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BMC Nephrol. 2019 Jan 31;20(1):31. doi: 10.1186/s12882-019-1228-y.

The value of maintaining normokalaemia and enabling RAASi therapy in chronic kidney disease.

Author information

Diabetes Resource Centre, Llandough Hospital, Cardiff, UK.
Global Health Economics, AstraZeneca, Cambridge, UK.
Department of Nephrology, Uppsala University Hospital, Uppsala, Sweden.
Health Economics and Outcomes Research Ltd, Cardiff, UK.
Heart and Vascular Theme, Karolinska University Hospital and Karolinska Instiutet, Stockholm, Sweden.
Global Health Economics, AstraZeneca, Gaithersburg, MD, USA.
Health Economics and Outcomes Research Ltd, Cardiff, UK.
School of Human and Health Sciences, Swansea University, Swansea, UK.
Department of Cardiology, Royal Free Hospital, London, UK.



People with chronic kidney disease (CKD) are at an increased risk of developing hyperkalaemia due to their declining kidney function. In addition, these patients are often required to reduce or discontinue guideline-recommended renin-angiotensin-aldosterone system inhibitor (RAASi) therapy due to increased risk of hyperkalaemia. This original research developed a model to quantify the health and economic benefits of maintaining normokalaemia and enabling optimal RAASi therapy in patients with CKD.


A patient-level simulation model was designed to fully characterise the natural history of CKD over a lifetime horizon, and predict the associations between serum potassium levels, RAASi use and long-term outcomes based on published literature. The clinical and economic benefits of maintaining sustained potassium levels and therefore avoiding RAASi discontinuation in CKD patients were demonstrated using illustrative, sensitivity and scenario analyses.


Internal and external validation exercises confirmed the predictive capability of the model. Sustained potassium management and ongoing RAASi therapy were associated with longer life expectancy (+ 2.36 years), delayed onset of end stage renal disease (+ 5.4 years), quality-adjusted life-year gains (+ 1.02 QALYs), cost savings (£3135) and associated net monetary benefit (£23,446 at £20,000 per QALY gained) compared to an absence of RAASi to prevent hyperkalaemia.


This model represents a novel approach to predicting the long-term benefits of maintaining normokalaemia and enabling optimal RAASi therapy in patients with CKD, irrespective of the strategy used to achieve this target, which may support decision making in healthcare.


Chronic kidney disease; Economic modelling; Potassium, Hyperkalaemia; Renin-angiotensin-aldosterone system inhibitor

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