What are the management options for 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, 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) 1, 2
• ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) indicate urgent treatment regardless of potassium level 1, 3
• ECG findings can be variable and less sensitive than laboratory tests, so treatment decisions should not be delayed when severe hyperkalemia is confirmed 3

Acute Management Algorithm

Step 1: Cardiac Membrane Stabilization (for severe hyperkalemia or ECG changes)

• Administer intravenous calcium chloride (10%): 5-10 mL (500-1000 mg) IV over 2-5 minutes (preferred due to higher ionized calcium) 1
• Alternatively, calcium gluconate (10%): 15-30 mL IV over 2-5 minutes 1
• Effects begin within minutes but are temporary (30-60 minutes) and do not lower serum potassium 1, 2
• Monitor heart rate during calcium administration and stop if symptomatic bradycardia occurs 1

Step 2: Shift Potassium into Cells

• Administer insulin with glucose: 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 1
• Add nebulized beta-2 agonists: albuterol 10-20 mg over 15 minutes 1
• Consider sodium bicarbonate: 50 mEq IV over 5 minutes (most effective in patients with concurrent metabolic acidosis) 1, 3
• Effects of these interventions begin within 15-30 minutes and last 4-6 hours 1, 2

Step 3: Eliminate Potassium from Body

• Loop diuretics (furosemide: 40-80 mg IV) for patients with adequate renal function 1, 2
• Newer potassium binders (patiromer, sodium zirconium cyclosilicate) are safer alternatives to traditional cation exchange resins 1, 2
• Sodium polystyrene sulfonate (15-50 g orally or rectally) - not for emergency treatment due to delayed onset of action 4
• Hemodialysis for severe or refractory cases, especially in patients with renal failure 1, 3

Chronic Hyperkalemia Management

• Review and adjust medications that contribute to hyperkalemia (ACE inhibitors, ARBs, MRAs, NSAIDs, beta-blockers) 2, 3
• For patients on RAAS inhibitors with K+ >5.0 mEq/L, initiate potassium-lowering agents while maintaining RAAS inhibitor therapy 1, 2
• For severe hyperkalemia (>6.5 mEq/L) in patients on RAAS inhibitors, consider discontinuing or reducing RAAS inhibitor dose 2
• Implement dietary potassium restriction 2, 5
• Consider loop or thiazide diuretics to increase potassium excretion when appropriate 2, 3

Special Considerations

• Temporary measures (insulin/glucose, beta-agonists) provide only transient effects (1-4 hours), and rebound hyperkalemia can occur after 2 hours 1
• Patients with cardiovascular disease and chronic kidney disease are at higher risk of recurrent hyperkalemia 2, 5
• Regular monitoring of potassium levels is essential for high-risk patients, including those with CKD, heart failure, diabetes, or on RAAS inhibitor therapy 2, 6
• Avoid chronic use of sodium polystyrene sulfonate with sorbitol due to risk of bowel necrosis 2, 3

Common Pitfalls to Avoid

• Delaying treatment when K+ >5.0 mEq/L in high-risk patients 2
• Discontinuing beneficial RAAS inhibitor therapy prematurely rather than managing hyperkalemia 2
• Relying solely on ECG changes to guide treatment decisions 3
• Using sodium polystyrene sulfonate for emergency treatment of life-threatening hyperkalemia 4
• Failing to monitor for rebound hyperkalemia after temporary treatment measures 1