Patient and Clinician Perspectives on Hyperkalemia Management Under Cardio-Kidney-Protective Therapy: A Three-Stakeholder Cross-Sectional Survey

Abstract

Background

Maintaining renin–angiotensin system inhibitor (RASi) and mineralocorticoid receptor antagonist (MRA) therapy in patients with hyperkalemia is now favored by contemporary guidelines, yet the perspectives of patients and clinicians on this shift have rarely been examined in parallel.

Methods

We conducted three parallel descriptive cross-sectional surveys in Korea between April and May 2026: a patient survey distributed through a kidney-disease patient community; a nephrologist survey; and a multispecialty physician survey. Patients, nephrology specialists, and multispecialty physicians were analyzed separately and in a combined nephrologist-versus-non-nephrologist comparison.

Results

A total of 125 patients, 82 nephrologists, and 255 multispecialty physicians completed the survey. Patient awareness of hyperkalemia was high (perceived risk, 3.97; 95% confidence interval, 3.84–4.10). More patients preferred potassium-lowering medication (68.8%) over strict dietary control (31.2%) for hyperkalemia management. Clinicians rated maintenance of RASi and MRA as 3.81 (3.72–3.90) and 3.47 (3.37–3.56), respectively; nephrologists rated maintenance as more important than non-nephrologists for both classes (p < 0.001 for RASi, p = 0.006 for MRA). For long-term outpatient hyperkalemia, nephrologists most often endorsed prescribing a potassium binder (68.2%), while non-nephrologists most often endorsed reducing or discontinuing the culprit drugs (55.5%).

Conclusion

Patients preferred to maintain cardio-kidney-protective therapy. A specialty gap in this preference was observed between nephrologists and non-nephrology clinicians, indicating a need to broaden clinician awareness of the full spectrum of hyperkalemia management options, including the more active use of potassium-lowering agents.

INTRODUCTION

Hyperkalemia is one of the most common electrolyte abnormalities in clinical practice in patients with chronic kidney disease (CKD) [1]. Its prevalence rises with declining kidney function, affecting up to one in five patients at CKD stage 4 and approximately one in three at stage 5 [2,3]. Even modest elevations have been associated with malignant arrhythmia, sudden cardiac arrest, and excess all-cause mortality [4]. Many patients with CKD also have diabetes mellitus, hypertension, and cardiovascular disorders, particularly heart failure [5,6]. Guideline-directed therapy for these conditions relies on renin–angiotensin system inhibitors (RASis) and mineralocorticoid receptor antagonists (MRAs), both of which improve cardio-kidney outcomes but impair renal potassium excretion [7]. Withdrawal of these cardio-kidney-protective agents in response to hyperkalemia has been linked to worse long-term outcomes [8,9,10].

Conventional management of hyperkalemia has combined down-titration or withdrawal of contributing drugs, low-potassium dietary education, diuretics, sodium bicarbonate, and oral potassium binders [11]. The first-generation binders—calcium polystyrene sulfonate (CPS) and sodium polystyrene sulfonate (SPS)—are limited by palatability issues, constipation, and rare cases of bowel necrosis [12]. The 2024 Kidney Disease: Improving Global Outcomes (KDIGO) CKD guideline and the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America heart failure guideline now favor maintaining cardio-kidney-protective therapy whenever potassium can be controlled by other managements [13,14,15], a shift that the newer potassium binders, sodium zirconium cyclosilicate (SZC) and patiromer, have made practical by maintaining normokalemia and supporting higher RASi/MRA persistence in phase III and real-world studies [16,17,18]. Although management guidelines have changed, the perspectives of the stakeholders most directly affected—patients with kidney-related diagnoses and the clinicians who treat them— have rarely been examined in parallel within a single national context.

We therefore conducted a nationwide descriptive cross-sectional survey of knowledge, attitudes, and practices (KAP) among three Korean clinical stakeholder groups: patients with kidney-related diagnoses and prior hyperkalemia care, nephrology specialists, and a multispecialty physician group. This study aimed to characterize the current state of awareness, perceived risk, and real-world management of hyperkalemia, and to identify where patient-side perception and clinician-side practice diverge.

METHODS

Study design

This survey study comprised three parallel, descriptive cross-sectional KAP surveys conducted in Korea between April and May 2026: a survey of patients with kidney-related diagnoses (Survey A), a survey of nephrology specialists (Survey B), and a survey of physicians spanning a range of clinical specialties (Survey C). Each survey was delivered electronically, completed anonymously, and analyzed separately, with pre-specified comparisons between corresponding items on the clinician questionnaires (B and C) and between aggregated clinician and patient responses on selected awareness items. Reporting of the study followed the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) recommendations (Supplementary Table 1) [19].

Patient survey (Survey A)

Participants for Survey A were recruited through a Korean online patient advocacy community for kidney disease, hosted as a moderated forum. The Korean Society of Nephrology (KSN) supported the study by posting the announcement and an anonymous survey link within the community for the duration of data collection, which corresponds to convenience sampling through an online patient community—an approach previously shown to yield substantial sample sizes for chronic-disease research while lowering the geographic and mobility barriers of clinic-based recruitment [20]. Individuals were eligible if they self-identified as a patient with a kidney-related diagnosis or as a family caregiver of such a patient, and reported a previous diagnosis of or treatment for hyperkalemia. Respondents who did not meet either criterion at the screening stage were not advanced to the substantive questionnaire. The instrument was co-developed by the research team and Korea Gallup, a professional survey organization, and was administered in Korean through Korea Gallup’s secure web-based platform. It followed a sequential flow of six thematic sections covering patient background; awareness of and risk perception of hyperkalemia; self-rated familiarity with three drug- or diet-related contributors to hyperkalemia; experience with cardio-kidney-protective therapy; hyperkalemia care experience; and potassium binder experience and treatment preference.

Nephrologist survey (Survey B)

Survey B was distributed by the Korean nephrologist group at KSN. The study purpose and a single-click survey link were circulated via email to nephrology specialists registered with the society, and the questionnaire was hosted on Korea Gallup’s secure web-based platform. Baseline characteristics captured at the start of the questionnaire included the volume of patients with hyperkalemia seen each month, the type of practice setting (clinic, hospital, general hospital, or tertiary/teaching hospital), and the number of years in clinical practice as a nephrologist.

Multispecialty physician survey (Survey C)

Survey C targeted the physician community of Korea through the Korean Medical Association (KMA). The official online news outlet of the KMA posted the study announcement and an embedded survey link as a banner notice on its portal for the duration of data collection; the questionnaire was hosted directly on the survey platform. In addition to the baseline characteristics captured in Survey B, Survey C respondents reported their primary clinical specialty, choosing from one of seven categories: nephrology, cardiology, endocrinology, other internal medicine subspecialty, family medicine, emergency medicine, or other.

Content shared between clinician surveys

Surveys B and C used an identical substantive item set spanning content domains, allowing direct between-group comparison on each matched item. The first domain captured awareness of the hyperkalemia threshold at which the respondent initiates intervention, as well as the factors most commonly perceived to provoke hyperkalemia in routine practice. The second domain examined how clinicians balance continuation of cardio-kidney-protective therapy against potassium control: respondents rated the importance of preserving RASi or MRA therapy in the face of recurrent hyperkalemia and reported the frequency with which they pursue three alternative responses to a hyperkalemic episode—dose reduction, drug discontinuation, or maintenance of the existing dose in combination with a potassium-lowering agent—separately for RASi and for MRA. The third domain addressed acute and chronic management: the first-line action when severe hyperkalemia is strongly suspected, the long-term strategy preferred for chronic or recurrent hyperkalemia in the outpatient setting, and the perceived feasibility of achieving stable control through dietary education alone. The fourth domain explored perceptions of potassium-binding agents: the principal limitations of the first-generation binders (CPS, SPS), the perceived clinical advantages of the newer binders (SZC, patiromer), and the practical barriers most commonly encountered when prescribing the newer agents.

Data quality

Multiple integrity checks were embedded in all three surveys to discourage fraudulent or duplicate participation, in line with recommendations for the conduct and reporting of internet-based health surveys [21]. In Survey A, eligibility was first verified through screening items on hyperkalemia diagnosis and prior treatment history; each participant additionally provided the name of the treating institution and the attending clinician, and responses with implausible or internally inconsistent entries were removed during data cleaning. A small set of follow-up items required knowledge consistent with actual hyperkalemia care (for example, the type of potassium binder previously prescribed), and respondents whose answers were incompatible with prior hyperkalemia treatment were excluded from the analytic sample. In Survey B, distribution was restricted to the KSN membership list, providing intrinsic verification of nephrology specialist status. In Survey C, access was restricted to the KMA members; respondents who did not select a clinical specialty or who reported never having managed hyperkalemia were excluded from the substantive analyses. To minimize the risk of duplicate participation, a single piece of contact information (a mobile phone number used for honorarium payment) was collected by the survey-administration companies—Korea Gallup (Surveys A and B) and the Korean Medical Times (Survey C)—and was used internally by those companies to deduplicate submissions; this contact information was never shared with the research team and was not used in any analyses.

Survey instruments and item formats

To minimize the risk of re-identification, Survey A recorded age in 10-year strata (< 20, 20s, 30s, 40s, 50s, 60s, 70s, and ≥ 80 years) rather than as an exact value, and no other personally identifying information was collected. The clinician surveys (Survey B and Survey C) likewise asked for years of nephrology practice in five ordinal categories (< 5, 5–10, 10–20, 20–30, and ≥ 30 years) and for the monthly volume of hyperkalemia patients in five ordinal categories (none, 1–10, 11–30, 31–100, and ≥ 101 patients), without recording exact counts. All three instruments used a mixture of single-select, multi-select, ranked-choice, and ordinal Likert response formats. In the clinician surveys, ten 5-point Likert items per respondent quantified the importance of maintaining RASi and MRA despite recurrent hyperkalemia, the frequency of three responses to hyperkalemia (dose reduction, discontinuation, and dose maintenance combined with a potassium-lowering agent) for both RASi and MRA, the perceived safety of the non-steroidal MRA relative to spironolactone, and the perceived proportion of chronic hyperkalemia patients who can be controlled by diet alone. Ranked-choice items included the perceived contributors to hyperkalemia (rank up to three), the long-term outpatient management strategy (rank up to two), the limitations of conventional potassium binders (rank up to three), and the unmet needs in long-term hyperkalemia management (rank up to three). The remaining items used single-select categorical formats.

Statistical analysis

Continuous variables derived from decadal categories (patient age via midpoint imputation) are presented as mean (standard deviation [SD]). Ordinal 5-point Likert responses are summarized as the mean (95% confidence interval [CI]), with the CI calculated from the t-distribution. All categorical and ranked-choice responses are presented as number (%). Ranked-choice items are reported both as the proportion endorsed as the top-ranked option and as the cumulative proportion endorsed within the top one to three options, with the cumulative endorsements treated analytically as multi-select binary responses.

Where the exposure variable was intrinsically ordered, monotonic trends across the ordered subgroups were tested rather than unstructured between-group differences. In the patient survey, comparisons across the four CKD strata (stage 1–2, stage 3, stage 4, and dialysis-dependent stage 5D) and in the clinician surveys, comparisons across the four monthly hyperkalemia patient-volume strata (none, 1–10, 11–30, and ≥ 31 patients) used the Cochran–Armitage trend test for binary outcomes, the Jonckheere–Terpstra test for ordinal Likert outcomes, and a t-test of the slope from linear regression of the response on group rank for the single continuous variable (patient age). Where the exposure was nominal—namely the two-group comparison of Korean nephrologists with non-nephrology clinicians in the combined Survey B + C dataset—Pearson χ² tests were used for binary outcomes, with Fisher’s exact tests substituted for 2 × 2 tables in which any expected cell count was below five, and the Mann–Whitney U test was used for ordinal Likert outcomes.

All p-values are two-sided, and a value below 0.05 was considered to indicate statistical significance. No correction for multiple comparisons was applied; the present analyses are descriptive and intended to characterize current KAP rather than to test pre-specified hypotheses. Statistical analyses were performed using R version 4.5.1 (R Foundation for Statistical Computing, Vienna, Austria), with the base stats package for χ², Fisher’s exact, and Mann–Whitney U tests, and with the DescTools package for the Cochran–Armitage and Jonckheere–Terpstra trend tests. All figures were generated in Python 3.10.12 using matplotlib version 3.8.

Ethics consideration

The surveys collected no personally identifying information and were administered as anonymous public questionnaires. Before entering the survey, the respondent reviewed an electronic information sheet that described the purpose of the survey, the voluntary nature of participation, the absence of personal data collection, and the intended use of aggregated findings, and then provided online consent to proceed. Survey responses were stored on the respective platform's secured research servers (Korea Gallup for Surveys A and B; Korean Medical Times for Survey C). The study was conducted in accordance with the principles of the Declaration of Helsinki.

RESULTS

Patient survey

Awareness, perception, and management of hyperkalemia

A total of 125 patients with CKD who had been diagnosed with or treated for hyperkalemia completed the survey. Thirty-four respondents (27.2%) were women, and most respondents (97.6%) received care at a tertiary or teaching hospital. Thirty-nine respondents (31.2%) were on maintenance dialysis. By self-reported information, 21 participants (16.8%) were in CKD stage 1–2, 24 (19.2%) in stage 3, 29 (23.2%) in stage 4, and 39 (31.2%) in stage 5D (37 hemodialysis, 2 peritoneal dialysis); 12 patients (9.6%) lacked sufficient information and were excluded from between-group analyses (Table 1).

Table 1. Baseline characteristics and awareness of hyperkalemia among patients with CKD, stratified by self-reported CKD stage (Survey A).

Variable		Total (n = 125)	Stage 1–2 (n = 21)	Stage 3 (n = 24)	Stage 4 (n = 29)	Stage 5D (n = 39)	p-value
Age (yr)		54.8 ± 10.0	61.2 ± 8.0	57.5 ± 10.7	54.0 ± 8.6	50.4 ± 9.4	< 0.001
Female sex		34 (27.2)	13 (61.9)	14 (58.3)	0 (0.0)	3 (7.7)	< 0.001
Awareness of hyperkalemia		114 (91.2)	10 (47.6)	24 (100.0)	29 (100.0)	39 (100.0)	< 0.001
Frequency of being told potassium is high		3.41 (3.30–3.52)	2.95 (2.62–3.29)	3.54 (3.33–3.76)	3.76 (3.52–4.00)	3.36 (3.20–3.52)	0.343
Perceived risk of hyperkalemia		3.97 (3.84–4.10)	2.90 (2.66–3.15)	4.00 (3.82–4.18)	4.45 (4.21–4.69)	4.21 (4.07–4.34)	< 0.001
Culprit cause knowledge: NSAIDs		3.62 (3.48–3.76)	2.62 (2.39–2.85)	3.83 (3.67–3.99)	4.07 (3.87–4.27)	3.82 (3.61–4.03)	< 0.001
Culprit cause knowledge: herbal supplements/fruit juices		3.56 (3.39–3.73)	3.81 (3.44–4.18)	3.96 (3.64–4.28)	4.00 (3.82–4.18)	2.87 (2.53–3.21)	< 0.001
Culprit cause knowledge: cardiorenal-protective drugs		3.78 (3.64–3.92)	2.86 (2.53–3.19)	4.00 (3.78–4.22)	4.24 (4.02–4.46)	3.97 (3.78–4.16)	< 0.001
Current K-management strategies
	Dietary K restriction	61 (48.8)	1 (4.8)	19 (79.2)	21 (72.4)	14 (35.9)	0.300
	Potassium-lowering drug	57 (45.6)	1 (4.8)	14 (58.3)	21 (72.4)	15 (38.5)	0.058
	Reduce or stop culprit drugs	18 (14.4)	4 (19.0)	2 (8.3)	5 (17.2)	3 (7.7)	0.349
Most burdensome aspect of hyperkalemia management
	Fear of hyperkalemia complications	41 (32.8)	4 (19.0)	1 (4.2)	21 (72.4)	10 (25.6)	0.082
	Dietary restrictions, cooking burden	26 (20.8)	0 (0.0)	11 (45.8)	3 (10.3)	10 (25.6)	0.329
	Hospital visits/blood testing burden	31 (24.8)	9 (42.9)	7 (29.2)	0 (0.0)	13 (33.3)	0.327
	Drug side effects/inconvenience	20 (16.0)	2 (9.5)	4 (16.7)	5 (17.2)	6 (15.4)	0.627
Preferred hyperkalemia management strategy
	No K-lowering drug + strict low-K diet	39 (31.2)	4 (19.0)	9 (37.5)	11 (37.9)	6 (15.4)	0.464
	Daily K-lowering drug + free diet	86 (68.8)	17 (81.0)	15 (62.5)	18 (62.1)	33 (84.6)	0.464
Most frustration with hyperkalemia management
	Inconvenience of taking K-lowering drugs	19 (15.2)	1 (4.8)	6 (25.0)	2 (6.9)	9 (23.1)	0.222
	Dietary control difficulty	41 (32.8)	3 (14.3)	13 (54.2)	18 (62.1)	5 (12.8)	0.406
	Frequent labs/clinic visits	17 (13.6)	4 (19.0)	2 (8.3)	1 (3.4)	9 (23.1)	0.495
	Cost burden	27 (21.6)	1 (4.8)	2 (8.3)	8 (27.6)	11 (28.2)	0.009
	Need to reduce/stop other important drugs	11 (8.8)	3 (14.3)	0 (0.0)	0 (0.0)	5 (12.8)	0.764
	No particular difficulties	10 (8.0)	9 (42.9)	1 (4.2)	0 (0.0)	0 (0.0)	< 0.001

Values are presented as number (%), mean ± standard deviation or median (minimum–maximum).

Trend across the four ordered CKD strata (stage 1–2, stage 3, stage 4, stage 5D) was tested with the Cochran–Armitage trend test for binary outcomes and the Jonckheere–Terpstra trend test for ordinal Likert outcomes; the slope from linear regression of the response on group rank was tested with a t-test for the continuous variable age.

CKD, chronic kidney disease; NSAID, non-steroidal anti-inflammatory drug; Stage 5D, dialysis-dependent stage 5 chronic kidney disease.

Awareness of hyperkalemia was high, with 114 patients (91.2%) reporting prior knowledge of the term, which increased monotonically across CKD stages (p = 0.001): every patient in stages 3, 4, and 5D was familiar with the term, whereas only 47.6% of those in stages 1–2 were. The perceived risk of hyperkalemia increased significantly with stage (p = 0.001), from 2.90 (95% CI, 2.66–3.15) in stage 1–2 to 4.45 (95% CI, 4.21–4.69) in stage 4 and 4.21 (95% CI, 4.07–4.34) in stage 5D. Recognition that cardio-kidney-protective drugs (RASi/MRA) and non-steroidal anti-inflammatory drugs (NSAIDs) contribute to hyperkalemia also increased monotonically across stages (RASi/MRA: 2.86 [2.53–3.19] in stage 1–2 versus 4.24 [4.02–4.46] in stage 4, p < 0.001; NSAIDs: 2.62 [2.39–2.85] versus 4.07 [3.87–4.27], p = 0.001).

Among current management practices, dietary education was the most common (48.8%), followed by potassium-lowering pharmacotherapy (45.6%); reduction or discontinuation of culprit medications was infrequent (14.4%; p = 0.349). The most frequently selected single burden of hyperkalemia care was fear of acute potassium-related emergencies (32.8%). Overall satisfaction with hyperkalemia care was 3.59 (3.46–3.72) and increased monotonically with stage (p = 0.002).

Experience of hyperkalemia management

Sixty-four respondents (51.2%) reported current or prior use of RASi or MRA and formed the analytic subgroup. The two most commonly endorsed clinician responses to a hyperkalemic episode were reduction of the culprit drug with low-potassium dietary counseling (42.2%) and maintenance of the existing dose with addition of a potassium-lowering agent (42.2%); only 3 patients (4.7%) reported complete discontinuation. Dose reduction without addition of a potassium-lowering agent clustered in stage 3 (15/16, 93.8%), whereas the dose-maintenance strategy with a potassium-lowering agent was more common in stages 4 (62.1%) and 5D (50.0%) (p = 0.011 and 0.113, respectively). When asked how they felt about dose reduction or discontinuation of cardio-kidney-protective therapy, 26 (40.6%) preferred to continue the original drug even if a potassium-lowering agent had to be added, 25 (39.1%) were concerned that withdrawal would worsen cardio-kidney outcomes, and only 13 (20.3%) felt reassured by drug withdrawal. The proportion of patients worried about cardio-kidney deterioration decreased monotonically with stage (p = 0.009) (Table 2).

Table 2. Experience of cardiorenal-protective therapy (RASi or MRA) in the patient subgroup who had used these agents (Survey A), stratified by self-reported CKD stage.

Variable		Total (n = 64)	Stage 1–2 (n = 2)	Stage 3 (n = 16)	Stage 4 (n = 29)	Stage 5D (n = 12)	p-value
The clinician’s strategy when hyperkalemia occurred
	Maintain RASi/MRA dose + low-K diet education	6 (9.4)	0 (0.0)	0 (0.0)	3 (10.3)	0 (0.0)	0.754
	Reduce RASi/MRA dose + low-K diet education	27 (42.2)	0 (0.0)	15 (93.8)	7 (24.1)	4 (33.3)	0.011
	Stop temporarily/permanently RASi/MRA + low-K diet education	3 (4.7)	0 (0.0)	0 (0.0)	1 (3.4)	1 (8.3)	0.235
	Maintain RASi/MRA dose + add K-lowering drug	27 (42.2)	2 (100.0)	1 (6.2)	18 (62.1)	6 (50.0)	0.113
	Reduce RASi/MRA dose + add K-lowering drug	1 (1.6)	0 (0.0)	0 (0.0)	0 (0.0)	1 (8.3)	0.137
	Stop RASi/MRA + add K-lowering drug	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	NA
	Reduce RASi/MRA only	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	NA
	Stop temporarily/permanently RASi/MRA only	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	NA
Emotional response to culprit drug reduction
	Relieved: high K is fatal, stopping helps lower it	13 (20.3)	0 (0.0)	1 (6.2)	6 (20.7)	3 (25.0)	0.130
	Worried: kidney/heart will worsen without the drug	25 (39.1)	2 (100.0)	12 (75.0)	6 (20.7)	5 (41.7)	0.009
	Prefer to keep the drug even if K-binder is added	26 (40.6)	0 (0.0)	3 (18.8)	17 (58.6)	4 (33.3)	0.143

Values are presented as number (%).

Reported clinician response to a hyperkalemic episode, patient emotional response, and preference for continued therapy were compared across the four ordered CKD strata. The trend across strata was tested using the Cochran–Armitage trend test.

CKD, chronic kidney disease; K-binder, potassium binder; MRA, mineralocorticoid receptor antagonist; RASi, renin–angiotensin system inhibitor; Stage 5D, dialysis-dependent stage 5 chronic kidney disease.

Nephrology expert survey

Practice profile and perception of hyperkalemia causes

A total of 82 nephrologists, all members of the KSN, completed the survey; tertiary or teaching hospitals were the most common practice setting (40.2%), and the mean duration of nephrology practice was 15.7 years (SD, 10.9). Respondents were stratified by self-reported monthly hyperkalemia patient volume into four groups (none, 1–10, 11–30, ≥ 31 patients): 6 (7.3%), 16 (19.5%), 17 (20.7%), and 43 (52.4%), respectively. The serum potassium threshold for active intervention was 5.5–5.9 mEq/L in 45 (54.9%), 5.0–5.4 in 23 (28.0%), and ≥ 6.0 in 14 (17.0%). Among the top three causes of chronic hyperkalemia, CKD was the most commonly endorsed (86.6%), followed by excessive dietary potassium intake (50.0%), RASi (42.7%), MRA (31.7%), and NSAIDs (25.6%). Endorsement of MRA as a top-three cause increased monotonically across patient-volume strata (0% versus 41.9%, p = 0.007).

Hyperkalemia management

Perceptions of RASi and MRA management are summarized in Fig. 1. The overall mean importance of RASi maintenance was 4.06 (3.91–4.22) and increased monotonically across patient-volume strata (3.67 [2.81–4.52] versus 4.23 [4.04–4.42] in the ≥ 31 group; p = 0.023; Fig. 1A). When hyperkalemia occurred during RASi therapy, the most frequent action was to maintain the dose and add a potassium binder (mean frequency 3.82 [3.55–4.08]); this strategy was reported more often as patient volume increased (2.17 [1.38–2.96] versus 4.26 [3.99–4.52], p < 0.001; Fig. 1D). Full RASi discontinuation was infrequent overall (1.65 [1.44–1.85]) and decreased monotonically (p = 0.003; Fig. 1C). For MRAs, the perceived safety of non-steroidal mineralocorticoid receptor antagonist (nsMRA) versus steroidal mineralocorticoid receptor antagonist (sMRA) was 3.51 (3.35–3.67) (Fig. 1E), and the importance of maintaining MRA was 3.67 (3.50–3.84) (Fig. 1F). When hyperkalemia occurred during MRA therapy, dose reduction (3.02 [2.79–3.26]) was the most frequent action, followed by maintenance with binder add-on (3.33 [3.05–3.61]); none of these strategies showed a significant linear trend (Fig. 1G and H).

Fig. 1. Self-reported perception and behavior regarding RASi and MRA management among Nephrologists (Survey B, n = 82), stratified by self-reported monthly hyperkalemia patient volume (none, 1–10, 11–30, ≥ 31 patients per month). Each panel shows a diverging stacked-bar Likert plot: negative responses (1–2) extend to the left, the neutral midpoint (3) is centered on zero, and positive responses (4–5) extend to the right. Subgroup sample sizes are shown next to each y-axis label. (A) Importance of maintaining RASi; (B) Frequency of RASi dose reduction; (C) Frequency of RASi discontinuation; (D) Frequency of RASi maintenance with K-binder add-on; (E) Perceived safety of nsMRA vs. sMRA; (F) Importance of maintaining MRA; (G) Frequency of MRA dose reduction; (H) Frequency of MRA maintenance with K-binder add-on.

K-binder, potassium binder; MRA, mineralocorticoid receptor antagonist; nsMRA, non-steroidal mineralocorticoid receptor antagonist; RASi, renin–angiotensin system inhibitor; sMRA, steroidal mineralocorticoid receptor antagonist.

For long-term outpatient management, the strategies most commonly endorsed within the top two ranks were potassium-binder prescription (75.6%) and dietary education (69.5%), both increasing monotonically with patient volume (binder 33.3% versus 93.0%, p < 0.001; diet 50.0% versus 83.7%, p = 0.005), whereas endorsement of reducing or stopping culprit drugs decreased (50.0% versus 9.3%, p < 0.001). Among limitations of existing CPS/SPS binders, constipation (80.5%) and taste, odor, or powder discomfort (69.5%) were the most frequently endorsed within the top three ranks. For newer potassium binders (SZC and patiromer), respondents most often identified faster and more predictable potassium reduction as the top advantage (32.9%); the most frequently selected single barrier was non-reimbursement with consequent cost burden (73.2%).

Physician survey

Practice profile and perception of hyperkalemia causes

A total of 255 multispecialty physicians completed the survey. The largest specialty groups were general internal medicine (26.7%), family medicine (14.5%), nephrology (11.0%), endocrinology (5.9%), cardiology (4.7%), and emergency medicine (4.3%); local clinics were the most common practice setting (36.5%). When stratified by monthly hyperkalemia patient volume, 27 (10.6%), 159 (62.4%), 42 (16.5%), and 27 (10.6%) respondents reported none, 1–10, 11–30, and ≥ 31 patients, respectively. The serum potassium threshold for intervention was 5.5–5.9 mEq/L in 136 (53.3%) and 5.0–5.4 in 49 (19.2%). Among the top three causes endorsed, CKD was again the most common (84.7%), followed by RASi (39.6%), MRA (34.1%), diabetes mellitus (29.8%), and metabolic acidosis (28.6%); MRA endorsement increased monotonically with patient volume (29.6% versus 55.6%, p = 0.006).

Hyperkalemia management

The perception and behavior patterns of physicians regarding RASi and MRA management are shown in Fig. 2. The mean importance of maintaining RASi was 3.73 (3.62–3.83), lower than the corresponding figure in Survey B, and rose monotonically with patient volume (p = 0.003; Fig. 2A). The frequency of maintaining the RASi dose with the addition of a potassium binder (2.94 [2.79–3.08]) also increased monotonically (2.59 versus 3.78, p < 0.001; Fig. 2D). For MRAs, dose reduction (3.25 [3.12–3.39]) was the most frequent action, and both dose reduction and maintenance with binder add-on increased in the ≥ 31 group (p = 0.049 and 0.033; Fig. 2G and H). A specialty-stratified analysis of the nine 5-point items in Survey C across the seven primary-specialty groups (nephrology, cardiology, endocrinology, general internal medicine, family medicine, emergency medicine, and other; Supplementary Fig. 1) showed that inter-specialty differences within the multispecialty physician cohort were concentrated in items related to maintaining RASi or MRA therapy and combining it with a potassium binder (p = 0.048 for the importance of maintaining RASi, p = 0.003 for RASi maintenance plus binder add-on, p = 0.004 for the importance of maintaining MRA, and p = 0.022 for MRA maintenance plus binder add-on).

Fig. 2. Self-reported perception and behavior regarding RASi and MRA management among Korean Medical Association members (Survey C, n = 255), stratified by self-reported monthly hyperkalemia patient volume. Each panel shows a diverging stacked-bar Likert plot: negative responses (1–2) extend to the left, the neutral midpoint (3) is centered on zero, and positive responses (4–5) extend to the right. Subgroup sample sizes are shown next to each y-axis label.

(A) Importance of maintaining RASi; (B) Frequency of RASi dose reduction; (C) Frequency of RASi discontinuation; (D) Frequency of RASi maintenance with K-binder add-on; (E) Perceived safety of nsMRA vs. sMRA; (F) Importance of maintaining MRA; (G) Frequency of MRA dose reduction; (H) Frequency of MRA maintenance with K-binder add-on.

K-binder, potassium binder; MRA, mineralocorticoid receptor antagonist; nsMRA, non-steroidal mineralocorticoid receptor antagonist; RASi, renin–angiotensin system inhibitor; sMRA, steroidal mineralocorticoid receptor antagonist.

For long-term outpatient management, the two strategies most often endorsed within the top two ranks were dietary education (60.4%) and reduction or discontinuation of culprit drugs (57.3%), whereas prescription of a potassium binder was less common (29.4%). Among the limitations of CPS/SPS binders, the most frequently endorsed were taste/odor discomfort (57.6%), constipation (52.5%), drug interactions or separation-of-dosing burden (43.9%), and limited prescribing experience (20.8%). For newer potassium binders, respondents most often selected selective potassium absorption as the top advantage (32.9%).

Combined comparison

Nephrology versus non-nephrology clinicians

Survey B respondents (n = 82) were merged with the Survey C nephrology subset (n = 28) to form a Nephrology group (n = 110); the remaining Survey C respondents formed the Non-nephrologist group (n = 227). Results are presented in Table 3. Nephrologists rated the importance of maintaining RASi higher than non-nephrologists (4.10 [3.96–4.24] versus 3.67 [3.55–3.78], p < 0.001) and reported maintaining the RASi dose with the addition of a potassium binder more frequently (3.79 [3.57–4.01] versus 2.84 [2.69–2.99], p < 0.001). Nephrologists reported reducing the RASi dose less often (2.46 versus 2.95, p < 0.001) and discontinuing RASi less often (1.84 versus 2.56, p < 0.001). For MRAs, nephrologists rated nsMRA as safer than sMRA (3.45 versus 3.22, p = 0.007), rated maintaining MRA as more important (3.64 versus 3.38, p = 0.006), and reported maintenance with binder add-on more frequently (3.37 versus 2.83, p < 0.001); MRA discontinuation differed modestly (2.51 versus 2.73, p = 0.037) and the frequency of dose reduction did not differ (p = 0.708).

Table 3. Comparison of clinician perspectives on hyperkalemia management between Korean nephrologists (combined Survey B and Survey C nephrology subset) and non-nephrology clinicians (Survey C non-nephrology subset).

Variable		Total (n = 337)	Nephrologists (n = 110)	Non-nephrologists (n = 227)	p-value
RASi management in patients with hyperkalemia
	Importance of maintaining RASi despite recurrent hyperkalemia	3.81 (3.72–3.90)	4.10 (3.96–4.24)	3.67 (3.55–3.78)	< 0.001
	Frequency: reduce RASi dose	2.79 (2.66–2.92)	2.46 (2.24–2.69)	2.95 (2.79–3.10)	< 0.001
	Frequency: discontinue RASi	2.32 (2.19–2.45)	1.84 (1.64–2.04)	2.56 (2.40–2.71)	< 0.001
	Frequency: maintain RASi + add potassium binder	3.15 (3.02–3.28)	3.79 (3.57–4.01)	2.84 (2.69–2.99)	< 0.001
MRA management in patients with hyperkalemia
	Perceived safety of nsMRA vs. sMRA	3.30 (3.22–3.38)	3.45 (3.31–3.60)	3.22 (3.13–3.32)	0.007
	Importance of maintaining MRA despite recurrent hyperkalemia	3.47 (3.37–3.56)	3.64 (3.47–3.80)	3.38 (3.27–3.49)	0.006
	Frequency: reduce MRA dose	3.20 (3.08–3.32)	3.16 (2.95–3.37)	3.22 (3.07–3.36)	0.708
	Frequency: discontinue MRA	2.66 (2.54–2.78)	2.51 (2.29–2.73)	2.73 (2.59–2.87)	0.037
	Frequency: maintain MRA + add potassium binder	3.01 (2.89–3.13)	3.37 (3.14–3.60)	2.83 (2.69–2.97)	< 0.001
Long-term outpatient strategy (multiple choices up to 2)
	Dietary education	211 (62.6)	68 (61.8)	143 (63.0)	0.929
	Reduce/stop culprit drugs (RASi/MRA)	165 (49.0)	39 (35.5)	126 (55.5)	< 0.001
	Add/up-titrate diuretics	60 (17.8)	11 (10.0)	49 (21.6)	0.014
	Prescribe potassium binder	137 (40.7)	75 (68.2)	62 (27.3)	< 0.001
	Shorten potassium monitoring interval	67 (19.9)	22 (20.0)	45 (19.8)	1.000
Is diet alone sufficient for stable K control
	Proportion of chronic hyperkalemia patients	2.61 (2.53–2.70)	2.65 (2.50–2.79)	2.60 (2.49–2.71)	0.847
Limitations of existing potassium binders (multiple choices up to 3)
	Taste/odor discomfort	204 (60.5)	78 (70.9)	126 (55.5)	0.009
	Constipation	200 (59.3)	91 (82.7)	109 (48.0)	< 0.001
	GI side effects other than constipation	126 (37.4)	38 (34.5)	88 (38.8)	0.528
	Reduced long-term adherence	145 (43.0)	60 (54.5)	85 (37.4)	0.004
	Unsatisfactory K-lowering effect	80 (23.7)	17 (15.5)	63 (27.8)	0.019
	Drug interactions + separation timing burden	132 (39.2)	29 (26.4)	103 (45.4)	0.001
	Cost burden	18 (5.3)	2 (1.8)	16 (7.0)	0.081
	Limited prescribing experience	54 (16.0)	3 (2.7)	51 (22.5)	< 0.001
Unmet needs in hyperkalemia management (multiple choices up to 3)
	Diet alone is insufficient	198 (58.8)	51 (46.4)	147 (64.8)	0.002
	Difficulty maintaining RASi/MRA long-term	150 (44.5)	20 (18.2)	130 (57.3)	< 0.001
	Poor convenience of existing binders	160 (47.5)	46 (41.8)	114 (50.2)	0.183
	GI side effects of existing binders	121 (35.9)	53 (48.2)	68 (30.0)	0.002
	Low adherence to existing binders	134 (39.8)	68 (61.8)	66 (29.1)	< 0.001
	Cost/insurance burden	95 (28.2)	51 (46.4)	44 (19.4)	< 0.001
	Burden of continual hyperkalemia monitoring	88 (26.1)	22 (20.0)	66 (29.1)	0.100

Five-point Likert items are summarized as mean (95% CI) and compared with the Mann–Whitney U test; binary categorical items are summarized as number (%) and compared with the Pearson χ² test, or with the Fisher’s exact test for 2 × 2 tables in which any expected cell count was below five. All p-values are two-sided.

GI, gastrointestinal; MRA, mineralocorticoid receptor antagonist; nsMRA, non-steroidal mineralocorticoid receptor antagonist; RASi, renin–angiotensin system inhibitor; sMRA, steroidal mineralocorticoid receptor antagonist.

The two groups also diverged in priorities for long-term outpatient management. Among the strategies endorsed within the top two ranks, potassium-binder prescription was chosen by 68.2% of nephrologists versus 27.3% of non-nephrologists (p < 0.001), whereas reduction or discontinuation of culprit drugs was chosen by 35.5% versus 55.5% (p < 0.001). Non-nephrologists more often endorsed limited prescribing experience as a binder limitation (22.5% versus 2.7%, p < 0.001) and difficulty in maintaining RASi or MRA long-term as an unmet need (57.3% versus 18.2%, p < 0.001), whereas nephrologists more often endorsed low adherence to existing binders (61.8% versus 29.1%, p < 0.001) and cost or insurance burden (46.4% versus 19.4%, p < 0.001).

DISCUSSION

In this nationwide descriptive cross-sectional study, we characterized contemporary KAP regarding hyperkalemia management among three Korean stakeholder groups—patients with kidney-related diagnoses and prior hyperkalemia care, nephrology specialists, and a multispecialty physician cohort—against the backdrop of expanding use of RASi, MRA, and high-potency potassium binders. To our knowledge, this is the first survey to bring these three stakeholder groups together within a single national context. The parallel design enabled direct comparison between patient-side perception and clinician-side practice, and between Korean nephrologists and non-nephrology clinicians—two contrasts that the existing literature has not systematically addressed. By aligning the data collection with the 2024 KDIGO CKD guideline and the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America heart failure guideline [13,14], the present study provides a contemporary snapshot of how the shift toward preserving cardio-kidney-protective therapy has been received by both patients and clinicians in routine Korean practice.

In this study, patient awareness of hyperkalemia and its clinical consequences was high. Self-reported familiarity with the term reached 91.2%; the overall perceived risk of hyperkalemia was 3.97 (95% CI, 3.84–4.10) on a five-point scale; and risk perception increased monotonically across CKD stages. Recognition that cardio-kidney-protective drugs such as RASi and MRA can raise serum potassium was also relatively high at 3.78 (3.64–3.92), again with a monotonic increase across CKD stages. Despite this elevated awareness, only 18 patients (14.4%) selected reduction or discontinuation of the culprit drug as their preferred response to a hyperkalemic episode, whereas dietary education (48.8%) and potassium-lowering pharmacotherapy (45.6%) were chosen more often. Among the subgroup who had used RASi or MRA, 40.6% expressed a preference to continue the original drug even if a potassium-lowering agent had to be added, and 39.1% reported concern that withdrawal would worsen cardio-kidney outcomes. This pattern is consistent with the direction of recent guideline updates, which favor maintenance of cardio-kidney-protective therapy whenever potassium can be controlled by other means [13,14].

Our findings extend and partly diverge from previous patient-facing works [22]. The Japanese cohort described by Shibagaki et al. [23] and Sada et al. [24] reported high self-reported adherence to potassium binders and perceived less impact on quality of life from binder therapy than from dietary restriction, supporting the view that pharmacologic potassium control is acceptable to patients managing multiple lifestyle limitations. In contrast, a Saudi Arabian survey reported that 79.7% of CKD patients had inadequate knowledge of potassium-rich foods [25], and a United States cohort showed that knowledge of dietary restrictions did not translate into measured potassium intake [26]. The Korean respondents in our study, therefore, appeared to combine relatively high disease-specific knowledge with an explicit willingness to preserve cardio-kidney-protective therapy, even at the cost of accepting additional medication. The greater representation of tertiary-hospital-treated and advanced-CKD patients in our sample may have contributed to this profile and should be considered when generalizing the findings to less-specialized care settings.

Both clinician surveys identified CKD as the most frequently endorsed cause of chronic hyperkalemia, followed by excessive dietary potassium intake, renin–angiotensin system blockers, and MRA. The importance of maintaining RASi and MRA despite recurrent hyperkalemia was rated 3.81 (3.72–3.90) and 3.47 (3.37–3.56), respectively, on the combined five-point scale, indicating broad recognition of these agents’ cardio-kidney-protective role across specialties. Nephrologists, however, rated maintenance as more important than non-nephrology clinicians for both drug classes (p < 0.001 for RASi, p = 0.006 for MRA).

This specialty gradient extended to reported management practices when hyperkalemia developed during ongoing therapy. For RASi, nephrologists reported dose reduction less often (mean 2.46 [2.24–2.69] versus 2.95 [2.79–3.10], p < 0.001), drug discontinuation less often (1.84 [1.64–2.04] versus 2.56 [2.40–2.71], p < 0.001), and dose maintenance with addition of a potassium binder more often (3.79 [3.57–4.01] versus 2.84 [2.69–2.99], p < 0.001) than non-nephrology clinicians. For MRA, nephrologists similarly reported dose maintenance with potassium-binder add-on more often (3.37 [3.14–3.60] versus 2.83 [2.69–2.97], p < 0.001) and discontinuation less often (2.51 [2.29–2.73] versus 2.73 [2.59–2.87], p = 0.037), whereas the frequency of dose reduction did not differ between groups (p = 0.708). These contrasts mirror those described in the Gulf Cooperation Council survey [27], the Spanish national multispecialty survey [28], the European Society of Cardiology Heart Failure Association survey [29], the nationwide Swedish survey [30], and the UK-based cardio-kidney perspective [31], all of which reported wide inter-specialty variation in dose reduction, discontinuation, and binder add-on once hyperkalemia developed.

The two clinician groups also diverged in their priorities for long-term outpatient management. Among the top two strategies endorsed for chronic outpatient hyperkalemia, nephrologists most often selected prescription of a potassium binder (68.2%) and dietary education (61.8%), whereas non-nephrology clinicians most often selected dietary education (63.0%) and reduction or discontinuation of culprit drugs (55.5%). The two groups held comparably neutral views on whether diet alone was sufficient for stable potassium control (2.65 [2.50–2.79] in the Nephrology group versus 2.60 [2.49–2.71] in the Non-nephrology group, p = 0.847), so the divergent strategy preferences appear to reflect different attitudes toward the active use of potassium-binding agents rather than different perceptions of dietary feasibility. The disproportionate endorsement of limited prescribing experience as a binder limitation among non-nephrology respondents (22.5% versus 2.7%, p < 0.001) suggests that lower familiarity with the newer potassium binders, rather than a different assessment of the clinical role of these agents, is a major contributor to the specialty gap in outpatient strategy [32,33,34].

This study has several limitations. First, the patient survey was distributed through a kidney disease patient community on the web-based platform rather than to consecutive clinic attendees, an approach that carries a recognized risk of fraudulent respondents [21]. To mitigate this risk, eligibility was first verified through screening items on hyperkalemia diagnosis and prior treatment history; each respondent additionally provided the name of the treating institution and the attending clinician, and a small set of follow-up items required knowledge consistent with actual hyperkalemia care. Responses with internally inconsistent or implausible entries were removed during data cleaning. Second, the clinician surveys were also web-based and did not collect any identifying information, leaving a residual possibility of duplicate or non-physician responses. Distribution was nevertheless restricted to the membership channels of trusted national societies, which provided intrinsic verification of professional status. Third, the patient sample was concentrated in tertiary or teaching hospitals (97.6%), which may not reflect the experiences of patients followed exclusively in primary or secondary care. Patients managed in primary or secondary care settings, whose access to up-to-date hyperkalemia education and to specialist-led prescribing of newer potassium binders may be more limited, are therefore under-represented in our data; the patient-side awareness and preference profiles reported here may overestimate those typically seen outside tertiary care, and targeted educational outreach at primary and secondary care levels may be needed to close this gap. Fourth, the cross-sectional design captured stated attitudes and intended management rather than observed prescribing or clinical outcomes; the specialty contrasts reported here therefore reflect differences in self-reported preference rather than measured behavior. Additionally, the present analyses were exploratory and descriptive: p-values were two-sided and were not adjusted for multiple comparisons, and the absence of a pre-specified hypothesis precludes causal inference. Finally, because the combined Nephrology group pooled respondents recruited through two different channels (Survey B via the KSN listserv, n = 82; Survey C nephrology subset via the Korean Medical Times portal, n = 28), a sensitivity comparison of the two sub-cohorts was performed; the distribution of practice setting did not differ significantly between them (p = 0.394; Supplementary Table 2), supporting the validity of the pooled analysis.

Patients with kidney-related diagnoses and prior hyperkalemia care showed both high awareness of hyperkalemia and a clear preference for maintaining cardio-kidney-protective therapy. Nephrologists and physicians outside nephrology rated the importance of maintaining RASi and MRA similarly highly, but the practical translation of this view diverged. Lower monthly patient volume with hyperkalemia and non-nephrology specialty were each associated with a greater willingness to reduce or discontinue these agents rather than combine them with a potassium binder. Together, these findings indicate a contemporary practice gap between the direction of recent guidelines and real-world clinician behavior outside nephrology, despite broadly shared recognition of the rationale for preserving cardio-kidney-protective therapy.

Conclusion

In a nationwide Korean survey covering patients, nephrologists, and a multispecialty physician cohort, awareness of hyperkalemia and of the contribution of cardio-kidney-protective drugs to elevated potassium was high across stakeholder groups, but the willingness to maintain RASi and MRA therapy while controlling potassium pharmacologically was substantially greater among nephrologists than among other specialties. Continued cross-specialty educational outreach on contemporary guideline recommendations for managing hyperkalemia in the setting of cardio-kidney-protective therapy may be particularly valuable for non-nephrology clinicians who manage CKD and heart failure outside specialist clinics. Future studies linking self-reported attitudes to actual prescribing patterns and to longitudinal patient outcomes will be needed to determine whether closing this specialty gap translates into improved cardio-kidney preservation.

SUPPLEMENTARY MATERIALS

Supplementary Table 1

CHERRIES compliance

Supplementary Table 2

Sensitivity comparison of the two nephrologist sub-cohorts that were pooled to form the Nephrology group used in the main Table 3 (n = 110 in the manuscript)

Supplementary Fig. 1

Self-reported perception and behavior regarding RASi and MRA management among Korean Medical Association members (Survey C, n = 255), stratified by self-reported clinical specialty (nephrology, cardiology, endocrinology, general internal medicine, family medicine, emergency department, and other).