How is hyperkalemia treated?

Hyperkalemia Treatment

Hyperkalemia requires a stepwise approach starting with calcium gluconate for cardiac stabilization in severe cases, followed by insulin with glucose for potassium redistribution, and ultimately potassium removal through diuretics, binders, or hemodialysis. 1

Classification and Assessment

Hyperkalemia severity is classified as:

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

ECG monitoring is essential to assess:

• Cardiac conduction abnormalities
• Response to treatment
• Potential complications 1

Acute Management Algorithm

Step 1: Cardiac Membrane Stabilization (for severe hyperkalemia >6.5 mmol/L or with ECG changes)

• Calcium gluconate: 10% solution, 15-30 mL IV
  • Onset: 1-3 minutes
  • Duration: 30-60 minutes 1

Step 2: Intracellular Potassium Redistribution

• Insulin with glucose: 10 units regular insulin IV with 50 mL of 25% dextrose
  • Onset: 15-30 minutes
  • Duration: 1-2 hours 1
• Inhaled beta-agonists (salbutamol): 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

Step 3: Potassium Removal

• Loop diuretics: 40-80 mg IV
  • Onset: 30-60 minutes
  • Duration: 2-4 hours 1
• Hemodialysis: For severe, refractory cases 1
• Potassium binders: For ongoing management
  • Sodium polystyrene sulfonate (not for emergency treatment due to delayed onset) 2
  • Newer agents: patiromer or sodium zirconium cyclosilicate 1

Chronic Hyperkalemia Management

Medication Review and Adjustment

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

Monitoring Protocol

• Serum potassium: Within 1 week of treatment initiation, more frequently in high-risk patients
• Serum creatinine and eGFR: Regular monitoring, especially in CKD patients
• ECG: To detect cardiac complications 1

RAAS Inhibitor Management

• For K+ levels between 4.5-5 mEq/L: Monitor and titrate RAAS inhibitors
• For K+ levels >5 mEq/L: Initiate K+ lowering agents and monitor levels
• Resume or titrate RAAS inhibitors when K+ levels are <5 mEq/L 1

Important Considerations

• Avoid overtreatment: Risk of rebound hypokalemia exists, especially with aggressive insulin/glucose treatment 1
• Sodium polystyrene sulfonate limitations: Not suitable for emergency treatment of life-threatening hyperkalemia due to delayed onset of action 2
• Lifestyle modifications: Recommend sodium restriction (<2g/day), regular physical activity, weight reduction if overweight/obese, and limited alcohol consumption 1

Special Populations

• CKD patients: Require more frequent monitoring of potassium, creatinine, and eGFR 1
• Heart failure patients: Hyperkalemia may lead to suboptimal dosing of beneficial RAAS inhibitors; consider potassium binders to maintain guideline-recommended doses 3
• Patients with primary aldosteronism: Present in 8-20% of hypertensive patients but screening rates are low (only 1.6% of eligible patients) 1