What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires a stepwise approach starting with calcium gluconate for cardiac stabilization, followed by insulin with glucose for intracellular potassium shift, and ultimately removal of potassium from the body through diuretics or dialysis. 1

Emergency Management of Hyperkalemia

Step 1: Cardiac Membrane Stabilization

• Calcium gluconate 10%: 15-30 mL IV over 2-5 minutes
  • Onset: 1-3 minutes
  • Duration: 30-60 minutes
  • Purpose: Stabilizes cardiac membranes to prevent arrhythmias
  • Note: Only effective for main rhythm disorders, not for non-rhythm ECG changes 2

Step 2: Shift Potassium Into Cells

• Insulin with glucose: 10 units regular insulin IV with 50 mL of 25% dextrose
  • Onset: 15-30 minutes
  • Duration: 1-2 hours
  • Monitor glucose levels to prevent hypoglycemia 1, 3
• Nebulized albuterol: 10-20 mg over 15 minutes
  • Onset: 15-30 minutes
  • Duration: 2-4 hours
  • Can be used alone or in combination with insulin 1
• Sodium bicarbonate: 50 mEq IV over 5 minutes
  • Use only if metabolic acidosis is present
  • Less effective when used alone 1, 4

Step 3: Remove Potassium From Body

• Diuretics: Furosemide 40-80 mg IV
  • Promotes potassium excretion through kidneys
  • Less effective in patients with renal impairment 1
• Potassium-binding agents:

  Agent	Starting Dose	Onset	Key Considerations
  Patiromer (Veltassa)	8.4g once daily	7 hours	Separate from other medications by 3 hours
  Sodium zirconium cyclosilicate (Lokelma)	5-10g once daily	1 hour	Contains sodium (400mg per 5g)
  Sodium polystyrene sulfonate	15-30g 1-4 times daily	Variable	Not for emergency use 5

• Hemodialysis:
  • Most effective method for severe hyperkalemia
  • Essential for refractory cases or severe renal impairment 1, 6

Important Considerations

Severity-Based Approach

• Mild hyperkalemia (K+ 5.0-5.9 mmol/L without ECG changes):
  • Discontinue potassium-raising medications
  • Dietary potassium restriction
  • Potassium-binding agents if persistent
• Moderate hyperkalemia (K+ 6.0-6.4 mmol/L or with mild ECG changes):
  • All steps for mild hyperkalemia
  • Insulin with glucose and/or albuterol
  • Diuretics if renal function adequate
• Severe hyperkalemia (K+ ≥6.5 mmol/L or significant ECG changes):
  • Immediate calcium gluconate
  • Insulin with glucose AND albuterol
  • Consider hemodialysis 1, 7

Medication Management

• Review and adjust medications that increase potassium:
  • ACE inhibitors/ARBs (consider dose reduction rather than discontinuation)
  • NSAIDs
  • Potassium-sparing diuretics
  • Potassium supplements 1

Sodium Polystyrene Sulfonate Cautions

• Not for emergency treatment due to delayed onset 5
• Administer at least 3 hours before or after other oral medications
• Contraindicated in:
  • Obstructive bowel disease
  • Neonates with reduced gut motility
  • Hypersensitivity to polystyrene sulfonate resins
• Risk of intestinal necrosis, especially when used with sorbitol 5

Dietary and Lifestyle Modifications

• Restrict potassium intake to <40 mg/kg/day
• Avoid high-potassium foods: bananas, oranges, potatoes, tomatoes, legumes, dairy products, nuts, and chocolate
• Limit sodium intake (<2g/day)
• Regular physical activity (150 min/week)
• Weight reduction if overweight/obese 1

Special Populations

• CKD patients: Higher risk of hyperkalemia (up to 73% in advanced CKD)
  • Consider nephrology consultation for CKD stage 4 (eGFR <30 mL/min/1.73 m²)
• Heart failure patients: Hyperkalemia occurs in up to 40% of patients
  • Benefits of ACEI therapy often outweigh risks
• Pediatric patients: More vulnerable to rapid potassium shifts 1