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      Chronic hyperkalemia in non-dialysis CKD: controversial issues in nephrology practice

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          Chronic hyperkalemia is a major complication of chronic kidney disease (CKD) that occurs frequently, heralds poor prognosis, and necessitates careful management by the nephrologist. Current strategies aimed at prevention and treatment of hyperkalemia are still suboptimal, as evidenced by the relatively high prevalence of hyperkalemia in patients under stable nephrology care, and even in the ideal setting of randomized trials where best treatment and monitoring are mandatory. The aim of this review was to identify and discuss a range of unresolved issues related to the management of chronic hyperkalemia in non-dialysis CKD. The following topics of clinical interest were addressed: diagnosis, relationship with main comorbidities of CKD, therapy with inhibitors of the renin–angiotensin–aldosterone system, efficacy of current dietary and pharmacological treatment, and the potential role of the new generation of potassium binders. Opinion-based answers are provided for each of these controversial issues.

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          Albuminuria reflects widespread vascular damage. The Steno hypothesis.

          Albuminuria in Type 1 (insulin-dependent) diabetes is not only an indication of renal disease, but a new, independent risk-marker of proliferative retinopathy and macroangiopathy. The coincidence of generalised vascular dysfunction and albuminuria, advanced mesangial expansion, proliferative retinopathy, and severe macroangiopathy suggests a common cause of albuminuria and the severe renal and extrarenal complications associated with it. Enzymes involved in the metabolism of anionic components of the extracellular matrix (e.g. heparan sulphate proteoglycan) vulnerable to hyperglycaemia, seem to constitute the primary cause of albuminuria and the associated complications. Genetic polymorphism of such enzymes is possibly the main reason for variation in susceptibility.
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            Hyperkalemia increases the risk of death and limits the use of inhibitors of the renin-angiotensin-aldosterone system (RAAS) in high-risk patients. We assessed the safety and efficacy of patiromer, a nonabsorbed potassium binder, in a multicenter, prospective trial.
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                Author and article information

                +39 081 2549404 , luca.denicola@unicampania.it
                J Nephrol
                J. Nephrol
                Journal of Nephrology
                Springer International Publishing (Cham )
                7 June 2018
                7 June 2018
                : 31
                : 5
                : 653-664
                [1 ]Division of Nephrology, University of Campania, Piazza L. Miraglia, 1, 80138 Naples, Italy
                [2 ]Nephrology and Dialysis Unit, Parodi-Delfino Hospital, Colleferro, Rome, Italy
                [3 ]ISNI 0000 0001 2151 3065, GRID grid.5606.5, Nephrology, Dialysis and Transplantation, , University of Genoa and Policlinico San Martino, ; Genoa, Italy
                [4 ]ISNI 0000 0004 1757 3729, GRID grid.5395.a, Department of Clinical and Experimental Medicine, , University of Pisa, ; Pisa, Italy
                [5 ]Nephrology Unit, Azienda USL Toscana Nord Ovest, Leghorn, Italy
                © The Author(s) 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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