Sustained potassium control and recurrent hyperkalemia during individualized potassium-guided sodium zirconium cyclosilicate titration in maintenance hemodialysis: a post hoc analysis of a randomized trial
Year: 2026
Type: article
Abstract: BACKGROUND: A mean predialysis potassium value at a single visit does not show whether the same patient remains controlled across consecutive months or repeatedly crosses hyperkalemic thresholds. We evaluated sustained patient-level potassium control and recurrent hyperkalemia during individualized potassium-guided sodium zirconium cyclosilicate (SZC) therapy on non-dialysis days. METHODS: This exploratory post hoc analysis used data from a previously reported single-center, open-label randomized trial of 116 patients with chronic hyperkalemia (58 per group). The primary outcome was sustained response during months 3-6, which required all four scheduled predialysis potassium measurements after the long interdialytic interval to be available, at least three of the four values to be within 4.0-5.0 mmol/L, and no unplanned hemodialysis triggered by potassium ≥ 6.5 mmol/L during the evaluation period. Missing measurements were classified as nonresponse. Adjusted risk ratios (aRRs) were estimated using modified Poisson regression with robust standard errors. RESULTS: The primary outcome occurred in 25/58 (43.1%) SZC-treated participants and 8/58 (13.8%) controls (aRR 3.02, 95% confidence interval [CI] 1.49-6.14). Sustained response within 4.0-5.5 mmol/L occurred in 38/58 (65.5%) and 22/58 (37.9%), respectively (aRR 1.74, 95% CI 1.19-2.54). At least two scheduled potassium values ≥ 5.5 mmol/L occurred in 11/58 (19.0%) and 36/58 (62.1%) (aRR 0.31, 95% CI 0.18-0.55). The adjusted incidence rate ratio for visits with potassium ≥ 5.5 mmol/L was 0.36 (95% CI 0.24-0.54). Complete-case and conservative extreme-case missing-data analyses were directionally consistent with the main analysis. CONCLUSIONS: Individualized potassium-guided SZC therapy was associated with a higher probability of meeting the sustained biochemical potassium-control criterion at scheduled monthly measurements and with fewer recurrent biochemical hyperkalemic excursions. Clinical outcomes were not evaluated in the present analysis; therefore, the observed biochemical improvements should not be interpreted as evidence of clinical benefit. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR2600119050. Registered on 14 February 2026; retrospectively registered.
Source: BMC Nephrology
Authors: Haiming Wang, Wei Zhou, Yan Jiang
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $3,090
OpenAlex ID: W7221521828