How to decrease hyperkalemia?

Management of Hyperkalemia

Hyperkalemia should be treated with a combination of dietary modifications, medication adjustments, and potassium-binding agents, with the specific approach determined by the severity and acuity of the condition. 1, 2

Assessment and Classification

• Hyperkalemia is commonly 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, flattened P waves, prolonged PR interval, widened QRS) indicate urgent treatment regardless of potassium level 2
• Evaluate for symptoms including muscle weakness, paresthesias, and cardiac arrhythmias 3

Acute Hyperkalemia Management

For severe or symptomatic hyperkalemia requiring immediate intervention:

• Cardiac membrane stabilization: Administer intravenous calcium gluconate (10%): 15-30 mL IV over 2-5 minutes, or calcium chloride (10%): 5-10 mL IV for cardiac protection 2
• Intracellular shifting: Use insulin (10 units IV) with glucose (25-50g) and/or nebulized beta-agonists to temporarily shift potassium into cells 2, 4
• Sodium bicarbonate: Consider only in patients with concurrent metabolic acidosis 2
• Elimination: Administer loop diuretics (furosemide 40-80 mg IV) in patients with adequate kidney function 2, 4
• Dialysis: Consider for severe hyperkalemia, especially in patients with renal failure 4

Chronic Hyperkalemia Management

Dietary Modifications

• Restrict intake of high-potassium foods such as bananas, oranges, potatoes, tomato products, legumes, lentils, yogurt, and chocolate 1
• Foods containing less than 100 mg or less than 3% DV are considered low in potassium 1
• Presoaking root vegetables, including potatoes, can effectively lower potassium content by 50% to 75% 1
• Avoid potassium-containing salt substitutes, which can cause dangerous hyperkalemia 1

Medication Adjustments

• Review and adjust medications that may contribute to hyperkalemia, including ACE inhibitors, ARBs, MRAs, NSAIDs, and beta-blockers 1
• For patients on RAAS inhibitors (ACEi or ARB):
  • Consider continuing therapy unless serum creatinine rises by more than 30% within 4 weeks or uncontrolled hyperkalemia persists despite treatment 1
  • Monitor potassium levels within 2-4 weeks of initiation or dose increase 1

Potassium-Binding Agents

• Sodium polystyrene sulfonate: Traditional resin but not for emergency treatment due to delayed onset of action 5, 4
• Newer potassium binders (patiromer and sodium zirconium cyclosilicate):
  • More effective for long-term management 1, 6
  • Allow continuation of beneficial RAAS inhibitor therapy 1, 6
  • In the PEARL-HF trial, patiromer led to lower potassium levels and allowed higher doses of spironolactone 1

Special Considerations

• In patients with CKD, when hyperkalemia persists despite dietary restriction, investigate non-dietary causes including:

  • Spurious values, hemolysis, metabolic acidosis
  • Constipation, inadequate dialysis
  • Medications (ACEi, ARBs, NSAIDs, potassium-sparing diuretics)
  • Tissue destruction due to catabolism, infection, surgery, or chemotherapy 1

• For children with CKD, a reasonable starting point for potassium restriction is 40-120 mg (1-3 mmol/kg/d) 1

• Patients with heart failure on RAAS inhibitors benefit from potassium binders to maintain optimal therapy rather than discontinuing these life-saving medications 1, 6

Monitoring

• Monitor potassium levels within 2-4 weeks of initiating or increasing doses of RAAS inhibitors 1
• For patients on chronic potassium-lowering therapy, regular monitoring is essential to prevent overcorrection and hypokalemia 2
• Patients with CKD, heart failure, or diabetes require more frequent monitoring due to higher risk 1

By following this comprehensive approach to hyperkalemia management, clinicians can effectively reduce potassium levels while maintaining essential therapies that improve morbidity and mortality outcomes.