What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia should follow a stepwise approach based on severity, with immediate administration of calcium gluconate for membrane stabilization, followed by insulin with glucose for intracellular potassium shift, and measures to eliminate potassium from the body. 1

Severity Assessment and Initial Management

ECG Changes by Potassium Level

• 5.5-6.5 mmol/L: Peaked/tented T waves (early sign)
• 6.5-7.5 mmol/L: Prolonged PR interval, flattened P waves
• 7.0-8.0 mmol/L: Widened QRS, deep S waves

• 10 mmol/L: Sinusoidal pattern, VF, asystole, or PEA 1

Emergency Treatment for Severe Hyperkalemia (K+ >6.5 mmol/L or ECG changes)

1. Membrane Stabilization

   • Calcium gluconate 10% solution, 15-30 mL IV (onset: 1-3 minutes, duration: 30-60 minutes) 1, 2
   • Note: Calcium chloride should be used instead of calcium gluconate in cardiac arrest 3

2. Intracellular Shift of Potassium

   • Insulin with glucose: 10 units regular insulin IV with 50 mL of 25% dextrose (onset: 15-30 minutes, duration: 1-2 hours) 1
   • Inhaled beta-agonists: 10-20 mg nebulized over 15 minutes (onset: 15-30 minutes, duration: 2-4 hours) 1
   • Sodium bicarbonate: 50 mEq IV over 5 minutes (onset: 15-30 minutes, duration: 1-2 hours) - particularly useful if metabolic acidosis is present 1, 4

Potassium Elimination

Potassium Removal Methods

1. Hemodialysis

   • Most efficient method for potassium removal 3
   • Indicated for severe, refractory hyperkalemia or in patients with renal failure 5

2. Diuretics

   • Loop and thiazide diuretics can enhance potassium excretion 3
   • Particularly useful in patients with adequate renal function 4

3. Potassium Binders

   • Sodium polystyrene sulfonate (SPS): 15-30g 1-4 times daily 1
     • Not for emergency treatment due to delayed onset of action 6
     • Limited efficacy and risk of GI side effects with chronic use 3
   • Newer agents:
     • Patiromer (Veltassa): 8.4g once daily (onset: 7 hours) - separate from other medications by 3 hours 1
     • Sodium zirconium cyclosilicate (Lokelma): 5-10g once daily (onset: 1 hour) - contains sodium (400mg per 5g) 1, 7

Prevention and Management of Chronic Hyperkalemia

Dietary and Lifestyle Modifications

• Limit potassium intake to <40 mg/kg/day 1
• Avoid high-potassium foods: processed foods, bananas, oranges, potatoes, tomatoes, legumes, yogurt, chocolate 1
• Sodium restriction (<2g/day) 1
• Regular physical activity (150 min/week) 1
• Weight reduction if overweight/obese 1
• Limited alcohol consumption 1

Medication Management

• Review and adjust medications that increase hyperkalemia risk:
  • ACE inhibitors
  • Angiotensin receptor blockers
  • Potassium-sparing diuretics
  • Mineralocorticoid receptor antagonists
  • NSAIDs
  • Beta-blockers
  • Trimethoprim-sulfamethoxazole 1

Monitoring

• Regular potassium monitoring (initially weekly, then monthly) for high-risk patients 1
• Optimize diuretic therapy in patients requiring RAAS inhibitors 1
• Monitor for excessive diuresis, as volume depletion can worsen renal function and paradoxically increase hyperkalemia risk 1

Special Considerations

Heart Failure Patients

• Maintain potassium levels ≤5 mmol/L as levels >5 mmol/L are associated with higher mortality 1
• Even potassium levels in the upper normal range (4.8-5.0 mmol/L) are associated with increased 90-day mortality 1
• Maintain potassium ≥4.0 mmol/L in patients with heart failure, ventricular arrhythmias, or digoxin therapy 1

Chronic Kidney Disease

• Higher risk of hyperkalemia (up to 73% in advanced CKD) 1
• Consider nephrology consultation for CKD stage 4 (eGFR <30 mL/min/1.73 m²) 1
• Begin education about dialysis options when eGFR <15 mL/min/1.73 m² 1

Pediatric Patients

• Neonates and pediatric patients are particularly vulnerable to rapid potassium shifts 1
• Risk of transfusion-associated hyperkalemic cardiac arrest (TAHCA) with rapid correction 1

Pitfalls and Caveats

• Sodium polystyrene sulfonate should not be used for emergency treatment of life-threatening hyperkalemia due to its delayed onset of action 6
• Calcium gluconate may be effective only for main rhythm disorders due to hyperkalemia, not for non-rhythm ECG disorders 2
• Avoid NSAIDs in patients on ACEIs as they significantly increase hyperkalemia risk 1
• Monitor glucose levels when administering insulin, as hypoglycemia is a potential complication 3
• Down-titration and/or discontinuation of renin-angiotensin-aldosterone inhibitors should be discouraged when possible, as these drugs improve outcomes in patients with heart failure and proteinuric kidney disease 7