Therapeutic Approach to Hyperkalemia

Abstract

The foremost step in the initial clinical management of hyperkalemia is to decide whether a hyperkalemic patient requires immediate treatment to avoid a life-threatening situation (serum potassium concentration >6.0 mEq/l and EKG changes). When the decision for urgent treatment of hyperkalemia is based on EKG changes, an important caveat for clinicians is that absent or atypical EKG changes do not exclude the necessity for immediate intervention. Once an urgent situation has being handled with intravenous push of a 10% calcium salt, the initiation of short-term measures can be launched by either a single or combined regimen of the three agents that cause a transcellular shift of potassium – insulin with glucose, β₂-agonist (albuterol), and NaHCO₃. As the first choice among these available options, we favor an intravenous bolus of 10 units of insulin with 50 ml of 50% glucose alone or in combination with 10–20 mg of albuterol by nebulizer. These can be repeated as required until the institution of hemodialysis. The combination of insulin with glucose and NaHCO₃ as an another option needs further clarification for its additive effects. However, NaHCO₃ has lost its favor because of its poor efficacy as a potassium-lowering agent when used alone. The next step is to remove potassium from the body – diuretics (furosemide), cation exchange resin (kayexelate) with sorbitol, and dialysis (preferably hemodialysis). The final important step for the managements of hyperkalemia is a long-term plan to prevent its recurrence or worsening. In addition to every effort to elucidate underlying causes and pathophysiologic mechanisms for hyperkalemia, an extensive search must be made to uncover overt or sometimes covert medications that may have led to the development of hyperkalemia. Furthermore, one must obtain detailed dietary and medical history of hyperkalemic patients.

Effect of amino acid infusion on potassium serum levels in neuroendocrine tumour patients treated with targeted radiopeptide therapy

“…Furosemide is a potent loop diuretic that increases renal excretion of K + by inhibiting the Na + -K + -Cl − symporter and is used for the acute therapy of hyperkalaemia [35]. The kaliuresis of 40 mg furosemide injected i.v.…”

Salbutamol to facilitate management of acute hyperkalemia in liver transplantation: a case report

“…3,5 The onset of action is usually within 15-30 min, with a peak effect between 30 and 60 min, and its effect lasts for 4-6 h. 3,5,12 The onset time and the duration of its hypokalemic effect are similar to those of insulin and sodium bicarbonate. 12 In this case, we administered a total of 20 g of nebulized salbutamol over two cycles.…”

“…3,12 In this case, we administered relatively small doses of sodium bicarbonate and furosemide (80 mEq and 10 mg, respectively) for intractable hyperkalemia, because the patient had satisfactory urine output and no documented metabolic acidosis. The potassium-lowering effects of insulin have been demonstrated in the setting of OLT.…”

“…1,2 We describe a case of acute hyperkalemia that was provoked by acute hepatic necrosis during the pre-anhepatic stage in living donor liver transplantation (LDLT). Despite initial treatment, including calcium insulin and glucose, sodium bicarbonate, and furosemide, 3 hyperkalemia did not resolve until nebulized salbutamol was administered. The efficacy of a selective β 2 -agonist, such as salbutamol, in lowering serum potassium has been established in normal volunteers 4 and in chronic renal failure patients.…”

Acute Kidney Injury Following Cardiac Surgery: Prevention, Diagnosis, and Management

“…In patients with AKI, it is important to restrict daily potassium intake by withholding food and medications containing potassium. When potassium levels become high or ECG changes develop, emergency treatment may include intravenous infusion of calcium, sodium bicarbonate, or glucose and insulin, or an inhaled betaagonist (Kim and Han 2002). These medications cause an intracellular potassium shift, thus decreasing serum levels.…”