What is the treatment for a 67-year-old male with hyperkalemia?

Treatment of Hyperkalemia in a 67-Year-Old Male with Potassium of 6.1

Immediate treatment for a 67-year-old male with a potassium level of 6.1 mmol/L should include calcium gluconate to stabilize cardiac membranes, followed by insulin with glucose to shift potassium intracellularly, and then measures to remove potassium from the body. 1

Assessment and Stabilization

1. Evaluate for ECG changes:

   • At potassium level of 6.1 mmol/L, expect peaked T waves, possibly prolonged PR interval
   • Continuous cardiac monitoring is essential 1

2. Immediate stabilization (membrane protection):

   • Calcium gluconate 10% solution, 15-30 mL IV over 5-10 minutes
   • Onset: 1-3 minutes; Duration: 30-60 minutes 1
   • Note: This does not lower potassium but protects against arrhythmias

Shifting Potassium Intracellularly

1. Insulin with glucose:

   • 10 units regular insulin IV with 50 mL of 25% dextrose
   • Onset: 15-30 minutes; Duration: 1-2 hours 1

2. Additional shifting strategies:

   • Inhaled beta-agonists: 10-20 mg nebulized over 15 minutes
   • Sodium bicarbonate: 50 mEq IV over 5 minutes (especially if acidotic) 1

Removing Potassium from Body

1. Potassium binders:

   • Patiromer (Veltassa): 8.4g once daily (onset within 7 hours) 1
   • Sodium polystyrene sulfonate: Consider for non-emergent management
     • Caution: Not for emergency treatment due to delayed onset 2
     • Risk of GI injury with sodium polystyrene sulfonate 1, 3

2. Loop diuretics:

   • IV furosemide if renal function permits
   • Enhances urinary potassium excretion 1

3. Consider hemodialysis if:

   • Severe hyperkalemia persists despite above measures
   • Patient has end-stage renal disease
   • Severe renal impairment present 3

Identify and Address Underlying Causes

1. Medication review:

   • Discontinue or adjust medications that may cause hyperkalemia:
     • ACE inhibitors/ARBs (especially if eGFR <60 mL/min/1.73m²)
     • Potassium-sparing diuretics
     • NSAIDs 1

2. Evaluate for renal dysfunction:

   • Check creatinine, eGFR, urine potassium, and osmolarity 4
   • Assess for hyporeninemic hypoaldosteronism, especially in diabetic patients 4

Long-term Management

1. Dietary modifications:

   • Limit potassium intake to <40 mg/kg/day
   • Avoid high-potassium foods: processed foods, bananas, oranges, potatoes, tomatoes, legumes 1
   • Focus on reducing non-plant sources of potassium 5

2. Monitoring:

   • Regular potassium checks within 2-3 days after medication changes
   • Serial ECGs if moderate to severe hyperkalemia 1

3. Consider newer potassium binders for chronic management:

   • Patiromer or sodium zirconium cyclosilicate for chronic hyperkalemia 3, 6
   • Separate patiromer from other oral medications by at least 3 hours 1

Special Considerations

• In patients with heart failure, hyperkalemia (>5.0 mmol/L) is associated with increased mortality risk, especially in those >65 years with comorbid CKD or diabetes 7
• If the patient has CKD, be aware that hyperkalemia is common and may limit optimal RAAS blockade therapy 8
• Avoid dual RAAS blockade in CKD patients due to markedly increased hyperkalemia risk 8

Note: The severity of hyperkalemia at 6.1 mmol/L warrants prompt intervention due to the risk of life-threatening arrhythmias, especially in an older adult who may have underlying cardiovascular disease.