Renin-angiotensin–aldosterone-system (RAAS) inhibitors protect against mortality when prescribed during the early stages of chronic kidney disease (CKD), despite the risk for hyperkalemia associated with these drugs, investigators confirmed at Kidney Week 2020 Reimagined.

A “fine balance” is needed to prevent mortality, according to Luis F. Goncalves, MD, and Mario R. Raimundo, MD, of Hospital Beatriz Angelo in Loures, Lisboa, Portugal.

In their study of 575 patients with stage 3 CKD referred to a nephrology clinic (mean age 70.4 years; 63.7% male; 94.0% White), 164 patients (28.5%) experienced at least 1 hyperkalemia episode and 101 (17.6%) died. A total of 8.7% had hyperkalemia (serum potassium of 5.5 mmol/L or higher) at their first nephrology consultation and 21.7% experienced hyperkalemia during a mean follow-up of 4.1 years.

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During the follow-up period, RAAS inhibitors were stopped or not started in 200 patients (34.8%) and diuretics were started in 165 (28.7%). At least 1 hyperkalemia episode was associated with diabetes (65.9% vs 42.3%; P <.001), heart failure (36.6% vs 28.0%; P =.007), diuretic initiation (38.4 vs 24.8%; P <.001), macroalbuminuria (34.1% vs 21.2%; P =.001), and CKD progression (33.5% vs 16.3%; P <.001). The mortality rate was higher among patients who experienced hyperkalemia (27.6% vs 13.7%; P <.001).

Having at least 1 hyperkalemia episode was independently associated with 1.8-fold increased odds for all-cause mortality. Heart failure and CKD progression also were associated with approximately 2- and 4-fold increased odds for death, respectively.

Patients who started or maintained RAAS inhibition during follow up, however, had significant 62% and 50% decreased odds for mortality.

“All efforts should be made to maintain these therapeutic agents, looking for other ways to control hyperkalemia rather than stop it,” Dr Goncalves and Dr Raimundo concluded.


Goncalves LF, Raimundo MR. Hyperkalemia, CKD, and RAAS inhibition: a triad with a fine balance to prevent mortality. Presented at: Kidney Week 2020 Reimagined, October 19-25, 2020. Poster PO0481.