What are the management steps for hyperkalemia?

Hyperkalemia Management

The management of hyperkalemia requires a stepwise approach based on severity, with immediate membrane stabilization using calcium gluconate for severe cases (K+ >6.0 mmol/L with ECG changes), followed by transcellular shifting with insulin/glucose or beta-agonists, and ultimately potassium removal through binders or dialysis. 1

Assessment and Severity Classification

• Definition: Hyperkalemia is defined as serum potassium >5.0 or >5.5 mEq/L (mmol/L) 1
• ECG changes by potassium level: 1
  • 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

Important caveat: Absent or atypical ECG changes do not exclude the necessity for immediate intervention in severe hyperkalemia 2

Acute Management Algorithm

Step 1: Membrane Stabilization (for severe hyperkalemia)

• Calcium gluconate: 10% solution, 15-30 mL IV 1
  • Onset: 1-3 minutes
  • Duration: 30-60 minutes
  • Purpose: Stabilizes cardiac membranes but does not lower potassium levels

Step 2: Intracellular Shifting

• Insulin with glucose: 10 units regular insulin IV with 50 mL of 25% dextrose 1

  • Onset: 15-30 minutes
  • Duration: 1-2 hours

• Inhaled beta-agonists: 10-20 mg nebulized albuterol over 15 minutes 1

  • Onset: 15-30 minutes
  • Duration: 2-4 hours
  • Can be used alone or in combination with insulin/glucose for additive effect

• Sodium bicarbonate: 50 mEq IV over 5 minutes 1

  • Onset: 15-30 minutes
  • Duration: 1-2 hours
  • Less favored due to poor efficacy when used alone 2

Step 3: Potassium Removal

• Potassium binders: 1, 3

  • Sodium zirconium cyclosilicate (Lokelma):

    • Acute: 10g three times daily for up to 48 hours
    • Maintenance: 5-10g once daily
    • Onset: 1 hour
    • Contains sodium (400mg per 5g)

  • Patiromer (Veltassa):

    • Starting dose: 8.4g once daily
    • Onset: 7 hours
    • Separate from other medications by 3 hours
    • No sodium content

  • Sodium polystyrene sulfonate:

    • Dose: 15-30g 1-4 times daily
    • Avoid chronic use due to serious GI adverse effects 3

• Loop diuretics: Furosemide IV for patients with adequate kidney function 2

• Hemodialysis: For severe, refractory hyperkalemia or in patients with end-stage renal disease 3, 4

Chronic Management

Medication Adjustments

• Review and adjust medications that can cause hyperkalemia 5:
  • RAAS inhibitors (ACEIs/ARBs)
  • Potassium-sparing diuretics
  • NSAIDs
  • Trimethoprim
  • Beta-blockers

Important note: Rather than discontinuing RAAS inhibitors, consider dose reduction as these medications provide significant cardiovascular benefits, especially in heart failure and proteinuric kidney disease 1, 5

Dietary Modifications

• Limit potassium intake to <40 mg/kg/day 1
• Focus on reducing non-plant sources of potassium rather than blanket restriction of all high-potassium foods 5
• High-potassium foods to limit: 1
  • Processed foods
  • Bananas, oranges
  • Potatoes, tomatoes
  • Legumes
  • Yogurt, chocolate

Other Lifestyle Modifications

• Sodium restriction (<2g/day)
• Regular physical activity (150 min/week)
• Weight reduction if overweight/obese
• Limited alcohol consumption 1

Special Populations

Chronic Kidney Disease

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

Heart Failure

• Hyperkalemia occurs in up to 40% of patients 1
• Balance RAAS inhibitor benefits against hyperkalemia risk
• Consider potassium binders to optimize RAAS inhibitor therapy 1

Diabetic Nephropathy

• May develop hyporeninemic hypoaldosteronism syndrome 6
• Requires careful monitoring and potentially lower threshold for intervention

Common Pitfalls and Caveats

1. ECG reliability: Do not rely solely on ECG changes to determine treatment urgency, as they may be absent despite dangerous potassium levels 2

2. Recurrence risk: Monitor potassium levels frequently after initial treatment as hyperkalemia may recur, especially if the underlying cause is not addressed 4

3. Sodium content: Be aware that some treatments (sodium bicarbonate, sodium zirconium cyclosilicate) contain significant sodium, which may be problematic in heart failure or hypertension 1

4. Glucose monitoring: When using insulin/glucose therapy, monitor blood glucose closely, especially in diabetic patients

5. Medication discontinuation: Avoid abrupt discontinuation of RAAS inhibitors when possible; instead, consider dose reduction and addition of potassium binders 5