From the Guidelines
Hyperkalemia is primarily caused by medications, kidney disease, and cellular breakdown conditions, and its management should prioritize the identification and treatment of the underlying cause to reduce morbidity, mortality, and improve quality of life. The causes of hyperkalemia can be categorized into three main mechanisms: increased potassium intake, decreased potassium excretion, and transcellular potassium shifts. Medications, particularly potassium-sparing diuretics, ACE inhibitors, ARBs, and NSAIDs, are the most common cause of hyperkalemia, as they can increase potassium levels by reducing excretion or increasing intake 1. Kidney disease, including acute kidney injury and chronic kidney disease, significantly impairs potassium excretion, leading to hyperkalemia 1. Cellular breakdown conditions, such as rhabdomyolysis, tumor lysis syndrome, and severe hemolysis, release intracellular potassium into the bloodstream, causing hyperkalemia 1.
Some key points to consider in the management of hyperkalemia include:
- Medications: Potassium-sparing diuretics, ACE inhibitors, ARBs, and NSAIDs can cause hyperkalemia by reducing potassium excretion or increasing intake 1.
- Kidney disease: Acute kidney injury and chronic kidney disease can impair potassium excretion, leading to hyperkalemia 1.
- Cellular breakdown conditions: Rhabdomyolysis, tumor lysis syndrome, and severe hemolysis can release intracellular potassium into the bloodstream, causing hyperkalemia 1.
- Dietary factors: Excessive potassium intake through supplements or potassium-rich foods can overwhelm excretion mechanisms and contribute to hyperkalemia 1.
- Metabolic acidosis: Can cause potassium to shift out of cells in exchange for hydrogen ions, leading to hyperkalemia 1.
- Insulin deficiency: Can remove insulin's normal effect of driving potassium into cells, contributing to hyperkalemia 1.
- Beta-blockers: Can impair cellular potassium uptake, leading to hyperkalemia 1.
- Pseudohyperkalemia: A falsely elevated measurement due to hemolysis during blood collection, should always be considered 1.
The most recent and highest quality study, published in 2021, highlights the importance of individualized monitoring of serum potassium levels and the use of newer potassium-binding agents to manage hyperkalemia 1. Therefore, it is essential to prioritize the identification and treatment of the underlying cause of hyperkalemia, and to consider the use of potassium-binding agents and other therapies to reduce morbidity, mortality, and improve quality of life.
From the Research
Causes of Hyperkalemia
- Decreased renal excretion of potassium, which can be due to chronic renal insufficiency or impairment of regulation 2, 3, 4, 5
- Excess intake of potassium from diet, supplements, or drugs that can increase serum potassium 2, 4, 5
- Potassium shifting from the intra- to the extracellular space, which can be caused by various factors such as cell lysis or metabolic acidosis 3, 4
- Use of certain medications, including angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB), and mineralocorticoid receptor antagonists, which can increase the risk of hyperkalemia, particularly in patients with chronic renal insufficiency or heart failure 2, 3, 6
- Intrinsic disease of the collecting duct or disturbances in mineralocorticoid activity, which can impair the kidney's ability to excrete potassium 5
- Decreased delivery of sodium to the distal nephron, which can reduce the kidney's ability to excrete potassium 4, 5
Patient-Specific Risk Factors
- Chronic kidney disease (CKD) or renal insufficiency, which can impair the kidney's ability to excrete potassium 2, 3, 5
- Heart failure, which can increase the risk of hyperkalemia due to the use of certain medications or decreased renal function 3, 6
- Diabetes mellitus, which can increase the risk of hyperkalemia due to renal insufficiency or other factors 3, 6
- Older age, which can increase the risk of hyperkalemia due to decreased renal function or other factors 6
- Dehydration or worsening heart failure, which can increase the risk of hyperkalemia due to decreased renal function or other factors 6