From the Guidelines
Management of hyperkalemia requires prompt intervention based on the severity and symptoms, with the most recent and highest quality study 1 guiding treatment decisions to prioritize morbidity, mortality, and quality of life.
Overview of Hyperkalemia Management
For mild hyperkalemia (5.0-5.9 mEq/L), dietary potassium restriction and discontinuation of potassium-sparing medications may be sufficient. However, for moderate to severe hyperkalemia (≥6.0 mEq/L) or in symptomatic patients, immediate treatment is necessary.
Treatment Approach
The treatment approach should include:
- Stabilizing cardiac membranes with intravenous calcium gluconate (10%, 10 mL over 2-3 minutes) if ECG changes are present, as recommended by 1.
- Shifting potassium intracellularly using insulin (10 units regular insulin IV with 25g dextrose) or nebulized albuterol (10-20 mg), with the understanding that these interventions do not reduce total body potassium but temporarily lower serum levels, as noted in 1.
- Using sodium bicarbonate (50 mEq IV over 5 minutes) in patients with metabolic acidosis to promote potassium excretion, as suggested by 1.
- Administering sodium polystyrene sulfonate (15-30g orally or 30-50g rectally), or preferably newer agents like patiromer (8.4-25.2g daily) or sodium zirconium cyclosilicate (10g TID for 48 hours, then 5-10g daily) for definitive removal of potassium, as discussed in 1 and 1.
- Considering hemodialysis in severe cases for rapid potassium removal, as indicated by 1 and 1.
Continuous Monitoring and Underlying Cause Identification
Continuous cardiac monitoring is essential during treatment. The underlying cause of hyperkalemia should be identified and addressed, which may include adjusting medications like ACE inhibitors, ARBs, or potassium-sparing diuretics, treating renal dysfunction, or correcting adrenal insufficiency, as emphasized by 1 and 1. These interventions work by either stabilizing cardiac membranes, shifting potassium into cells temporarily, or eliminating excess potassium from the body, ultimately aiming to reduce morbidity, mortality, and improve quality of life.
From the Research
Management Strategies for Hyperkalemia
The management of hyperkalemia involves several strategies to reduce potassium levels and prevent life-threatening complications. These strategies include:
- Elimination of reversible causes, such as dietary changes and medication adjustments 2
- Rapidly acting therapies to shift potassium into cells and block cardiac membrane effects, including:
- Measures to facilitate removal of potassium from the body, including:
- New medications to promote gastrointestinal potassium excretion, such as patiromer and sodium zirconium cyclosilicate 4
Treatment Approach
The treatment approach for hyperkalemia depends on the severity of the condition and the presence of electrocardiogram (ECG) changes. For life-threatening hyperkalemia, treatment should be started with calcium gluconate to stabilize cardiomyocyte membranes, followed by insulin injection and beta-agonist administration 2, 3, 4. For less severe cases, treatment may involve a combination of these therapies, as well as measures to remove potassium from the body 2, 3, 4, 6, 5.
Long-term Management
Long-term management of hyperkalemia involves identifying and addressing the underlying causes of the condition, such as kidney disease or medication use 2, 3, 5. It also involves making lifestyle changes, such as dietary modifications, to prevent the recurrence or worsening of hyperkalemia 5.