When do you decide to initiate potassium binders for patients with hyperkalemia in the setting of CKD?

This is a complicated question and requires a lot of thought. In brief, first, I will determine if the serum potassium is high enough (usually around 5.3-5.5) and if it is increasing rapidly. Then I will determine if the patient is on a drug that will worsen hyperkalemia (mainly ACE/ARB/MRB). Then I have to evaluate how important it is to continue that medication. If it is not so crucial, I would stop the offending medicine first to see if the potassium will improve. If the medicine is absolutely needed, then I would start the potassium binder. I am sure I missed something in this brief synopsis, but I will add it later if needed.

I would generally start a K binder for K of 5.4 mmol/L or higher despite diet modification and appropriate use of diuretics