What are the management options for hyperkalemia?

Management of Hyperkalemia

For acute severe hyperkalemia (≥6.5 mEq/L or any ECG changes), immediately administer IV calcium gluconate 15-30 mL of 10% solution over 2-5 minutes for cardiac membrane stabilization, followed simultaneously by insulin 10 units IV with 25g dextrose and nebulized albuterol 10-20 mg to shift potassium intracellularly, then initiate definitive potassium removal with loop diuretics or hemodialysis. 1

Initial Assessment and Classification

Verify true hyperkalemia by excluding pseudohyperkalemia from hemolysis, repeated fist clenching, or poor phlebotomy technique before initiating treatment. 1 Repeat the measurement with appropriate technique or arterial sampling if pseudohyperkalemia is suspected. 1

Classify severity as follows: 1

• Mild: 5.0-5.9 mEq/L
• Moderate: 6.0-6.4 mEq/L
• Severe: ≥6.5 mEq/L

Obtain an ECG immediately to assess for peaked T waves, flattened P waves, prolonged PR interval, or widened QRS complexes—these findings mandate urgent treatment regardless of the exact potassium level. 1 However, absent or atypical ECG changes do not exclude the necessity for immediate intervention. 2

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

Step 1: Cardiac Membrane Stabilization (Onset: 1-3 minutes)

Administer IV calcium first to protect against arrhythmias: 1

• Calcium gluconate 10%: 15-30 mL IV over 2-5 minutes (preferred for peripheral access) 1
• Calcium chloride 10%: 5-10 mL IV over 2-5 minutes (for central access or cardiac arrest) 1

Critical points about calcium: 1

• Effects begin within 1-3 minutes but last only 30-60 minutes 1
• Calcium does NOT lower potassium—it only stabilizes cardiac membranes temporarily 1
• Repeat dosing may be necessary if no ECG improvement within 5-10 minutes 1
• Continuous cardiac monitoring is mandatory during and after administration 1
• Never administer calcium through the same IV line as sodium bicarbonate (precipitation will occur) 1

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

Administer all three agents together for maximum effect: 1

Insulin with glucose (first choice): 1

• Standard dose: 10 units regular insulin IV + 25g dextrose (50 mL of 50% solution) 1
• Alternative dose: 0.1 units/kg (approximately 5-7 units in adults) 1
• Critical: Never give insulin without glucose—hypoglycemia can be life-threatening 1
• Verify potassium is not below 3.3 mEq/L before administering insulin 1
• Monitor glucose every 2-4 hours after administration 1
• Patients at higher risk for hypoglycemia: low baseline glucose, no diabetes, female sex, altered renal function 1

Nebulized albuterol (adjunctive therapy): 1

• Dose: 10-20 mg in 4 mL nebulized over 10 minutes 1
• Effects last 2-4 hours 1

Sodium bicarbonate (ONLY if metabolic acidosis present): 1

• Indication: pH <7.35, bicarbonate <22 mEq/L 1
• Dose: 50 mEq IV over 5 minutes 1
• Effects take 30-60 minutes to manifest 1
• Do not use without metabolic acidosis—it is ineffective and wastes time 1

Insulin can be repeated every 4-6 hours if hyperkalemia persists or recurs, with careful monitoring of potassium and glucose levels. 1

Step 3: Remove Potassium from the Body

Loop diuretics (if adequate renal function): 1

• Furosemide: 40-80 mg IV 1
• Increases renal potassium excretion by stimulating flow to renal collecting ducts 1
• Titrate to maintain euvolemia, not primarily for potassium management 1

Hemodialysis (most effective method): 1

• Reserved for severe cases unresponsive to medical management, oliguria, or end-stage renal disease 1
• Most reliable and effective method for potassium removal 1
• Monitor for rebound hyperkalemia within 4-6 hours post-dialysis as intracellular potassium redistributes 1

Step 4: Medication Review During Acute Episode

Temporarily discontinue or reduce at K+ ≥6.5 mEq/L: 1

• RAAS inhibitors (ACE inhibitors, ARBs, mineralocorticoid antagonists) 1
• NSAIDs 1
• Potassium-sparing diuretics (spironolactone, amiloride, triamterene) 1
• Trimethoprim 1
• Heparin 1
• Beta-blockers 1
• Potassium supplements and salt substitutes 1

Chronic Hyperkalemia Management (K+ 5.0-6.5 mEq/L)

Medication Optimization Strategy

For K+ 5.0-6.5 mEq/L: 1

• Maintain RAAS inhibitor therapy at current dose (provides mortality benefit in cardiovascular and renal disease) 1
• Initiate approved potassium-lowering agent (patiromer or sodium zirconium cyclosilicate) 1
• Eliminate contributing medications: NSAIDs, trimethoprim, heparin, potassium supplements, salt substitutes 1

For K+ >6.5 mEq/L: 1

• Temporarily reduce or hold RAAS inhibitor 1
• Initiate potassium-lowering agent 1
• Restart RAAS inhibitor at lower dose once potassium <5.0 mEq/L with concurrent potassium binder therapy 1

Never permanently discontinue RAAS inhibitors in patients with cardiovascular disease or proteinuric CKD—they provide mortality benefit and slow disease progression. 1

Potassium Binder Therapy (Preferred Agents)

Sodium zirconium cyclosilicate (SZC/Lokelma) - First choice for urgent scenarios: 1

• Acute phase: 10g three times daily for 48 hours 1
• Maintenance: 5-15g once daily 1
• Onset of action: ~1 hour 1
• Mechanism: Exchanges hydrogen and sodium for potassium 1
• Monitor for edema due to sodium content 1

Patiromer (Veltassa) - First choice for chronic management: 1

• Starting dose: 8.4g once daily with food 1
• Titration: Up to 25.2g daily based on potassium levels 1
• Onset of action: ~7 hours 1
• Mechanism: Exchanges calcium for potassium in the colon 1
• Separate from other oral medications by at least 3 hours 1
• Monitor magnesium levels (causes hypomagnesemia) 1

Sodium polystyrene sulfonate (Kayexalate) - AVOID: 3

• Should not be used as emergency treatment due to delayed onset of action 3
• Associated with intestinal ischemia, colonic necrosis, and doubling of risk for serious gastrointestinal adverse events 1
• Variable and inconsistent onset of action 1

Additional Chronic Management Options

Loop or thiazide diuretics: 1

• Promote urinary potassium excretion 1
• Furosemide 40-80 mg daily if adequate renal function present 1

Fludrocortisone: 1

• Increases potassium excretion but carries significant risks 1
• Risks: fluid retention, hypertension, vascular injury 1
• Use cautiously and only when other options are exhausted 1

Monitoring Protocol

Initial monitoring when starting or escalating RAAS inhibitors: 1

• Check potassium within 1 week of starting or escalating doses 1
• Reassess 7-10 days after dose changes 1

After initiating potassium binder therapy: 1

• Reassess potassium 7-10 days after initiation 1
• Monitor closely for both efficacy and hypokalemia (which may be more dangerous than hyperkalemia) 1

High-risk patients requiring more frequent monitoring: 1

• Chronic kidney disease 1
• Heart failure 1
• Diabetes mellitus 1
• History of hyperkalemia 1

For hemodialysis patients: 1

• Target predialysis potassium of 4.0-5.5 mEq/L to minimize mortality risk 1
• Monitor for rebound hyperkalemia every 2-4 hours initially after dialysis if severe initial hyperkalemia (>6.5 mEq/L) 1

Special Population Considerations

Patients with Chronic Kidney Disease

Optimal potassium ranges vary by CKD stage: 1

• Stage 1-2 CKD: 3.5-5.0 mEq/L 1
• Stage 4-5 CKD: 3.3-5.5 mEq/L (broader range due to compensatory mechanisms) 1
• Target for all stages: 4.0-5.0 mEq/L minimizes mortality risk 1

Maintain RAAS inhibitors aggressively in proteinuric CKD using potassium binders—these drugs slow CKD progression. 1

Patients with Cardiovascular Disease

Patients on RAAS inhibitors require careful monitoring: 1

• Assessment 7-10 days after starting or increasing doses 1
• High "normal" potassium concentrations (>5.0 mEq/L) may be associated with adverse outcomes 1

The triple combination of ACE inhibitor + ARB + MRA is NOT recommended due to excessive hyperkalemia risk. 1

Hemodialysis Patients

First-line agent - Sodium zirconium cyclosilicate: 1

• Start with 5g once daily on non-dialysis days 1
• Adjust weekly in 5g increments based on predialysis potassium 1
• Target predialysis potassium 4.0-5.0 mEq/L 1

Second-line agent - Patiromer: 1

• Start with 8.4g once daily with food 1
• Titrate up to 16.8g or 25.2g daily based on response 1
• Monitor magnesium levels closely 1

Consider adjusting dialysate potassium concentration (typically 2.0-3.0 mEq/L) based on predialysis levels, but monitor for intradialytic arrhythmias. 1

Dietary Considerations

Dietary potassium restriction should be approached cautiously: 1

• Evidence linking dietary potassium intake to serum levels is limited 1
• Potassium-rich diet provides cardiovascular benefits, including blood pressure reduction 1
• Newer potassium binders may allow for less restrictive dietary potassium restrictions 1

Avoid potassium supplements and salt substitutes (which have high potassium content). 1

Critical Pitfalls to Avoid

Never delay treatment while waiting for repeat lab confirmation if ECG changes are present—ECG changes indicate urgent need regardless of the exact potassium value. 1

Do not rely solely on ECG findings—they are highly variable and less sensitive than laboratory tests. 1

Do not use sodium bicarbonate in patients without metabolic acidosis—it is only indicated when acidosis is present (pH <7.35, bicarbonate <22 mEq/L). 1

Never give insulin without glucose—hypoglycemia can be life-threatening. 1

Remember that calcium, insulin, and beta-agonists are temporizing measures only—they do NOT remove potassium from the body. 1 Failure to initiate concurrent potassium-lowering therapies will result in recurrent life-threatening arrhythmias within 30-60 minutes. 1

Avoid amiloride and triamterene when using mineralocorticoid receptor antagonists due to increased hyperkalemia risk. 1

Team Approach

Optimal chronic hyperkalemia management involves a multidisciplinary team: 1

• Cardiologists 1
• Nephrologists 1
• Primary care physicians 1
• Nurses 1
• Pharmacists 1
• Social workers 1
• Dietitians 1