What are the steps for managing 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 stabilization, followed by measures to shift potassium into cells, and ultimately elimination of excess potassium from the body. 1

Classification of Hyperkalemia

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

Urgent Management of Severe Hyperkalemia (K+ >6.0 mEq/L or ECG Changes)

Step 1: Cardiac Membrane Stabilization

• Administer intravenous calcium (calcium gluconate or calcium chloride) to protect the heart from arrhythmias 1
• Effects begin within minutes but last only 30-60 minutes, requiring repeated doses if definitive treatment is delayed 1, 2
• This is a temporizing measure that does not lower serum potassium levels 3

Step 2: Shift Potassium Into Cells

• Administer intravenous insulin (10 units) with glucose (50 ml of 50% solution) to drive potassium intracellularly 2
  • Onset within 15-30 minutes, effect lasts 4-6 hours 1
  • Recent evidence suggests lower insulin doses may be effective with fewer hypoglycemic events 4
• Consider nebulized beta-2 agonists (albuterol 10-20 mg) which can be used alone or in combination with insulin/glucose 2
• Sodium bicarbonate can be used, particularly in patients with concurrent metabolic acidosis 1

Step 3: Eliminate Potassium From Body

• Initiate hemodialysis for severe, refractory hyperkalemia, especially in patients with kidney failure 2
• Administer loop diuretics (furosemide) in patients with adequate renal function 1
• Use potassium binders:
  • Newer agents (patiromer sorbitex calcium or sodium zirconium cyclosilicate) are preferred over traditional resins 1, 4
  • Sodium polystyrene sulfonate with sorbitol should be avoided for chronic use due to risk of bowel necrosis 5

Management of Chronic or Recurrent Hyperkalemia

For Patients on RAAS Inhibitors (ACEi, ARBs, MRAs)

• For K+ levels >5.0 mEq/L: Initiate an approved K+-lowering agent while maintaining RAAS inhibitor therapy 5
• For K+ levels >6.5 mEq/L: Discontinue/reduce RAAS inhibitor and initiate K+-lowering agent 5
• Once K+ levels are controlled (<5.0 mEq/L), consider reintroduction of RAAS inhibitors at lower doses with close monitoring 5

Preventive Measures

• Evaluate patient's diet, supplements, salt substitutes, and medications that may contribute to hyperkalemia 5
• Consider low-potassium diet, focusing on reducing non-plant sources of potassium 6
• Use loop or thiazide diuretics to increase potassium excretion when appropriate 5
• Regular monitoring of potassium levels in high-risk patients (CKD, heart failure, diabetes, RAAS inhibitor therapy) 1

Special Considerations

• Patients with cardiovascular disease and chronic kidney disease are at higher risk of recurrent hyperkalemia, with 50% having two or more recurrences within 1 year 1
• Newer potassium binders may allow continuation of beneficial RAAS inhibitor therapy in patients with heart failure, hypertension, or chronic kidney disease 1
• Sodium-glucose cotransporter 2 (SGLT2) inhibitors may help manage chronic hyperkalemia while maintaining RAAS inhibitors 6
• Monitor for rebound hyperkalemia after temporary treatments that only shift potassium intracellularly 7
• Avoid chronic use of sodium polystyrene sulfonate due to risk of severe gastrointestinal side effects 5