Overcoming Hyperkalaemia as a Barrier to Achieving Optimal RAASi Therapy and Cardiorenal Protection in Individuals with Cardiorenal Disease: A Podcast Discussion.

Background and Aims Hyperkalaemia is a barrier to achieving guideline-directed renin-angiotensin-aldosterone system inhibitor (RAASi) therapy. This observational cohort study compared the likelihood of maintained (stabilised or up-titrated) RAASi therapy at 6 months following an episode of hyperkalaemia in patients with chronic kidney disease (CKD) from the US and Japan, in patients who were treated with sodium zirconium cyclosilicate (SZC) for at least 120 days, relative to those with no potassium (K+) binder prescription. Method Using data from healthcare registers and hospital medical records, patients with CKD receiving RAASi therapy who had an episode of hyperkalaemia in an inpatient or outpatient care setting were identified. Propensity score (PS) matching (up to 1:4) was applied to balance the SZC cohort to a No K+ binder cohort on baseline characteristics. The proportions of patients in each cohort who had discontinued, down-titrated, stabilised or up-titrated their RAASi treatment at 6 months were described, with P values for differences between cohorts calculated using Chi-squared tests. Logistic regression analysis was performed to compare the odds of maintained RAASi therapy at 6 months in the SZC versus No K+ binder cohorts, and a meta-analysis across countries was performed using a random effects model. Results After PS-matching, the SZC cohorts included 530 (US) and 211 (Japan) patients, and the No K+ binder cohorts included 1937 and 711 patients, respectively. Mean ages of patients were 72 (US) and 74 (Japan) years, and 44% and 30% were females, respectively. Most US patients had CKD Stage 3−4 (∼89%), while CKD Stage 5 was more common in Japan (∼47% of patients). Comorbid heart failure was less common in the US than in Japan (∼33% versus ∼74%, respectively). The proportions who discontinued RAASi therapy at 6 months were consistently lower in the SZC cohorts than in the No K+ binder cohorts in both countries (Table). At 6 months, 69.8% (US) and 79.6% (Japan) of the SZC cohorts had maintained their RAASi therapy, while corresponding proportions for the No K+ binder cohorts were 53.6% (US) and 52.6% (Japan). The odds ratios (95% confidence interval) for maintained RAASi therapy in the SZC cohort versus the No K+ binder cohort were 2.09 (1.70–2.58) in the US and 3.54 (2.43–5.17) in Japan; the meta-analysed odds ratio was 2.65 (1.62–4.34). Conclusion In contemporary routine clinical practice of patients with CKD, the likelihood ofstabilised or up-titrated RAASi therapy at 6 months following an episode of hyperkalaemia was substantially higher in patients treated with SZC for at least 120 days versus those with no prescribed K+ binder treatment. These data demonstrate the potential for SZC to facilitate maintained, guideline-concordant RAASi therapy following an episode of hyperkalaemia to achieve optimal treatment outcomes in patients with CKD.

BACKGROUND: Atrioventricular nodal reentrant tachycardia (AVNRT) is considered a sporadic disease occurring in ≈22.5 cases per 10 000 in the general population.We define the prevalence and characteristics of familial AVNRT among patients who underwent radiofrequency ablation. METHODS AND RESULTS:Ablation reports of all patients with familial AVNRT (at least 2 first-degree family members) who underwent radiofrequency ablation in our institution and in another hospital were reviewed.There were 1587 patients from our institution, of whom 20 had ≥1 first-degree relatives with AVNRT.This indicates a familial AVNRT prevalence of 127 cases per 10 000 (95% confidence interval, 82-196/10 000).First-degree relatives of patients with AVNRT presented a hazard ratio of at least 3.6 for exhibiting AVNRT compared with the general population.After inclusion of 4 families with familial AVNRT who underwent ablation at another hospital our population study comprised a total of 24 families (50 patients) with AVNRT.Patients at ablation were younger in the familial AVNRT group when compared with the sporadic AVNRT group (44.2±19 versus 54.8±18 years old, P=0.0001).The male/female ratio was similar, with female predominance.The supraventricular tachycardia mechanism was typical slow/fast reentry in most cases in both groups.The most common familial relationship in our 24 families included a parent and a child in 67% of cases and less often 2 siblings (29%).CONCLUSIONS: Familial AVNRT prevalence is higher than previously believed suggesting that this arrhythmia may have a genetic component.Autosomal dominance with incomplete penetrance is the most likely mode of inheritance.

Aims: Patients with heart failure are at increased risk of hyperkalemia, particularly when treated with renin-angiotensin-aldosterone system inhibitor (RAASi) agents. This study developed a model to quantify the potential health and economic value associated with sustained potassium management and optimal RAASi therapy in heart failure patients.Materials and methods: A patient-level, fixed-time increment stochastic simulation model was designed to characterize the progression of heart failure through New York Heart Association functional classes, and predict associations between serum potassium levels, RAASi use, and consequent long-term outcomes. Following internal and external validation exercises, model analyses sought to quantify the health and economic benefits of optimizing both serum potassium levels and RAASi therapy in heart failure patients. Analyses were conducted using a UK payer perspective, independent of costs and utilities related to pharmacological potassium management.Results: Validation against multiple datasets demonstrated the predictive capability of the model. Compared to those who discontinued RAASi to manage serum potassium, patients with normokalemia and ongoing RAASi therapy benefited from longer life expectancy (+1.38 years), per-patient quality-adjusted life year gains (+0.53 QALYs), cost savings (£110), and associated net monetary benefit (£10,679 at £20,000 per QALY gained) over a lifetime horizon. The predicted value of sustained potassium management and ongoing RAASi treatment was largely driven by reduced mortality and hospitalization risks associated with optimal RAASi therapy.Limitations: Several modeling assumptions were made to account for a current paucity of published literature; however, ongoing refinement and validation of the model will ensure its continued accuracy as the clinical landscape of hyperkalemia evolves.Conclusions: Predictions generated by this novel modeling approach highlight the value of sustained potassium management to avoid hyperkalemia, enable RAASi therapy, and improve long-term health economic outcomes in patients with heart failure.

Introduction: Renin-angiotensin-aldosterone system inhibitors (RAASis) in patients (pts) with heart failure (HF) and hypertension (HTN) are associated with a reduced risk of death or disease progression, but increased risk of hyperkalemia (HK) with RAASis may lead to discontinuation and reduced benefit. This real-world study evaluated RAASi use patterns in pts who initiated sodium zirconium cyclosilicate (SZC) for HK. Methods: Adult (≥18 years) outpatients who initiated SZC (index date) while on RAASis were retrospectively identified from a large US claims database (Jan 2018 to Jun 2020). Analyses were conducted among all pts with HK and separately in those with HF or HTN. Outcomes included the proportion of pts with a new RAASi script (different or refill RAASi within 90 days of ending their index RAASi) and median time from index to RAASi discontinuation. A multivariable logistic regression assessed predictors of a new RAASi script among all pts. Results: Of 589 pts who initiated SZC during RAASi therapy (mean age 61.0 years, male 65%), 487 (83%) received a new RAASi script post index. In the HF (n=149) and HTN (n=538) cohorts, 120 (81%) and 446 (83%) received a new RAASi script. At index, the most common RAASi prescribed were ACE inhibitors (51%) and ARBs (42%). Among pts with a new RAASi script, median time from index to RAASi discontinuation was not reached ( Figure ), whereas in pts with no new RAASi script, median time from index to RAASi discontinuation was 29 days. Significant predictors of a new RAASi script (vs no new RAASi script) after SZC initiation were fewer prior hospitalizations (adjusted OR 0.77; 95% CI 0.60-0.98; P <0.05) and fewer ED visits (0.78; 0.63-0.97; P <0.05). Conclusions: Consistent with clinical trial findings, >80% of pts on RAASi therapy who initiated SZC for HK had a new RAASi script; similar results were observed in pts with HF or HTN. Pts with inpatient and ED visits may require additional follow-up care to encourage continuation of RAASi therapy.

Outcomes in patients with cardiometabolic disease who develop hyperkalemia while treated with a renin-angiotensin-aldosterone system inhibitor

The classical endocrine renin-angiotensin aldosterone system (RAS) plays an important role in blood pressure and fluid balance regulation. Important effectors of the RAS are small bioactive peptides like angiotensin II (Ang 1-8) or Ang 1-7. The possibility to reliably quantify the low abundance RAS peptides in serum using a mass spectrometry based method opened up new opportunities to investigate their role as possible biomarkers in patients treated with cardiovascular drugs that modulate the RAS cascade. In a pilot study in healthy individuals, RAS peptide concentrations were quantified under normal conditions and after administration of approved drugs that inhibit key enzymes of the RAS (renin, angiotensin-converting enzyme) or block the effect of Ang 1-8 (angiotensin receptor antagonists). Changes reflecting the mechanism of action of the different drugs were evident within a few hours after single dose administration. Based on these promising pilot data, the goal of the subsequent three clinical studies performed in the framework of this dissertation was to systematically characterize the RAS peptide profiles in normotensive healthy subjects as well as in patients with arterial hypertension. The work should contribute to a better understanding of the RAS peptides and investigate their possible role as biomarkers for patients under treatment with RAS modulating drugs. In the first study, we assessed RAS peptide concentrations after single and repeated oral administration of the renin inhibitor aliskiren, the ACE inhibitor enalapril, and the angiotensin receptor antagonist losartan in healthy normotensive subjects. RAS peptide profiles showed drug-specific changes which directly reflected the mechanism of action of the different RAS inhibitors after single and multiple dose treatment for one week. While inhibition of renin decreased downstream RAS peptide concentrations, the ACE inhibitor caused a decrease of the ACE products Ang 1-8 and Ang 1-5. The angiotensin receptor antagonist on the other hand caused an increase of upstream Ang 1-10 and Ang 1-8 mainly by enhanced renin-feedback. Overall, the data suggested that RAS peptide profiles could be of value for the assessment of patients under RAS inhibitor therapy. In the second study, the potential of drug-specific profiles found in healthy normotensive subjects as possible biomarkers were assessed in patients before and after start of monotherapy for arterial hypertension. Patients were randomized to four groups and RAS peptide concentrations were assessed after 4 weeks of consecutive oral treatment with intermediate or high doses of the ACE inhibitor perindopril, the angiotensin receptor antagonist olmesartan, the calcium channel antagonist amlodipine or the thiazide diuretic hydrochlorothiazide. These four drugs are used as first line treatments in clinical practice. After treatment with the ACE inhibitor and the angiotensin receptor antagonist, RAS peptide profiles again showed the drug-specific changes observed in healthy normotensive subjects. The changes observed with the calcium channel antagonist and the thiazide diuretic were similar but less pronounced as for the ones observed after an angiotensin receptor antagonist treatment. The study showed that the drug-specific changes are preserved for at least 8 weeks of treatment. Next it was of interest whether drug-specific changes could also be detected in patients under combination drug treatment. In the third study we therefore investigated RAS peptide profiles in patients with uncontrolled arterial hypertension, as such patients per definition are treated with at least three different antihypertensive drugs. With insufficient therapeutic response despite receiving combination drug treatment, patients with treatment resistant arterial hypertension belong to the most complex patient group. However, these patients are at great risk of stroke, myocardial infarction, heart failure, and/or chronic kidney disease and the benefits of successful treatment are substantial. Even in this heterogeneous patient group, the drug-specific RAS peptide profile changes observed in healthy normotensive subjects and patients under antihypertensive monotherapy were maintained. Data generated by this study suggest that RAS peptide profiles might also be useful in other patient populations treated with cardiovascular drug combinations. In conclusion, data generated by our studies showed a correlation between RAS peptide concentrations and treatment with an ACE inhibitor or angiotensin receptor antagonist in normotensive healthy subjects as well as in patients with arterial hypertension under monotherapy or in patients with uncontrolled hypertension with a combination drug treatment. Taken together, RAS peptide profiles as biomarkers for the assessment of drug adherence and (in combination with drug concentrations in plasma) true drug resistance as well as their potential usefulness in the guidance of antihypertensive treatment in patients with insufficient treatment response merits further investigation.

Background and Aims Best practice for treatment of patients with chronic heart failure involves beta-blockers and renin-angiotensin-aldosterone system inhibitors (RAASi) such as ACE inhibitors (ACE-i), angiotensin receptor blockers (ARB), mineralocorticoid antagonists (MRA) and neprolysin inhibitor/ARB. However, use of these agents, and optimisation of their dosage, is frequently limited by hyperkalaemia, the incidence of which is increased by the co-prevalence of chronic kidney disease (CKD). Management of patients in a bespoke Hyperkalaemia Clinic can be advantageous in facilitating optimal use of RAASi. Method A Hyperkalaemia Clinic was opened in July 2019 in this tertiary renal centre within an NHS trust that hosts 4 district hospital heart failure services. Referrals of patients with left ventricular systolic dysfunction whose RAASi could not be optimised because of hyperkalaemia were encouraged from heart failure specialist nurses and cardiologists. Management of the patients incorporated commencement of patiromer at 8.4g daily and increases in RAASi was usually devolved to the referring team. This report describes the activity and short-term outcomes of the first 17 months after opening of the clinic (follow up until 1st January 2021). Results 34 patients with systolic heart failure and problems with RAASi-associated hyperkalaemia were referred to the clinic. Mean age was 74 (range 44-88) years, 28% had stage 3a, 28% 3b and 8% stage 4 CKD. ACE-I or ARB were being used in 73% of patients at referral, 73% were using beta blockers and 50% MRA with loop diuretic use in 70%. At first visit 64% had normokalaemia, and 36% serum potassium 5.4-6.0 mmol/L. During follow-up, 6 (18%) patients discontinued patiromer due to gastrointestinal side effects, 3 no longer required the binder because of decrease in RAASi use and 2 patients died (one each from stroke and sepsis). One patient was switched to an alternative potassium binder. As of 1st January 2021, patiromer was still being administered to 22 (65%) patients, 8 of which had received this for >12 months; all patients remained normokalaemic and none of them required magnesium supplementation. An increase in RAASi therapy had occurred in only 12 (35%) patients. Conclusion Our experience demonstrates the relative simplicity of managing hyperkalaemia via a bespoke clinic in cardio-renal patients. As this was nephrology-led, optimised management was dependent upon the assertive and collaborative involvement of the referring heart failure teams who helped with biochemical monitoring and alteration of RAASi therapy. However, less than half of the patients benefitted from an increase in RAASi therapy after normalisation of serum potassium, and there was definitely scope for improving this component of the care pathway via more direct multi-disciplinary interaction with the heart failure teams.

The combined post-operative use of diuretics and/or renin-angiotensin-aldosterone system (RAAS) inhibitors may increase the risk of nonsteroidal anti-inflammatory drug (NSAID) associated renal failure because of a drug-drug interaction. The aim of this study was to investigate the effect of the short-term (<4 days) post-operative combined use of NSAIDs with diuretics and/or RAAS inhibitors on renal function and blood pressure. One teaching hospital in the Netherlands. The study-design was a prospective, observational cohort-study. Based on postoperative treatment with NSAIDs, the intervention-group was compared to a control-group (no NSAIDs treatment). Systolic blood pressure and renal function expressed by the estimated glomular filtration rate (eGFR) calculated with the modification of renal desease formula. 97 patients were included in the intervention-group, 53 patients in the control-group. Patient characteristics were comparable except for one variable: 'combined use of a diuretic with a RAAS inhibitor' which was higher in the control-group (62 vs. 43 %, p = 0.046). Odds ratio for clinically relevant increase in systolic blood pressure was 0.66 (CI95 % 0.3-1.5). Odds ratio for clinical relevant decrease in renal function was 2.44 (CI95 % 1.1-5.2). On day 4 eGFR of 3 patients in the intervention- and 1 in the control-group was <50 ml/min/1.73 m(2). Odds ratios showed no significant difference of a clinically relevant increase in systolic blood pressure but showed a higher risk for a clinically relevant decrease in renal function in the intervention group. However this decrease resulted in a relevant impaired renal function (<50 ml/min/1.73 m(2)) in only 3 patients in the interventiongroup and 1 patient in the control-group. In the post-operative patient, without preexisting impaired renal function, concurrent diuretics and/or renin-angiotensinaldosterone system inhibitor therapy can be combined with short-term NSAID treatment.

AimsRenin–angiotensin–aldosterone system inhibitors (RAASi) are guideline‐recommended therapy for individuals with cardiorenal disease. They are associated with increased risk of hyperkalaemia, a common and life‐threatening disorder for this population. RAASi‐induced hyperkalaemia often leads to dose reduction or discontinuation, reducing cardiorenal protection. Guideline recommendations differ between specialties for the clinical management of hyperkalaemia. Using a modified Delphi method, we developed consensus recommendations for optimal management of hyperkalaemia in adults with cardiorenal disease.Methods and resultsAn international steering group of cardiologists and nephrologists developed 39 statements regarding hyperkalaemia care, including risk factors and risk stratification, prevention, correction, and cross‐specialty coordination. Consensus was determined by agreement on an online questionnaire administered to cardiorenal specialists across Europe and North America. The threshold for consensus agreement was established a priori by the steering group at 67%. Across November 2021, 520 responses were received from Canada (n = 50), France (n = 50), Germany (n = 54), Italy (n = 58), Spain (n = 57), the UK (n = 49), and the US (n = 202); 268 from cardiologists and 252 from nephrologists. Twenty‐nine statements attained very high agreement (≥90%) and 10 attained high agreement (≥67%–<90%), with strong alignment between cardiologists and nephrologists.ConclusionA high degree of consensus regarding hyperkalaemia evaluation and management exists among healthcare professionals. Based on high levels of agreement, the steering group derived six key recommendations for hyperkalaemia prevention and management in people with cardiorenal disease. Future studies examining the quality of hyperkalaemia care delivery are required.

Introduction: Risk adjustment variables for population stratification are based, primarily, on the burden of disease and the pattern of use of resources. They do not include other variables that, according to available evidence determines the complexity, such as coordination of care on a regional level, certain patient characteristics (adherence to treatments or visits, mental disorders, etc...) and, especially, socioeconomic, cultural, environmental and behavioural context.In Catalonia, a strategy for proactive identification of complex chronic patients (CCP) by healthcare professionals in primary care, based on clinical judgment and broad criteria, encompassing clinical and psychosocial variables, combined with Clinical Risk Groups (CRG, a risk-adjustment tool and clinically-based classification system used to measure a population’s burden of illness) has been promoted by the Chronicity Prevention and Care Program (CPCP) from the Department of Health. To the best of our knowledge, this strategy of identifying CCP from combination of risk adjustment and clinical judgment is a pioneering and unique experience worldwide. 101415 persons (1.3% of the population of Catalonia) have been identified as CCP by healthcare professionals in primary care between 1st February and 31st December 2013.43.3% of CCP identified (44014 persons) present a complexity not explained by theoretical construct proposed for identifying complex chronic population, defined by mortality, primary care contacts, hospitalization, emergency hospitalizations and pharmaceutical expenditure in the fourth and fifth quintiles of population distribution (CRG 5 severity 6; CRG 6 severity 5-6; CRG 7 severity 2-6, CRG 8 severity 3-6; and CRG 9 severity 2-6), increasing the possibility of being identified in this group when decreases the number of advanced chronic organic failure diseases, visits to primary care, urgent hospitalization and pharmaceutical spending and when increases age. But to date, it is unknown what the variables that would explain this complexity are. On the other hand, prevalence of CCP and, within these group, prevalence of those patients with advanced chronic disease (CCP-ACD) has not been yet established.The objectives of this study are 1) to determine the population prevalence of patients with chronic diseases and complex care needs (CCP and CCP-ACD), according to the construct based on clinical judgment and broad criteria, encompassing clinical and psychosocial variables, promoted by the CPCP in an urban population, 2) to describe the frequency and distribution of CPCP criteria for identifying patients with chronic diseases and complex care needs, and 3) to identify CPCP criteria that predict complexity.Methods: Population-based cross-sectional study based on information contained in the morbidity database of Catalonia in 2015 and professional electronic medical records. Setting: three primary care urban practices placed in Sabadell (Barcelona) belonging to the Catalan Institute of Health (ICS). According to this database, population with CRG≥5 and older than 14 years old (24762 inhabitants) were reviewed and CCP and CCP-ACD were identified and coded in the Shared Clinical Record of Catalonia, a common technological platform accessible to all providers of public health network.Study population is that which was recorded by healthcare professionals as CCP and CCP-ACD in the Shared Clinical Record of Catalonia on 30th September 2015.We will characterize chronic patients and compare the characteristics of people with and without complex care needs, according to professionals’ criteria by using chi-square or t-student tests, as appropriate. We will also compare the characteristics of primary care professionals who report the highest versus the lowest proportions of patients with complex care needs. We will construct a multivariate logistic regression model to identify independent predictors of professional-defined patient complexity with the following steps: a) selection of variables that predict complex care needs identified according to professionals’ criteria (bivariate analysis); b) process of model construction (likelihood ratio test) and c) validation of its predictive ability (goodness of fit) using discrimination index (C statistic) and index calibration (Hosmer-Lemeshow). In addition, there will be a logistic regression tree and, as an exploratory way, a multivariate factor analysis will be performed.Results: (progress report) The identification and data collection was carried out between 1st July and 30th September 2015. It is expected to have the results of the study in February 2016.Discussion: Patient complexity is probably a multifaceted concept not fully captured by the number or type of medical conditions or by previous health care costs. The data provided by this study will allow to characterize the complexity beyond the risk-adjustment tools that, according to available evidence, are not enough to identify people with chronic complex care needs. This research can also help for a deeper understanding of the multiple sources of patient complexity and their interactions.Conclusion: Not applicable

Patients with chronic kidney disease (CKD) are at an increased risk of developing hyperkalemia, which can be potentially life threatening. Hyperkalemia is frequently encountered with renin-angiotensin-aldosterone system inhibitor (RAASi) therapy use in patients with CKD and often results in the underdosing or discontinuation of these drugs. RAASi therapy has been proven to delay the progression of CKD, ameliorate proteinuria, and reduce the overall risk of cardiovascular morbidity and mortality. Patiromer is a sodium-free, potassium-binding polymer used for the treatment of hyperkalemia. We present a case series of four patients with Stage 4 or 5 CKD in whom the initiation of dialysis was delayed with the use of patiromer. For one patient, dialysis was delayed by 18 months, whereas the remaining three patients, in whom hyperkalemia was one of the main complications, remain dialysis independent to date.

Hyperkalemia is a common electrolyte abnormality in patients with CKD, which is associated with worse outcomes and limits use of renin-angiotensin-aldosterone system inhibitors (RAASi). This post hoc subgroup analysis of three clinical trials evaluated the efficacy and safety of the sodium-free, potassium-binding polymer, patiromer, for the treatment of hyperkalemia in adults with nondialysis CKD. Data from the 4-week treatment periods of AMETHYST-DN, OPAL-HK, and TOURMALINE studies were combined. Patients had baseline diagnosis of CKD, hyperkalemia (serum potassium >5.0 mEq/L), and received patiromer 8.4-33.6 g/day. Patients were stratified by baseline eGFR into two subgroups: severe/end-stage CKD (stage 3b-5; eGFR <45 ml/min per 1.73 m2) and mild/moderate CKD (stage 1-3a; eGFR ≥45 ml/min per 1.73 m2). Efficacy was assessed by the change in serum potassium (mean±SE) from baseline to week 4. Safety assessments included incidence and severity of adverse events (AEs). Efficacy analyses (n=626; 62% male, mean age 66 years) included 417 (67%) patients with severe/end-stage CKD and 209 (33%) with mild/moderate CKD. Most patients were receiving RAASi therapy at baseline (severe/end-stage CKD 92%; mild/moderate CKD 98%). The mean±SE change in serum potassium (baseline to week 4) was -0.84±0.03 in the severe/end-stage CKD subgroup, and -0.60±0.04 mEq/L in the mild/moderate CKD subgroup. AEs were reported for 40% and 27% patients in the severe/end-stage and mild/moderate CKD subgroups, respectively, with 16% and 12% reporting AEs considered related to patiromer. The most frequent AEs were mild-to-moderate constipation (8% and 3%) and diarrhea (4% and 2%). AEs leading to patiromer discontinuation occurred in 6% and 2% of patients with severe/end-stage CKD, and mild/moderate CKD, respectively. Patiromer was effective for treatment of hyperkalemia and well tolerated in patients across stages of CKD, most of whom were receiving guideline-recommended RAASi therapy.

Meaningful and high-quality interactions between people with COPD and healthcare professionals are essential to accomplish effective and efficient self-management. This study’s aim was to explore how people with COPD experience COPD-related interactions with healthcare professionals in primary care, and how these interactions influence their self-management and how they cope with their disease. Interviews were performed with eight women and five men with COPD, and grounded theory guided data collection and analysis. The analysis resulted in a theoretical model and the core category (Re)acting in an ambiguous interaction, representing a dynamic process in which healthcare priorities, healthcare professionals’ attitudes and participants’ personal emotions were important for the participants’ experiences of interactions, and how they managed and coped with their disease. Mutually respectful and regular relationships with healthcare professionals, along with a personal positive view of life, empowered and facilitated participants to accept and manage their disease. In contrast, experiences of being deprioritized and not taken seriously, along with experiences of fear and stigma, disempowered and inhibited participants in making healthcare contacts or forced them to compensate for experienced insufficiencies in primary care. In order to facilitate meaningful and high-quality interactions and enhance patient-provider partnerships in primary care, there is a need to improve the status of COPD, as well as to increase competence in COPD management among healthcare professionals and support the empowerment of people with COPD. Findings from this study could guide the implementation of improved self-management support in primary care for COPD and other chronic conditions.

EDITOR—Brassey et al in their paper describe the ATTRACT project in Wales, which received 193 queries from general practitioners in a period of 13 months.1 Many of these entailed therapeutics....

ABSTRACTBackgroundSodium and calcium polystyrene sulfonate (SPS/CPS) cation-exchange resins have had long-standing clinical use for hyperkalemia in patients with chronic kidney disease (CKD). However, uncertainty exists regarding the real-world usage of SPS/CPS for acute and chronic management of hyperkalemia. We evaluated the prescription patterns of SPS/CPS and their impact on renin–angiotensin–aldosterone system inhibitor (RAASi) treatment in patients with CKD Stages G3–G5 after an episode of de novo hyperkalemia.MethodsWe conducted a retrospective cohort study using population-level administrative databases in Manitoba, Canada, which included adults with CKD and a RAASi prescription who had an episode of de novo hyperkalemia (≥5.5 mmol/L) between January 2007 and December 2017.ResultsA total of 10 009 individuals were included in our study cohort. Among the study population, 4% received an SPS/CPS prescription within 30 days of their hyperkalemia episode. Of those, 22% received a 1-day supply of SPS/CPS and 7% received a prescription for more than 30 days. There were 8145 patients using RAASi at baseline who survived 90 days after their first hyperkalemia episode. Of those, 1447 (18%) discontinued their RAAS inhibitor and 339 (5%) received a prescription of SPS/CPS. Also, the proportion of patients who discontinued their RAASi was similar among those who did and did not receive a prescription of SPS/CPS.ConclusionIn patients with CKD receiving RAASi therapy, there is a low frequency of SPS/CPS prescription after an episode of hyperkalemia. RAASi discontinuation or downtitration is the most used pharmacologic approach for the management of hyperkalemia, a strategy that deprives patients of the cardiac and renal protective benefits of RAASi. New options for the management of hyperkalemia in this population are needed.