What are the management steps for hyperkalemia?

Management of Hyperkalemia

The management of hyperkalemia requires a stepwise approach based on severity, with immediate treatment for life-threatening cases involving calcium administration for cardiac membrane stabilization, followed by measures to shift potassium into cells, and ultimately elimination of excess potassium from the body. 1, 2

Classification of Hyperkalemia

• Mild hyperkalemia: K+ level >5.0 to <5.5 mEq/L 1, 2
• Moderate hyperkalemia: K+ level 5.5 to 6.0 mEq/L 1, 2
• Severe hyperkalemia: K+ level >6.0 mEq/L (life-threatening) 1, 2

Step 1: Cardiac Membrane Stabilization (for Severe Hyperkalemia or ECG Changes)

• Administer intravenous calcium to protect the heart from arrhythmias:
  • Calcium chloride (10%): 5-10 mL IV over 2-5 minutes, OR
  • Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes 2, 3
• Effects begin within minutes but are temporary (30-60 minutes) 2
• Note: Calcium does not lower serum potassium but protects against arrhythmias 2, 4

Step 2: Shift Potassium into Cells

• Insulin with glucose: 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 1, 2, 3
  • Onset within 15-30 minutes, effect lasts 4-6 hours 2
• Nebulized beta-2 agonists: Albuterol 10-20 mg over 15 minutes 2, 5
  • Can be used alone or in combination with insulin/glucose for additive effect 3, 6
• Sodium bicarbonate: 50 mEq IV over 5 minutes (most effective in patients with concurrent metabolic acidosis) 1, 2
• Important: These measures provide only temporary effects (1-4 hours), and rebound hyperkalemia can occur after 2 hours 1, 2

Step 3: Eliminate Potassium from Body

• Loop diuretics: Furosemide 40-80 mg IV (effective only in patients with adequate renal function) 1, 2, 6
• Potassium binders:
  • Traditional: Sodium polystyrene sulfonate (Kayexalate) 15-50g orally or rectally with sorbitol 1, 5
  • Newer agents: Patiromer sorbitex calcium (PSC) or sodium zirconium cyclosilicate (SZC) - safer alternatives to traditional resins 1, 2
• Hemodialysis: Most effective method for severe hyperkalemia, especially in patients with renal failure 2, 3

Management Based on Severity

Mild Hyperkalemia (K+ 5.0-5.5 mEq/L)

• Review and adjust medications that may contribute to hyperkalemia 1, 2
• Consider potassium binders if patient is on RAASi therapy that needs to be continued 1
• Monitor K+ levels closely 1

Moderate Hyperkalemia (K+ 5.5-6.0 mEq/L without ECG changes)

• Initiate potassium binders 1
• Consider temporary reduction (not discontinuation) of RAASi therapy 1
• More frequent K+ monitoring 1

Severe Hyperkalemia (K+ >6.0 mEq/L or with ECG changes)

• Immediate implementation of all three steps: membrane stabilization, cellular shift, and elimination 1, 2
• Temporarily discontinue RAASi therapy 1
• Consider hemodialysis for refractory cases or severe renal impairment 2, 3

Special Considerations

• ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) indicate urgent treatment regardless of potassium level 2, 6
• Patients with cardiovascular disease and chronic kidney disease are at higher risk of recurrent hyperkalemia (50% have two or more recurrences within 1 year) 1
• Newer potassium binders (patiromer, sodium zirconium cyclosilicate) may allow continuation of beneficial RAASi therapy in patients with heart failure, hypertension, or chronic kidney disease 1
• Avoid sodium polystyrene sulfonate for prolonged use due to risk of bowel necrosis 1

Prevention of Recurrence

• Identify and address underlying causes of hyperkalemia 3, 7
• Review medications that can cause hyperkalemia (ACEi, ARBs, MRAs, NSAIDs, beta-blockers) 2, 7
• For patients requiring RAASi therapy with recurrent hyperkalemia, consider chronic use of newer potassium binders 1
• Monitor potassium levels regularly in high-risk patients (CKD, heart failure, diabetes, on RAASi therapy) 1