How to manage hyperkalemia?

Management of Hyperkalemia

The most effective approach to reducing potassium levels involves a stepwise strategy based on severity, with acute management focusing on cardiac membrane stabilization using IV calcium gluconate, followed by insulin/glucose or beta-agonists to shift potassium intracellularly, and ultimately removing excess potassium through diuretics or potassium binders. 1, 2

Assessment and Classification

• 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) may indicate urgent treatment, though they can be variable and less sensitive than laboratory tests 1
• Symptoms are often nonspecific, making laboratory confirmation essential 1

Acute Hyperkalemia Management

Step 1: Cardiac Membrane Stabilization

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

Step 2: Intracellular Potassium Shifting

• Administer intravenous insulin (10 units regular insulin) with glucose (25-50g) to shift potassium into cells 1, 2
• Consider inhaled beta-agonists (e.g., albuterol) which act within 30 minutes 1, 3
• Both treatments temporarily reduce serum potassium but do not eliminate it from the body 1

Step 3: Potassium Elimination

• For patients with adequate kidney function, administer loop diuretics (e.g., furosemide 40-80 mg IV) 2, 4
• In patients with metabolic acidosis, sodium bicarbonate may promote potassium excretion 1, 2
• Hemodialysis is the most effective method for severe hyperkalemia, especially in patients with renal failure 1, 2

Chronic Hyperkalemia Management

Medication Review and Adjustment

• Identify and adjust medications that may contribute to hyperkalemia (ACE inhibitors, ARBs, NSAIDs, beta-blockers) 2, 5
• Consider maintaining beneficial medications (like RAASi) at adjusted doses rather than discontinuing them completely 1

Pharmacological Management

• Initiate loop or thiazide diuretics to promote urinary potassium excretion in patients with adequate kidney function 1
• Consider potassium binders for long-term management 1, 2:
  • Newer FDA-approved agents (patiromer, sodium zirconium cyclosilicate) are preferred over older agents like sodium polystyrene sulfonate 1, 2
  • Sodium polystyrene sulfonate should not be used for emergency treatment due to its delayed onset of action 6

Dietary Considerations

• Traditional strict dietary potassium restriction is being reassessed, with focus now on reducing non-plant sources of potassium 7
• Adequate hydration supports renal potassium excretion 3

Special Considerations

• Patients with chronic kidney disease, heart failure, or diabetes require more frequent monitoring of potassium levels 2
• When using RAAS inhibitors, assess potassium levels 7-10 days after starting or increasing doses 2
• A team approach involving specialists, primary care physicians, and other healthcare professionals is optimal for chronic hyperkalemia management 1, 3
• For dialysis patients, consider adjusting the dialysate potassium concentration and session frequency 8

Common Pitfalls to Avoid

• Do not rely solely on ECG findings to diagnose or rule out hyperkalemia 1
• Avoid sodium polystyrene sulfonate for emergency treatment of life-threatening hyperkalemia due to its delayed onset 6
• Do not discontinue beneficial medications like RAASi without first trying other strategies to manage hyperkalemia 1
• Recognize that chronic hyperkalemia is not benign and is associated with increased morbidity and mortality even when asymptomatic 7