---
title: "Nephrologists’ approaches to hyperkalaemia and RAASi preservation in Spain"
id: "plos-one-23-navigating-the-potassium-dilemma-a-qualitative-study-of-nephrologists"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-23-navigating-the-potassium-dilemma-a-qualitative-study-of-nephrologists"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354854"
published_at: "2026-07-30T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Nephrologists’ approaches to hyperkalaemia and RAASi preservation in Spain
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-23-navigating-the-potassium-dilemma-a-qualitative-study-of-nephrologists
- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354854)
- **Published At:** 2026-07-30T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This qualitative study used semi-structured interviews with 12 practising nephrologists across six Spanish autonomous communities to explore management of **hyperkalaemia** in predialysis chronic kidney disease (CKD stages 3–5). - Investigators sought clinicians with experience prescribing both traditional resins and at least one newer binder (patiromer or **sodium zirconium cyclosilicate**). - Interviews were transcribed verbatim and analysed using ATLAS.ti with a codebook-based thematic approach, producing 15 sub-themes grouped into five overarching themes. - Theme 1: Nephrologists described using a structured clinical algorithm—dietary measures, correction of metabolic contributors, diuretics, and pharmacotherapy—to manage hyperkalaemia and attempt **RAASi** continuation when possible. - Theme 2: Newer potassium binders (patiromer and SZC) were perceived as more effective and better tolerated than traditional resins, and seen as tools that support continued RAASi therapy. - Theme 3: System-level barriers—mandatory prior authorisation (_visado_), regional formulary differences, and fragmented inter-specialty communication—limited timely access to newer binders and were thought to contribute to RAASi dose reduction or discontinuation. - Theme 4: Patient engagement (clear communication, trust, nursing-led education) promoted adherence; clinician confidence with nutritional counselling varied across participants. - Theme 5: Hyperkalaemia and its management affected patients’ daily functioning and emotional well-being, but formal assessment of **HRQoL** was uncommon in routine practice. - Authors conclude that nephrologists prioritise preservation of RAASi therapy; while newer binders support this goal, access and coordination challenges restrict their use. - The study emphasises system and process improvements—streamlined access pathways, better multidisciplinary communication, and routine HRQoL assessment—to enable more patient-centred, guideline-concordant care. - As a qualitative study, findings reflect clinicians’ perspectives and not direct evidence of clinical or economic effectiveness.
## Clinical Analysis & Structured Key Points
Navigating the potassium dilemma: a qualitative study of nephrologists’ strategies for renin–angiotensin–aldosterone system inhibitor preservation and hyperkalaemia management in Spain | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Reader Comments Figures Figures Abstract Background Hyperkalaemia is a common complication among patients with predialysis chronic kidney disease (CKD) and a leading reason for modifying or discontinuing renin–angiotensin–aldosterone system inhibitor (RAASi) therapy despite its proven cardiorenal benefits. Although newer potassium binders may improve potassium control while enabling RAASi use, real clinical practice remains poorly characterised. This study explored how nephrologists in Spain manage hyperkalaemia in patients with predialysis CKD (stages 3–5), with particular emphasis on RAASi continuation. Methods Semi-structured interviews were conducted with 12 practising nephrologists across Spain who routinely manage hyperkalaemia in patients with predialysis CKD. Interviews were transcribed verbatim and analysed using ATLAS.ti. A codebook-based thematic analysis was performed, with codes iteratively refined into 15 sub-themes and grouped into five overarching themes. Results Five themes were identified: (1) hyperkalaemia was managed using a structured clinical algorithm incorporating dietary, metabolic, diuretic, and pharmacological strategies, to preserve RAASi therapy where possible; (2) newer potassium binders (patiromer and sodium zirconium cyclosilicate) were viewed as effective and better tolerated than traditional resins, supporting greater RAASi continuity; (3) system-level barriers, including visado requirements, regional formulary variation, and fragmented communication across specialties, limited timely use of newer binders were perceived to contribute to RAASi discontinuation; (4) patient engagement, underpinned by clear communication, trust, and nursing-led education, facilitated adherence, although clinician-level nutrition expertise varied; and (5) hyperkalaemia management affected patients’ daily functioning and emotional well-being, yet formal assessment of health-related quality of life (HRQoL) was infrequent. Conclusions Nephrologists in Spain prioritised preservation of RAASi therapy when managing hyperkalaemia in predialysis CKD. Although newer potassium binders supported this objective, their use was limited by access and care coordination challenges. Streamlined access pathways, improved multidisciplinary communication, and routine HRQoL assessments may enable more patient-centred and guideline-concordant care. These implications reflect qualitative clinician perspectives rather than evidence of clinical or economic effectiveness. Citation: Gimenez-Stamminger N, Mateus C, Mason T, Harding A (2026) Navigating the potassium dilemma: a qualitative study of nephrologists’ strategies for renin–angiotensin–aldosterone system inhibitor preservation and hyperkalaemia management in Spain. PLoS One 21(7): e0354854. https://doi.org/10.1371/journal.pone.0354854 Editor: Mogamat-Yazied Chothia, Stellenbosch University Faculty of Medicine and Health Sciences, SOUTH AFRICA Received: March 3, 2026; Accepted: July 13, 2026; Published: July 30, 2026 Copyright: © 2026 Gimenez-Stamminger et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The data underlying the findings of this study consist of qualitative interview transcripts with practising nephrologists. Due to the potentially identifiable nature of qualitative data and to protect participant confidentiality, the full transcripts cannot be made publicly available. De-identified excerpts supporting the findings are included within the manuscript. De-identified data may be made available upon reasonable request to the corresponding author, subject to review and approval by the Faculty of Health and Medicine Research Ethics Committee, Lancaster University, and in accordance with participant consent and applicable data protection regulations. Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Introduction Hyperkalaemia is a common and potentially life-threatening electrolyte disturbance in patients with predialysis chronic kidney disease (CKD; stages 3–5) [ 1 ]. Impaired renal potassium excretion, together with comorbidities such as heart failure and diabetes and the widespread use of renin–angiotensin–aldosterone system inhibitors (RAASis), increases both the incidence of hyperkalaemia and the risk of adverse outcomes [ 2 ]. Observational studies indicate that elevated serum potassium concentrations (commonly defined as ≥5.1 mmol/L) are associated with higher mortality, cardiovascular events, and renal disease progression [ 3 , 4 ]. This creates a clinical conflict, often referred to as the “potassium dilemma.” The cardiovascular and renal benefits of RAASi therapy, including angiotensin-converting enzyme inhibitors (ACEis), angiotensin receptor blockers (ARBs), and steroidal and non-steroidal mineralocorticoid receptor antagonists, are supported by high-quality evidence and recommended in clinical guidelines [ 5 – 8 ]. These guidelines also advise using the highest tolerated doses of RAASi for optimal therapeutic effect [ 9 , 10 ]. However, real-world data suggest that RAASi doses are frequently reduced or discontinued following the development of hyperkalaemia [ 11 , 12 ]. Discontinuing RAASi has been associated with increased mortality and adverse cardiorenal outcomes compared with continued maximal therapy [ 13 – 16 ]. Therefore, strategies that prevent hyperkalaemia and support continued optimal RAASi therapy are of therapeutic interest. Potassium binders, including sodium polystyrene sulfonate, calcium polystyrene sulfonate (CPS), and the more recently approved sodium zirconium cyclosilicate (SZC) and patiromer, effectively reduce excess potassium ions by binding them in the gastrointestinal tract [ 17 ]. CPS use has been limited by variable serum potassium-lowering effects and a higher incidence of gastrointestinal adverse events [ 18 , 19 ]. In contrast, patiromer and SZC have demonstrated improved tolerability and effectiveness in managing serum potassium [ 20 – 24 ]. Evidence suggests that patiromer enables continued RAASi therapy in patients with CKD, heart failure, and hypertension by reducing serum potassium [ 21 , 23 , 25 – 30 ], whereas SZC optimises RAASi in smaller patient cohorts [ 31 ]. Recent real-world data from the United States, Japan, and Spain indicate that longer outpatient treatment with SZC is associated with a higher likelihood of continued RAASi therapy, although the protective effect diminishes following SZC discontinuation [ 32 ]. The efficacy of these agents is established; however, their use in routine clinical practice remains poorly understood. This is particularly relevant in Spain, where the National Health System provides universal healthcare coverage, but access to newer potassium binders is subject to specific administrative controls, including visado , a mandatory prior authorisation process for selected medicines that may delay or restrict prescribing in routine practice [ 33 ]. Understanding how nephrologists experience and respond to these access conditions is important because administrative and organisational factors may influence whether evidence-based therapies can be implemented consistently in everyday care. In this study, we explored nephrologists’ perspectives and clinical decision-making when managing hyperkalaemia among patients with predialysis CKD (stages 3–5) in Spain. Specifically, we examined how clinicians navigate the “potassium dilemma,” including their rationale for continuing or down-titrating RAASi, perceptions of potassium binders, and the influence of system-level constraints, patient-related factors, and perceived health-related quality-of-life (HRQoL) considerations. As this was a qualitative study, the objective was not to estimate treatment effects or test statistical associations, but to characterise clinicians’ experiences, reasoning, and perceived barriers in routine practice. Materials and methods Study design We conducted a qualitative study using semi-structured interviews to explore nephrologists’ perspectives on the management of hyperkalaemia in patients with predialysis CKD (stages 3–5) in Spain. A qualitative approach was used to capture the clinical reasoning, perceived barriers to optimal treatment, and contextual factors influencing the use of RAASi and newer potassium binders. The study did not involve recruitment of patients or collection of patient-level clinical outcome data; instead, it focused on clinicians’ experiences and decision-making in routine practice. Accordingly, no inferential statistical analyses, hypothesis testing, confidence intervals, or multivariable models were planned or conducted. This study is reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [ 34 ]. Participants Participants were eligible if they: 1) were practising nephrologists based in Spain; 2) were directly involved in the management of patients with CKD (stages 3–5); 3) had experience treating hyperkalaemia; 4) had ≥ 3 years of independent clinical practice; and 5) had documented experience prescribing traditional resins and at least one of the newer potassium binders (patiromer and/or SZC) within the previous 12 months. Nephrologists without regular direct patient-care responsibilities or prescribing experience in both binder classes (traditional and newer) were excluded. As participants were clinicians rather than patients, eligibility criteria were based on professional role, clinical experience, prescribing experience, and direct involvement in the management of predialysis CKD and hyperkalaemia. Purposive sampling was used to include participants with varying years of clinical experience, practice settings, and geographical locations to capture diverse perspectives on regional health administration. Participants were recruited from six autonomous communities (Andalusia, Castilla-La Mancha, Castilla y León, Catalonia, Madrid, and Valencia), representing different regional health systems. The sample included clinicians from universities and general hospitals. Potential participants were identified through professional networks and invited via email. Interested clinicians received a participant information sheet outlining the study objectives, procedures, confidentiality, and terms of voluntary participation. Twelve nephrologists provided written informed consent and completed interviews. Recruitment ceased when the research team determined that data sufficiency had been reached, defined as the point at which no substantially new concepts emerged. The sample size was therefore justified on qualitative grounds, based on purposive sampling, diversity of participant characteristics, and the stability of emerging themes across interviews rather than statistical power. Participants’ demographics are summarised in Table 1 . Download: PNG larger image TIFF original image Table 1. Characteristics of the participants (N = 12). https://doi.org/10.1371/journal.pone.0354854.t001 Data collection A semi-structured interview guide was iteratively developed to elicit nephrologists’ experiences and decision-making processes when managing hyperkalaemia in patients with predialysis CKD (stages 3–5). The guide was informed by a review of the published literature and informal clinical discussions with practising nephrologists regarding the management of hyperkalaemia in predialysis CKD. We pilot-tested the guide with two nephrologists to assess the relevance and clarity of the interview questions and prompts. Following the pilot interviews, minor refinements were made, primarily involving wording adjustments to improve clarity and the addition of probes exploring access to newer potassium binders and multidisciplinary communication. Data from the pilot interviews were excluded from the analysis. The final interview guide ( S1 File ) invited clinicians to reflect on: (1) their overall clinical approach to hyperkalaemia management; (2) the use and sequencing of dietary, pharmacological, and procedural interventions; (3) their experience prescribing traditional resins and newer potassium binders; (4) approaches to maintaining or adjusting RAASi therapy; (5) health-system or organisational factors influencing treatment decisions; and (6) patient-level considerations, including education, treatment adherence, and the perceived impact of hyperkalaemia management on HRQoL. Demographic information (including years in practice, primary clinical setting, and geographical region) was collected via a brief electronic screener completed prior to the interview. Interviews were conducted in Spanish in October 2025 by a trained qualitative researcher via video conference. Each interview was held in a private setting, lasted approximately 45–60 min, and began with oral confirmation of informed consent. Interviews were digitally recorded and professionally transcribed verbatim. Transcripts were subsequently reviewed, cleaned, and pseudonymised by the research team prior to analysis. Analysis was conducted using the Spanish-language transcripts; illustrative quotations selected for publication were translated into English after analysis to preserve the meaning of participants’ accounts. Analysis A thematic analysis following the six-phase approach described by Braun and Clarke [ 35 ], adapted for a structured, team-based codebook, was employed. This approach combined inductive coding grounded in the data with deductive coding informed by the study objectives and prior literature, and is commonly used in applied health research to enhance analytic transparency and consistency [ 36 , 37 ]. The transcripts were imported into ATLAS.ti version 25 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). Two researchers independently coded an initial subset of transcripts to develop a draft codebook that combined inductive codes derived from the data and deductive codes reflecting predefined areas of interest (such as RAASi management and binder use). The initial coding subset was used to assess consistency in code interpretation and to refine code definitions, inclusion and exclusion criteria, and illustrative examples. Coding discrepancies were resolved through discussion, and the codebook was iteratively refined during analysis of subsequent transcripts in accordance with the familiarisation, coding, and refinement stages of thematic analysis. Once the codebook had been stabilised, the remaining transcripts were coded using the agreed coding framework, with additional team discussions held when new or ambiguous concepts emerged. During the formal analysis phase, codes were compared within and across interviews to identify patterns and conceptual relationships. Through systematic comparison and team discussions, codes were grouped into higher-order categories and developed into overarching themes consistent with established approaches to thematic analysis in qualitative health research [ 38 ]. After code consolidation, 30 final codes were organised into 15 sub-themes and five overarching themes, reflecting clinical, system-level, and patient-centred aspects of hyperkalaemia management. Rigour was supported through peer debriefing, maintenance of an audit trail documenting coding decisions and theme development, and regular reflexive discussions to minimise interpretive bias. The audit trail included successive versions of the codebook, notes on code merging and refinement, and documentation of decisions made during theme development. Reflexive discussions considered how the research team’s prior knowledge of CKD, hyperkalaemia management, and health-system access issues could influence interpretation of the data. Data sufficiency was assessed based on the stability of emerging concepts across interviews, with no substantively new themes identified in later transcripts [ 39 ]. Ethical considerations Data collection began after the research protocol was approved by the Ethics Committee of Lancaster University, United Kingdom (Approval no.: FHM-2025–4671-RECR-4). All participants received a participant information sheet before enrolment and provided written informed consent before taking part in the interview. Transcripts were pseudonymised, and data were stored on secure, access-restricted servers. The study was conducted in accordance with the principles of the Declaration of Helsinki. Data availability statement The data underlying this study consist of qualitative interview transcripts from practising nephrologists in Spain. Full transcripts cannot be made publicly available because they contain potentially identifying contextual information, including participants’ clinical roles, regional practice settings, institutional contexts, and experiences with local access pathways for potassium binders. Given the small number of specialist participants and the specificity of the information provided, complete anonymisation cannot be guaranteed without substantially reducing the interpretive value of the data. To support transparency and reproducibility, four Supporting Information files are provided: the semi-structured interview guide ( S1 File ), the codebook and code frequencies ( S2 Table ), anonymised participant characteristics ( S3 Table ), and anonymised illustrative quotations organised by theme ( S4 Table ). Requests for access to additional de-identified qualitative excerpts may be directed to the corresponding author. Requests will be reviewed in consultation with the research supervisor and, where necessary, the Ethics Committee of Lancaster University, United Kingdom. Access will be considered subject to applicable ethical, legal, and confidentiality requirements, including the terms of participant consent and the approval granted by the Ethics Committee of Lancaster University, United Kingdom. Results Twelve nephrologists from across Spain participated in the study. All practised in hospital-based settings, including university, tertiary, and general hospitals. Three-quarters (75%) of participants had more than 15 years of clinical experience. All were actively involved in treatment decision-making for patients with predialysis CKD (stages 3–5) and recurrent hyperkalaemia. All participants had recent experience prescribing newer potassium binders, with usage in the past year evenly distributed between patiromer (50%) and SZC (50%). Nephrologist interviews averaged 53 min (range: 45–60 min). A total of 30 codes were identified, with their frequencies and distributions provided in S1 Table. Five key themes and 15 subthemes characterising the real-world management of hyperkalaemia in patients with predialysis CKD emerged from the analysis, as summarised in Table 2 . Download: PNG larger image TIFF original image Table 2. Study themes and sub-themes. https://doi.org/10.1371/journal.pone.0354854.t002 Safeguarding cardiorenal protection through stepwise clinical reasoning Nephrologists consistently described hyperkalaemia as an expected and recurrent feature of advanced CKD, rather than an isolated biochemical abnormality. Their accounts reflected a shared clinical logic in which potassium management was embedded within a broader strategy to preserve long-term cardiorenal protection. Rather than reacting to isolated potassium values, clinicians emphasised a structured, step
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