Chinese Medical Sciences Journal ›› 2024, Vol. 39 ›› Issue (2): 79-90.doi: 10.24920/004327
• Guideline and Consensus • Next Articles
Ming-Hui Zhao1, *(), Wei Chen2(
), Hong Cheng3(
), Bi-Cheng Liu4(
), Zhi-Guo Mao5(
), Zhuang Tian6(
), Gang Xu7(
), Jing-Min Zhou9(
)
Received:
2023-12-05
Accepted:
2024-04-08
Published:
2024-06-30
Online:
2024-06-07
Contact:
* Ming-Hui Zhao, Wei Chen, Hong Cheng, Bi-Cheng Liu, Zhi-Guo Mao, Zhuang Tian, Gang Xu, Jing-Min Zhou. A Chinese Multi-Specialty Delphi Consensus to Optimize RAASi Usage and Hyperkalaemia Management in Patients with Chronic Kidney Disease and Heart Failure[J].Chinese Medical Sciences Journal, 2024, 39(2): 79-90.
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Table 1.
Consensus agreement by statement of five topics on RAASi usage and hyperkalaemia management"
No. | Statements | Agreement |
---|---|---|
Topic A. Risk factors and risk stratification for managing hyperkalaemia in cardiorenal patients | ||
1. | Patients with chronic kidney disease, heart failure, or diabetes are at increased risk of hyperkalaemia | 97% |
2. | Patients on RAASi and MRA treatments are at increased risk of hyperkalaemia | 95% |
3. | Cardiorenal patients should have their serum potassium levels tested at least every 6 months or more according to disease severity | 89% |
4. | Cardiorenal patients undergoing RAASi up-titration should have their serum potassium levels tested at least every two weeks during the up-titration period and monitored routinely thereafter | 97% |
5. | Patients with CKD stage 4/5 should have their serum potassium levels tested at least every 3 months | 89% |
6. | Patients who have an episode of hyperkalaemia should have their serum potassium levels tested two weeks later and at least every 3 months thereafter | 89% |
Topic B. Prevention of hyperkalaemia for at-risk cardiorenal patients | ||
7. | For those patients with a known history of hyperkalaemia preventing optimization of RAASi therapy, a novel potassium binder can be used to enable RAASi optimization | 98% |
8. | For those patients at risk of hyperkalaemia using RAASi therapy, advice about dietary considerations and the impact on potassium levels should be provided | 96% |
9. | While a low potassium diet is commonly advised, this approach may be counter to a heart healthy diet that is beneficial to cardiorenal patients | 81% |
10. | Low potassium diets can be difficult to follow, especially during certain seasons where different fruits are more readily available | 93% |
11. | Advising a low potassium diet to control hyperkalaemia is increasingly controversial: the evidence for the effectiveness of a low-potassium diet is not strong | 84% |
Topic C. Correction of hyperkalaemia for at-risk cardiorenal patients with the use of potassium-lowering therapy | ||
12. | Hyperkalaemia should be recognized as a predictable, treatable, and manageable side effect of optimal heart failure/chronic kidney disease therapy | 96% |
13. | Optimizing and maintaining RAASi therapy provides better outcomes for cardiorenal patients including morbidity and mortality | 97% |
14. | In practice, the occurrence of hyperkalaemia may lead to the down-titration or discontinuation of RAASi therapy | 97% |
15. | When managing mild-to-moderate hyperkalaemia in cardiorenal patients, RAASi therapy should be maintained due to the cardioprotective benefit in this patient type | 79% |
16. | A goal for the management of cardiorenal patients should be to utilise the maximum recommended dose of RAASi therapy | 86% |
17. | Action to manage hyperkalaemia should be taken when the serum potassium level exceeds 5.0 mmol/L | 97% |
18. | RAASi use should not be de-escalated or discontinued due to hyperkalaemia unless alternative methods of hyperkalaemia management have been optimised, including initiation of potassium binder therapy | 88% |
19. | Novel potassium binders enable guideline recommended RAASi dosing and the proven benefits that they bring to patients | 97% |
20. | When potassium levels exceed 6.5 mmol/L, RAASi treatment down-titration, suspension, or cessation should be considered | 97% |
21. | When treating cardiorenal patients, permanent discontinuation of RAASi therapy should be considered a last resort strategy | 75% |
22. | Where disease-modifying therapy has been reduced or ceased due to hyperkalaemia, it should be reinstated once normokalaemia is achieved | 89% |
23. | Prolonged use of SPS should be avoided due to the association with severe gastrointestinal side effects, including bowel necrosis | 89% |
24. | Prolonged use of SPS should be avoided due to its poor palatability and poor patient acceptance | 81% |
Topic D. Cross-specialty alignment (cardiology & nephrology) | ||
25. | Continuity of care is important in the management of hyperkalaemia | 97% |
26. | Significant variation in approach to cardiorenal diseases and hyperkalaemia management in China leads to variable patient outcomes | 93% |
27. | There is a need for a consistent and agreed understanding of hyperkalaemia management within the hospital setting, especially between cardiology & nephrology | 97% |
28. | Cardiology and nephrology guidelines should contain aligned recommendations for the management of hyperkalaemia | 95% |
29. | Patients with cardiorenal comorbidities should be managed by a MDT with an agreed management plan | 99% |
30. | Cross-specialty alignment can enable optimal doses of disease-modifying drugs (e.g., RAASi) to be maintained | 96% |
31. | Primary care is an important component of the MDT for the management of cardiorenal patients | 95% |
32. | Endocrinology is an important component of the MDT for the management of cardiorenal patients | 88% |
33. | Emergency care is an important component of the MDT for the management of cardiorenal patients | 89% |
34. | Before making a treatment decision regarding down-titration or cessation of a disease-modifying therapy (e.g., RAASi), primary care should refer to a specialist cardiologist or nephrologist | 97% |
Topic E. Education of clinicians and patients | ||
35. | Up-to-date education on the management of hyperkalaemia and guidelines for RAASi therapy is needed | 100% |
36. | Structured education of healthcare providers (HCPs) on routine serum potassium testing and hyperkalaemia management improves patient outcomes | 99% |
37. | Education for patients at risk of hyperkalaemia improves their outcomes | 99% |
38. | Education of hyperkalaemia management is best delivered by cardiology or nephrology specialists | 96% |
39. | Education of non-specialist HCPs (e.g., primary care physicians, emergency physicians, endocrinology physicians, dialysis centre nurses) regarding hyperkalaemia improves patient outcomes | 97% |
40. | Patients need to understand the consequences of hyperkalaemia and how to avoid it through lifestyle modification and appropriate use of potassium-lowering therapies | 99% |
41. | Patients should be aware of the potential impact that herbal medicines may have on the risk of hyperkalaemia | 97% |
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