How to manage hyperkalemia?

Management of Hyperkalemia

The management of hyperkalemia requires a systematic approach based on severity, with acute interventions for severe cases (K+ >6.0 mEq/L) including IV calcium, insulin with glucose, and beta-agonists, while chronic management involves potassium binders and addressing underlying causes. 1

Classification of Hyperkalemia

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

Acute Management (Severe Hyperkalemia)

Immediate Interventions (for ECG changes or K+ >6.0 mEq/L)

1. Calcium gluconate: 10% solution, 15-30 mL IV

   • Onset: 1-3 minutes, Duration: 30-60 minutes
   • Stabilizes cardiac membranes 1

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

   • Onset: 15-30 minutes, Duration: 1-2 hours
   • Shifts potassium intracellularly 2, 1

3. Nebulized beta-agonists: 20 mg salbutamol in 4 mL

   • Onset: 15-30 minutes, Duration: 2-4 hours
   • Shifts potassium intracellularly 2, 1

Additional Measures Based on Clinical Context

• Sodium bicarbonate: 50 mEq IV (only in patients with metabolic acidosis)

  • Promotes potassium elimination through increased urinary excretion 2, 1

• Loop diuretics: 40-80 mg IV furosemide (in non-oliguric patients)

  • Effective in patients with some kidney function and hypervolemia 2, 1

• Hemodialysis: Consider for:

  • Severe hyperkalemia (>6.5 mEq/L) resistant to medical treatment
  • Persistent ECG changes
  • Oliguric/anuric renal failure
  • End-stage renal disease 2, 1

Chronic Management

Potassium Binders

• Newer potassium binders (patiromer or sodium zirconium cyclosilicate) are recommended over sodium polystyrene sulfonate due to better safety profile 1
• Sodium zirconium cyclosilicate: 10g TID for 48 hours can effectively lower potassium levels 1
• Sodium polystyrene sulfonate should not be used as emergency treatment due to delayed onset of action 3

RAAS Inhibitor Management

For patients requiring RAAS inhibitors (RAASi):

• K+ >6.5 mEq/L: Discontinue/reduce RAASi and initiate K+-lowering agent 2
• K+ >5.0-<6.5 mEq/L: Initiate K+-lowering agent and maintain RAASi if possible 2
• K+ 4.5-5.0 mEq/L: Up-titrate RAASi with close monitoring 2

Dietary Modifications

While dietary potassium restriction (<3g/day) is traditionally recommended, evidence supporting this practice is limited 2, 4. Consider:

• Educating patients about high-potassium foods and appropriate serving sizes
• Teaching cooking methods (boiling) to reduce potassium content
• Avoiding hidden sources of potassium (additives, salt substitutes)
• Maintaining adequate fiber intake to prevent constipation (which can worsen hyperkalemia) 5

Monitoring

• Monitor potassium levels every 2-4 hours until stable in acute settings
• For chronic management, check potassium within 1 week of treatment initiation
• Regular monitoring of kidney function (creatinine, eGFR) 1

Important Caveats

1. ECG monitoring is essential in severe hyperkalemia - watch for:

   • K+ 5.5-6.5 mmol/L: Peaked T waves
   • K+ 6.5-7.5 mmol/L: Prolonged PR interval, flattened P waves
   • K+ 7.0-8.0 mmol/L: Widened QRS
   • K+ >10 mmol/L: Sinusoidal pattern, VF, asystole 1

2. Avoid potassium-containing fluids (Lactated Ringer's) in suspected hyperkalemia 1

3. Consider continuing RAASi therapy when indicated with close monitoring, as discontinuation is associated with higher mortality risk 1

4. Sodium polystyrene sulfonate with sorbitol should be avoided for chronic use due to risk of bowel necrosis 2