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Welcome to que digo 
conversations in. 

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Nephrology this episode is 
titled approaches to rassi 

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optimization for disclosure 
information. 

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Please go to que digo dot org, 
slash podcasts. 

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Here's your host dr. 
Roberto Pourquoi. 

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Filho. 
Hello and welcome to the 

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cadyville conversations in 
biology. 

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I am dr. 
Roberto Pavilion, senior 

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research scientist. 
Just at the arbor research 

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collaborative. 
Health professor of medicine at 

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the pontifical Catholic 
University of Montana on the 

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program, with me today to 
discuss, approaches to the 

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optimization of raining, and the
tensing of those turn system. 

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In addition is dr. 
Patrick row. 

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Single doctor rosie. 
No is a nephrologist. 

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Vascular medicine specialist. 
So certainly the perfect gas for

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our topic today. 
Patrick welcome to the program. 

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Thank you very much for Berto. 
Delighted to be here. 

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That's okay. 
It looks like as ears go by 

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therapies that inhibit the 
renin-angiotensin system or 

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rassi as I'll refer to this from
now on the continue to be 

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important tools in the 
management of patients with CKD.

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See you in the real world. 
Listen, struggle to align with 

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recommendation. 
What is your approach to rassi 

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optimization or SEO titration is
indeed desirable throughout the 

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quadrant? 
The Continuum as universally 

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emphasized by International 
guidelines. 

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This is true in chronic kidney 
disease patients without without

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hypertension as emphasized Again
by the latest 221 que digo 

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guidelines on blood pressure 
Management in CKD. 

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For instance, stating that resi 
s Inhibitors or are bees should 

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be administered using the 
highest approved dose. 

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That is tolerated to achieve the
benefits described because the 

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proven benefits were achieved in
Trials using these doses. 

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This is also true in patients 
with heart failure on reduced, 

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ejection fraction. 
That's confirmed by the latest. 

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European Cardiology guidelines 
published in August to 21. 

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Importantly, CKD must redefine 
us egfr below 60 million per 

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minute per 1.73. 
M2 is a highly prevalent 

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condition in patients. 
With acute on chronic heart 

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failure, approximately one-third
recording to a meta-analysis 

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published some Years Ago by cave
in demand in the European. 

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Aldrin are in 2013 of 57 
studies. 

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Comprising, more than 1 million 
patients. 

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In both settings, especially in 
elderly patients on in patients 

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with diabetes, hyperkalemia was 
found the true world or toward 

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rescue optimization in the art. 
Fair setting, we on orders? 

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We plotted that hyperkalemia is 
one of the main triggers of 

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received, no news, underdosing 
on discontinuation. 

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Thereby leading to deep rib, our
patients for this category, no 

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protective agent. 
It's on partly mediating, The 

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observed association between 
hyperkalemia on two outcomes. 

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Intel urinal patients, looking 
at the conversations in the 

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biology and Cardiology seems 
like the community has finally 

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decided to approach the problem 
or hyperkalemia. 

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In a more proactive approach, 
don't you think so? 

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Yes, indeed. 
So, let us 221. 

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Can you go guide lines and blood
pressure Management in CKD 

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stated that I procured in your 
associate We use of recipe can 

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often be managed by measures to 
reduce the serum potassium 

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levels, rather than decreasing 
the dose of stopping resi. 

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On that potassium. 
Restriction discontinuation of 

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potassium supplements, certain 
salt substitutes on 

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hyperkalemic, drugs, adding 
potassium, wasting diuretics and

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or potassium. 
Binders in CKD. 

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Patients receiving receipt, we 
develop hyperkalemia. 

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The letter can be controlled 
with newer or potassium, binders

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in many. 
A patients with the effects that

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Pharisee can be continued as a 
recommended dose. 

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Furthermore, the latest 2021 is 
here for your guylines stated 

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that administration of the 
catering agents, fetch your 

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mother or sodium zirconium Sacra
silicate, may allow any 

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uncertainty reduction system 
inhibitor initiation or up 

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titration in the literature. 
Proportion of patients. 

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That's really interesting. 
Patrick, so you were an 

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experienced clinician and you 
probably treat patients with 

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these therapies a lot. 
Not in a daily basis. 

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Can you provide the nor audience
with your approach to monitoring

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measures impatient studying and 
long-term Russell therapies? 

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Well, it is universally 
acknowledged that creatinine and

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potassium must be adequately. 
Monitored in cked on or off for 

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your patience. 
Why the proper monitoring was 

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unfortunately reported to be 
poor after mineral particular 

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receptor. 
Antagonist. 

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Initiation in heart failure, 
patients both in the US and in 

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Europe. 
The latest 221 cadigal 

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guidelines on blood pressure 
Management in CKD stated that 

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changes in blood pressure serum 
creatinine, turn potassium 

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should be checked within two to 
four weeks of initiation or 

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increasing the dose of resi. 
C, depending on the current 

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differ on serum potassium. 
Furthermore, in patients at risk

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for iplock alinea, measuring 
serum potassium before on at one

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to two weeks after initiation, 
of recipe is recommended. 

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Patients should also be 
monitored for symptomatic. 

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Hypotension. 
I broke a linear on serum 

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creatinine within two to four 
weeks after initiating or 

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changing the dose of the drug 
with the time interval depending

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on Baseline blood pressure, 
serum creatinine, some potassium

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on, only the shorter time. 
Interval is indicated, is a 

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baseline serum creatinine is I 
or some potassium is already a 

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normal, or is, there is a 
history of I Academia or an 

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acute rise in some creatinine 
with blood pressure lowering or 

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raising as far as the easiest 
federal guidelines concern. 

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So let us is Jeffrey. 
Guidelines repeatedly stated 

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that in advisor on reduce 
ejection fraction. 

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Firstly after s Inhibitors are 
be initiation. 

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Recheck, blood chemistry. 
In other words urea be un 

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creatinine, potassium one to two
weeks after initiation on one to

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two weeks. 
After final dose titration, 

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monitor blood, chemistry for 
monthly thereafter, The syrup 

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potassium monitoring is 
warranted in patients. 

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Treated with an Metacritic, 
restore antagonist, check blood 

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chemistry are torn on for weeks 
after starting increasing those 

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on that 8 and 12 weeks 69 on 12 
months, four months he's after. 

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So don't the close protection, 
monitoring is warranted under 

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potassium, lowering agents for 
those just joining us. 

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This is que digo conversations 
in virology, I'm dr. 

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Gilberto topography And I'm 
speaking with dr. 

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Patrick real signal on 
approaches to Rossi 

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optimization, Patrick, the 
guidelines are providing a clear

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message in terms of the 
importance of keeping patients 

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on this life-saving therapies. 
However, it's not really an easy

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task to optimize patients. 
And this requires a diversity of

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strategies different phases of 
treatment acute, or chronic 

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hospital or ambulatory. 
Can you provide some tips on how

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to optimize that? 
Therapies. 

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Well Roberto it should be 
emphasized that as yet no 

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monitoring regime and has been 
prospectively. 

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Evaluated in patients initiating
a potassium boring agent for the

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treatment of I Britannia in 
editorial. 

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Bertram. 
Didn't I published a couple of 

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years ago? 
In pharmacological research, 

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2017 we are ever suggested the 
following regimen based upon the

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experience in initiating. 
These agents in the pivotal 

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clinical trials. 
On our own experience on resi 

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under etic management, as a 
basis for discussion on further 

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prospective evaluation. 
First serum potassium should be 

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measured before. 
Initiation of potassium boring 

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agent on should be above 50 
minimal per liter on a known 

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immunized, blood sample in 
patients without 

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life-threatening, I practically 
Nia, it will be prudent to 

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repeat the measurement on to 
confirm that their own 

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potassium, is truly above. 
Five me. 

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Immortality before initiating, 
your potassium roaring agent 

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one, should also measure some 
magnesium bicarbonate on access 

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when I'll function with the 
egfr. 

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Second after initiating, you put
a silver ring. 

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Agent serum potassium should be 
measured within 48 to 72 hours 

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on repeated at one week. 
If at one rig, the sun 

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protection remains above five, 
millimoles per liter 

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consideration. 
Should be given to increasing 

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the dose of the potassium. 
Boring agent on tour. 

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Check some potassium? 
No, l. 

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And one week later, Once the 
same potential is below 5 

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minimal pollinator, it would 
appear reasonable to based upon 

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the experience in the pivotal 
Trials of procurement on a sec 

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to measure some potassium at one
month on then every three to six

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months at regular follow-up. 
Visits. 

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Importantly, any time that the 
change in electrolyzed Staters 

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is suspected such as during an 
episode of diarrhea. 

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The or vomiting or after each 
recipe or directly to change 

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some potassium and creatinine 
should be remeasured on the 

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monitoring sequence. 
Repeated, I'm sure that there 

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are different Regional realities
and really the, the 

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fragmentation of care and 
problems with the communication 

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between Specialties that take 
care of the patients is really 

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difficult. 
Don't you think why do you think

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is Of chemical education is 
exist, especially between 

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Cardiology Nephrology emergency 
medicine. 

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Why. 
Roberto in my view is the 

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workload is certainly a measure 
or do Lashley along with some 

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inconsistencies between 
Nephrology and Cardiology 

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guidelines. 
For instance, regarding 

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thresholds to discontinue, don't
die traitor. 

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SE in the presence of a rational
function on or I truck anemia, 

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and I'm fully agree with that. 
Patrick Well, any final advice 

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to clinicians sure. 
Please don't hesitate to titrate

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for a see as much as you can 
which monitoring creatinine and 

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potassium closely and be ready 
to introduce a new petition 

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binder to enable resi as 
repeatedly. 

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Demonstrated whispered. 
Shermer, for instance, in the on

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betrayal, I was involved in the 
steering committee in patients 

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with Advanced, chronic kidney 
disease on resistant 

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hypertension. 
A tumor compared to Placebo, 

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enables a more persistent shoes 
of the steroidal. 

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Emery spironolactone, the 
primary endpoint of this Phase 2

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trial. 
Well, that, take away in mind, I

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want to thank my guest, dr. 
Patrick Rocio for joining me and

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discussed the different 
approaches to Rossi 

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optimization. 
Patrick was great having you on 

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the program, my pleasure rattle,
I am Doctor Who bear to people 

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are feeling to access this and 
other episodes in the series. 

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Series please. 
Visit KD V Dot org slash 

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00:12:19,000 --> 00:12:21,100
podcast. 
Thanks for listening. 

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00:12:21,700 --> 00:12:26,900
This episode was provided by KD 
go and supported by V4 Pharma. 

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00:12:15,800 --> 00:12:19,000
Series please. 
Visit KD V Dot org slash 

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podcast. 
Thanks for listening. 

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00:12:21,700 --> 00:12:26,900
This episode was provided by KD 
go and supported by V4 Pharma.