Hyperkalemia Management

Definition and Diagnosis

Hyperkalemia is defined as serum potassium >5.0 or >5.5 mEq/L, with a potassium level of 5.5 mEq/L considered moderate hyperkalemia that warrants intervention 1
The relationship between potassium levels and ECG changes is as follows:

Potassium Level	ECG Changes
5.5-6.5 mmol/L	Peaked/tented T waves (early sign)
6.5-7.5 mmol/L	Prolonged PR interval, flattened P waves
7.0-8.0 mmol/L	Widened QRS, deep S waves
>10 mmol/L	Sinusoidal pattern, VF, asystole, or PEA

Lokelma has demonstrated efficacy across various patient populations, including patients with chronic kidney disease, heart failure, diabetes mellitus, and patients on RAAS inhibitor therapy 1
Neonates and pediatric patients are particularly vulnerable to rapid potassium shifts, with risk factors including rapid transfusions and increased extracellular potassium levels, as identified by the American Academy of Pediatrics 3
Hyperkalemia occurs in up to 40% of patients with chronic heart failure, and the benefits of ACEI therapy often outweigh the risks 4
Patients with chronic kidney disease have a higher risk of hyperkalemia (up to 73% in advanced CKD) 4

Treatment	Dosage	Onset of Action	Duration of Action
Calcium gluconate	10% solution, 15-30 mL IV	1-3 minutes	30-60 minutes
Insulin with glucose	10 units regular insulin IV with 50 mL of 25% dextrose	15-30 minutes	1-2 hours
Inhaled beta-agonists	10-20 mg nebulized over 15 minutes	15-30 minutes	2-4 hours
Sodium bicarbonate	50 mEq IV over 5 minutes	15-30 minutes	1-2 hours

1, 5, 4

The American Heart Association recommends stabilizing the cardiac membrane with Calcium gluconate 10%: 15-30 mL IV over 2-5 minutes, shifting potassium into cells with Insulin and glucose, and removing potassium from the body through Diuresis or Dialysis 5
The American College of Cardiology recommends treatment of acute hyperkalemia with a potassium binder, with a goal of maintaining normal potassium levels in patients with chronic hyperkalemia 1

Agent	Starting Dose	Onset	Key Considerations
Patiromer (Veltassa)	8.4g once daily	7 hours	Separate from other medications by 3 hours; no sodium content
Sodium zirconium cyclosilicate (Lokelma)	5-10g once daily	1 hour	Contains sodium (400mg per 5g); more rapid onset
Sodium polystyrene sulfonate	15-30g 1-4 times daily	Variable	Avoid chronic use due to GI side effects; high sodium content

Limiting potassium intake to <40 mg/kg/day and avoiding high-potassium foods, such as processed foods, bananas, oranges, potatoes, tomatoes, and legumes, is recommended 6
Patients should be educated on high-potassium foods to avoid, such as bananas, oranges, potatoes, tomato products, legumes, yogurt, and chocolate 7
Lifestyle modifications, including sodium restriction (<2g/day), regular physical activity (150 min/week), weight reduction if overweight/obese, and limited alcohol consumption, can help prevent hyperkalemia 8
The Kidney International guideline recommends restricting phosphate-rich foods, such as dairy products, nuts, legumes, and cola, to manage hyperkalemia 9

The European Journal of Heart Failure guideline recommends reviewing current medications, particularly ACE inhibitors, ARBs, NSAIDs, and other medications that affect potassium levels, to manage hyperkalemia 10
The American Heart Association recommends ACE inhibitors/ARBs as first-line medications after CABG, but they are a leading cause of hyperkalemia even in patients with normal renal function 11, 12
Reducing the dose of ACE inhibitors/ARBs rather than discontinuing is recommended, as these medications provide significant cardiovascular benefits post-CABG 11, 12
The American College of Cardiology recommends avoiding NSAIDs as they significantly increase hyperkalemia risk in patients on ACEIs, and monitoring for excessive diuresis, as volume depletion can worsen renal function and paradoxically increase hyperkalemia risk 13