The Impact of Potassium Binders on Mortality in Patients with Hyperkalemia: A Single-Center Study

Round 1

Reviewer 1 Report

Thank you for giving me the opportunity to review this paper. My comments and suggestions are as follows:

·         Line 18: The  meaning of CPS (calcium polystyrene sulfonate ) should appear at this point

·         The introduction´s redaction  should be improved since there are redundant sentences e.g. “Hyperkalemia is a serious condition that can result from CKD, among other causes, and can have potentially life-threatening complications” means the same as “ The consequences of untreated hyperkalemia can be severe, including abnormal heart rhythms and potentially fatal cardiac arrest.”

·         Figure 1: change luck for lack in the exclusion box

·         Figure 1: eliminate who in both boxes with CPS-ON and OFF groups

·         Table 1: Were there no diabetics in either group? if not, this should be specified.

·         Line 143: “These findings are of significant importance, as they highlight the potential impact of CPS use on patient health outcomes” This sentence needs to be explained as it does not follow from the previous statement.

·         Line 152: The authors affirm “the incidence of death, (…) was higher in the CPS_OFF group than in the CPS_ON group”.  CPS_OFF group had a better renal function and lower K levels, so, why do they attribute the worse outcome to the use of potassium binders? Or do they attribute it to the most frequent use of RAASi in the CPS_ON group? Given that is the central message of the work, I believe that it is not sufficiently explained.

·         Line 294 Given that there are many factors that affect the survival of a patient with CKD, the phrase "potassium chelators may reduce the risk of death in patients with CKD" may not be entirely appropriate. It should be changed to "patients taking potassium chelators have better outcomes than those not taking them" or similar.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

-       It should be noted in the introduction section that diabetics with CKD are even more prone to developing hyperkalemia due to hyporeninemic hypoaldosteronism. This is important due to new drugs that are being developed and used for treating diabetic CKD, for example, finerenone (which also has a slight tendency to cause hyperkalemia). 

-       What is your opinion on how the results of your study could impact future treatment with selective, non-steroid mineralocorticoid receptor antagonists (finerenone)?

-       Did you check what were the most common causes of death in both groups of patients?

-       What about the side effects of using potassium binders?

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Thank you for your work