What is the best treatment approach for hyperkalemia in an 87-year-old female patient with acute kidney injury (AKI) and impaired renal function, presenting with abdominal pain?

From the Guidelines

The best treatment approach for hyperkalemia in this 87-year-old female patient with acute kidney injury (AKI) and impaired renal function is to immediately intervene with multiple strategies, prioritizing stabilization of cardiac membranes and reduction of potassium levels. Initial management should focus on stabilizing cardiac membranes with intravenous calcium gluconate (10 mL of 10% solution over 2-3 minutes), which protects against arrhythmias but doesn't lower potassium levels, as recommended by the most recent study 1. To shift potassium intracellularly, administer insulin (10 units regular insulin IV) with glucose (25-50g dextrose) to prevent hypoglycemia, and consider nebulized albuterol (10-20 mg) 1. For potassium removal, sodium polystyrene sulfonate (15-30g orally or rectally) or the newer potassium binders patiromer or sodium zirconium cyclosilicate can be used, with the newer potassium binders being effective in normalizing elevated K+ levels and maintaining normo-kalaemia over time, as shown in clinical trials 1. Some key points to consider in the treatment of hyperkalemia include:

• The importance of continuous cardiac monitoring during treatment
• The need to address the underlying AKI by maintaining adequate hydration, avoiding nephrotoxic medications, and treating any reversible causes of kidney injury
• Special consideration for this elderly patient, including careful dosing to prevent adverse effects and close monitoring of renal function, electrolytes, and glucose levels throughout treatment
• The potential for dietary restrictions to help manage hyperkalemia, including limiting intake of high-potassium foods such as bananas, oranges, and potatoes 1. In severe cases with ECG changes or very high potassium levels, urgent hemodialysis may be necessary, as it increases total K+ elimination and may be used for resistant acute hyperkalemia 1.

From the FDA Drug Label

The average total daily adult dose of Sodium Polystyrene Sulfonate Powder, for Suspension is 15 g to 60 g, administered as a 15-g dose (four level teaspoons), one to four times daily. The intensity and duration of therapy depend upon the severity and resistance of hyperkalemia.

For an 87-year-old female patient with acute kidney injury (AKI) and impaired renal function, presenting with abdominal pain and hyperkalemia (potassium 5.8 mmol/L), the best treatment approach is to administer Sodium Polystyrene Sulfonate Powder, for Suspension at a dose of 15 g to 60 g per day, given as a 15-g dose one to four times daily, depending on the severity and resistance of hyperkalemia.

• The treatment should be tailored to the individual patient's needs, taking into account the severity of hyperkalemia and the patient's renal function.
• It is essential to monitor the patient's potassium levels and adjust the treatment as needed.
• The patient should be administered the treatment with caution, considering their age and comorbidities, such as abdominal pain and AKI 2.

From the Research

Treatment Approach for Hyperkalemia

The treatment approach for hyperkalemia in an 87-year-old female patient with acute kidney injury (AKI) and impaired renal function, presenting with abdominal pain, involves several key strategies:

• Membrane Stabilization: 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.
• Cellular Shift: Beta-agonists and intravenous insulin should be given to shift potassium from extracellular to intracellular stores. However, hypoglycemia after insulin use is a frequent complication, and strategies such as 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 can reduce the risk of hypoglycemia 4.
• Potassium Excretion: Dialysis is the most efficient means to enable removal of excess potassium. Loop and thiazide diuretics can also be useful 3.
• New Medications: New medications to promote gastrointestinal potassium excretion, such as patiromer and sodium zirconium cyclosilicate, hold promise 3.
• Avoidance of Ineffective Treatments: Sodium polystyrene sulfonate is not efficacious and has been associated with colonic necrosis and other serious gastrointestinal adverse reactions 5.

Considerations for Patients with Impaired Renal Function

For patients with impaired renal function, such as the 87-year-old female patient with AKI, it is essential to monitor serum potassium levels closely and adjust treatment accordingly. Calcium polystyrene sulfonate has been shown to be effective in reducing potassium levels in patients with stage 3-5 non-dialysis chronic kidney disease without adverse effects on sodium, phosphorus, or calcium levels 6.

Key Points to Consider

• Hyperkalemia is a life-threatening condition requiring emergent therapy 3, 4.
• The treatment approach should involve a combination of membrane stabilization, cellular shift, and potassium excretion strategies.
• Patients with impaired renal function require close monitoring of serum potassium levels and adjustment of treatment accordingly.
• New medications and treatments, such as patiromer and sodium zirconium cyclosilicate, may offer alternative options for managing hyperkalemia in patients with impaired renal function.