How do you manage a patient with hyperkalemia?

Management of Hyperkalemia 5.7 mEq/L

For a potassium level of 5.7 mEq/L (moderate hyperkalemia), immediately obtain an ECG to assess for cardiac changes, then implement dietary potassium restriction, review and adjust contributing medications, and consider adding a potassium binder (patiromer or sodium zirconium cyclosilicate) rather than discontinuing beneficial RAAS inhibitors. 1

Immediate Assessment

• Obtain an ECG immediately to evaluate for cardiac conduction abnormalities (peaked T waves, flattened P waves, prolonged PR interval, widened QRS complex), even if the patient is asymptomatic, as cardiac effects can occur without symptoms 1, 2
• Rule out pseudohyperkalemia by ensuring proper blood draw technique and considering repeat measurement if there was hemolysis or prolonged tourniquet time 1, 2
• Confirm this is not a laboratory error through repeat measurement 1

Risk Stratification

• A potassium of 5.7 mEq/L classifies as moderate hyperkalemia (5.5 to 6.0 mEq/L) according to European Society of Cardiology guidelines 1
• This level requires prompt attention but not emergency intervention if the ECG is normal and the patient remains asymptomatic 1
• Hospital admission is indicated if potassium exceeds 6.0 mEq/L, ECG changes develop, symptoms appear (muscle weakness, paresthesias), or rapid deterioration of kidney function occurs 1

Treatment Strategy

Dietary Modifications

• Restrict potassium intake to <3 grams per day 1, 2
• Eliminate high-potassium foods including bananas, oranges, potatoes, tomatoes, and salt substitutes containing potassium 1, 2

Medication Review and Adjustment

• Evaluate and adjust medications that contribute to hyperkalemia, including potassium supplements, NSAIDs, and other drugs that impair renal potassium excretion 1, 3
• Do not discontinue RAAS inhibitors (ACE inhibitors, ARBs) prematurely, as this increases mortality risk in patients with cardiovascular disease and proteinuric kidney disease 4, 2, 5

Pharmacologic Interventions

• Consider adding a potassium binder such as patiromer (starting at 8.4 g once daily) or sodium zirconium cyclosilicate (SZC, starting at 10 g three times daily for 48 hours, then 5-15 g once daily for maintenance) to enable continuation of RAAS inhibitor therapy 4
• These newer potassium binders have been shown to effectively normalize elevated potassium levels and maintain normokalemia over time in patients on RAAS inhibitor therapy 4
• If the patient has adequate kidney function (eGFR >30 mL/min), consider loop diuretics (furosemide 40-80 mg) or increase thiazide diuretic dose to enhance potassium excretion 1, 2

Monitoring Protocol

• Recheck serum potassium within 24-48 hours to assess response to initial interventions 1
• Schedule additional follow-up potassium measurement within 3-7 days after implementing dietary changes and medication adjustments 1, 2
• Establish ongoing monitoring: monthly for the first 3 months, then every 3 months thereafter 2
• Monitor more frequently if the patient has high-risk comorbidities such as advanced chronic kidney disease, heart failure, or diabetes mellitus 1

Special Considerations for Patients on RAAS Inhibitors

• Therapies aimed at lowering potassium levels should be considered to enable patients to continue RAAS inhibitor therapy, as these medications reduce mortality and morbidity in patients with cardiovascular disease 4
• In patients with potassium levels >5.0 mEq/L on maximum tolerated RAAS inhibitor doses, treatment with a potassium-lowering agent should be initiated as soon as potassium exceeds 5.0 mEq/L 4
• Potassium levels and renal function should be closely monitored when potassium-lowering treatment is initiated, not only to follow the potassium-lowering effect but also to protect against development of hypokalemia, which may be even more dangerous than hyperkalemia 4

Common Pitfalls to Avoid

• Do not ignore the need for repeat potassium measurement to confirm hyperkalemia and monitor treatment response 1
• Do not permanently discontinue beneficial RAAS inhibitors due to moderate hyperkalemia; dose reduction and addition of potassium binders is preferred to maintain cardioprotective and renoprotective benefits 1, 2, 5
• Do not delay treatment if clinical suspicion is high while waiting for confirmation of repeat laboratory values 1
• Do not overlook potential pseudohyperkalemia from poor phlebotomy technique or delayed sample processing 1

When to Escalate to Emergency Treatment

If potassium rises above 6.0 mEq/L or ECG changes develop, immediate emergency treatment is required 1:

• Administer calcium gluconate 1-2 grams IV (or calcium chloride) for cardiac membrane stabilization 1, 6, 7
• Shift potassium intracellularly with rapid-acting insulin 10 units IV with 25 grams of dextrose 1, 7, 8
• Consider nebulized albuterol (10-20 mg) as an adjunct 7, 8
• Consider hemodialysis for refractory cases or severe renal impairment 1, 6, 8