What is the treatment for hyperkalemia?

Treatment for Hyperkalemia

The treatment of hyperkalemia requires a stepwise approach based on severity, with immediate calcium gluconate administration for cardiac membrane stabilization, followed by insulin with glucose for intracellular potassium redistribution, and ultimately potassium removal from the body through diuretics, potassium binders, or hemodialysis. 1

Classification of Hyperkalemia

• Mild: >5.0 to <5.5 mmol/L
• Moderate: 5.5 to 6.0 mmol/L
• Severe: >6.0 mmol/L 1

Emergency Treatment for Severe Hyperkalemia (>6.0 mmol/L or with ECG changes)

Step 1: Cardiac Membrane Stabilization

• Calcium gluconate 10% solution, 15-30 mL IV
• Onset: 1-3 minutes
• Duration: 30-60 minutes
• Purpose: Protects the heart from arrhythmias by stabilizing cardiac membranes 1
• Note: This does not lower potassium levels but prevents cardiac complications

Step 2: Shift Potassium Intracellularly

• Regular insulin 10 units IV with 50 mL of 25% dextrose
  • Onset: 15-30 minutes
  • Duration: 1-2 hours 1
• Inhaled beta-agonists (albuterol) 10-20 mg nebulized over 15 minutes
  • Onset: 15-30 minutes
  • Duration: 2-4 hours 1
• Sodium bicarbonate 50 mEq IV over 5 minutes
  • Onset: 15-30 minutes
  • Duration: 1-2 hours 1
  • Most effective in patients with metabolic acidosis

Step 3: Remove Potassium from the Body

• Loop diuretics (furosemide 40-80 mg IV)
  • Onset: 30-60 minutes
  • Duration: 2-4 hours 1
  • Effective only in patients with adequate kidney function
• Hemodialysis
  • Most effective method for severe, refractory hyperkalemia 1
• Cation exchange resins (sodium polystyrene sulfonate)
  • Important limitation: Not for emergency treatment of life-threatening hyperkalemia due to delayed onset of action 2

Treatment for Chronic or Non-Emergency Hyperkalemia

Pharmacological Management

• Potassium binders:
  • Patiromer or sodium zirconium cyclosilicate for long-term management 1
  • Sodium polystyrene sulfonate for subacute treatment 1, 2

Dietary and Lifestyle Modifications

• Restrict dietary potassium intake
• Avoid foods rich in potassium and salt substitutes
• Maintain adequate hydration 1

Medication Review

• Identify and modify medications that contribute to hyperkalemia:
  • ACE inhibitors
  • Angiotensin II receptor blockers
  • Potassium-sparing diuretics
  • NSAIDs
  • Beta-blockers
  • Calcineurin inhibitors
  • Heparin and derivatives
  • Trimethoprim
  • Pentamidine 1

Monitoring

• Serum potassium: Within 1 week of treatment initiation, more frequently in patients with CKD, heart failure, or diabetes
• Serum creatinine, eGFR, and urine analysis: Regularly, especially in patients with chronic kidney disease 1

When to Seek Urgent Medical Care

• Potassium >6.5 mEq/L
• Presence of cardiac symptoms
• ECG changes
• Rapid rise in potassium
• Severe kidney disease
• Diabetic ketoacidosis 1

Important Considerations

• ECG changes may be absent even in severe hyperkalemia; do not rely solely on ECG to determine treatment urgency 3
• Combination therapy (insulin/glucose plus albuterol) may be more effective than single agents 3, 4
• Rebound hyperkalemia can occur after initial treatment; close monitoring is essential 5
• For chronic hyperkalemia, focus on reducing non-plant sources of potassium rather than restricting all potassium-rich foods 4