What is the treatment for hyperkalemia?

From the Guidelines

Treatment for hyperkalemia involves a combination of immediate interventions to stabilize cardiac membranes and longer-term strategies to reduce potassium levels.

Immediate Treatment

• Calcium gluconate or calcium chloride to stabilize cardiac membranes within 1 to 3 minutes 1
• Insulin (with glucose to prevent hypoglycemia) and beta-agonists (such as salbutamol) to redistribute potassium into cells, effective within 30 to 60 minutes but with a short duration of action (2 to 4 hours) 1
• Sodium bicarbonate may be used in the context of metabolic acidosis to promote potassium elimination through increased urinary excretion 1

Longer-term Management

• Loop diuretics to increase renal potassium excretion, effective in patients with residual kidney function 1
• Potassium binders such as sodium polystyrene sulfonate, patiromer, or sodium zirconium cyclosilicate to enhance fecal potassium excretion 1
• Hemodialysis for severe, resistant hyperkalemia to directly remove potassium from the blood 1
• Dietary modification to reduce potassium intake and avoidance of medications that can contribute to hyperkalemia 1
• Fludrocortisone may be considered in specific cases, such as aldosterone deficiency, to increase potassium excretion, though it carries risks of fluid retention, hypertension, and vascular injury 1

Considerations in Clinical Practice

• The choice of treatment should be guided by the severity of hyperkalemia, the presence of symptoms or ECG changes, and the patient's underlying renal function and medical conditions 1.
• Patients on renin-angiotensin-aldosterone system inhibitors (RAASi) who develop hyperkalemia may require adjustment of their medication regimen, but the benefits of RAASi in reducing mortality and morbidity should be weighed against the risks of hyperkalemia 1.
• Regular monitoring of potassium levels is crucial, especially in patients at high risk of hyperkalemia or those on treatments that can affect potassium levels 1.

From the Research

Treatment Options for Hyperkalemia

The treatment for hyperkalemia involves several strategies, including:

• Elimination of reversible causes, such as diet and medications 2
• Rapidly acting therapies to shift potassium into cells and block cardiac membrane effects, such as calcium gluconate, insulin, and beta-2 agonists 2, 3
• Measures to facilitate removal of potassium from the body, including saline diuresis, oral binding resins, and hemodialysis 2, 3

Acute Hyperkalemia Treatment

Acute hyperkalemia requires immediate attention and treatment, which may include:

• Stabilizing the cardiac membrane with calcium gluconate 2, 3
• Shifting potassium into cells with insulin and beta-2 agonists 2, 3
• Initiating strategies to decrease total body potassium content, such as hemodialysis 2, 3

Chronic Hyperkalemia Treatment

Chronic hyperkalemia treatment involves:

• Reviewing medications that may be contributing to the disorder 4
• Ensuring effective diuretic therapy and correcting metabolic acidosis if present 4
• Using potassium-binding drugs and sodium-glucose cotransporter 2 inhibitors to maintain the use of renin-angiotensin-aldosterone inhibitors 4
• Implementing nuanced dietary restrictions, focusing on reducing nonplant sources of potassium 4

Hyperkalemia Management in Specific Patient Populations

Hyperkalemia management may vary in specific patient populations, such as:

• Patients with chronic kidney disease, who require careful monitoring and treatment to prevent life-threatening cardiac arrhythmias 5, 6
• Patients with heart failure, who may require down-titration or discontinuation of renin-angiotensin-aldosterone inhibitors 4
• Patients with diabetes, who may require careful monitoring and treatment to prevent hyperkalemia 6