What is the management of hyperkalemia?

Management of Hyperkalemia

The management of hyperkalemia requires a structured approach based on severity, with acute treatment focusing on cardiac membrane stabilization using IV calcium gluconate, followed by potassium redistribution with insulin/glucose and beta-agonists, and ultimately potassium elimination through diuretics, potassium binders, or hemodialysis. 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, flattened P waves, prolonged PR interval, widened QRS) indicate urgent treatment regardless of potassium level 2
• Laboratory confirmation is essential as ECG findings can be variable and less sensitive than laboratory tests 1, 2

Acute Hyperkalemia Management

Step 1: Cardiac Membrane Stabilization (Immediate)

• Administer intravenous calcium gluconate 10% (15-30 mL IV over 2-5 minutes) 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 (30-60 minutes)

• Administer insulin with glucose: 10 units regular insulin IV with 50 mL of 50% dextrose 1
• Consider nebulized beta-agonists (e.g., salbutamol 20 mg in 4 mL) 1
• For patients with metabolic acidosis, add IV sodium bicarbonate 1, 2

Step 3: Potassium Elimination

• Administer loop diuretics (e.g., furosemide 40-80 mg IV) in patients with adequate kidney function 2
• Consider hemodialysis for severe, resistant hyperkalemia or in patients with renal failure 1
• Note that sodium polystyrene sulfonate should not be used for emergency treatment due to its delayed onset of action 3

Chronic Hyperkalemia Management

Medication Review and Adjustment

• Review and adjust medications that contribute to hyperkalemia (ACE inhibitors, ARBs, MRAs, NSAIDs, beta-blockers) 2
• Consider maximum tolerated doses of RAASi when indicated, with close monitoring 1

Ongoing Treatment Options

• Prescribe loop or thiazide diuretics to promote urinary potassium excretion 1
• Consider newer FDA-approved potassium binders (patiromer, sodium zirconium cyclosilicate) for long-term management 1, 2
• Fludrocortisone can increase potassium excretion but carries risks of fluid retention and hypertension 1

Monitoring and Follow-up

• Reassess potassium levels within 1 week after initiating or adjusting treatment 1
• Monitor more frequently in high-risk patients (CKD, heart failure, diabetes) 2
• Implement a team approach involving specialists and primary care physicians 1, 2

Special Considerations

• Patients with cardiovascular disease on RAAS inhibitors require careful monitoring 7-10 days after starting or increasing doses 2
• For patients with concurrent metabolic acidosis, sodium bicarbonate promotes potassium excretion through increased distal sodium delivery 2
• Dietary restriction should focus on reducing non-plant sources of potassium rather than complete restriction 4

Common Pitfalls to Avoid

• Do not rely solely on ECG findings to rule out severe hyperkalemia, as they can be variable and less sensitive than laboratory tests 1
• Avoid sodium polystyrene sulfonate for emergency treatment of life-threatening hyperkalemia due to its delayed onset of action 3
• Do not discontinue RAAS inhibitors prematurely; consider potassium binders to maintain these beneficial medications 4