Patiromer Efficacy across Kidney Function and Hyperkalemia Subgroups in Heart Failure and Reduced Ejection Fraction: A DIAMOND Post Hoc Analysis.
Year: 2026
Type: article
Abstract: BACKGROUND: In the DIAMOND (Patiromer for the Management of Hyperkalemia in Subjects Receiving RAASi Medications for the Treatment of Heart Failure) trial, patiromer enabled optimization of renin-angiotensin-aldosterone system inhibitors (RAASi) for patients with heart failure and reduced ejection fraction (HFrEF) and current or recent hyperkalemia. Impaired kidney function substantially increases hyperkalemia risk due to impaired potassium excretion. Therefore, in this post hoc analysis, we examined the efficacy of patiromer across baseline kidney function and hyperkalemia subgroups. METHODS: We classified all patients randomized to patiromer (N=439) or placebo (N=439), after successful run-in optimization, into 4 subgroups according to estimated glomerular filtration rate (eGFR) <45 vs ≥45 mL/min/1.73m2 (trial eligibility criterion: ≥30 mL/min/1.73m2) and baseline hyperkalemia (≤5.0 vs >5.0 mEq/L; trial required K >5.0 or prior RAASi discontinuation for hyperkalemia). RESULTS: Patiromer reduced adjusted mean change in serum potassium (primary outcome) across all subgroups, with the largest effect in patients with eGFR <45 mL/min/1.73m2 and hyperkalemia (-0.28 mEq/L, 95% CI -0.38 to -0.18, P<0.001) and the smallest in those with eGFR ≥45 mL/min/1.73m2 and normokalemia (-0.08 mEq/L, 95% CI -0.12 to -0.04, P<0.001; Pinteraction <0.001). Patiromer reduced time-to-first hyperkalemia consistently across subgroups. Patients with eGFR <45 mL/min/1.73m2 and baseline hyperkalemia derived the numerically greatest effect in prevention of mineralocorticoid receptor antagonist down-titration (hazard ratio 0.39, 95% CI 0.18-0.84, P=0.02) and had the highest win ratio for hyperkalemia-related morbidity-adjusted outcomes (3.03, 95% CI 1.96-4.70, P<0.001). However, Pinteraction values for these secondary endpoints were not statistically significant. CONCLUSIONS: Patiromer reduced serum potassium across baseline kidney function and hyperkalemia subgroups, with greater effect in patients with reduced kidney function and baseline hyperkalemia. These findings suggest potential heterogeneity in potassium-lowering effects of patiromer across subgroups, although the analysis is exploratory and should be considered hypothesis-generating.
Source: PubMed
Authors: Andreas P Kalogeropoulos, Ahmed Mustafa Rashid, Stefan D Anker, Antoni Bayes-Genis, Michael Böhm, Jeffrey Budden, John G F Cleland, Andrew J S Coats, Justin A Ezekowitz, Gerasimos Filippatos, Assen Goudev, Muhammad Shahzeb Khan, JoAnn Lindenfeld, Lars H Lund, Bela Merkely, Robert J Mentz, Marco Metra, Jude Moutchia, Piotr Ponikowski, Elisa L Priest, Patrick Rossignol, Michele Senni, Sandra Waechter, Matthew R Weir, Bertram Pitt, Javed Butler
Institutions: Stony Brook University, Baylor Scott & White Research Institute, Berlin-Brandenburger Centrum für Regenerative Therapien, German Centre for Cardiovascular Research, Charité – Universitätsmedizin Berlin, Centro de Investigación en Red en Enfermedades Cardiovasculares, Hospital Universitari Germans Trias i Pujol, Saarland University, University of Glasgow, The Heart Research Institute, University of Alberta, National and Kapodistrian University of Athens, Medical University of Sofia, Baylor College of Medicine, Heart Hospital Baylor Plano, Vanderbilt University, Vanderbilt University Medical Center, Karolinska University Hospital, Karolinska Institutet, Semmelweis University, Duke University, Duke Medical Center, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Wroclaw Medical University, Inserm, Princess Grace Hospital Centre, Centre Hospitalier Régional et Universitaire de Nancy, French Clinical Research Infrastructure Network, Université de Lorraine, Ospedale Papa Giovanni XXIII, University of Milano-Bicocca, Vifor Pharma (Switzerland), University of Maryland, Baltimore, University of Michigan
Language: English
Subfield: Nephrology
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W7223448770