated their clinical efficacy in reducing serum potassium with a good safety profile. The use of the newer potassium binders may allow continuing and optimizing RAASi therapy in patients with hyperkalemia keeping the cardio-renal protective effect in patients with CKD and cardiovascular disease. However, further research is needed to address some questions related to potassium disorders (definition of chronic hyperkalemia, monitoring strategies, prediction score for hyperkalemia or length for treatment).
高钾血症是慢性肾脏病（CKD）患者主要的电解质紊乱之一。随着肾小球滤过率（GFR）下降，高钾血症的患病率会升高。尽管慢性高钾血症并非医疗急症，但从中长期来看，它会对充分的心肾管理产生负面影响。高钾血症在使用肾素 - 血管紧张素 - 醛固酮系统抑制剂（RAASi）或盐皮质激素受体拮抗剂（MRA）的患者中很常见，并且会影响高血压、糖尿病、心力衰竭（HF）和CKD的治疗优化。与全剂量RAASi给药相比，CKD、糖尿病或HF患者中给药剂量不足时死亡率更高，而在停用RAASi的患者中死亡率最高。慢性高钾血症的治疗仍然具有挑战性。因此，在现实世界中，停用或减少RAASi治疗可能会导致不良的心肾结局，并且目前关于增强心肾保护作用的RAASi治疗建议的指南存在差异。自50多年前引入阳离子交换树脂以来，高钾血症的治疗选择变化不大。如今，两种已获美国食品药品监督管理局（FDA）和欧洲药品管理局批准的新型钾结合剂，帕替罗姆山梨醇钙和环硅酸锆钠（SZC），已证明它们在降低血清钾方面具有临床疗效且安全性良好。使用新型钾结合剂可能允许高钾血症患者继续并优化RAASi治疗，同时在CKD和心血管疾病患者中保持心肾保护作用。然而，需要进一步研究来解决一些与钾紊乱相关的问题（慢性高钾血症的定义、监测策略、高钾血症预测评分或治疗时长）。
