A 70-year-old man with stage 3 chronic kidney disease (CKD) and heart failure with reduced ejection fraction (HFrEF; left ventricular ejection fraction 30%) is seen in the clinic for follow-up. He is taking sacubitril/valsartan, carvedilol, spironolactone, empagliflozin, and furosemide.
His potassium (K+) level is 5.8 mmol/L, creatinine level is 1.8 mg/dL (baseline 1.4 mg/dL), and estimated glomerular filtration rate is 45 mL/min/1.73 m2.
The correct answer is: C. Initiate sodium (Na+) zirconium cyclosilicate and continue current HFrEF therapy.
RAAS inhibitors and mineralocorticoid-receptor antagonists improve morbidity and mortality in HFrEF and are often limited by hyperkalemia in CKD.
Na+ zirconium cyclosilicate is a nonabsorbed K+ binder that works in the gastrointestinal tract by exchanging Na+ for K+, leading to a gradual reduction in serum K+ levels within hours to days. Use of Na+ zirconium cyclosilicate or patiromer allows continuation and optimization of guideline-directed medical therapy rather than downtitration.
Dietary K+ intake and other contributing medications (e.g., nonsteroidal anti-inflammatory drugs, trimethoprim) should always be addressed.
This patient case quiz is part of the larger Managing HF Across the Spectrum: From Recognizing Symptoms to Implementing Appropriate Treatment initiative, supported by Bayer. To visit the Managing HF Across the Spectrum page and access additional educational activities on this topic, click here.
References
- Ferreira JP, Butler J, Rossignol P, et al. Abnormalities of potassium in heart failure: JACC state-of-the-art review. J Am Coll Cardiol. 2020;75(22):2836-2850. doi:10.1016/j.jacc.2020.04.021
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