There are no official guidelines to assist in answering this question. I will search for relevant research papers instead.
From the FDA Drug Label
Digoxin is primarily excreted by the kidneys; therefore, patients with impaired renal function require smaller than usual maintenance doses of digoxin Use in Patients with Impaired Renal Function: Deficiencies of these electrolytes may result from malnutrition, diarrhea, or prolonged vomiting, as well as the use of the following drugs or procedures: diuretics,amphotericin B, corticosteroids, antacids, dialysis, and mechanical suction of gastrointestinal secretions. Severe digitalis intoxication can cause a massive shift of potassium from inside to outside the cell, leading to life-threatening hyperkalemia.
The role of Digoxin in patients with impaired renal function and those undergoing dialysis who have hyperkalemia is not directly related to the treatment of hyperkalemia. Digoxin is a cardiac glycoside used to treat heart failure and atrial fibrillation, and its use in patients with impaired renal function requires careful dose adjustment to avoid toxicity. Hyperkalemia caused by massive digitalis toxicity is best treated with DIGIBIND, and initial treatment with glucose and insulin may also be required if hyperkalemia itself is acutely life-threatening 1 1.
From the Research
Role of Digoxin in Patients with Impaired Renal Function
- Digoxin is a cardiac glycoside that can be used in patients with impaired renal function, but its use requires careful consideration of the patient's renal clearance and plasma concentration 2.
- The efficiency of hemodialysis in eliminating cardiac glycosides, including digoxin, is low, but it can still be effective in reducing plasma concentrations 2.
- In patients with advanced renal insufficiency, the tolerance to cardiac glycosides is reduced with respect to the daily dose, but it is rather increased in relation to the plasma concentration required to maintain the positive inotropic effect 2.
Hyperkalemia and Digoxin Toxicity
- Hyperkalemia can occur in patients with renal failure who are taking digoxin, and it can be a sign of digoxin toxicity 3.
- Digoxin toxicity can be treated with digoxin-specific Fab antibody fragments, and peritoneal dialysis may be used to support the treatment 4.
- However, the use of digoxin in patients with end-stage renal disease (ESRD) has been associated with increased mortality, especially in those with low predialysis serum potassium levels 5.
Clinical Considerations
- The use of digoxin in patients with impaired renal function and hyperkalemia requires careful monitoring of plasma concentrations and renal function 2, 6.
- Serial measurements of steady-state plasma concentration of cardiac glycosides may be the only way to reduce the risk of under- and overtreatment in patients with impaired renal function 2.
- The combination of hyperkalemia, hypermagnesemia, hypocalcemia, and acidosis, which is common in chronic renal failure, may explain the reduced myocardial sensitivity to cardiac glycosides 2.