What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires a tiered approach based on severity, with calcium gluconate for cardiac membrane stabilization, insulin with glucose for intracellular potassium shifting, and potassium binders for total body potassium reduction. 1

Assessment and Classification

Hyperkalemia severity guides treatment approach:

• Mild: 5.5-6.4 mmol/L - Peaked/tented T waves
• Moderate: 6.5-8.0 mmol/L - PR interval prolongation, flattened P waves, QRS widening
• Severe: >8.0 mmol/L - Bradycardia, junctional rhythm, sine wave pattern, ventricular fibrillation 1

Emergency Treatment Algorithm

For Life-Threatening Hyperkalemia (Severe or Symptomatic)

1. Cardiac Membrane Stabilization

   • Calcium gluconate 10% solution (15-30 mL IV)
   • Onset: 1-3 minutes
   • Duration: 30-60 minutes
   • Critical point: Calcium does NOT lower potassium levels but protects the heart 1, 2

2. Shift Potassium Intracellularly

   • 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 (albuterol): 10-20 mg nebulized over 15 minutes
     • Onset: 15-30 minutes
     • Duration: 2-4 hours
   • Sodium bicarbonate: 50 mEq IV over 5 minutes (if acidemic)
     • Onset: 15-30 minutes
     • Duration: 1-2 hours 1, 2

3. Remove Potassium from Body

   • Loop diuretics (if renal function adequate)
   • Consider hemodialysis for severe cases, especially with renal failure 2, 3

For Non-Emergency Hyperkalemia

1. Potassium Binders

   • Newer agents (preferred):
     • Patiromer: Onset ~7 hours
     • Sodium zirconium cyclosilicate (SZC): Onset ~1 hour
   • Traditional option:
     • Sodium polystyrene sulfonate (SPS): Variable onset (several hours)
     • Important caveat: SPS should NOT be used for emergency treatment due to delayed onset 1, 4, 2

2. Address Underlying Causes

   • Review and adjust medications that contribute to hyperkalemia
   • Treat metabolic acidosis if present 1, 5

Monitoring During Treatment

• Serial ECGs to track changes
• Continuous cardiac monitoring for moderate to severe cases
• Regular potassium level checks
• Monitor for rebound hyperkalemia, especially after shifting treatments 1, 6

Special Considerations

• Medication management: Avoid premature discontinuation of beneficial medications like ACE inhibitors/ARBs when possible. Consider potassium binders to maintain these medications 1, 5

• Dietary modifications: Limit potassium intake to <40 mg/kg/day. Focus on reducing non-plant sources of potassium rather than complete restriction 1, 5

• Pitfall alert: Transcellular shifts can cause rebound hyperkalemia after initial treatment. Continue monitoring even after initial improvement 6, 2

• Caution with SPS: Associated with serious gastrointestinal adverse effects. Newer binders (patiromer and SZC) have better safety profiles 2

Long-Term Management

• Correct underlying conditions
• Dietary counseling
• Adjust medications contributing to hyperkalemia
• Consider chronic use of potassium binders in recurrent cases 2, 5