What is the treatment for hyperkalemia?

Treatment of Hyperkalemia (Potassium 6.0)

The treatment for hyperkalemia with a potassium level of 6.0 mmol/L should follow a stepwise approach: first stabilize the cardiac membrane with calcium gluconate, then shift potassium into cells with insulin and glucose, and finally remove excess potassium from the body through binding agents, diuresis, or dialysis. 1

Immediate Management

Step 1: Cardiac Membrane Stabilization

• Administer calcium gluconate 10% solution: 15-30 mL IV over 2-5 minutes 1
  • Onset of action: 1-3 minutes
  • Duration: 30-60 minutes
  • Purpose: Protects the heart from arrhythmias but does not lower potassium levels

Step 2: Shift Potassium Into Cells

• Administer 10 units regular insulin IV with 50 mL of 25% dextrose 1
  • Onset: 15-30 minutes
  • Duration: 1-2 hours
• Consider additional options:
  • Inhaled beta-agonists: 10-20 mg nebulized over 15 minutes 1
  • Sodium bicarbonate: 50 mEq IV over 5 minutes (particularly useful if metabolic acidosis is present) 1

Step 3: Remove Potassium From Body

• Potassium-binding agents:
  • Sodium zirconium cyclosilicate (Lokelma): 5-10g once daily (faster onset - 1 hour) 1
  • Patiromer (Veltassa): 8.4g once daily (onset: 7 hours) 1
  • Sodium polystyrene sulfonate: 15-30g (note: not for emergency treatment due to delayed onset) 1, 2
• Consider diuretics if renal function is adequate
• Dialysis for severe, refractory cases or in patients with renal failure

ECG Monitoring

• For potassium 6.0 mmol/L, expect to see peaked/tented T waves 1
• Continuous ECG monitoring is recommended to identify potential arrhythmias 1
• ECG changes worsen as potassium levels increase:
  • 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

Medication Review and Adjustment

• Identify and adjust medications that may cause or worsen hyperkalemia 1, 3, 4:
  • ACE inhibitors/ARBs (consider dose reduction rather than discontinuation)
  • Potassium-sparing diuretics
  • NSAIDs
  • Calcineurin inhibitors
  • Heparin and derivatives
  • Trimethoprim
  • Beta-blockers

Long-term Management

• Dietary modifications:
  • Limit potassium intake to <40 mg/kg/day 1
  • Avoid high-potassium foods: processed foods, bananas, oranges, potatoes, tomatoes, legumes 1
• Consider chronic potassium binder therapy for recurrent hyperkalemia 1, 3, 5
• Regular monitoring of serum potassium levels

Special Considerations

• For patients with heart failure or proteinuric kidney disease, try to maintain RAAS inhibitors if possible, as they improve outcomes 3
• In chronic kidney disease patients, hyperkalemia is common (up to 73% in advanced CKD) and may require ongoing management 1, 5
• For diabetic patients, consider the syndrome of hyporeninemic hypoaldosteronism as a potential cause 6

Common Pitfalls to Avoid

• Don't rely solely on sodium polystyrene sulfonate for acute, life-threatening hyperkalemia due to its delayed onset of action 2
• Don't automatically discontinue ACE inhibitors/ARBs; consider dose reduction first as these medications provide significant cardiovascular benefits 1, 3
• Don't forget to investigate the underlying cause of hyperkalemia to prevent recurrence
• Don't overlook the need for continuous cardiac monitoring in moderate to severe hyperkalemia 1