From the Guidelines
Management of hyperkalaemia in the UK should follow a structured approach based on severity and symptoms, prioritizing the use of the most recent and highest quality evidence, as outlined in the 2021 study published in the Mayo Clinic Proceedings 1. For mild hyperkalaemia (potassium 5.5-5.9 mmol/L), addressing underlying causes and reviewing medications is essential, as suggested by the European Heart Journal study 1.
- Key considerations include:
- Reviewing medications that may contribute to hyperkalaemia, such as potassium-sparing diuretics, beta-blockers, and NSAIDs
- Addressing underlying causes, such as renal impairment or excessive potassium intake For moderate hyperkalaemia (6.0-6.4 mmol/L), in addition to the above, considering oral potassium binders like sodium zirconium cyclosilicate (SZC) 10g three times daily for 1-3 days or calcium resonium 15g up to three times daily is recommended, as outlined in the Mayo Clinic Proceedings study 1.
- The selection of potassium binders should be based on their mechanism of action, selectivity for potassium, and potential adverse effects, as discussed in the study published in the Mayo Clinic Proceedings 1. For severe hyperkalaemia (≥6.5 mmol/L) or if ECG changes are present, immediate treatment is required, starting with 10ml of 10% calcium gluconate IV over 2-5 minutes to stabilize cardiac membranes, followed by 10 units of soluble insulin with 50ml of 50% glucose IV over 15-30 minutes to shift potassium intracellularly, as recommended by the European Heart Journal study 1 and the Mayo Clinic Proceedings study 1.
- Additional considerations include:
- Nebulized salbutamol 10-20mg and IV sodium bicarbonate 50mmol if acidotic
- Arranging urgent dialysis if necessary
- Continuous cardiac monitoring during treatment of severe hyperkalaemia The approach works by first protecting the heart from arrhythmias (calcium), then temporarily shifting potassium into cells (insulin/glucose, salbutamol), and finally removing excess potassium from the body (binders, dialysis), as explained in the Mayo Clinic Proceedings study 1. Regular monitoring of potassium levels, renal function, and addressing the underlying cause are crucial for effective management, as emphasized by the European Heart Journal study 1 and the Mayo Clinic Proceedings study 1.
From the Research
Management Strategies for Hyperkalemia
According to the UK guidelines, the management of hyperkalemia involves several strategies, including:
- Prompt recognition of the disorder and patient risk management 2
- Administration of appropriate treatment to prevent serious cardiac complications 2
- Stopping further potassium intake and careful review of prescribed drugs that may be adversely affecting potassium homeostasis 2
- Changes to prescribing systems and an agreed institutional protocol for management of hyperkalemia to improve patient safety 2
Treatment of Life-Threatening Hyperkalemia
For life-threatening hyperkalemia, particularly those patients with ECG changes, treatment involves:
- Administration of intravenous calcium salts to stabilize the resting cardiac membrane potential 2
- Administration of intravenous insulin combined with an infusion of glucose to stimulate intracellular uptake of potassium 2
- Use of nebulised β-2 adrenoceptor agonists to augment the effects of intravenous insulin and glucose 2
Pharmacological Interventions
Pharmacological interventions for the acute management of hyperkalemia include:
- Salbutamol administered via either nebulizer or metered-dose inhaler, which significantly reduces serum potassium compared with placebo 3
- Intravenous insulin-dextrose, which is effective at reducing serum potassium 3
- Potassium binding resins and IV calcium salts, which have not been tested in RCTs and require further study before firm recommendations for clinical practice can be made 3
Long-Term Management
Long-term management of hyperkalemia involves:
- Elucidating underlying causes and pathophysiologic mechanisms for hyperkalemia 4
- Uncovering overt or sometimes covert medications that may have led to the development of hyperkalemia 4
- Obtaining detailed dietary and medical history of hyperkalemic patients 4
- Preventing recurrence or worsening of hyperkalemia through a systematic and overarching approach, such as the proposed A-to-H clinical strategy 5