What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires a stepwise approach based on severity, with calcium gluconate administration as the first-line treatment for patients with ECG changes, followed by insulin with glucose for intracellular potassium shifting, and consideration of newer potassium binders such as patiromer or sodium zirconium cyclosilicate for ongoing management. 1

Classification and Assessment

Hyperkalemia is classified according to severity:

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

ECG changes correlate with potassium levels:

• 5.5-6.5 mmol/L: Peaked/tented T waves, nonspecific ST segment abnormalities
• 6.5-7.5 mmol/L: Prolonged PR interval, flattened or absent P waves
• 7.0-8.0 mmol/L: Widened QRS, deep S waves, fusion of S and T waves

• 10 mmol/L: Sinusoidal wave pattern, ventricular fibrillation, asystole, or pulseless electrical activity 1

Emergency Treatment Algorithm

Step 1: Membrane Stabilization (for ECG changes or severe hyperkalemia)

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

Step 2: Intracellular Shifting of Potassium

• Insulin with glucose: 10 units regular insulin IV with 50 mL of 25% dextrose

  • Onset: 15-30 minutes
  • Duration: 1-2 hours
  • Monitor glucose levels to prevent hypoglycemia 1

• Inhaled beta-agonists: 10-20 mg nebulized over 15 minutes

  • Onset: 15-30 minutes
  • Duration: 2-4 hours 1

• Sodium bicarbonate: 50 mEq IV over 5 minutes (particularly in metabolic acidosis)

  • Onset: 15-30 minutes
  • Duration: 1-2 hours
  • Use with caution in fluid-overloaded patients 1

Step 3: Potassium Removal from Body

• Loop diuretics: 40-80 mg IV furosemide (for patients with some kidney function)

  • Onset: 30-60 minutes
  • Duration: 2-4 hours
  • Higher doses may be needed in CKD patients 1

• Potassium binders:

  • Newer agents (preferred): Patiromer or sodium zirconium cyclosilicate (SZC)
    • SZC: 10g TID for 48 hours 1
  • Sodium polystyrene sulfonate: 15-60g daily in divided doses
    • Not recommended for emergency treatment due to delayed onset 2
    • Must be administered at least 3 hours before or after other oral medications 2
    • Contraindicated in patients with obstructive bowel disease 2

• Hemodialysis: Consider for:

  • Severe hyperkalemia (>6.5 mEq/L) resistant to medical treatment
  • Persistent ECG changes
  • Oliguric/anuric renal failure
  • End-stage renal disease 1

Monitoring and Follow-up

• Monitor serial potassium levels every 2-4 hours until stable 1
• Perform daily electrolytes, BUN, creatinine, and acid-base status 1
• Point-of-care testing can provide quick potassium measurements for rapid assessment 1

Important Precautions

• Avoid potassium-containing fluids (Lactated Ringer's solution, Hartmann's solution) 1
• Do not rely solely on diuretics in anuric patients 1
• Sodium polystyrene sulfonate should not be used as emergency treatment due to delayed onset 2
• Avoid sodium polystyrene sulfonate in patients with bowel obstruction, reduced gut motility, or at risk for constipation/impaction 2
• Be cautious with sodium bicarbonate in fluid-overloaded patients 1

Treatment Selection Based on Clinical Scenario

1. Life-threatening hyperkalemia with ECG changes: Start with calcium gluconate, followed immediately by insulin with glucose 1, 3

2. Severe hyperkalemia without ECG changes: Insulin with glucose and inhaled beta-agonists, consider loop diuretics if kidney function is present 1

3. Moderate hyperkalemia: Consider loop diuretics and potassium binders 1

4. Mild hyperkalemia: Dietary modifications and review of medications that may contribute to hyperkalemia 1

5. Refractory hyperkalemia: Hemodialysis remains the most reliable method to remove potassium from the body 1, 3