What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires a stepwise approach based on severity, with acute life-threatening hyperkalemia requiring immediate membrane stabilization with IV calcium gluconate, followed by potassium redistribution therapies and ultimately removal strategies. 1

Acute Hyperkalemia Management

Immediate Interventions for Severe/Symptomatic Hyperkalemia

1. Cardiac membrane stabilization

   • IV calcium gluconate 10% (10 mL) - acts within 1-3 minutes
   • Protects against cardiac arrhythmias
   • May repeat after 5-10 minutes if no effect observed 1
   • Does not lower serum potassium levels

2. Potassium redistribution into cells (30-60 minute onset)

   • IV insulin (10 units) with glucose (50 mL of 50% dextrose)
   • Nebulized β-agonists (salbutamol/albuterol 20 mg in 4 mL)
   • These can be used together for additive effect 1
   • Note: These provide only temporary benefit (1-4 hours) with risk of rebound hyperkalemia 1

3. Additional measures for specific situations

   • IV sodium bicarbonate - for patients with concurrent metabolic acidosis 1
   • Loop diuretics - for hypervolemic, non-oliguric patients 1
   • Hemodialysis - for severe, resistant cases or patients with oliguria/ESRD 1

Important Caveats

• ECG findings (peaked T waves, prolonged QRS) may be variable and not as sensitive as laboratory tests 1
• Sodium polystyrene sulfonate should NOT be used for emergency treatment due to delayed onset of action 2
• Rebound hyperkalemia can occur after 2 hours with redistribution therapies, necessitating definitive treatment 1

Chronic Hyperkalemia Management

1. Medication review and adjustment

   • Identify and discontinue medications causing hyperkalemia when possible (NSAIDs, potassium-sparing diuretics, etc.) 1
   • Consider modification of RAAS inhibitor doses rather than complete discontinuation 1

2. Pharmacological management

   • Loop or thiazide diuretics to promote urinary potassium excretion 1
   • Potassium binders:
     • Sodium polystyrene sulfonate for non-urgent cases 2
     • Newer agents: patiromer or sodium zirconium cyclosilicate 1

3. Monitoring recommendations

   • Assess potassium levels within 1 week of starting or increasing doses of RAAS inhibitors 1
   • More frequent monitoring for high-risk patients (CKD, diabetes, heart failure) 1

Special Considerations

• Heart failure patients: Maximum tolerated RAAS inhibitor therapy should be maintained when possible, with hyperkalemia treated if it develops 1
• Chronic kidney disease: Effectiveness of diuretics depends on residual kidney function 1
• Dialysis patients: May require more frequent or urgent dialysis for hyperkalemia management 1

Risk Factors for Hyperkalemia

• Decreased renal function (CKD, acute kidney injury)
• Medications (RAAS inhibitors, potassium-sparing diuretics, NSAIDs)
• Metabolic acidosis
• Diabetes mellitus
• Heart failure
• Excessive potassium intake 1

The treatment approach should be guided by the severity of hyperkalemia, presence of ECG changes, and underlying conditions, with the primary goal of preventing life-threatening cardiac arrhythmias while addressing the underlying cause.