Concerns about hyperkalemia may result in the under-utilization of established and novel therapies that improve kidney and/or cardiovascular outcomes in patients with type 2 diabetes (T2D) and chronic kidney disease (CKD). Hyperkalemia-related issues are of particular relevance in patients with CKD who are commonly on other hyperkalemia-inducing agents such as renin-angiotensin-aldosterone system inhibitors (RAAS inhibitors), and non-steroidal mineralocorticoid receptor antagonists (ns-MRA). In contrast, sodium-glucose transporter-2 (SGLT2) inhibitors mitigate the risk of serious hyperkalemia in clinical trials. We aim to review recent evidence surrounding the risk of hyperkalemia in patients with T2D, and CKD treated with established and novel therapies for diabetic kidney disease (DKD), focusing on SGLT2 inhibitors and ns-MRA. We conclude that SGLT2 inhibitors can be used safely in patients with T2D at high cardiovascular risk and with CKD without increasing the risk of hyperkalemia. Routine potassium monitoring is generally required when finerenone is used as a kidney and cardiovascular protective agent in patients with T2D. Based on existing data, when added to the standard of care, combining SGLT2 inhibitors with finerenone is safe and has the potential to exert additional cardiorenal benefits in patients with DKD. The use of potassium binders should be considered to enable optimal doses of guideline-based therapies for patients with DKD to maximize the kidney and cardiovascular benefits.
Copyright © 2023. Published by Elsevier Inc.