Guideline 7.1 – Use of diuretics for managing Hyperkalaemia in the community
We suggest that loop diuretics may be a useful adjunct for the treatment of chronic hyperkalaemia in patients who are non oliguric and volume replete. (2C)
Rationale (Guideline 7.1)
In patients with preserved renal function, the kidneys are the primary route of potassium elimination. Loop and thiazide diuretics enhance K+ excretion by increasing flow and delivery of sodium to the collecting ducts and may be useful in treating mild to moderate hyperkalaemia in patients with adequate renal function.1,2 Loop diuretics (e.g. furosemide, bumetanide) are the most effective class that promote urinary K+ excretion and remain effective in patients with moderate renal impairment.1,3 On the other hand, thiazide diuretics are effective in patients with an eGFR > 30ml/min.1 Diuretics should be avoided in patients who are hypovolaemic or oliguric.
Role of Diuretics in chronic hyperkalaemia
Diuretic therapy has a place in the management of chronic hyperkalaemia in patients who are normovolaemic or hypervolaemic. A multi modal approach including diuretics, treatment of metabolic acidosis and dietary potassium restriction may allow the continuation of cardioprotective medications in patients with mild hyperkalaemia. The ‘sick day rules’ apply, therefore diuretics should be withheld during acute illness.4,5
Patients with heart failure
Patients with heart failure are susceptible to both hyperkalaemia and volume overload. RAASi therapy is frequently used in this setting and loop diuretics are a useful adjunct in controlling chronic hyperkalaemia whilst treating congestion.6,7
The joint guideline from the UK Kidney Association and British Society of Heart Failure (2019) recommends consideration of combination therapy with a loop and thiazide diuretic in patients with decompensated heart failure (HFrEF) and mild moderate hyperkalaemia.6 This combination potentiates diuresis and should theoretically enhance K+ excretion.
References
1. Palmer, B.F. and D.J. Clegg, Diagnosis and treatment of hyperkalemia. Cleve Clin J Med, 2017. 84(12): p. 934–942.
2. Nyirenda, M.J., et al., Hyperkalaemia. BMJ, 2009. 339: p. b4114.
3. Sterns, R.H., et al., Ion exchange resins for the treatment of hyperkalemia: are they safe and effective? J Am Soc Nephrol, 2010. 21(5): p. 733–5.
4. Watson, K.E., et al., Sick Day Medication Guidance For People With Diabetes, Kidney Disease, or Cardiovascular Disease: A Systematic Scoping Review. Kidney Med, 2022. 4(9): p. 100491.
5. KDIGO 2023 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. (draft). July 2023.
6. Clark, A.L., et al., Change in renal function associated with drug treatment in heart failure: national guidance. Heart, 2019. 105(12): p. 904–910.
7. Rosano, G.M.C., 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. 4(3): p. 180–188.