What is the treatment for a patient with hyperkalemia?

Treatment of High Potassium (Hyperkalemia)

Immediate Assessment and Emergency Treatment

For 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 to stabilize cardiac membranes, followed by insulin 10 units with 50 mL of 50% dextrose IV and nebulized albuterol 20 mg to shift potassium intracellularly. 1, 2

First: Rule Out Pseudohyperkalemia

• Verify the result is not pseudohyperkalemia from hemolysis, repeated fist clenching, or poor phlebotomy technique by repeating the measurement with proper technique or arterial sampling 1, 2

Severity Classification

• Mild: 5.0-5.9 mEq/L 1, 2
• Moderate: 6.0-6.4 mEq/L 1, 2
• Severe: ≥6.5 mEq/L 1, 2

ECG Assessment

• Look for peaked T waves, flattened P waves, prolonged PR interval, and widened QRS complexes—these indicate urgent treatment regardless of potassium level 1, 2
• Critical pitfall: Do not rely solely on ECG findings, as they are highly variable and less sensitive than laboratory tests 1, 2
• Critical pitfall: Do not delay treatment while waiting for repeat lab confirmation if ECG changes are present 1

Acute Management Algorithm

Step 1: Cardiac Membrane Stabilization (if K+ ≥6.5 or ECG changes)

• Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes 1, 2
• Alternative: Calcium chloride (10%): 5-10 mL IV over 2-5 minutes 1, 2
• Onset: 1-3 minutes; Duration: 30-60 minutes 1
• Monitor ECG continuously during and for 5-10 minutes after administration 1
• If no ECG improvement within 5-10 minutes, repeat the dose 1
• Critical understanding: Calcium does NOT lower potassium—it only temporarily stabilizes cardiac membranes 1, 2

Step 2: Shift Potassium Intracellularly (for all acute cases)

• Insulin + Glucose: 10 units regular insulin IV with 50 mL of 50% dextrose (or 25g dextrose) 1, 2

  • Onset: 15-30 minutes; Duration: 4-6 hours 1
  • Critical pitfall: Never give insulin without glucose—hypoglycemia can be life-threatening 1
  • Can be repeated every 4-6 hours if hyperkalemia persists 1
  • Monitor glucose closely, especially in patients with low baseline glucose, no diabetes, female sex, or altered renal function 1

• Nebulized Albuterol: 20 mg in 4 mL 1, 2

  • Onset: 15-30 minutes; Duration: 2-4 hours 1
  • Use as adjunctive therapy with insulin 1

• Sodium Bicarbonate: 50 mEq IV over 5 minutes 1

  • ONLY use if metabolic acidosis is present (pH <7.35, bicarbonate <22 mEq/L) 1, 2
  • Onset: 30-60 minutes 1
  • Critical pitfall: Do not use sodium bicarbonate in patients without metabolic acidosis—it is ineffective and wastes time 1, 2

Step 3: Remove Potassium from the Body

• Loop Diuretics: Furosemide 40-80 mg IV 1

  • Only effective in patients with adequate kidney function 1
  • Increases renal potassium excretion 1

• Hemodialysis: 1, 2

  • Most effective and reliable method for severe hyperkalemia 1, 3
  • Reserved for severe cases unresponsive to medical management, oliguria, or end-stage renal disease 1
  • Important: Potassium levels can rebound 4-6 hours post-dialysis as intracellular potassium redistributes 1

• Sodium Polystyrene Sulfonate (Kayexalate): 4

  • FDA indication: Treatment of hyperkalemia, but NOT for emergency treatment due to delayed onset of action 4
  • Major limitation: Risk of bowel necrosis, especially with sorbitol 1
  • Should be avoided for acute management 1
  • Reserved for subacute treatment only 5

Chronic Hyperkalemia Management

Medication Review and Adjustment

• Review and adjust these medications: 1, 2

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

• For patients with cardiovascular disease or proteinuric CKD: 1

  • Do NOT permanently discontinue RAAS inhibitors—they provide mortality benefit and slow disease progression 1
  • Temporarily hold or reduce RAAS inhibitors if K+ >6.5 mEq/L 1
  • Restart at lower dose once K+ <5.0 mEq/L with concurrent potassium binder therapy 1

Newer Potassium Binders (Preferred for Long-Term Management)

• Patiromer (Veltassa): 1, 2

  • Starting dose: 8.4 g once daily with food 1
  • Titrate up to 25.2 g daily based on potassium levels 1
  • Onset: ~7 hours 1
  • Separate from other oral medications by at least 3 hours 1
  • Monitor magnesium levels (can cause hypomagnesemia) 1

• Sodium Zirconium Cyclosilicate (SZC/Lokelma): 1, 2

  • Acute phase: 10 g three times daily for 48 hours 1
  • Maintenance: 5-15 g once daily 1
  • Onset: ~1 hour (suitable for more urgent scenarios) 1
  • Monitor for edema due to sodium content 1

Diuretic Therapy

• Loop or thiazide diuretics promote urinary potassium excretion 1, 2
• Furosemide 40-80 mg daily can be used in patients with adequate renal function 1

Monitoring Protocol

• After starting or escalating RAAS inhibitors: Check potassium within 1 week, then reassess 7-10 days after dose changes 1, 2
• After initiating potassium binder therapy: Reassess 7-10 days later 1
• High-risk patients (CKD, heart failure, diabetes, history of hyperkalemia) require more frequent monitoring 1, 2
• After acute treatment: Monitor potassium every 2-4 hours initially, especially if initial K+ >6.5 mEq/L 1

Special Populations

Patients on Thromboprophylaxis

• Maintain thromboprophylaxis in patients with mild or moderate hyperkalemia 2, 6
• Consider temporary suspension only in cases of severe hyperkalemia 2, 6
• Newer potassium binders may allow safe continuation of thromboprophylaxis 6

Patients with CKD

• Patients with advanced CKD tolerate higher potassium levels (optimal range 3.3-5.5 mEq/L for stage 4-5 CKD) 1
• Maintain RAAS inhibitors aggressively using potassium binders, as these drugs slow CKD progression 1

Critical Pitfalls to Avoid

• Do not delay calcium administration if ECG changes are present—ECG changes indicate urgent need regardless of exact potassium value 1
• Remember that calcium, insulin, and beta-agonists do NOT remove potassium from the body—they only temporize 1, 2
• Never give insulin without glucose to prevent life-threatening hypoglycemia 1, 2
• Do not use sodium bicarbonate without metabolic acidosis—it is only indicated when acidosis is present 1, 2
• Do not permanently discontinue RAAS inhibitors in patients with cardiovascular disease or CKD—use potassium binders instead 1
• Avoid sodium polystyrene sulfonate for acute management due to delayed onset and risk of bowel necrosis 1, 4