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Hyperkalemia

Definition
Hyperkalemia is defined as an increase in serum potassium levels > 5.0 mmol/L.
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Pathophysiology
The pathophysiology of hyperkalemia involves disruptions in potassium balance due to excess potassium intake, impaired potassium excretion, or transcellular shifts. The etiology is often multifactorial, with impaired renal function, medication use, and hyperglycemia being the most common contributors.
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Epidemiology
The prevalence of hyperkalemia in the US is estimated at 1,550 per 100,000 population.
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Disease course
Mild and moderate hyperkalemia are usually asymptomatic. Severe cases may manifest as muscle weakness, ascending paralysis, heart palpitations, and paresthesias. ECG changes associated with hyperkalemia include peaked T waves, P-wave flattening, PR-interval prolongation, widening of the QRS complex, and sine waves.
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Prognosis and risk of recurrence
The prognosis of hyperkalemia is dependent on the severity of the condition and the promptness of treatment. Severe untreated hyperkalemia can lead to life-threatening cardiac arrhythmias and cardiac arrest.
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Key sources
The following summarized guidelines for the evaluation and management of hyperkalemia are prepared by our editorial team based on guidelines from the United Kingdom Kidney Association (UKKA 2023), the American Academy of Family Physicians (AAFP 2023), the American Heart Association (AHA 2020), and the Guidelines and Audit Implementation Network (GAIN 2014).
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Guidelines

1.Screening and diagnosis

Indications for screening, patients at risk, AAFP: obtain routine serum potassium level monitoring in patients with CVD or CKD, especially if it is < 4 or > 5 mEq/L.
B
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  • Indications for screening (before initiating RAAS inhibitors)

  • Indications for monitoring (history of hyperkalemia)

  • Indications for monitoring (after initiating RAAS inhibitors)

  • Confirmatory testing

2.Classification and risk stratification

Severity grading: as per UKKA 2023 guidelines, use an early warning scoring system for urgent clinical assessment to assess the level of acuity in all patients presenting to the hospital with known or suspected hyperkalemia.
B

3.Diagnostic investigations

History and physical examination
As per UKKA 2023 guidelines:
Elicit a comprehensive medical and drug history and perform a clinical examination to determine the cause of hyperkalemia in all patients presenting to the hospital with hyperkalemia.
B
Obtain urgent clinical assessment using an early warning scoring system to assess the level of acuity in all patients presenting to the hospital with known or suspected hyperkalemia.
B

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  • Laboratory tests

  • ECG

4.Medical management

Indications for outpatient treatment
Initiate interventions to lower serum potassium in patients with serum potassium ≥ 5.5 mmol/L.
B
Guide treatment of hyperkalemia in the outpatient setting by its severity and clinical condition of the patient.
B

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  • Indications for urgent treatment

  • Discontinuation of contributing medications

  • Intravenous calcium

  • Intracellular shifting, insulin/glucose

  • Intracellular shifting, salbutamol

  • Intracellular shifting, sodium bicarbonate

  • Gastrointestinal excretion, sodium zirconium cyclosilicate

  • Gastrointestinal excretion, calcium polystyrene

  • Gastrointestinal excretion, patiromer

  • Renal excretion, loop diuretics

5.Inpatient care

Laboratory monitoring: as per UKKA 2023 guidelines, monitor serum potassium closely in all patients with hyperkalemia to assess the efficacy of treatment and monitor for rebound hyperkalemia after the initial response to treatment wanes.
B
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  • Cardiac monitoring

6.Nonpharmacologic interventions

Low-potassium diet
As per UKKA 2023 guidelines:
Offer dietary strategies to modify potassium intake in non-hospitalized patients with CKD and persistent hyperkalemia with serum potassium > 5.5 mmol/L after addressing non-dietary causes of hyperkalemia, such as constipation, acidosis, and poorly controlled diabetes.
B
Offer dietary strategies to modify potassium intake for hospitalized patients with moderate or severe hyperkalemia after addressing non-dietary causes of hyperkalemia.
B
Offer expert assessment by a registered or specialist renal dietitian and advice on dietary strategies to modify potassium intake in patients with CKD and persistent hyperkalemia with serum potassium > 5.5 mmol/L.
B

7.Therapeutic procedures

Renal replacement therapy
As per UKKA 2023 guidelines:
Decide on the timing, suitability, and modality for initiation of RRT in patients with life-threatening hyperkalemia, either from the outset or resistant to initial medical therapy, urgently by a nephrologist or critical care specialist.
B
Perform urgent dialysis in hemodialysis patients with severe hyperkalemia (serum potassium ≥ 6.5 mmol/L).
A

8.Specific circumstances

Patients on renin-angiotensin-aldosterone system inhibitor therapy, monitoring: obtain urea and electrolytes testing before initiating ACEIs or ARBs, and use these drugs with caution if the serum potassium is > 5.0 mmol.
A
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  • Patients on RAAS inhibitor therapy (treatment modification)

  • Patients on digoxin

  • Patients on hemodialysis

  • Patients with cardiac arrest (evaluation)

  • Patients with cardiac arrest (prevention)

  • Patients with cardiac arrest (management)

  • Patients with cardiac arrest (resuscitation)

9.Preventative measures

Prescribing caution
Use caution when prescribing trimethoprim in patients with renal impairment or taking RAAS inhibitors.
A
Review the need for prescribed medication that can cause hyperkalemia in the context of the current illness and level of renal function both on and during hospital admission.
B

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  • Counseling during acute illness

10.Follow-up and surveillance

Referral to renal or critical care services: consider referring patients with severe hyperkalemia (serum potassium ≥ 6.5 mmol/L) to their local renal or critical care team for an urgent opinion, guided by the clinical scenario and its persistence after initial medical treatment.
C
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