What are the causes and treatments of hyperkalemia (elevated potassium levels)?

From the Guidelines

Hyperkalemia is a life-threatening condition that requires immediate treatment, and the most effective approach is to administer calcium gluconate 10% (10 mL IV over 2-3 minutes) to stabilize cardiac membranes, followed by insulin (10 units regular insulin IV) with glucose (25g IV) to shift potassium intracellularly, as recommended by the most recent and highest quality study 1.

Key Considerations

• The severity of hyperkalemia can be classified as mild (>5.0 to <5.5 mEq/L), moderate (5.5 to 6.0 mEq/L), and severe (>6.0 mEq/L) 1.
• The risk of arrhythmic emergencies and sudden arrhythmic death in patients with hyperkalemia is widely variable, and life-threatening arrhythmias may occur at different thresholds and vary between different patients 1.
• Hyperkalemia frequently occurs in patients with cardiovascular diseases, particularly when combined with renal function impairment, diabetes, and advanced age 1.

Treatment Options

• For acute management, the following treatments can be used:
  • Calcium gluconate 10% (10 mL IV over 2-3 minutes) to stabilize cardiac membranes
  • Insulin (10 units regular insulin IV) with glucose (25g IV) to shift potassium intracellularly
  • Sodium bicarbonate (50 mEq IV over 5 minutes) in acidotic patients
• For ongoing management, the following treatments can be used:
  • Loop diuretics like furosemide (40-80 mg IV) to increase potassium excretion
  • Potassium binders such as sodium polystyrene sulfonate (15-30g orally or rectally), patiromer (8.4-25.2g daily), or sodium zirconium cyclosilicate (10g three times daily initially) to remove potassium from the body
  • Hemodialysis for life-threatening cases or when medical therapy fails

Underlying Causes

• Underlying causes must be addressed, including medication review (discontinuing ACE inhibitors, ARBs, potassium-sparing diuretics), treating acidosis, and managing renal dysfunction 1.
• The use of renin-angiotensin-aldosterone system inhibitors (RAASi) therapy should be considered, as it reduces mortality and morbidity in patients with cardiovascular disease, but can increase potassium levels 1.

Monitoring and Prevention

• Monitoring serum potassium levels should be individualized, and increased frequency of monitoring should be considered for patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia, and for those receiving RAASi therapy 1.
• The use of newer potassium binders, such as patiromer sorbitex calcium and sodium zirconium cyclosilicate, may facilitate optimization of RAASi therapy and more effective management of hyperkalemia 1.

From the FDA Drug Label

1 INDICATIONS AND USAGE Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia.

Hyperkalemia is treated with Sodium Polystyrene Sulfonate Powder, for Suspension, as it is indicated for this condition 2.

• The treatment of hyperkalemia with Sodium Polystyrene Sulfonate Powder, for Suspension is its primary use.
• However, it should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action.

From the Research

Definition and Causes of Hyperkalemia

• Hyperkalemia is a common electrolyte disorder characterized by an elevated extracellular fluid potassium concentration 3, 4.
• It can result from various factors, including kidney failure, limited delivery of sodium and water to the distal nephron, and drugs that inhibit the renin-angiotensin-aldosterone system 4.
• Other causes of hyperkalemia include acute kidney injury, critical illness, crush injuries, and massive red blood cell transfusions 5.

Symptoms and Diagnosis of Hyperkalemia

• Hyperkalemia can be asymptomatic, but it may also be associated with electrocardiogram (ECG) changes and life-threatening cardiac arrhythmias 4.
• The diagnosis of hyperkalemia is typically made through serum clinical laboratory measurement 3.
• ECG changes can be used to assess the severity of hyperkalemia, but absent or atypical ECG changes do not exclude the necessity for immediate intervention 6.

Treatment of Hyperkalemia

• The treatment of hyperkalemia involves measures to stabilize cardiac membranes, shift potassium from extracellular to intracellular stores, and promote potassium excretion 3.
• Calcium gluconate 10% can be administered intravenously to stabilize cardiac membranes, unless the patient is in cardiac arrest, in which case calcium chloride is warranted 3.
• Beta-agonists, intravenous insulin, and dextrose can be used to shift potassium from extracellular to intracellular stores 3, 4.
• Dialysis is the most efficient means to enable removal of excess potassium, and loop and thiazide diuretics can also be useful 3.
• New medications, such as patiromer and sodium zirconium cyclosilicate, have been developed to promote gastrointestinal potassium excretion 3, 5.

Management of Severe Hyperkalemia

• Severe hyperkalemia can lead to cardiac arrest, and prompt recognition and treatment are essential to prevent serious cardiac complications 4, 7.
• In cases of cardiac arrest due to hyperkalemia, prolonged cardiopulmonary resuscitation along with hemodialysis may be necessary to restore spontaneous heartbeat 7.
• The management of hyperkalemia requires a long-term plan to prevent its recurrence or worsening, including elucidating underlying causes and pathophysiologic mechanisms, and searching for medications that may have led to the development of hyperkalemia 6.