(See also Overview of Disorders of Potassium Concentration Overview of Disorders of Potassium Concentration Potassium is the most abundant intracellular cation, but only about 2% of total body potassium is extracellular. Because most intracellular potassium is contained within muscle cells, total... read more .)
Etiology of Hyperkalemia
A common cause of increased serum potassium concentration is
Pseudohyperkalemia is most often caused by hemolysis of red blood cells in a blood sample. Pseudohyperkalemia can also occur as a result of prolonged application of a tourniquet or excessive fist clenching when venous blood is drawn. Thrombocytosis can cause pseudohyperkalemia in serum (platelet potassium is released during clotting), as can extreme leukocytosis.
Normal kidneys eventually excrete potassium loads, so sustained, nonartifactual hyperkalemia usually implies diminished renal potassium excretion. However, other factors usually contribute. They can include increased potassium intake, increased potassium release from cells, or both (see table Factors Contributing to Hyperkalemia Factors Contributing to Hyperkalemia ). When sufficient potassium chloride is rapidly ingested or given parenterally, severe hyperkalemia may result even when renal function is normal, but hyperkalemia is usually temporary.
Hyperkalemia due to total body potassium excess is particularly common in oliguric states (especially acute kidney injury Acute Kidney Injury (AKI) Acute kidney injury is a rapid decrease in renal function over days to weeks, causing an accumulation of nitrogenous products in the blood (azotemia) with or without reduction in amount of urine... read more ) and with rhabdomyolysis Rhabdomyolysis Rhabdomyolysis is a clinical syndrome involving the breakdown of skeletal muscle tissue. Symptoms and signs include muscle weakness, myalgias, and reddish-brown urine, although this triad is... read more , burns Burns Burns are injuries of skin or other tissue caused by thermal, radiation, chemical, or electrical contact. Burns are classified by depth (superficial and deep partial-thickness, and full-thickness)... read more , bleeding into soft tissue or the gastrointestinal tract, and adrenal insufficiency. In chronic kidney disease, hyperkalemia is uncommon until the glomerular filtration rate falls to < 10 to 15 mL/minute unless dietary or IV potassium intake is excessive.
Symptoms and Signs of Hyperkalemia
Although flaccid paralysis occasionally occurs, hyperkalemia is usually asymptomatic until cardiac arrhythmias Overview of Arrhythmias The normal heart beats in a regular, coordinated way because electrical impulses generated and spread by myocytes with unique electrical properties trigger a sequence of organized myocardial... read more develop.
In the rare disorder hyperkalemic familial periodic paralysis Hyperkalemic periodic paralysis Familial periodic paralysis is a rare autosomal dominant condition with considerable variation in penetrance characterized by episodes of flaccid paralysis with loss of deep tendon reflexes... read more , weakness frequently develops during attacks and can progress to frank paralysis.
Diagnosis of Hyperkalemia
Serum potassium measurement
Review of drug use
Assessment of renal function
Hyperkalemia (serum potassium > 5.5 mEq/L [> 5.5 mmol/L]) may be found on routine serum electrolyte measurement. It should be suspected in patients with typical changes on an ECG or in patients at high risk, such as those with chronic kidney disease Chronic Kidney Disease Chronic kidney disease (CKD) is long-standing, progressive deterioration of renal function. Symptoms develop slowly and in advanced stages include anorexia, nausea, vomiting, stomatitis, dysgeusia... read more , acute kidney injury Acute Kidney Injury (AKI) Acute kidney injury is a rapid decrease in renal function over days to weeks, causing an accumulation of nitrogenous products in the blood (azotemia) with or without reduction in amount of urine... read more , advanced heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular failure causes shortness of breath and fatigue, and right ventricular failure causes peripheral and abdominal fluid... read more , or urinary obstruction, or treated with ACE (angiotensin-converting enzyme) inhibitors and potassium-sparing diuretics.
Pseudohyperkalemia should be considered in patients without risk factors or ECG abnormalities. Hemolysis may be reported by the laboratory. When pseudohyperkalemia is suspected, potassium concentration should be repeated, taking measures to avoid hemolysis of the sample (such as avoiding small-gauge needles or tourniquet use and limiting fist clenching) and blood should be promptly processed by the laboratory.
ECG should be done on patients with hyperkalemia. ECG changes (see figure ECG patterns in hyperkalemia ECG patterns in hypokalemia ) are frequently visible when serum potassium is > 5.5 mEq/L. Slowing of conduction is characterized by an increased PR interval and shortening of the QT interval. Tall, symmetric, peaked T waves are visible initially. Potassium > 6.5 mEq/L (> 6.5 mmol/L) causes further slowing of conduction with widening of the QRS interval, disappearance of the P wave, and nodal and escape ventricular arrhythmias. Finally, the QRS complex degenerates into a sine wave pattern, and ventricular fibrillation or asystole ensues.
ECG patterns in hyperkalemia
Serum potassium is in mEq/L and mmol/L.
Diagnosis of cause
Diagnosis of the cause of hyperkalemia requires a detailed history, including a review of drugs, a physical examination with emphasis on volume status, and measurement of electrolytes, BUN (blood urea nitrogen), and creatinine. In cases in which renal failure is present, additional tests, including renal ultrasonography to exclude obstruction, are needed.
Treatment of Hyperkalemia
Treatment of the cause
For mild hyperkalemia, sodium polystyrene sulfonate, patiromer, or sodium zirconium cyclosilicate
For moderate or severe hyperkalemia, IV insulin and glucose, an IV calcium solution, possibly an inhaled beta 2-agonist, and usually hemodialysis
Patients with serum potassium < 6 mEq/L (< 6 mmol/L) and no ECG abnormalities may respond to diminished potassium intake or stopping potassium-elevating drugs. The addition of a loop diuretic enhances renal potassium excretion as long as volume depletion is not present.
Sodium polystyrene sulfonate in sorbitol can be given (15 to 30 g in 30 to 70 mL of 70% sorbitol orally every 4 to 6 hours). It acts as a cation exchange resin and removes potassium through the gastrointestinal mucosa. Sorbitol is administered with the resin to ensure passage through the gastrointestinal tract. Patients unable to take drugs orally because of nausea or other reasons may be given similar doses by enema. Enemas are not as effective at lowering potassium in patients with ileus. Enemas should not be used if acute abdomen is suspected. About 1 mEq (1 mmol) of potassium is removed per gram of resin given. Resin therapy is slow and often fails to lower serum potassium significantly in hypercatabolic states. Because sodium is exchanged for potassium when sodium polystyrene sulfonate is used, sodium overload (see Hypernatremia Hypernatremia Hypernatremia is a serum sodium concentration > 145 mEq/L (> 145 mmol/L). It implies a deficit of total body water relative to total body sodium caused by water intake being less than water... read more ) may occur, particularly in patients with oliguria and preexisting volume overload.
In patients with recurrent hyperkalemia, avoidance of drugs that can induce hyperkalemia (see table Factors Contributing to Hyperkalemia Factors Contributing to Hyperkalemia ) is generally all that is needed. In patients who need ACE inhibitors and angiotensin receptor blocking drugs (eg, patients with chronic heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular failure causes shortness of breath and fatigue, and right ventricular failure causes peripheral and abdominal fluid... read more or diabetic nephropathy Diabetic Nephropathy Diabetic nephropathy is glomerular sclerosis and fibrosis caused by the metabolic and hemodynamic changes of diabetes mellitus. It manifests as slowly progressive albuminuria with worsening... read more ), the polymer resin patiromer can be taken daily to help decrease gut absorption of potassium and prevent hyperkalemia. Sodium zirconium cyclosilicate is being used increasingly. It is a polymer matrix that binds to potassium in the gut. It decreases serum potassium over several hours and has few gastrointestinal adverse effects.
Moderate to severe hyperkalemia
Serum potassium between 6 and 6.5 mEq/L (6 and 6.5 mmol/L) needs prompt attention, but the actual treatment depends on the clinical situation.
If no ECG changes are present and renal function is intact, maneuvers as for mild hyperkalemia are usually effective. Follow-up serum potassium measurements are needed to ensure that the hyperkalemia has been successfully treated.
If serum potassium is > 6.5 mEq/L (> 6.5 mmol/L), more aggressive therapy is required. Administration of regular insulin 5 to 10 units IV is followed immediately by or administered simultaneously with rapid infusion of 50 mL 50% glucose. Infusion of 10% dextrose in water (D/W) should follow at 50 mL/hour to prevent hypoglycemia. The effect on serum potassium peaks in 1 hour and lasts for several hours.
If ECG changes include the loss of P-wave or widening of the QRS complex, treatment with IV calcium as well as insulin and glucose is indicated; 10 to 20 mL of 10% calcium gluconate (or 5 to 10 mL of 22% calcium gluceptate) is given IV over 5 to 10 minutes. If the ECG shows a sine wave pattern or asystole, calcium gluconate may be given more rapidly (5 to 10 mL IV over 2 minutes). Calcium antagonizes the effect of hyperkalemia on cardiac muscle. Calcium should be given with caution to patients taking digoxin because of the risk of precipitating hypokalemia-related arrhythmias. Calcium chloride can also be used but can be irritating to peripheral veins and cause tissue necrosis if extravasated. Calcium chloride should be given only through a correctly positioned central venous catheter.
The benefits of calcium occur within minutes but last only 20 to 30 minutes. Calcium infusion is a temporizing measure while awaiting the effects of other treatments or initiation of hemodialysis and may need to be repeated.
A high-dose beta 2-agonist, such as albuterol 10 to 20 mg inhaled over 10 minutes (5 mg/mL concentration), can lower serum potassium by 0.5 to 1.5 mEq/L (0.5 to 1.5 mmol/L) and may be a helpful adjunct. The peak effect occurs in 90 minutes. However, beta 2-agonists are contraindicated in patients with unstable angina or acute myocardial infarction.
Administration of IV sodium bicarbonate (NaHCO3) is controversial. It may lower serum potassium over several hours. Reduction may result from alkalinization or from the hypertonicity due to the concentrated sodium in the preparation. The amount of sodium contained in the infusion may be harmful for dialysis patients who also may have volume overload. Another possible complication of IV sodium bicarbonate is that it acts to acutely lower the ionized calcium concentration, which further exacerbates the cardiotoxicity of hyperkalemia. When sodium bicarbonate is given, the typical dose is 3 ampules of 7.5% sodium bicarbonate in one liter 5% D/W infused over 2 to 4 hours. Bicarbonate therapy has little effect when used by itself in patients with severe renal insufficiency unless acidemia is also present.
In addition to strategies for lowering potassium by shifting it into cells, maneuvers to remove potassium from the body should also be done early in the treatment of severe or symptomatic hyperkalemia. Potassium can be removed via the gastrointestinal tract by administration of sodium polystyrene sulfonate Mild hyperkalemia Hyperkalemia is a serum potassium concentration > 5.5 mEq/L (> 5.5 mmol/L), usually resulting from decreased renal potassium excretion or abnormal movement of potassium out of cells. There are... read more , but because the rate of potassium removal is somewhat unpredictable, close monitoring is needed.
Patiromer and sodium zirconium silicate are not recommended for use as an emergency treatment to acutely lower potassium because of these drugs' delayed onset of action.
Hemodialysis Hemodialysis In hemodialysis, a patient’s blood is pumped into a dialyzer containing 2 fluid compartments configured as bundles of hollow fiber capillary tubes or as parallel, sandwiched sheets of semipermeable... read more should be instituted promptly when emergency medical treatment is ineffective especially in patients with severe chronic kidney disease and/or acute kidney injury. Dialysis should be considered early in patients with end-stage renal disease and hyperkalemia because they are at increased risk of progression to more severe hyperkalemia and serious cardiac arrhythmias. Peritoneal dialysis is relatively inefficient at removing potassium acutely.
Common causes of hyperkalemia include potassium-retaining drugs, renal insufficiency, adrenal insufficiency, and disorders involving cellular breakdown (eg, rhabdomyolysis, burns, bleeding into soft tissue or the gastrointestinal tract).
Hyperkalemia is usually asymptomatic until cardiac toxicity develops, although some patients have weakness.
ECG changes begin with an increased PR interval, shortening of the QT interval, and tall, symmetric, peaked T waves; with potassium > 6.5 mEq/L (> 6.5 mmol/L), QRS interval widens, and P wave disappears; ultimately, the QRS complex degenerates into a sine wave pattern, and ventricular fibrillation or asystole ensues.
Give sodium polystyrene sulfonate, patiromer, or sodium zirconium cyclosilicate for mild hyperkalemia.
Give IV insulin, glucose, and calcium, and possibly an inhaled beta 2-agonist for moderate to severe hyperkalemia.
Use hemodialysis for patients with chronic kidney disease and those with significant ECG changes.