What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires immediate intervention with calcium gluconate for cardiac stabilization, followed by insulin with glucose and beta-agonists to shift potassium intracellularly, while simultaneously initiating measures to eliminate potassium from the body. 1

Classification and Assessment

Hyperkalemia is classified into three categories:

• Mild: 5.0-5.5 mmol/L
• Moderate: 5.6-6.5 mmol/L
• Severe: >6.5 mmol/L 1

ECG assessment is crucial, with changes correlating to potassium levels:

• 5.5-6.5 mmol/L: Peaked/tented T waves (early sign)
• 6.5-7.5 mmol/L: Prolonged PR interval, flattened P waves
• 7.0-8.0 mmol/L: Widened QRS, deep S waves

• 10 mmol/L: Sinusoidal pattern, VF, asystole, or PEA 1

Treatment Algorithm

1. Cardiac Membrane Stabilization (Immediate)

• Calcium gluconate: 10% solution, 15-30 mL IV
  • Onset: 1-3 minutes
  • Duration: 30-60 minutes
  • Particularly effective for main rhythm disorders due to hyperkalemia 1, 2

2. Intracellular Potassium Shift (15-30 minutes)

• Insulin with glucose: 10 units regular insulin IV with 50 mL of 25% dextrose
  • Onset: 15-30 minutes
  • Duration: 1-2 hours
• Inhaled beta-agonists: 10-20 mg nebulized over 15 minutes
  • Onset: 15-30 minutes
  • Duration: 2-4 hours
• Sodium bicarbonate: 50 mEq IV over 5 minutes (less favored due to poor efficacy when used alone)
  • Onset: 15-30 minutes
  • Duration: 1-2 hours 1, 3

3. Potassium Elimination (30+ minutes)

• Loop diuretics: 40-80 mg IV (for patients with adequate renal function)
  • Onset: 30-60 minutes
  • Duration: 2-4 hours
• Potassium binders:
  • Sodium Zirconium Cyclosilicate (SZC): Faster onset, acts in both small and large intestines
  • Patiromer: Alternative binder with good selectivity
  • Sodium Polystyrene Sulfonate (SPS): Not for emergency treatment of life-threatening hyperkalemia due to delayed onset 1, 4, 5
• Hemodialysis: Most effective method for severe or refractory hyperkalemia 1, 6

Treatment Based on Severity

Mild Hyperkalemia (5.0-5.5 mmol/L)

• Consider potassium binders for chronic management
• Adjust medications that affect potassium levels
• Increase monitoring frequency 1

Moderate Hyperkalemia (5.6-6.5 mmol/L)

• Consider all treatments for mild hyperkalemia
• Add insulin with glucose and/or beta-agonists if symptomatic or with ECG changes 1, 7

Severe Hyperkalemia (>6.5 mmol/L)

• Immediate calcium gluconate administration
• Insulin with glucose and beta-agonists
• Consider hemodialysis, especially if refractory to medical therapy 1, 6

Monitoring and Follow-up

• Continuous cardiac monitoring during treatment
• Serial potassium measurements:
  • First check: 1-2 hours after initial treatment
  • Subsequent checks: every 4-6 hours until stable 1

Important Considerations and Pitfalls

1. Do not rely solely on ECG changes to determine treatment urgency, as absent or atypical ECG changes do not exclude the need for immediate intervention 3

2. Avoid potassium-containing fluids such as Lactated Ringer's solution or Hartmann's solution in patients with suspected hyperkalemia 1

3. Identify and hold medications that can worsen hyperkalemia:

   • Renin-angiotensin-aldosterone system inhibitors (RAASi)
   • Mineralocorticoid receptor antagonists (MRAs)
   • Potassium-sparing diuretics 1

4. Be aware of rebound hyperkalemia after initial treatment, especially when transcellular shifts are involved 7

5. Sodium Polystyrene Sulfonate (SPS) should not be used for emergency treatment of life-threatening hyperkalemia due to its delayed onset of action 4

6. More aggressive management may be required for patients with heart failure, chronic kidney disease, or diabetes mellitus, even for potassium levels in the high-normal range (>5.0 mmol/L) 1