A 68-year-old woman is on ACEI for CKD stage 3b (eGFR 34). Her serum potassium is 5.8 mEq/L and creatinine is 2.4 mg/dL. She has no oedema and BP is well-controlled at 128/78. What is the MOST appropriate management?
- A Stop the ACEI immediately to prevent hyperkalaemia progression
- B Add a potassium binder (patiromer or sodium zirconium cyclosilicate) and continue ACEI ✓
- C Switch to an ARB which causes less hyperkalaemia
- D Add furosemide to promote kaliuresis
Explanation
ACEIs are nephroprotective and cardioprotective in CKD (especially with albuminuria); stopping them due to mild-moderate hyperkalaemia (5.5-6.0 mEq/L) is not recommended. Novel potassium binders — patiromer (calcium-sorbitol exchange) and sodium zirconium cyclosilicate (ZS-9) — have been shown in the OPAL-HK (NEJM 2015) and HARMONIZE (JAMA 2014) trials respectively to safely lower serum potassium and enable continuation of RAAS inhibitors. ARBs cause equivalent hyperkalaemia. Furosemide is reasonable adjunct but not the primary solution for ACEI-related hyperkalaemia.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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