What is the treatment for hyperkalemia?

Treatment for Hyperkalemia

Hyperkalemia treatment follows a three-step approach: cardiac membrane stabilization with intravenous calcium, shifting potassium into cells with insulin/glucose and beta-agonists, and eliminating potassium from the body through diuretics, potassium binders, or hemodialysis—with the specific strategy determined by severity and ECG changes. 1

Severity Assessment

• Mild hyperkalemia is defined as potassium 5.0-5.9 mEq/L 1
• Moderate hyperkalemia is defined as potassium 6.0-6.4 mEq/L 1
• Severe hyperkalemia is defined as potassium ≥6.5 mEq/L and represents a life-threatening emergency 1
• ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) mandate urgent treatment regardless of the potassium level 1

Step 1: Cardiac Membrane Stabilization (Immediate Effect)

For severe hyperkalemia or any ECG changes, immediately administer intravenous calcium to protect against arrhythmias:

• Calcium chloride (10%): 5-10 mL (500-1000 mg) IV over 2-5 minutes—this is the preferred agent as it provides more rapid increase in ionized calcium than calcium gluconate 1
• Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes as an alternative 1
• Onset of action is within 1-3 minutes, but effects are temporary (30-60 minutes) 1, 2
• Critical caveat: Calcium does not lower serum potassium—it only stabilizes cardiac membranes 1
• Administer through central venous catheter when possible, as extravasation through peripheral IV may cause severe tissue injury 1
• Monitor heart rate during administration and stop if symptomatic bradycardia occurs 1

Step 2: Shift Potassium into Cells (Effect Within 15-30 Minutes)

Administer multiple agents simultaneously to maximize potassium shift:

• Insulin with glucose: 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 1

  • Onset within 15-30 minutes, duration 4-6 hours 1
  • Can be repeated every 4-6 hours if hyperkalemia persists 2
  • Monitor glucose closely to avoid hypoglycemia, especially in patients with low baseline glucose, no diabetes, female sex, or renal dysfunction 2
  • Verify potassium is not below 3.3 mEq/L before administering 2

• Nebulized beta-2 agonists: Albuterol 10-20 mg nebulized over 15 minutes 1

  • Can reduce serum potassium by approximately 0.5-1.0 mEq/L 1
  • Onset within 15-30 minutes, duration 4-6 hours 1
  • Use in conjunction with insulin/glucose for additive effect 2

• Sodium bicarbonate: 50 mEq IV over 5 minutes 1

  • Only use in patients with concurrent metabolic acidosis (pH <7.35, bicarbonate <22 mEq/L) 1, 2
  • Promotes potassium excretion through increased distal sodium delivery and counters acidosis-induced potassium release 2
  • Effects take 30-60 minutes to manifest 2

Important warning: These are temporary measures with effects lasting only 1-4 hours, and rebound hyperkalemia can occur after 2 hours 1

Step 3: Eliminate Potassium from Body (Definitive Treatment)

For Acute Management:

• Loop diuretics: Furosemide 40-80 mg IV 1

  • Only effective in patients with adequate renal function 1
  • Increases urinary potassium excretion 2

• Hemodialysis: Most effective method for severe hyperkalemia, especially in renal failure 1

  • Use for severe cases (>6.5 mEq/L) or refractory hyperkalemia 1, 2

For Chronic Management:

• Sodium polystyrene sulfonate (Kayexalate): 15-50 g orally or rectally 1

  • FDA limitation: Should NOT be used as emergency treatment due to delayed onset of action 3
  • Average adult dose is 15-60 g daily (15 g one to four times daily orally, or 30-50 g every 6 hours rectally) 3
  • Caution: Risk of intestinal necrosis and serious gastrointestinal events; concomitant use with sorbitol is not recommended 3
  • Avoid in patients with heart failure, severe hypertension, or marked edema due to sodium load 4

• Newer potassium binders: Patiromer (Veltassa) and sodium zirconium cyclosilicate (SZC/ZS-9) 4, 1

  • Safer alternatives to traditional cation exchange resins 1
  • Effective for maintaining normokalemia over time and preventing recurrence 4
  • Allow continuation of RAAS inhibitors in patients with cardiovascular disease 4

Special Considerations for Patients on RAAS Inhibitors

The European Society of Cardiology provides specific guidance for managing hyperkalemia in patients on ACE inhibitors, ARBs, or mineralocorticoid antagonists:

• Potassium 5.0-6.5 mEq/L on RAAS inhibitors: Initiate approved potassium-lowering agent and maintain RAAS inhibitor therapy 4
• Potassium >6.5 mEq/L: Discontinue or reduce RAAS inhibitor temporarily, initiate potassium-lowering agent, and monitor closely 4, 2
• Potassium 4.5-5.0 mEq/L not on maximal RAAS inhibitor dose: Up-titrate RAAS inhibitor and monitor closely; if potassium rises above 5.0 mEq/L, initiate potassium-lowering agent 4

Maintaining RAAS inhibitors is preferable to discontinuation in patients with cardiovascular disease, as these medications reduce mortality and morbidity 4

Critical Clinical Pitfalls

• Exclude pseudohyperkalemia from hemolysis or improper sampling before initiating aggressive treatment—repeat measurement with appropriate technique or arterial sampling 1, 2
• Monitor for rebound hyperkalemia after temporary measures wear off (2-4 hours); initiate potassium-lowering agents early to prevent rebound 1
• Avoid overcorrection leading to hypokalemia through close monitoring during treatment 1
• Review all medications that may contribute: ACE inhibitors, ARBs, mineralocorticoid antagonists, NSAIDs, beta-blockers, potassium-sparing diuretics 1, 2
• Assess dietary sources: Review potassium-containing supplements, salt substitutes, and nutraceuticals 4
• Monitor potassium levels 7-10 days after starting or increasing RAAS inhibitor doses in high-risk patients (chronic kidney disease, heart failure, diabetes) 2