Overcoming Hyperkalaemia as a Barrier to Achieving Optimal RAASi Therapy in Individuals with Cardiorenal Disease

00:00:05: You are listening to an ADIS Journal podcast.

00:00:10: Hello and welcome, To our podcast discussion on overcoming hyperkalemia as a barrier to achieving optimal rassy therapy And Cardiorenal protection in individuals with cardiorenal disease.

00:00:25: My name is Dr Andrew Frankel.

00:00:27: I'm a consultant kidney doctor at Imperial College Health Care NHS Trust In London.

00:00:33: I'm joined by my colleague, Professor Stephen Wecraft for this discussion.

00:00:38: This podcast and its transcript will be published in Advances In Therapy.

00:00:44: The work that we'll be discussing is an industry-sponsored initiative That was initiated funded And coordinated by AstraZeneca And AstraZenac.

00:00:54: employees are also credited as authors.

00:00:57: the initiative has been supported By Cardio Renal Metabolic partnership known as CareMeUK.

00:01:05: That is a collaboration between UK national societies representing cardiovascular disease, kidney disease and diabetes across both primary-and secondary care including the British Cardiovascular Society The UK Kidney Association The association of British clinical diabetologists The Primary Care Cardiovascular society And the Primary Care Diabetes Society.

00:01:32: Established in two thousand and nineteen, Care Me UK focuses on education guidance.

00:01:38: And support the health care practitioners to provide them with the skills knowledge necessary to optimize management of people cardiovascular disease chronic kidney disease and diabetes.

00:01:51: And Professor Stephen Wheatcroft is currently The National Lead for Care Me U K.

00:01:59: Hello everyone My name is Stephen Weacroft and I'm a professor of Cardiometabolic Medicine and Consultant Cardiologist in Leeds, UK.

00:02:08: And chair of the KME-UK partnership.

00:02:10: Andrew!

00:02:11: I am looking forward to this discussion

00:02:13: So Am I Steven?

00:02:15: But before we delve into the main topic... ...I think it's important to recap for the audience The value Of Rassie Rennan Jutensen Alder-Stevenson system inhibitors In managing CKD & heart failure.

00:02:30: Absolutely.

00:02:31: As I'm sure many already know, rassy therapies are an evidence-based and guideline director treatment in a cornerstone of CKD and heart failure management proven to provide effective cardioreal protection.

00:02:45: indeed guidelines such as the Kedigo twenty four clinical practice guideline for the evaluation The ESC guidelines for the diagnosis and treatment of acute and chronic heart failure, and the AHA-ACC HFSA guideline for management of heart failure recommend treatment with rassiotherapy at a maximum tolerated dose to achieve best clinical outcomes.

00:03:12: Unfortunately we know that in clinical practice Rassey therapy is often not prescribed to optimal target dose according to these treatment guidelines.

00:03:21: One UK study showed that forty-two percent of rassey prescriptions for CKD and thirty seven percent of prescriptions, for heart failure were at less than half the guideline recommended dose.

00:03:32: CKd in heart failure are risk factors for hyperkalemia a disorder characterized by high serum potassium levels typically greater than five millimoles per litre and rasi therapy poses an additional hyperkalemia risk.

00:03:46: In fact, individuals with cardiorenal disease treated with rasi-therapy have almost twofold increase in the risk of hyperkalemia relative to those not treated with Rasi Therapy.

00:03:57: Hyperkalemia is considered as a substantial barrier for individuals receiving guideline recommended doses of Rasi therapy.

00:04:04: It's unfortunate that populations who are known to derive greatest benefit from Rasi are the same populations who have at their highest risk of developing hyperkalemia.

00:04:14: I think that is a great summary.

00:04:17: to start with, thank you!

00:04:18: It's important to note... ...that current international guidelines for both CKD and heart failure which you've described….

00:04:26: …which include K-DIGO, ESC & ACAC & HFSA guidelines state clearly that hyperkalemia should not be a barrier to racytherapy.

00:04:41: Unfortunately, when hyperkalemia occurs in clinical practice clinicians often down-titrate or discontinue racy therapy and these down titrations and discontinuation are then maintained over time.

00:04:56: this has a really negative effect for individuals with Cardioenol disease as both discontinuation is associated with increased morbidity and mortality.

00:05:09: So this is the central clinical dilemma for primary and secondary care clinicians how to attain, and then maintain optimized rassy therapy while simultaneously preventing a managing hyperkalemia.

00:05:25: And that nicely leads us to the objective of his podcast eleven multidisciplinary and multi professional experts including ourselves from the fields of nephrology cardiology and primary care, gathered to consider how overcome hyperkalemia as a barrier to rasi-therapy optimization in cardiorenal protection.

00:05:45: In individuals with cardioreal disease who experience hypokalemia the care pathway was analyzed and experts identified four key areas of suboptimal unvariable clinical practice.

00:05:56: these were rasi therapy optimization definition management acute hypo kalemia communications between secondary and primary and patient education.

00:06:07: Exactly right!

00:06:08: In this podcast article we are going to discuss those four key areas including the reason for focus on each area, clinical challenges and principles of optimal practice as proposed by the expert group.

00:06:25: Additionally in tandem with his podcast The Expert Group produced a series to enable them to implement the principles of optimal practice.

00:06:36: The link to these practical guides can be found in the key summary points and reference list.

00:06:57: an absent or cautious approach to rassy re-initiation following hyperkalemia, many individuals miss out on optimal cardiorenal protection.

00:07:13: Stephen would you like to begin with the challenges that we identified in this key area?

00:07:19: Absolutely!

00:07:20: We identified several key challenges Andrew.

00:07:23: first there are unclear and variable definitions of what and rasi-optimization in clinical practice.

00:07:31: We define rasi therapy as angiotensin converting enzyme inhibitors or ACE inhibitors, angiotencin two receptor blockers or ARBs, angiotensin receptor neprilicine inhibitors are arny and mineralocorticoid receptor antagonists or MRA.

00:07:48: we defined rasi optimization has the attainment maintenance of either highest recommended license dose for the indication the closest maximum tolerated dose.

00:07:59: Continuing with this variability theme, it's important to note that rasi optimization will not be the same for all individuals.

00:08:06: For example some key variables that influence prescribing decisions and concerns regarding optimizing rasi are patient age frailty comorbidities polypharmacy renal function And blood pressure.

00:08:20: Yes!

00:08:20: This variability is very challenging To consistent care.

00:08:24: Another key challenge is that not all prescribing clinicians recognize the importance of optimizing and maintaining RASI in individuals with cardiorenal disease.

00:08:37: The involvement to multiple specialties, their different guidelines can complicate decisions on treatment pathways.

00:08:44: This ultimately creates a barrier for patients receiving optimal cardioreal protection.

00:08:50: And then we come into consideration of hyperkalemia.

00:08:54: Guidelines clearly recommend that potassium-lowering strategies which facilitate rasi optimization should be employed before clinicians downtitrate or discontinue rasi, and that rasi therapy down titration or discontinuation should be seen as a last resort.

00:09:14: However these approaches are not widely implemented in clinical practice among healthcare professionals.

00:09:26: Stephen, how can we change practice in order to improve rasi therapy optimization?

00:09:33: Based on these challenges the expert group proposed seven principles of optimal care for rasi optimization in patients with cardiorenal disease.

00:09:41: firstly patients should be prescribed and maintained on optimised rassy therapy for cardiorenal protection.

00:09:47: To reiterate, this is defined as the attainment and maintenance of either highest license dose for the indication or failing this –the closest maximum tolerated dose.

00:09:58: Secondly hyperkalemia shall be seen at a predictable and recurrent risk in individuals living with cardioreal disease and treated with rassy-therapy.

00:10:06: It requires a preemptive proactive long term approach therefore.

00:10:11: Thirdly, all patients prior to starting on rassy therapy need thorough assessment for risk factors for hyperkalemia which should be regularly reviewed and addressed as part of the long-term monitoring strategy.

00:10:23: Risk factors include current potassium level, potassium elevating drugs poor glycemic control constipation metabolic acidosis And a diet that is high in animal or processed foods.

00:10:36: Next, many individuals can tolerate rapid rassy therapy optimization such that maximum dose is prescribed with minimal-dose increments.

00:10:44: However a more cautious optimisation approach

00:10:47: i.e.,

00:10:48: A smaller starting dose and incremental dose adjustments should be considered in people with multi morbidity & frailty.

00:10:55: .

00:10:57: Rasi-down titration and discontinuation should be a last resort in the prevention of management of hyperkalemia, In individuals living with cardiorenal disease and treated with rasi therapy.

00:11:08: Utilised only once alternative potassium lowering strategies and therapies have been exhausted.

00:11:13: Point six, regards should given to importance seeking specialist advice whenever rasi down titration or discontinuing is being considered due to hypokalemia.

00:11:23: And finally Individuals with cardiorenal disease should be empowered with knowledge regarding the importance of optimised racy therapy in cardioreinal disease.

00:11:32: The next key area that we identified is the definition and management of acute hyperkalemia in patients with cardioereal disease.

00:11:40: on racytherapy.

00:11:41: Andrew, can you tell us a bit more about the importance to this topic?

00:11:45: Well I would start by saying Hyperkalemia should be considered a predictable recurrent a manageable issue in those living with cardiorenal disease and on rassy therapy.

00:11:59: However, there is considerable variation in the many guidelines regarding the definitions of mild, moderate or severe hyperkalemia.

00:12:09: at what potassium level hypokalemia should be treated?

00:12:12: And where to best manage these individuals.

00:12:15: Indeed, this lack of consensus between guidelines professional bodies and hospital trusts can cause confusion and inconsistency in clinical practice.

00:12:24: Hyperkalemia may present as a primary or secondary medical issue In the community at hospital admission Or during hospital admission.

00:12:32: Different severities of hyperkalemia May require different approach.

00:12:36: For example potassium levels from five point five to five point nine millimoles per litre May not require secondary care involvement whilst urgent hospital assessment is needed in individuals who have Assyrian potassium greater than or equal to six point five millimoles per litre, or associated acute kidney injury.

00:12:55: Or Who are acutely unwell?

00:12:56: Or Have ECG changes.

00:13:00: Another challenge Is that the existing guidelines and local protocols for acute hyperkalemia Are limited by The use of long established but potentially problematic interventions including insulin and dextrose, calcium resonium and dietary potassium intake interventions.

00:13:20: There are alternative potassium-lowering therapies which are more effective with less adverse ink packed And these have become available on the NHS but they're not widely prescribed.

00:13:33: They should be considered where clinically appropriate in management of acute hyperkalemia.

00:13:39: Such therapies can also be prescribed longer term for prevention recurrent hyperkalemia.

00:13:46: That's exactly right, a further key point is that existing guidelines and local protocols are limited in focus to the short-term lowering of potassium levels.

00:13:54: this fails to consider the essential longer term needs to prevent hyperkalemia recurrence ,and to maintain optimized rassy for cardioreal protection or restarting rassy therapies if they're paused.

00:14:06: so what are principles optimal care recommended by experts?

00:14:11: So let me summarise Six principles that relate the definition and management of acute hyperkalemia in patients with cardiorenal disease who are on rassy therapy.

00:14:25: Let's start with acute hypochalemia, which can be defined as mild where the potassium is five point five to five point nine.

00:14:33: moderate with a potassium six two six point four or severe when it is greater than, or equal to six point five.

00:14:41: Once you have that definition the second principle is always consider pseudo-hyperkalemia and this may need be ruled out actively by a repeat sample taken in circumstances where there's less likely to be pseudo hyperkalemia.

00:14:59: Thirdly When considering The decision of Where To Manage The Patient You Need Look at a number of factors, the potassium level.

00:15:08: If you have access to this an ECG and whether there are changes on the ECG that suggest severe hyperkalemia?

00:15:16: The presence of unacute kidney injury?

00:15:18: The actual condition of the patient And availability local resources and expertise.

00:15:25: It's also worth considering why and where the potassium measurement was taken if it is part of regular monitoring in otherwise well individual or was it taken during an intercurrent illness?

00:15:37: That will also significantly contribute to the decision of where to manage a patient.

00:15:44: Fourthly, you must consider all appropriate potassium lowering strategies and therapies both for pharmacological and non-pharmacological.

00:15:55: They should be considered used in treatment of acute hypochlemia.

00:15:59: only town titrate withholds or discontinue rassy therapy when all other appropriate interventions have been exhausted.

00:16:08: Consider adjustment of any other potassium elevating drugs that the patient is on, consider education in regard to diet correction of metabolic acidosis optimization of glycemic control addressing constipation and consider the role of potassium lowering medications.

00:16:28: The fifth point must always include a plan to prevent recurrence of hyperkalemia, and ensure as far possible continuation or reintroduction of the rasi therapy.

00:16:44: And finally for individuals with cardioreal disease you should empower them regarding hyperkalemia in context of their cardiorenal disease and rasi-therapy so that they understand the rationale and the importance of maintaining this.

00:17:02: The third area that we identified focuses on communications between secondary and primary care for the management to patients with cardioreal disease, on racy therapy Stephen can you tell us a bit more why this is important?

00:17:16: Of course as we know careful patients with cardioreal diseases on rassy therapy who experience hyperkalemia requires consistent but their care involves multiple specialties across multiple clinical environments, including emergency departments hospital wards outpatient clinics and general practice.

00:17:36: Effective communication between secondary and primary care professionals is therefore a vital element of the treatment pathway.

00:17:43: unfortunately multiple-care transitions can make ongoing care challenging and communications often fall short of desired requirements.

00:17:51: this makes it difficult for primary care professional to manage on going and places patients at risk of adverse outcomes.

00:17:58: I completely agree, this is due to several reasons.

00:18:02: First of all communications are often limited by unclear or absent definitions in regard the roles & responsibilities of primary and secondary care in the management of these individuals.

00:18:15: Communications must be clear enough To enable primary care professionals to fulfil their role in terms of the ongoing management of individuals once they are established on therapy and overseeing RACI and potassium lowering therapies.

00:18:31: Also, where secondary care specialists identified a need for referral to other secondary care specialist They should complete their referrals themselves rather than requesting that general practitioners refer patients.

00:18:47: Another important factor is that secondary to primary care communications are highly variable in terms of access, content and clarity.

00:18:55: For example lack of access to Secondary Care medical notes, variable access to specialist advice... ...and slow response times can exacerbate the difficulties of managing unfamiliar treatment plans.

00:19:07: in Primary Care And In many cases secondary to Primary Care Communications are completed by time-constrained healthcare professionals using suboptimal templates, or training grade health care professionals who may not have been involved in the individual's care.

00:19:23: Or be aware of information required for ongoing management.

00:19:28: And what do you find then?

00:19:30: other consequences to these challenges?

00:19:33: Unfortunately, communications often lack clarity on or omit important information that enables primary care to optimize ongoing management.

00:19:42: This includes changes in RACI and potassium blurring therapies, intended treatment titrations and durations monitoring requirements and referrals to other specialists.

00:19:52: We also miss an opportunity to communicate key and timely messages to primary care regarding the real importance of continuation the risk of recurrent hyperkalemia and the need for ongoing potassium layering strategies

00:20:31: primary care professionals to fulfill their role.

00:20:34: Communications should also be shared with all relevant treating specialists, to ensure continuity of care.

00:20:42: Communications present an opportunity for education and key messaging which should include the importance of rassy therapy optimization in Cardioenol disease.

00:20:54: not to reduce or stop rassy therapies indefinitely due to hyperchlemia or other reasons, without specialist input.

00:21:02: If rasi therapies are reduced or paused.

00:21:05: emphasizing the importance of re-initiation and optimization wherever possible.

00:21:11: seeking specialist advice if required.

00:21:14: information on potassium luring strategies or therapists initiated including advice that if rasi therapy's are paused The Potassium Luring Therapist must also be paused.

00:21:26: It is also one of our key points that communications should provide key content on.

00:21:32: Changes in medication, including rasi and potassium lowering therapy, intended treatment titrations and durations.

00:21:40: ongoing clinical and electrolyte monitoring requirements.

00:21:44: any further investigations to be carried out.

00:21:46: what the follow-up will be by the admitting team or specialist teams.

00:21:50: that referral to other specialists if indicated has been made.

00:21:54: and whether required actions are a responsibility of secondary care or primary care.

00:21:58: In addition, communications should signposts to further specialist information on points of contact.

00:22:06: Always individuals with Cardioenal disease should give copies relevant documentation.

00:22:14: The final key area that we identified is education for patients with cardioreal disease on rassy therapy.

00:22:21: Patient education is extremely important and several of the other key areas we discussed have included principles for empowering patients, We focused on this area specifically as patient education empowers individuals to take greater control And make informed decisions over factors affecting their own health.

00:22:39: Andrew how are you doing in terms of patient?

00:22:44: Individuals with Cardioenal Disease experience complex and often comorbid disease, so high-quality education is crucial.

00:22:53: Unfortunately, Education for individuals with Cardiorenal Disease and Omrassie Therapy—with acute auricone hypochlemia—is often absent or inadequate.

00:23:05: This leads to a lack of understanding – non adherence to therapy Reduced Cardioereinal Disease Control an increased risk of hyperkalemia and other complications.

00:23:16: Several factors result in absent or inadequate education in these patients, Andrew would you like to begin describing them?

00:23:24: Sure first of all multiple specialties manage these patients And it is important that all health care professionals involved have the required knowledge are able to confidently manage The interplay between cardiorenal disease, rassy therapy & hyperkalemia.

00:23:41: If a healthcare professional lacks knowledge.

00:23:44: This can result in insufficient and even differing information being provided to the patient.

00:23:49: High quality education, provided by well-informed health care professionals therefore is crucial.

00:23:56: The individual with Cardio-Renal disease Is the only common denominator In all of the Health Care interactions And if that Individual is Well educated They become a valuable member Of their own care team.

00:24:10: That's a great point, Andrew.

00:24:12: However the challenges are not all healthcare professional focused.

00:24:15: there are also challenges with patients themselves.

00:24:18: individuals with cardioreal disease or diverse population and the desire for information on the capacity to access understand retain and use this information varies between individuals.

00:24:30: age culture language and health literacy are just a few of the factors that may contribute here.

00:24:37: We must remember, that a higher proportion of older adults might prefer less participation and more likely to defer decision making for healthcare professionals And both chronic kidney disease or heart failure maybe associated with cognitive impairment which can further impact patient involvement.

00:24:55: Of course there is also diverse preferences for print or digital information With many patients preferring physical information.

00:25:02: Patient's stories and peer support may be impactful.

00:25:05: So Andrew, how do we improve patient education?

00:25:09: That is a good indeed very important question.

00:25:12: We actually have an excellent opportunity to educate patients if we utilise all clinical encounters across primary & secondary care And repetition of key messages can be delivered... ...and it's essential to reinforce understanding.

00:25:27: This approach of course aligns with the making every contact count framework, the national initiative that encourages health and social care staff to use opportunities arising during all routine interactions with patients.

00:25:41: To have conversations about how they might make positive improvements.

00:26:01: First, individuals with cardioreal disease are at risk of serious complications from their diseases or prescribed medications if not managed correctly.

00:26:12: Second, key messages must be conferred in the education of individuals with cardiorenal disease on racytherapy.

00:26:19: With acute or recurrent hyperkalemia.

00:26:21: This includes the importance of optimised and maintained racy therapy In the treatment of cardioreal disease.

00:26:27: The link between cardioreinal disease, racy-therapie & hyperkalemia.

00:26:32: The importance a preemptive proactive And long term approach to hyperkalemea.

00:26:37: What potassium learning strategies and therapies this may involve?

00:26:41: The direct connection between RACI and potassium-blowering therapies, especially the absolute need to discontinue potassium lowering therapies if RACi therapy is discontinued.

00:26:51: The requirements for clinical review and monitoring of blood tests related to disease status in medications And points of contact with clinical or medication queries such as heart failure nurses.

00:27:03: Third education should be introduced by healthcare professionals and supported by accessible resources.

00:27:10: All interactions between healthcare professionals and individuals with cardioreal disease must be used as an opportunity for education, with repetition and refreshing of this education over time to reinforce up-to-date understanding and explain changes to treatment.

00:27:27: So Stephen we have discussed some very important topics today regarding how to overcome hyperkalemia.

00:27:39: Stephen, what would you say are the key takeaways from The Principles proposed by experts?

00:27:46: Yes Andrew we definitely have.

00:27:48: In summary I think that the key takeaway principles of optimal practice that we propose today is first, rassy therapies are a guideline directed and evidence based treatment for both chronic kidney disease and should be initiated, optimised and maintained wherever possible to provide cardiorenal protection.

00:28:08: Second, hyperkalemia shall be considered a predictable and manageable condition in individuals with chronic kidney disease or heart failure treated with rassy therapy – with a proactive plan in place for its prevention & management.

00:28:23: Third when hyperkalemia occurs on individuals with Chronic Kidney Disease or Heart Failure treated with Rassy Therapy All appropriate non-pharmacological and pharmacological strategies and therapies should be considered and implemented, with racy down titration or discontinuation seen as a last resort.

00:28:43: Fourth secondary and primary care must communicate effectively and work collaboratively to optimise care –with the shared focus on racy optimization for cardioreal protection.

00:28:56: And fifth, patients should be educated with key messages concerning chronic kidney disease heart failure, rassy therapy and hyperkalemia so that they can better understand discuss.

00:29:10: Take some ownership in the management of their

00:29:12: conditions.".

00:29:14: That was a great summary.

00:29:16: thank you!

00:29:17: Hopefully adoption of these principles in clinical practice will help to optimize rassy in individuals with Cardioenol disease.

00:29:28: Yes, that was a great conversation Andrew and I hope those of you listening have found our podcast to be useful.

00:29:34: Thank You so much!

00:29:56: Please visit the article page on the journal website.

00:29:59: The link to the article can be found in podcast description.