What are the causes and treatments of Hyperkalemia (elevated potassium levels)?

From the Guidelines

Hyperkalemia treatment should prioritize urgent intervention with calcium gluconate, insulin, and loop diuretics for moderate to severe cases, as recommended by the most recent and highest quality study 1.

Treatment Approach

The treatment of hyperkalemia depends on the severity and symptoms of the condition. For mild cases (5.0-5.9 mEq/L), discontinuing potassium-raising medications like ACE inhibitors, ARBs, and potassium-sparing diuretics is recommended, along with dietary potassium restriction.

• Discontinuing potassium-raising medications
• Dietary potassium restriction

Moderate to Severe Cases

For moderate to severe cases, the following treatments can be used:

• Calcium gluconate (1 ampule IV over 2-3 minutes) to stabilize cardiac membranes, as recommended by 1
• Insulin (10 units regular insulin IV with 25g glucose) and albuterol nebulization (10-20mg) to shift potassium intracellularly
• Sodium bicarbonate (50 mEq IV over 5 minutes) may help in acidotic patients

Potassium Removal

For potassium removal, the following options can be used:

• Loop diuretics like furosemide (40-80mg IV)
• Sodium polystyrene sulfonate (15-30g orally or rectally)
• Patiromer (8.4-16.8g daily)

Hemodialysis

Hemodialysis is reserved for life-threatening cases or renal failure, as stated in 1.

Regular Monitoring

Regular monitoring of potassium levels is essential during treatment, especially in patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia, as highlighted in 1.

From the FDA Drug Label

1 INDICATIONS AND USAGE Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia.

Limitation of Use: Sodium Polystyrene Sulfonate Powder, for Suspension should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action [see Clinical Pharmacology (12.2)].

• Hyperkalemia treatment: Polystyrene sulfonate (PO) is indicated for the treatment of hyperkalemia.
• Limitation: It should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 2.

From the Research

Definition and Causes of Hyperkalemia

• Hyperkalemia is a common electrolyte disorder that can result in morbidity and mortality if not managed appropriately 3.
• It occurs when there is a sufficiently marked elevation in extracellular fluid concentrations of potassium (K+) 3.
• Hyperkalemia can be detected via serum clinical laboratory measurement 3.

Effects of Hyperkalemia

• The most severe effect of hyperkalemia includes various cardiac dysrhythmias, which may result in cardiac arrest and death 3.
• Hyperkalemia can be deadly, and treatment requires specific measures including membrane stabilization, cellular shift, and excretion 3.
• Chronic hyperkalemia is associated with increased morbidity and mortality 4.

Treatment of Hyperkalemia

• Treatment includes measures to "stabilize" cardiac membranes, to shift K+ from extracellular to intracellular stores, and to promote K+ excretion 3.
• Calcium gluconate 10% dosed 10 mL intravenously should be provided for membrane stabilization, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted 3.
• Beta-agonists and intravenous insulin should be given, and some experts recommend the use of synthetic short-acting insulins rather than regular insulin 3.
• Dialysis is the most efficient means to enable removal of excess K+ 3.
• Loop and thiazide diuretics can also be useful 3.
• Sodium polystyrene sulfonate is not efficacious 3.
• New medications to promote gastrointestinal K+ excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise 3.
• Inhaled beta-agonists, nebulised beta-agonists, and intravenous (IV) insulin-and-glucose were all effective in treating hyperkalemia 5.
• The combination of nebulised beta agonists with IV insulin-and-glucose was more effective than either alone 5.

Management of Hyperkalemia with Insulin and Glucose

• Insulin and dextrose are frequently used to manage patients with hyperkalemia 6.
• Hypoglycemia after insulin use is a frequent complication during hyperkalemia management 6.
• Several strategies can reduce the risk of hypoglycemia with insulin therapy, which include using insulin 5 units or 0.1 units/kg instead of 10 units, administering dextrose 50 g instead of 25 g, or administering dextrose as a prolonged infusion instead of a rapid intravenous bolus 6.
• Patients receiving insulin for hyperkalemia should be monitored for hypoglycemia hourly for at least 4-6 h after administration 6.