What is the best course of treatment for a 42-year-old female patient with Chronic Kidney Disease (CKD) Stage 5 on maintenance Hemodialysis (HD), Diabetic Kidney Disease (DKD), and Hypertension (HTN), presenting with severe Hyperkalemia, marked Azotemia, Hyponatremia, Hypocalcemia, and Transaminitis?

Emergency Management of Severe Hyperkalemia in CKD Stage 5 on Hemodialysis

This patient requires immediate emergency hemodialysis as the definitive treatment for life-threatening hyperkalemia (K⁺ 8.85 mmol/L), combined with urgent temporizing measures to stabilize cardiac membranes and shift potassium intracellularly while dialysis is being arranged. 1, 2

Immediate Stabilization (Within Minutes)

Step 1: Cardiac Membrane Stabilization

• Administer IV calcium gluconate (10%) 15-30 mL over 2-5 minutes immediately to protect against fatal arrhythmias, regardless of whether ECG changes are visible 1
• Effects begin within 1-3 minutes but last only 30-60 minutes 1
• Critical caveat: Calcium does NOT lower potassium—it only temporarily stabilizes the cardiac membrane 1
• If no ECG improvement within 5-10 minutes, repeat the dose 1
• Obtain ECG immediately to assess for peaked T waves, widened QRS, prolonged PR interval, or absent P waves 1

Step 2: Intracellular Potassium Shift (Simultaneous with Step 1)

Administer all three agents together for maximum effect 1:

• Insulin 10 units regular IV + 25g dextrose (D50W 50 mL) 1

  • Onset: 15-30 minutes, duration: 4-6 hours 1
  • Monitor glucose closely to prevent hypoglycemia 1

• Nebulized albuterol 20 mg in 4 mL 1, 3

  • Onset: 15-30 minutes, duration: 2-4 hours 1
  • Highly effective and safe in acute hyperkalemia 3

• Sodium bicarbonate 50 mEq IV over 5 minutes ONLY if metabolic acidosis is present 1

  • Check pH and bicarbonate level first 1
  • Do NOT use if no acidosis present—it wastes time and is ineffective 1

Definitive Treatment: Emergency Hemodialysis

Hemodialysis is the most effective and reliable method for severe hyperkalemia, especially in ESRD patients, and should be initiated urgently 1, 2

• Arrange emergency dialysis immediately while administering temporizing measures 1
• In cardiac arrest from severe hyperkalemia, hemodialysis should be initiated during CPR if conventional therapies fail 2
• Critical point: The temporizing measures above only redistribute potassium temporarily—they do NOT remove it from the body 1
• Hemodialysis is the only definitive treatment that actually removes total body potassium 1

Post-Dialysis Management

Monitor for Rebound Hyperkalemia

• Check potassium levels 2-4 hours post-dialysis, as intracellular potassium can redistribute back to extracellular space 1
• Continue monitoring every 2-4 hours initially if severe hyperkalemia (>6.5 mEq/L) was present 1

Identify and Address Root Causes

Medication Review 1:

• Temporarily hold or reduce ACE inhibitors/ARBs if K⁺ was >6.5 mEq/L 1
• Review and discontinue: NSAIDs, potassium-sparing diuretics, trimethoprim, heparin, beta-blockers, potassium supplements, salt substitutes 1

Initiate Chronic Hyperkalemia Prevention

Start a newer potassium binder once K⁺ <5.5 mEq/L 1, 4, 5:

• Sodium zirconium cyclosilicate (SZC/Lokelma) - preferred for dialysis patients 1, 4

  • For hemodialysis patients: Start 5g once daily on non-dialysis days 4
  • If K⁺ >6.5 mEq/L, consider starting dose of 10g once daily on non-dialysis days 4
  • Onset of action: ~1 hour 1
  • Adjust weekly in 5g increments based on pre-dialysis K⁺ after long interdialytic interval 4
  • Maintenance range: 5-15g once daily on non-dialysis days 4

• Patiromer (Veltassa) - alternative option 1, 5

  • Starting dose: 8.4g once daily with food 1
  • Separate from other medications by at least 3 hours 1
  • Onset of action: ~7 hours 1
  • Titrate up to 25.2g daily based on K⁺ levels 1

Target predialysis potassium: 4.0-5.5 mEq/L to minimize mortality risk 1

Addressing Other Electrolyte Abnormalities

Hypocalcemia

• Correct after hyperkalemia is addressed 1
• Calcium administration for hyperkalemia will partially address this 1

Hyponatremia

• Will improve with dialysis 1
• Avoid rapid correction to prevent osmotic demyelination 1

Transaminitis

• Likely secondary to acute illness/uremia 1
• Monitor liver function but focus on primary emergency (hyperkalemia) first 1

Critical Pitfalls to Avoid

• Never delay treatment waiting for repeat lab confirmation if patient has acute inability to stand or other symptoms 1
• Never use sodium bicarbonate without documented metabolic acidosis—it is ineffective and wastes time 1
• Never give insulin without glucose—hypoglycemia can be life-threatening 1
• Remember that calcium, insulin, and beta-agonists are temporizing only—they do NOT remove potassium from the body 1
• Do NOT use sodium polystyrene sulfonate (Kayexalate) in this acute setting—it has delayed onset, variable efficacy, and risk of bowel necrosis 1
• Do NOT discontinue RAAS inhibitors permanently—restart at lower dose once K⁺ <5.0 mEq/L with concurrent potassium binder therapy 1

Monitoring Protocol

• Immediate phase: Check K⁺ every 2-4 hours until stable 1
• Post-dialysis: Check K⁺ 2-4 hours after dialysis, then daily until stable 1
• Long-term: Check pre-dialysis K⁺ weekly after initiating potassium binder, then adjust frequency based on stability 4
• Monitor for hypokalemia with potassium binders—this can be even more dangerous than hyperkalemia 1