What is the management of hyponatremia (low sodium) and hyperkalemia (high potassium), and what are their causes?

From the Guidelines

Management of hyponatremia and hyperkalemia requires a multifaceted approach, prioritizing the correction of electrolyte imbalances while addressing underlying causes, with the goal of minimizing morbidity, mortality, and improving quality of life.

Causes of Hyponatremia and Hyperkalemia

The causes of hyponatremia and hyperkalemia can be diverse, including but not limited to, adrenal insufficiency, certain medications such as ACE inhibitors, ARBs, potassium-sparing diuretics, and NSAIDs, renal failure, and heart failure 1.

Management of Hyponatremia

For hyponatremia, the management strategy depends on the severity and symptoms of the condition.

• Mild hyponatremia (Na 126-135 mEq/L) in cirrhosis without symptoms may not require specific management apart from monitoring and water restriction 1.
• Moderate hyponatremia (120-125 mEq/L) can be managed with water restriction to 1,000 mL/day and cessation of diuretics 1.
• Severe hyponatremia (<120 mEq/L) may require a more severe restriction of water intake with albumin infusion, and in some cases, the use of vasopressin receptor antagonists or hypertonic saline for short-term treatment, especially in symptomatic patients or those with imminent liver transplantation 1.

Management of Hyperkalemia

For hyperkalemia, acute management involves:

• Stabilizing cardiac membranes with calcium gluconate 10% (10 mL IV over 2-3 minutes) 1.
• Shifting potassium intracellularly with insulin (10 units regular insulin IV with 25g dextrose) and sodium bicarbonate (50 mEq IV) if acidosis is present 1.
• Removing potassium from the body using sodium polystyrene sulfonate (15-30g orally or rectally), loop diuretics like furosemide (20-40mg IV), or hemodialysis in severe cases 1.

Key Considerations

• Regular monitoring of electrolytes is crucial during correction to prevent overcorrection or undercorrection of either imbalance.
• Discontinuing contributing medications when possible and treating the underlying condition are essential components of management.
• The use of renin-angiotensin-aldosterone system inhibitors, which are common in patients with cardiovascular diseases, can increase the risk of hyperkalemia, necessitating careful monitoring and management strategies 1.

Prioritizing Recent and High-Quality Evidence

Given the complexity of managing hyponatremia and hyperkalemia, it is crucial to prioritize the most recent and highest quality evidence, such as the 2021 practice guidance by the American Association for the Study of Liver Diseases for hyponatremia management in cirrhosis 1, and expert consensus documents on hyperkalemia management in patients with cardiovascular disease treated with renin-angiotensin-aldosterone system inhibitors 1.

From the Research

Management of Hyponatremia and Hyperkalemia

• The management of hyponatremia is not discussed in the provided studies, however, the management of hyperkalemia is discussed in several studies 2, 3, 4, 5, 6.
• Hyperkalemia is treated with measures to stabilize cardiac membranes, shift potassium from extracellular to intracellular stores, and promote potassium excretion 3, 5.
• Treatment options for hyperkalemia include:
  • Calcium gluconate 10% to stabilize cardiac membranes 3
  • Beta-agonists and intravenous insulin to shift potassium into cells 3, 5
  • Dextrose to prevent hypoglycemia 3
  • Dialysis to remove excess potassium 3
  • Loop and thiazide diuretics to promote potassium excretion 3
  • New medications such as patiromer and sodium zirconium cyclosilicate to promote gastrointestinal potassium excretion 3, 5

Causes of Hyperkalemia

• Hyperkalemia can result from:
  • Kidney disease 2, 6
  • Hyperglycemia 2
  • Medication use 2
  • Excessive intake of potassium, usually in the setting of impaired renal function 6
  • Shift of potassium out of cells 6
  • Abnormal renal potassium excretion 6

Diagnosis of Hyperkalemia

• Hyperkalemia is usually detected via serum clinical laboratory measurement 3
• Clinical manifestations of hyperkalemia can be vague, making diagnosis challenging 4, 6
• Electrocardiography changes can indicate the presence of hyperkalemia 2, 3