What causes hyperkalemia (elevated potassium levels)?

From the Guidelines

Hyperkalemia is primarily caused by kidney disease, certain medications such as ACE inhibitors, ARBs, and potassium-sparing diuretics, excessive potassium intake, and various other factors including Addison's disease, uncontrolled diabetes, and severe tissue damage. These factors can lead to an imbalance in potassium levels, where the body either retains too much potassium or is unable to effectively filter it out. According to the most recent evidence from 1, treatment with ACE inhibitors and ARBs or MRAs can cause acute kidney injury (AKI) and hyperkalemia, emphasizing the importance of monitoring serum creatinine and potassium levels during treatment with these medications.

Causes of Hyperkalemia

• Kidney disease, which impairs the body's ability to filter excess potassium
• Certain medications like ACE inhibitors, ARBs, potassium-sparing diuretics (spironolactone, eplerenone), NSAIDs, and some antibiotics
• Excessive potassium intake from supplements or salt substitutes
• Addison's disease, which affects adrenal hormone production
• Uncontrolled diabetes
• Severe tissue damage from burns, trauma, or rhabdomyolysis
• Certain blood disorders like hemolysis
• Dehydration, which can concentrate potassium levels in the blood
• Lab errors, particularly if blood samples are mishandled or if there's significant hemolysis during collection

Importance of Monitoring and Management

Monitoring serum creatinine and potassium levels is crucial, especially when using medications that can cause hyperkalemia, as highlighted in 1. The management of hyperkalemia involves addressing the underlying cause and may include treatments such as calcium gluconate for cardiac protection, insulin with glucose to shift potassium into cells, sodium bicarbonate for acidosis, diuretics, or dialysis in severe cases. Identifying and addressing the underlying cause is essential for long-term management, as emphasized in the example answer.

Recent Guidelines and Recommendations

Recent guidelines, such as those from 1 and 1, emphasize the importance of monitoring and managing hyperkalemia, especially in patients with reduced glomerular filtration who are at increased risk. These guidelines provide recommendations for the management of hyperkalemia and highlight the need for periodic monitoring of serum creatinine and potassium levels when using certain medications.

From the Research

Causes of Hyperkalemia

• Hyperkalemia is a condition where serum potassium levels exceed 5.0-5.5 mmol/L 2, 3, 4, 5, 6
• It can be caused by:
  • Impaired renal excretion 3, 4, 6
  • Transcellular shifts 3, 4, 5, 6
  • Increased potassium intake 3, 4, 6
  • Certain medical conditions, such as:
    • Chronic kidney disease (CKD) 2, 6
    • Diabetes mellitus 2
    • Hypoaldosteronism 6
    • Massive tissue breakdown (e.g. rhabdomyolysis) 6
    • Hyperglycemia 5
• Drug-induced hyperkalemia is also a common cause, with various mechanisms including:
  • Interference with potassium homeostasis 4
  • Promotion of transcellular potassium shift 4
  • Impairment of renal potassium excretion 4
  • Increase in potassium supply 4
  • Examples of drugs that can cause hyperkalemia include:
    • Angiotensin-converting enzyme inhibitors 4
    • Angiotensin-II receptor blockers 4
    • Direct renin inhibitors 4
    • Nonsteroidal anti-inflammatory drugs 4
    • Calcineurin inhibitors 4
    • Heparin and derivatives 4
    • Aldosterone antagonists 4
    • Potassium-sparing diuretics 4
    • Trimethoprim 4
    • Pentamidine 4