What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires a stepwise approach consisting of cardiac membrane stabilization, intracellular potassium shifting, and total body potassium reduction, with immediate interventions for severe cases and longer-term management for chronic hyperkalemia. 1

Immediate Treatment for Severe Hyperkalemia

Step 1: Cardiac Membrane Stabilization

• Calcium Gluconate 10%: 15-30 mL IV (10% solution) over 5-10 minutes
  • Onset: 1-3 minutes
  • Duration: 30-60 minutes
  • Purpose: Protects the heart from arrhythmias but does not lower potassium levels
  • Note: For cardiac arrest, calcium chloride is preferred 1, 2

Step 2: Intracellular Potassium Shifting

1. Insulin with Glucose:

   • 10 units regular insulin IV with 50 mL of 25% dextrose
   • Onset: 15-30 minutes
   • Duration: 1-2 hours
   • Most reliable agent for promoting transcellular shift 1, 3

2. Beta-agonists:

   • 10-20 mg nebulized over 15 minutes
   • Onset: 15-30 minutes
   • Duration: 2-4 hours
   • Can be used alone or to augment insulin's effect 1, 4

3. Sodium Bicarbonate:

   • 50 mEq IV over 5 minutes
   • Only recommended if metabolic acidosis is present
   • Limited efficacy for shifting potassium alone 1, 3

Step 3: Potassium Removal from Body

1. Hemodialysis:

   • Most efficient and reliable method for potassium removal
   • Indicated for severe, refractory hyperkalemia or in renal failure 1, 5

2. Loop Diuretics:

   • IV furosemide if renal function permits
   • Promotes urinary potassium excretion 1, 4

3. Potassium Binders:

   • Not for emergency treatment due to delayed onset 6, 7
   • Options include:
     • Patiromer (Veltassa): 8.4g once daily, onset 7 hours
     • Sodium zirconium cyclosilicate (Lokelma): 5-10g once daily, onset 1 hour
     • Sodium polystyrene sulfonate: 15-30g 1-4 times daily, variable onset 1

Monitoring During Treatment

• Continuous cardiac monitoring for moderate to severe hyperkalemia
• Serial ECGs to monitor for improvement of changes
• Regular serum potassium measurements to avoid overcorrection 1

ECG Changes to Monitor

Potassium Level	ECG Changes
5.5-6.5 mmol/L	Peaked/tented T waves (early sign)
6.5-7.5 mmol/L	Prolonged PR interval, flattened P waves
6.5-8.0 mmol/L	Widened QRS, deep S waves
>10 mmol/L	Sinusoidal pattern, VF, asystole, or PEA

Long-term Management

1. Eliminate Reversible Causes:

   • Review and adjust medications that can cause hyperkalemia
   • Dietary potassium restriction (<40 mg/kg/day) 1, 5

2. Dietary Modifications:

   • Avoid high-potassium foods: processed foods, bananas, oranges, potatoes, tomatoes, legumes, yogurt, chocolate 1
   • Sodium restriction (<2g/day)
   • Regular physical activity (150 min/week)
   • Weight reduction if overweight/obese 1

3. Chronic Potassium Binder Therapy:

   • For recurrent or persistent hyperkalemia, especially in CKD
   • Patiromer preferred over sodium polystyrene sulfonate for chronic use due to fewer GI side effects 1, 4

4. Nephrology Referral:

   • Essential for CKD stage 4 (eGFR <30 mL/min/1.73 m²)
   • Early involvement improves outcomes 1

Important Caveats and Pitfalls

• Potassium binders (Lokelma, sodium polystyrene sulfonate) should NOT be used for emergency treatment of life-threatening hyperkalemia due to delayed onset 6, 7
• Calcium gluconate is primarily effective for main rhythm disorders due to hyperkalemia but has limited effect on non-rhythm ECG disorders 2
• Bicarbonate is less efficacious than previously thought and should only be used if metabolic acidosis is present 3
• Physicians frequently fail to use effective treatments appropriately - follow the stepwise approach 3
• Regular insulin is traditionally used, but some experts now recommend synthetic short-acting insulins 4