A 60-year-old man with hypertension and CKD Stage 4 (eGFR 24) has serum potassium 5.8 mEq/L on ACE inhibitor + spironolactone. He has no ECG changes. He is on dietary potassium restriction. What is the preferred pharmacological approach to hyperkalemia in this CKD patient?
- A Sodium polystyrene sulfonate (Kayexalate)
- B Stop ACE inhibitor and spironolactone
- C Patiromer (potassium-binding polymer) ✓
- D Emergency dialysis
Explanation
Patiromer (a non-absorbed potassium-binding polymer) and sodium zirconium cyclosilicate (SZC) are the preferred newer potassium binders for chronic hyperkalemia management in CKD, validated in OPAL-HK and DIAMOND trials respectively. They allow continuation of RAAS therapy (ACE inhibitor) which has proven cardiorenal protective benefits — stopping RAAS in CKD to manage hyperkalemia is specifically the scenario these agents are designed to prevent. Sodium polystyrene sulfonate (Kayexalate) carries risks of intestinal necrosis, especially post-operatively, and has limited evidence; it should be avoided. Emergency dialysis is reserved for severe hyperkalemia with ECG changes or anuric AKI.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.