Interdisciplinary recommendations for recurrent hyperkalaemia: insights from the GUARDIAN-HK European Steering Committee

Recurrent hyperkalaemia (HK) is associated with increased morbidity and mortality, and is common among patients with cardiorenal disease. Many of these patients require renin–angiotensin–aldosterone system inhibitor (RAASi) therapies that further enhance the risk of HK. Every acute HK episode constitutes an opportunity to treat and prevent recurrent HK. This report aims to support multidisciplinary team efforts in managing patients who may be affected by recurrent HK. A panel of nine European experts in the management of HK (four nephrologists, four cardiologists, one internist) reviewed existing guidance and evidence on the diagnosis and management of HK at a face-to-face (26th September 2023) and two virtual meetings (24th January and 14th March 2024). The panel developed 10 consensus recommendations and a management algorithm across three domains: duty of care, identifying patients at risk of HK recurrence and managing the risk of HK recurrence. Early identification and management of those at risk of recurrent HK will improve clinical outcomes but requires an interdisciplinary, co-ordinated approach. Disease-modifying therapies such as RAASi should no longer be considered reversible causes of HK, and efforts should be taken to up-titrate these to guideline-directed target doses even in the setting of an acute HK event. Every acute HK episode constitutes an opportunity to treat and prevent recurrent HK, contributing to long-term clinical benefits. The recommendations, intentionally broad in scope, complement existing management guidelines and plans, fostering a collective responsibility among healthcare professionals managing patients with HK.