Clinical Management of Hyperkalemia

Abstract

Hyperkalemia is an electrolyte abnormality with potentially life-threatening consequences. Despite various guidelines, no universally accepted consensus exists on best practices for hyperkalemia monitoring, with variations in precise potassium (K þ) concentration thresholds or for the management of acute or chronic hyperkalemia. Based on the available evidence, this review identifies several critical issues and unmet needs with regard to the management of hyperkalemia. Real-world studies are needed for a better understanding of the prevalence of hyperkalemia outside the clinical trial setting. There is a need to improve effective management of hyperkalemia, including classification and K þ monitoring, when to reinitiate previously discontinued renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, and when to use oral K þ-binding agents. Monitoring serum K þ should be individualized; however, 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. Recent clinical studies suggest that the newer K þ binders (patiromer sorbitex calcium and sodium zirconium cyclosilicate) may facilitate optimization of RAASi therapy. Enhancing the knowledge of primary care physicians and internists with respect to the safety profiles of these newer K þ binders may increase confidence in managing patients with hyperkalemia. Lastly, the availability of newer K þ-binding agents requires further study to establish whether stringent dietary K þ restrictions are needed in patients receiving K þ-binder therapy. Individualized monitoring of serum K þ among patients with an increased risk of hyperkalemia and the use of newer K þ-binding agents may allow for optimization of RAASi therapy and more effective management of hyperkalemia.

Management of Chronic Hyperkalemia in Patients With Chronic Kidney Disease: An Old Problem With News Options

“…Moreover, new onset or persistence of mild-to-moderate hyperkalemia (potassium 5.0-6.0 mmol/L) during 12 months of observation significantly increased by 30% the risk of End Stage Renal Disease (ESRD) (4,17,18). It has been suggested that CKD patients adapt to elevated potassium concentrations through modifications in gastrointestinal secretions which may favor intracellular potassium storage, or by increasing insulinmediated intracellular potassium uptake in splanchnic and peripheral muscle tissues (19). On the other hand, relevant are also the related economic costs that double in the presence of persistent hyperkalemia (20).…”

“…suboptimal dosing/discontinuation of RAASi among patients with CKD, diabetes or HF compared with those with full RAASi dose (19,47).…”

Alternating and Concurrent True Hyperkalemia and Pseudohyperkalemia in Adult Sickle Cell Disease

“…We must draw attention to the availability of the new potassium binders, patiromer and sodium zirconium cyclosilicate. 9 We would advocate for caution in the use of these potent potassium binders and to always give consideration to the presence of pseudohyperkalemia under appropriate clinical scenarios. [6][7][8]10 We posit that providers managing adult patients with sickle cell disease must be aware of such a phenomenon to avoid the dangers of overtreatment of episodes of pseudohyperkalemia in such patients.…”

Consensus-Based Recommendations for the Management of Hyperkalemia in the Hemodialysis Setting

“…Recommendations on the monitoring of hyperkalemia in patients with CKD are largely indirect, 1,33 and there is no evidence to inform on the ideal timing or frequency in the hemodialysis setting (Box 2). The association between elevated serum K 1 ($5.5 mmol/L) and hospitalizations has been observed to be stronger when measurements were done on a Friday, rather than a Monday or Wednesday (for patients on a Monday-Wednesday-Friday schedule).…”

“…22 Not all current guidelines and recommendations on managing hyperkalemia address the use of newer K 1 binders, or how to treat hyperkalemia in the hemodialysis setting. 33 This consensus statement from experienced nephrologists covers current gaps in clinical practice recommendations regarding the management of hyperkalemia in the hemodialysis setting and identifies areas where future research is needed to further reinforce the evidence base supporting these recommendations.…”