Hyperkalemia Management in the US Cohort of the Prospective, Observational, Real-World TRACK Study

The Tracking Treatment Pathways in Adult Patients with Hyperkalemia (TRACK) study demonstrated that clinical practice guidelines for hyperkalemia are inconsistently implemented and a conservative approach to management is often preferred. We report additional analyses focusing on routine clinical practice in the USA. TRACK was an observational prospective cohort study (July 2022–December 2024) including adults in the USA with a recent index hyperkalemia episode (serum potassium [K+] > 5.0 mmol/L ≤ 21 days of enrollment). Primary and secondary data were obtained from participants, their respective healthcare professionals (HCPs), and medical records. Clinical characteristics, hyperkalemia management decisions and rationales, and treatment outcomes over 12 months were evaluated. The final cohort included 229 participants, of whom 66.4% and 30.6% had mild (serum K+ > 5.0 and ≤ 5.5 mmol/L) and moderate (serum K+ > 5.5 and ≤ 6.5 mmol/L) hyperkalemia at baseline, respectively. Only 51.5% of participants received renin–angiotensin–aldosterone system inhibitors (RAASis) at baseline, despite 95.2% having concomitant chronic kidney disease (CKD), heart failure (HF), or both. HCP-reported hyperkalemia management approaches at baseline and month 12, respectively, included monitoring serum K+ levels (79.5%; 79.3%), a low-K+ diet (73.4%; 72.6%), continuation of RAASi therapy (49.8%; 49.0%), and prescription of a K+ binder (28.4%; 15.4%). The most commonly reported rationales for management decisions at baseline and month 12, respectively, were ease of treatment (47.3%; 55.3%), alignment with CKD treatment guidelines (46.4%; 36.7%), and safety (20.7%; 21.1%). Over 12 months, 82.5% of participants achieved K+ normalization (≤ 5.0 mmol/L) at any timepoint. Hyperkalemia recurrence was reported in 32.9% of participants at month 6, 34.2% at month 9, and 28.0% at month 12. This study shows that conservative hyperkalemia management and hyperkalemia recurrence are common in routine practice in the USA. Additionally, among individuals with hyperkalemia at baseline, only half of eligible patients with CKD and/or HF were prescribed RAASi therapy. These data highlight the need for effective strategies to treat hyperkalemia and to improve implementation of guideline-directed therapy for CKD and HF. Graphical Abstract available for this article. ClinicalTrials.gov identifier, NCT05408039 Hyperkalemia is a condition caused by elevated blood potassium levels, which can cause cardiac dysfunction. Clinical practice guidelines recommend renin–angiotensin–aldosterone system inhibitor (RAASi) medications for patients with chronic kidney disease, heart failure, or both; however, RAASi medications can cause hyperkalemia. Under these circumstances, guidelines indicate that dose reduction or discontinuation of RAASi treatment should not occur unless alternative management strategies to reduce hyperkalemia do not work. The TRACK study used data collected over 12 months from medical records of participants with recent hyperkalemia and their healthcare professionals to understand treatment decisions, the reasons for those choices, and participant outcomes in routine clinical practice. These analyses focus on findings from the USA. At the start of the study, only about half of participants were receiving RAASi medications, despite most having chronic kidney disease, heart failure, or both. The study found that healthcare professionals often managed hyperkalemia with a conservative approach (no hyperkalemia treatment, monitoring potassium levels, or a low-potassium diet). Fewer than one-third of participants were prescribed a potassium binder, a treatment that helps lower potassium levels. Although potassium levels returned to normal at some point for most participants during the 12-month follow-up, hyperkalemia often returned. These findings suggest that treatment guidelines for hyperkalemia are not always fully applied in routine clinical practice in the USA. They also highlight the need for more proactive and long-term management of hyperkalemia.