Expert Opinion on the Management of Hyperkalemia in Patients with Cardiorenal Diseases Treated with Renin Angiotensin Aldosterone System Inhibitors: An Indonesian Perspective
Keywords:
Hyperkalemia, Cardio-Renal Syndrome, Renin-Angiotensin System, IndonesiaAbstract
Hyperkalemia (serum potassium >5.0 mEq/l) is a significant complication in patients with heart failure, chronic kidney disease, and diabetes mellitus, particularly when treated with renin-angiotensin-aldosterone system inhibitors (RAASi). Both hyperkalemia and RAASi interruption are associated with increased cardiovascular events, hospitalizations, and mortality. This expert opinion document, developed between January and December 2024 through a systematic process, aims to establish guidance for hyperkalemia treatment in Indonesian patients with cardiorenal diseases receiving RAASi therapy, addressing the unique challenges within the Indonesian healthcare context. A comprehensive literature review of international guidelines and regional studies was conducted by a panel of 11 expert specialists (3 cardiologists, 6 internist-nephrologists, and 2 internist-cardiologists), who evaluated 29 statements covering diagnosis, monitoring, prevention, and treatment of hyperkalemia. Of the 29 statements, 26 reached consensus: 17 statements achieved very high agreement (≥90%) and 9 attained high agreement (≥67% – <90%). The agreed statements covered key areas, including potassium monitoring frequency, RAASi dose optimization strategies, dietary modifications, and treatment thresholds. Three statements regarding alternative therapeutic approaches did not receive agreement (<67%) due to limited local availability and cost considerations. Key recommendations include structured monitoring protocols for high-risk patients, strategies for RAASi dose optimization while managing hyperkalemia risk, and specific interventions adapted to local resources. This document provides a practical approach for managing hyperkalemia in Indonesian patients with cardiorenal diseases while maintaining optimal RAASi therapy, considering local Indonesian healthcare resources and constraints.References
Rosano GMC, Tamargo J, Kjeldsen KP, et al. Expert consensus document on the management of hyperkalaemia in patients with cardiovascular disease treated with renin angiotensin aldosterone system inhibitors: coordinated by the Working Group on Cardiovascular Pharmacotherapy of the European Society of Cardiology. Eur Heart J Cardiovasc Pharmacother. 2018 Jul 1;4(3):180–8.
Simon L, Hashmi M, Farrel M. Hyperkalemia. In: StatPearls. 2023.
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 Nov;21(15 Suppl):s307-15.
Lindner G, Burdmann EA, Clase CM, et al. Acute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference. Eur J Emerg Med. 2020 Oct;27(5):329–37.
Sinnathamby ES, Banh KT, Barham WT, et al. Hyperkalemia: Pharmacotherapies and clinical considerations. Cureus. 2024 Jan;16(1):e52994.
Hunter RW, Bailey MA. Hyperkalemia: pathophysiology, risk factors, and consequences. Nephrol Dial Transplant [Internet]. 2019 [cited 2025 Feb 8];34(Suppl 3):iii2. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6892421/
Humphrey T, Davids MR, Chothia MY, Pecoits-Filho R, Pollock C, James G. How common is hyperkalaemia? A systematic review and meta-analysis of the prevalence and incidence of hyperkalaemia reported in observational studies. Clin Kidney J. 2022 Apr;15(4):727–37.
Gaol DL, Nilasari D, Halim DS, Cahyantari RA. WCN24-2258 serum potassium profile and associated factors in hemodialysis patients: Single-center study. Kidney Int Rep. 2024 Apr;9(4):S8.
De Nicola L, Ferraro PM, Montagnani A, Pontremoli R, Dentali F, Sesti G. Recommendations for the management of hyperkalemia in patients receiving renin-angiotensin-aldosterone system inhibitors. Intern Emerg Med. 2024 Mar;19(2):295–306.
Larivée NL, Michaud JB, More KM, Wilson JA, Tennankore KK. Hyperkalemia: Prevalence, predictors and emerging treatments. Cardiol Ther [Internet]. 2023 Mar 1 [cited 2025 Feb 8];12(1):35–63. Available from: https://pubmed.ncbi.nlm.nih.gov/36503972/
Sarnowski A, Gama RM, Dawson A, Mason H, Banerjee D. Hyperkalemia in chronic kidney disease: Links, risks and management. Int J Nephrol Renovasc Dis. 2022;15:215–28.
Nyirenda MJ, Tang JI, Padfield PL, Seckl JR. Hyperkalaemia. BMJ. 2009 Oct 23;339(oct23 1):b4114–b4114.
Palmer BF. Regulation of potassium homeostasis. Clin J Am Soc Nephrol [Internet]. 2014 [cited 2025 Feb 8];10(6):1050. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4455213/
Ksiazek SH, Hu L, Andò S, et al. Renin-angiotensin-aldosterone system: From history to practice of a secular topic. Int J Mol Sci. 2024 Apr 4;25(7).
Fountain J, Kaur J, Lappin S. Physiology, renin angiotensin system. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.
Abrignani MG, Gronda E, Marini M, et al. Hyperkalaemia in cardiological patients: New solutions for an old problem. Cardiovasc Drugs Ther. 2024 Jan 30;
Schrauben SJ, Apple BJ, Chang AR. Modifiable lifestyle behaviors and CKD progression: A narrative review. Kidney 360. 2022 Apr 28;3(4):752–78.
Ortiz A, Galán CDA, Carlos Fernández-García J, et al. Consensus document on the management of hyperkalemia. Nefrologia (Engl Ed). 2023 Nov-Dec;43(6):765-82.
Svensson MK, Fischereder M, Kalra PR, et al. Estimated number needed to treat to avoid a first hospitalization by maintaining instead of reducing renin-angiotensin-aldosterone system inhibitor (RAASi) therapy after hyperkalemia. Kidney360. 2024 Dec;5(12):1813–23.
Svensson MK, Murohara T, Lesén E, et al. Hyperkalaemia-related reduction of RAASi treatment associates with more subsequent inpatient care. Nephrol Dial Transplant. 2024 Jul 31;39(8):1258–67.
Hasanah D, Zulkarnain E, Arifianto H, et al. Pedoman tatalaksana gagal jantung [Internet]. 3rd ed. Indonesia: Perhimpunan Dokter Spesialis Kardiovaskular Indonesia; 2023 [cited 2025 Feb 8]. Available from: https://inahfcarmet.org/library/pedoman-tatalaksana-gagal-jantung-2023
Burton JO, Coats AJS, Kovesdy CP, et al. An international Delphi consensus regarding best practice recommendations for hyperkalaemia across the cardiorenal spectrum. Eur J Heart Fail. 2022 Sep;24(9):1467–77.
Massicotte-Azarniouch D, Canney M, Sood MM, Hundemer GL. Managing hyperkalemia in the modern era: A case-based approach. Kidney Int Rep. 2023 Jul 1;8(7):1290–300.
Linde C, Bakhai A, Furuland H, et al. Real-world associations of renin–angiotensin–aldosterone system inhibitor dose, hyperkalemia, and adverse clinical outcomes in a cohort of patients with new-onset chronic kidney disease or heart failure in the United Kingdom. J Am Heart Assoc [Internet]. 2019 Nov 19 [cited 2025 Feb 8];8(22). Available from: https://www.ahajournals.org/doi/10.1161/JAHA.119.012655
Carrero JJ, Sood MM, González-Ortiz A, Clase CM. Pharmacological strategies to manage hyperkalaemia: out with the old, in with the new? Clin Kidney J [Internet]. 2023 [cited 2025 Feb 8];16(8):1213–20. Available from: https://academic.oup.com/ckj/article/16/8/1213/7136168
Ward T, Brown T, Lewis RD, Kliess MK, de Arellano AR, Quinn CM. The cost-effectiveness of patiromer for the treatment of hyperkalaemia in patients with chronic kidney disease with and without heart failure in Ireland. Pharmacoecon Open [Internet]. 2022 Sep 1 [cited 2025 Feb 8];6(5):757–71. Available from: https://link.springer.com/article/10.1007/s41669-022-00357-z
Rossing P, Caramori ML, Chan JCN, et al. Executive summary of the KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease: an update based on rapidly emerging new evidence. Kidney Int. 2022 Nov;102(5):990–9.
McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599–726.
Santoro A, Perrone V, Giacomini E, Sangiorgi D, Alessandrini D, Degli Esposti L. Association between hyperkalemia, RAASi non-adherence and outcomes in chronic kidney disease. J Nephrol [Internet]. 2021 Mar 1 [cited 2025 Feb 8];35(2):463. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8927011/
Mahendradhata Y, Trisnantoro L, Listyadewi S, et al. The Republic of Indonesia health system review [Internet]. 1st ed. Vol. 7, Health Systems in Transition. WHO Regional Office for South-East Asia; 2017 [cited 2025 Feb 8]. Available from: https://iris.who.int/handle/10665/254716
Evans M, Palaka E, Furuland H, et al. The value of maintaining normokalaemia and enabling RAASi therapy in chronic kidney disease. BMC Nephrol [Internet]. 2019 Jan 31 [cited 2025 Feb 8];20(1):31. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6357372/
Menteri Kesehatan Republik Indonesia. Peraturan Menteri Kesehatan Republik Indonesia. 2013.
Menteri Kesehatan Republik Indonesia. Peraturan Menteri Kesehatan Republik Indonesia Nomor 28 Tahun 2014 tentang Pedoman Pelaksanaan Program Jaminan Kesehatan Nasional. 2014.
Clase CM, Carrero JJ, Ellison DH, et al. Potassium homeostasis and management of dyskalemia in kidney diseases: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int [Internet]. 2020 Jan 1 [cited 2025 Feb 8];97(1):42–61. Available from: https://pubmed.ncbi.nlm.nih.gov/31706619/
Morris A, Lycett D. Experiences of the dietary management of serum potassium in chronic kidney disease: interviews with UK adults on maintenance hemodialysis. J Ren Nutr [Internet]. 2020 Nov 1 [cited 2025 Feb 8];30(6):556–60. Available from: https://pubmed.ncbi.nlm.nih.gov/32273228/
Morris A, Love H, Van Aar Z, Liles C, Roskell C. The Problematic world of following a renal diet outside the home. J Ren Care [Internet]. 2015 Dec 1 [cited 2025 Feb 8];41(4):253–9. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/jorc.12134
Morris A, Krishnan N, Kimani PK, Lycett D. Effect of Dietary potassium restriction on serum potassium, disease progression, and mortality in chronic kidney disease: a systematic review and meta-analysis. Journal of Renal Nutrition [Internet]. 2020 Jul 1 [cited 2025 Feb 8];30(4):276–85. Available from: http://www.jrnjournal.org/article/S1051227619303486/fulltext
Nurhasan M, Ariesta DL, Utami MMH, et al. Dietary transitions in Indonesia: the case of urban, rural, and forested areas. Food Sec [Internet]. 2024 Dec 1 [cited 2025 Feb 8];16(6):1313–31. Available from: https://link.springer.com/article/10.1007/s12571-024-01488-3
Anyanwu OA, Naumova EN, Chomitz VR, et al. The socio-ecological context of the nutrition transition in Indonesia: A Qualitative investigation of perspectives from multi-disciplinary stakeholders. Nutrients [Internet]. 2022 Jan 1 [cited 2025 Feb 8];15(1):25. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9823366/
Palmer BF, Carrero JJ, Clegg DJ, et al. Clinical management of hyperkalemia. Mayo Clin Proc [Internet]. 2021 Mar 1 [cited 2025 Feb 8];96(3):744–62. Available from: https://pubmed.ncbi.nlm.nih.gov/33160639/
Rossignol P, Lainscak M, Crespo-Leiro MG, et al. Unravelling the interplay between hyperkalaemia, renin-angiotensin-aldosterone inhibitor use and clinical outcomes. Data from 9222 chronic heart failure patients of the ESC-HFA-EORP Heart Failure Long-Term Registry. Eur J Heart Fail [Internet]. 2020 Aug 1 [cited 2025 Feb 8];22(8):1378–89. Available from: https://pubmed.ncbi.nlm.nih.gov/32243669/
Beusekamp JC, Tromp J, van der Wal HH, et al. Potassium and the use of renin–angiotensin–aldosterone system inhibitors in heart failure with reduced ejection fraction: data from BIOSTAT-CHF. Eur J Heart Fail [Internet]. 2018 May 1 [cited 2025 Feb 8];20(5):923–30. Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/ejhf.1079
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 Sep;21(11 Suppl):S212-20.
Scicchitano P, Iacoviello M, Massari F, et al. Optimizing Therapies in heart failure: the role of potassium binders. Biomedicines [Internet]. 2022 Jul 16 [cited 2025 Feb 8];10(7):1721. Available from: https://www.mdpi.com/2227-9059/10/7/1721/htm
Palmer BF. Potassium Binders for hyperkalemia in chronic kidney disease—diet, renin-angiotensin-aldosterone system inhibitor therapy, and hemodialysis. Mayo Clin Proc. 2020 Feb 1;95(2):339–54.
Berita Negara Republik Indonesia. Pelaksanaan skrining riwayat kesehatan dan pelayanan penapisan atau skrining riwayat tertentu serta peningkatan kesehatan bagi peserta penderita penyakit kronis dalam program jaminan kesehatan [Internet]. 2019. Available from: www.peraturan.go.id
Cheung AK, Chang TI, Cushman WC, et al. KDIGO 2021 Clinical Practice guideline for the management of blood pressure in chronic kidney disease. Kidney Int. 2021 Mar;99(3):S1–87.
Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation [Internet]. 2022 May 3 [cited 2025 Feb 8];145(18):E895–1032. Available from: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063
Laksono AD, Wulandari RD, Rohmah N, Rukmini R, Tumaji T. Regional disparities in hospital utilisation in Indonesia: a cross-sectional analysis of data from the 2018 Indonesian Basic Health Survey. BMJ Open [Internet]. 2023 Jan 1 [cited 2025 Feb 8];13(1):e064532. Available from: https://bmjopen.bmj.com/content/13/1/e064532
Mulyanto J, Kringos DS, Kunst AE. Socioeconomic inequalities in healthcare utilisation in Indonesia: a comprehensive survey-based overview. BMJ Open [Internet]. 2019 Jul 1 [cited 2025 Feb 8];9(7):e026164. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6661624/
Septiono W, Ayubi D, Anshari D, et al. Indonesia’s progress report on social determinants of health actions [Internet]. Depok, West Java, Indonesia: UI Publishing; 2023 [cited 2025 Feb 8]. Available from: www.uipublishing.ui.ac.id
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Copyright (c) 2026 Pringgodigdo Nugroho, Aida Lydia, Haerani Abdul Rasyid, Zulkhair Ali, Pranawa, Nyoman Paramita Ayu, Birry Karim, Erwin Sukandi, Siti Elkana Nauli, Hary Sakti Muliawan, Edrian Zulkarnain
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