Kleinman N, Desai T, Thakar C. Long-term patiromer adherence and renin-angiotensin aldosterone system inhibitor utilization: A retrospective study. World J Nephrol 2026; 15(1): 113599 [DOI: 10.5527/wjn.v15.i1.113599]
Corresponding Author of This Article
Nathan Kleinman, PhD, Department of Data Analysis and Research, Kleinman Analytic Solutions, LLC., 405 Cool Valley Dr., Paso Robles, CA 93446, United States. nathan@kleinmansolutions.com
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Health Care Sciences & Services
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Retrospective Cohort Study
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Mar 25, 2026 (publication date) through Mar 14, 2026
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World Journal of Nephrology
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2220-6124
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Kleinman N, Desai T, Thakar C. Long-term patiromer adherence and renin-angiotensin aldosterone system inhibitor utilization: A retrospective study. World J Nephrol 2026; 15(1): 113599 [DOI: 10.5527/wjn.v15.i1.113599]
World J Nephrol. Mar 25, 2026; 15(1): 113599 Published online Mar 25, 2026. doi: 10.5527/wjn.v15.i1.113599
Long-term patiromer adherence and renin-angiotensin aldosterone system inhibitor utilization: A retrospective study
Nathan Kleinman, Tejas Desai, Charuhas Thakar
Nathan Kleinman, Department of Data Analysis and Research, Kleinman Analytic Solutions, LLC., Paso Robles, CA 93446, United States
Tejas Desai, United States Medical and Scientific Affairs - Nephrology/Dialysis, CSL, Charlotte, NC 28201, United States
Charuhas Thakar, Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast BT9 7BL, United Kingdom
Author contributions: Kleinman N performed the statistical analysis; Kleinman N, Desa T, and Thakar C made substantial contributions to the design of the work, interpretation of data, and the drafting or revision of the manuscript; and have approved this version of the manuscript and have agreed to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated, resolved, and documented.
Institutional review board statement: The need for ethics committee or institutional review board approval were unnecessary, because the dataset used for this study did not meet the definition of “human subjects” in federal requirement 45 CFR 46.102(f). It did not meet the definition of “human subjects” because the data were de-identified, and the investigators had no way to identify the subjects. Thus, all experiments were performed in accordance with relevant guidelines.
Informed consent statement: The need for informed consent to participate were unnecessary, because the dataset used for this study did not meet the definition of “human subjects” in federal requirement 45 CFR 46.102(f). It did not meet the definition of “human subjects” because the data were de-identified, and the investigators had no way to identify the subjects. Thus, all experiments were performed in accordance with relevant guidelines.
Conflict-of-interest statement: Kleinman N reports personal fees from CSL Vifor, during the conduct of the study; personal fees from SeaStar Medical, outside the submitted work.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: The prescription claims data used to support the findings in this study are available in the Symphony Health Dataverse (https://www.iconplc.com/solutions/symphony-health/integrated-dataverse-and-source-solutions). Restrictions apply to the availability of these data, which were used under license for this study. Access to the data was provided by CSL Vifor for this study.
Corresponding author: Nathan Kleinman, PhD, Department of Data Analysis and Research, Kleinman Analytic Solutions, LLC., 405 Cool Valley Dr., Paso Robles, CA 93446, United States. nathan@kleinmansolutions.com
Received: August 29, 2025 Revised: October 27, 2025 Accepted: January 7, 2026 Published online: March 25, 2026 Processing time: 197 Days and 11 Hours
Abstract
BACKGROUND
Renin-angiotensin aldosterone system inhibitors (RAASi) reduce mortality risk in patients with heart failure, and slow progression of chronic kidney disease. However, hyperkalemia limits initiation, continuation, and reaching adequate dosing of RAASi therapy. Randomized trials have shown that patiromer users are more likely to continue taking RAASi.
AIM
To test the hypothesis of whether patiromer facilitates optimal RAASi use in the real-world.
METHODS
This study compared RAASi use in patients adherent with patiromer [proportion of days covered (PDC) > 80%] to patients with lower adherence (PDC ≤ 80%). Pre-pandemic (2014 to 2019) prescription claims data, member demographics, and plan information were used for individuals whose first patiromer prescription (index date) was during 2015-2018. PDC for patiromer was measured 6 months post-index. Patients were divided into two cohorts: Those with patiromer PDC > 80% (adherent) and those with patiromer PDC ≤ 80% (lower adherence). RAASi use was compared between cohorts during the 6 months post-index period.
RESULTS
Nearly 25% of all patiromer users were adherent, with a patiromer PDC > 80%. Adherent patiromer use was associated with significantly more angiotensin-converting enzyme inhibitor, angiotensin-receptor blocker, and mineralocorticoid receptor antagonist days supply than lower patiromer adherence (10%, 8%, and 9% higher, respectively). Also, angiotensin-converting enzyme inhibitor, angiotensin-receptor blocker, and mineralocorticoid receptor antagonist PDC were significantly greater in adherent patiromer patients than in lower adherence patiromer patients (5%, 6%, and 10% higher, respectively).
CONCLUSION
This study provides evidence that patients adherent with patiromer use more RAASi than lower-adherence patients. Prior studies show RAASi use reduces mortality risk and kidney disease progression.
Core Tip: Increased use and optimal dosing of guideline-recommended renin-angiotensin aldosterone system inhibitors (RAASi) improve patient outcomes in patients with heart failure, chronic kidney disease, and diabetes. However, RAASi use is also associated with increased occurrence of high potassium levels (hyperkalemia). Patiromer is indicated for the treatment of hyperkalemia, and patients taking patiromer are better able to tolerate optimal doses of RAASi than patients not taking patiromer. In this United States study from 2014 to 2019, 3323 patients who were more adherent with patiromer proportion of days covered > 80% used more RAASi than 10124 patients who were less adherent with patiromer (proportion of days covered ≤ 80%).
