Treatment of Hyperkalemia
The treatment of hyperkalemia requires a stepwise approach based on severity, with calcium gluconate for membrane stabilization, insulin with glucose or beta-agonists for intracellular potassium shifting, and potassium binders or hemodialysis for potassium removal 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 (Severe Hyperkalemia with ECG Changes)
Cardiac Membrane Stabilization:
- Calcium gluconate 10% solution, 15-30 mL IV (onset: 1-3 minutes, duration: 30-60 minutes) 1
Intracellular Potassium Shifting:
- 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) 1
Important: Sodium Polystyrene Sulfonate should NOT be used for emergency treatment of life-threatening hyperkalemia due to its delayed onset of action 2
Potassium Removal Strategies
Pharmacological Removal
- Potassium Binders:
- 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
- Sodium polystyrene sulfonate: 15-30g 1-4 times daily; avoid chronic use due to GI side effects 1, 2
Non-Pharmacological Removal
- Loop Diuretics: Furosemide to enhance urinary potassium excretion (in patients with adequate kidney function) 3
- Hemodialysis: Most effective method for severe cases, especially in patients with kidney failure 4
Special Populations 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 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
Pediatric Patients
- Pediatric patients are particularly vulnerable to rapid potassium shifts 1
- Salbutamol (5 μg/kg over 15 minutes) has been shown effective and safe in treating hyperkalemia in children 5
- Monitor for transfusion-associated hyperkalemic cardiac arrest (TAHCA) during rapid correction 1
Prevention of Recurrence
Medication Review
- Evaluate and potentially modify medications that increase hyperkalemia risk:
- Potassium-sparing diuretics
- Mineralocorticoid receptor antagonists
- NSAIDs
- Beta-blockers
- Trimethoprim-sulfamethoxazole 1
Dietary Modifications
- Limit potassium intake to <40 mg/kg/day 1
- Avoid high-potassium foods: processed foods, bananas, oranges, potatoes, tomatoes, legumes, yogurt, and chocolate 1
- Focus on reducing intake of non-plant sources of potassium rather than complete restriction 6
Monitoring
- Regular potassium monitoring: initially weekly, then monthly 1
- Optimize diuretic therapy 1
- Monitor for excessive diuresis, as volume depletion can worsen renal function and paradoxically increase hyperkalemia risk 1
Clinical Pitfalls to Avoid
Relying solely on ECG changes: Absent or atypical ECG changes do not exclude the necessity for immediate intervention in severe hyperkalemia 3
Discontinuing beneficial medications: Down-titration or discontinuation of renin-angiotensin-aldosterone inhibitors should be discouraged as these drugs improve outcomes in heart failure and proteinuric kidney disease 6
Delayed nephrology consultation: Early nephrology involvement is essential for CKD stage 4 (eGFR <30 mL/min/1.73 m²) and improves outcomes 1
Overlooking sodium content in treatments: Some treatments (sodium bicarbonate, sodium zirconium cyclosilicate) contain significant sodium, which may be problematic in certain patients 1