From the Guidelines
Hyperkalemia is primarily caused by kidney dysfunction, medications such as ACE inhibitors, ARBs, potassium-sparing diuretics, and NSAIDs, as well as other factors like massive cell destruction, metabolic acidosis, and excessive potassium intake, as supported by the most recent evidence from 2021 1.
Causes of Hyperkalemia
The causes of hyperkalemia can be broadly categorized into:
- Kidney dysfunction, which impairs potassium excretion
- Medications like ACE inhibitors, ARBs, potassium-sparing diuretics (spironolactone, eplerenone), and NSAIDs
- Massive cell destruction (rhabdomyolysis, tumor lysis syndrome, hemolysis)
- Metabolic acidosis
- Insulin deficiency
- Excessive potassium intake through supplements or potassium-rich foods
- Adrenal insufficiency, which reduces aldosterone production and thus impairs potassium excretion
- Certain medical conditions like type 4 renal tubular acidosis and pseudohyperkalemia (a laboratory artifact from hemolysis during blood collection)
Underlying Mechanism
The underlying mechanism of hyperkalemia typically involves either excessive potassium release from cells, inadequate potassium excretion by the kidneys, or excessive potassium intake that overwhelms the body's regulatory mechanisms. Identifying the specific cause is crucial for effective treatment and prevention of potentially life-threatening cardiac complications, as highlighted in recent guidelines 1.
Recent Guidelines and Recommendations
Recent studies and guidelines, including those from 2021 1 and 2025 1, emphasize the importance of monitoring serum creatinine and potassium levels in patients treated with ACE inhibitors, ARBs, MRAs, or diuretics, particularly among those with reduced glomerular filtration who are at increased risk of hyperkalemia and acute kidney injury.
Key Considerations
- Monitoring: Regular monitoring of potassium levels and kidney function is essential in patients at risk of hyperkalemia.
- Medication Management: Careful management of medications known to contribute to hyperkalemia, such as ACE inhibitors, ARBs, and potassium-sparing diuretics, is critical.
- Dietary Considerations: Patients should be advised on low-potassium diets and the avoidance of potassium-rich foods and supplements when necessary.
- Treatment: Treatment of hyperkalemia should be tailored to the underlying cause and may involve the use of potassium-lowering agents, diuretics, and other interventions as needed, as discussed in recent expert consensus documents 1.
From the Research
Causes of Hyperkalemia
- Hyperkalemia is a condition where serum potassium levels exceed 5.5 mmol/l, and it can be caused by various medical conditions, including chronic kidney disease (CKD), diabetes mellitus, and heart failure 2, 3, 4, 5
- Certain medications, such as inhibitors of the renin-angiotensin-aldosterone system, potassium-sparing diuretics, nonsteroidal anti-inflammatory drugs, succinylcholine, and digitalis, can also contribute to hyperkalemia 3, 5
- Tissue trauma and hyperglycemia can also lead to hyperkalemia 3, 6
- Reduced urinary potassium excretion in CKD patients can lead to an inability to maintain potassium homeostasis, resulting in hyperkalemia 4
Underlying Predisposing Conditions
- Moderate or severe kidney disease is a common underlying condition that can lead to hyperkalemia 3
- Heart failure and diabetes mellitus are also associated with an increased risk of hyperkalemia 3, 5
- Significant tissue trauma can also predispose individuals to hyperkalemia 3