Patients with chronic kidney disease, heart failure, and diabetes are at increased risk for hyperkalemia and warrant consistent care across nephrology and cardiology, according to the authors of a new study published in the European Heart Journal.

Hyperkalemia guidelines from cardiology and nephrology societies differ in some key areas, such as a lack of consistent thresholds for defining and treating hyperkalemia across the cardiorenal spectrum. In light of these differences, a steering committee sought expert opinion from 268 cardiologists and 252 nephrologists from the United States, Europe, and Canada. Using a modified Delphi method, these specialists responded to 39 statements on hyperkalemia risk factors, risk stratification, prevention, correction, and cross-specialty coordination. The committee found 90% or higher agreement on 29 statements and 67% or more agreement on the other 10 statements.

Based on responses, the committee offered 6 overarching recommendations:

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1. Recognize hyperkalemia as a “predictable, treatable, and manageable” side effect of optimal heart failure and chronic kidney disease therapy.

2. Do not reduce the dose or discontinue renin-angiotensin-aldosterone system (RAAS) inhibitors over hyperkalemia concerns unless you have optimized other strategies to reduce this risk.

3. Consider using novel potassium binders to enable RAAS inhibitor therapy. (The committee cautioned that sodium polystyrene sulfonate carries gastrointestinal side effects.)

4. Conduct a thorough medical history for patients at high-risk for hyperkalemia to inform preventative steps. Some possibilities include elimination of salt substitutes, use of diuretics, and elimination of non-disease-modifying therapies.

5. Find ways to work collaboratively across specialties to better care for patients with cardiorenal disease.

6. Seek consistent treatment approaches and cross-specialty support when updating and implementing new hyperkalemia guidelines for cardiorenal disease.

“The strong agreement levels achieved from many experienced specialists support the collaborative, optimal management of hyperkalaemia in individuals with comorbid cardiorenal disease,” according to the committee.

Disclosure: This research was supported by AstraZeneca. Please see the original reference for a full list of disclosures.


Burton JO, Coats AJ, Kovesdy CP, et al. An international Delphi consensus regarding best practice recommendations for hyperkalaemia across the cardiorenal spectrum. Eur J Heart Fail. Published online July 5, 2022. doi:10.1002/ejhf.2612