Date of publication: September 5, 2017

Expert Perspectives

Expert Round Table: Hyperkalaemia Management in the Cardio-Renal Patient

Patients with both chronic kidney disease and heart failure present a unique range of challenges to physicians, particularly in relation to the use of Renin Angiotensin Aldosteron System Inhibition (RAASi).

Cardio-renal patients are treated with RAASi therapy at high doses[1] due to their positive effects in reducing proteinuria, hypertension and improving outcomes[2]; as recommended in heart failure[3],[4],[5] and KDIGO renal guidelines.[6]  However, these benefits need to be considered in the context that RAASi therapy may cause or worsen hyperkalaemia,[7] requiring a dose reduction or discontinuation of RAASi treatment,[8],[9],[10] a change which is associated with poor patient outcomes.[11]

In recognition of this, COMPACT RENAL assembled an expert panel in spring 2017 to discuss the specific problems which cardio-renal patients face, as well as possible solutions to these challenges.

Professor Carolyn Lam Su Ping from the Asia Pacific region provided the cardiologist perspective and Asian clinical experience in the panel, with Professors Angel de Francisco (Spain), Austin Stack (Ireland ) and Laurent Juillard (France) adding insights into nephrology practices across Europe.


Whether we’re cardiologists or nephrologists, sometimes we have to dose-reduce or indeed, as kidney function declines, stop [RAASi] therapies – stopping therapies that have a potential therapeutic value.”

– Professor Austin Stack

In this round table video, the panel discusses:

  • How to define the cardio-renal patient and the need for greater collaboration between specialties
  • The considerable benefits of RAASi therapy at optimal doses for cardio-renal patients, as well as the difficulties in maintaining the therapeutic doses of RAASi, due to hyperkalaemia in the presence of declining kidney function
  • Current treatment options for hyperkalaemia, both acute and chronic[12]
  • The needs that physicians would like to see met by future hyperkalaemia therapies


  1. Ouwerkerk W, Voors AA, Anker SD, et al. Determinants and clinical outcome of uptitration of ACE-inhibitors and beta-blockers in patients with heart failure: A prospective European study. Eur Heart J. 2017;38(24):1883-1890. doi:10.1093/eurheartj/ehx026.
  2. Epstein M. Hyperkalemia constitutes a constraint for implementing renin-angiotensin-aldosterone inhibition: the widening gap between mandated treatment guidelines and the real-world clinical arena. Kidney Int Suppl. 2016;6(1):20-28. doi:
  3. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: A report of the american college of cardiology foundation/american heart association task force on practice guidelines. Circulation. 2013;128(16). doi:10.1161/CIR.0b013e31829e8776.
  4. Ponikowski P, Voors A, Anker S, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2016;18:891-975. doi:doi:10.1093/eurheartj/ehw128.
  5. Lindenfeld J, Albert N, Boehmer J, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail. 2010;16(6):1-94.
  6. KDIGO. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int Suppl. 2013;3(1):4-4. doi:10.1038/kisup.2012.76.
  7. Kovesdy CP. Management of Hyperkalemia: An Update for the Internist. Am J Med. 2015;128(12):1281-7.
  8. Yildirim T, Arici M, Piskinpasa S, et al. Major Barriers against Renin–Angiotensin–Aldosterone System Blocker Use in Chronic Kidney Disease Stages 3–5 in Clinical Practice: A Safety Concern? Ren Fail. 2012;34(July):1095-1099. doi:10.3109/0886022X.2012.717478.
  9. Komajda M, Anker SD, Cowie MR, et al. Physicians’ adherence to guideline-recommended medications in heart failure with reduced ejection fraction: Data from the QUALIFY global survey. Eur J Heart Fail. 2016;18(5):514-522. doi:10.1002/ejhf.510.
  10. Maggioni AP, Anker SD, Dahlström U, et al. Are hospitalized or ambulatory patients with heart failure treated in accordance with European Society of Cardiology guidelines? Evidence from 12 440 patients of the ESC Heart Failure Long-Term Registry. Eur J Heart Fail. 2013;15(10):1173-1184. doi:10.1093/eurjhf/hft134.
  11. Epstein M, Reaven NL, Funk SE, Mcgaughey KJ, Oestreicher N, Knispel J. Evaluation of the Treatment Gap Between Clinical Guidelines and the Utilization of Renin-Angiotensin- Aldosterone System Inhibitors. Am J Manag Care. 2015;V21, No11(September):212-220.
  12. Dunn JD, Benton WW, Orozco-Torrentera E, Adamson RT. The burden of hyperkalemia in patients with cardiovascular and renal disease. Am J Manag Care. 2015;21(15 Suppl):s307-15. Available at:

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