Nephrologists in this study described a stepwise, structured approach to managing hyperkalaemia in patients with predialysis chronic kidney disease (CKD stages 3–5). Management began with non-pharmacological measures such as dietary review and correction of metabolic contributors, progressed to optimization of diuretics and other supportive measures, and then to pharmacological interventions when required. The overriding clinical priority reported by participants was to preserve RAASi therapy where possible because of its established cardiorenal benefits. Decisions to down-titrate or discontinue RAASi were presented as last-resort options after exhausting preventative and corrective strategies.
Clinical algorithms reported by participants therefore combined multiple domains—nutrition, fluid and electrolyte management, medication review, and targeted pharmacotherapy—rather than relying on a single intervention. The interviews emphasised individualized decision-making, weighing serum potassium levels, trends over time, comorbidities, and perceived risks versus benefits of continuing RAASi at target doses.
Participants contrasted traditional resins (for example, sodium polystyrene and calcium polystyrene sulfonate) with the newer agents patiromer and sodium zirconium cyclosilicate (SZC). Nephrologists commonly reported that patiromer and SZC were more predictable in their potassium-lowering effects and better tolerated than older resins. These newer binders were described as practical tools to maintain lower serum potassium and thereby facilitate the continuation or up-titration of RAASi therapy when clinically indicated.
Clinicians framed the newer binders as complementary to the broader management algorithm: used once conservative measures were insufficient or when hyperkalaemia recurred despite earlier interventions. While participants reported clinical confidence in the efficacy and tolerability of patiromer and SZC, the decision to prescribe these agents was influenced by access considerations and administrative requirements (see system-level barriers).
A recurrent theme was the impact of organisational and administrative factors on treatment choices. In Spain, participants identified visado—a mandatory prior authorisation process for selected medicines—as a practical impediment that could delay or restrict prescribing of newer potassium binders. Regional variation in formularies across autonomous communities and inconsistent criteria for access were also noted.
Fragmented communication and coordination between specialties (for example, nephrology, primary care, and cardiology) were cited as challenges that could lead to suboptimal timing of interventions or defaulting to RAASi reduction/discontinuation. Together, these system-level constraints were perceived by nephrologists to contribute to treatment decisions that prioritize immediate safety (reducing potassium) at the expense of maintaining evidence-based RAASi therapy.
Clinicians stressed the role of patient engagement in effective hyperkalaemia management. Clear clinician–patient communication, establishing trust, and nursing-led education programmes were described as facilitators of adherence to dietary and medication plans. Participants reported variability in clinician-level expertise and confidence in providing detailed nutritional counselling; in some settings, dietitians or nurses provided structured support, while in others the nephrologist assumed the role.
Interviewees linked strong patient education to fewer recurrence episodes and better ability to maintain RAASi therapy. Nonetheless, barriers included limited time in clinic, inconsistent access to multidisciplinary support, and variability in patients’ ability or willingness to follow dietary recommendations.
Nephrologists reported that hyperkalaemia and its management affected patients’ daily lives and emotional wellbeing, influencing diet, social activities, and anxiety about medication changes. Despite these observations, formal assessment of health-related quality of life (HRQoL) was infrequent in routine practice according to participants. Most clinicians relied on informal discussion and clinical judgement rather than structured HRQoL instruments.
Participants suggested that routine HRQoL assessment could better capture the patient-centred impact of hyperkalaemia and treatment decisions, informing shared decision-making and potentially guiding prioritisation of interventions such as newer binders when appropriate.
This study used semi-structured interviews with 12 practising nephrologists recruited purposively from six autonomous communities in Spain (Andalusia, Castilla‑La Mancha, Castilla y León, Catalonia, Madrid, and Valencia). Eligible clinicians had at least three years of independent practice and recent prescribing experience with both traditional resins and at least one newer binder (patiromer or SZC).
Interviews were audio-recorded, transcribed verbatim, and analysed using ATLAS.ti. The research team applied a codebook-based thematic analysis: codes were iteratively refined into 15 sub-themes and grouped into five overarching themes. Recruitment ceased when the researchers judged that no substantially new concepts were emerging, a qualitative criterion for data sufficiency.
The study reported adherence to the Consolidated Criteria for Reporting Qualitative Research (COREQ) and explicitly focused on clinician perspectives and decision-making rather than measuring clinical outcomes or testing hypotheses.
Nephrologists prioritised the preservation of RAASi therapy when managing hyperkalaemia in predialysis CKD. Newer potassium binders (patiromer and SZC) were valued for their tolerability and role in supporting RAASi continuity, but access to these agents was constrained by administrative processes (including visado), regional formulary variability, and care coordination issues. Participants recommended system-level improvements—streamlined access pathways, enhanced multidisciplinary communication, and more consistent use of HRQoL assessment—to enable more patient-centred and guideline-concordant care.
The authors emphasise that these conclusions reflect clinicians’ experiences and perceptions; the study does not provide direct evidence of clinical or economic effectiveness of specific management strategies.
As a qualitative study, findings describe clinicians’ perspectives and are not intended to estimate treatment effects or establish causal relationships. The sample comprised 12 nephrologists selected purposively to represent geographic and practice diversity; results may not generalise to all clinicians or health systems. Full interview transcripts are not publicly available to protect participant confidentiality; de-identified excerpts are included in the manuscript, and de-identified data may be available on reasonable request subject to ethical review and consent provisions stated by the authors.