Acute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference

Abstract

Hyperkalemia is a common electrolyte disorder observed in the emergency department. It is often associated with underlying predisposing conditions, such as moderate or severe kidney disease, heart failure, diabetes mellitus, or significant tissue trauma. Additionally, medications, such as inhibitors of the renin-angiotensin-aldosterone system, potassium-sparing diuretics, nonsteroidal anti-inflammatory drugs, succinylcholine, and digitalis, are associated with hyperkalemia. To this end, Kidney Disease: Improving Global Outcomes (KDIGO) convened a conference in 2018 to identify evidence and address controversies on potassium management in kidney disease. This review summarizes the deliberations and clinical guidance for the evaluation and management of acute hyperkalemia in this setting. The toxic effects of hyperkalemia on the cardiac conduction system are potentially lethal. The ECG is a mainstay in managing hyperkalemia. Membrane stabilization by calcium salts and potassium-shifting agents, such as insulin and salbutamol, is the cornerstone in the acute management of hyperkalemia. However, only dialysis, potassium-binding agents, and loop diuretics remove potassium from the body. Frequent reevaluation of potassium concentrations is recommended to assess treatment success and to monitor for recurrence of hyperkalemia.

Fig. 1

Severity of acute hyperkalemia: expert opinion based risk classification. Reproduced with permission [1].

Fig. 2

Typical ECG changes associated with hyperkalemia. It is important to note that ECG changes may not correlate closely with serum potassium concentration or be useful in predicting outcomes. As such, a normal ECG should not necessarily be regarded as reassuring if elevated potassium concentration has been definitively observed. Such patients may still experience sudden hyperkalemic cardiac arrest episodes. Reproduced with permission [48].

Fig. 3

Treatment algorithm for management of acute hyperkalemia in the emergency department. The thresholds for actions are opinion based. Suggested drug doses are based on a 2010 systematic review [80] and a subsequent observational study [81]. ECG changes commonly reported with increasing potassium concentrations have been described in the literature [,–42,82]. *IV 3 times 1 g calcium gluconate (3 × 10 ml of 10% solution, each containing 93 mg elemental calcium, 2.3 mmol; total 279 mg elemental calcium, 6.9 mmol) or 1 g calcium chloride (10 ml of 10% solution, 273 mg elemental calcium, 6.8 mmol) †IV regular insulin 5 units plus 25 g glucose (50 ml of 50%) is as effective as albuterol (salbutamol) 10 mg nebulized; insulin and albuterol may have an additive effect. Beware of hypoglycemia. §IV bicarbonate (1 amp of 50 ml of 8.4% solution, Na⁺ 50 mmol, HCO₃⁻ 50 mmol) over 15 min. **Potassium binders: sodium polystyrene sulphonate (SPS) 15–60 g po/pr (do not give with sorbitol) or sodium zirconium cyclosilicate 10 g 3×/d po (patiromer not advisable as onset of action is 7 h). This guidance is suggestive as there are limited data on onset of action with no head-to-head studies between potassium binders. ‡Hemodialysis is the modality of preference. AKI, acute kidney injury; CKD, chronic kidney disease; ECG, electrocardiogram; ESKD, end-stage kidney disease; GFR, glomerular filtration rate; IV, intravenous; K⁺, potassium; VF, ventricular fibrillation. Reproduced with permission [1].