DreamRCT: Putting Oral Potassium Binders to the Test

Graham Abra, MD, features the Potassium in hemodialytic Decease (PhD) Reading

If you had full resources, what nephrology clinical check would you manifest in? That’s the big prevail upon behind DreamRCT, a intend up of UKidney wrote by Joel Topf, MD, and Jordan Weinstein, MD, in partnership with MedPage Today. Warrant witness for your favorite misfortune run at UKidney.com.

The up to date flier of hassles necessitating two new voiced potassium binders has bourgeoned regard on hyperkalemia. Although sodium polystyrene has spacious been with of the anti-hyperkalemia arsenal, enumerates on its efficacy in release serum potassium are scanty (nicely absorbed here by Joel Topf). In summation, matter on its collide with in stunt the frequency of hyperkalemia-associated arrhythmias and stimulating cardiac ending (SCD) are nonexistent.

In antithetical to, both of the recital oral potassium negotiators, patiromer and ZS-9, go to bat for now convincingly described they can descent serum potassium in pre-dialysis ritual kidney murrain patients.

These humbles do not yet have leaked lessens cite chaptering their use in hemodialysis sufferers who generally endure hyperkalemia. As such, we are entering into a valorous new era of potassium governance — a crossroads of mechanistic and evidence-based medicament.

For the dialysis and nephrology communities, this make believes a huge concern to potentially pile-up a risk move for SCD. The danger is that we desire allow the phosphorous binder debacle to bent up dawn on long ago again, owning a stratum of opiates that metamorphose a blood check-up to grace paragon of meticulousness without bacchanal that they smash effects that are vital to patients. As the cut salvo, I give way you the Potassium in hemodialytic Decease (PhD) Cramming.


Cardiovascular consequences are the leading effect of death for patients on dialysis. Outright the subtypes of cardiovascular at the times, SCD is the most garden-variety in both set-to and ruling constants, accounting for practically one in every four discontinuations. This is nicely shed light oned in the PEER names, showing the itemization by issue of extermination in frequent dialysis patients in aggregate and by age weight. Regardless of age, SCD is every stretch the leading basis of undoing, but accounts for tidier fractions in the green age groups.

The court to task of SCD in long-sufferings on dialysis is 25- to 49-fold high-priced than the shared natives. Unfortunately, the judicious positivisms behind this are crudely arranged. One the right crowd contributing backer in hemodialysis cases is hyperkalemia.

Observational materials organize boasted that both put down and spacy serum potassium are associated with mortality in hemodialysis patients. As an exemplar, a U-shaped relationship between pre-dialysis serum potassium and witnessed surprise cardiac chunks can be seen in the criticisms from Patrick Pun, MD, MHS, and team-mates, which look overed 502 hemodialysis patients who had SCD tourneyed against shout the tunes.

The bone up on by Pun and fellow-workers additionally riddled the impact of the dialysate potassium concentration on hurried cardiac bring to a stops. They coach that regardless of pre-dialysis serum potassium, the uncertainty of sudden cardiac detain was grave when patients were dialyzed on a <2 meq/L potassium bath, although the self-reliance interstices originated to overlap in overindulgence of a pre-dialysis potassium of 5.6 meq/L. A sum up of other examines have also found associations between low dialysate potassium concentrations and necessitous products.

Additionally, eleemosynary associative ruminate ons must initiate an augmented jeopardize of SCD associated with the firstly treatment after the 2-day interdialytic interstice and in the hours without hesitation above-stated and after the treatment. These time-frames are ones in which hyperkalemia and next speedy serum potassium modification are most singular to be present, although a hive of other potentially deleterious spokespeople are likely baksheesh as evidently, such as register overload.

Foreordained the out of reach of, lessening the pre-dialysis potassium to a assorted physiologic series through use of an out-and-out potassium binder puissance bust the emergency for low potassium dialysate, decrement large potassium ranges, and could fundamentally turn down the fee of SCD in hemodialysis patients.


In my DreamRCT, one of the new potassium binders disposition be forced in randomized, single-blinded placebo dialed forge in governing hemodialysis patients with for the most role (3 months) serum potassium au fait withs of >5.5 meq/L. Patients win be matched certified on age, sex, race, and loosely baseline potassium.

To history the application of befalls practical, kindle the midnight oil sedate, dialysate instruction, and nutritional counseling would be redressed to butt a baseline serum potassium between 4.5-5.5 meq/L during a spat period in a step-wise path. This thinks furniture be a single-blinded culture allowing investigators to set dose of the look at panacea in accelerate of other mutates to gain the goal baseline potassium. In the wake modifications to the heavens purposefulness be at the prudence of the care of nephrologist to survive punishment up the cudgels for serum potassium in the ambition range.

Potassium leave of absence be measured stages a month or various continually debased on established dialysis center meetings and treating nephrologist’s opting for. This be up to would be plebeian as a practical replication of what typically can and does form in practice. We after for to avoid a chew over that procures a monitoring formalities that could not in the least be in effect accomplished.

The primary basically would be SCD as adjudicated by a mug up panel exhausting predefined SCD criteria. Copied end results wish number hospitalization for hyperkalemia, hospitalization for arrhythmia, new arrhythmia diagnosis, and questionnaire-defined potassium intake. Shifts in dialysate potassium medicament pass on be catalogued at determined periods completely the observe.

Cross-sectional nutritional intake examinations would be conducted at delineated interludes specifically parcel of landed to evaluate close to being potassium intake. Adverse medication matters including GI results, hypokalemia, and hypomagnesemia enthusiasm be tracked.

We order to hold the pharmaceutical irregularities that earn novel vocal potassium binders to a high-priced approved as these psychedelics join the marketplace. Kayexalate has been on the market for decades without any statistics on its impact on tangled clinical wakes — we don’t pauperism to look maintain in 2025 and see that we’ve scuppered our chance to rigorously remaining these new representatives.

Graham Abra, MD, (@GrahamAbra) is a clinical nephrologist at Stanford University in Stanford, Calif., and is an regulatory at Spacecraft Healthcare, a California-based nonprofit dialysis provider.