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Patients with cardiovascular, renal, and metabolic diseases are at increased risk of hyperkalemia, particularly when treated with RAASi. However, data on the management of hyperkalemia in German primary care practices are limited.The retrospective, cross-sectional study WATCH-K included 411202 patients from primary care practices with documented chronic kidney disease (CKD), heart failure (HF), hypertension, and/or diabetes mellitus, all at elevated risk for hyperkalemia. Patients were observed for ≥1 year. The study analyzed the frequency of serum potassium measurements, the prevalence and diagnosis of hyperkalemia, and its treatment with potassium binders.In the overall population 70.8% of patients received RAASi therapy, and 35.2% had their serum potassium levels measured at least once during the year, most frequently among patients with CKD (44.8%) and HF (42.8%). Among all patients tested, 24.5% (n=35368) showed hyperkalemic values, but only 2.0% (n=696) had a recorded diagnosis. Only 10.9% (n=76) of them were treated with potassium binders, and only 15.8% (n=12) of them received modern agents such as sodium zirconium cyclosilicate or patiromer.The management of hyperkalemia in high-risk patients in German primary care should be significantly improved through more frequent potassium monitoring and guideline-directed use of potassium binders to enhance patient outcomes. Furthermore, exploring the reasons behind the cautious use of medication to treat hyperkalemia may provide valuable insights.