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==Overview==
==Overview==
Treatment of hyperkalemia includes lowering of serum [[potassium]] levels, [[cardiac membrane]] stabilization and removal of excess [[potassium]] from the [[body]].When [[Cardiac arrhythmia|arrhythmias]] occur, or when [[potassium]] levels exceed 6.5 mmol/l, [[emergency]] lowering of [[potassium]] levels is mandated. Several agents are used to lower [[potassium]] levels. Choice depends on the degree and cause of the hyperkalemia, and other aspects of the patient's condition.Treatment also depends on the cause of hyperkalemia.
Treatment of hyperkalemia includes lowering of serum potassium levels,cardiac membrane stabilization and removal of excess potassium from the body.When [[Cardiac arrhythmia|arrhythmias]] occur, or when potassium levels exceed 6.5 mmol/l, emergency lowering of potassium levels is mandated. Several agents are used to lower potassium levels. Choice depends on the degree and cause of the hyperkalemia, and other aspects of the patient's condition.Treatment also depends on the cause of hyperkalemia.
==Medical Therapy==
==Medical Therapy==
*[[Pharmacological]] [[therapy]] in hyperkalemia is dependent on serum [[potassium]] levels and the development of [[symptoms]].
*Pharmacological therapy in hyperkalemia is dependent on serum potassium levels and the development of symptoms.<ref name="pmid8589279">{{cite journal| author=Allon M| title=Hyperkalemia in end-stage renal disease: mechanisms and management. | journal=J Am Soc Nephrol | year= 1995 | volume= 6 | issue= 4 | pages= 1134-42 | pmid=8589279 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8589279  }} </ref>
*[[Therapy]] 1 is used in hyperkalemic [[emergency]]([[emergency]] lowering of serum K+ required) which is :
*Therapy 1 is used in hyperkalemic emergency(emergency lowering of serum K+ required) which is :
**Serum [[potassium]] level > 6.5 mEq/L
**Serum potassium level >6.5 mEq/L
**[[ECG]] changes present.
**ECG changes present.
**Serum K+ >5.5 mEq/L and [[patient]] has severe [[renal impairment]].
**Serum K+ >5.5 mEq/L and patient has severe renal impairment.
*[[Therapy]] 2 is used when [[emergency]] lowering of [[potassium]] levels not required:
*Therapy 2 is used when emergency lowering of potassium levels not required:


=== Medical management ===
=== Medical management ===


==== 1.Hyperkalemic emergency ====
==== 1.Hyperkalemic emergency ====
1.1. [[Pharmacotherapy]]
1.1. Pharmacotherapy


1.1.1. [[Cardiac]] membrane stabilization
1.1.1. Cardiac membrane stabilization
*Preferred regime: [[Calcium gluconate]] 10% 0.5ml/kg IV loading dose. (contraindicated in [[digoxin toxicity]] and [[hypercalcemia]])
*Preferred regime:Calcium gluconate 10% 0.5ml/kg IV loading dose.(contraindicated in digoxin toxicity and hypercalcemia)<ref name="pmid25415806">{{cite journal| author=Ingelfinger JR| title=A new era for the treatment of hyperkalemia? | journal=N Engl J Med | year= 2015 | volume= 372 | issue= 3 | pages= 275-7 | pmid=25415806 | doi=10.1056/NEJMe1414112 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25415806  }} </ref>


*Alternate regime: [[Magnesium sulfate]] 2gm IV over 5 minutes(in [[digoxin toxicity]] and [[hypercalcemia]])
*Alternate regime:Magnesium sulfate 2gm IV over 5 minutes(in digoxin toxicity and hypercalcemia)
1.1.2. Increase potassium shift from extracellular to intracellular spaces
* Preferred regime(1):IV insulin with 2.5-5 ml/kg/h 20% [[dextrose]] (0.5-1 g/kg/h) with insulin 0.2 units for every gram of glucose administered..<ref name="pmid6364842">{{cite journal| author=Alvestrand A, Wahren J, Smith D, DeFronzo RA| title=Insulin-mediated potassium uptake is normal in uremic and healthy subjects. | journal=Am J Physiol | year= 1984 | volume= 246 | issue= 2 Pt 1 | pages= E174-80 | pmid=6364842 | doi=10.1152/ajpendo.1984.246.2.E174 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6364842  }} </ref><ref name="pmid3052050">{{cite journal| author=Blumberg A, Weidmann P, Shaw S, Gnädinger M| title=Effect of various therapeutic approaches on plasma potassium and major regulating factors in terminal renal failure. | journal=Am J Med | year= 1988 | volume= 85 | issue= 4 | pages= 507-12 | pmid=3052050 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3052050  }} </ref>


1.1.2. Increase [[potassium]] shift from [[extracellular]] to [[intracellular]] spaces
*Preferred regime(2):Salbutamol nebulization: 2.5 mg if <25 kg and 5 mg if >25 kg.
* Preferred regime(1): IV [[insulin]] with 2.5-5 ml/kg/h 20% [[dextrose]] (0.5-1 g/kg/h) with [[insulin]] 0.2 units for every gram of glucose administered..
* Alternate regime:Sodium bicarbonate 8.4%- 1-2 mmol/kg IV over 30-60 min only in cases of [[acidosis]].
1.1.3. Loop diuretics<ref name="pmid1552710">{{cite journal| author=Blumberg A, Weidmann P, Ferrari P| title=Effect of prolonged bicarbonate administration on plasma potassium in terminal renal failure. | journal=Kidney Int | year= 1992 | volume= 41 | issue= 2 | pages= 369-74 | pmid=1552710 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1552710  }} </ref>
* Preferred regime:Furosemide 40mg IV laoding dose and then 1-2mg/kg/day tillpotassium levels <5.1 mEq/L.
1.2 Renal replacement therapy.<ref name="pmid7573015">{{cite journal| author=Allon M, Shanklin N| title=Effect of albuterol treatment on subsequent dialytic potassium removal. | journal=Am J Kidney Dis | year= 1995 | volume= 26 | issue= 4 | pages= 607-13 | pmid=7573015 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7573015  }} </ref>


*Preferred regime(2): [[Salbutamol]] nebulization: 2.5 mg if <25 kg and 5 mg if >25 kg.
*Haemodialysis ( when renal function is impaired)
* Alternate regime: [[Sodium bicarbonate]] 8.4%- 1-2 mmol/kg IV over 30-60 min only in cases of [[acidosis]].
 
1.1.3. [[Loop diuretics]]
* Preferred regime: [[Furosemide]] 40mg IV laoding dose and then 1-2mg/kg/day tillpotassium levels <5.1 mEq/L.
 
1.2 [[Renal replacement therapy]].
 
*[[Haemodialysis]] ( when [[renal function]] is impaired)


==== 2.When emergency lowering of serum K+ not required. ====
==== 2.When emergency lowering of serum K+ not required. ====
2.1. [[Pharmacotherapy]]
2.1. Pharmacotherapy
 
2.1.1. [[Gastrointestinal]] [[cation]] exchangers
*Preferred regime:[[Polystyrene sulfonate]] ([[Calcium]] Resonium, [[Kayexalate]]) given 1g/kg/ PO till serum k+ <5.1 mEq/L.
 
2.1.2. [[Loop diuretics]]
 
*Preferred regime: [[Furosemide]] 40mg/kg PO till serum K+ <5.1 mEq/L.
 
2.2 [[Renal replacement therapy]]


*[[Haemodialysis]](when [[renal function]] is impaired)
2.1.1. Gastrointestinal cation exchangers
*Preferred regime:[[Polystyrene sulfonate]] (Calcium Resonium, Kayexalate) given 1g/kg/ PO till serum k+ <5.1 mEq/L.
2.1.2. Loop diuretics
*Preferred regime:Furosemide 40mg/kg PO till serum K+ <5.1 mEq/L.
2.2 Renal replacement therapy
* Haemodialysis(when renal function is impaired)


==== Contraindicated medications ====
==== Contraindicated medications ====

Revision as of 09:55, 29 April 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2] Jogeet Singh Sekhon Syed Ahsan Hussain, M.D.[3]

Overview

Treatment of hyperkalemia includes lowering of serum potassium levels,cardiac membrane stabilization and removal of excess potassium from the body.When arrhythmias occur, or when potassium levels exceed 6.5 mmol/l, emergency lowering of potassium levels is mandated. Several agents are used to lower potassium levels. Choice depends on the degree and cause of the hyperkalemia, and other aspects of the patient's condition.Treatment also depends on the cause of hyperkalemia.

Medical Therapy

  • Pharmacological therapy in hyperkalemia is dependent on serum potassium levels and the development of symptoms.[1]
  • Therapy 1 is used in hyperkalemic emergency(emergency lowering of serum K+ required) which is :
    • Serum potassium level >6.5 mEq/L
    • ECG changes present.
    • Serum K+ >5.5 mEq/L and patient has severe renal impairment.
  • Therapy 2 is used when emergency lowering of potassium levels not required:

Medical management

1.Hyperkalemic emergency

1.1. Pharmacotherapy

1.1.1. Cardiac membrane stabilization

  • Preferred regime:Calcium gluconate 10% 0.5ml/kg IV loading dose.(contraindicated in digoxin toxicity and hypercalcemia)[2]
  • Alternate regime:Magnesium sulfate 2gm IV over 5 minutes(in digoxin toxicity and hypercalcemia)

1.1.2. Increase potassium shift from extracellular to intracellular spaces

  • Preferred regime(1):IV insulin with 2.5-5 ml/kg/h 20% dextrose (0.5-1 g/kg/h) with insulin 0.2 units for every gram of glucose administered..[3][4]
  • Preferred regime(2):Salbutamol nebulization: 2.5 mg if <25 kg and 5 mg if >25 kg.
  • Alternate regime:Sodium bicarbonate 8.4%- 1-2 mmol/kg IV over 30-60 min only in cases of acidosis.

1.1.3. Loop diuretics[5]

  • Preferred regime:Furosemide 40mg IV laoding dose and then 1-2mg/kg/day tillpotassium levels <5.1 mEq/L.

1.2 Renal replacement therapy.[6]

  • Haemodialysis ( when renal function is impaired)

2.When emergency lowering of serum K+ not required.

2.1. Pharmacotherapy

2.1.1. Gastrointestinal cation exchangers

  • Preferred regime:Polystyrene sulfonate (Calcium Resonium, Kayexalate) given 1g/kg/ PO till serum k+ <5.1 mEq/L.

2.1.2. Loop diuretics

  • Preferred regime:Furosemide 40mg/kg PO till serum K+ <5.1 mEq/L.

2.2 Renal replacement therapy

  • Haemodialysis(when renal function is impaired)

Contraindicated medications

Hyperkalemia is considered a relative contraindication to the use of the following medications:


Hyperkalemia (Serum potassium >5.5 mEq/L) is considered an absolute contraindication to the use of the following medications:

References

  1. ↑ Allon M (1995). "Hyperkalemia in end-stage renal disease: mechanisms and management". J Am Soc Nephrol. 6 (4): 1134–42. PMID 8589279.
  2. ↑ Ingelfinger JR (2015). "A new era for the treatment of hyperkalemia?". N Engl J Med. 372 (3): 275–7. doi:10.1056/NEJMe1414112. PMID 25415806.
  3. ↑ Alvestrand A, Wahren J, Smith D, DeFronzo RA (1984). "Insulin-mediated potassium uptake is normal in uremic and healthy subjects". Am J Physiol. 246 (2 Pt 1): E174–80. doi:10.1152/ajpendo.1984.246.2.E174. PMID 6364842.
  4. ↑ Blumberg A, Weidmann P, Shaw S, Gnädinger M (1988). "Effect of various therapeutic approaches on plasma potassium and major regulating factors in terminal renal failure". Am J Med. 85 (4): 507–12. PMID 3052050.
  5. ↑ Blumberg A, Weidmann P, Ferrari P (1992). "Effect of prolonged bicarbonate administration on plasma potassium in terminal renal failure". Kidney Int. 41 (2): 369–74. PMID 1552710.
  6. ↑ Allon M, Shanklin N (1995). "Effect of albuterol treatment on subsequent dialytic potassium removal". Am J Kidney Dis. 26 (4): 607–13. PMID 7573015.
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