What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

For severe hyperkalemia (K+ ≥6.5 mEq/L or ECG changes), immediately administer calcium chloride 10%: 5-10 mL IV over 2-5 minutes for cardiac protection, followed within 15 minutes by insulin 10 units + glucose 25g IV and nebulized albuterol 10-20 mg to shift potassium intracellularly, then initiate definitive removal with loop diuretics or hemodialysis. 1, 2

Severity Classification

Before initiating treatment, classify hyperkalemia severity:

• Mild: K+ 5.0-5.9 mEq/L 1, 3
• Moderate: K+ 6.0-6.4 mEq/L 1, 3
• Severe: K+ ≥6.5 mEq/L (life-threatening) 1, 2

ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) mandate urgent treatment regardless of potassium level. 1, 3 However, absent or atypical ECG changes do not exclude the need for immediate intervention. 4

Critical pitfall: Exclude pseudo-hyperkalemia from hemolysis, repeated fist clenching, or poor phlebotomy technique before initiating aggressive treatment by repeating the measurement with proper technique or arterial sampling. 1, 3

Step 1: Cardiac Membrane Stabilization (Immediate - Within 1-3 Minutes)

Calcium chloride (10%): 5-10 mL (500-1000 mg) IV over 2-5 minutes is the preferred first-line agent because it provides more rapid increase in ionized calcium than calcium gluconate. 1, 2, 3

• Alternative: Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes 1, 3
• Effects begin within 1-3 minutes but last only 30-60 minutes 1, 3
• Does not lower serum potassium—only protects against arrhythmias 1, 2
• Administer through central line when possible; peripheral extravasation causes severe tissue injury 1
• Monitor heart rate during administration; stop if symptomatic bradycardia occurs 1

Step 2: Shift Potassium Intracellularly (Onset 15-30 Minutes, Duration 4-6 Hours)

Administer these agents simultaneously for additive effect:

Insulin + Glucose (Primary Agent)

• Insulin 10 units regular IV + glucose 25g (50 mL D50W) over 15-30 minutes 1, 2, 3
• Onset: 15-30 minutes; Duration: 4-6 hours 1, 2
• Can be repeated every 4-6 hours if hyperkalemia persists, monitoring potassium every 2-4 hours and glucose to avoid hypoglycemia 1
• Do not administer if baseline potassium <3.3 mEq/L 1
• Higher hypoglycemia risk in patients with low baseline glucose, no diabetes, female sex, and renal dysfunction 1

Beta-2 Agonist (Adjunctive)

• Nebulized albuterol 10-20 mg over 15 minutes 1, 2, 3
• Reduces serum potassium by approximately 0.5-1.0 mEq/L 1
• Duration: 2-4 hours 3
• Can use fenoterol as alternative 1

Sodium Bicarbonate (Only if Metabolic Acidosis Present)

• Administer ONLY if pH <7.35 and bicarbonate <22 mEq/L 1, 3
• Dose: 50 mEq IV over 5 minutes 1
• Onset: 30-60 minutes 3
• Promotes potassium excretion through increased distal sodium delivery 1, 3
• Do not use in patients without metabolic acidosis—it is ineffective and potentially harmful 3, 4

Critical warning: These temporizing measures provide only transient effects (1-4 hours), and rebound hyperkalemia can occur after 2 hours. 1 Definitive potassium removal must be initiated simultaneously.

Step 3: Eliminate Potassium from Body (Definitive Treatment)

Loop Diuretics (If Adequate Renal Function)

• Furosemide 40-80 mg IV 1, 2, 3
• Effective only if kidney function is preserved 2, 3

Potassium Binders (Subacute to Chronic Management)

• Newer agents (patiromer, sodium zirconium cyclosilicate) are preferred over traditional resins 1, 2, 3
• Sodium zirconium cyclosilicate reduces potassium within 1 hour of a single 10g dose 3
• Sodium polystyrene sulfonate (Kayexalate) should NOT be used for acute management due to delayed onset of action and risk of intestinal necrosis, especially with concomitant sorbitol 1, 5
• FDA labeling explicitly states: "Should not be used as emergency treatment for life-threatening hyperkalemia because of delayed onset of action" 5

Hemodialysis (Most Effective Method)

• Indicated for severe hyperkalemia, especially with renal failure or unresponsive to medical management 1, 2, 3
• Most reliable and effective method for potassium removal 3

Treatment Algorithm by Severity

Severe Hyperkalemia (K+ ≥6.5 mEq/L or ECG Changes)

1. Calcium chloride 10%: 5-10 mL IV over 2-5 minutes (immediate) 1, 2
2. Insulin 10 units + glucose 25g IV (within 15 minutes) 1, 2
3. Albuterol 10-20 mg nebulized (within 15 minutes) 1, 2
4. Hemodialysis or loop diuretics (definitive removal) 1, 2

Moderate Hyperkalemia (K+ 6.0-6.4 mEq/L Without ECG Changes)

1. Insulin/glucose + albuterol for intracellular shift 2
2. Loop diuretics or potassium binders for removal 2

Mild Hyperkalemia (K+ 5.0-5.9 mEq/L)

1. Review and discontinue offending medications (ACE inhibitors, ARBs, MRAs, NSAIDs, beta-blockers, heparin) 1, 2, 3
2. Initiate potassium binder for chronic management 2, 3
3. Maintain RAAS inhibitor therapy when possible (see below) 2, 3

Special Population: Patients on RAAS Inhibitors

For patients requiring RAAS inhibitors (heart failure, proteinuric kidney disease), maintain these life-saving medications by using potassium binders rather than discontinuing therapy. 1, 2, 3

Management Strategy:

• K+ 5.0-6.4 mEq/L: Initiate approved potassium-lowering agent (patiromer or sodium zirconium cyclosilicate) and maintain RAAS inhibitor 1, 2, 3
• K+ >6.5 mEq/L: Temporarily discontinue or reduce RAAS inhibitor, initiate potassium-lowering agent, monitor closely, then attempt to restart RAAS inhibitor once K+ <5.0 mEq/L 1, 2

Monitoring Protocol

• Check potassium within 1 week of starting or escalating RAAS inhibitors 3
• Reassess 7-10 days after dose changes 3
• Monitor every 2-4 hours after acute treatment until stable 1
• More frequent monitoring required in high-risk patients: chronic kidney disease, heart failure, diabetes 3

Critical Pitfalls to Avoid

• Do not rely solely on ECG findings—they are highly variable and less sensitive than laboratory values 3
• Do not use sodium bicarbonate without metabolic acidosis—it is only effective when acidosis is present 1, 3
• Always administer glucose with insulin to prevent hypoglycemia 3
• Remember calcium, insulin, and beta-agonists do not remove potassium—they only temporize; definitive removal is essential 3
• Avoid sodium polystyrene sulfonate with sorbitol due to risk of intestinal necrosis 1, 5
• Separate sodium polystyrene sulfonate from other oral medications by at least 3 hours (6 hours in gastroparesis) 5
• Do not use sodium polystyrene sulfonate in patients with obstructive bowel disease, reduced gut motility, or constipation 5

Dietary Considerations

Evidence linking dietary potassium intake to serum potassium is limited, and potassium-rich diets have multiple health benefits including blood pressure reduction. 3 Focus dietary restriction on reducing nonplant sources of potassium rather than blanket restriction. 6