Navigating the Complexities of RAASi Therapy, with Kam Kalantar-Zadeh, MD, MPH, PhD

Renin–angiotensin–aldosterone system inhibitors (RAASi), play a crucial role in regulating sodium absorption, potassium excretion, and ultimately blood pressure throughout the body. While primarily active in the kidneys, their effects extend systemically, influencing cardiovascular health and overall circulation. However, the use of RAASi medications can lead to hyperkalemia, a condition marked by elevated potassium levels in the blood, increasing potential risks to cardiovascular function, including heart failure.

In an interview with HCPLive, Kam Kalantar-Zadeh, MD, MPH, PhD chief of the Division of Nephrology, Hypertension, and Transplantation at the University of California Irvine Medical Center, discusses the complex dilemma faced by healthcare providers, who must navigate the balance between the cardiovascular benefits of RAASi therapy and the risks associated with hyperkalemia.

Current guidelines offer some guidance, recommending adjustments to RAASi dosages in response to potassium level changes. However, these adjustments may limit the therapeutic effectiveness of RAASi treatment, prompting the consideration of alternative approaches.

In Kalantar-Zadeh's National Kidney Foundation (NKF) 2024 Spring Clinical Meeting presentation, he mentioned one such strategy involving dietary modifications aimed at reducing potassium intake, although this presents challenges as many potassium-rich foods are integral to a healthy diet.

Limiting these foods, therefore, may impact a patient's quality of life and nutritional status, adding another layer of difficulty to the management of hyperkalemia. Another approach involves the use of potassium-binding medications, which can help lower potassium levels by binding to excess potassium in the gut, preventing its absorption into the bloodstream.

Although these medications offer a potential solution to hyperkalemia, they also come with their own set of challenges, including adherence issues and possible side effects. Additionally, the use of potassium binders may require careful monitoring to ensure optimal dosing and effectiveness.

Overall, managing hyperkalemia in patients receiving RAASi therapy requires a comprehensive and individualized approach that considers both the benefits and risks of treatment. Providers, therefore, must weigh the potential cardiovascular benefits of RAASi therapy against the risks of hyperkalemia, taking into account factors such as patient comorbidities, medication adherence, and dietary habits.

By carefully balancing these factors and employing a multidisciplinary approach to care, providers can optimize RAASi therapy to improve clinical outcomes while minimizing the risk of hyperkalemia-related complications.

Disclosures: Kalantar-Zadeh sporadically consults for Vifor Pharma.