Management of Hyperkalemia in Heart Failure with Reduced Ejection Fraction (HFrEF) and Chronic Kidney Disease (CKD)

Clinical Context and Rationale

• The European Society of Cardiology recommends stopping spironolactone when potassium levels rise to ≥6.0 mEq/L, and at 5.9 mEq/L, this patient is at the critical threshold 1
• The patient's eGFR of 26 mL/min/1.73 m² is below the safety threshold for spironolactone use, and the American Journal of Kidney Diseases curriculum emphasizes that mineralocorticoid receptor antagonists should be used cautiously below this threshold 2

Management Algorithm

• The European Heart Journal recommends stopping spironolactone immediately and monitoring serum potassium daily until <5.5 mEq/L 1
• The American Journal of Kidney Diseases recommends maintaining other guideline-directed medical therapy (GDMT) such as ACE inhibitors, which provide mortality benefit 2
• The Hepatology journal suggests continuing furosemide to promote potassium excretion 3

Long-term Considerations

• The American Journal of Kidney Diseases recommends optimizing SGLT2 inhibitor therapy, which reduces hyperkalemia risk and provides both cardiac and renal protection in this population 2
• The European Heart Journal emphasizes the importance of monitoring for heart failure decompensation given the loss of MRA therapy 1
• The American Journal of Kidney Diseases curriculum emphasizes maintaining RAAS inhibition whenever possible, and not stopping the ACE inhibitor instead of spironolactone 2