How to manage hyperkalemia?

Management of Hyperkalemia

The management of hyperkalemia requires a stepwise approach based on severity, with immediate stabilization of cardiac membrane using calcium gluconate for severe cases, followed by shifting potassium into cells with insulin/glucose or beta-agonists, and ultimately removing excess potassium from the body using potassium binders or dialysis. 1

Assessment and Stratification

• Definition: Hyperkalemia is defined as serum potassium >5.0 or >5.5 mEq/L (mmol/L) 1
• Severity assessment based on ECG changes:
  • 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 Management of Severe Hyperkalemia

1. Cardiac membrane stabilization (immediate effect, does not lower K+):

   • Calcium gluconate 10%: 15-30 mL IV over 2-5 minutes
   • Onset: 1-3 minutes; Duration: 30-60 minutes 1

2. Shift potassium into cells (temporary measure):

   • Insulin with glucose: 10 units regular insulin IV with 50 mL of 25% dextrose
     • Onset: 15-30 minutes; Duration: 1-2 hours
   • Nebulized albuterol: 10-20 mg over 15 minutes
     • Onset: 15-30 minutes; Duration: 2-4 hours
   • Sodium bicarbonate: 50 mEq IV over 5 minutes (if metabolic acidosis present)
     • Onset: 15-30 minutes; Duration: 1-2 hours 1

3. Remove potassium from body:

   • Diuresis: furosemide 40-80 mg IV
   • Dialysis: Most effective method for severe cases 1

Important Caveat

Sodium polystyrene sulfonate should NOT be used for emergency treatment of life-threatening hyperkalemia due to its delayed onset of action 2, 3.

Non-Emergency Management and Chronic Hyperkalemia

Potassium Binders

Agent	Starting Dose	Onset	Key Considerations
Patiromer (Veltassa)	8.4g once daily	7 hours	Separate from other medications by 3 hours; no sodium content
Sodium zirconium cyclosilicate (Lokelma)	5-10g once daily	1 hour	Contains sodium (400mg per 5g); more rapid onset
Sodium polystyrene sulfonate	15-30g 1-4 times daily	Variable	Avoid chronic use due to GI side effects; high sodium content

• For acute hyperkalemia: 10g of a potassium binder three times daily for up to 48 hours
• For maintenance therapy: 5-10g once daily 1
• Newer agents (patiromer and sodium zirconium cyclosilicate) are preferred over sodium polystyrene sulfonate due to fewer gastrointestinal adverse effects 3

Medication Review and Adjustment

• Review and adjust medications that contribute to hyperkalemia 1, 4:
  • ACE inhibitors/ARBs (consider dose reduction rather than discontinuation)
  • Potassium-sparing diuretics
  • NSAIDs
  • Aldosterone antagonists
  • Calcineurin inhibitors
  • Heparin and derivatives
  • Trimethoprim
  • Beta-blockers

Dietary Modifications

• Restrict potassium intake to <40 mg/kg/day 1
• Limit high-potassium foods such as:
  • Processed foods
  • Bananas, oranges
  • Potatoes, tomatoes
  • Legumes
  • Yogurt, chocolate 1

Special Considerations

Chronic Kidney Disease

• Hyperkalemia occurs in up to 73% of patients with advanced CKD 1, 5
• Consult nephrology for CKD stage 4 (eGFR <30 mL/min/1.73 m²) 1
• Consider potassium binders for long-term management 5

Heart Failure

• Hyperkalemia occurs in up to 40% of heart failure patients 1
• Benefits of ACEI/ARB therapy often outweigh risks; consider dose reduction rather than discontinuation 1

Monitoring

• Monitor potassium levels every 1-4 weeks, especially when changing therapy 1
• Watch for signs of hypomagnesemia (muscle cramps, arrhythmias, weakness) 1
• Monitor for gastrointestinal side effects from potassium binders 1

Pitfalls to Avoid

1. Don't rely on sodium polystyrene sulfonate for emergency treatment of life-threatening hyperkalemia due to its delayed onset of action 2

2. Don't discontinue beneficial medications like ACE inhibitors/ARBs without attempting dose reduction first 1

3. Don't overlook drug interactions that may worsen hyperkalemia, particularly NSAIDs in patients on ACEIs 1, 4

4. Don't forget to monitor for excessive diuresis, as volume depletion can worsen renal function and paradoxically increase hyperkalemia risk 1

5. Don't assume all dietary potassium sources have equal impact on serum potassium levels; focus on limiting the most problematic high-potassium foods 6