What is the management approach for hyperkalemia?

Management of Hyperkalemia

The management of hyperkalemia requires a structured approach based on severity, with acute life-threatening hyperkalemia requiring immediate cardiac membrane stabilization with intravenous calcium gluconate, followed by potassium redistribution therapies and ultimately removal strategies. 1, 2

Classification and Assessment

• Hyperkalemia is classified as mild (5.0-5.9 mEq/L), moderate (6.0-6.4 mEq/L), or severe (≥6.5 mEq/L) 2
• ECG changes (peaked T waves, prolonged QRS complexes, flattened P waves) indicate urgent treatment regardless of potassium level, though ECG findings can be variable and less sensitive than laboratory tests 1
• Symptoms may be nonspecific, making laboratory confirmation essential 1

Acute Hyperkalemia Management

Step 1: Cardiac Membrane Stabilization (1-3 minutes onset)

• Administer intravenous calcium gluconate 10% (15-30 mL IV over 2-5 minutes) to stabilize cardiac membranes 2
• Effects begin within 1-3 minutes but are temporary (30-60 minutes) and do not reduce serum potassium 1
• If no effect observed within 5-10 minutes, another dose may be given 1

Step 2: Intracellular Potassium Shifting (15-30 minutes onset)

• Administer intravenous insulin (10 units) with glucose (50 mL of 50% solution) to shift potassium into cells 1, 3
• Consider inhaled β-agonists (e.g., albuterol/salbutamol 10-20 mg via nebulizer) which act within 30 minutes 1, 3
• Sodium bicarbonate may be used in patients with concurrent metabolic acidosis 1

Step 3: Potassium Removal from Body

• Initiate loop diuretics (e.g., furosemide 40-80 mg IV) in patients with adequate kidney function 3, 4
• Consider hemodialysis for severe hyperkalemia, especially in patients with renal failure 1, 3
• Note that sodium polystyrene sulfonate (SPS) should not be used for emergency treatment due to its delayed onset of action 5

Chronic Hyperkalemia Management

Medication Review and Adjustment

• Review and adjust medications that contribute to hyperkalemia (ACE inhibitors, ARBs, MRAs, NSAIDs, beta-blockers) 2
• Monitor potassium levels 7-10 days after starting or increasing doses of RAAS inhibitors 1

Long-term Management Strategies

• Prescribe loop or thiazide diuretics to promote urinary potassium excretion in patients with adequate kidney function 1, 2
• Consider newer FDA-approved potassium binders such as patiromer and sodium zirconium cyclosilicate (SZC) for long-term management 1, 2
• SZC has shown efficacy in reducing serum potassium within 48 hours and maintaining normokalemia over 14-28 days 1

Special Considerations

• Patients with chronic kidney disease, heart failure, or diabetes require more frequent potassium monitoring 1, 2
• A team approach involving specialists (cardiologists, nephrologists), primary care physicians, and other healthcare professionals is optimal for chronic hyperkalemia management 1
• Dietary restriction should focus on reducing intake of non-plant sources of potassium rather than broad restrictions 6
• When possible, maintain RAAS inhibitors in patients with heart failure and proteinuric kidney disease, using potassium binders if needed 6

Common Pitfalls to Avoid

• Relying solely on ECG changes to diagnose hyperkalemia (they can be variable and insensitive) 1
• Using sodium polystyrene sulfonate for emergency treatment (delayed onset of action) 5
• Discontinuing beneficial RAAS inhibitors without considering alternative strategies to manage potassium 6
• Failing to monitor potassium levels after initiating treatments that affect potassium homeostasis 1