Management of patients with acute hyperkalemia

Abstract

A 72-year-old man presents to his family physician for follow-up of hypertension, reporting fatigue and generalized weakness. His medical history also includes peptic ulcer disease, type 2 diabetes mellitus and chronic kidney disease. The estimated glomerular filtration rate is 30 mL/min per 1.73 m 2 . His medications include metformin, lansoprazole, acetylsalicylic acid, hydrochlorothiazide and ramipril, the dose of which was increased two weeks earlier to address suboptimal blood pressure control. Blood work at the time of the current presentation shows that the serum potassium level is 6.7 (normal range 3.3-5.1) mmol/L from a nonhemolyzed sample. The patient's family physician refers him to the emergency department urgently. In the emergency department, the patient is hemodynamically stable, with blood pressure 124/70 mm Hg and heart rate 80 beats/min (regular). Repeat testing shows a potassium level of 6.9 mmol/L, and electrocardiography shows sinus rhythm with peaked T waves, prolonged PR interval (240 milliseconds) and a narrow QRS interval. This patient requires urgent treatment of hyperkalemia. What therapeutic options are available, and what is the evidence supporting their use? H yperkalemia is a common disorder, occurring both in the outpatient setting and in up to 10% of patients who have been admitted to hospital. [1][2][3][4] Underlying renal insufficiency and use of medications that disrupt potassium balance, such as angiotensin-converting enzyme inhibitors and potassium-sparing diuretics, are welldescribed risk factors. [4][5][6][7] Although mild hyperkalemia is often asymptomatic and easily treated, acute, severe hyperkalemia that is left untreated can result in fatal cardiac arrhythmias. [8][9][10] In addition to discontinuation of precipitants, steps in the management of acute hyperkalemia include protecting the heart from arrhythmias by administering calcium-based salts, 11 shifting potassium into the cells and enhancing elimination of potassium. Several treatment options have been proposed, particularly for shifting potassium into the cells, with differing onset and duration of action. 12 In addition, available studies conflict with respect to the efficacy of the various treatment options, which has led to differences in recommendations among practitioners and institutions. 5,13The level of potassium at which treatment should be initiated has not been established by evidence. However, we recommend initiating nonpharmacologic steps for management at levels above 5.5 mmol/L, with pharmacologic interventions as outlined in this review being instituted at levels of 6.0 mmol/L or greater.Given uncertainties regarding the optimal management of this condition, we undertook a review of randomized controlled trials of therapies for the management of acute hyperkalemia in the adult population. MethodsFor the current review, we updated a previously published systematic review on this topic, 14 using a similar search strategy and similar criteria for selecting studies for inclusion. We identified all po...

Association between Serum Potassium and Outcomes in Patients with Reduced Kidney Function

“…Therefore, it is advisable that serum K + be maintained within the normal range (3.5-5.0 mEq/L) among patients with CKD. For hypokalemia, management is reasonably straightforward because most patients can be corrected with oral supplements (13). Clinicians should be particularly vigilant in monitoring for hypokalemia, a potent precipitant in the setting of diuretic use, as this and other studies have shown (14).…”

Spontaneous tumour lysis syndrome

“…Hyperkalemia should be monitored closely and treated with insulin, glucose and calcium gluconate, 4 as per established protocols. 20 Hemodialysis should be considered for refractory hyperkalemia, especially in the setting of oliguria. The rapid accumulation of potassium in the setting of oliguria and the potential for hypocalcemia from the hyperphosphatemia are two reasons why a lower threshold for starting dialysis in these patients has been suggested.…”

New Potassium Binders for the Treatment of Hyperkalemia

“…Hyperkalemic patients presenting with evidence of cardiac instability should receive rapid therapy to stabilize the myocardium according to the standard of care (eg, intravenous calcium chloride or gluconate). 32 Dialysis may also be considered for the treatment of acute hyperkalemia. 32 Acute therapy is recommended when serum potassium is >6.5 mmol/L or when cardiac manifestations of hyperkalemia are present regardless of the serum potassium concentration.…”

“…32 Dialysis may also be considered for the treatment of acute hyperkalemia. 32 Acute therapy is recommended when serum potassium is >6.5 mmol/L or when cardiac manifestations of hyperkalemia are present regardless of the serum potassium concentration. 33 However, it is important to recognize that the ECG can be normal, even with severe hyperkalemia.…”