From the Guidelines
Hyperkalemia is a life-threatening condition that requires immediate treatment, and the most effective approach includes administering calcium gluconate 10% (10 mL IV over 2-3 minutes) to stabilize cardiac membranes, followed by insulin (10 units regular insulin IV) with glucose (25g IV) to shift potassium intracellularly, as recommended by the most recent and highest quality study 1.
Causes of Hyperkalemia
The causes of hyperkalemia include:
- Kidney dysfunction
- Medication effects, such as ACE inhibitors, potassium-sparing diuretics, and NSAIDs
- Adrenal insufficiency
- Massive cell destruction
- Excessive potassium intake
Treatment of Hyperkalemia
The treatment of hyperkalemia depends on the severity and symptoms of the condition. For severe hyperkalemia (>6.5 mEq/L) or with ECG changes, emergency treatment includes:
- Calcium gluconate 10% (10 mL IV over 2-3 minutes) to stabilize cardiac membranes
- Insulin (10 units regular insulin IV) with glucose (25g IV) to shift potassium intracellularly
- Sodium bicarbonate (50 mEq IV over 5 minutes) may help in acidotic patients For ongoing management, potassium-binding resins like sodium polystyrene sulfonate (15-30g orally or rectally) or newer agents like patiromer (8.4-25.2g daily) can be used. Diuretics such as furosemide (20-40mg IV) help eliminate potassium through urine. Hemodialysis is necessary for life-threatening cases or renal failure.
Importance of Monitoring
Regular monitoring of potassium levels is crucial in patients treated with renin-angiotensin-aldosterone system inhibitors, especially in those with cardiovascular disease and chronic kidney disease, as they are at higher risk of developing hyperkalemia 1. Quality improvement programs are needed to improve rates of laboratory monitoring for patients initiated on mineralocorticoid receptor antagonist therapy, particularly in high-risk patients.
From the Research
Causes of Hyperkalemia
- Hyperkalemia is a condition where serum potassium levels exceed 5.5 mmol/l, often resulting from extracellular potassium shift or decreased renal potassium excretion 2
- Certain medical conditions, such as chronic kidney disease (CKD), diabetes mellitus, and others, can lead to hyperkalemia 2
- Acute kidney injury, critical illness, crush injuries, and massive red blood cell transfusions can also result in hyperkalemia 3
- The use of certain medications, such as angiotensin-converting enzyme inhibitors, direct renin inhibitors, beta-adrenergic receptor antagonists, angiotensin receptor blockers, and mineralocorticoid receptor antagonists, can modulate potassium excretion and contribute to hyperkalemia 3
Symptoms and Diagnosis of Hyperkalemia
- Hyperkalemia can present with non-specific symptoms, and early recognition is vital in preventing fatal cardiac arrhythmias and muscle paralysis 4
- A history and physical examination can be beneficial in the diagnosis of hyperkalemia, along with characteristic electrocardiogram findings and laboratory potassium levels 2
- Hyperkalemia can be detected via serum clinical laboratory measurement, and the most severe effect includes various cardiac dysrhythmias, which may result in cardiac arrest and death 5
Treatments for Hyperkalemia
- Treatment includes measures to stabilize cardiac membranes, shift potassium from extracellular to intracellular stores, and promote potassium excretion 5
- 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 5
- Beta-agonists and intravenous insulin should be given, and some experts recommend the use of synthetic short-acting insulins rather than regular insulin 5
- Dextrose should also be administered, as indicated by initial and serial serum glucose measurements 5
- Dialysis is the most efficient means to enable removal of excess potassium, and loop and thiazide diuretics can also be useful 5, 4
- New medications to promote gastrointestinal potassium excretion, such as patiromer and sodium zirconium cyclosilicate, hold promise 5, 2, 3
- Sodium polystyrene sulfonate is not efficacious 5, but can be used in certain cases, although it is poorly tolerated due to gastrointestinal adverse effects 3