What are the management strategies for Hyperkalemia (elevated potassium levels)?

From the Guidelines

Hyperkalemia management requires prompt intervention based on severity and symptoms, with the most recent and highest quality study 1 guiding treatment decisions to prioritize morbidity, mortality, and quality of life. For mild hyperkalemia (K+ 5.0-5.9 mEq/L), management strategies include:

• Restricting dietary potassium
• Discontinuing potassium-sparing medications, ACE inhibitors, ARBs, and NSAIDs For moderate hyperkalemia (K+ 6.0-6.9 mEq/L) without ECG changes, treatment options are:
• Administering sodium polystyrene sulfonate 15-30g orally or 30-50g rectally
• Using patiromer 8.4g daily For severe hyperkalemia (K+ ≥7.0 mEq/L) or with ECG changes, immediate treatment includes:
• Calcium gluconate 10% 10-20mL IV over 2-3 minutes to stabilize cardiac membranes
• Insulin 10 units IV with 50mL of 50% dextrose to shift potassium intracellularly (monitoring glucose levels)
• Nebulized albuterol 10-20mg Sodium bicarbonate 50mEq IV over 5 minutes can be given if metabolic acidosis is present, as noted in 1. Hemodialysis should be considered for life-threatening hyperkalemia or renal failure, as indicated in 1. After acute management, it is essential to identify and address the underlying cause, which may include renal dysfunction, medication effects, tissue breakdown, or adrenal insufficiency, and serial potassium monitoring is crucial to assess response to treatment and prevent recurrence, as emphasized in 1. The physiological basis for these interventions involves membrane stabilization, intracellular shifting of potassium, and enhanced potassium elimination through the gastrointestinal tract or dialysis, as explained in 1. Key considerations in hyperkalemia management include:
• Recognizing the risk of hyperkalemia in patients with cardiovascular disease, particularly those with heart failure, arterial hypertension, and chronic kidney disease, as highlighted in 1
• Being aware of the potential for hyperkalemia with renin-angiotensin-aldosterone system inhibitors, as discussed in 1
• Monitoring potassium levels regularly, especially in high-risk patients, to prevent hyperkalemia-related adverse events, as recommended in 1

From the Research

Management Strategies for Hyperkalemia

The management of hyperkalemia involves several strategies to stabilize cardiac membranes, shift potassium from extracellular to intracellular stores, and promote potassium excretion. The following are some of the management strategies for hyperkalemia:

• Stabilization of cardiac membranes: Calcium gluconate 10% dosed 10 mL intravenously should be provided for membrane stabilization, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted 2.
• Shifting potassium from extracellular to intracellular stores: Beta-agonists and intravenous insulin should be given, and some experts recommend the use of synthetic short-acting insulins rather than regular insulin 2. Insulin, usually with concomitant glucose, and albuterol are preferred to lower serum potassium levels in the acute setting 3.
• Promoting potassium excretion: Dialysis is the most efficient means to enable removal of excess potassium 2. Loop and thiazide diuretics can also be useful 2. New medications to promote gastrointestinal potassium excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise 2, 4.
• Long-term management: Long-term management of potassium disturbances includes correcting underlying conditions, dietary counseling, and adjusting causative medications 4. An extensive search must be made to uncover overt or sometimes covert medications that may have led to the development of hyperkalemia 5.

Treatment Approaches

The treatment approach to hyperkalemia depends on the severity of the condition and the presence of electrocardiography changes. The following are some of the treatment approaches:

• Urgent treatment: Indications for urgent treatment include severe or symptomatic hyperkalemia, abrupt changes in potassium levels, electrocardiography changes, or the presence of certain comorbid conditions 3.
• Acute treatment: Acute treatment may include intravenous calcium, insulin, sodium bicarbonate, diuretics, and beta agonists 4.
• Subacute treatment: Sodium polystyrene sulfonate is reserved for subacute treatment, but it is associated with serious gastrointestinal adverse effects 3, 4.

Prevention of Recurrence

Prevention of recurrence is an important aspect of hyperkalemia management. The following are some strategies to prevent recurrence:

• Identifying underlying causes: Further assessment of the underlying basis for hyperkalemia usually reveals a problem with renal potassium excretion 6.
• Reviewing prescribed drugs: Careful review of prescribed drugs that may be adversely affecting potassium homeostasis is necessary 6.
• Dietary counseling: Dietary counseling is an important aspect of long-term management of potassium disturbances 4.